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Restrictive Eating Disorder: Symptom Profile and Long-Term Outlook
Abnormal Psychology · Chapter 16: Eating Disorders: Psychological and Physical DimensionsSection 16.1 · lesson 58 of 9713 min · free with a free account
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Next lesson: Purging and Bingeing Cycles and Recurrent Overeating Disorder: Signs, Characteristics, and Recovery →← Feeling Detached from Oneself, Symptoms and Therapeutic InterventionsNext lesson: Purging and Bingeing Cycles and Recurrent Overeating Disorder: Signs, Characteristics, and Recovery →
In this lesson
A psychological condition with serious physical consequences - and a treatable one.
- Describe anorexia nervosa and the psychological feature at its center
- Explain the psychological and physical dimensions, and how it sustains itself
- Describe course, outcome, and treatment approaches
- Recognize the barriers that delay help-seeking
Transcript
Everything said in the video, section by section (1,760 words). Read along, or search it.
Eating Disorders: Psychological and Physical Dimensions
Restrictive Eating Disorder: Profile and Outlook
This chapter covers eating disorders, and this first section focuses on the restrictive eating disorder, anorexia nervosa. We describe it clinically, and identify the psychological feature at its center. We look at how it sustains itself once established, and at why it is so often missed. And we finish with course, treatment, and how to support someone you are worried about.
Before You Begin
Treatable - and Help Works
First, some important framing. This material describes these conditions clinically, so they can be recognized and understood. It is not a basis for self-diagnosis, or for diagnosing anyone else. Some viewers may find this subject personally affecting. If you are worried about your own eating, or about someone else's, please speak with a qualified professional. These conditions are treatable. Help is available, and it works. You will notice that no weights, numbers, or specific behaviors are described anywhere in this section. That is deliberate. Detail of that kind has no educational value here, and real potential for harm.
The Family
Psychological Conditions, Not Choices
The feeding and eating disorders are a group of conditions, in which a person's relationship with eating becomes seriously disturbed. It becomes disturbed enough to damage their health, their wellbeing, or their ability to live an ordinary life. They are grouped because they share that territory, not because they share one cause. Anorexia nervosa involves restriction, fear of weight gain, and self-evaluation dominated by weight and shape. It is covered here. Bulimia nervosa, binge eating disorder, and avoidant restrictive food intake disorder are covered in the next section. Two points need fixing from the start, because popular accounts almost always get them wrong. These are psychological conditions with serious physical consequences. They are not lifestyle choices, phases, or matters of willpower. And they are treatable. Earlier treatment does better, and full recovery is a common outcome, not a rare one.
Anorexia Nervosa
3 Components Together
Anorexia nervosa involves three components, and all three must be present together. A physical component. Restriction of intake relative to what the body requires, to the point of a significantly low body state. A fear or behavioral component. An intense fear of weight gain, or persistent behavior that interferes with it. And a psychological component. Weight or shape experienced in a distorted way, that dominates how the person judges themselves. Someone can be physically unwell without the psychological component, and not have this condition. The combination is what defines it. The classification also includes a severity specifier. But severity as classified is not the same as severity as experienced. A person whose presentation is classified as less severe may be in as much distress, and as much danger, as anyone else.
The Central Feature
Overvaluation of Weight and Shape
The feature at the center of this condition is the overvaluation of weight and shape. Most people judge their own worth across many domains at once. Relationships, work or study, interests, values, the kind of person they believe themselves to be. In this condition, that range collapses. One domain comes to carry the weight that several used to carry. That matters for understanding. Once self-worth depends on one domain, behavior that looks inexplicable becomes intelligible, as protecting the only source of self-esteem left. And it matters clinically. Treatment that addresses only the physical consequences, and leaves the overvaluation untouched, tends not to hold. That is why clinicians describe the eating itself as the surface of the condition, not its core. A related feature is a disturbed experience of the body. The person's perception of their own shape may not match what others see. That is not vanity, and not deception. It is a disturbance in how information about the self is processed, and arguing with it directly rarely helps.
Egosyntonicity
Why It Often Isn't Experienced as a Problem
This condition has a characteristic that sets it apart from most others in this course. It is often egosyntonic. That means it is experienced as consistent with the person's values and goals, rather than as an unwanted intrusion. A person with panic wants the panic to stop. Here, the condition is often experienced as an achievement, a source of order, or a form of protection. So removing it feels like a loss. It is important to be precise. This does not mean the condition brings any benefit. It does not. It describes how it feels from the inside. And it does not mean the person is content. Many are acutely distressed, and the same person may want help and resist it in the same conversation. What it does mean is that motivation cannot be assumed, and that ambivalence is the norm, not a sign of a difficult patient. A person may also not recognize how serious their situation has become. That is better understood as a feature of the condition than as denial. So self-report alone is an unreliable guide to risk. A person who says they are fine should be listened to respectfully, and assessed anyway.
Undernutrition and the Mind
Effects in Anyone - Which Lift With Nutrition
One finding has shaped clinical practice more than almost any other in this area. Sustained undernutrition produces psychological changes in its own right, in anyone, whether or not an eating disorder is present. Preoccupation with food, low mood, irritability, impaired concentration, social withdrawal, and increased rigidity. Two practical consequences follow. Some of what looks like personality, or psychological pathology, is the undernutrition, and it lifts as nutrition is restored. Judgments made in that state are unreliable. And psychological work is genuinely harder in that state, because the flexibility it depends on is reduced. That is why nutritional restoration comes first in treatment. Not instead of psychological work, but as what makes it possible. Other features are common too. Cognitive rigidity, perfectionism, and difficulty tolerating uncertainty, which often predate the condition.
Medical Seriousness
Among the Highest Mortality in Psychology
The medical seriousness of this condition must be stated plainly. Sustained undernutrition affects every organ system. No mechanisms, thresholds, or warning signs are set out here, deliberately. That detail is of no educational value here, and of real potential harm. What must be said is the conclusion. Anorexia nervosa carries one of the highest mortality rates of any psychological condition. Deaths arise from physical consequences, and from associated risk. Elevated risk of self-harm is a recognized clinical fact that requires professional care. That is why medical assessment and ongoing monitoring are not optional parts of treatment. They are the foundation. And no psychological service manages this condition without medical involvement.
Who Is Affected
The Narrow Picture Causes Harm
The popular picture of who develops this condition is narrow, and that narrowness causes harm. These conditions occur in men and boys, in older adults, across ethnic groups, and across income levels. They occur in people whose lives look outwardly successful, and in people who have never mentioned weight to anyone. The narrow picture produces a patterned failure of recognition. People who do not match the expected image are identified later, referred less often, and offered specialist care less often. That disparity is produced by the assumptions of services, not by anything about the people affected. People may also present with low mood, fatigue, or a physical complaint, rather than the eating difficulty itself. The correction is not a screening tool. It is a habit. Asking about eating, and about the place of weight and shape in self-evaluation, routinely, of everyone.
Contributing Factors
A Combination, Not a Single Cause
No single cause has been established. The condition arises from a combination of contributions that differ between people. There is a substantial genetic contribution. That is a statistic about populations, never a statement about an individual. And temperamental traits like anxiety and perfectionism often appear before onset. Perfectionism and cognitive rigidity are often present before onset, and often persist after recovery. Sociocultural appearance pressure is real and documented. But it cannot be the whole account, since most people exposed to it do not develop the condition. Adverse experiences and life transitions, like moving away from home, often precede onset. But a precipitant is not a cause. And one sentence should be taken at face value. Families do not cause these conditions. Older clinical writing that blamed families was wrong, and that blame did lasting damage. Families matter in treatment for a different reason. They are among the most powerful resources available for recovery.
Figure 16.1.3
How the Condition Sustains Itself
Whatever started the condition, something different keeps it going. And it is the maintaining process that treatment targets. Sustained undernutrition narrows attention, and makes thinking more rigid. That makes the overvaluation harder to question. Contact with others falls away, removing the outside feedback, and other sources of worth, that might loosen its grip. And avoidance is followed by short-term relief and a sense of control, which strengthens it. Each element makes the next more likely, so the condition no longer needs whatever began it. Treatment enters at three points, in a deliberate order. First, nutritional restoration, under medical monitoring. Second, psychological work, once nutrition allows it. And third, re-engaging relationships and ordinary activity. Nutritional restoration comes first because it is what makes the others possible.
Course and Treatment
Recovery Is Common
The course of this condition is variable. Some people have a single episode and recover fully. Some have a course that fluctuates over years. A minority develop a long-standing difficulty. But the older assumption that this is the typical outcome is wrong. Treatment that begins earlier does better. And full recovery is common. Setbacks happen, and a setback is not a failure of treatment, or of the person. Treatment is specialist-led and multidisciplinary, described here only at the level of approach. Medical stabilization and monitoring come first, and continue throughout. Nutritional restoration is the precondition for psychological work, and is delivered by a clinical team. For adolescents, family-based approaches have the strongest evidence. They mobilize the family as a resource, explicitly without blame. For adults, several specialist therapies exist. They converge on the same target, the overvaluation of weight and shape. Medication has a limited role, usually for a co-occurring condition, and decisions rest with a prescriber.
Supporting Someone
Lead With the Person, Not the Eating
If you are worried about someone, the instinct is to comment on what you can see. Usually that backfires. Comments on appearance, of any kind and in any direction, feed the very domain the condition has made too important. Name a change in mood, energy, or withdrawal instead. Confronting someone about eating tends to produce concealment, not change. Express concern about the person, and ask how they are. Ultimatums turn the relationship into a contest the condition can win. Stay in contact, and remain available over time. And waiting for them to ask for help often fails, because the condition makes asking less likely. Help them reach a professional assessment, and offer to go with them. Many things delay help. Stigma, ambivalence, cost, and waiting times. And a common, mistaken belief, that one is not unwell enough to deserve help. Everyone who is struggling deserves assessment and care.
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