Maybe Descartes had a point

I met two women the other day with a similar complaint. Both reported the experience of having daughters diagnosed (and hastily referred elsewhere by the doctor) as anorexic because of a low body weight and no other symptoms. Both mothers were annoyed by the experience. It would be so helpful if the public and especially doctors stopped seeing an eating disorder as a weight problem.

Bear with me, because this isn't what you are hearing everywhere, and it is complicated: People who are constitutionally of low body mass aren't ill, nor are those who are "traditionally-built." People suffering from malnourishment for any reason need healthcare, whether they are suffering from a mental illness or not. People suffering from artificially high weight due to medical or psychiatric problems need attention to those health issues, but not in some simplistic goal of changing their weight.

Anorexia isn't low weight. High weight isn't an eating disorder.

Altered weight can be an symptom of one stage of anorexia, as it can be a symptom of a stage of binge eating disorder, but the distinction is important. Most of the suffering of any eating disorder goes on at average weight; weight can't be sole or primary diagnostic tool. The suffering is mental: emotional, cognitive, interpersonal, attentional, proprioceptive. Most of the effective treatment needs to go on at so-called "normal weights" as well.

We need to intervene and remain engaged in the treatment of our loved ones with mental illness at all weights. This is an underlying brain disorder, not a weight problem.


  1. wow, thank you so much for this.. I am currently seeking help for Anorexia and so many times I tell myself I cant be anorexic because my BMI is normal. I do have all the 'mental' side of an anorexia though but my mind trick me into thinking maybe there is nothing wrong because I am a healthy weight. (although I stopped menstruating roughly a year ago) But thank you for this, it has really helped :)

  2. How true, Laura. Yet all four of the criteria for diagnosis of anorexia have in some way to do with weight. It is discouraging, since this prevents some of the people who actually do have mental health care insurance from getting help when they need it.

  3. Dear Laura,

    Well said! Eating disorders are complex and cannot be defined by weight.

    High and low weight can be caused by other factors in a person's life. And, most importantly to understand, a person can be of normal weight and suffer from an eating disorder.

    I appreciate your clarifying this point in your post. You may help uninformed individuals to be more aware and discerning.

    I'm especially glad to see Sheena's comment. I hope other people with eating disorders who thought they were fine because they were at a normal weight will also seek treatment.


    Joanna Poppink, MFT

  4. Scientific research has shown that the brains of individuals with anorexia nervosa appear to be functioning in a manner that's different from healthy controls. But much, if not all, of that difference seems to go away when the brain is renourished and allowed to repair the effects of semi-starvation. A question I have for Joanna Poppink is whether her treatment model includes refeeding an anorexic in order to give the brain a chance. I have read much of what she's written and haven't seen any mention of the importance of food in recovery, or any acknowledgment that food is medicine. Perhaps Joanna could comment.

  5. Dear Anonymous,

    Please go to my website, Eating Disorder Recovery. The url is below.

    In the search function insert the word, food. Also, in a separate search, insert the word, meal.

    You will find several of my articles about eating in recovery.

    Eating nourishing food on a regular basis is essential for maintaining health and keeping the brain functioning normally.

    A starved brain creates passionate and distorted thinking.
    IMO learning to eat well is a fundamental part of any eating disorder recovery method.


    Joanna Poppink, MFT

  6. this comment helps so much, I might even show my family. as when I have gotten to a normal weight range in the past we have relxed when it comes to going to therpy and continuing with recovery... until then next crisis.
    I always read your blog, this post is the top one for me right now.

  7. Dear Joanna, I did search the word food on your website. I did not, however, find therapeutic techniques for re-establishing full nutrition in someone suffering from restricting anorexia. Instead, most of your discussion of food relates not to the undernutrition one finds in restricting anorexia, but instead to what you characterize as the overconsumption of food in bulimia and binge eating disorder. What little on your site talks about restricting anorexia simply seems to urge the sufferer to eat more. But if it were as simple as that, restricting anorexia would be easy to cure.
    The theme of your website seems to be that eating disorders, including restricting anorexia, are the product of dysfunctional interpersonal relationships. You seem to be saying that treating the emotional harm resulting from relationships will restore the patient to a healthy emotional state and that a restoration of healthy emotions will then result in eating returning to normal. The modern evidence-based view, however, is largely the opposite of your theory. The evidence-based approach is to see the eating disorder as causing malnutrition of the brain, which then produces disordered thinking, which then causes dysfunctional interpersonal relationships. The way out of the problem is to first restore the brain to full nutrition. After that happens, thinking becomes ordered again and interpersonal relationships are improved.
    The sufferer, because of distortions in thinking resulting from the state of semi-starvation, cannot accomplish refeeding on his or her own. Loved ones, therefore, usually parents or other family members, need to step up and think for the ill person, temporarily making the food choices for him or her. This approach, often called Family Based Treatment or the Maudsley Model, is the treatment technique now used with success by the leading clinicians around the world. In 2008 the United States National Institute of Mental Health funded a study of all clinical trials for the treatment of anorexia nervosa in adolescents, and concluded that the Maudsley model has the strongest evidence base to support it at the present time. I looked for, but surprisingly could not find, any mention of the Maudsley model of treatment on your website.
    Instead, your philosophy is the opposite, expressed in your website's article entitled "Please Don't Burden Families with Unnecessary Guilt," for example, where you argue that it is "unfair and unreasonable to expect family members to become qualified treatment providers." It is this philosophy that burdens families with guilt, by accusing them of causing anorexia nervosa, then excluding them from the leading role in treatment. Maudsley, on the other hand, assumes the family did not cause the illness and empowers them to take the lead in treatment. The result is not only the most successful treatment, but also the absence of guilt.
    By the way, I think you should at least inform your patients and their families of the Maudsley model, and the evidence that supports it, even if you do not offer it as a therapeutic option in your practice.
    Thank you for inviting me to review your website.

  8. Kristine,
    The DSM-IV is far from perfect, but 2 of the 4 AN criteria (intense fear of weight gain and distortion in the experience of weight/shape) are cognitive. They're more about how people FEEL about weight and shape than weight itself. People troubled with eating disorder thoughts can and should seek treatment.

    It seems the examining doctors in the original post referred although the patients exhibited only one major symptom. I'd rather see a referral to a competent provider to rule out an eating disorder than the "wait and see" many parents hear when they express concerns to a pediatrician, especially given that denial and minimization can be a symptom of AN.

  9. Anonymous,
    I completely agree that denial and minimization can be a HUGE symptom of AN. Even after being diagnosed with restricting anorexia I still dont think I have a problem some days because my weight is normal. Even if I eat barely next to nothing and my weight is 'normal' I believe I do not have a problem. I think people should seek help weather or not they meet all the 'criteria'. To be honest, i think a lot of people with ED's use the criteria of ED's to discount the severity of it and to make themselves believe they dont have a problem.

  10. I agree. That's why I said, "People troubled with eating disorder thoughts can and should seek treatment."


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