Updated: Apr 21
I opened the doors of Anorexia and Bulimia Resource Center in 1983, after a year’s sabbatical in New York City, where I did post-doctoral work at the Center for the Study of Anorexia and Bulimia (CSAB,) and the Ackerman Institute for Family Therapy.
Eating Disorders were a ‘hot’ topic at the time; Karen Carpenter had recently died, patients were coming out of the closets, university campuses were offering groups for sufferers, national organizations were forming, People Magazine had a new anorexic Hollywood star on every cover, and every TV host wanted to know more about these curious new disorders called Anorexia and Bulimia. I was even flown to NYC to be an ‘expert’ on the Sally Jesse Raphael Show, with a panel of 3 anorexic women of various ages and very low weights. Had I known who the ‘guests’ were going to be, I would never have agreed to be a part of something that was so sensationalized, done in such poor taste, and with no respect for the guests.
However, very little was known then, and unfortunately, very little is still understood today about the genesis (and genetics) of these disorders, why millions of young girls grow up in the same weight-obsessed, diet-crazed culture and yet only some of them succumb to the “relentless pursuit of thinness,” why some patients respond very rapidly to treatment, while others need multiple interventions over long periods of time, caught up in the “revolving door” of inpatient and outpatient treatments, while still others never seem to recover and continue to struggle throughout their adult years.
Because body dissatisfaction and dieting are cultural norms today, particularly amongst women, and because the media continues to harass women who are not conforming to the cultural norms of thinness, I treat eating disorders from a bio-psycho-social perspective. Biology and heredity are important, individual psychology and self-esteem are paramount, and society, the prevailing culture that we live in, also plays a big role.
Research is beginning to discover that eating disorders are to some extent inherited, or at least that there is a biological/genetic predisposition to their onset. At least 3 heritable factors come to mind as possible precursors to eating disorders and they are (1) addiction, (2) depression, and (3), obesity.
Re (1), ADDICTION: Some researchers and clinicians view anorexia and bulimia, particularly relentless self-starvation, laxative abuse, compulsive exercising, and the binge-purge cycle as addictions not unlike alcoholism or drug abuse. Therefore, if there is a history of substance abuse in one generation, it increases the likelihood that someone in the next generation might develop an eating disorder, instead of or in addition to a problem with substance abuse. Many patients have shared with me, “bulimia (or food, binging, binge-purging) became my drug of choice.”
Re (2), DEPRESSION: Often eating disorders and depression are 2 sides of the same coin. Since we now know that depression is heritable, it is speculated that in some cases the eating disorder actually develops as a coping mechanism, as a way of handling, or fighting, or masquerading an underlying depression. When an anorexic spends all her time relentlessly pursuing thinness, or a bulimic is binging and purging 5-10 times a day, she is distracted from her depression because she has ‘found a higher calling,’ i.e., following the dictates, or the inner voice of her eating disorder that demands she follow the rules. She dismisses her low moods with “I hate myself because I just ate 10 brownies,” or “I can’t believe I didn’t lose even ½ pound today.”
Re (3), OBESITY: There is indisputable evidence that obesity “runs in families,” that just like addiction and depression, it is passed down genetically from one generation to the next. So how does obesity play into the development of an eating disorder? The DSM V, our profession’s Diagnostic and Statistical Manual, recently labelled ‘Binge-Eating-Disorder’ (BED) the 3rd official eating disorder, in addition to Anorexia Nervosa and Bulimia Nervosa. While not all obese people suffer from BED, at least one third do, and constant, uncontrollable binging without purging, the major difference between bulimia and BED, may lead to obesity.
Secondly, and equally important, there is a whole subset of young girls in our thinness-crazed society, who do NOT want to look like their heavy-set mothers or grandmothers, or older sisters or cousins and aunts. In short, they do NOT want to be fat like the rest of the women in their family. They know obesity is inherited, they see it in all their family members, particularly the females, and they begin, at a very early age, to protest…to eat differently, dress differently, even cook for themselves and eat alone. Of course in many cultures where food and the family meal are highly valued, this rebellion can cause turmoil at home, and the tension then adds to the already developing full-fledged eating disorder.
Why did I just spend so much time talking about addiction, depression and obesity? I did so because if you are reading this at all, the chances are you are probably looking for help for yourself or a loved one. And you have probably asked yourself a hundred times, “What is this eating disorder REALLY all about? Do I simply want to look like all the skinny models, or all my skinny friends, or feel better about myself, or look better in clothes…or are there deeper underlying issues? And if so, what are they? Why is my friend, Nicole, perfectly content with how she looks…and so confident with boys…and such a good swimmer…and yet she’s a size 10…yikes! And she wears a bikini and doesn’t even have a flat stomach!”
So now you know that at least one of the ‘underlying issues’ has to do with your heredity, your particular family background. And if there are addiction(s), depression (and /or other mood disorders, including bipolar or manic-depressive illness,) or obesity in your family, then you are more at risk, more likely, more predisposed to developing an eating disorder than someone who does NOT have those predisposing factors. And if 2 or 3 of those factors are evident and prevalent in your family, then the dice are even more loaded…does that make sense? I hope so.
I want to say a few words about perfectionism and self esteem. So many young women today are filled with low self-esteem and body loathing; “I’m just not good enough, I’m never going to be good enough, I hate my body, I hate my life, I’ll never be happy, I’ll never find a man to love me, and I’ll never live up to my own or anybody else’s expectations.” Yet the irony is that these are the same women who have higher and more unrealistic expectations of themselves than anyone else on the planet! They want to be perfect in every way---straight A’s, super-athletic, super-beautiful, super-skinny, super-popular, super-involved in extra-curricular activities---in short, perfect.
So how do we resolve this irony, how do we go about narrowing the gap between a woman’s incredibly low self-esteem and her unrealistically high expectations? How do we RAISE self-esteem and at the same time, LOWER expectations, and is it even possible? Well, not only is it POSSIBLE, I must say it is ESSENTIAL, and one of the core issues to be addressed in treatment. I personally think that ONLY when the patient truly embraces and accepts herself for who she really is, not for what she weighs or what she looks like, is treatment really successful and a full and lasting recovery possible. And only when she challenges her perfectionistic expectations and realizes that she is human and fallible and endowed with unique strengths, weaknesses, and potential, will she truly flourish and blossom into a happy and contented human being.
I want to say just a few more words about treatment. Eating disorders are difficult and challenging to treat and they require a multi-pronged approach by a team of knowledgeable and dedicated professionals. At Miami Counseling and Resource Center, I work closely with Amy Jaffe, our excellent nutritionist who advocates an intuitive, non-diet approach to eating, as well as our two competent and highly-trained staff psychiatrists. Medication is often considered as a viable adjunct to psychotherapy and nutritional counseling, particularly when there is a high level of co-morbid depression or obsessive thinking that might be preventing the psychotherapy from being more effective. Finally, I work with several physicians in the community who specialize in eating disorders, I have no problem recommending a higher level of care when appropriate, and I welcome working with family members when I believe their presence in sessions will enhance the patient’s treatment.
"The names in case studies and testimonials have been changed in order to protect patient confidentiality."
See what some of my colleagues have learned about eating disorders: