Dr. Sarah Ravin - Psychologist | Eating Disorders |Body Image Issues | Depression | Anxiety | Obsessive-Compulsive Disorders | Self-Injury
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Dr. Sarah Ravin

Welcome to my professional blog. I am a Florida Licensed Psychologist and trained scientist-practitioner. In 2008, I received my Ph.D. in clinical psychology. A major component of my professional identity is staying informed about recent developments in the field so that I may provide my clients with scientifically sound information and evidence-based treatment. There is a plethora of information on the internet about Eating Disorders, Depression, Anxiety, Psychotherapy. Unfortunately, much of this information is unsubstantiated and some of it is patently false. It is my hope that by sharing my thoughts and opinions on psychological issues, with scientific research and clinical experience sprinkled in for good measure, I can help to bridge the gap between research and treatment.

We’ll Always Have Fiji

I do not believe that the media plays a major role in the etiology of eating disorders. And yet, in much of the eating disorder world, it has become accepted as an unspoken, self-evident truth that patients with anorexia and bulimia have developed their illnesses in large part due to their desire to emulate “the thin ideal” which our media promotes. Those who espouse this idea cite the Fiji Study, which demonstrated dramatically increased rates of body dissatisfaction and disordered eating amongst Fijian adolescent girls within the first few years after television was first introduced to the island.

I, along with several of my like-minded colleagues, have raised concern over NEDA’s choice of Naomi Wolfe as the conference’s keynote speaker. As a feminist, I am a huge fan of Wolfe’s work. In her groundbreaking book The Beauty Myth, she presents convincing arguments about the myriad ways in which our culture and society are toxic to women. I couldn’t agree more.

Our culture and society are harmful to all women and men, and certainly the media plays a huge role in triggering body dissatisfaction and disordered eating. (Incidentally, the media is a major culprit in the perpetuation of myths about eating disorders.) But disordered eating is not the same as an eating disorder. The Fiji study measured body dissatisfaction and disordered eating, not eating disorders.

The disordered eating / eating disorder distinction is not just a matter of semantics. In fact, I believe that eating disorders are quantitatively AND qualitatively distinct from disordered eating, much as major depression is both quantitatively AND qualitatively different from sadness. Anorexia nervosa has existed for centuries, long before the advent of television and internet and fashion magazines, and long before disordered eating became the norm.

I think it would benefit our profession tremendously to arrive at a consensus regarding the definition of “disordered eating” and how it differs from eating disorders.

The confusion between eating disorders vs. disordered eating is a major contributor to society’s (and some professionals’) lack of understanding of eating disorders. People who engage in disordered eating are, on some level, responding to their environment in choosing to engage in certain eating behaviors, whereas people with eating disorders are caught in the grips of a terrifying mental illness which will not allow them to do otherwise.

Disordered eating is very widespread in our country, especially among women. I define disordered eating as a persistent pattern of unhealthy or overly rigid eating behavior – chronic dieting, yo-yo dieting, binge-restrict cycles, eliminating essential nutrients such as fat or carbohydrates, obsession with organic or “healthy” eating – coupled with a preoccupation with food, weight, or body shape.

By this definition, I think well over half of the women in America (and many men as well) are disordered eaters.

The way I see it, disordered eating “comes from the outside” whereas eating disorders “come from the inside.” What I mean is this: environment plays a huge role in the onset of disordered eating, such that the majority of people who live in our disordered culture (where thinness is overvalued, dieting is the norm, portion sizes are huge, etc) will develop some degree of disordered eating, regardless of their underlying biology or psychopathology.

In contrast, the development of an eating disorder is influenced very heavily by genetics, neurobiology, individual personality traits, and co-morbid disorders. Environment clearly plays a role in the development of eating disorders, but environment alone is not sufficient to cause them. The majority of American women will develop disordered eating at some point, but less than 1% will fall into anorexia nervosa and 3% into bulimia nervosa.

The Fiji study was indeed groundbreaking. It demonstrated the enormous impact of the media on teenage girls’ feelings about their bodies and attitudes towards food. But the study did not demonstrate a causal link between the media and eating disorders. Furthermore, our knowledge that the media makes girls dislike their bodies, while important in its own right, has not yielded useful information with regards to developing effective treatments for eating disorders. And isn’t that the whole point?

I would like for our field to accept the Fiji study for what it is – a fascinating sociological study which confirmed empirically what we already knew intuitively – and push forward towards a deeper understanding of eating disorders so that we may develop and implement more effective treatments.

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9 Responses to We’ll Always Have Fiji

  1. Anonymous says:

    I understand what you’re saying about disordered eating coming from the outside and eating disorders coming from the inside. I have questions: Let’s say there’s a person who chronically diets. She restricts her food. Sometimes she binges. She lives in a way that is controlled by a binge/restrict cycle. She feels “good” when she is restricting and “bad” when she is bingeing. Does this person have an eating disorder (EDNOS I guess) or does this person have disordered eating? Do some people with this behavior have eating disorders (if this behavior is driven from the inside) and some people with this behavior have disordered eating (if the behavior is driven from the outside? If so, how can you tell? I am assuming you would say that the person needs help, regardless of if they have disordered eating or an eating disorder. I’m assuming the only point in distinguishing between ED and DE is that it might influence treatment approaches. Is that right?

  2. Dr. Ravin says:

    Annonymous,

    Excellent questions. Here are my opinions.

    The person you describe who is caught in a binge-restrict cycle definitely has disordered eating and could benefit from learning a more healthful, balanced, moderate approach to eating. I think a majority of American women are caught in a diet/overeat or binge/restrict cycle of varying degrees.

    Based on the behaviors you describe, this person would not meet criteria for AN or BN. The criteria for EDNOS are quite vague, and she may or may not meet criteria depending on the extent to which her behaviors are damaging her health, interfering with her functioning, and / or causing significant distress. Frankly, it also depends on the psychologist who is evaluating her and how he/she interprets the criteria.

    I am typically able to tell with pretty good accuracy whether a person has disordered eating vs. an eating disorder by doing a thorough clinical interview with the patient and his/her parents (if it’s a child or adolescent). I can’t quite put it into words, but I can definitely sense the difference. People with DE are dissatisfied with their bodies and preoccupied with food but still able to think rationally (at least to a degree) and still able to change their behavior on their own. People with EDs are completely consumed by their illness, often compelled to act on symptoms by a metaphorical “voice” in their head, and unable to pull themselves out of their symptoms without significant external support.

    The distinction between DE and ED matters a lot because the former is a set of behaviors whereas the latter is a serious and potentially deadly mental illness. People with DE can usually correct their behavior on their own (but perhaps could use assistance from a dietician in some cases), whereas people with EDs require many months of intensive treatment.

  3. Anonymous says:

    Thank you for taking the time to answer my questions. I appreciate it, and I understand your response. I was originally diagnosed with AN, but on my way towards recovery, I found myself going through binge/restrict phases. Those phases were way more distressing than when I just purely restricted. Thank goodness those phases are over. And I started to wonder if I no longer had an ED. When I hear people talk about DE, I end up convincing myself that I no longer have an ED (just DE) and I minimize my ED and wonder if I don’t deserve help. Your descriptions of DE and ED make a lot of sense to me. Thank you!

  4. Dr. Ravin says:

    Annonymous,

    Nearly 50% of people with AN experience binge-eating symptoms on their road to recovery. It is the body’s healthy and adaptive response to a period of starvation, and it usually abates once your body is convinced that it will get plenty of food on a regular basis.

    Regardless of whether your symptoms meet criteria for an ED, you need and deserve help if you are distressed. Treatment is just as essential in the phase after weight restoration as it is when a person is underweight.

  5. Anonymous says:

    Thank you, Dr. Ravin.

  6. [...] disorder expert Sarah Ravin makes a key distinction as well. In her post on the media’s influence on eating disorders, she says that, The way I see it, disordered eating “comes from the outside” whereas eating [...]

  7. CB says:

    Good point about the Fiji study. It turns out that the
    number of individuals who participated in the study was very small. Nobody suffered from anorexia nervosa before television was introduced into the culture. Nobody suffered from anorexia nervosa after TV was introduced. Consequently, the study doesn’t provide evidence that TV causes anorexia nervosa. Maybe the TV did cause distress about body image. But not anorexia nervosa.

  8. Dr Ravin,

    I admire you putting this out there for all to see. These thought-errors are truly not just semantics: a study that is too small and which garbles outcome (“disordered eating vs eating disorders”) can lead an amazingly unchallenged life for YEARS.

    Disordered eating is a broad category, including yo-yo dieting, meal skipping, eating only junk food, solitary or secretive eating, etc is very prevalent in our society. The blame for some of this doubtless belongs to the media—but the real problem is the low prevalence of critical thinking. Think critically, folks, about what anyone tells you–including the media!

    Perhaps, in fact, this lack of critical thinking is a product of poor education. I think it matters more that you learn to think critically in school than that you memorize any number of facts that entitle you to any degree you can mention–including medicine.

    Julie O’Toole MD, MPH Kartini Clinic

  9. Annonymous, Nearly 50% of people with AN experience binge-eating symptoms on their road to recovery. It is the body’s healthy and adaptive response to a period of starvation, and it usually abates once your body is convinced that it will get plenty of food on a regular basis. Regardless of whether your symptoms meet criteria for an ED, you need and deserve help if you are distressed. Treatment is just as essential in the phase after weight restoration as it is when a person is underweight.

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