Listen to the podcast and view the transcript

[1:15] Early childhood weight loss
[4:50] Food as a reward
[6:28] Predispositions and risk factors
[12:46] The impact of trauma
[21:33] Loneliness
[25:44] The role of the media
[30:04] Nervous system and personality changes
[36:22] Early-stage recovery and the spectrum of eating disorders
[47:27] Gut health and orthorexia
[54:42] Chronic pain and neurochemical changes
[1:00:50] Thyroid dysregulation
[1:08:25] Recovery

Danny Urbinder: Eating disorders are serious mental health conditions that involve an unhealthy relationship with food, eating, exercise and body shape. For those affected, the physical and emotional repercussions can be overwhelming, impacting many aspects of health, as well as family and social wellbeing. In Australia, it’s estimated that 4 in every 100 people are affected and about 1 in 7 will experience an eating disorder in their lifetime. Those numbers have been increasing over the past 50 years, while at the same time, the age of onset appears to be decreasing and also includes a growing incidence among adolescent boys. In this episode of patient journeys, we hear from Natalie Douglas who, from the ages of 13 to 22, suffered from multiple eating disorders. As Natalie describes her many challenges, frustrations and lessons, you’ll also hear commentary from a range of relevant experts to provide important insights along the way. Natalie first went on to describe her early childhood, before she became unwell.

Natalie Douglas: Yeah, so I mean it started quite early. So, I grew up, you know, up until I was about twelve and a half, I had, I ate a lot of food, like overate. And I was quite chubby, but I wasn’t aware that I was overweight, it was just not on my radar kind of thing. Even though I did get teased occasionally for being “fat” as children would word it, it wasn’t in my awareness. And, then what happened was when I was about twelve and a half or twelve, I think, my grandma on my dad’s side passed away, and I had quite a very familiar relationship with her. We weren’t close in terms of sharing all of our feelings, but I lived with her for quite a long time and so she was very much part of my world. And, when she passed away it was quite traumatic for me because we’d also looked after her because she had Alzheimer's disease and I was involved a lot, as much as a 12-year-old can be, in helping her manage that.

And, I think I stopped eating as much, not out of ‘I want to lose weight’ just out of I was upset, and my natural reaction was ‘I'm not hungry, I'm gonna not eat because I don’t feel hungry’. And, because I’d gone from such a contrast of eating so much to not eating very much, I started to lose weight and I got a lot of attention for that. So I got a lot of, ‘oh wow, you’ve lost weight, what have you been doing?’.

I think I was in year 7 when that attention really started to happen, year 7 or 8 and I really liked that because my personality from a very young age was quite competitive; always into sports, always wanting to be the best at things. And, so I got this attention and I thought, ‘oh I like this so I'm going to keep going at this and I'm going to get better at it.’ And, it wasn’t like it was a conscious choice like, ‘oh I'm going to get better at being anorexic’ because I wasn’t necessarily there yet. But, I was losing weight and starting to look into calories and exercise and, at first, it started off as just trying to eat really healthy and then it gradually went down that calorie counting path and I just started to get addicted to the attention of, you know, what I was getting from losing weight.

Gabe Covino: Yes, overweight children going on to manipulate their intake into adulthood, yeah, or late adolescence, absolutely. And, I think that kids can be cruel and bully and say things about you when you're overweight.

Danny Urbinder: That's Gabe Covino, a naturopath with a strong focus on clinical nutrition and a special interest in eating disorders.

Gabe Covino: And, then have positive reinforcement when you do lose weight and people say ‘you look fantastic, oh my god’. And, you know, they’re largely well-intentioned, but it can absolutely feed into that personal ideal that you’ve got and then feed into what your idea of your ideal body image looks like. But, I think in Natalie’s case, what I heard was it was very nice to hear really positive reinforcement about herself and positive reinforcement about her choices. And, you know, that ended up becoming obviously extreme and fuelled and sustained that kind of thinking for a while until it expressed itself as a full eating disorder. But, I think that it’s a common thing, the language that’s used around weight, when you have been carrying weight as a child, is really affirming.

Natalie Douglas: My mum never cared about her weight and I never, she never made comment on her weight or on my own weight. She was never funny around food, nothing like that. My dad used food as a reward and my brother and I were rewarded with food and distracted with food a lot, but there was no body-image necessarily related stuff in my family that was in my immediate environment at home.

Gabe Covino: Natalie had that kind of reinforcement about food as a reward and this is a really common thing that’s done in childhood. And, that can make us look at food in a different way other than nourishing our body and being a source of nutrients that we require to grow and be strong and healthy.

Dr Jeffrey DeSarbo: So, it’s not uncommon for a father or parent or anyone in today's culture we do reward people with food, we reward ourselves with food.

Danny Urbinder: You're listening to Dr Jeffrey DeSarbo, a physician and psychiatrist whose special interest is in how bio-neurological factors correlate with eating disorders and mental health conditions.

Dr Jeffrey DeSarbo: Because food can be used as a reward and it makes us feel good and it elevates our dopamine, it doesn’t mean that alone is going to cause an eating disorder. You have to kind of have that genetic predisposition kind of set up and then that starts to be one of the factors that usually, you know, you need several different factors that trigger the onset of an eating disorder. So, again, a lot of times with families, its parents sometimes worry ‘did I cause this, did I cause that, it's more or less like, well, the genetics may have been there, but one factor alone isn’t usually enough to set something like that in motion.

Natalie Douglas: There’s definitely, there’s bipolar in my family on my dad's side and there’s also, my brother also definitely has, or had anxiety. I’m homozygous for the MTHFR C677T gene, and so, and I also firmly believe the way I ate both pre and during that anorexic journey was largely like, not very nutrient-dense. I would have definitely had a zinc deficiency and multiple B vitamin deficiencies, especially when I was going through anorexia, because the way that I approached it, or the way that I did it was very much a reflection, I guess, of the era we’re in. It was very low fat and lean protein and it just got more and more restrictive and I would say the main things that I ate were, I would pick a particular fruit or a particular vegetable to just eat a lot of for a period of time. And, so I really was not eating the amount of nutrients that I needed to, so there’s that. And, then also, there is autoimmunity in my family, particularly celiac disease and I don’t recall having really overt gut issues growing up, but also I wasn’t very tuned in to my body full stop. So, I don’t know whether that, you know, was playing out or not. And, I also, there is also kind of a lot of dementia and Alzheimer's in my family as well, on both sides.

Danny Urbinder: None of the factors that Natalie has described is, in themselves, a direct cause of eating disorders. However, when taken together they do paint a picture of her predispositions and risks. As Dr DeSarbo described, several factors affect the development of eating disorders, these include genetic factors, diet, stress, drugs and environmental factors. In Natalie’s case, having a poor diet prior to her developing anorexia is a commonly observed pattern. While nutritional deficiencies can certainly be caused by eating disorders, what should also be understood is that nutritional deficiencies can also be associated with their development. Natalie identified that she was likely deficient in zinc and B complex vitamins, key nutrients for normal brain function and neurotransmitter production. One study looking at the association of zinc deficiency and childhood-onset anorexia nervosa found that zinc deficiency could add to the chronicity of anorexia and appears to be secondary to self-starvation. Regarding Natalie’s family history of bipolar disorder, research has shown that patients with anorexia nervosa who present with a personal or family history of bipolar disorder had an earlier onset of anorexia nervosa, more numerous hospitalisations, more suicide attempts and more psychiatric comorbidities. Also, the fact that Natalie is homozygous for MTHFR C677T, seems to be significant. A study from 2021 found that girls with anorexia nervosa had over 2 and a half times the odds of carrying an MTHFR polymorphism, which is also associated with greater weight loss. There is also evidence of epigenetic dysregulation in patients with anorexia nervosa showing a significant reduction of DNA methylation which can switch on those genes associated with the disease.

Natalie Douglas: I think for me it was a lot about control and distraction. So, my home environment was quite unsettled, like my parents separated a couple of years before I had an, I got the eating disorder. And I was, you know, my dad moved homes a lot, so I was quite unsettled. And, then at my own home, we kind of had different people living with my mum and then moving out and then coming back in. Not that were necessarily partners, but just, you know, roommates kind of thing. And, my whole home environment felt very unsettling and so I think one of the ways that I used to self soothe is to control food and at one point I think it was to eat food and get that dopamine hit and then it became about controlling food because everything outside of me was kind of out of my control whereas, I knew that I could control this part.

Dr Jeffrey DeSarbo: Ahh, yes, especially when you're looking at her age at the time of that, that it can be a very traumatic experience to have parents who go through a divorce and perhaps the environment surrounding that situation in the home. So, a child you know, they’re not thinking, they don’t control their emotions. Feelings come about and it’s not something you can take out and manipulate. It’s not something you can measure even how, you know, you don’t say I’m 11 and have depression today, you know. A child is just experiencing and feeling these things and so sometimes that aspect of control is a key feature because you can control what you eat. You can control what goes in, you can control what goes out, people try to control a number on a scale, they try to control what they look like. So, the aspect of an eating disorder for many people it’s that concept that there’s an issue of control. I can’t control aspects of my life or my feelings or my emotions, so I'll just focus on controlling this. And, that becomes a key question when I'm working with a patient. My key question of how I follow where they are and how they progress is I ask them the question; 'what percentage of your thoughts do you think about food, body image, calories, exercise, weight’ and most people, when they’re in an acute state, they’re saying 90-100%, you know. So, that’s controlling their thoughts, they think they’re in control of those thoughts, but in the reality, their mind is actually out of control with those thoughts. But, it still provides a sense of comfort.

Natalie Douglas: I never was like, physically or sexually abused, but very much emotionally, and manipulated a lot, and it’s hard, it was hard at the moment because I couldn’t recognise that’s what was happening in terms of emotional manipulation. Particularly, within my family, like coming from my dad's side, there was a lot of that and there was also a lot of, with the environment I was in around adults, it was very, nothing was very stable. So, what I mean by that is, that it’s almost like the trauma was that because I didn’t feel safe or didn’t feel like I belonged anywhere.

It was like my nervous system was constantly switched on from that. And, that really only started to happen a couple of years before I got the eating disorder. And, the real triggering event was more so, just noticing that I started to lose weight, as I said, with my grandma and stuff. But, I would say that’s not necessarily the underlying factor. I think the underlying factor was, the trauma was my environment was out of my control, and so I felt constantly unsettled and unsure of where I stood or what I could and couldn’t do. You know, how I could seek love or seek belonging and it just kind of wasn’t very predictable. Whereas with this, I knew what I had to do and I knew I could do it, and it was almost like an internal self-creation of safety because it was okay, like, if I control my food and I achieve this, I know I’m gonna feel a little bit better and it's predictable and I am the one in control of this. I don’t have to rely on this external environment that I can’t figure out.

Gabe Covino: So look, I think trauma and family dynamic contribute to eating disorders. So again, that kind of that psychological, looking at the collision of different components, trauma is absolutely something that sits in the background, commonly. And, this is why it’s very important that practitioners have strong mental health literacy. They need to understand that component of it. And, we also know that the developing brain is impacted by trauma as well and the shaping of the brain and the development of the brain is shaped by trauma and kind of pruned in a different way. And, because of the age and the time in the life span where we see this increased prevalence in eating disorders and the onset of eating disorders, the trauma and childhood trauma, one theory that’s postulated is that the reshaping of the brain has kind of predisposed to different neurobiology than you might otherwise have.

Marci Evans: What we do know, is that individuals who develop an eating disorder do have higher rates of PTSD and trauma histories than the typical population.

Danny Urbinder: That's Marci Evans, a registered dietitian who’s dedicated her career to counselling, supervising and teaching in the field of eating disorders. In particular, she’s known for her expertise related to the intersection of gut health and eating disorders and is currently focused on the role of trauma.

Marci Evans: So, if we think about, and I'm not a trauma expert, but generally, I think about trauma as being an event or set of events that, for whatever reason, was far more than a person could manage at that time. It was too big, it was too much, it was too fast, it was overwhelming to the person's system, their sense of safety in the world. So, it is completely reasonable that in the context of experiencing something that is too much and unmanageable that different strategies are discovered and eating disorders are very effective in the beginning strategies. When a person is either psychologically preoccupied with food, what they’re eating, what they’re not eating, or they’re so deprived that their brain can’t think about anything but food, its a very clever way to push away past events that were too overwhelming to be dealing with. And so, there you have the perfect coping mechanism that becomes this sort of centralising focus in their life, and they’re very organising.

Dr Jeffrey DeSarbo: Right, well trauma is usually present in anywhere from 30-60% of the cases, and if your talking about people who often are admitted to residential treatment facilities, I’ve always found it to be, you're having trauma in 60% or more of the patients. And, so we’ve mentioned the food as a reward, and her parents being separated and now there’s this additional, her grandma passes away, very traumatic event in her life. And, those triggers is that concept of genetics we call epigenetics. It’s like, you can be predisposed to develop a condition, and then these triggers kind of cause this chemical formulation to take place on the DNA strand to activate it, it turns on those genes. And, that’s where you see the eating disorder start to either become more serious, develop in its full intensity, so trauma is one of the leading factors. The death of a parent, the death of a grandma, ultimately comes back to that sense of feeling alone.

Danny Urbinder: Molecular genetic studies have shown that the development of eating disorders are associated with the activation of genes linked to such factors as mood, anxiety, impulse regulation, appetite, body weight, and related metabolic factors. This gene activation process is understood to be commonly triggered by stressors occurring in infancy and childhood. Dopaminergic genes have also been of particular interest due to their relationship with pleasure and reward. A 2010 study of patients with anorexia nervosa showed elevated expression of dopamine transporter genes due to hypermethylation of the genes promoter region. Most epigenetic studies have focused on the methylation of genes that have been studied previously in eating disorders and have shown how environmental factors such as childhood trauma and abuse can switch on genetic susceptibilities related to eating disorders.

Dr Jeffrey DeSarbo: Well, by its very nature, trauma has a significant intensity to it as opposed to our daily stressors. So, and when we do talk about stress and things like cortisol as our stress hormone and everything, one of the regions that will affect, and cortisol effects, is the hippocampus, which is involved so much in emotional memory.

And, in childhood development, when traumas happen at a younger age, the thinking cortex hasn’t fully developed. So, I always say a young person's brain is an emotional brain. And, they have these things take place that they don’t know why they happened, they don’t feel they have a sense of control and it caused this real intense emotional feeling inside. That’s being stored in the hippocampal area amongst other areas, as well. And, you’re hardwiring that part of the brain early on, okay.

So, I always say, the experiences one individual has compared to another is what colours their world. It’s what makes one person grow up and say, ‘you know, the world is a safe place, people are so helpful, we can count on people that we trust’ and another person's experience will be ‘you can’t trust that things are gonna be here I'm going to be all alone in life. People leave me in this world or people hurt me’ you know. And again, it’s that colouring of that world takes place because of their experiences while developing in childhood, in the limbic system, the emotional pain and that’s usually where you see some intense trauma.

And, of course, adults can develop it with very intense events as well and what you’ll see is with trauma and cases of post-traumatic stress disorder, you get a significant loss of brain volume in the hippocampal area as well as other areas like the amygdala. So, you get these biological changes that kind of hardwire them into the individual and that can be something like you said, it lingers and it’s hard to get to. Those traumatic events tend to make one feel an extreme sense of a loss of control, so that’s where you can see the eating disorders kind of fill the gap. And, it’s not the most effective way, but it still, for the individual, it’s what they have to work with.

Natalie Douglas: And, I think that’s when I became anorexic. I got a lot of attention for it in that way, in terms of that victim role, and so I felt looked after and that felt really, I guess, you know, comforting to me. So I actually enjoyed, as “sick” as that sounds, I enjoyed being in that victim role and needing to be looked after.

Dr Jeffrey DeSarbo: Some people want that attention. Other people, as they, let’s say with anorexia, they’re beginning to lose weight, there’s this ‘I want to disappear, I don’t want to be noticed’. So again, it’s how that individual perceives the type of attention they’re receiving that you have to look at with an eating disorder. Now, for the most part, this isn’t just with eating disorder patients, it can be with anybody, even patients who are experiencing anxiety, depression, or just don’t even have a psychiatric diagnosis. If I ask the question, ‘what is your biggest fear in life?’ and I'm just pausing with that, so people can think about it. It’s usually, in one form or another, if not directly, it’s about being alone, okay, especially in today's world.

So, a lot, when an eating disorder takes place, one of the thoughts is ‘you’re not good enough, you don’t deserve to be with somebody.’ And that fear, let’s say with body image disturbances, is present and I can’t be huge and I don’t know why. If I follow a line of thought, ‘well what would happen if you were huge?’ ‘Well, this would happen and that would happen’ and it always comes back down to, in essence, ‘I'm going to be alone in the world’. And that ultimately is one of the fears that’s trying to be avoided. Although, it's not a conscious fear that people realise.

So, if they say they get attention, they’re being noticed, it’s, it’s like, and they appreciate I'm not invisible, that’s one thing. And, I also think, a lot of times, that image that they see when they look in the mirror, they sometimes want and again on an unconscious level, they want their outside to match what’s on the inside. That’s why, you know, I have to tell people all the time, you cannot say with anorexia nervosa, again specifically, things like you look healthy, you look good. And, people may be very well-intentioned when they’re in recovery to say those things, but it’s always heard as ‘you look fat’ and then it goes down to ‘I'm not doing good enough. You don’t recognise what’s going on, I’m hurting inside, I have a lot of pain and you’re telling me I look better and you're telling me I look healthy’. And, the further away that they feel someone’s perceiving them to how they actually are, the more disconnected they get to others. And, that disconnection is breeding a feeling of loneliness.

Danny Urbinder: That feeling of loneliness can be an agonising experience that contributes to and then fuels eating disorder symptoms. Not only do sufferers feel alienated from others through their feelings of low self-worth and negative perceptions of the world, but they’re also alienated from their inner drives of hunger. In a 2012 paper titled ‘Loneliness and Eating Disorders’, Martha Peaslee-Levine notes that individuals who later develop eating disorders are often sensitive to issues within the family and might fear rejection, abuse, or even disintegration of the family. As a coping mechanism, they often bury their perceptions and learn to base their behaviours on others’ expectations, which can lead to existential loneliness. In an attempt to overcome loneliness anxiety, the person tries to stop feeling altogether and tries to live solely by cognitive control. In this sense, an eating disorder represents an effort to keep these feelings under control. Add to this a growing culture of individualism, social isolation, social media and problematic media messaging and we can begin to understand why eating disorders are steadily on the rise.

Natalie Douglas: I did start to read more magazines at that point in time and there are a lot of really skinny, as always, models on the front of the covers and I was aware of that and aware that that’s what people admired. And, I also had, throughout high school, a best friend who was like, naturally very thin, blonde, beautiful, tanned, and all of the boys like really liked her or thought she was ‘hot’ if we’re going back to high school talk. And, I was really aware of that and I kind of never felt seen and so I think, in my mind, I was like well, they must really like her because she’s skinny because she was, but naturally so. It wasn’t, she wasn’t, she didn’t have an eating disorder, that’s just her genetic makeup and so I think that was definitely an influence there for sure.

Gabe Covino: It’s staggeringly frightening the role of where social media is at, the role that it kind of plays. I think a lot of meaningful, long-standing research that’s documented the impact of, I guess, the appearance focused media and the associated kind of development of body image concerns. It was certainly in the, in that demographic, the highest risk factor that early teens, early adulthood, you know, they are bombarded daily, hourly, with what has been described as perfect, manipulated, filtered and digitally enhanced images. So this is, absolutely, plays into that kind of body ideal.

I think that kind of exposure is a totally unrealistic, unachievable appearance ideal and social media can absolutely cause body dissatisfaction, which we know is an absolute risk factor. It promotes weight-loss strategies and it promotes the thin ideal.

I think a secondary thing about social media that’s also really interesting is that, you know, that it’s not just in social media the images at issue, it’s also reading the appearance-related comments that come with social media. So, on Instagram, it’s also this secondary reinforcing as well. So, it’s the visual image, that is one thing, and then it’s this support of these, kind of reading appearance-related comments. So, feeling like they, you can’t live up to that kind of image that’s being presented. I’d challenge anyone not to have some negative self-worth feelings when you’re embedded in the social media space. Now, what’s happening with the younger generation, is that social media is causing people to compare their insides with somebody else’s outsides and that’s obviously going to be a challenge.

Dr Jeffrey DeSarbo: Especially, in this day and age, with social media, it’s worse than ever. Whether you’re prone to an eating disorder or depression or anxiety or any other mood condition, social media is having a tremendous impact because, one thing with an eating disorder is, you’re always comparing yourself and you're always comparing yourself to others. So, if you're prone to having an eating disorder, you’re going to be comparing yourself to thin bodies, you're almost going to only notice that.

And, even the bodies that are not as thin as your own, the perception is still they are thinner, you know. Because, you’re misperceiving your own, and you know social media because, we don’t live in a world where you just have to get a magazine and look through it, had miss universe once a year, now with social media, everything’s out there. It’s constantly in everyone's face and at their fingertips 24 hours.

So, you know, and we do live in a world where comparisons have escalated amongst our peer groups because we used to before we had social media, we couldn’t do that. Only, if we saw people, but it’s out there now. And, if you make a mistake or you look bad in a photograph, it used to be a photograph that you might have in a packet of photos at home and now somebody else can post a photo of you that you don’t like and, if you're someone who's dealing with body image or an eating disorder, it can be downright humiliating.

Natalie Douglas: So, it started off as, yeah, being interested in eating healthy, and what that looked like was certainly not what I view eating healthy as now. It was having, you know, cereal for breakfast and orange juice, and then having a sandwich for lunch, and then having, you know, lean protein and vegetables for dinner, which was quite a contrast to what I had grown up on. Like, I ate so much processed food, and a lot of it, all of the time. And, so that to me was eating healthy, as like a step in the right direction. And, then it wasn’t until I kind of plateaued with my weight loss that I started to look into, you know, how do you lose weight and then I just started counting calories.

Gabe Covino: Are they excluding particular food groups? Are there times in the day they’re not eating? Do they have an understanding of calories, how many calories are in food, you know? When they, when patients know more about calories in food than you do, those things can kind of be a little bit of a red flag.

Natalie Douglas: And, at that point, I think it did become a little bit about, a little bit about body image, because I was obsessed with being skinny. And, it’s like, it is an addiction. It feels very much, when you're in it, like an addiction. And, I was very anxious if I wasn’t losing weight and if I put on weight, it was a horrible feeling.

Dr Jeffrey DeSarbo: A lot of the eating disorder pathways you’ll see in the brain that light up are the similar pathways you do see with conditions of obsessive-compulsive disorder. In fact, a lot of times people will tell me, I have obsessive-compulsive disorder because I have to eat my foods in a certain way or I have to have my meals structured like this. Technically, that’s not OCD because it’s in the context of another diagnosis, which is the eating disorder. But, the brain is functioning, many times, in a similar fashion when obsessive-compulsive disorder takes place and obsessive-compulsive disorder, the compulsions are a way to alleviate that distress that someone has.

Natalie Douglas: I think I was so hyper-focused on what was important to me at that time that I blocked out a lot of other things that were going on around me. Because, it was almost like being in a constant state of survival, and in hindsight, I feel like my nervous system was just constantly switched on to the point where, even when I was sleeping, I would sometimes have dreams of eating something and then I’d wake up in a panic. And so, it was kind of like this, I didn’t really have much awareness about what was going on around me because I was so focused on surviving that it just wasn’t working so much.

Danny Urbinder: By the time Natalie had reached her early to mid-teens her need to control food and her obsession with exercise had reached a point that started to alarm her mother.

Natalie Douglas: And, also, I think the biggest thing that alerted her, was the change in my personality because I was once this free-spirited, bright, social, happy, energetic, you know, child and then I had become just like I shell of myself. I became very reactive, irritable, anxious, controlling. I used to be very flexible and go with the flow and all of a sudden everything needed to be a certain way and I would flip out if, for example, she went, I asked her to buy something like bread from the store and she would come back with the wrong brand, and it would have 20 more calories than the brand I had asked her for and I would, you know, flip out in terms of anger or rage. Or, I would start to be really, we were in a shopping centre and I said to her once, which is horrible looking back at it, and I would never say anything like this now, but I looked around at people and, I was like ‘it’s disgusting, all these people eating’. And, I don’t, I also don’t recall a lot of that period in my life, in terms of how I was. There are things that my friends or my family will say that I did or said and I actually can’t recall doing some of those things.

Dr Jeffrey DeSarbo: There’s a part of the brain called the anterior cingulate cortex, the ACC. And, what was interesting about this study was that they found in some studies that it didn’t always recover when someone recovered from anorexia. Now, I’ve read other studies since that says no it does seem to recover, so that’s still a question. But, it seems to be an area that sometimes recovers a little slower and may, in some people, not recover. But, the anterior cingulate cortex is a region of the brain, there’s a great book called a users guide to the brain by Richard Restack, and he described that area as the region of the brain where heated emotion meets cool rationality. And, when somebody is really suffering from anorexia, heated emotions, they can’t calm themselves down is clearly present, and that’s a feeling again that you’re almost out of control. And, family members will say, ‘you know, I don’t understand, this is not my daughter or this is not my son’. They are angry, they’re impulsive, they’re yeah. With recovery, amongst that area of the ACC, they’ll often say 'I feel like I have my son or my daughter back’. So that’s a thing when areas of the brain like that get affected you get all these presentations that you observe of this person is just not the same person. And, it’s just very common, I’ve had several people say ‘when my daughter, has anorexia nervosa, she looks like the girl in The Exorcist. It really, it like possessed her and she’s not the same person.’ And I think that’s a pretty good analogy of what it looks like and I think for the individual suffering, that’s what it feels like.

Natalie Douglas: I definitely got worse before I got better. So, for a good, maybe 3 years, of that period in the very beginning, when it first started into an eating disorder, I lost quite a lot of weight. Like, I think at my lowest weight, I was about 39-40 kilos, which is quite tiny. And, as I progressed further, I kind of hovered around that weight for a really long time and my addiction to exercise got worse and worse. Especially, as I started to go in to see dietitians because the idea was you need to eat more. And, I would kind of sneakily exercise more as well, because I liked the attention of going to a dietitian and almost being looked after. And, it almost gave me a sense of calm as well, however, I wasn’t comfortable yet with putting on weight, which was essentially what the goal was for me. It wasn’t my goal, but outside of me, it was the goal.
And I think that the way that it progressed as well, was that with my exercise, how it was previously 20 minutes of exercise a day, I was now in a space where I was doing 2 hours of exercise every day, about six to seven days a week. So, I was kind of burning the candle at both ends. And again, being in very formative years there, in terms of really being in that 13-16 years old age range, I kind of got a reputation for being the person who was great at exercising and really “healthy”. And, so I felt that, like, almost trapped in that, if I stopped doing that, who was I? So, it kind of kept going in that way for a number of years and then I would say, at some point in there, and it’s all a bit of a blur in terms of timeline, but perhaps around age 15 or 16 I did start to see the dietitian, as I mentioned, and the psychologist as well. And, I gradually started to put on a little bit of weight because it would kind of be a few steps forward and a few steps back, because I’d feel like ‘okay, I’ve got this.’ And, then when I would go in and get weighed every week, which is what happened. If I had put on weight I would just feel so anxious that I just couldn’t deal with it.

Even though I could see that it was starting to really affect my mum and I had a very close relationship with her, I was kind of pulled between these two worlds of ‘I really don’t want to upset her and also I can’t deal with the anxiety of putting on weight.’ I said I’d be willing to get some help and, in saying that, I was willing to get help because I liked the attention of it. I didn’t, at that time, want to get better for me.

And, there was one defining moment where I made the decision to actually try and get better and that was when we were maybe 2 years or 3 years into seeing the dietitian and the psychologist and my mum would come to the dietitian appointments with me. And, when I came out of that appointment if I had lost weight again and they were going to put me in the hospital because I think my body fat percentage was going down around 6%. They were worried about my heart and my bones and I really wasn’t progressing very much at all. And, I think that really shook my mum and she was a single mum, working full time and had another anxious child and dealing with me as well. And, she never, ever yelled at me in my life, like ever. So, up until that point, I’d never really been yelled at. I pretty much just did whatever I want and I was a good kid, I didn’t have, there was not much to yell at me about. But, at that moment, we got out of the dietitian's office and she just broke down and said, and crying and yelling, and I’d never seen her like this and she just said ‘you're killing yourself and, you're not just killing yourself, you're killing me!’ and just was distraught. Like, pure distraught. And, as a very emotionally intuitive person, and also someone who was very close to my mum, like attached to my mum, I would say it was really traumatic. And so, at that moment, I made the decision, well actually I don’t want to get better for me, but I do want to get better for her. And from that point, I did start to really try and I did start to make some progress towards putting on weight.

Dr Jeffrey DeSarbo: It's not common, but if I hear that, it’s not surprising, you know. Usually, we’re saying to an individual or treating them, except when they're very young children, of course, it’s like, you have to be doing this for yourself. But, people sometimes reach this point where they are so sick and fed up, and if they’re getting the right help and they realise, I'm really hurting people around me as well, and they want that love because they don’t want to be alone, it can be a motivating factor. I would never be consulting a family to tell them to tell this person how much it’s hurting you because, I would say, more people are on the other side where, if you say that, it can turn into, they always have this thought in their head ‘I'm not worth anything, I don’t deserve anything, I'm a bad person, people would be better off without me.’ So, saying something like that, people would definitely run a risk of increasing suicidal thoughts or worsening of the condition. And, I’ve heard things, you know, I’ve heard worse than that, you know, you should just die because you're useless and you never going to be anything.

And, here’s the thing, even when a person recovers, they don’t forget that, you know. If it’s someone that’s close to them, when parents are saying that, it’s usually out of their own sense of helplessness and frustration and they just want somebody to feel better, you know. But, again, it’s that increased sensitivity that the brain has in ED. That’s what we say is your ED voice, you know. It’s that eating disorder part of your head hears that as ‘see, I told you, you shouldn’t even be alive.’ So, you know, I would never want that.

Sometimes, people will say, you know, my parent say things like that and I have to help them understand that, it’s coming from a place of their own frustration. Because, a parent would like to fix it and usually the parent is way too close to the situation. Except, in very young children, you use something like the Maudsley approach. But, sometimes, you know, one of the things with eating disorders is people fear judgement and, of course, they take criticism and judgment the heaviest by people who are closest to them. So, of course, you know, it’s a difficult thing and that’s why family therapy is often an integral part of the treatment process.

Natalie Douglas: And, she was really my only safety network in my whole life. Like, I didn’t really have anyone else in my life that looked after me like that. I still had contact with my dad at that point in time, but he wasn’t a safe place for me. And, you know my brother was dealing with his own stuff and I wouldn’t really call that a safe place. I didn’t have any other people in my life, it was really just me and my mum. So, it was almost like I picked up on, well ‘if my mum’s not okay, I'm not going to be okay’. Not consciously, but in terms of like hindsight, subconsciously knowing, you know, this is my person and if this person’s not okay then how will I be okay? Because, I think we had a very, you know, attached relationship our whole life and she really never left me, at all. So, I was used to her being there and my sense of safety had a lot to do with her.

Danny Urbinder: From that point on Natalie made a concerted effort to put on weight. And, while she did make some progress, her underlying issues were still at play.

Natalie Douglas: I would go through these cycles of having to put on weight and eating more. And, then I would start to eat more, the anxiety would come up in me of ‘oh my god, I'm eating more, what have I done?’ And, then it’s almost like you keep eating or I kept eating, I should speak from me. I kept eating to not have to deal with the anxiety of the fact that I had just eaten more. And, so that’s kind of what got me into the binge cycle. And, then it was, to take that control back, it was like well now I need to get it out, literally. I need to get it out of my system so that I am back in control of what’s actually in my mind, being consumed. So, it was very much, it just flipped me into a different way of trying to control food, that was almost, even more, it was almost extreme.

Gabe Covino: It’s absolutely a possible scenario because the behaviours that sit around these conditions is to control and it's also hiding. They don’t want their parents to see, they don’t want their friends to see and so behaviours can change and develop over time or change and morph over time. So, if it looks to be that there is behaviour around or a lens now on how much somebody is eating then it will move to ‘maybe I will continue to eat but, I will start purging so that I can continue to kind of hide those behaviours.’

Dr Jeffrey DeSarbo: Yeah, that’s very common actually. I always think of when I'm working with a patient, in the beginning, I always look at eating disorders as they’re kind of these spectrum disorders and they can slide. You can go from anorexia nervosa to binge eating disorder to bulimia. You can, kind of, be up and down on the scale and that, of course, scares the heck out of a person. If they’re going from anorexia nervosa and, now they’re developing binge eating disorder, they can feel way out of control and they feel a sense of panic. But, like, we can work on this, we can.

To me, I always say, anorexia nervosa is one of the hardest conditions and the most risky of conditions. If I have someone with binge eating disorder, I can usually have interventions that can kind of mitigate what’s going on rather quickly, from a biological point so they can work on it therapeutically. But, there are a handful of people that, and they find that genetically, they can be prone to just that one specific type of eating disorder, anorexia, binge-purge versus anorexia nervosa restrictive type and they will kind of be like in that zone. If they relapse it’s going to be back to there and they don’t slide as much.

But, for the most part, there’s always a little sliding on that scale and it can go from binging to bulimia or maybe not eating syndrome or maybe just purging disorder so it can kind of go a little bit around, it’s like tweaking it until you get it right.

Natalie Douglas: So, I got a belly button piercing, which is relevant, when I was about 18 or 19, and it actually got infected. It got cellulitis because I had no immune system at that point in time and from that infection, I actually ended up in hospital because it almost went in, almost got septic in my blood. Because, you know, they had obviously said don’t exercise for a period of time while this heals, but I couldn’t like, that was just not something I could do. So, I just kept exercising and kept going to boxing and that’s how it got infected and continued to not heal.

And then, so, I had a lot of IV antibiotics and hospital nurses coming to my house to give me IV antibiotics. And then, from there, I got quite sick, digestively. And so, I had two parasites, I got h. pylori and that was undiagnosed for, I’d say, about a good year. It just got progressively worse and worse and I lost a lot of weight just from having that. I didn’t change my food at that point in time, but I lost a lot of weight, again, in that process from having the parasite. And, then I also had Blastocystis hominis as well, kind of at the same time, and was treated with triple therapy antibiotics off the back of just having a lot of antibiotics for the cellulitis.

And, then I kind of got projected into this more holistic field where, for a long time, I wasn’t getting better from the antibiotics I took for the h. pylori and I still had a lot of lingering digestive issues. And, so I started to do a lot of reading and research and ended up in the hands of a naturopath, at that time, who gave me lots of herbs and different things and put me on quite a restrictive diet. I guess it was pretty much what we’d call, or kind of keto now, as to put a close enough label to it. It was pretty much just eat protein and, you know, really low starch vegetables and do that. And, while my digestion got a lot better, I became obsessed, like orthorexic, I guess. I became obsessed with what was okay and not okay to put in my body.

Gabe Covino: Orthorexia, which is not necessarily categorised in the DSM as an eating disorder, but is something that is worth mentioning. So, a person with orthorexia is focused on the quality of the diet rather than, kind of the quantity. So, this can start, and what we see a lot in practice is, this obsession with clean and healthy eating. And, this is becoming much, much more prevalent now, and I guess a way to hide the way you're engaging with food.

Marci Evans: What I have found is that, of course, for some people, there may be foods that just do not agree with their system. And, if there’s a way to kind of work around that, to have a very liberalised diet, a very flexible diet, as much as possible so that they can have a positive relationship with food, then we’ll go that route. But, what I have found with functional gut disorders is that it is, it’s very complicated. It’s a host of symptoms that require different tools to help them manage it. You know, for some clients saying I can’t ever eat bread is going to be a setup for them and they will end up binging or binging and purging on bread. I had a client, I’ll just tell a quick anecdote. We worked together for years on her bulimia and she had a beautiful recovery, was quite stable for years, but found she had really uncomfortable bloating. She was really constipated, she just didn’t feel great in her digestion. So, she found that when she removed a couple of key ingredients, including gluten and dairy, her digestive symptoms improved. However, the dietary restriction itself ended up sending her into a very severe relapse of her bulimia. And, so we had to find a middle ground between having a lot of other foods that were satisfying but then integrating some of the foods that maybe weren’t the best for her digestion, but really vital for her to maintain her psychological and emotional wellbeing. And, so it was a little bit of a dance that we had to figure out together.

Natalie Douglas: He did some further gut testing and his conclusion from that was that I did better with a fat and protein-based diet and not a high carbohydrate type diet. This was part of his rationale for putting me on, you know, a keto style of diet which, in hindsight, probably not the best thing for someone not menstruating and doing 2 hours plus exercise a day. But, to his defence, it did definitely help my gut symptoms. I remember being instructed to eat organ meats, so I remember eating liver for breakfast which would’ve been a little bit of food as medicine for me. And, at that point in time, I was pretty much willing to do anything and everything. And, that was probably when I was about 18 or 19, it’s a bit of a blur. So, then I started to get a bit better digestively, and I kind of found paleo after that. And, so that’s when my fixation on food started to focus more on quality and I did eat more at that point in time. But again, I was quite obsessive about what I could and couldn’t have and attached my self worth to it.

Marci Evans: Part of the work for anybody who’s looking to recover from an eating disorder is increasing the capacity to tolerate discomfort and obviously we’re talking about psychological and emotional discomfort. But in addition to that, a part of having a functional gut disorder is about being able to tolerate a bit of digestive discomfort, which does not mean I'm saying people have to just grit through pain and just sort of bear it unnecessarily. But often, individuals who have a functional gut disorder have the type of personality where there’s a little bit of discomfort coming in and there’s a very strong anxiety-based reaction. And, that is not to say the discomfort is all in their minds or their reaction isn’t valid, not at all. In fact, individuals who have functional gut disorders and eating disorders tend to experience things in their systems much stronger than the average person. And, so part of my role then is to help alongside them to be able to slow down and to diminish that very strong anxiety response and to be able to be with some of this discomfort so that they aren’t jumping down into that rabbit hole of taking out this food or removing this whole entire set of foods which, for most people, not everybody, but for most people is not sustainable.

Natalie Douglas: Probably, the next quite significant thing that happened in my journey with all of this was, I woke up one day, I had no pain the day before, I woke up and I had like this neck pain. And, I never had neck pain before, and I thought this is weird. And, I automatically freaked out because I thought, ‘oh my god, I'm not going to be able to exercise’. And, I went to a physio and they massaged it, you know, told me to rest for a couple of days, but it never went away. And, it started to progressively get worse and go down my spine. And, I went from exercising 7 days a week, twice a day, to nothing at all. I ended up not being able to walk further than maybe 20 meters and I wore a neck brace for about 9 months.

I didn’t cope very well at all. I went into a really deep depression, I isolated myself from my friends because, at that time, you know I was in my late teens, early 20s I’d say, so and my friends were social, they wanted to go out and I couldn’t leave the house. Like, I was in pain, and I think anyone who’s experienced chronic pain knows how debilitating it can be. So, I think there were many layers to it. I think I was depressed because I had built my whole life on being the one who was fit and healthy and my identity around that and, all of a sudden, I couldn’t do those things and I couldn’t get that validation and I pretty much stayed home all of the time. And, I was quite suicidal at one point in time there as well.

And again, it was you know, my friends kind of stopped checking on me because I wasn’t very responsive which, you know, that’s just, you’re at a very, not self-absorbed in a negative way but, you know, you're just going about your life. And, I didn’t share very much and I was a bit of a Debby Downer, you know, for when I was with them because I was in pain and it was just me and my mum, and my brother had moved out at that point. So, I didn’t really, I was very alone.

Danny Urbinder: Natalie was desperate to find relief from the pain she was experiencing. She saw numerous healthcare providers including a physiotherapist, a chiropractor and a spinal surgeon, and yet no one could find anything structurally wrong with her spine or neck. She did find some relief from acupuncture, but that would only last for a couple of days.

In the end, Natalie found herself seeing an endocrinologist and a gynaecologist who put her on hormone replacement therapy and an antidepressant and, within 24 hours, her pain was gone. But, she never got a satisfactory answer as to why this treatment worked. It is worth considering, however, those hormones and neurotransmitters that may be impacted in those with an eating disorder and how these might affect both mood and chronic pain.

Anorexia nervosa and other eating disorders can result in significant reductions in oestrogen production, resulting in the absence of menstruation and loss of bone density. Research has also shown that oestrogen also plays an important role in pain modulation and perception, which is mediated by neurochemical changes affecting both the central and peripheral nervous systems. It's conceivable that by taking hormone replacement therapy, Natalie’s neurological symptoms may have improved, helping to address both her pain and depression.

Furthermore, oestrogen can modify serotonin synthesis and metabolism, which is one of the most-studied neurotransmitters related to chronic pain. We also know that disruption in both oestrogen and serotonin homeostasis leads to dysregulation of another important modulating factor, known as BDNF.

Dr Jeffrey DeSarbo: So, BDNF is brain-derived neurotrophic factor and it’s a protein that we produce on our own. It’s not something that we’re taking in our foods or anything like that. It’s a neuroprotective protein, it protects the dendrites, the parts of the neuron, those little finger-like projections that connect to each other. Where one cell of a neuron may have one dendrite, or ten thousand of these little arms and it protects them and those connections and, when people are under stress, including things like an eating disorder but also post-traumatic stress disorder and chronic levels of stress in life, the brain, the body kind of stops producing this substance and when you do that, you start to get a withering of all those connections from neuron to neuron.

And, of course, that’s going to affect how the central nervous system and the brain are sending signals and communicating from cell to cell. It’s like, I often show this little slide of a healthy brain firing off and it’s got lots of energy and then, a deprived brain like, barely firing off, it’s really slow. That often has an impact when I'm working with patients and I show them this because they see these slides and they know, they feel what they’re looking at.

So it's things like BDNF and cortisol, which can be neurotoxic, like we talked about, especially in the hippocampal area with memory and sleep and everything else. So, our body produces cortisol on its own, it’s a necessary stress hormone. But, when you get high levels of it, it’s not good for us, you know. Sometimes, people say they worry, you know, I don’t want to take a medication for my stress levels. Even though medication often can lower your cortisol levels, it can help you reestablish, the body starts producing BDNF. And I say, ‘imagine if I could take cortisol and I put it in a capsule and sold them’ and I said, 'hey, look, this may be neurotoxic to your central nervous system and cause lots of problems, you know. Would you swallow that and take that?’ And by living with chronic levels of stress you're essentially doing that, you know. And, I'm not saying taking medications are, I'm saying taking care of yourself, going to therapy, finding ways to learn, you know, through meditative practices. I'm very big into mindfulness training and everything, you have to. By learning these techniques and learning how to cope with stressors in life you protect your brain.

Natalie Douglas: So then after then, I gradually started to make my way back into exercise. It started with just walking a bit further, I started with doing some swimming and I was, I would say in hindsight quite traumatised from all of that experience. Like I was very nervous about exercising for a long time because, I was so scared of that being taken away from me again. So it was a very slow, slow return to exercise. However, I did eventually get back to exercise, and I was very passionate about you know, being healthy and healing my body and eating the quote on quote “right foods”, and got very much down that paleo type bandwagon. And it did help shift my mindset from calories and quantity of food to the quality of food, but I still think that I probably took it to more of an extreme. And then what happened was, as I got better, I think I had forgotten some of the lessons that I had learnt, and I ended up in cross-fit. Which for someone with an addictive, performance-driven personality, probably wasn’t the best place to land. But, the reason I landed there was I had previously been training in a very traditional kind of gym where you just go and lift weights or you go and do a class. And, I didn’t want to go back to an environment where I had been quite skinny and anorexic and in that kind of mindset. I thought that was not going to be very conducive for my healing and I want to go somewhere where they care about more what you can do, as opposed to what you look like. And so, I was drawn towards more of a CrossFit style gym and entered in there and it was very much focused on, you know, what could you do. But again, my personality of just trying to be the best at things got the better of me and I started to focus on performance. And, I also put on a lot of weight during that period of time, despite not hugely changing what I was doing with my food. Like, I put on about, I'm going to say 10-15 kilos in about like, a 6-8 month period. So, a very rapid increase in my weight and some of it was muscle and a bunch of it was fat. And, I think I used the performance side of it to try and ignore the fact that I was really uncomfortable with how much weight I had put on because, I also was conscious enough that I didn’t want to go back to, you know, starving myself again. And, I ended up getting more blood tests done and I had an under-active thyroid and I had a lot of hypothyroid symptoms. And, at the time, I also recall doing a DUTCH test and had quite low cortisol. I actually just begged an integrative doctor to put me on thyroid replacement therapy like T3 because I was just so at my wit's end with having no energy and still feeling quite sad and low. And, so I did take that T3 and it did give me a boost, but then I started to hit a plateau and that started to not kind of work, which, in hindsight, I think that you can put thyroid hormones in, but unless they’re getting into the cell they’re not going to really do what they’re supposed to do.

Marci Evans: In terms of cooccurring autoimmune, or immune-related, or immune-mediated conditions, I see often issues related to thyroid and issues related to endocrine function including diabetes. Those I would say for me, are probably the most common. And one of the things that, unfortunately, a lot of the medical providers don’t know, is that dysregulation in both the thyroid and as well as in interestingly enough, lipid metabolism, is actually quite common in the context of malnutrition and dietary restriction. So, one of the unfortunate things, is that sometimes some medical providers can get a little bit carried away in treating the symptoms, which of course it needs to be treated. If somebody has hypothyroid, it needs to be treated. But the underlying restriction and malnutrition sometimes aren’t identified. And so again it’s looking at that whole picture that yes, there is some issue with the thyroid, but are we enquiring about the person's intake and the history there. Because if that’s the case and there’s an active eating disorder, then the eating disorder needs to be treated and the malnutrition needs to be corrected as opposed to solely focusing on medication interventions alone.

Natalie Douglas: So, after that point, I saw another naturopath and she put me on some herbs to bring my period back. And, it took about a year of being on herbs and, still on HRT, but kind of weening off that, to get my period back. And, when it came back, it was quite regular and no big issues. But then, as my cross fitting years went on and my age went on, I actually started to get really severe pain. I haven’t officially been diagnosed with endo, because I don’t want to do the laparoscopy at this point in time however, from a symptom picture perspective, I think that that’s fairly likely that could be a component of what’s going on with me. And, as you know, and a lot of the listeners probably know with endo is, the actual official diagnosis, or the gold standard for diagnosing that, is a laparoscopy. So, that’s why I say I can’t say that with absolute certainty. However, that certainly played out for me.

I did end up coming off the thyroid medication and my thyroid has been fine since in the terms of the gland is producing enough hormone. However, I still think that for a number of years after doing CrossFit, I was quite ‘burnt out’ and I ended up stopping CrossFit when I was about 25 or 26 and I just did yoga and walking for a bit and that helped my body heal a little bit. But, I had struggled losing the weight that I had put on.

Ever since then my weight kind of just kept going up and up and up and then I didn’t really get to a point where, like, weight loss is not easy for me. In terms of, I think that there’s because my body has gotten really good, for a really long time, at protecting itself and keeping itself alive, I have what I would call a really adaptive metabolism, as in, when food is less, my body just adapts to be really efficient. And, it’s my belief that it’s a bit of a learned response in terms of what it had to endure from, you know, age 13 into my late 20s.

Danny Urbinder: In response to years of caloric restriction and nutrient depletion, Natalie’s body would have gone into a physiological survival response known as metabolic adaptation. In a desperate attempt to preserve energy, her body would have slowed down its metabolism to burn fewer calories throughout the day. The impact of this would have been extensive, impacting her thyroid gland, pituitary, adrenals and ovaries. Fortunately, she was able to adopt a new perspective which meant she was now consciously making different decisions for her health.

Natalie Douglas: I think what happened was my heath became incredibly important to me because it was taken away. And, I was so fearful and, to be completely honest, still carry a bit of that fear in me, of it being taken away again. I think because I was, I went through the medical system for sure, like I saw multiple doctors, multiple specialists in that journey, particularly when I started to get all that pain in my body. And, I once had a lot of faith in the medical system, but I felt that no one was listening to me because it took a long time for those gut issues to be listened to. No one could figure out the pain, so when I finally got better and was functional in terms of, I could exercise again, I could, I wasn’t having all of these debilitating symptoms, I became very scared of my health ever being taken away from me. And so, I think that shifted me out of just worrying about calories, to really being hyper-obsessed with my health and protecting it. And, then I think, over the years of starting to develop a lot more self-awareness, self-love, my relationship with food now is that I'm still very intentional with what I choose to put in my body and what I don’t. However, the place where that comes from within me is a completely different one. I no longer feel like I can’t have certain foods or, you know, foods are good or foods are bad or that I should or shouldn’t eat X amount of food. For me now, it's very much about choosing an intentional way of eating for the purpose of nourishing myself and valuing my body.

I’m really grateful for my experience and I think we are only sent what we can handle. And, I think that, although everything that I experienced was incredibly uncomfortable and painful for me and I'm sure many others around me, I also feel like, if that hadn’t happened, many of those things, I don’t think I would’ve had enough motivation to learn to love myself and to learn to really create safety in my own self and know what is right and what is wrong for my body. I think that it’s part of the journey.

I also think a big message that has come through for me is about taking radical self-responsibility for your life and for your health and not outsourcing it and knowing that, there is so much power in doing that. Because, we have as individuals, so much, so many tools and so much that we can do that does make a difference and I think that, that’s healing in itself. To be in that empowering mindset and to be in a place where you don’t accept that your body is just broken, but that’s a story. And also, that makes me really conscious with my clients, when I can see them attaching themselves to their illness as if they are one and the same.

And also, having gone through everything that I’ve gone through, I can really empathise with people when they are experiencing helplessness or a lack of faith in being able to heal or get better and what that feels like. I think when you can connect to someone on a level of depth, beyond rote knowledge or, not rote knowledge but, just knowledge of what’s playing out in the body, you capture them and you can inspire them to know that, 'hey, I see you, I was where you're at and I can help you.’ And, I think that it’s now something that brings so much joy to my life to be that person that holds that space for other people to get to a place where they too feel like they’ve been given their life back. Because, I feel like I have almost done a full circle back to the joyful, lighthearted, optimistic, spiritual kid I once was. And, it feels really empowering to know that while I had a lot of help along that journey, that, you know, I am the person ultimately that created my reality now, which is feeling confident and comfortable and content, for the most part, in this body and in this mind.

Marci Evans: Yes, so the incredible thing about going through the process of eating disorders recovery, is that this person has worked so hard to develop incredible resilience, incredible self-insight and self-awareness, as well as the capacity to be able to have a greater bandwidth of tolerating difficult emotions and to work with their thoughts differently so that they’re thoughts are not only less negative, but also have less impact on them, right. So, that they can be at ease, a little bit more at ease, in their own internal dialogue.

And, as a result, when someone has increased skilfulness, the increased capacity to self regulate better and is more at ease in their relationship to food and their body. The working with the lingering stuff, whether it’s lingering gut stuff or any other things that are lingering, is that it’s maybe not fun, it can be challenging, but it’s more doable, right. They’re not simultaneously battling both the eating disorder actively alongside all of this digestive stuff. So, it’s one of the ways in which I'm paying so much attention to the psychology and relationships so, as that gets ironed out, there’s more peace there, the lingering pieces are less of a struggle.

Dr Jeffrey DeSarbo: It is the critical point, whether it’s the thing that triggers them into accepting, ‘I have to really work on my recovery’ or it’s the thing that says, ‘I have to move on with my life’. And, I’ve had patients this week that I’ve spoken to, where they kind of describe a similar situation. And, now they’re living life saying, ‘I have to just accept that this is how I see myself still, but I have to take care of myself, I have to give my body what it needs, you know, so that I can have the other fulfilling aspects’. Because, an eating disorder, its ultimate job, I always tell my patients, is to kill you. Whether it kills you physically or it kills the quality of your life and your existence, that’s its motivation, its objective. So, you want recovery and it’s about living life but accepting who you are.

But, it isn’t something that you just say to a person and it happens. So, that’s the art of the therapy, is to get to, how do I find the combination to allow an individual to accept who they are, so they can move on with their life, you know because there’s a tremendous fear with the concept of moving on. One of the most common fears is, ‘but what if it doesn’t work, what if it all fails, what if I disappoint?’ So, a lot of that’s gotta be worked out but then, everyone has got to get to that point of if you don’t reach acceptance you're still going to be living with an eating disorder. And, you mention, like living with those thoughts, I always say, someone walks into my office and they are ‘normal weight’, ‘normal height’ and they say ‘I eat 3 meals, a variety of snacks, no behaviours’ but if I ask them, ‘what percentage of your free thoughts do you spend thinking about food, weight, body image, calories, exercise’ and they tell me ’90-100%’, that’s the eating disorder. That’s what people don’t understand. They look at someone and go, ‘oh, you're a normal weight, you seem to eat fine, I guess you don’t have an eating disorder' because they can’t see inside someone's head. But that 90% is where someone's life is in total disarray and distress and anguish. But, recovery, I have to tell you, from my position, I’ve worked with thousands of eating disorder patients, I’ve never felt I’ve had a patient where that’s it, it’s never going to work. I can tell you I’ve felt frustrated that I haven’t figured out the solution yet and, I'm not saying that all these patients have a full recovery, but it’s not, ‘well we tried, let's give up.’ If a person has struggled they just need to have a treatment team that is looking for a different approach to this. And, like, I said, it isn’t one thing, it’s a comprehensive team approach like you said, it’s integrative, there’s a lot of components to this. But, recovery is possible for, I believe, pretty much everyone.

Natalie Douglas: Yeah, it’s a lesson and I think you know, what I try to do now is listen to the whispers that my body is telling me instead of waiting for the big thump. Because, I think when you’ve been thumped a number of times with things, you know, the kind of moments that just pull the rug out from under you or you really get hit sideways by something, you know what that feels like. Both, in terms of I think, an intellectual sense and also a feeling sense, like you, your body remembers what that feels like and it, so it’s now, it’s about can I listen to the whispers, instead of waiting for that.

And I'm a big believer that it’s in the daily actions that we take and the way that we set up our lives. And, also accepting, as well, that like, not playing the comparison game. I think that when you’ve been chronically ill or when you are someone whom you feel like, ‘gosh, I have to put a lot more effort into my health compared to someone who’s just cruising and has never had anything go wrong’ you can play that victim card and you can say, you know, ‘poor me that I have to do all these things, why is it so easy for someone else’ but, it’s a really disempowering place to be.
So, I now really focus on keeping my eyes in my own lane and trying to focus on how lucky I am that I have awareness of the tools that help keep my body in balance.

And, recognise as well, that we don’t know everyone’s story. And, I’m a perfect example of someone who, at one point in time, might have looked really healthy on the outside but, on the inside, mentally and physically, I was anything but healthy. And so, I think that yeah, for me, it’s really about, as you said, having really good self-awareness, having good body awareness and I know we say it all the time but, truly seeing health as holistic. Because, I think that until I dealt with my emotions, with my trauma, with my nervous system activation, with all that was going on emotionally and mentally, I don’t feel like I fully healed, so to speak. I think most of my true, deep-felt healing happened when I started to address that side of things. And, it made the application of continuing to eat well and exercise well, in terms of what was optimal for me, so much easier, instead of just following something someone had said.

I’m really grateful for my experience and I think we are only sent what we can handle. And, I think that, although everything that I experienced was incredibly uncomfortable and painful for me and I'm sure many others around me, I also feel like, if that hadn’t happened, many of those things, I don’t think I would have had enough motivation to learn to love myself and to learn to really create safety in my own self and know what is right and what is wrong for my body. I think that it’s part of the journey.

I also think a big message that has come through for me is about taking radical self-responsibility for your life and for your health and not outsourcing it and knowing that, there is so much power in doing that. Because we have, as individuals, so much, so many tools and so much that we can do that does make a difference and I think that that’s healing in itself. To be in that empowering mindset and to be in a place where you don’t accept that your body is just broken, but that’s a story. And, also, that makes me really conscious with my clients, when I can see them attaching themselves to their illness as if they are one and the same. And also, having gone through everything that I’ve gone through, I can really empathise with people when they are experiencing helplessness, or a lack of faith in being able to heal, or get better and what that feels like. And I think when you can connect to someone on a level of depth, beyond rote knowledge or, not rote knowledge, but just knowledge of what’s playing out in the body, you capture them and you can inspire them to know that hey, I see you. I was where you're at, and I can heal you. And I think that it’s now something that brings so much joy to my life. To be that person that holds that space for other people to get to a place where they too feel like they’ve been given their life back. Because, I feel like I have almost done a full circle back to the joyful, lighthearted, optimistic, spiritual kid I once was. And it feels really empowering to know that while I had a lot of help along that journey, that, you know, I am the person ultimately that created my reality now, which is feeling confident and comfortable and content, for the most part, in this body and in this mind.

Danny Urbinder: If you’d like to learn more about the integrated medicine approach to eating disorders, be sure to visit the IMH website. There, you’ll find the full audio interviews for each of our guest experts as well as transcripts, references and resources related to this, and previous patient journey podcasts. Also, be sure to download the IMH app so that you can join the conversation on this topic with other healthcare practitioners in the IMH community. I’d like to thank our guests Natalie Douglas, Gabe Covino, Dr Jeffrey DeSarbo and Marci Evans who so generously provided their time and knowledge for this production. I’m Danny Urbinder, and this has been a Patient Journey’s Podcast.