For National Eating Disorders Awareness Week, I tweeted that people could ask me anything about eating disorders. Thank you to everyone who submitted questions – they were very interesting and thoughtful! I aimed to be as concise as possible, while providing links for more in-depth information. If I didn’t fully answer a question, made an error, or was unclear, please e-mail me at kathrynhgordon@gmail.com to let me know. Thanks for reading!

1) @KCapo45 asked:

Is bullying by everyone on social media making it harder for people to be honest in therapy about their true feelings about their body because they are being shouted down by groupthink for not loving their body and being afraid of gaining weight*?

*For extra context, listen to this interview I did with Ken about his recovery from anorexia nervosa. We talked about whether there were any possible negative effects of body positivity movements.

Because Ken specifically asked about people being honest about their feelings toward their bodies in therapy, and I couldn’t find any data on the topic, I’ll share my clinical observations as a therapist:

• It’s striking to me that many of the patients I see — across a broad range of sizes, mental health issues, and ages — struggle with body image issues.
• Many don’t hold back and will openly say that they feel bad about their bodies, even when changes are linked to having babies, medical conditions, or menopause.
• A subset have tried to follow body positivity social media accounts and question beauty norms, so that they can love their bodies more. Still, many have body dissatisfaction and then feel like failures for not 100% loving their bodies. This is the group that will say things like, “And I know I shouldn’t care…” or “And I know I shouldn’t feel this way…” or “I know this sounds superficial, but…” and who end up in an even deeper state of shame and self-criticism.

For these patients, I recommend aiming for body neutrality over body positivity. That means that they accept their body as it is (not reject it or love it, but accept it) and accept their feelings about their body (good, bad, and all else). If they want to make changes in their body and/or their feelings about their body, we can collaboratively discuss those longer-term goals. However, in the short-term, what I’d like is for them to be okay enough with their bodies that they engage in their lives, rather than avoiding valued activities (e.g., socializing, exercising, sex, going out) due to feeling self-conscious or waiting until a time when their body is different. Here are some suggestions for ways to feel more okay about your body.

I think I’m already missing my goal of being concise, but in short, I’ll link to some other approaches I use to work toward this point of acceptance: cognitive-behavioral therapy for body image, I Am Me by Virginia Satir, self-compassion exercises, and opposite action.

Below are some interesting articles on this topic that provide history, context, and more nuance than the headlines suggest.

‘Body Positivity’ Has Had Its Day. Let’s Find Peace with Ourselves.

Body Positivity is a Scam (the author discussed the article on this podcast)

The Problem with Body Positivity

An Evidence-Based Rationale for Adopting Weight-Inclusive Health Policy

Self-Care Has to be Rooted in Self-Preservation, Not Just Mimosas and Spa Days by Lizzo

What Jillian Michaels Got Wrong about Lizzo and Body Positivity

2) @on_perspectives asked:

ED is extremely complex and certain treatments can backfire. Does the timing of treatment, in regard to what is going on in a patient’s life, play a role in recovery? When would immediate treatment of ED not be recommended because it would mean a lesser chance of success?

In the vast majority of cases, earlier treatment is associated with better treatment outcomes. The general rule is that a person with an eating disorder should get treatment as quickly as possible. If a person gets worse while in treatment, it’s extremely important to identify the factors that are responsible and adjust the treatment approach accordingly. With regard to what is going on in the patient’s life at the time of treatment, we appear to generally have more effective treatments for anorexia nervosa in youth than adulthood. I think this is due to younger patients being treated within the context of family-based care, though there are treatments aimed toward bringing in a support system for adults as well. Other factors that are likely to play a role in recovery: comorbid psychological problems (e.g., depression, PTSD, substance abuse), social support, access to empirically-supported interventions, readiness to change, other general life stressors (e.g., divorce, moving, bereavement, financial stability), functioning in other areas (e.g., academics, romantic relationships, at work), etc. On average, people who have good social connections and fewer additional stressors in their life tend to do better. This is why it’s important for therapists to look at the whole person and the environment they exist in when planning treatment.

I was trying to think about a time when you wouldn’t want someone to get immediate treatment for an eating disorder. It would be dependent on an individual’s particular circumstances, but some possibilities that came to mind would be if the person has some other more dangerous issue that needs to be immediately addressed and can’t be treated at the same time as the eating disorder (e.g., imminent threat of harm to others, imminent suicidal risk, drug dependence with a high level of associated, immediate dangerousness).

3) @mwebb22752561 asked: 

Re: goal setting in therapy, should target weights be set by the client, collaboratively or prescriptively on the basis of a healthy weight determined by BMI or similar measurement tool?

Whenever possible, all therapy goals should be set collaboratively with clients. This guideline is the same for people with eating disorders, except that sometimes eating disorders (especially anorexia nervosa) can interfere with the person’s ability to set a healthy target weight. The eating disorder can influence the person such that setting a healthy body weight does not feel like a goal they can agree to. When I have treated people with eating disorders, I find the most effective approach is to work with a team that includes a physician that can speak to medical factors relevant for setting the target weight (e.g., lab results, weight/growth history, menstrual status, etc.). I have seen therapists set a prescriptive target weight (in collaboration with a physician) only when the individual with the eating disorder cannot (due to interference from their eating disorder) and is in a state of medical risk.

4) @lluaces said (and @BianchiKristin said she was curious about this too):

Disorders that don’t have to do with body image like ARFID a lot of people get curious about

Anorexia nervosa and bulimia nervosa are eating disorders with DSM-5 diagnostic criteria that specifically mention an excessive concern with body shape and weight that leads to distress and unhealthy behaviors. Binge eating disorder has also been found to be linked to body image issues. In contrast, avoidant/restrictive food intake disorder (ARFID) is characterized by a disturbance in eating, but specifically excludes people whose behavior is driven by a fear of weight gain or disturbance in body image. ARFID often presents as an avoidance, pickiness (e.g., with textures, types) or low/lack of interest in food associated with at least 1 of the following: 1) significant weight loss or failure to achieve expected weight gain in children, 2) nutritional deficiency, 3) dependence on nutritional supplements, 4) interference with social functioning. For a fuller description, please visit this link. ARFID is typically treated with cognitive-behavioral therapy, and I have included links on the model and its treatment below. The purpose of the therapy is to identify and modify the factors that maintain ARFID (e.g., sensory sensitivity, fear of aversive consequences, lack of interest in eating or food).

Avoidant/Restrictive Food Intake Disorder: A Three-Dimensional Model of Neurobiology with Implications for Etiology and Treatment

Cognitive-Behavioral Therapy for Avoidant/Restrictive Food Intake Disorder: Children, Adolescents, and Adults by Jennifer Thomas and Kamryn Eddy

Should Non-Fat-Phobic Anorexia Nervosa Be Included in DSM-V?

5) @ThisIsSpecious asked:

Is it possible to have an eating disorder and not realise it?

Yes, these are the most common scenarios I have observed:

• people with anorexia nervosa who are severely underweight or who have medical problems, but believe that they are overweight or in good health (this is a particularly painful part of the eating disorder that can make it hard to seek help)
• people who have binge eating disorder, but think that their problem is “weak willpower” or “no self-control” because they don’t know about the disorder or know about it, but blame themselves anyway
• people who are dieting, exercising, or fasting to an extent that it is causing significant problems for their health, distress, and/or functioning but who don’t attribute it to an eating disorder (e.g., they think they have an unrelated medical issue causing it)

In these types of scenarios, it often takes a friend, family member, or physician stepping in to suggest that they seek help.

Here are some useful tips for talking to a loved one about an eating disorder, and here is a post about how psychologists determine if someone has an eating disorder.

If you were to go and advise anyone who might have an ED how would you advise them to seek help? Particularly if there is a stigma around that person’s preconceived conditions? (i.e. being overweight etc)

I am most familiar with the U.S. health care system, but I recommend starting with telling your general practitioner/physician about your concerns and asking for a referral/recommendations for local eating disorders treatment. Alternatively, the Academy for Eating Disorders is an excellent organization that has an expert directory search to help you identify an eating disorder practitioner near you (the directory is international). Unfortunately,  people, including health professionals, may have weight stigma or bias that interferes with their ability to recognize an eating disorder in an person who is overweight. If a physician or other health professional is dismissive of eating disorder concerns, please seek care from someone who specializes in eating disorders. Professionals with expertise in eating disorders should be aware that people of all different body sizes are affected by eating disorders.

6) @ahlandreth asked:

Would love to know more about body dysmorphia and the way trauma (injury, illness etc) can play into that

Body dysmorphia is currently classified with obsessive-compulsive and related disorders rather than with eating disorders, but there are definitely overlapping features. Body dysmorphic disorder is diagnosed when someone is overfocused on an aspect of their physical appearance (thinking about it at least 1 hour per day), such that it is causing them distress and impacting their functioning (e.g., in their relationships, in their ability to work). While eating disorders are often related to disturbances in perceptions of body shape and weight, body dysmorphia tends to focus on particular body parts or features (e.g., perceived inadequate muscularity, skin, nose). People with body dysmorphia range from relatively high levels of insight about their misperceptions of their body to relatively low levels and engage in repetitive behaviors related to their concerns (e.g., reassurance seeking, mirror checking, skin picking, extensive grooming routines). For more detailed information, this is an excellent resource.

I did not find much research on the role of trauma, illness, and injury in body dysmorphia, and I have not treated many people who have it. However, people with body dysmorphic disorder do report higher rates of abuse and neglect compared to people without the disorder (e.g., 1, 2, 3). Research suggests that body dysmorphic disorder is caused by both genetic and environmental factors. If someone has a genetic risk for body dysmorphia and then experiences a significant stressor (e.g., illness, injury, abuse), it may increase their risk for developing body dysmorphic disorder through a number of pathways. Their self-esteem, emotional coping, anxiety, negative mood, attitudes toward their body, social support, and other life factors may worsen under conditions of the stressor(s), leaving them more prone to developing the disorder. Importantly, there are treatments available for body dysmorphic disorder, including cognitive-behavioral therapy.

7) @Ivuoma asked:

Can you talk about racial disparities in these disorders and/or disorders that manifest mainly in certain groups?

Udo and Grilo (2018) examined prevalence rates of eating disorders in a nationally representative sample of U.S. adults (n = 36,306) and found:

*Lifetime anorexia nervosa rates were significantly higher among White participants as compared to non-Hispanic Black and Hispanic participants.

*Lifetime and 12-month rates of bulimia nervosa did not significantly differ by race/ethnicity.

*Lifetime binge eating disorder rates were significantly higher among non-Hispanic White participants than among non-Hispanic Black participants, with no significant differences between non-Hispanic White and Hispanic participants.

Due to small ns, the authors combined Asian, Native Hawaiian, Pacific Islander, and Native American participants into one group. Here is the table of lifetime rates:

Here is the table of past 12-month prevalence rates:

For more information, I recommend:

America is Utterly Failing People of Color with Eating Disorders

National Eating Disorders Association – People of Color and Eating Disorders 

I’ve done some research examining acculturative stress, perceived discrimination, and body shape ideals and how they’re potentially related to differing prevalence rates:

Cultural Body Shape Ideals and Eating Disorder Symptoms among White, Latina, and Black College Women

An Examination of the Relationships between Acculturative Stress, Perceived Discrimination, and Eating Disorder Symptoms among Ethnic Minority College Students

We need a lot more research in this area! I’m glad to see that it is has picked up quite a bit in recent years.

8) @jonathanstea said:

Brief overview of evidence-based treatments might be helpful. In my clinical experience, our teams find these disorders particularly difficult to treat, especially when concurrent with addictive disorders—and especially when addictive sxs in remission/eating sxs increase.

I completely agree that eating disorders are challenging to treat and that we need to keep improving on existing treatments. I also agree that one of the difficult aspects of the treatment is that many people with eating disorders suffer from multiple mental health issues. I have observed what you are describing too – that some patients were using substances to cope with emotional pain and other stressors. When that strategy is no longer being used (i.e., when they are in remission), you can see an increase in eating disorder symptoms. I find it beneficial to treat the complexities of eating disorders within a team context to best conceptualize and individualize each person’s care with multidisciplinary expertise (e.g., physicians, psychiatrists, dietitians).

The major evidence-based treatments that we currently have include:

• Family-based treatment (AKA Maudsley) for children and adolescents with anorexia nervosa or bulimia nervosa. This treatment involves empowering caregivers (typically a parent) to warmly and firmly help their child to eat in a healthy, non-disordered way (e.g., meet their nutritional needs, prevent purging and excessive exercise). This is a great article written by a parent and child who received this treatment. More information on the scientific backing for it is available here and here.
• Cognitive-Behavioral Therapy is used in a transdiagnostic protocol for different eating disorder presentations. It targets maintenance factors for the disorder (e.g., negative mood intolerance, all-or-nothing thinking, body dissatisfaction, perfectionism, fasting/restriction). More information on the empirical evidence is available here and here.
• Interpersonal Psychotherapy for eating disorders helps the patient recover by identifying and targeting a particular interpersonal domain that is maintaining the disorder: 1) lack of intimacy and interpersonal deficits, 2) interpersonal role disputes, 3) role transitions, 4) complicated grief, or 5) life goals. There is a good review of available evidence here.
• Integrative Cognitive-Affective Therapy is a relatively newer therapy that appears to be as effective as cognitive-behavioral therapy for bulimia nervosa. It has also been tested in binge eating disorder, but those results are not yet published. It focuses on helping the patient to regulate their eating patterns and then identify an area for skill-building (e.g., assertiveness, healthy ways of relating to one’s self, coping with emotions).
• Dialectical Behavior Therapy has been used to treat both bulimia nervosa and binge eating disorder. It focuses on increasing skills in mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. More research is needed on the effectiveness of the approach, but here is a useful article on its application.

9) @DrSamanthaMyhre asked:

A general discussion on the overlap of BDD and EDs and how to differentiate (I typically revert to clinical interview + BDD Y-BOCS and EDE-Q to help, but definitely interested in learning other strategies).

Using the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and Eating Disorder Examination-Questionnaire (EDE-Q) is an excellent way to approach this differential diagnosis. The only other approach I’ve used is the Structured Clinical Interview for DSM-5 (SCID). I think that the distinction is tricky, but body dysmorphic disorder (BDD) often focuses on a particular feature (e.g., skin, nose, ears), while eating disorders tend to focus on body shape and weight. That being said, you can definitely see overlap in checking behaviors, self-esteem issues, and appearance anxiety — especially with muscle dysmorphia (MD). The International OCD Foundation website makes this distinction, “While individuals with MD often follow very precise, time-consuming, and painstakingly picky diets, their eating habits are driven by an all-consuming concern with improving the mass and leanness of their muscles, as opposed to issues relating to their weight or body fat percentage, as seen in individuals with eating disorders.”

I liked the way that the website discussed differential diagnosis:

I also like their short version as a rule of thumb:

I could not find a large study with very clear statistics on rates of comorbidity between BDD and eating disorders, but one study found that approximately 1/3 of people with a BDD diagnosis had a lifetime eating disorder diagnosis and another study  found that ~1/2 of people seeking treatment for an eating disorder screened positive for BDD. Therefore, it is certainly appropriate to diagnose both if you see symptoms that are not fully captured by one diagnosis. Our diagnostic system is far from perfect, and I think it makes sense to choose the diagnosis(es) that seems like the best description and guide for treatment for the patient. If you are gathering data from the measures that you mentioned, your clinical judgment and decision-making will be very well-informed.

For more information:

Clinical Assessment of BDD

Male Eating Disorders (discusses muscle dysmorphia)

Thank you so much to everyone who sent questions! I hope that I provided the information you were looking for – but please reach out if you’d like to know more.

For more information, check out my Short Guide to Everything You Need to Know About Eating Disorders.