Perspective Disordered Eating, Danyael Lutgens and Andrew Ryder

PERSPECTIVE DISORDERED EATING AND ANDREW RYDER DISORDERED EATING is a psychology instructor in the Department of Social Sciences at University in North Vancouver , Canada . Her research focuses on psychopathology , in developmental and sociocultural context , with a growing interest in the use of mixed methods . Over the years , she has trained in psychology , neuroscience , and journalism at universities in British Columbia , and the Netherlands Andrew Ryder is professor of psychology in the Centre for Clinical Research in Health and the Department of Psychology at University in , Canada , where he directs the Culture , Health , and Personality Lab . His research focuses on variation in emotional disorders , the mental health of migrants , and how best to train researchers and AND ANDREW RYDER 387

in . He is also a licensed cal psychologist in the province of . Learning Outcomes After reading and discussing this text , students should be able to Name and describe the differences among key eating orders . Express disordered eating as an intersection of , physiological , and psychological elements . INTRODUCTION Have you ever heard someone describe themselves as hungry for love ?

Or conversely , so heartbroken that they can not eat ?

Or more extreme , that they are dying to fit into this dress ?

If you are East Asian , there is a good chance you have been asked have you eaten rice today ?

instead of how are you ?

And if you are feeling ill , there may well be a dish , personally and culturally , that can make you feel a bit preferably made by , or at least following the recipe of , a parent or grandparent . At the core of these links are expressions of care . Elsewhere in this book are descriptions of how food may be used as a tool for ritual and social cohesion . Here , we consider how food may also work Within these sociocultural frames to serve individual psychological needs . One person may fail to find the love they are hungry for in their environment and turn to food instead . 388 DISORDERED EATING

Another may fail to live up to unhealthy body image norms and turn away from food , despite mounting hunger and tion . Indeed , food is a daily necessity and key to sustaining life and health . The search for food is thus essential , not only to being human , but to being any living thing . Biological evolution brought teeth and tongues , throats and stomachs to the animal kingdom . Those who ate lived to survive and procreate . In this sense , food and eating are central and truly universal . But then in humans , cultural evolution also brought a series of innovations , from tools for hunting and gathering , to agricultural techniques , to contemporary and . over , cultural evolution built innumerable innovations on top of the basic biology of food . To take one example , disgust , which is an emotion grounded in the ancient physiological imperative to expel potential poisons . Yet this same emotion system also folds a very complex , culturally shaped , set of responses moral The human experience of food and eating is at once deeply shared and personally idiosyncratic , biologically grounded and culturally shaped . One lens through which to view this ity is that of disordered eating the various ways in which our experience of food and eating goes wrong . As with any other form of What are commonly called mental disorders , or , We can understand disordered eating at the plex intersection of three levels culture ( and society ) mind ( and behavior ) and brain ( and genetics ) In this chapter , we consider some of the major ways in which eating can go wrong , several disorders described within the psychiatric manual commonly used in North America The Diagnostic and . 2013 . Ryder , 2020 . AND ANDREW RYDER 389

cal Manual of Mental Disorders , or . We look first at distress , in which problems of anxiety and depression can lead to weight and appetite change . Then , we turn our attention to the eating disorders of anorexia , bulimia , and binge eating . After describing these disorders , We explore some examples of how they are shaped by ture , mind , and brain . Finally , we will look at traditional and temporary treatments , noting ways in which food has been used to treat emotional problems , along with ways in which logical interventions have been used to treat eating problems . We observe effects in both directions because culture , mind , and brain are not three separate domains , but are instead deeply interconnected . DISORDERS AFFECTING FOOD AND EATING Imagine that you have an upcoming exam or that you are getting ready for a first date . Many people find that increased levels of stress or anxiety will suppress their appetite . For most , the passes and the appetite for someone with an anxiety disorder , appetite may be compromised for a longed period of time . This occurs because stress and anxiety lead to arousal of the autonomic system , which leads to many different physiological changes including symptoms that reduce appetite , such as nausea , diarrhea , and a subjective sense of ing . Chronic sadness or loss of pleasure can also have an impact on appetite , with depressive disorders including Weight or appetite change as one of the core symptoms . Appetite may be lost because of direct physiological effects of depression on the gastrointestinal system , but also because depression can affect the hedonic pleasure obtained from the When someone is exceptionally sad , foods that were previously enjoyed and . Simmons 2016 . 390 DISORDERED EATING

very tempting , like chocolate cake or French fries , may be described as unappealing , tasting instead like cardboard . Stress , anxiety , and depression do not always lower one appetite . A sizeable minority of sufferers instead report increased appetite , often accompanied by weight gain . Some people cope with anxiety through what is popularly known as stress This phenomenon can be observed , for example , in people who are quitting smoking and no longer experiencing either the subjective calming or the appetite suppression caused by nicotine . One subtype of Major Depressive Disorder , known as atypical depression , involves weight and appetite gain , along with other less common symptoms , such as increased sleep . Another subtype follows a seasonal pattern where sufferers are prone to depression during the winter months . A common ture of this Seasonal Affective Disorder is weight and appetite gain , driven especially by powerful cravings for carbohydrates . also includes a chapter on specific Feeding and Eating The most widely studied eating disorder is Anorexia , characterized by marked restriction of caloric intake resulting in strikingly low body weight . Bulimia , while , involves a pattern of recurrent episodes of binge eating in combination with recurrent compensatory behaviors , such as purging or use of diuretics . A more recent inclusion in the nostic system is Binge Eating Disorder , characterized by sumption of a vast amount of food in a discrete period of time . Up to of Canadian women report an eating Although men generally face pressure to increase musculature , eating disorder symptoms are observed in some men . There is evidence that these rates , especially among youth , are steadily . et al . 2012 . 2021 . AND ANDREW RYDER 391

FOCUS ON FEEDING AND EATING DISORDERS Convinced that any extra weight would slow her down , and hearing coaches make offhand remarks about whether she had gotten bigger , Ruck began to fixate Out with her teammates that evening , Ruck later ducked into a nearby cafe and forced herself to throw up the meal , telling no one . Purging had become as much a part of her routine as laps in the Athlete Taylor Description and Symptoms Anorexia . The North American obsession with thinness as an ideal of beauty grew steadily over the century , but came to public attention in the as several celebrities died from anorexia complications . Others , such as Princess Diana , began to talk openly about their struggles with food and its relation to their . Anorexia is a serious disorder associated with a high mortality rate if left untreated . Indeed , death rates are about ten times higher for ple with anorexia compared to the general This disorder is considered visible , in that we can often see when a person has abnormally low body weight . Other signs include the appearance of fine downy hair on the body ( Lanugo hair ) loss of tooth enamel , and fidgeting . Subjective experiences of people with anorexia include intense fear of gaining weight , distorted body image , and difficulty standing the consequences of the problem . Although some impacts such as gastric complications are reversible , physical such as low bone density may remain . Robertson Brady 2021 . 2010 . 392 DISORDERED EATING

And when I feel lonely , my heart feels hungry and I end up bingeing , Simply Complicated , 2017 Bulimia . In contrast to anorexia , bulimia is an invisible disorder , as those who suffer from it are often normal weight , or even overweight . A person struggling with this disorder may thus be able to keep their overwhelming hunger a secret for a very long time . An individual with bulimia will experience repeated episodes of binge eating , of highly palatable ( ready to consume , high calories ) and easy to purge ( soft texture , mild ) foods , such as pizza , ice cream , or donuts . These episodes are not like the overeating you may have occasionally indulged in at a holiday or celebration with good , plentiful food . Rather , a binge averages up to a single episode , along with a subjective sense of little or no control during these times . The sufferers then engage in various activities to counteract the feared weight gain , including vomiting misuse of laxatives , diuretics , or other medications or excessive exercise . Over time , a person with bulimia may experience ous physical Some may find it more difficult to convince their body to purge , further worsening mood . Binge eating disorder . Binge eating disorder has received much less research attention , as it is a relatively new addition to the diagnostic system . As in bulimia , people with binge ing disorder will regularly eat large amounts of food in a short period of time . Unlike bulimia , however , they do not engage in compensatory behaviors . Moreover , people with binge eating disorder are likely to eat for reasons other than hunger , such as coping with stress or loneliness , and find this behaviour . 2015 . AND ANDREW RYDER 393

to be significantly distressing . Subjectively , they report low esteem , even , as a consequence of the binges they often report feelings of repressed anger and depressive Although people with binge eating disorder are often overweight or obese , some may have a body weight within the normal range . Now that this disorder has been admitted into the and formally defined , we should expect to see more research on it in the future . Causes and Culture and society . In the and , anorexia was thought to be a disorder of young , white , upper class , Western women . This is no longer the case . As industrialization and increase the reach of the internalization of Western beauty ideals through media , including social media , so too does the prevalence of eating disorders increase around the world . For example , in the , after television was introduced to the island of , eating disorders that were previously unheard of escalated Anorexia and bulimia were previously thought to be infrequent in China , but this may have been because many Chinese eating disorder sufferers lacked the fear of fat required for a diagnosis . Moreover , there is evidence from Hong Kong that greater cultural ity with Western concepts of eating disorders has actually shifted the symptom presentation of these disorders , closer to Eating disorders are especially common in social where body image is particularly important , such as models or dancers . Bulimia in particular seems to affect minority Women in North America . 1996 . Becker 2002 . Wu et al . 2020 . 394 DISORDERED EATING

Mind and behavior . People suffering from eating disorders are likely to have distorted thoughts , especially about their body but also regarding their and relationships with others . Some research suggests that individuals with eating disorders may have difficulty being aware of their own bodily sensations ( like being hungry or satiated ) Childhood trauma and mood , including with depression and anxiety , are also linked with eating disorders . Anorexia stands out as having a particularly strong association with obsessional with sufferers reporting that they experience a feeling of reward in their ability to exert control to override their hunger instinct and successfully limit their eating . People with bulimia may be more prone to act impulsively and they may also be more likely to prefer novelty and They may be prone to being people and may feel an averse tion to negative social interactions , which may even trigger a binge . People with binge eating disorder may find that they use food to avoid , cope With , or numb out negative emotions . Brain and genetics . A child who restrains their eating is more likely to have a mother with anorexia , or a family with high expectations for their child or one that emphasizes the importance of Genetic studies suggest that inheritance plays a role in eating disorders and that chemical messengers in the brain ( neurotransmitters ) as serotonin and dopamine , responsible for regulated mood and feelings of implicated . In many cases , stress may trigger a desire to eat an abundance of food containing carbohydrates , which help the brain to create and release serotonin , in an effort to calm the body down . Unfortunately , in both bulimia and binge eating disorder , the brain and body simply do not register the 12 . 2007 . 13 . et . 14 . Herman 2002 . AND ANDREW RYDER 395

15 . chemical message that the body is now satiated . Some studies have even shown that foods high in carbohydrates and sugar present the brain with such a powerful reward that it overrides the body signals of being full and even of the associated pain . Indeed , foods high in sugar trigger the same reward hormone ( dopamine ) in the same brain pathway associated with addiction to TREATMENT INTERVENTIONS Antidepressant medication is often incorporated into eating order treatment , as mood ( anxiety ) and eating are often . Appetite and weight symptoms in mood disorders respond to but need to be careful many of these medications have weight gain as a side although some of them instead can lead to sea and weight loss . Anorexia , in particular , can demand quite radical interventions because it is potentially ing . The most immediate goal of treatment is to introduce food incrementally , safely increasing weight to an acceptable level . In some cases , such treatment ( food ) may need to be given . Psychological approaches to anxiety , depression , and eating orders often include interventions grounded in cognitive therapy ( For people with eating disorders , the aim is to help develop normal eating patterns a similar goal can be seen in for anxiety or depression when applied to weight and appetite symptoms . Eating journals may be employed as a technique to keep track of moods and to connect various states to eating . can also be used to bring attention to internal as stress , sadness , or to Frank et al . 2021 . Fava 2000 . 396 DISORDERED EATING

exchange unhealthy coping mechanisms with healthy coping ( exchanging binge eating for breathing exercises ) Exercise may also be utilized to improve mood and increase bodily ness . For bulimia , the core of this approach is a focus on dismantling unhealthy beliefs about the self and the body . who binge may learn to override the impulse both to eating after eating a forbidden food and also to purge in response . People who previously binged on foods may learn to cook and prepare foods carefully , thereby a new relationship with food . The sociocultural context should also be considered when cussing treatment . In many cultural , food is an essential part of maintaining or recovering good health . In Traditional Chinese Medicine , various can include mood or appetite understood as deficits of hot and cold , wet and Specific foods are then prescribed to help correct any imbalances . In Ayurvedic Medicine , disorders might arise through a person eating foods that are not compatible with one body type treatment would then correct In any case , working with eating disorder patients should not assume that these patients inhabit a cultural world similar to the themselves . Culturally sensitive treatment involves finding out about the patients own beliefs about food , Weight , and health , as well as beliefs commonly held in the patients munity . There are also direct interventions at a societal level , although these are most often implemented by public health and , rather than psychiatrists or . For example , some magazines have introduced a diversity of models into their fashion pages , 19 thereby attempting to widen the definition of beauty , to include a variety of body shapes . 17 . Flaws 2001 18 . 1996 . 19 . Singer 2021 . AND ANDREW RYDER 397

interventions can also help young people to increase their and body image REFLECTIONS Food and eating can be understood as biological necessities grounded in evolution , as deeply shaped by sociocultural text , and as varying across individual people depending on their temperament , family of origin , social network , and so on . ordered eating can be understood in a similar manner . Dividing our overall story into culture and society , on mind and behaviour , on brain and it easier to tell . This chapter began by considering both North American but also metaphors and analogies linking food and eating with expressions of longing , of pain , and of care for another . We see that human relationships with food and eating are deep and universal . These relationships bring such pleasure , joy , and tate connection but when they go wrong , can also be a signal that it is time to pay attention to the of mind , body , and culture where suffering and healing are both possible . If you or someone you know needs help with an eating disorder , please visit the National Eating Disorder Center ( for information and to find links for local resources . 20 . Le et . 398 DISORDERED EATING

Discussion Questions What are some of the common impacts of stress on eating habits ?

What are the key characteristics of each of the three main eating disorders described in this chapter ?

This chapter identifies three intertwined of disordered eating culture and society , mind and behaviour , and brain and genetics . How are each of these causes distinct ?

How are they related ?

How might an understanding of the intersection of the sociocultural , physiological , and ical dimensions of disordered eating contribute to an integrative approach to treatment ?

Consider the following synthesis of a case study in disordered ing A girl in her late teens , a competitive dancer , has recently moved to Canada from abroad . She has an evolved biological tendency to seek out food and eat it when hungry but she also has evolved logical tendencies to seek the company of others , fit in reasonably well with them , use people as models for behaviour , and so on . At her new dance school , she is among the heavier the dancers are particularly thin . Unlike in her home country , she now frequently sees unusually skinny AND ANDREW RYDER 399

models on billboards and in magazines . Just as frequently , she finds many more opportunities to eat food high in sugar and . Her dance teacher criticizes her weight the teacher also several other students in a similar way , but this girl already has a family history of parental criticism and a temperament that is unusually likely to respond badly to such criticism . She starts to restrict her food intake , her classmates give her some positive reinforcement for it , the teacher is still critical but starts easing up a little . But she finds it hard to resist junk food , the sugar is so readily available and helps her deal with her stress . Then she regrets it and starts to purge . The more she purges , the more she starts to like the of endorphins and the feeling of relief that comes . But she needs to hide her purging , so as not to alarm her parents her parents might be critical , but mostly about school rather than weight , as she is normal weight where they come from . Indeed , she is normal weight outside the dance text , except that her slimmer frame is now attracting some positive feedback from her regular classmates , outside of dance . by some of these classmates helps her feel a bit less foreign , but they also want to go out for fast food . She starts to contemplate increasing her exercise routine . A cycle of disordered eating is now well underway . And we would be hard pressed to describe what is happening as strictly biological , psychological , or even where , precisely , one ends and the other begins . Consider the etiology ( causes of ) of the teenage dancer eating order and describe how this might lead you towards different interventions . What interventions might follow from culture , mind or brain perspectives ?

Given that culture , mind , and brain are intertwined , how might your proposed interventions be grated ?

21 . A possible response to the question above A pharmaceutical intervention might introduce chemical alterations that include boosting her tolerance of criticism . A psychotherapeutic intervention might help her to think through ways of navigating her social world , helping her to make better 400 DISORDERED EATING

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