When an Eating Disorder Isn't Just About Body Image
For many, perfectionism and stress are the primary drivers of eating disorders.
In some cases, a desire for thinness is not the primary motivation for an eating disorder.
For many, an eating disorder is a stress management tool arising in response to chronic stress.
A tendency toward perfectionism is also a risk factor for eating disorders.
More than 20 percent of people with eating disorders also battle substance use disorders.
Semantically, eating disorders are highly associated with body image. Clinically, this association makes complete sense as approximately one-third of people with eating disorders also experience body dysmorphic disorder,1 and many more struggle with negative body image. However, for some people body image concerns are not the primary trigger of an eating disorder, making these challenges somewhat less relevant when we consider why these individuals develop eating disorders.
Studies have found that, in general, individuals with certain genetic variations and experiences of abuse and trauma are more likely to develop eating disorders at some point in their lives.2,3 Likewise, people with higher “baseline” levels of anxiety are more likely to develop disordered eating later in life.4,5
It’s also well-established, even at the cellular level, that chronic stress alters our brain and body in a way that increases our chances of developing an eating disorder.6 This appears to be particularly true for people who develop bulimia and binge eating disorder. In other words, when we try to understand the reason behind someone's eating disorder, we must consider far more than whether they are satisfied with their body or not.
Purging to Be the Best
Earlier this year, I had the opportunity to interview Jessica Grenzy, a 41-year-old female in recovery from bulimia nervosa. In 2018, she went into cardiac arrest. She survived to tell her story.
Jessica grew up in a competitive household. At age 12, she began swimming and quickly rose to a competitive level. In parallel, she excelled in school and earned a spot on the honor roll. She was a child to be proud of—but it was not necessarily priding that Jessica experienced at home.
Her father, competitive by nature, paced Jessica and her sister to excel in everything they did, applying relentless pressure to perform at the highest caliber. This home environment was a tremendous source of stress, leading Jessica to constantly wonder how she could improve both physically and mentally. Her father was shaping her into becoming a perfectionist, a mindset that is well-known to increase people’s risk of developing an eating disorder.7
Despite growing up surrounded by diet culture and the thinness ideal, Jessica did not experience disordered eating until she saw a particular movie at age 16. In the movie, two volleyball players used purging in an attempt to stay fit.
Jessica was hooked. This was her ticket to not just be but also look the best.
Her primary goal was to meet the high expectations instilled in her. At the time, she would have even insisted there was nothing wrong with her body. Her actions were driven primarily by her desire to excel, and perhaps please her father, rather than by the desire to be skinny.
Never in my wildest dreams did I think that it would go anywhere or continue to this day. But I remember that [this movie] is what triggered my first [purging] behavior.
From Eating Disorder to Substance Use Disorder and Back Again
Jessica’s eating disorder was not a reflection of disliking her body; it was a means to achieve perfection. At 18, her swimming career ended, and with it, so did her eating disorder.
This sort of “spontaneous” recovery is not unusual; I experienced it myself as a teenager. But it's typically not a “true” recovery, just a shift in behaviors.
In Jessica's case, as she lessened her eating disorder behaviors, she started leaning into alcohol. Feeling like she had missed out on social life during her teens, she was determined to make college about having fun, which for her meant drinking. But beyond fun, alcohol became a tool to manage stress. It is estimated that 22 percent of people with eating disorders also experience a substance use disorder.8
Jessica slowly but steadily developed into what many would refer to as a “functional alcoholic.” She managed to maintain good grades, later excelled at her job, and kept up social relationships, but she was dependent on alcohol. As is common with heavy and regular alcohol intake, Jessica started gaining weight and suddenly the dormant eating disorder behaviors returned in full force.
This time, body size and shape were at the center of her restriction and purging behaviors. Drinking, restricting, and purging became daily activities, and working in the food and beverage industry only perpetuated her behaviors. It is estimated that 17 percent of workers in this industry experience a substance use disorder and 63 percent report signs of disordered eating.
When Cardiac Arrest Keeps You Alive
In 2017, Jessica met her now-husband; inspired by his alcohol abstinence, she quit drinking too. Recovering from her alcohol use disorder was relatively easy; living with a sober partner and attending regular Alcoholics Anonymous meetings provided her with a supportive community.
However, what was not easy was the sudden and unexpected exaggeration of her eating disorder behaviors. Left with only one strategy to manage stress, Jessica purged and restricted more than usual. Up until this point, no one knew about her eating disorder.
On December 29, 2018, two months after quitting alcohol, Jessica went into cardiac arrest.
The cardiac arrest was probably the best thing that ever happened to me.
Regular vomiting can lead to severe electrolyte imbalances and, ultimately, heart failure. Jessica says that her heart attack was her real wake-up
Regular vomiting can lead to severe electrolyte imbalances and, ultimately, heart failure.9,10 When assessing the physiological impacts of an eating disorder, it’s crucial to always include blood work. Failing to do so can lead to unexpected and serious consequences, such as organ failures. This complication is one of the primary reasons eating disorders remain among the top two deadliest psychiatric disorders.11
The cardiac arrest was a turning point for Jessica; for the first time, she sought treatment. For over 15 years, Jessica had been one of the approximately 27 percent of people with eating disorders who go untreated. She was ready to change that, but a lack of access to specialized providers in her area delayed her treatment by almost one year. This issue is well-documented and disproportionately affects people of color and those with public insurance.12
For Jessica, recovery is more than just stopping purging and restricting; it means redefining what it means to be a good person, a good wife, a good colleague, and a good mother. Perfectionism, along with the stress of it, was instilled in her at a young age, but managing it required substantial coping mechanics. Treatment had taken away her usual tools: alcohol and purging. Now she’s working on finding new, healthier ways to cope.
I was a new mom, a new wife. I had to be the perfect mother.
Now I have just learned that there is no such thing as that.
Pernille Yilmam, Ph.D., - Website -
References
1 - Ruffolo, J. S., Phillips, K. A., Menard, W., Fay, C., & Weisberg, R. B. (2006). Comorbidity of body dysmorphic disorder and eating disorders: severity of psychopathology and body image disturbance. The International journal of eating disorders, 39(1), 11–19.
2 - Barakat, S., McLean, S. A., Bryant, E., Le, A., Marks, P., National Eating Disorder Research Consortium, Touyz, S., & Maguire, S. (2023). Risk factors for eating disorders: findings from a rapid review. Journal of eating disorders, 11(1), 8.
3 - Batista, M., Žigić Antić, L., Žaja, O., Jakovina, T., & Begovac, I. (2018). PREDICTORS OF EATING DISORDER RISK IN ANOREXIA NERVOSA ADOLESCENTS. Acta clinica Croatica, 57(3), 399–410.
4 - Frank, G. K. W., Shott, M. E., Pryor, T., Swindle, S., Nguyen, T., & Stoddard, J. (2023). Trait anxiety is associated with amygdala expectation and caloric taste receipt response across eating disorders. Neuropsychopharmacology : official publication of the American College of Neuropsychopharmacology, 48(2), 380–390.
5 - Schaumberg, K., Zerwas, S., Goodman, E., Yilmaz, Z., Bulik, C. M., & Micali, N. (2019). Anxiety disorder symptoms at age 10 predict eating disorder symptoms and diagnoses in adolescence. Journal of child psychology and psychiatry, and allied disciplines, 60(6), 686–696.
6 - Hardaway, J. A., Crowley, N. A., Bulik, C. M., & Kash, T. L. (2015). Integrated circuits and molecular components for stress and feeding: implications for eating disorders. Genes, brain, and behavior, 14(1), 85–97.
7 - Bardone-Cone, A. M., Wonderlich, S. A., Frost, R. O., Bulik, C. M., Mitchell, J. E., Uppala, S., & Simonich, H. (2007). Perfectionism and eating disorders: current status and future directions. Clinical psychology review, 27(3), 384–405.
8 - Bahji, A., Mazhar, M. N., Hudson, C. C., Nadkarni, P., MacNeil, B. A., & Hawken, E. (2019). Prevalence of substance use disorder comorbidity among individuals with eating disorders: A systematic review and meta-analysis. Psychiatry research, 273, 58–66.
9 - Puckett L. (2023). Renal and electrolyte complications in eating disorders: a comprehensive review. Journal of eating disorders, 11(1), 26.
10 - Ewan, S. L., & Moynihan, P. C. (2013). Cardiac arrest: first presentation of anorexia nervosa. BMJ case reports, 2013, bcr2013200876.
11 - van Hoeken, D., & Hoek, H. W. (2020). Review of the burden of eating disorders: mortality, disability, costs, quality of life, and family burden. Current opinion in psychiatry, 33(6), 521–527.
12 - Moreno, R., Buckelew, S. M., Accurso, E. C., & Raymond-Flesch, M. (2023). Disparities in access to eating disorders treatment for publicly-insured youth and youth of color: a retrospective cohort study. Journal of eating disorders, 11(1), 10.
