The “Eating Disorder Voice”

The “Eating Disorder Voice”

By Therese S. Waterhous, PhD, RDN, CEDRD

Eating disorders are frequently misunderstood—not only by family and friends, but also by health care professionals. It is essential, in order to be helpful and effective to a person diagnosed with an eating disorder, that people understand the nature of eating disorders.

One aspect of the nature of eating disorders is the “eating disorder voice,” which most people with an eating disorder will attest to knowing. This “voice” is the near-constant dialogue or self-talk that a person experiences as a result of the illness and makes it feel as though one has two brains. There is the healthy brain, which recalls what life was like before the eating disorder. The healthy brain voice remembers enjoying food, not thinking about food all the time, not overanalyzing every aspect about food, and not torturing the person with thoughts about having eaten too much, where and how to purge next, and getting fat. The eating disorder part of the brain, or the “eating disorder voice,” is the monkey on one’s back that feeds the stream of lies about both food and body. Researchers have identified this “voice” and state that it can be helpful for clinicians to address it with a person both in terms of content and how the person with an eating disorder responds to it.1 In addition, research has shown that a more powerful eating disorder voice is associated with a lower body mass index in those with restricting-type eating disorders.2

It is advantageous to the individual with the eating disorder for that person’s treatment providers and family and loved ones to know and understand what that voice says and how to respond to it.

Some situations and examples:

A person has anorexia nervosa and compulsive-exercise or exercise-purging behaviors. The individual states that he cannot eat unless he exercises or “burns off” enough calories, or he states that he can’t be still, as movement helps him relax. Yes, movement does help most people relax, but excess movement (movement that continues despite pain, exhaustion, and too little fuel) is the work of an eating disorder. Professionals, family, and friends do not need to give in to the individual’s pleas to continue to work out, stay in competitive sports, etc., as those pleas are the voice of the eating disorder.

The “eating disorder voice” will create intense negotiations over how much food to eat, or it will create food rules about what foods are “good” and what foods are “bad” or when and how to eat. This is seen in all eating disorders, including binge eating disorder. You might notice that it takes a person a very long time to make up her mind about what to eat. Or, if this person eats one thing, she can’t eat another thing. It is helpful for supportive others to call out reality here. Tell the person in a kind manner what you notice, and then separate the illness from the person. Say something like, “I notice that if you eat bacon, you will not put butter on your toast.” This occurs because the “eating disorder voice” might be saying something about “too much fat.” Especially if this is a person who restricts and needs to gain weight, call out the reality that her restriction is what is unhealthy, that she does need to gain weight, and that this one meal is not going to result in any type of drastic physical change. Tell her that you are sorry the “eating disorder voice” is making this hard, but that you understand. This is a time when knowing the nature of eating disorders—that this person is not choosing to have an eating disorder, that she really does want to be a normal eater, and that she is frightened and anxious—can be quite useful. It has been suggested that one way to discuss the “eating disorder voice” or negative self-talk is to frame it as “an abusive relationship.” Eating disorder self-talk that is abusive in nature is strongly associated with illness severity.3

Understand that eating disorders are promoted when a person experiences increased anxiety, and prepare for those times, as this is when the “eating disorder voice” will get louder and stronger. State this in advance of transitions and other anxiety-provoking situations. For example, when a person with an eating disorder goes to a new place to eat, talk ahead of time about whether this could contribute to anxiety. Talk about what the eating disorder might say. Join to come up with coping strategies ahead of time. Prepare in advance by looking at menus before the outing, and preplan what to order. Develop the plan ahead of time and talk about potentially triggering situations, as this helps diffuse the “eating disorder voice.” Talking out loud when the “eating disorder voice” is screaming can help diminish that voice.

The “eating disorder voice” can be very nasty. Many health care professionals, family, and friends, at times, find it hard to not take personally what the “eating disorder voice” can dish out. Don’t! If you understand the nature of eating disorders, you will know to not take that voice personally. It is the voice of delusion and fear. It is the eating disorder protecting itself. Stay calm, even when you are being yelled at. Later, you can state that you understand that the person did not want to hurt or insult you and you are sorry the “eating disorder voice” made it so hard on them. Many people with an eating disorder feel terrible if they have become enraged as a result of their illness. They feel bad enough and do not need a lecture from us. Rather, they need compassionate understanding, and they need us to get on their side against the eating disorder and its “voice.”

About the author:

Therese S. Waterhous PhD/RDN, CEDRD is an eating disorder expert in private practice in Corvallis, Oregon. She has worked with families and their children for over 25 years, having completed a pediatric fellowship at the University of Alabama at Birmingham during graduate school. Therese was one of the founding board members for the international non profit advocacy group FEAST-ED (Families Empowered and Supporting Treatment for Eating Disorders) and she has worked with the Eating Disorders Coalition during one of its the Washington DC lobbying days.

Therese co-authored the ADA Practice Paper on nutrition interventions in eating disorders. She is immediate past Director of the Sports, Cardiovascular and Wellness nutrition practice group’s subunit on disordered eating and eating disorders. Dr. Waterhous is a professional advisor for FEAST-ED.org. and has served on the board of the Oregon IAEDP (International Assn. of Eating Disorders Professionals) chapter. She has been active in the International Academy for Eating Disorders, serving as co-chair of the Family Based Treatment SIG, serving as a member of the Partnership, Chapter and Affiliate committee and currently serving on the Medical Care Standards Committee.

Therese recently received a health transformation grant from the Intercommunity Health Network Coordinated Care Organization to advance provider training in eating disorder evaluation and treatment.

References:

1.     Tartakovsky, M. The voice of an eating disorder. Retrieved from

2.     Pugh, M., & Waller, G. (2017). Understanding the ‘anorexic voice’ in anorexia nervosa. Clinical Psychology & Psychotherapy, 24(3), 670-676. DOI: 10.1002/cpp.2034

3.     Pugh, M., & Waller, G. (2016). The anorexic voice and severity of eating pathology in anorexia nervosa. International Journal of Eating Disorders, 49(6), 622-625. DOI: 10.1002/eat.22499

4.     Scott, N., Hanstock, T.L., & Thornton, C. (2014). Dysfunctional self-talk associated with eating disorder severity and symptomatology, Journal of Eating Disorders, 2,14. DOI: 10.1186/2050-2974-2-14

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