Parent: Are Anorexia Behaviors Learned from Other Patients?

By December 10, 2012

My 13 year old is in an eating disorder outpatient unit, diagnosed with EDNOS. We know that she was obsessed with running and for the two months prior had been running a lot on our treadmill along with other indoor exercises. Her downfall into anorexia came very fast and we checked her into a hospital with heart rate and electrolyte issues two weeks ago. Since then she has been in outpatient unit, and is gradually showing more and more signs of anorexia. Could some of this be learned from the other girls? Or was this bound to happen? We are a little confused at how quickly this came about. – Carol

Dear Carol,

Let me start by talking about the diagnosis Eating Disorder, Not Otherwise Specified (ED,NOS). This diagnosis is made when a person has significant eating disordered problems that do not meet all of the criteria for a diagnosis of anorexia or bulimia. People tend to think of EDNOS as a milder condition than anorexia or bulimia. That is not always true. In fact, on the Eating Disorder Inventory (3rd edition), EDNOS patients often score as high or higher on certain scales than anorexic and bulimic patients. The underlying eating disorder issues can be just as strong as anorexia and bulimia, even when the full criteria for these disorders are not met.

In terms of learning things from other girls in treatment, that is a possibility. However, especially with anorexia, the primary eating disordered behaviors are food restriction and exercise. Most treatment programs do not allow underweight patients to engage in vigorous exercise. Their food intake is also closely monitored. What they may learn from others patients are methods to hide their exercise and food restriction while they are in treatment. Even so, because of the monitoring, they cannot exercise nearly as much as they do at home nor can they restrict food as easily.

On the other hand, peer influence is a major issue with individuals who have eating disorders, especially teens. Seeing other eating disordered patients could have had a negative influence on your daughter.

With eating disorders, especially in teens, there is usually a constant comparison with others in terms of body size. Because their perception of their own bodies is usually distorted, they often see others as much thinner than themselves. In treatment with other overly thin patients there is a tendency to feel that “I am the fattest one here.” This can lead to food refusals and weight loss that has to be addressed by the treatment team.

However, peer influence is not limited to the confines of treatment centers. I have seen hundreds of adolescent girls who compare their bodies negatively with non-eating disordered peers (or siblings) who are not nearly as thin as they are. Your daughter almost certainly has body distortions or she would not be that obsessed with exercise. That her heart rate and electrolytes became a problem provides evidence that this distortion and the other factors behind her eating disorder were very strong before she went into the eating disorder program.

With any treatment for any condition there are always some risks. The risks have to be balanced against the benefits of treatment. In your daughter’s case, I believe you did the right thing in pursing the treatment path that you took. She had exercised herself to a place where she was becoming (if she had not already become) medically compromised. That is a serious issue.

Eating disorders often evolve over time. They very often start with a teen going on a diet, or trying to eat healthier foods, or starting to exercise. This seemingly innocent beginning becomes more intense and occupies more and more of their thoughts and time. Adult patients often have problems identifying exactly when their eating disorder began because of this evolutionary process of the disorder. 

I don’t have enough information to know what they are, but given your daughter’s obsession with exercise, she likely has issues that are pushing her towards anorexia. Given her age, these issues are probably related to self-esteem, identity, fitting in with peers, and moving from a child’s body to an adult body (which includes sexual development).

In the adolescent years status is very important. One way to obtain status is to do be good at something that other teens value. For girls being thin is highly valued. If she can be thinner than others, it can help deal with the insecurities that abound during these years. When she sees others thinner than her (or believes they are thinner) it can be very upsetting causing her to work harder at being thin, leading to a serious eating disorder.

Regardless of what issues have been pushing her to exercise to the point that she was having medical complications, the issues need to be addressed. They are not likely to just go away. Although it is possible that treatment may have some negative influence, it was the right call. Although no one can say for certain, she was most likely moving towards anorexia.

The good news is that early treatment is the best.

Warmest regards,

A. David Wall, PhD