Eating Disorder Behaviors Are Adaptive Functions

A struggling will, an insecure feeling, and despair may manifest themselves in problems with the care and feeding of the body but are fundamentally a problem with the care and feeding of the soul. In her aptly titled book The Obsession: Reflections on the Tyranny of Slenderness, Kim Chernin has written, "The body holds meaning . . . when we probe beneath the surface of our obsession with weight, we will find that a woman obsessed with her body is also obsessed with the limitations of her emotional life. Through her concern with her body she is expressing a serious concern about the state of her soul."

What are the emotional limitations commonly seen in individuals with eating disorders? What is the state of their souls?

Common States of Being for the Eating Disordered Individual

• Low self-esteem
• Diminished self-worth
• Belief in the thinness myth
• Need for distraction
• Dichotomous (black or white) thinking
• Feelings of emptiness
• Quest for perfection
• Desire to be special/unique
• Need to be in control
• Need for power
• Desire for respect and admiration
• Difficulty expressing feelings
• Need for escape or a safe place to go
• Lack of coping skills
• Lack of trust in self and others
• Terrified of not measuring up

The scope of this book does not allow a detailed analysis of every possible reason or theory that could explain the development of an eating disorder. What the reader will find is this author's overview explanation, which involves the discussion of common underlying issues observed in patients. Additional information on the development and treatment of eating disorders from varying theoretical viewpoints can be found in chapter 9 on treatment philosophies.

Eating disorder symptoms serve some kind of purpose that goes beyond weight loss, food as comfort, or an addiction, and beyond a need to be special or in control. Eating disorder symptoms can be seen as behavioral manifestations of a disordered self, and through understanding and working with this disordered self the purpose or meaning of the behavioral symptoms can be discovered.

In trying to understand the meaning of someone's behavior, it is helpful to think of the behavior as serving a function or "doing a job." Once the function is discovered, it becomes easier to understand why it is so difficult to give it up and, furthermore, how to replace it. When exploring deep within the psyche of eating disordered individuals, one can find explanations for a whole series of adaptive functions serving as substitutes for the missing functions that should have been, but weren't, supplied in childhood.

Paradoxically, then, an eating disorder, for all of the problems it creates, is an effort to cope, communicate, defend against, and even solve other problems. For some, starving may be in part an attempt to establish a sense of power, worth, strength and containment, and specialness because of inadequate mirroring responses, such as praise, from caregivers.

Binge eating may be used to express comfort or to numb pain, due to a developmental deficit in the ability to self-soothe. Purging may serve as an acceptable physiological and psychological release of anger or anxiety if the expression of one's feelings in childhood was ignored or led to ridicule or abuse. Eating disorder symptoms are paradoxical, in that they can be used as an expression of and defense against feelings and needs. The symptoms of eating disorders can be seen as a repression or punishment of the self, or as a way of asserting the self, which has found no other way out.

Here are some examples of how these behaviors fill emotional needs:

• An expression of and defense against early childhood needs and feelings. It's too scary to need anything, I try not to even need food.
• Self-destructive and self-affirming attitudes. I will be the thinnest girl at my school, even if it kills me.
• An assertion of self and a punishment of self. I insist on eating whatever and whenever I want, even though being fat is making me miserable . . . I deserve it.
• Used as cohesive functions, psychologically holding the person together. If I don't purge I'm anxious and distracted. After I purge I can calm down and get things done.

The development of an eating disorder can begin early in life when childhood needs and mental states are not properly responded to by caregivers and thus get disowned, repressed, and shunted off into a separate part of a person's psyche. The child develops deficits in his or her capacities for self-cohesion and self-esteem regulation. At some point in time, the individual learns to create a system whereby disordered eating patterns, rather than people, are used to meet needs because previous attempts with caregivers have brought about disappointment, frustration, or even abuse.

For example, caregivers who do not properly comfort and soothe their babies, allowing them to eventually learn how to comfort themselves, create lacks in their children's ability to self-soothe. These children grow up needing to seek abnormal amounts of external comfort or relief. Caregivers who do not accurately listen, acknowledge, validate, and respond make it difficult for a child to learn how to validate himself. Both of these examples could result in:

• a distorted self-image (I am selfish, bad, stupid)
• no self-image (I don't deserve to be heard or seen, I don't exist)

Disruptions or deficits in self-image and self-development make it increasingly difficult for people to function as they grow older. Adaptive measures are developed, the purpose of which is to make the individual feel whole, safe, and secure. With certain individuals, food, weight loss, and eating rituals are substituted for responsiveness from caregivers. Perhaps in other eras different means were sought as substitutes, but today turning to food or dieting for validation and acknowledgment is understandable in the context of the sociocultural factors described in the previous chapter.

Personality development is disrupted in persons with eating disorders, as eating rituals are substituted for responsiveness and the usual developmental process is arrested. The early needs remain sequestered and cannot be integrated into the adult personality, thus remaining unavailable to awareness and operating on an unconscious level.

Some theorists, including this author, view this process as if, to a greater or lesser degree in each individual, a separate adaptive self is developed. The adaptive self operates from these old sequestered feelings and needs. The eating disorder symptoms are the behavioral component of this separate, split-off self, or what I have come to call the "eating disorder self." This split-off, eating disorder self has a special set of needs, behaviors, feelings, and perceptions all dissociated from the individual's total self-experience. The eating disorder self functions to express, mitigate, or in some way meet underlying unmet needs and make up for the developmental deficits.

The problem is that the eating disorder behaviors are only a temporary Band-Aid and the person needs to keep going back for more; that is, she needs to continue the behaviors to meet the need. Dependency on these "external agents" is developed to fill the unmet needs; thus, an addictive cycle is set up, not an addiction to food but an addiction to whatever function the eating disorder behavior is serving. There is no self-growth, and the underlying deficit in the self remains. To get beyond this, the adaptive function of an individual's eating and weight-related behaviors must be discovered and replaced with healthier alternatives. The following is a list of adaptive functions that eating disorder behaviors commonly serve.

Adaptive Functions of Eating Disorders

• Comfort, soothing, nurturance
• Numbing, sedation, distraction
• Attention, cry for help
• Discharge tension, anger, rebellion
• Predictability, structure, identity
• Self-punishment or punishment of "the body"
• Cleanse or purify self
• Create small or large body for protection/safety
• Avoidance of intimacy
• Symptoms prove "I am bad" instead of blaming others (example, abusers)

Eating disorder treatment involves helping individuals get in touch with their unconscious, unresolved needs and providing or helping to provide in the present what the individual was missing in the past. One cannot do this without dealing directly with the eating disorder behaviors themselves, as they are the manifestation of and the windows into the unconscious unmet needs. For example, when a bulimic patient reveals that she binged and purged after a visit with her mother, it would be a mistake for the therapist, in discussing this incident, to focus solely on the relationship between mother and daughter.

The therapist needs to explore the meaning of the bingeing and purging. How did the patient feel before the binge? How did she feel before the purge? How did she feel during and after each? When did she know she was going to binge? When did she know she was going to purge? What might have happened if she didn't binge? What might have happened if she didn't purge? Probing these feelings will provide rich information concerning the function the behaviors served.

When working with an anorexic who has been sexually abused, the therapist should explore in detail the food-restricting behaviors to uncover what the rejection of food means to the patient or what the acceptance of food would mean. How much is too much food? When does a food become fattening? How does it feel when you take food into your body? How does it feel to reject it? What would happen if you were forced to eat? Is there a part of you that would like to be able to eat and another part that won't allow it? What do they say to each other?

Exploring how acceptance or rejection of food may be symbolic of controlling what goes in and out of the body is an important component of doing the necessary therapeutic work. Since sexual abuse is frequently encountered when dealing with eating disordered individuals, the whole area of sexual abuse and eating disorders warrants further discussion.

SEXUAL ABUSE

A controversy has long been brewing about the relationship between sexual abuse and eating disorders. Various researchers have presented evidence supporting or refuting the idea that sexual abuse is prevalent in those with eating disorders and can be considered a causal factor. Looking at the current information, one wonders if early male researchers overlooked, misinterpreted, or downplayed the figures.

In David Garner and Paul Garfinkel's major work on treating eating disorders published in 1985, there were no references to abuse of any nature. H. G. Pope, Jr. and J. I. Hudson (1992) concluded that evidence did not support the hypothesis that childhood sexual abuse is a risk factor for bulimia nervosa. However, on close examination, Susan Wooley (1994) called their data into question, referring to as highly selective. The problem with Pope and Hudson, and many others who early on refuted the relationship between sexual abuse and eating disorders, is that their conclusions were based on a cause-and-effect link.

Looking only for a simple cause-and-effect relationship is like searching with blinders on. Many factors and variables interacting with one another play a role. For an individual who was sexually abused as a child, the nature and severity of the abuse, the functioning of the child prior to the abuse, and how the abuse was responded to will all factor in as to whether this individual will develop an eating disorder or other means of coping. Although other influences need to be present, it is absurd to say that just because the sexual abuse is not the only factor, it is not a factor at all.

As female clinicians and researchers increased on the scene, serious questions began to be raised regarding the gender-related nature of eating disorders and what possible relationship this might have abuse and violence against women in general. As the studies increased in number and the investigators were increasingly female, the evidence grew to support the association between eating problems and early sexual trauma or abuse.

As reported in the book Sexual Abuse and Eating Disorders, edited by Mark Schwartz and Lee Cohen (1996), systematic inquiry into the occurrence of sexual trauma in eating disorder patients has resulted in alarming prevalence figures:

Oppenheimer et al. (1985) reported sexual abuse during childhood and/or adolescence in 70 percent of 78 eating disorder patients. Kearney-Cooke (1988) found 58 percent a history of sexual trauma of 75 bulimic patients. Root and Fallon (1988) reported that in a group of 172 eating disorder patients, 65 percent had been physically abused, 23 percent raped, 28 percent sexually abused in childhood, and 23 percent maltreated in actual relationships. Hall et al. (1989) found 40 percent sexually abused women in a group of 158 eating disorder patients.

Wonderlich, Brewerton, and their colleagues (1997) did a comprehensive study (referred to in chapter 1) that showed childhood sexual abuse was a risk factor for bulimia nervosa. I encourage interested readers to look up this study for details.

Although researchers have used varying definitions of sexual abuse and methodologies in their studies, the above figures show that sexual trauma or abuse in childhood is a risk factor for developing eating disorders. Furthermore, clinicians across the country have experienced countless women who describe and interpret their eating disorder as connected to early sexual abuse. (Visit HealthyPlace.com Abuse Community Center for extensive information on different types of abuse)

Anorexics have described starving and weight loss as a way of trying to avoid sexuality and thus evade or escape sexual drive or feelings or potential perpetrators. Bulimics have described their symptoms as a way of purging the perpetrator, raging at the violator or oneself, and getting rid of the filth or dirtiness inside of them. Binge eaters have suggested that overeating numbs their feelings, distracts them from other bodily sensations, and results in weight gain that "armors" them and keeps them unattractive to potential sexual partners or perpetrators.

It is not important to know the exact prevalence of sexual trauma or abuse in the eating disorder population. When working with an eating disordered individual, it is important to inquire about and explore any abuse history and to discover its meaning and significance along with other factors contributing to the development of disordered eating or exercise behaviors.

With more women in the field of eating disorder research and treatment, the understanding of the origins of eating disorders is shifting. A feminist perspective considers sexual abuse and trauma of women as a social rather than an individual factor that is responsible for our current epidemic of disordered eating of all kinds. The subject calls for continued inquiry and closer scrutiny.

Considering the cultural and psychological contributions to the development of an eating disorder, one question remains: Why don't all people from the same cultural environment, with similar backgrounds, psychological problems, and even abuse histories develop eating disorders? One further answer lies in genetic or biochemical individuality.

By Carolyn Costin, MA, M.Ed., MFCC WebMD Medical Reference from "The Eating Disorders Sourcebook"