Mental Illness First, Eating Disorder Second
A closer look at "Eating Disorders Unspecified"
Eating Disorders don’t always present in neat little packaging. We have all heard of “health kicks gone awry” where eating becomes more and more restrictive and exercise more compulsive. But we don’t hear as much about the day-to-day struggle to eat for people with significant mental health challenges. Some of the primary diagnoses we see include depression, anxiety, post-traumatic stress disorder, borderline personality disorder, dissociative disorders, and bipolar disorder.
When eating disorders are not primary, they are said to be “secondary" to another more pressing mental health diagnosis. Often these diagnoses are what create the need for the eating disorder to begin with. However, “not primary” often gets interpreted as “not as serious” or “not as valid” and can make it difficult for folks to qualify for typical ED treatment. They may not meet all the standard criteria for say, Anorexia or Bulimia Nervosa. They are told that their "other issues" need to be taken care of first. Then, sadly, the mental health facilities will often deny care because they do not feel equipped or comfortable treating the eating disorder (and they likely fear liability). And so, clients are left without providers to care for them. These folks may get diagnosed with eating disorder “unspecified”, in other words, eating disorders that do not fit in a neat little DSM package. I argue that they are still very much struggling with eating disorders and that their struggle matters. They matter.
Their presentation may look something like this…
Malnutrition/nutrient deficiencies such as anemias
Food obsession
Food fears
Absence of regular hunger and fullness cues
Low motivation to make and eat food
Low appetite, “nothing sounds good”
Difficulty making food decisions
Overwhelmed by the thought of having to eat or make food, or food decisions
Fear of fat
Body image distress
Body dysmorphia
Anxiety with grocery shopping
GI disturbance
Vomiting
Sleep disturbance
Feeling cold
Shame for eating
Eating in secret
Hiding or Hoarding food
Fatigue
Weakness
Dizziness/lightheadedness
Average or higher weighted bodies
Irregular or absent menstrual cycles in women
Altered hormones including sex, thyroid, stress, insulin, etc.
Sound familiar? Clearly, they share many of the same symptoms as their Anorexic and Bulimic counterparts. What are the effects of their “unspecified” eating disorder? Well, they’re very much the same.
However, the origin of the disorder and the rules may differ.
Many of our clients who fall into this default category come from childhoods with trauma.
Perhaps their rules look less health-focused, and more safety-focused. Textures or associations with trauma might create restrictions around specific foods. Food insecurity might have played a role in their early relationship to eating. Low motivation and appetite related to depression may create more snacking and consumption of simple, easier-to-prepare foods. Their bodies may be of average of higher weight, making it even easier to be invalidated and missed.
Eating enough and addressing the ED may help with their primary mental health diagnosis.
Blood sugar stability can improve mood fluctuations and cravings
Food helps make the precursors to our feel-good neurotransmitters.
Eating consistently and enough improves ability to sleep and sleep quality.
Following a consistent meal pattern creates a predictable, helpful structure to the day.
Correcting malnutrition allows for overall health of the body eliminating one more worry that might be present.
Fatigue present from depression can potentially improve with adequate calories.
Microbiome improvement which is thought to directly impact positive brain neurotransmitter changes
Understanding the eating disorder and its function can lead to better emotional awareness and identification of needs.
There are so many good reasons to not let these folks fall through the cracks! They need just as much, if not more, handholding to get food in. I encourage providers to be less afraid of seeing folks that may present differently. They deserve and need it just as much support as those presenting with a primary diagnosis of eating disorder.