Eating Disorders and Psychology

What Is an Eating Disorder?

It is defined as clinical conditions characterized by disturbances in eating behavior, persistent weight control behaviors, impairment in physical and psychosocial functioning due to these factors, and the fact that these symptoms and functional impairments are not secondary to a medical condition or another psychiatric disorder.

General Characteristics of Eating Disorders

It is not possible to explain the development of disorders in this group with a single factor. They are mostly disorders seen in women. They are the group of psychiatric illnesses in which medical complications are most frequent and severe. They are also the psychological disorders with the highest mortality rates. Personality traits seen in individuals with eating disorders include low self-esteem, a sense of powerlessness over the environment, being assertive yet unable to express emotions and needs, and difficulty expressing emotions (alexithymia). Family characteristics of those with eating disorders often include the inability to openly express and accept emotions and conflicts, the avoidance of discussing sexual issues, the rejection of individuality, perfectionism as the only accepted behavior, and rigid family rules. Eating disorders consume the individual with obsessive and negative thoughts and behaviors, and the person’s relationships with family members, loved ones, and life itself become impaired. They may avoid forming relationships because they think others will pressure them to eat. Symptoms related to eating disorders are a way for the person to avoid facing problems.

What Are the Subtypes of Eating Disorders?

1. Obesity

Obesity is defined as excessive body fat. Since accurately determining body fat percentage takes time and is costly, body weight is often used to identify obesity.

Obesity is one of the biggest health problems. In the United States, 54.9% of adults are overweight and 22.3% are obese. Studies have shown that obesity increases the risk of hypertension, type 2 diabetes mellitus, dyslipidemia, cardiovascular diseases, and certain types of cancer (colon, breast, gallbladder, and endometrial cancers). The main psychological factors contributing to obesity include:

• Close family relationships
• Social environment factors
• Eating in response to emotions such as stress, loneliness, helplessness, unhappiness, and anger (emotional eating), depression, anxiety, night eating syndrome, and binge eating disorder
• In addition to the biological development of obesity, childhood trauma is also a major factor. Conflicts in family dynamics or divorce processes may lead the individual to develop overeating as a mechanism for coping with sadness during preadolescence.

Etiology

Among the many factors involved in the etiology of obesity are excessive energy intake, insufficient energy expenditure, genetic predisposition, low fat oxidation, reduced sympathetic activity, stress, and low socioeconomic status. Approximately 25–30% of obese patients have depression or other psychological problems. Emotional tension is often associated with overeating. These individuals eat large amounts in short periods of time and lose control while doing so.

Treatment Methods

In the treatment of obesity:

• Diet regulation,
• Increasing physical activity,
• Psychotherapy,
• Pharmacotherapy,
• Surgical treatment,
• And the combined application of these are among the most effective methods.

2. Anorexia Nervosa

In AN, the patient refuses to eat. There is excessive weight loss and weakness. Due to distortion in body image, the person still perceives themselves as fat.

AN includes 2 types:

1- Restricting type: Patients refuse to eat or eat very little in order to control their weight.

2- Binge-eating/purging type (Bulimic type): In addition to restriction regarding food intake, there is an effort to control calories through self-induced vomiting, laxative use, and diuretic use.

Clinical Features

Weight loss is initially slow and then rapid. Vomiting, laxatives, diuretics, and exercise are seen. Self-confidence based on weight, the intensity of weight-loss discipline, inability to lose weight due to impaired self-control, obsessive preoccupation with food (such as feeding others), avoidance of eating with others, and hyperactivity are observed. It is the disorder least related to bariatric surgery, but there are claims that some patients may become anorexic after bariatric surgery because they cannot stop losing weight. This has not been conclusively proven by research.

Causes

Biological causes include family genetics, hormonal effects, and neurotransmitter cycles in the brain. Psychological causes include rejection of sexuality, the search for autonomy in the mother-child relationship, and dysfunctional family relationships (the family’s dependency needs). Social causes include social acceptance and cultural pressures (20th–21st century), which contribute to body obsession.

Treatment Methods

The treatment of this disease is generally carried out by specialist physicians in hospital and outpatient settings. The goal of treatment is to restore the person’s eating habits to their former healthy pattern and thereby eliminate the physical problems caused by disordered eating. In the psychological stage of treatment, the main goals are to help the person love their own body and correct false judgments about their body, weight, or eating habits. In this stage, cognitive behavioral therapy (CBT) methods are highly effective. Due to the various physical illnesses anorexia nervosa causes in the body, the patient may also need to use certain medications recommended by their doctor. In some cases, antidepressants may also be recommended.

3. Bulimia Nervosa

BN is characterized by episodes of excessive eating. The patient is constantly mentally preoccupied with body image and develops compensatory behaviors to offset overeating. Examples include voluntary/involuntary vomiting, abuse of diuretics and laxatives, and excessive physical activity. Bulimia means Bous (Ox) + Limos (Hunger). Binge eating attacks may occur twice a week for 3 months.

Bulimia Nervosa DSM-IV Diagnostic Criteria

Binge eating episodes, inappropriate compensatory behaviors (vomiting, laxatives, diuretics, etc.), and excessive preoccupation with weight and body are the core symptoms. Recurrent binge eating episodes include eating, within a certain period of time, an amount of food definitely larger than what most people would eat under similar circumstances in a similar time period.

Types of Bulimia Nervosa

Purging type: During a BN episode, the person regularly engages in self-induced vomiting or misuse of laxatives, diuretics, or enemas.

Non-purging type: During a BN episode, the person uses other inappropriate compensatory behaviors such as excessive exercise, but does not regularly engage in self-induced vomiting or misuse of laxatives, diuretics, or enemas.

Causes

The exact cause of bulimia nervosa is currently unknown; however, many factors are thought to contribute to the development of this eating disorder, including genetic, environmental, psychological, and cultural influences. Obesity and bulimia nervosa, although two different eating disorders, can actually be seen as two different symptomatic faces of the same psychological issue. In some patients who have undergone bariatric surgery, a bulimia nervosa pattern may be observed. If this disorder is not treated, the person may regain weight.

Treatment Methods

The treatment of bulimia nervosa is considered long and difficult. Patients may reject treatment because they often think that the professionals treating them are trying to make them gain weight. However, the primary aim of treatment is not to bring the patient to their ideal weight, but to restore the body to a sufficiently healthy state and help the person develop a new and appropriate eating habit. Over the last 20 years, effective treatment has been carried out with Cognitive Behavioral Therapy in addition to medication. Professional intervention alone is not enough for recovery; family and friends also play an important role in the healing process. Therefore, family therapies are also effective. In addition to SSRI (selective serotonin reuptake inhibitor) type medication, interventions such as individual and group therapy, body therapy, and social worker support may be applied.

During the nutritional counseling phase, patients should work with a dietitian specializing in eating disorders. This can help break the cycle of overeating and purging. The patient should be helped to gain healthy eating habits and appropriate daily calorie intake.

4. Orthorexia

Orthorexia is the term used for an obsession with healthy eating. “Ortho” in Greek means “correct” and “normal.” In other words, even eating correctly can turn into an obsession, and this can create psychological problems in individuals. In recent publications of the American Dietetic Association, it is stated that this problem may become widespread within the next 10 years.

Are You Orthorexic?

1. Do you plan tomorrow’s meals today?
2. Is the healthiness of food more important to you than how delicious it is?
3. Have you ever noticed your health worsening as you eat more sterile foods?
4. Does the diet you followed yesterday seem insufficient to you today?
5. Do you ever look down on people who do not eat healthily?

Those who answer “Yes” to these questions may be in the orthorexic risk group. Orthorexia may emerge in people who turn diet culture into an obsession after bariatric surgery. For this reason, internalizing diet as a “healthy eating” pattern and adapting it into life in this way, and having occasional reward days under the guidance of a dietitian after reaching the ideal weight, can help keep you away from becoming orthorexic.

5. Eating Disorders Not Otherwise Specified

a) Binge Eating Disorder

People with Binge Eating Disorder lose control while eating. Unlike Bulimia Nervosa, they do not compensate for eating behavior (such as vomiting, exercising, or starving). At the same time, the shame, guilt, and distress caused by overeating lead them back into the same eating cycle. As a result, these patients are usually somewhat above normal weight or significantly overweight. Obese individuals with Binge Eating Disorder especially carry a risk for cardiovascular disease and high blood pressure. Most binge episodes occur secretly. Therefore, binge eating can be associated with feelings of guilt and shame. It has been found that binge eaters have parents with higher rates of depression, greater predisposition to obesity, greater exposure to negative comments about their bodies, and a negative perfectionistic structure.

Diagnostic criteria

1. Having binge eating episodes, along with recurrence of the following during these episodes:

1. • Eating, within a short period of time (for example, within 2 hours), a much larger amount of food than most people would eat under similar circumstances and in a similar time period,
   • A sense of loss of control during the episode (for example, being unable to stop eating or control how much is eaten),
2. Binge eating episodes must include at least 3 of the following:
   • Eating much more rapidly than normal,
   • Eating until feeling uncomfortably full,
   • Eating large amounts of food when not physically hungry,
   • Eating alone because of embarrassment about how much one is eating,
   • Feeling depressed or guilty after eating,
3. Binge eating episodes occurring at least once a week for 3 months,
4. Are there no compensatory behaviors (such as vomiting, laxative use, or enemas) after a binge eating episode?

Treatment methods

Binge Eating Disorder is the most common eating disorder seen in obese individuals. These patients also have a high probability of depression, alcohol dependence, and impulse control disorders. Psychotherapy plays a major role in the treatment of this disorder. The most effective therapy method is Cognitive Behavioral Therapy. If medication is used, accompanying psychological disorders (such as depression, anxiety, and impulse control disorders) must also be treated. This disorder, which is quite common in bariatric surgery patients, should be treated by a Psychologist in order to prevent recurrence during the postoperative diet process.

b) Emotional Eating

Emotional eating can be defined as trying to cope with many negative emotions such as anger, sadness, and shame by eating. Because of the temporary relief it provides, the individual may feel that they are escaping from the emotions they are trying to avoid. However, eating when hunger is not felt leads to stomach enlargement and an increase in the calories consumed during daily meals. This creates the risk of serious weight problems and loss of self-esteem.

Causes

In emotional eating behavior, the way individuals interpret daily events and whether basic needs such as being loved and feeling valued were met or unmet in the past play a major role. According to Erickson, when needs such as being loved, valued, and approved are met in childhood, the human mind stores these experiences as resources to be used later and chooses functional solutions in the face of negative life events. People deprived of such emotional nourishment, however, may choose eating as a way of coping with negative experiences. This can also be interpreted as an effort to fill the emotional void a person feels. Other research on this subject shows that emotional eating may become a habit through learning. Repeating eating habits most often learned in the family environment is one example of this.

Treatment methods

In psychotherapy aimed directly at emotional eating, therapeutic approaches designed to increase awareness of our body and emotions are used. For example, in a therapy based on Gestalt principles, there are many exercises aimed at distinguishing the taste and smell of what we eat, how hungry our stomach actually feels, and the emotions accompanying us at that moment. In addition, Mindfulness-based therapy techniques also play a major role in eating awareness. Cognitive Behavioral Therapies also help us understand the relationship between our thoughts, emotions, and behaviors. After bariatric surgery, a therapist working with CBT can provide counseling to help the patient recognize their emotions, express them appropriately, and find constructive solutions to their problems, thereby supporting a healthy diet process and lasting weight loss.

c) Night Eating Syndrome

People with night eating syndrome wake up feeling full in the morning, delay their first meal for several hours after waking, eat excessively in the evening, and experience sleep interruptions accompanied by food intake during the night. Night eating syndrome is characterized by consuming at least 50% of daily calories through snacks after dinner, waking up at least once during the night on three nights a week, and eating high-calorie snacks afterward, with this pattern continuing for at least three months. In people with this condition, feelings such as guilt, distress, tension, pessimism, and irritability may occur after eating.

Causes

• Sleep disorder

• Psychological problems (depression or high levels of anxiety)
• Hormonal causes (the person feels hungry due to imbalances in blood sugar)

In addition to night eating syndrome, there is also the very common “binge eating disorder” seen frequently in recent years.

In bariatric surgery patients, this syndrome is also quite common. Even if hormonal problems are treated with endocrinology specialists and sleep irregularity is resolved with sleep hygiene rules or sleep medications, support from a Psychologist and a Dietitian is essential.

Treatment Methods

• During night eating syndrome, the primary goal should be to balance the daytime eating plan.
• Efforts should be made to avoid the stress factors that trigger night eating. Then, foods that lead to overeating should be removed from the table and, if possible, not kept at home.
• During night eating syndrome, foods high in sugar and fat are generally preferred. These foods are low in volume but high in calories. Therefore, dietitian supervision is very important in the treatment stage.
• Exercise regulates a person’s entire biorhythm. It helps balance appetite metabolism, preventing problems such as loss of appetite or a sudden increase in appetite, and it also reduces emotional eating attacks. Because exercise also increases the release of the happiness hormone (serotonin), it helps the person feel more positive and may help protect against such syndromes.
• If there is a psychologically based (depression, anxiety) night eating syndrome, psychological counseling must also be received.