What if feeling fat could be triggered by being too thin?

I don't usually use the terms 'fat' and 'thin' or 'triggered' as they are so fraught as to have little meaning but I'm using them here to make an unambiguous point.

Gaining weight makes you feel fatter, right? Losing weight makes you feel thinner, right?

Not if you are wired for body dysmorphia when you are undernourished. This is the point that many of us try in vain to explain to people unfamiliar with eating disorders. If you are underweight and you have a certain biological predisposition not only will you feel fatter when you lose weight you will feel more normal when you gain it back.


This isn't just theory. I've seen it and countless families see this when they get their loved one eating normally again and not only reach a "safe" weight but actually find their normally functional body composition and stay there. The sense of being 'too big' abates. The visual distortion in the mirror flickers and fades. Not for everyone, and less so for those who have been marinading in malnourishment for a long time.

The problem is that parents, and often clinicians, can't bear that excruciating middle ground - the extinction burst - the increase in anxiety and distress that attends the normalization of body and brain. The patient is in extreme distress and desperate for relief. The doctors can't claim medical emergency and the world is saying "he looks fine now" and there are no good rules for when normal has arrived. There are no agreed upon biomarkers for weight normalization.

So patients get stuck in the body dysmorphia at its worst point and steep in it, writhing - with the endorsement of their team and with parents cowering in fear and exhaustion.

I didn't really believe it either - that the final bit was necessary and would lead to LESS distress and dysmorphia. But it did. Almost like a spigot was turned to a trickle instead of an open firehose. Not gone, mind you, but the volume reduced greatly. To the level that, frankly, most western women simply live with.
**though of course we should not have to because there shouldn't be all this fat-phobia and moralizing and appearance-consciousness and judging and women-degrading going on at all. but that is a battle for another day and not just for the ED world, frankly.


  1. This is definitely consistent with my own experience. I can remember hitting certain milestones in restoring weight that seemed/felt HUGE to me, I couldn't stand it and it just felt alien, like someone else's body under my skin. More than a few times, I stalled out and drifted back towards more ED behaviors because I couldn't handle the change. But in retrospect, now you could not pay me to drop back down to those "huge" weight milestones, because I know I'd be unhealthily thin and would just feel and look awful. Perspective definitely does change throughout the process, and coping with that awkward period is the critical part.

  2. This also tallies with my experience. I had a really hard time for the first week at my target weight back in January - but after that my body magically "shrunk" in my perception and I just thought that I looked like a healthy, slim 25 year old woman. My eating disorder was not driven by body dysmorphia, I was a non-fat phobic anorexic, but even so, I couldn't see how underweight I was until I was better.

  3. Cammy, that's so cool. Brava! Time and work and support - that's the medicine!

  4. It's definitely an interesting phenomenon.

    For me I think it's more about nutrition than about the actual weight. Even if I'm at a fairly low weight, if I am constantly well-nourished for a sufficient amount of time, the body dysmorphia will go away.

    (I'm not saying full weight restoration isn't important, though, and it's probably worth noting that I was naturally at a really low weight my entire life before my ED.)

  5. Cammie, Katie, and A - this is the makings of some excellent case studies!

  6. What's interesting is that I rarely felt fat when in the throes of AN. My problem was/is that I don't perceive the weight loss. Even at my lowest weight, I thought I looked pretty normal. During my relapse last year, I lost a lot of weight very, very quickly. I could see that my clothes were baggier, and I could notice some slight changes in the mirror, but I still "felt" the same size.

    For me, the body dysmorphia began long before the AN started and has persisted even at 9 months post-weight restoration. I don't know what this says about my ability to see my body correctly. The big difference is that I can look at the body dysmorphia much more rationally now that I'm healthy. I can understand that I don't see what other people see, even if I can't see it.

  7. 'The extinction burst' Wow you've hit the nail on the head - this is where we're currently at - pulling her to that last few kilos. And what a battle! Not only dealing with ed but with the raw nerve ends of a teenager. And the dysmorphia is still there. We teeter on the edge of recovery and then some earlier behaviour - exercising at night - hello thought we'd seen an end to that - rears its head as well. And yes we are tired. We want the intensity to lessen. But we breath regroup and push on. But something else for thought - Maudsely model suggests stage one requires weight restoration to 90- 95 weight. So many parents I have spoken to have followed that and with therapist support began to hand back some independence (stage 2) and bam major relapse. - are the stages then helpful or hindering. Should the model be tweaked to better reflect the experince with weight restoration. Should there also be more support for this end of first stage? A way to name it and acknowlwdge it. I've gone of the track of dysmporphia but I feel like this is sooo important - parents would be less likely to 'cower' if they were prepared for this stage. Maudsley a linear model does imply things get 'better' as the weight goes on. (I wish)

  8. I had to come back and agree with A - I think nutrition is important too. Anecdotally I've noticed that people in recovery who are weight restored but follow rather orthorexic low fat diets or who eat a relatively low number of calories for a recovering person seem to have a harder time with body image and eating disordered thoughts after weight restoration. I am unfortunately allergic to dairy products, and if I don't make a concerted effort to get enough fat from other sources my mental state does begin to suffer. I know that correlation does not equal causation and I'm sure there are many other factors which determine how well one does after weight restoration, but it's an interesting observation to me because I'm a nerd like that!

  9. That's an important point, too, about nutrition being more than just weight restoration. It is also about the balance and individual needs. We get so caught up in fighting over the number but it is important to keep in mind that malnutrition can be going on even when at normal or 'over' weight.

    On the stages, oh Amaya, interesting issue and one I really hope is discussed and refined over time as FBT develops. There are so many 'active ingredients' to FBT and it has so many factors different than other approaches that we don't know which parts are important and which parts need tweaking. I'm with you, though, that a major weakness is in the timing of transferring accountability.

  10. Amaya,

    I am a psychologist who practices FBT. I have found that the FBT manual has a glitches that haven't worked well in my experience. So I don't do FBT "by the book." For example, I wait until the patient is 100% weight-restored to their optimal weight (not some statistical minimum) before beginning to hand back any control, and before allowing the patient to exercise. Many patients need to stay at 100% IBW for a number of weeks or months before they demonstrate readiness to resume any degree of independent eating. This means that my kids stay in Phase I a lot longer than the manual suggests!

    Another difference is that my approach is a lot more directive (offering very specific advice and guidelines rather than leaving the parents to figure it out on their own).

    One of the biggest shortcomings of the FBT manual, in my opinion, is that it doesn't offer advice on how to deal with the extreme resistance that most families encounter. I make a point of telling families from the beginning all of the extreme reactions they should expect - suicide threats, running away, self-harm, violence, throwing plates, screaming, etc. - that these are the norm, not the exception, and not an indication that the parents are doing anything wrong. The kids described in the manual are so darned compliant! I also think the manual should make it clear that often times things do get worse as the weight goes on.

    I am young and new to the field, so I have wondered whether a more experienced clinician would be able to implement FBT "by the book" with more success. I'm not sure. I just do what works for the families I see, and very often that involves significant modifications to the manualized FBT.

  11. Just wanted to chime in on the nutrition part as well. I had major anxiety and OCD issues when I was very underweight, and have been absolutely floored at how they've melted away as my brain has restored itself along with my body as I allowed fats and protein back into my diet as I built my food intake up. I'll always have an anxious personality, but the full on panic attacks over getting just 5 minutes off of routine schedule are HISTORY!


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