Navigating the complexities of eating disorders

The term “eating disorder” conjures different images for different people. Perhaps one imagines the stereotypical middle-class adolescent girl restricting her food intake to change the way her body looks. As advocacy efforts have increased, perhaps one envisions a more diverse presentation, maybe someone who engages in regular episodes of binge-eating. Whatever image happens to come to mind, it is likely representative of at least one out of the over 55,000 Vermonters who will face the challenges of an eating disorder in their lifetime, according to the Vermont Department of Mental Health (2023).

What is an eating disorder?

For a long time, this question may have been easily answered by two items: anorexia nervosa or bulimia nervosa.

Anorexia nervosa is the intentional restriction of dietary intake to prevent weight gain, accompanied by an intense fear of gaining weight. It is often referred to as the least common eating disorder, as reflected in data from the National Comorbidity Survey Replication.

Bulimia nervosa is defined as a pattern of binge-eating episodes, followed by episodes of compensatory behavior, often through purging, like self-induced vomiting, or non-purging behaviors, like fasting or excessive exercise. Recent enhancements to the understanding of eating disorders have established binge-eating disorder as its own diagnosis, which is characterized by episodes of binge-eating accompanied by intense feelings of guilt and often secretive behavior surrounding eating.

There has also been increased focus on avoidant/restrictive food intake disorder, ARFID, as a pattern of decreased food intake due to an aversion to or fear of food.

While these diagnoses provide neat little checklists for understanding the clusters of eating disorder symptoms clients often experience, the reality is that they often fail to encompass the unique thoughts, emotions and behaviors that make up an eating disorder. Thus, the most common eating disorder is actually other specified feeding or eating disorder, referred to as OSFED. Increasing attention has been given to a pattern known as disordered eating, which can refer to a variety of behaviors and attitudes that deviate from what is considered “normative” and “healthy” eating behaviors and attitudes.

What does treatment look like for an eating disorder?

Eating disorders present complex psychological and nutritional demands. For some people, these demands require 24/7 monitoring in an inpatient hospitalization or a residential setting. Other structured treatment settings include partial hospitalization and intensive outpatient programs, which can offer a range of individual and group therapy, dietetic counseling, and psychiatric medication management. The most common setting of eating disorder treatment occurs in the traditional outpatient environment, featuring individual psychotherapy sessions with maybe a handful of additional appointments sprinkled in for medical monitoring and sessions with a dietitian. Regardless of the level of care, it is recommended that people with eating disorders receive treatment from an interdisciplinary team, which includes a psychotherapist, dietitian, and psychiatric and medical providers.

While recommended treatment is great in theory, there is a reality of limited access pervasive across individuals with eating disorders. The Academy for Eating Disorders (2022) has called attention to the possible relationships between eating disorders and risk factors such as food insecurity and trauma endemic within rural areas, while also acknowledging not only a lack of eating disorder-specific treatment but of mental health care as a whole.

Strides have been made to increase access to treatment, including Vermont Medicaid’s removal of prior authorization required for eating disorder treatment across levels of care in early 2023. However, Medicaid does not cover residential treatment for individuals over the age of 20 with eating disorders. The Department of Mental Health’s Eating Disorders Workgroup has prepared recommendations for increasing access to eating disorder care in Vermont. These recommendations involve awareness, education, and prevention.

Mary Iellamo, M.Ed. is a Doctor of Psychology candidate at the Brattleboro Retreat with a background in inpatient behavioral health and integrated health care, as well as specialized training in eating disorder treatment.