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In eating disorder treatment, a client’s nutrition status and ability to regulate their nervous systems are intertwined. A body and brain struggling with nourishment is a body in distress and a brain that doesn’t have the capacity to engage in higher-level healing. When the sympathetic nervous system rules, the client is stuck in survival mode.
The vagus nerve is like an information superhighway in our body, providing a two-way connection between the brain and our face, heart, respiratory system, and gut.
The Polyvagal Theory, developed by Dr. Stephen Porges, revolutionized our understanding of how our body responds to and processes stress and trauma.1
The theory proposes that the evolution of the autonomic nervous system (ANS) provides neurophysiological substrates (a part of the nervous system that underlies a specific behavior or psychological state) for adaptive behavioral strategies to deal with stress.2
The theory provides a possible explanation for the correlation between atypical ANS regulation (such as reduced vagal activity) and psychiatric disorders that involve issues regulating appropriate social, communication, and emotional behaviors, like eating disorders.
Porges discovered that trauma and stress are a lot more nuanced than previously thought, with there being multiple states of nervous system activation:2,3
We move through the polyvagal states at various times, which can be visualized as moving up and down the rungs of a ladder.4 The stressors (including trauma) we experience can cause us to move up from social engagement to sympathetic activation. However, our body cannot sustain this state for long periods, so as an act of self-preservation the body may enter dorsal vagal shutdown.
Both sympathetic activation and dorsal vagal shutdown are survival states, which can sensitize us to pain, affect how threatening we see the world (very), and can change our perception of our own reality.
Being in these dis-regulated states, energy levels are low and the body is diverting resources away from replenishing itself e.g. in the sympathetic activation state, the body is not focusing on digestion, but instead preparing the body to respond to the perceived threat. Over time this can impair digestive function, recovery, cognitive function, and the ability to connect to others.
According to the polyvagal theory, an eating disorder appears when ingestive behaviors replace social behavior as a primary regulator of the autonomic state i.e disordered eating behaviors are used as a way to regulate the autonomic state to soothe, calm and “feel safe”. Eating disorders can also be an indication that a person is unable to regulate the autonomic state with social behaviors.5
When in sympathetic activation eating disorders can present in disordered eating thoughts and behaviors, such as obsessive thoughts about food, food rituals, loss of appetite, bingeing, restriction, over-exercising, and self-harm behaviors, in an effort to self-soothe or calm themselves.
The shutdown phase presents itself in eating disorders via the symptoms of irritable bowel syndrome, the desire to disappear, and using extreme measures to feel, which can be disordered eating behaviors or risk-taking activities, like extreme sports.
Trauma and eating disorders interfere with a person’s ability to relate to self, others, and self-in-space distorting the "ceptions":
Some eating disorder symptoms involve heightened interoception, particularly related to the gut or enteric nervous system. These people may feel bloated or nauseated, or find the act of digestion extremely uncomfortable. Coupled with a dorsal vagal (below the diaphragm) fear response, they may feel full or lack appetite, despite not eating for a period of time.5
For example, those living with anorexia may be instinctively afraid to eat because their body is telling them it’s dangerous.
Other individuals with eating disorders may display dulled interoception, which means they can't recognize internal signs, such as hunger or satiety cues. Dulled interoception is typically associated with more dissociated disordered eating behaviors, like bingeing and purging. Dissociation is a protective response to stress and trauma.5
Insidious diet culture permeates every aspect of our society, from medicine to headline news, to the playground to the dinner table, and almost everywhere in between. Diet culture’s ideas are taught in schools and reinforced by doctors, peer groups, social media, families, and employers.
With roots in racism, misogyny, capitalism, and colonialism, diet culture teaches that acceptable and valuable bodies come in one small size (or in those that strive to be that size). The further away from this idealized body type a person is the less value they have and therefore the less access they should have to the privileges afforded to those matting the socially accepted beauty standards. In this way, diet culture promotes the idea that value is earned and not intrinsic.
The trauma of diet culture can make a person feel severed from the safety and acceptance of the community and an eating disorder can emerge as an early balm for the wounds of trauma, which can further fray an already insecure attachment.
Along the way, clients with eating disorders may experience increasing anosognosia, i.e., don’t believe that they are sick or have a problem with disordered eating. It’s hard to recognize "sick enough" when a culture idolizes thinness and the eating disorder has become a key attachment figure.
Fear of fatness doesn’t just cause serious harm via the specific discrimination felt by those in larger bodies, but “average” and small bodies are traumatized by diet culture as well.
Diet culture provides no space for diversity and denies decades of research that disproves harmful diet culture beliefs such as:
Whether trauma is event-related or ongoing (as with the ubiquitous nature of diet culture), the impact of trauma is seen in the physiological, psychological, and socioenvironmental experiences of clients.
Prolonged exposure to trauma impacts the brain creating physiological and functional changes to the limbic system (the part of the brain involved in our behavioral and emotional responses). This includes increased responses of hormones and neurotransmitters involved in “flight or fight” to subsequent stressors, which can persist in the long term. Other symptoms of trauma include:
Trauma distorts the connection between mind and body and when the trauma remains in the body, it will emerge in behavior, the somatic experience of self, and through the relationship with the eating disorder via heightened anxiety surrounding food, social situations, and body perception.
In treatment, a key factor for clients is gently increasing facility with the "ceptions" and helping them to regulate a limbic system that may be in overdrive.
Attachment theory is invaluable in treating clients with eating disorders as it respects the relationship between the patient and therapist as a significant step towards recovery.
When we are young, we develop templates for how the world works and where we fit into it. These templates are based on our early relationships with our primary caregivers and their ability to self-regulate.
Emotionally supportive and comforting caregivers are available during times of stress and trauma throughout childhood, enabling the child to develop a sense of self-security, self-trust, and a sense of safety in their environments and relationships.
By contrast, if a child grows up with primary caregivers who are inconsistent, reject their needs, or invalidate their trauma, may start to see themselves as unloveable or inadequate. Consequently, they may develop an insecure attachment style.6
While a person’s attachment style is formulated in their early years, it’s not fixed and can shift throughout life and in the context of individual relationships. Secure attachment can be earned, just as trauma can injure attachment.
The attachment style that we develop is vital in the management of developmental life changes, such as physical changes, forming a strong sense of self, and setting life goals. Put simply, our attachment styles act as a barrier to potential psychological harm.6
There are four main attachment styles: Secure and three Insecure attachment styles (anxious, avoidant, and disorganized)
Having an insecure attachment style is a risk factor for developing an eating disorder and association is likely mediated by affect dysregulation associated with trauma (inability to regulate and/or tolerate negative emotional states) and perfectionism.7
Insecure attachment has also been found to be a risk for disordered eating patterns that don’t meet the threshold for an eating disorder diagnosis, such as compulsive eating, heightened focus on appearance, and chronic restrained eating.6
Also, evidence indicates that insecure attachment is linked to eating disorder signs before it fully manifests, such as weight concerns, binge eating, skipping meals, and dissatisfaction with body shape.6 This indicates that eating disorder symptoms may be the outward expression of the emotional and psychological issues that commonly result from insecure attachment styles.
While it should be said that not every person with an insecure attachment style will develop an eating disorder, there are certain traits of insecure attachers that put them at higher risk:6
The therapeutic relationship between a client and a registered dietician or therapist can itself act as a stimulant for shifting insecure attachment styles in clients.8 If a therapist is emotionally attuned to the client and offers stable boundaries, and a safe place, they can play a key role in helping insecure attachers to form a healthy attachment relationship.
Practicing from an attachment theory perspective requires you to have a handle on your own emotions and psychology. Attachment theory is not always a comfortable lens from which to practice and therefore requires compassion and empathy, and the ability to tolerate a certain level of dependency from clients.9
Take a thorough history from your client to assess for signs and symptoms of hyper/hypo-activation from day one.
Help clients identify body language for different sensations, starting with what they can already identify and as questions to explore more, such as:
As somatic (related to the body, but distinct from the mind) awareness focuses on bodily sensations and regulating the emotional system it can teach clients better thinking patterns and help rewire the brain to form a productive balance. This can give clients greater awareness of their internal experiences, emotions, and sensations, like hunger cues.
Somatic experiencing is a specific approach to somatic therapy, based on the idea that trauma can lead to dysfunction in the nervous system. The goal is to help clients to address the trauma that lingers in the body, not by examining memories or emotions but to uncover the bodily sensation linked to those thoughts and feelings.10
For many clients, the eating disorder has become the primary attachment figure, and this relationship is abusive. The eating disorder uses threats, shame, false promises, isolation, and cruelty to further its cause.
An important role of the therapist and other clinicians on the treatment team is to help the client increase response flexibility so they can begin to transfer the attachment from the eating disorder to the team. Then they can begin the process of building self-trust, self-compassion, and a sense of security within the self, as well as the ability to have healthy inter-reliance in relationships.
Part of trauma-informed care includes understanding what your client is getting from their eating disorder and how it has become their key attachment figure, place of safety, and/or connection to the community via engaging in diet culture. In your client, the eating disorder may be providing:
Trauma-informed care respects client autonomy, and pace, and provides support as the client learns to increase their window of tolerance and exit the sometimes dissociative state of the eating disorder.
Somatic practices and helping clients swing through dysregulation and back into the window of tolerance are important parts of trauma-informed care.
Before working with eating disorder clients, it’s important to explore and address your own entrenched and harmful weight bias and fatphobia, perpetuated by diet culture.
Regardless of body size, people seeking treatment for eating disorders struggle with nutrition and this can have a significant impact on cognitive capacity and flexibility, fight-flight-freeze-fawn response, and ability to connect.
As most people living with eating disorders are insecure attachers, fostering the growth of gentle and consistent trust and allowing the occurrence of co-regulation—to build towards healing attachment—are key.