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02/07/2014 08:14 EST | Updated 04/09/2014 05:59 EDT

The Best Way to Understand an Eating Disorder

Lady Gaga aside, not everyone who has struggled with an eating disorder can say (as Gaga does in the March 14 issue of Harper's Bazaar) that they're done with it. They may not exist for her anymore, but with Eating Disorder Awareness weeks taking up most of February here and in the U.S.. it's worth taking another look at this illness that, some say, affects 24 million North Americans, most of them women and many of whom have struggled with the disorder for years if not decades.

I don't know whether they are actually on the increase. But I do know that they are expanding in definition in that eating disorders were once limited to anorexia nervosa and bulimia. But now we hear about so many subtypes: Like anorexia athletica (compulsive exercising to avoid gaining weight), drunkorexia (not eating so you can save your calories for alcohol), orthorexia (a fixation with only "pure" foods) and manorexia or men who strive for an unhealthy weight.

"We do talk of other subtypes when we talk about eating disorders today," Dr. Howard Steiger told me. He explained that in the current psychiatric diagnosis manual, the DSM5 (www.dsm5.org/), anorexia and bulimia are still there as they were for many years but now binge eating is also an official sub-type. Another addition is something called avoidant restrictive food intake disorder or ARFID which encompasses people who are limited in their ability to eat but who are not concerned with weight gain but rather are crippled by a fear of consuming impurities: When I think of ARFID I think of people who are extremely obsessed with avoiding foods perceived to be unhealthy to the point where they plan tomorrow's menu today, cannot go out to dinner and become increasingly isolated.

Dr. Steiger is director of the Douglas Mental Health University Institute's Eating Disorders Program in Montreal, Quebec, and he's a great communicator about these illnesses that so many of us find so hard to comprehend. Most of us realize that people with eating disorders have such a constant preoccupation with body image and weight gain that they develop problem behaviours around eating -- often with serious consequences. But I didn't know that eating disorders not only mess up people psychologically and physically, but as Dr. Steiger says, they also have the highest mortality rate of all mental illnesses.

The best way to understand eating disorders is to think of them as a phobia, for that is exactly what they are: It's a terror of weight gain so profound that it can become a fear of eating anything that is unfamiliar or new or where the ingredients are unknown or even eating in a place where it's difficult to purge or exercise if she (or he) feels she must.

"It's a very massive fear," says Dr. Steiger, "and it may be helpful for people, particularly families, to think of it this way." Instead of just thinking she's being stubborn or weak-willed ("Why doesn't she just eat!") thinking of the problem as a phobia makes sense. After all, you wouldn't expect someone with a terror of spiders to "just" go over and pick up a tarantula or even sit down on a bench next to a spider spinning its web.

Thinking of people with eating disorders as crazy or self-destructive is just wrong, says Dr. Steiger. In fact, there are still too many myths attached to eating disorders -- like the following.

It's a rich girl's disease: In fact, eating disorders cut across all economic groups. Goals and values of being upwardly mobile, of being achievement oriented affect all social groups.

Eating disorders are a North American invention: Not so. In a lecture Dr. Steiger gave www.youtube.com/watch?v=10-fit-GYx4 on the subject, he says there is nowhere on the planet that is free of eating disorders. Even Fiji Islanders have reported having them.

They are a creation of our time: Nope. Catherine of Siena, Mary Queen of Scots, Franz Kafka, lists Dr. Steiger. "Anorexia has been around for ages." While binge-eating is more of a modern creation, the first medical account of anorexia dates back to 1600.

Bad mothering is likely the cause: Thankfully, this theory has gone the way of the do-do. "Families with eating disorders do not function in any way that is different from families without eating disorders," he says. Neither do you have to have had a traumatic or abusive childhood to develop an eating disorder.

For the most part, the family model doesn't hold water as a cause, he says, adding that eating disorders appear in all types of families: "We used to think it was overprotective and over involved parenting that was to blame. But when you see your kid disappearing in front of you (as with anorexia), it's difficult not to be over involved."

Neither is there evidence that weight preoccupied parents are to blame. Sports could be a factor, says Dr Steiger: There are some sports like gymnastics, dance or being a jockey where weight is important. Teasing is a factor that could precipitate an eating disorder.

One of the fields that holds a clue to why eating disorders may develop is epigenetics and the gene-environmental relationship. Funded by the Canadian Institutes of Health Research (CIHR), one of Dr. Steiger's studies looks at the effects of genetic variations upon the serotonin system. Seratonin plays a role in satiety and mood disregulation, he says, adding to the argument that anorexia and bulimia are not social cultural creations as once assumed. Research by him and others indicate that there's a genetic component involved that would make someone more susceptible to developing such a disorder.

Eating disorders are not just about eating. They often dovetail with other mental illnesses such as depression and anxiety or obsessive compulsive disorders. And according to Toronto's Bellwood Health Services eating disorders and addiction often go hand in hand; over half the people seeking treatment for an eating disorder also have an addiction or substance abuse problem.

The more that science provides biological explanations for these illnesses, the more therapy can be humanized, says Dr. Steiger. "Instead of seeing patients as weak or superficial, we can begin to understand the vulnerabilities that may have precipitated the illness. People get eating disorders in a way that is real and beyond their conscious control. It's not something you can just choose not to do."

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