**3.1 Myths and misconceptions regarding clinical ED abound**

Consider the following examples of decoys to the recogntion and understanding of ED:


### *3.1.1 The physician's role in weight management detection*

Though early detection of ED warning signs is pivotal in disease prevention and/ or promoting a timely recovery, the medical community has been known to overlook opportunities for early disease recognition.


*A patient of mine had been treated by a psychiatrist for 7 years, during which time, she never told him that she vomited 30 times a day, for fear of his finding her "disgusting" and therefore refusing to treat her. This physician failed to "read between the lines" of her symptoms and to intuit and investigate the presence of an ED from the constellation of personality traits, temperament, and behaviors that she did reveal to him. Through our work together, she came to understand her problem and her self. The quality of our relationship led to the improvement of all her significant relation-*

The unique requirements of weight management issues demand the uniquely specialized skills of an informed, intentional, and intuitive diagnostician, capable of hearing what has not yet been spoken. Within the context of initial history-taking, the nature of weight-related dysfunctions is likely to remain elusive in the absence of an active probe for problem origins in pathology. The diagnostician's enlightened line of questioning will substantiate, or negate, such a presence, revealing the subtleties of distinctions between the nature of eating behaviors as they reside along the healthy eating continuum. When eating behaviors do appear to cross the line into pathology, the diagnostician takes on the role of crisis interventionist, through immediate responsiveness to the needs of the moment through an investigation into the past. Because the patient's quality of life may depend upon assessment accuracy, the obligation for first responders or clinicians to detect, explore, and interpret issues yet to be unearthed becomes a unique challenge within the confines of the limited timeframe of a single-session weight management consultation. On high alert for potentially unseen issues, the proactive first responder must be prepared to offer psychoeducation, a plan of action, and, where appropriate, referrals to collaborating experts and/or higher-level treatment milieus. If it looks like a duck and acts like a duck, it is for the responsible practitioner to treat it like a duck, unless proven

*ships—with food, with her self, and with others.*

*Weight Management*

otherwise, even before the assignment of a definitive diagnosis.

*Esther was a 29-year-old woman who came to treatment for depression, poor selfesteem, and relationship problems. In response to her description of her college days during which she spoke of herself as perfectionistic, highly compulsive, anxious, and depressed, I chose to wonder aloud if she had ever struggled with an ED or other eating-related issues. "My God!" she responded. "How did you know? I have never told a soul!" By understanding the nature of her personality structure and recognizing characteristics of her emotional functioning, I was able to intuit and surmise the possible existence of a past ED, which upon inquiry, I discovered had yet to be fully resolved. Following the tenet of John Muir, "If we try to pick out anything by itself, we find it hitched to everything else in the universe." By following my hunch and having made this discovery, I was able to launch the ED treatment process immediately.*

Where the clinician's depth and breadth of understanding of weight management issues is limited and non-integrative, the patient is liable to leave the treatment office with a diet plan in hand, yet without a practicable and sustainable solution for pressing weight-related concerns. More significantly, the loss of a timely and poignant opportunity for the patient to discover unknown problem origins and aspects

Factors further clouding the differential diagnosis of eating-related pathology include the elusive assessment of evolving and ambiguous DE patterns, and the widespread misunderstanding and erroneous information surrounding the issues of eating, weight control, and ED. In asking my ED patients what triggered the onset of their ED, a frequently heard response is that they "started to diet in an effort to lose weight, and ultimately found themselves feeling compelled to eat 'healthier and

of self and personality represents a lost opportunity for self-reflection, selfawareness, and self-integration, all leading to healthier lifestyle choices.

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• Cardiologists, in the face of a co-occurring activity disorder that takes the form of excessive and compulsive exercise, frequently miss an ED diagnosis by attributing a low heart rate and amenorrhea to "healthy athleticism."

body which, when fed healthfully, and having reached its ideal set point weight, will predictably sustain that appropriate weight-to-height ratio indefinitely, through its own natural functions. In most cases, the healthfully fed and exercised body with a healthfully functioning metabolism needs no help from arbitrarily devised dietary interventions to sustain a healthy weight throughout one's lifetime.

*Discretion or Disorder? The Impact of Weight Management Issues on the Diagnosis…*

At times we are all a little eating dysfunctional. Bombarded by nutritional research and food fads in an age of pervasive social media, "normal" eating (i.e., eating all food groups, including moderate amounts of processed foods and sugar) is no longer considered to be "healthy" eating. Certain patterns of DE, in light of their prevalence, are becoming increasingly difficult to recognize as pathological. A study found that nearly 91% of female college students use dieting as a weight control mechanism [15], putting many of them at risk to develop a clinical ED. The prevalence of AN and BN is relatively rare among the general population [16], affecting 1% to 4% of adolescents and young adult women [17]; DE, however, which has been defined as a psychological illness, [18], and the misguided attitudes about food and weight management that lead to them, are widespread and prevalent among all age groups. The consequences of DE, which include rampant dieting and body image obsessions, can be devastating; though not the cause of eating disorders, they are often precursors to their onset. Occasional DE, as well as certain behaviors that manifest themselves in clinical ED, are not in themselves abnormal. Differentiating normalcy from pathology is best accomplished by assessing the patient's attitudes towards food and eating. Benign forms of DE are fully discretionary, dependent upon the individual's capacity for self-awareness, self-regulation, and choice-

Picky eating syndrome is a DE pattern that originates in early childhood. Typically indicative of a sensory processing disorder (SPD), food choices tend to be limited to bland "white" foods (containing sugar and flour) of specific textures. Picky eating often results in overweight. Studies show that 40% of overweight girls and 37% of overweight boys are teased/bullied about their weight by peers or family members and that traumatic experiences such as these during the formative years are predictive of weight gain, binge eating, and extreme weight control measures [14]. DE patients have experienced a higher frequency of traumas (childhood adversities in particular), especially in circumstances related to childhood obesity [18]. Childhood picky eaters who do not grow out of the condition and who become malnourished because of the limited variety of foods that they eat qualify for a diagnosis of avoidant restrictive food intake disorder (ARFID), a condition which typically extends into adulthood. Rising obesity rates, the result of DE lifestyles, clinical ED, and hereditary factors have become a major concern worldwide, especially in North America, where more than 2 in 3 adults (70.2%) are considered to be overweight or obese [19]. Obesity, DE, and ED are considered major health problems among adolescents because of their increasing prevalence in this age group and their potentially serious physical and psychosocial consequences [20, 21]. Dieting and unhealthful weight control practices lead to eating psychopathology in DE, ED, and obesity, particularly when associated with variables such as personality characteristics like perfectionism or anxious temperament, a microbial imbalance, or a genetic predisposition to be influenced by an obesogenic environment. Other possible causal mechanisms linking dieting to later problems are neurophysiological mechanisms associated with food restriction (e.g., effects on neurotransmitters that could increase risks for either obesity or ED via influences on food regulation processes) [21]. In the face of a genetic, hormonal, or metabolic predisposition to obesity, following a healthy lifestyle in which the

**4.3 Understanding disordered eating**

*DOI: http://dx.doi.org/10.5772/intechopen.92152*

making through their own free will.

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When driven by the fear of weight gain, individuals who suffer from ED, cooccurring anxiety, and obsessive-compulsive disorders (OCD), are particularly susceptible to developing activity disorders. Also known as anorexia athletica, exercise bulimia, or exercise addiction, ED individuals engage in such compensatory compulsions with the intention of burning calories. Between 40% and 80% of AN patients are prone to excessive exercise in their efforts to avoid putting on weight [13].

*Binny ran 10 miles a day, followed by 2 hours of working out. She ate no more than 750 calories a day while training regularly for countrywide marathon races. One 26.2-mile event landed her in a hospital, where her legs swelled and she required an emergency blood transfusion. Because her eating and running regime provided her with a sense of being "alive," upon release from the hospital she felt incapable of curtailing the compulsive behaviors that threatened her life. Her emergency room doctors attributed her blood disorder and amenorrhea to her athleticism, failing to recognize both conditions as signs of ED pathology.*
