What pulls the trigger?

Gun shaped man hand

Eating disorders can often wax and wane throughout a person’s life course. Most clinicians and theorists attribute this vacillation to ‘stress’ but they fail to specify the types of stress that actually trigger the disease. In the world of someone with an eating disorder, not all stress is created equal. I once asked a group of women with eating disorder if their car getting a flat tire would trigger symptoms of eating pathology to worsen. The response was a resounding ‘no’. However, earlier in the group many mentioned that ‘stress’ worsened their urges to purge and restrict. I reflected back to them that getting a flat tire is very stressful, as would be enduring a hurricane, having one’s cat die, having one’s wallet stolen, etc., yet none of these events could be imagined by the group as triggering their eating pathologies. However, when I mentioned the type of stress such as mom and dad getting in an argument and the client getting pulled into the middle, your mother telling you she is very embarrassed by you because you didn’t make the cheer squad, or being told by your husband that you are not a good mother, these ‘stressors’ were endorsed as being very triggering of eating disorder. I feel this is important, because the type of stressor that triggers symptoms speaks highly to the social and psychological origins of those symptoms. I am frustrated that most people believe that skinny models and dieting ads are ‘triggering’. Granted, a lot of people with eating pathology would endorse that these issues are triggering, but I believe this is due to a superficial understanding of what really causes eating disorders. Skinny models and dieting ads may make urges to restrict and body image concerns more salient for a short time, but it is the self-system and feedback about roles and place in the family that actually changes one’s self-worth, triggers feelings of failure, which triggers urges to self-punish and self-neglect. Most individuals are exposed to images of emaciated models and actresses, and may even experience a desire to be thinner, but eating disorders are NOT a desire to be thinner. Eating disorders are patterns of self-deprivation and self-punishment that result from a crisis of self and a severe imbalance of energy in the social system. I believe targeting the media as a cause for eating disorders is the same as believing cold weather causes the flu. Yes cold weather can worsen a flu if an individual is carrying the virus, but it is the virus itself that causes the illness of the flu, not cold weather. Yes there is an association, but I think in the field of eating disorders, we have mistaken correlation with causation.

Beneath the will lies the ill

Weight Scale

During this time of year we are inundated with stories of weight-loss resolutions, dietary goals and exercise aspirations. Most of us want something approximating the media-dictated “perfect body” but, luckily, never get there because in the healthy person, normal appetite overrules the drive to be stick-thin. It is apparent that drive to be thin and a belief that one’s body is too large is not a recipe for weight loss. In extreme cases, people are literally told by their doctors “if you don’t lose weight, you will suffer dire health consequences, even death”. At that point, motivation to eat less would be probably as high as it could be, and yet still many in that position can’t lose the pounds needed to achieve even the most basic health.

This brings up an interesting question: if Anorexia is really about a desire to lose weight and a belief that one is ‘too fat’, then how is it that people without Anorexia who want nothing more than to lose weight, who believe their bodies to be severely overweight, can’t lose the weight they want? I propose that viewing your body as being too large and strongly desiring weight loss is not what causes Anorexia, otherwise we would see the Anorexic eating habits in everyone whose New Year’s resolution is to lose weight. I’ve even heard people say “I wish I could catch Anorexia for just a month or two to get this damned weight off!” Certainly there is more to this equation than is apparent at first glance.

Anorexia (and eating disorders generally) are not something one can turn off and turn on. It is not a function of wanting to lose weight, and recovery is not a function of wanting to gain weight. There is something much deeper going on with this illness that has nothing to do with feeling too big and wanting to be smaller. Yes, being distressed about one’s body, feeling it is too big and wanting to lose weight are associated with Anorexia, but they do not cause Anorexia. Otherwise, there would be an epidemic of “Anorexia” on January 1, and all the people who are on diets would instantly “catch it” as part of their diet plans.

No, Anorexia is much more complicated than that. It frustrates me how much research and clinical effort is spent on variables that, in my view, are the result of the Anorexia process but not the cause of the illness itself. The approach we have is similar to treating a patient for the flu, and believing that lowering the fever is going to resolve the illness. Yes, the fever is associated with the flu, but the fever didn’t cause the flu, the flu caused the fever. Similarly with Anorexia, wanting to lose weight and thinking you are too fat is a symptom of the illness, but didn’t cause the illness itself. The illness causes affected individuals to start feeling too large and wanting to take pounds off, but that is not how it starts and not how a meaningful resolution is achieved.

To provide people with Anorexia the recovery and understanding they truly deserve and desperately need, we must avoid confusing the outcomes with the causes of this illness. We must stop being so distracted by the idea that this illness is caused by wanting to lose weight. That viewpoint is simply shortsighted and erroneous, and all it takes is to look around at the tens of millions of people on diets to see that wanting to lose weight and hating your body does not cause Anorexia.