How Developmental Trauma Impacts Eating Disorders ED 0 2

Author: Ilene Smith

Ilene Smith: Hello. I'm Ilene Smith, and I'm here today with Dr. Kim DiRe to talk about eating disorders and trauma. Hello, Dr. Kim DiRe.

Dr. Kim DiRe: Hi, Ilene. How are you? Ilene: I'm good. Dr. Kim: Good. [laughs] Ilene: I just want to introduce you briefly and just share a little bit about what you do, and then please chime in and add whatever you'd like. Dr.

DiRe works with trauma and eating disorders. She has a quite a busy private practice and a practice mostly focuses around trauma patients, long‑term trauma, and eating disorders. Dr. DiRe's theoretical orientation is Somatic Experiencing. The work is about trauma healing. If Kim, if you wouldn't mind just explaining a little bit about Somatic Experiencing and the trauma healing piece of how it relates. Then again maybe how it relates to eating disorder patients, maybe just a little background on yourself and those pieces.

Dr. Kim: Those were a lot of questions. I'll try to break it down as understandably as we can. The work I do, I mostly see things as trauma. How I would simply define trauma, and then I'll make a longer explanation is the inability to stay in the now or the inability to stay in the present. There are a lot of breaches that happen in a normal nervous system that doesn't have trauma, where they can self‑protect or function through a day fluidly. Then if there is a justifiable threat then the adrenal system will kick off some adrenal, so that they can fight of flee. In an 8 to 12 minute is when the adrenaline goes off.

How Developmental Trauma Impacts Eating Disorders ED 0 2

Cortisol hormone that's sent to the adrenal system to shut it off, so when the justifiable threat...What I mean by justifiable is a threat between life and death. When the justifiable threat is dealt with either by fighting or fleeing, then the cortisol is sent in. The parasympathetic nervous system takes over. It starts to regulate the heartbeat, the breathing, and then a normalcy is functioning for the person. What happens in somebody with trauma is that the system that is built in survival has been interrupted. It's interrupted in lots of different ways, but the simple, understandable way that I'm going to explain it is the organism or the being didn't get to fight or flee or complete the self‑protective response. A lot of times, there are places where we as humans are not able to fight or flee, and the easiest piece we can do in order to survive is to go into a freeze mode. We are built in survival, so the freeze mode is a really great safety.

When it is overused or part of an automatic response to life around the human that's been traumatized, then that person, whenever they're activated by something, is going to go into this freeze response. The eating disorder, which is a maladaptive freeze response, happens for that person because a breach in their system has happened, usually by another human being. The eating disordered person creates a relationship with the eating, with the food, in a way that is set in safety, either by feeling like they have a loyal friend or control of their life because they can control the food, or an emotional piece where they're soothing. That's the binge eating disorder, they're soothing themselves with this place of the eating disorder. All kinds of maladaptive...What I mean by maladaptive is really unhealthy over a long period of time, unhealthy eating patterns. Usually, there is a pre‑cursor to this, or something that's set up in the biology where somebody is genetically predisposed to an eating disorder and then an outsider or environmental breach has happened, and then those two come at one point in one time and ignite, or an environmental piece happens for them in over a long period of time, then it is ignited slowly and then this automatic pattern to go to the eating disorder or the maladaptive eating behaviors becomes this place where a person can go into freeze, because that feels like safety for them. Numb feels safer than feeling. [laughs] Ilene: Thank you.

I appreciate that long explanation about it. Essentially, what I'm hearing this day is that the eating disorder is the way that the person is going to be able to function to the...Maybe there was some early life trauma. As time goes on and the trauma is unresolved and the person is moving through life, this is the way that they're dealing with the unresolved trauma. Is that correct? Dr.

Kim: Let me go back and just...It's correct. Just let me go back and give some more examples of how everybody has their own kind of perspective or trauma. Trauma is...I'm going to redefine it as the inability to stay in the now or the present. A trauma event is what is the breach of the person's autonomic nervous system, so that we understand that there's an event that happens.

An event can be a very long period of time or it can be a specific event, a specific surgery. I think that when you were talking, I think it sounded like you were talking about birth trauma. I deal with attachment issues that way. When you say "over a long period of time," or "early," I think you mentioned something like an early piece, there are in utero trauma events for the fetus. Sometimes, there's birthing trauma. Some children, not pushing off the uterine wall, the uterine wall, and that push, that surge that happens in child labor, childbirth, today in the childbirth's piece, where the baby is pushing off the uterine wall, is one of the first survival mechanisms, the first safety mechanisms, that some children, from what I've experienced with my clients, if they don't get to push up the uterine wall, then that becomes the breach in their system, because their survival didn't get to be met by self‑protection. That's one of the first self‑protections that they have.

Then other attachment pieces, not being cared for by their caregiver, some children, and it's needed because of a medical issue are immediately whisked into some kind of a medical event, because it's life or death at that point, but the medical event becomes a breach, and they don't get to attach to the mom in a way that becomes natural and the one that becomes a secure attachment. Those are types of events that can create this place where the young person, the baby, the fetus, and then young children developing, their organism doesn't get to feel safe. It doesn't get to be cared for by some of these events. Each system decided the breach of the trauma.

They're not deciding it cognitively, but decides the breach. Maybe something that felt traumatic to you wouldn't feel traumatic to me, or I would interpret myself protection differently than you. Really not to set anything in stone is to define somebody's trauma for them, it's the breach of their own system. As my long‑winded [laughs] explanation goes is, when a young being does not get to fight or flee and young beings can't. Children in households that are really with disregulated parents and maybe there's lots of yelling going on, that could be a breach or a trauma to someone's system. It can then create this place where the child can't fight, they can't flee, then they shut into this free system.

What happens with the young being, even with older [laughs] adults is, they have to create some kind of saving of the energy in order to survive this long‑term traumatic yelling or neglect. They cannot shut down their pulmonary system, it can't shut down their respiratory system, because they need those to survive. Remember, we're all beings built in survival. What I say is, "We're animals without tails." We go into this place that's set up for our system that's called freeze so that we can then save our energy in order to survive.

A being, that one of the best places to save the energy is for the digestive tract to start shutting down, because it can save energy. From there, it becomes an automatic response to all kinds of eating issues. Then if there's a biological component, then an eating disorder. Young beings are predisposed if those two pieces are ignited. Then there's adults who get an eating disorder at a later date. No one is, I think, at all discriminated against when eating disorders come.

[laughs] Ilene: Thank you. Obviously, you're treating eating disorders across the board. You're treating everything from avoidant/restricted food intake disorder, all the way to binge eating disorder. What are some of the things that you notice that might be similar and might be different across the different eating disorder populations, or as you see continuity throughout? Dr. Kim: I think that piece where I view it in the continuity is that a trauma piece has happened and there's a biological predisposition. How it manifests whether it's anorexia nervosa or bulimia nervosa or binge eating disorder, or what you'd mentioned is, ARFID, avoidant/restricted food intake disorder, which I classify more as a sensory disorder, so I work with it a little bit differently. To me, there's a precursor there of a birthing breach.

What I see in those different categories are similarities, the ARFID piece, the avoidant/restrictive food intake disorder, ARFID, there's a sensory component, and there's high anxiety, perfectionism. The people that come to me with ARFID had those similar features. Sometimes, the anxiety is so high, it looks like social anxiety. Because they are posed to eating certain foods, sometimes, they've been diagnosed as oppositional/defiant.

I've had some ARFID people who have been diagnosed on the autism spectrum. Because of the high sensory pieces, they're cutting out labels of their shirts or having to turn their socks inside out because the seam is too aggravating for them to wear, so that has a similar dose. Individuals have similar components. With the anorexia nervosa, really, the breach of feeling not worthy, really trying to become invisible in the world, I find that that's a common component. Then with bulimia nervosa, a lot of times, it's words unsaid or words unspoken. A lot of times, the release for them is not being able to protect themselves in a place where they have no voice. I see that as a commonality.

In the binge eating disorder, a lot of times, it's soothing from a breach to their body. A lot of times, that's a protective shield, soothing food becomes love and the shame component is pretty high in that category. [laughs] Ilene: Just share with me a little bit about or walk me through, someone comes into your office, they've been diagnosed with an eating disorder, where do you start with those patients, with a new patient? Dr. Kim: The piece where I start with this, the least restrictive or least objective avenue, the trust, usually, isn't high for people with eating disorders. A lot of times, they've gone through multiple treatments, multiple treatment centers. They are very suspicious of anyone harming them anymore. Their eating disorder has been their friend, their lifelong friend.

We as practitioners are trying to get rid of their abusive friend. How I explain it to families who don't understand is, "Just imagine that your child has," child or family member, it doesn't have to be a child, "has an abusive boyfriend or abusive partner. That abusive partner's living internally in them, telling them all kinds of things.

As practitioner, I'm lying to them, because I'm trying to get rid of their eating disorder, which is their most loyal companion. I worked with a place, but I can get into as far as what to do. Sometimes, because it's not safe to work in the body sometimes, I just do psycho‑education about eating disorders, about trauma. When I show the activation cycle with trauma and how the system works, then they're able to go, "Oh, that's me. Oh, yeah, that's me. I go into freeze.

Yes. I know that place." Then from that place, that's the least objectionable avenue or door opening so that we can work together. Each person, each session is completely different. I think the main piece that helps is that we're building a relationship, a human relationship. Eating disorders, in a simple way, from what I find in my practice is that they are created by breaches of a human being and then healed by continual consistency and compassion and gentleness, and some really good skills from another human being. A lot of times, that's a psychotherapy relationship.

What we're doing is, we're adapting a healthy relationship between the two of us so that they can go out and practice healthy relationships outside of the therapy office and then heal that way. That's usually what happens. That's usually what I'm doing. The ARFID has a little bit different piece to it, because what we're doing there is creating the automatic nervous system to autonomic nervous system, to calm, to re‑balance the system's pretty overrun by adrenaline.

Re‑balancing that system is what I'm usually doing. Then the piece that happen with that is allowing them the patient, the client, the eating disorder individual with ARFID to start taking more control of their eating, having more say in it. A lot of times, parents are really, really scared of their child becoming malnutritioned so then the bribery or the force of food happens. We have to rework that system with the families because a lot of times they're just begging their ARFID family member to eat, "Please, please, please eat." It becomes a battle between them and one of the breaches. Ilene: It's interesting. One of the things that you've talked about is the idea of the therapeutic relationship and getting into the client's system where you can, which is very different than something a lot of the therapies that were used in the past or that are still being used, such as EMDR or really addressing the trauma piece head on. Maybe you can share a little bit about that from the somatic experiencing perspective? Dr. Kim: Yes.

That's one of the things I love about somatic experiencing is that it's such a gentle work and it's so powerful. One of the pieces that I found with working with the trauma with eating disorder individuals is they don't want to go into their body or go back into their trauma. Trauma re‑traumatizes if we go back into the trauma. We can go to the periphery of the trauma, but really we'd work in a pendulating back‑and‑forth fashion at the periphery of the trauma.

These great compensation pieces that the individual has for living a life or surviving through that trauma event, those pieces then we pendulate to because then we're building the resilience of that organism and how they've been able to survive. Survival becomes their foundation. They have all kinds of really great, creative ways that they manage to survive. We move to those pieces that have been self‑protective and then back over to the edge of the trauma but not going into the trauma because I don't even need to know the story of the trauma event in order to heal it.

We don't need to know that. It recreates this activation in the trauma system. We really move away from that in somatic experiencing and really work on the pendulation piece between the resilience of the organism, the resilience of this person that's lived through this. Also the part where we have these completions of self‑protective responses from a trauma event that didn't get completed when they were having that event. We work in a couple of different levels. Somatic experiencing, it can be worked with at top down or the bottom up. What I mean by that is this top‑down would be the cycle therapy that we're working within and usually facing each other and then talking through and completing the self‑protective responses by imagination or sometimes we'll allow to push or allow to flee where the event didn't get that or the person didn't get to do that. The bottom‑up piece would be working with the body and the tissue.

The tissue has a memory. That's one of the things I want to talk about is in these trauma events or in this place where the eating disorder has been maladapted but adapted. We really need to heal this and come back to a better functioning or a better flow for the nervous system because it becomes medical at one point. When it becomes medical, now we've got so many things going.

We've got a larger treatment team, but there are so many things happening that the body just doesn't have that kind of capability to heal through surgery and the eating disorder. Now we're even fragmenting more about the power of the healing. We really want to work on the eating disorder before it becomes medical and reverse the pieces.

Now sometimes it becomes medical and we need to deal with that, too. If we can catch it early on, if the person can catch it early on, the body then has this wonderful ability to heal and then start generating this new cellular structure of flow and the way our systems are to work in survival. We're all captive. [laughs] We're all caged animals, the way our society has been set up. If we're living out in the caveman era, we would be probably fine and not traumatized, but we have to work with trauma.

I don't know anyone that has gone through life that doesn't experience some kind of trauma. It's pretty, pretty... Ilene: Aligned. Dr. Kim: Yeah, normalized in this world. Sometimes there's little T's and sometimes there's big T's. The part where there's an eating disorder, it becomes a big T.

[laughs] Ilene: Right. What I think I'm hearing you say is that with the somatic experiencing work and the body work getting into tissues that the goal of the treatment would be to build resilience. Dr. Kim: The ultimate goal of that treatment is to re‑balance the nervous system. That's what I do in all my work, is we're working on a place to re‑balance the nervous system so it works in conjunction with the whole mind‑body piece in a flow, in a way that the person can then respond to a justifiable threat, life‑threatening threat in the way that would be more... [crosstalk] Dr.

Kim: ...they complete the self‑protective response and then move forward with their life. That's what I'm doing. I'm reworking or helping the person rework their nervous system to balance. Balance is never studied whole, but that's the somatic work goal, is to create that balance or helping creating an environment, and then the person creates the balance or the body creates the balance. If I give the environment and the person working with me, the patient or the client, we're creating that space for that to happen.

When we have that space, then it automatically, because we're built in survival, it re‑balances to get rid of some of the barriers. [laughs] Ilene: My curiosity would be is that as you move towards a more balanced state, do you see more recovery as that happens? Is recovery really possible with eating disorders? What does that look like? Dr. Kim: Recovery is possible with eating disorders.

I get to witness that all the time and a lot of times in sessions. The re‑balancing comes in the smallest of steps. The fastest way we can get to eating disorder recovery is by the smallest of steps. That's how we work really in what we would call in somatic experiencing language, a titration, a really small, small step.

If a client or a patient goes into an overwhelm, that's just a signal from their system that the step was too big and we just move it down to a smaller step, so that this place happens where the person and the body...I'll look at it and one says, "I can," not, "I can't." The eating disorder is the big "I can't" and the recovery is a big "I can." The part where they have the resources internally to grasp that or to scale towards when there is an activation to their system, that's the piece that we're working with. That's the piece that I see all the time in working with these lovely people, who have a really difficult time. No one wants an eating disorder, believe me.

[laughs] They are courageous people. Yes, they do get to the point where there is recovery. There's a balanced life.

There's a meaningful life after recovering from an eating disorder... [crosstalk] Dr. Kim: ...along with another, that's all. Ilene: It didn't happen overnight? Dr.

Kim: Right. Ilene: What would you say that parents should look for signs or red flags that there might be an eating disorder? What would be some of the things that you would say a parent might look for? Dr. Kim: I see that when there is an emotional issue, then a disruption in the food, how it's taken in, the language around it becomes different. A lot of times, especially children, they cannot name their emotions or talk about their emotions. It comes out in their food behavior. Adults, too, there are some adults who were not able to grasp. It's a very hard concept to grasp, a sensation that you're feeling and then being able to express it and express your wants and needs in a way that they'll match. [laughs] Adult children and then children is that the food behavior will change.

There becomes this more secretive piece. A lot of times, isolation is part of it. They become more wanting to be alone, shutting people out, not having as much social contact. Children in school are not able to concentrate as much.

Sometimes there's a higher anxiety piece because if their system doesn't have enough food, then the adrenaline that's sent for forging food is sent and they're not responding to it by feeding. Oftentimes there's hiding food if there's a binge eating disorder, the wrappers, even if there's purging, hiding that in a closet, or drawers. As weird as that seems, they're trying to hide this piece that they sometimes can identify as an eating disorder. Sometimes just identifying that something is really off, they have to hide the pieces that they know aren't normal, the pieces that, "If I'm discovered, then I lose my new‑found friend or the coping mechanism that I have for my system." Even though it's not maladapted, remember this is not a logical disease. It won't make sense to some of the parents.

Pardon me? Ilene: It's a coping mechanism. Dr. Kim: It's a coping mechanism, but for families to look for shifts in the eating behavior, a lot of families now, because they're so busy, do not sit at a table and eat. We're finding so much research about table time with families and so really encouraging families to make sure that the connection, the security of eating at a table with others and really gentle conversation with gentle tones is such a great, secure bonding piece that shows itself over a period of time as balancing out individuals. I believe the research shows that there's a lot of people who feel secure, and have high esteem that have this table time with their families. If they don't have that, we really want to generate it, even if it's one time a week, it's really important.

Those kinds of cries for help are going to be, "Hey, I'm having trouble with my eating." We have to watch a shift in behavior, I think, so families can look for that. Ilene: As you wind up when you have, let's say a child who comes into you for treatment. How do you often wind up treating other family members to help the child, and support, and to create a different kind of environment at home? Dr. Kim: Absolutely. When I have a child with an eating disorder, the family system, the family comes in and we rebalance that for their support, always.

Also, to explain what's going on, and then to have some kind of dialogue that the family can work with, outside of the therapy office. Whenever a child comes in, their family's automatically included in the treatment, and the recovery. Ilene: Thank you.

What else would you like us to know in this segment, about trauma and eating disorders? Is there anything else that you think we need to know before we finish? Dr. Kim: That's a popular segment. There's a lot of times where people with eating disorders, or people who have had a trauma event go into a place where there's no voice. They don't have explanations for things, and it doesn't translate into the English language. Those are pieces that I work with the body, so a lot of people who come to my practice think that somatic experiencing is through the touch work that I do. The touch work that I do is that they lay on a table, it looks like a massage table. I call it a regulation table, and regulating the autonomic nervous system is part of that work. I use attention, intention and awareness in order to create this balance for these people who have a place without a voice, or a way to speak about what's happening to their system.

That happens sometimes, when something is a pre‑verbal trauma event, like the birthing sequence, or sometimes there's sexual abuse pre‑verbal, or from surgeries. Someone is in a place with no voice, when there were surgeries. I work with the tissue, the tissue has a memory.

I work with the body, in that aspect. A lot of times, I do both the top‑down and the bottom‑up. I think that combination works, but for young children, and I've worked with children as early as nine months, because of the adoption piece. There's attachment issues in adoption pieces, still around the world. We have places that use time to a crib or bed is the babysitter for those babies, because there's too many of these orphanages for the staff, and the staff is really understaffed, but under‑educated as well. When families get these adopted children attachment, and those trauma events are already set up, and like I said before, their digestive tracts need to create a place for them to save energy, so the digestive tract shuts down. Anyway, I've worked with a baby as young as nine months, and then children that have no memory of their adopted situation.

They don't really have a way to process that. We can do a play therapy, but working with the body is a really good way or the tissues because the tissues hold the memory. Flashbacks are another piece that happen, where there's really not a place where a voice can be captured at that moment, and so I work a lot with the body, or the autonomic nervous system for them to come present, and work with releasing that ability to, where they didn't get to fight or flee, with the touch work that I do.

The patient lays on the regulation table, and the first thing I do, automatically, as I place my hand, they lay with their clothes on. Anyone under 18, a parent is in the room with them. I place my hand where the kidney is to be, and I use attention to start moving tissue. It's taken a lot of good training, and a lot of skill to be able to do this work, but I find it so important in the work that I do, with people that have eating disorders, but don't have really the language to express it. Ilene: That makes perfect sense. Thank you so much for taking time to share all that wonderful information with us today. Dr. Kim: My pleasure.

I loved the work I do, and I love the people that I get to work with. I'm so honored, and so thank you for asking me. Hopefully, we'll continue on these conversations, and we'll get to share more, so that maybe somebody can be helped, or at least understand a little bit more, and seek out someplace where they can recover, or a family loved one can recover. Ilene: Thank you so much. Dr. Kim: Thank you, Ilene.

Bye. Ilene: Kim? Dr. Kim: Yeah, I'm right here.

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