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Monday, August 7, 2017

Don't Tell Me I Have An Eating Disorder

5:53 AM Posted by Tiffany Taft , , , , ,
dis·or·der
disˈôrdər/
a disturbance in physical or mental health or functions; malady or dysfunction

I was in New York this weekend for the annual meeting of the American Neurogastroenterology and Motility Society, a gathering of experts in the field of functional digestive illness. This year had a heavy psychology presence, which was pretty exciting since psychology was integrated into most sets of talks on a certain topic or condition. Because, you know, psych is important.


On Saturday, Dr. Sarah Kinsinger, now director of the adult GI behavioral medicine program at Loyola University outside of Chicago, spoke on the topic of eating disorders. Sarah and I worked together at Northwestern for about a decade before she moved on to start the Loyola program. We talked a bit the day before about her presentation and she expressed some concerns about the potential for controversy due to the highly sensitive nature of the topic.

If you live with a chronic illness that makes you feel nauseous 23 hours a day or causes vicious abdominal pain or explosive diarrhea or constipation that makes your guts feel like they’re full of cement, you’re probably going to adjust your eating habits. It’s the logical and protective thing to do.

Temporary changes in diet are sometimes recommended to people with digestive illness.  Low residue or even enteral nutrition are used for active inflammatory bowel disease. Elimination diets for IBS (e.g. low FODMAP) or eosinophilic esophagitits (e.g. 6 food elimination diet) are evidence-based treatments regularly recommended by physicians and dietitians.

So who the hell are we to come in and talk about eating disorders in this context? Eating disorders are mental illnesses and the vast majority of people with GI illness are not mentally ill.

Traditional psychiatric eating disorders include anorexia nervosa and bulimia nervosa, with some variants based on symptom presentation, but overall these are the 2 most people have heard of. These are highly stigmatized conditions, even though the culture of the United States values thinness and equates it with beauty and health. That’s a whole other post. Hell, a whole series of posts.

 So when psychologists who operate in the gastroenterology world start talking about eating disorders, haunches can get raised. And I get that, both personally and as a professional. Let’s break down a few reasons why.

Back to the protective behavior of adjusting diet to control symptoms. I can’t think of a single patient I’ve seen over the past decade who came into my office and said “nope, haven’t done a thing to my diet since all this happened.

It’s a fundamental part of the information gathering I do when I meet with someone the first time - tell me about your diet and how it impacts your symptoms.

What have you tried to change? 
What works? What doesn't?
How does this impact your life? 

Answers range considerably, but overall I see some degree of food restriction, whether it’s a type of food (e.g. pizza or broccoli) or a group of foods (e.g. dairy), all the way to the extreme answers such as “I only eat white foods” or “I can only eat these 6 foods.”


People's relationship to food and eating can get dicey when, again, food is causing some pretty awful symptoms.  In an attempt to control these symptoms, we try to identify cause-and-effect patterns so we can make the necessary changes to feel better.  This is where the "disorder" thing can come in.  There's a line.

If I restrict my eating to the point my weight becomes unhealthy, this is a problem.

If I restrict my foods to the point I become malnourished, this is a problem.

If I become so anxious about eating that I avoid it as much as I can, this is a problem.

If I restrict my social life to the point of depressing isolation because of food, this is a problem.

Are these problems, either on their own or collectively, an eating disorder? Without the traditional criteria of fear of weight gain, body image distortion, or some other red flag behaviors absolutely not.

They are, however, disordered eating behaviors that need to be addressed.  But there's that word disorder again.  I honestly prefer to say unhelpful or problematic with my patients to avoid the sense of stigma that "disorder" when paired with eating can elicit in some.  But if we're honest, typically the behaviors that are intended to be solutions aren't solving the symptoms OR they're resulting in so many other issues both physically and psychologically that the person is still coming in to their doctor and they've been referred to me to help.  So something needs to change.

How do we change them?  That's complicated and a topic for another post that I'll get to soon. But I wanted patients to know that while us psychologists use the term disorder when talking about eating issues in digestive illness, it's much more complex than that 3 syllable word.

--T2