Introduction
Eating disorders are complex conditions, particularly during the adolescent years. 95% of those with eating disorders are between the ages of 12 to 25, with anorexia nervosa being the third most common chronic illness among adolescents (“Exploring the Physical and Emotional Complexities of Eating Disorders”, 2024).
As a therapist who specializes in working with teens and eating disorders, I have seen firsthand the complexities of eating disorders for teens, their families, and their treatment teams. Understanding these complexities can help provide effective treatment for these adolescents.
Medical Impacts
One reason that eating disorders are so complex is because of the medical and physical complications that can arise from them. Eating disorders have the highest mortality rate compared to any other mental health conditions (“Exploring the Physical and Emotional Complexities of Eating Disorders”, 2024). Patients with anorexia nervosa, a condition in which all major organ systems are impacted, may develop a lack of menses in people with uteruses, low heart rate, low energy, osteoporosis, hypotension, changes to skin and hair texture, anemia, structural changes to the brain, and dehydration (Lock & LeGrange, 2015).
As you can see, the potential medical and physical complications of these disorders are vast and quite concerning. While seeing these medical complications written out can certainly be scary and jarring, there are treatments that can help! Additionally, if parents really understand the seriousness of eating disorders, they can be big helpers in their teen’s weight restoration process and recovery. Without adequate understanding of these potential complications, there may not be the urgency needed for tackling the eating disorder. Family-based treatment (FBT) enlists parents in helping their teen recover from their eating problem.
Digging Deeper: Ego-syntonic, Ego-Alien, and Stigma
Another complicating factor for eating disorders, particularly anorexia nervosa, is that it is considered ego-syntonic. Ego-syntonic means that someone’s actions align with their values and goals. Therefore, someone with anorexia nervosa may not see their restrictive eating behavior as problematic and may even see it as positive because they want to be thin and avoid weight gain at all costs (Lock & LeGrange, 2015). Teens may have many people in their lives express concern about their eating habits or weight loss, but they are happy that what they are doing is “working.” Sometimes comments from friends and family about weight loss could even reinforce their disordered eating behavior, resulting in them doing it even more. 
Ego-alien behaviors are behaviors that people feel shame and embarrassment about. People with bulimia nervosa often feel shame about their binge/purge behaviors. This shame can get in the way of people seeking treatment (Lock & LeGrange, 2015). Shame tells people to hide, and person struggling with binging and purging behaviors may not get the help that they need because of it. They may hide what they are doing and be secretive about it – sometimes people run the shower to cover up vomiting noises or hide wrappers from food consumed during a binge. Secretive behavior can keep the eating disorder alive, and being aware of the signs is crucial in spotting and treating the eating disorder.
Stigma means that people hold negative, inaccurate beliefs about a group of people. According to Hudson et al. (2007), over 70% of those who suffer with eating disorders do not receive treatment because of stigma. Examples of this include the incorrect perception that their condition “isn’t that bad” and they “should be able to tackle it on their own without treatment.”
Cognitive Distortions
Cognitive distortions are a psychological factor that both complicate and maintain eating disorders. As mentioned above, because of the ego-syntonic nature of the eating disorder, people who experience them will likely deny the seriousness of their eating problem (Lock & LeGrange, 2015).
For adolescents with eating disorders, their brain is not functioning properly as a side effect of starvation, and reason and logic will not be effective in getting them to stop having an eating disorder. An underweight person will need to have their weight restored in order to think in effective ways (Lock & LeGrange, 2015). Additionally, starvation makes people become preoccupied with weight and food. People with anorexia nervosa lose sight of accomplishments and become hyper-focused on things such as weight gain being a “failure”, even if those “failures” are only their perception and not the reality (Lock & LeGrange, 2015).
If individuals with eating disorders are praised for losing weight (as with Restrictive Food Intake Disorder, Anorexia, etc.) this positive reinforcement can make the individual believe they are “good” at having an eating disorder, resulting in the eating disorder taking an even stronger hold. For some people with eating disorders, it feels as though it has complete control over their life and there is an intense fear of change. A developmental need for adolescents is to become more independent, though the adolescent will need parental involvement to help with the eating problem. The malnourished adolescent brain can see parents as the enemy when the true enemy is the eating disorder (Lock & LeGrange, 2015).
Along with this sense of control, adolescents may focus on food or appearance because that feels “easier” than focusing on life’s struggles, such as break ups, life transitions, or conflict (Lock & LeGrange). Similarly, purging can give a sense of relief and can be a coping strategy for life’s problems in bulimia nervosa (Lock & LeGrange, 2015). Teens with eating disorders may have distorted perceptions about how much food has been consumed. Distorted body image and low self esteem are cornerstones of eating disorders (Lock & LeGrange, 2015). There are a lot of different ways that thinking errors perpetuate eating disorder behavior.
Sociocultural Factors
There is a beauty ideal of thinness that is portrayed in the media which often results in people experiencing body dissatisfaction. People, particularly people assigned female at birth, are inundated with messages about having to look a certain way. People can then begin to associate thinness with success or other positive outcomes. Some popular messages right now are to eat a carnivore diet, do mewing exercises to have a “better” jawline, and to be thin and toned. Social media influencers emphasize what they eat in a day, what their exercise routine is, only show their body at certain angles and use filters to change their appearance. People seeing the videos may try to look like them and may have a fear of weight gain. There are also ads with thin and photoshopped models, though the average American woman is between size 16 and 18 (Nunes, 2024). Billboards display ads for plastic surgery for a flatter stomach.
It’s no wonder that these societal pressures to be thin contribute to disordered eating behavior! These societal pressures correlate to some of the cognitive distortions mentioned above, such as putting too much emphasis on appearance, rather than other areas of life, and low self esteem. One’s self worth can become intertwined with how they look, often stemming from these cultural beauty ideals. Additionally, the media can misrepresent what it means to be healthy, putting an emphasis on low fat foods, dieting, and intense exercise regimens, which in the hands of someone with an eating disorder can be quite problematic (Lock & LeGrange, 2015).
Biological Factors
Biological factors can contribute to individuals developing an eating disorder. Research suggests that genetic factors make up over half of the risk factors for developing an eating disorder. Family history of anorexia nervosa makes individuals 12 times more likely to develop the disorder, and abnormalities in neurotransmitters including serotonin, dopamine, and norepinephrine are all involved in the development of eating disorders (“Exploring the Physical and Emotional Complexities of Eating Disorders”, 2024).
Parental Issues
Another complicating factor with treating eating disorders in teens is their parents. Conflict can happen between parents and their teenagers in a typical family dynamic. There can be even more conflict when an eating disorder is part of the picture. Teens with eating disorders may not see the eating disorder as a problem. Parents can become frustrated when trying to get their teen to address their eating disorder. Sometimes teens
might lie about how much they are eating as a way to continue engaging in eating disorder behavior (often the case with Binge-Eating Disorder, Bulimia and Anorexia). Additionally, because an eating disorder can affect the size of the stomach, a teen might become full after only a few bites. A parent can work with their teen in Family-Based Treatment and has to be diligent to understand how much food is actually being consumed, as a teen with an eating disorder who says they ate a sandwich might have only had a few bites (Lock & LeGrange, 2015). Teens might feel a loss of control; like they are losing independence during the eating disorder treatment process, though their parents are just trying to help them get back to a healthy weight. Parents may disagree with each other on how to approach the eating disorder.
It is very important for parents to be a united front in how they help their teenager manage their eating disorder, otherwise the unhealthy behaviors may slip through the cracks. Sometimes parents might be reluctant to take the necessary steps to help their child because they blame themselves for their child developing an eating disorder or feel like treatment is a punishment. As teens begin to recover from their eating disorders, parents may also be hesitant to give back age-appropriate control over eating to their adolescent (Lock & LeGrange, 2015).
Getting Help
Therapy can help treat eating disorders! Therapy assists parents and teens in separating the eating disorder from the client. Clients begin to dismiss what the eating disorder tells them to do. Therapists provide support to parents in helping their teens develop healthy eating behaviors. Once a client has returned to healthy weight, therapy can then help with mindful or intuitive eating. Therapy helps adolescents with eating disorders get back to who they are. In a training I attended, the trainer said it is like “the lights turn back on.” Through recovery, teens become more vibrant, joke around with friends and family, and participate in activities they enjoy.
Conclusion
As you can see eating disorders are complex conditions, especially in adolescence. Medical complications,
cognitive distortions, family conflict, and more can be contributing factors to this complexity. You don’t have to go through this alone. Therapy can help.
If you or a loved one are struggling with an eating disorder, contact Sentier’s Client Care Coordinator at [email protected] to schedule a consultation.
Blog written by Sentier therapist Andrea Schroeder, MS, LPCC.
Sources:
Exploring the physical and emotional complexities of eating disorders. (2024) Power Pak. https://www.powerpak.com/course/print/120996
Hudson J, Hiripi E, Pope H, Kessler R. The prevalence and correlates of eating disorders in the national comorbidity survey replication. Biological Psychiatry. 2007;61(3):348–58.
Lock, J. & LeGrange, D. (2015). Help Your Teenager Beat an Eating Disorder. The Guilford Press.
Nunes, Mary (2024). The “Healthiest” Weight Range Is Different for Every Body—Here’s What to Know. Byrdie. https://www.byrdie.com/average-body-weight
