Is an Eating Disorder a Kind of Anxiety Disorder? An Expert Explains

Jessica Flint 0:02 Welcome to recover strong a podcast will transform your recovery from an eating disorder by helping you go from theory to practice to mastery. This is your special time to learn new skills, tools and get the inspiration you need to recover strong. Let’s get started. Hello, my warrior friends. How are you all doing? Welcome to this podcast. My name is Jessica Flint. I’m the founder and CEO of recovery warriors, a multimedia resource hub for all things related to eating disorder recovery. I personally recovered from an eating disorder and I’m here to inspire you to do the same. I believe recovery is not only possible, but it’s worth it. That is why recover strong exists to help you see and connect to the potential that lies within you to find freedom from an eating disorder. I’ve got my good friend Dr. Norman Kim, here with us. Norman is a highly sought after speaker, educator and advocate for Eating Disorder Awareness. Now, I deeply admire his passion for diversity, equity and inclusion in mental health and the work he is doing in this arena as the co founder of the Institute for anti racism and equity in mental health, with a PhD in Clinical Psychology from UCLA, and decades of clinical research and practice. I’m so grateful to have Norman on the show to share his knowledge and experience with you. Welcome to the show, Norman. How are you doing?

Norman Kim 1:55 I’m good. Thank you so much for having me.

Jessica Flint 1:57 I’m so excited to have you here. Because it’s been a long time. And your bio is so amazing that I want to go through chronologically. Where did you start with your undergraduate work?

Norman Kim 2:06 So I did my undergraduate at Yale, and was really interested in well, actually, I was originally a music and English major and didn’t want anything to do with anything other than sort of being creative and taking the whole liberal arts idea very literally. And at some point, I think I had my first probable sort of grown up recognition that I needed to do something that could actually turn into a career and it wasn’t going to be music, nor was it going to be writing poetry or something. So I switched to being pre med and Psych and I always had an interest in working with kids with developmental disabilities, even in high school. And so I found a class that was around that topic. And it happened to be a class on autism. And it really spoke to me and I just found it very interesting on a lot of levels. So that started my interest boring in psychology and, and looking at the brain and especially where the brain is involved in emotional expression, emotional recognition, things like that. So I switched to being a psych major.

Jessica Flint 3:14 And did you keep up with music while doing the psychology studies.

Norman Kim 3:19 And when I was an undergrad, I was in an acapella singing group, which is awesome, but also super nerdy. So I’ve been a singer for my whole life. And I’ve played, you know, instruments for my whole life. But I started writing my own songs and performing in LA and the singer songwriter circuit and did a good amount of touring sort of during grad school and after grad school and ran a showcase in LA for about five years where I performed and I had other people perform with me. And it was just it was a blast. It was really fun. And it was a good exercise and sort of flexing those creative muscles.

Jessica Flint 3:57 Yeah. And I imagine it was good outlet to with all the research. I mean, that’s very rigorous.

Norman Kim 4:03 yeah, and yeah, I’m a Gemini, so I think I’ve always had that duality thing. That’s yeah, going for me. And no, it was I think it was actually looking back on things. It was really important to keep things balanced. Because what I was doing was really heavy. And it was good to have not just a fun outlet, but a really meaningful outlet in expressing myself in a different way.

Jessica Flint 4:28 Yeah, I heard you play at the marginalized voices event at the NIDA conference, and you had so much soul on your voice. And I was taken aback because I’ve always known you know, Norman, the researcher and clinician, not the norm and the kick ass musicians. It was cool to be like, Wow, that’s Norman. Awesome. Yeah, it’s cool to see that other side of you, do you so you’re in LA, and that’s where you did your PhD?

Norman Kim 4:55 Yeah, I did my PhD at UCLA in clinical psychology and was still I was studying autism and Asperger’s syndrome. And that was really remained that really remained my focus until probably my internship year when one of my rotations happened to be on an eating disorders unit with Mike Strober, UCLA who’s really a pioneer in eating disorder research. And he offered me a postdoc position after, after I finished my internship. And it was also on something that wasn’t eating disorders, it was childhood bipolar disorder, but the eating disorders unit was just down the hall from my office. And so I just started seeing patients on the unit because honestly, because it was easy, but it really it very quickly turned into something that really connected with me on a number of levels. I love the complexity of the patients, I love the the nature of the work that we had to do with the patients, they were extraordinarily challenging, and in good and bad ways. And also, I think my personality, and my style seemed to work well with the population. And so all of a sudden, I became sort of a specialist, because there weren’t too many people who really wanted to work with the eating disorder population.

Jessica Flint 6:10 Yeah. And I imagine with your background in autism, I’m not sure if there’s much correlation between the two, but kind of the emotional distress and regulation aspect of it, it would, would you say there is some overlap between what you were learning about treating people with autism, and treating people with eating disorders,

Norman Kim 6:28 the connection was something just like you’re saying was just in that both involve emotional understanding, and both involve emotional expression difficulties, but in very different ways. And it’s actually only been fairly recently that there’s been a lot more attention paid on more direct linkage between autism and anorexia in particular. And actually, I was at the International Academy breeding sort of conference. And there were a number of talks on the looking at very direct connection between autism and anorexia, which has been, which has been sort of hypothesized for a number of years. But it actually does look like there are more connections on the biologic level, as well as on the behavioral level. So it feels like my career is kind of coming full circle, in a weird way. So it really was sort of ideal trading, for me to think about the kinds of questions we’re dealing with now.

Jessica Flint 7:27 Yeah, I remember, one time I was hanging out with you in LA, and you pretty much said eating disorders are anxiety disorders. And it was kind of one of these moments where it was just like, wow, you’re right. And it kind of was just like an epiphany. And from from all your clinical work, have you seen that a majority of your patients struggle with anxiety?

Norman Kim 7:51 Yeah, so I can’t take any credit for that idea. Because it’s an idea that a lot of people, especially on the research side have been pushing for a long time, Glenn Waller, who’s the former president of the Academy for eating disorders, has been arguing this for a very long time as as Michael Stover. And the idea that eating disorders are just better thought of as anxiety disorders, I think just makes a lot more sense than almost anything else. And without going into too much of the technicalities behind like how diagnostic entities kind of get categorized in the first place. You know, we know for example, on the simplest level that symptoms of anxiety almost always precede eating disorder symptoms and people who suffered really, almost 100% of the time, as far as we can tell, there are some symptoms that are clearly indicative of anxiety that are present well before the first sort of clear eating disorder symptoms managed to come up for most people. We also know that anxiety symptoms are among the last things to go, you know, when people can be fully recovered in terms of their symptoms or in terms of weight restoration and visit and be physically, you know, recovered from their eating disorder symptoms. But what tends to last for a much longer time is, is the anxiety it’s the preoccupation, it’s the obsessiveness, it’s focused on, you know, just focus on yourself issues with self esteem, those things are the characteristics that we know really are present Well, after you know, your actual eating disorder symptoms might have been taken care of. And that’s why eating disorders I think, take so long to to recover from for many people. We also know that the rates of comorbidity are extraordinarily high anywhere from I think it’s greater than 60% of people with eating disorders have a comorbid anxiety disorder diagnosis, which is a really, really high level of comorbidity between the two. So obsessive compulsive disorder, social anxiety, social phobia, generalized anxiety disorder, all are present at much higher rates. They’re also present at higher rates in family members of people with eating disorders, which suggests that there’s a A strong genetic link between the two illnesses as well.

Jessica Flint 10:03 Yeah, what are successful treatment approaches for anxiety, kind of what’s out there right now that people are using for anxiety and eating disorders?

Norman Kim 10:12 You know, it depends on what kind of anxiety disorder you’re talking about. But in general, you know, cognitive behavioral approaches have been very, very effective for anxiety in general, because they’re going directly at either the somatic symptoms, or some of the more cognitive symptoms of catastrophic thinking, or really black and white thinking extremely rigid kinds of thinking, which have their obvious parallels with eating disorders. You know, for something like OCD, there’s a very specific kind of behavioral intervention, which is called exposure response prevention, which has proven to be extremely effective for obsessive compulsive disorder. And because of the much clearer links between obsessive compulsive disorder and, and eating disorders, a big part of that approach takes advantage of the way that we all learn and the way that we’re all wired, which, to some extent, is through fear. You know, when we first learned to swim, you’ve got to conquer your fear of drowning, I guess, by set some point jumping in the bladder, right? When we learn how to ride a bike, or drive a car, those are fairly dangerous, but those are things where you could hurt yourself. And we all have to get over that those initial fears, but the only way to get over them is to actually do the task and practice and then you get better. So it takes advantage of the way that we all learn and the way that we’re all wired to also, you know, help people who are really stuck in certain patterns of behavior that they can’t get out of, you know, in addition to behavioral kinds of approaches, it’s also dialectical behavior therapy, which is proven to be enormously successful in as a component of eating disorder treatment, there are also narrative approaches that directly work with people’s stories, and they’re telling the stories that have shown to have some efficacy, you know, family based therapies can be very, very effective for some people. So most programs will will have elements of of all of these, there’s this core element of someone’s story and their experience, you know, you’re talking about something that’s been with somebody for as long as they can remember? And how do you start developing a sense of purpose and meaning, and sense of connectedness to their person, like to their and whatever their identity might be, in a way that is in a way that’s healing, and in a way that will also sort of stick around? And that’s, you know, that’s much bigger work. So I think, you know, there’s no ignoring the I don’t know, I don’t really know what else to call it, but that spiritual element, because it’s terribly important in terms of if we’re, if we’re talking about recovery with a capital R. I don’t think that happens without addressing that. That deeper thing.

Jessica Flint 13:06 Yeah. Because we’re, I mean, the reality is Bert, no two people are like, we have some genetic kind of similarities, things like that family history, but I you know, it’s in our fingerprints were different of all of us.

Norman Kim 13:21 Yeah, no, absolutely. And everyone’s journey to healing is going to be different, because everyone has pain is different, even though your pain and my pain might on surface look similar in how it expresses itself or something. At our core, my life experience is different from everyone else’s life experience. And that also means that the way in which I experienced the world is going to be very different. Even though obviously, we all have a lot of commonalities. I think we can all empathize with a feeling of insecurity, I think we can all emphasize, emphasize empathize with feeling some sense of being different, or some sense of being excluded or some sense of not fitting in or not belonging, you know, to some extent, those are universal experiences. But what’s more important is, what my particular feeling of belonging is, and what my particular pain in this world is. And that’s absolutely going to be different from one person to the next.

Jessica Flint 14:24 Yeah. I kind of want to circle back to the OCD excited question about that. I was talking with an expert, and she said that OCD. To actually be diagnosed, you need to be doing the behavior five hours a day, and I was a little bit surprised by that. Is there kind of subclinical OCD because I think there’s OCD tendencies, like I used to write out all my homework and I could not cross it out. I literally could not cross it out. And I would have to rewrite the whole page again. And so homework took me a long time, but it was like perfect, but it was very OCD in the way I handled it.

Norman Kim 15:01 Yeah, so there’s, they’re the obsessive thoughts, as well as the behaviors that people engage in to try to manage those thoughts and the accompanying anxiety that comes along with them. So, you know, that’s clinical OCD. And it’s also got to, it also has to affect your functioning in some profound way. And but most people like you’re describing, most people with OCD, full blown OCD really can’t function because they’re spending so much time consumed by their obsessive thoughts, and then trying to engage in their compensatory behaviors to manage the extreme anxiety and fear and panic that comes up because of it. But you’re absolutely right, there’s all levels of subclinical obsessive compulsive behaviors, and obsessive compulsive personality styles that absolutely get into people’s way and affect their functioning in the world, but maybe don’t quite reach the level of clinical significance that would be necessary for diagnosis. And like with all things, you know, it’s not like, only people who meet full diagnostic criteria are people who suffer, anyone who’s struggling with those impulses, you know, is going to is also going to be suffering just in a different, you know, maybe to a different degree, but it’s not a difference in kind. And that’s where, you know, in addition to full blown OCD, and people with eating disorders, there’s definitely a lot of connection and a lot of overlap in just the patterns of obsessive thinking and the patterns of needing to do things in a compulsive way. As well as the nature of the anxiety and fear that that’s present for people with them with that kind of obsessive compulsive tendency or personality style, as well as people with eating disorders who may not have full blown OCD. But, you know, there’s another argument to be made that just focusing on the kind of behavior that’s present is also important to look at, which is, you know, which is part of the argument for thinking about eating disorders in a broader sense of anxiety disorders, because we know that’s a common element. And we know that different kinds of anxiety behaviors are present in this population as well.

Jessica Flint 17:17 So would you say like, anxiety is kind of the overarching, broader, and then underneath, you can have eating disorders, OCD, there can be overlap between those. But you say it like at the root of all of these anxieties kind of there?

Norman Kim 17:33 I think, yeah, it does make most sense to look at eating disorders as a kind of anxiety disorder. Again, I think the more genetic evidence comes out and the more biologic evidence, we’re starting to understand, the stronger and stronger that argument makes, to another extent, it kind of doesn’t matter how we categorize these things relative to one another. But you know, in from a way of thinking, I think it kind of does, because it does affect how we approach treatment. If eating disorders are just this unicorn, then it’s harder to, to take what we do know from this other area of you know, of anxiety disorders, for example, and try to apply it to something like an eating disorder. But if we, if we start to think about it as having lots of common elements, then it does make sense to see if the same approaches that work for other anxiety disorders might also work for eating disorders, understanding that there are also going to be differences, in the same way that OCD is very different from social phobia, for example, even though they’re both anxiety disorders.

Jessica Flint 18:37 Yeah, I also really liked that point you made earlier about people just because you don’t have the clinical OCD doesn’t mean that you’re you don’t have pain. And I think that’s really important for eating disorders. Because a lot of people, you know, don’t meet the DSM five is now six now, right, and 655 still dominate the DSM five. And they feel like, well, I don’t have anorexia and I don’t have a low enough body weight. But it I think that prevents a lot of people from getting the help they need because they don’t feel like they’re sick enough, because they’re not meeting the full clinical criteria.

Norman Kim 19:13 Yeah, and it’s particularly important because one of the characteristics of people with eating disorders, I think, is a feeling of I don’t deserve help, right? That I don’t, because I don’t look sick to the world all the time. either. I have to make myself look sick to the world bit to match how I feel inside or I have to find some other way to to sort of justify the level of pain that I’m feeling. And that’s a horrible thing like that disconnect between how one might be feeling inside and then how you think other people are perceiving you. That when that when those two things are far apart from one another. That’s a horrible, horrible feeling. And it’s tremendously distressful. And so especially because it’s such a core feature of EBIT, what needing to sort of feels like, because you already feel like you’re not deserving of love and care and, you know, and people’s time and energy, etc. And you don’t feel like you’re as good as the person next to you, if those are all common features, then having these diagnostic criteria that kind of reinforced that, that belief is really problematic. There are many, many people struggling with eating disorders that are not getting help, because they don’t meet these like, kind of arbitrary distinctions that we’re making and criteria. And because of the way that, you know, unfortunately, because of the way that insurance coverage works, and that this expensive is, this treatment can be quite expensive. You know, we’re sort of bound by fitting people into these into these boxes, when we know the illness doesn’t always fit into those boxes, there are significantly more people like, you know, many times fold number of people who have subclinical eating disorders, that are nevertheless impairing our ability to function in life and their happiness and well being causing them a tremendous amount of pain, like all of the things that we would say would be worthy of clinical attention worthy of treatment. There are many, many more people or who are in that camp than there are people who actually meet criteria for one eating disorder or the other. And that’s, that’s something we need to do a lot of thinking about as a field. And now we’re going to address it at the level of education, as well as at the level of how do we bring those people into treatment?

Jessica Flint 21:39 Yeah, there needs to be every form with insurance for sure. It’s, they’re just big bullies. Yeah, you have to do you have to fight them a lot.

Norman Kim 21:51 We would need a whole other show or two. about insurance. Yeah.

Jessica Flint 21:56 I really liked that we’re covering anxiety on this because I personal my personal story, that was a major breaking point for me, when I realized I had anxiety because for a long time, I thought I was stressed, overwhelmed, nervous energy. And I had so many ways that I described and I was actually going through my journals the other day, I do that from time to time, and I was seeing all these patterns of describing anxiety, but without the word anxiety. And in a way that label once I kind of took it in, and I realized why I have anxiety. It really helped me and it helped with kind of understanding the way I behaved in the past and in the present and probably in the future. And how has how have you seen clients describe anxiety?

Norman Kim 22:41 I mean, I think your experience, unfortunately, is probably what most people’s experience is that there’s just this thing. And when it’s something that’s been a part of you for as long as you can remember, that’s just, that’s your normal, right? So even if, if there is a word for it, if you don’t necessarily connect that word to your own experience, then it kind of doesn’t matter. I think, you know, the, I’ve heard people describe it in any number of ways, just feeling. Some people it’s as basic as fear. And for other people, it’s more a sense of just constant overwhelm. For other people, it’s a sense of being always having to be in a state of alarm, or in a state of being vigilant in you know, in the world to make sure you know, not just make sure that you’re not going to get hurt, but just make sure that you’re not doing something to offend somebody, or just doing something wrong. Like that kind of vigilance is really exhausting. If you’re constantly sort of worried about what you’re saying and what you’re doing, and worried about how it’s going to impact other people around you, as well as yourself out and moving into the future. Like that’s what anxiety is. Now, the problem is anxiety is actually really useful. More than just useful, actually, it’s essential anxiety is what allowed our ancestors to survive so that we would exist now, you know, if cavemen out there weren’t anxious, then they wouldn’t survive, because they wouldn’t be worried about where the next threat was. And they wouldn’t be thinking ahead to, if I turn this corner, I wonder if I should take a peek first before I get eaten by something. Anxiety is what allowed all of us to survive. And the problem is that that instinct still stays with us because it’s been, it’s been a, it’s evolved to become an essential part of of all of our wiring for, you know, 99.99% of our history as a species. And it’s a very small percentage of time, you know, if we’re thinking about geologic time or evolutionary time, when we’ve not had those kinds of threats in our environment. So we still have those instincts, and they’re still really important. So anxiety now is something that helps us study. Maybe one more time for that test tomorrow to make sure we get a good grade on on, you know, on the test is what maybe makes us make sure we know where we’re going for a really important employment because we’re not so we’re not late for it, you know, anxiety is enormously beneficial. But for some people, when it takes over, it starts to get in your way more than more than it helps. And when it gets in your way, because it involves this really fundamental part of who we are, it’s really, it’s profoundly impactful on your on your functioning, it’s exhausting to feel that level of worry all the time and that level of fear all the time. And when you find something that helps with it even just a little bit, which is something that eating disorder behaviors are great at doing. Of course, you know, it’s going to feel wonderful, it’s going to feel, it’s very hard when you’ve been in that state to feel to know the difference between something that makes you feel good, and something that just makes you feel less bad. Because when you’ve been in a chronic state of feeling, either unhappiness or a chronic state of feeling, worry and chronic state of of anxiety, and preoccupation, and all of that. Anything that makes you feel less of that feels amazing. And that’s in that’s a big pull of for these behaviors. And it’s a big reason why, what stopping the behaviors is so terrifying, and so difficult to do.

Jessica Flint 26:31 Yeah, you’re like the master of profoundly simple statements. Well, one thing I would say to like, the way I would describe it is it feels like anxiety is like really in the head, like, sometimes, you know, you just when you’re in an anxious moment, you can like sit and just stare at the wall and just be thinking, and people who said to me like, well, you’re way too in your head? And what I like, is somatic coping strategies? And is this a way to kind of get people out of their head and into their body?

Norman Kim 27:03 No, that’s exactly right. Because anxiety does have those components. Because, you know, because it’s coming from that, it’s, you know, we call it our reptile brain, because it’s coming from that the oldest parts of our brain, what it’s doing is it’s preparing our bodies to it’s fight or flight, right, it’s preparing our bodies to take some action in response to a threat. So heart racing, you know, palms sweating, like being really super, hyper vigilant, or of your surroundings. All of those are things that we need to do in order to make a quick decision about what do I do here? Do I run? Or do I fight? Or do I freeze, right, so all of the somatic symptoms, the bodily symptoms that are present in anxiety are, you know, can be seen as a version of that really ancient impulse, and it’s connected to the stuff that’s going on in our head, because those instincts still remain, even though we don’t have the kinds of threats in our environment that we used to. That is we don’t have threads that could kill us like right now. It still feels the same. You know, our, as far as our brains and our bodies are concerned, there’s no difference. Anxiety is anxiety. And fear is fear. So it’s, it’s always both of those components. Now, for some people, some people are just more connected to their bodies and other people, some people are much more in their heads than other people. But there’s always both, you know, they’re always both things happening, whether or not they’re aware of it, and from but for most people, I think they would probably most people who are who are anxious, are probably going to experience anxiety, more, you know, more in their heads and more the cognitive pieces, and the just being sort of stuck up here in the way that you’re describing it. And so it’s important to also call their attention to what’s happening bodies, because, you know, we’re not, those are not two separate things. It’s all interconnected. So if you can get away, get out of your head, and more into your bodily sensations, that’s also good. But also be paying more attention to your bodily sensations. So you can do something to try to change it. If you can do something to try to change even your posture, the way that you’re sitting to relax your shoulders, for example, most of us who are, who are anxious probably do kind of live up here, a lot of the time. And even if you’re not anxious, if you just do this, it doesn’t feel good. It makes you feel more anxious. And so calling attention to those sensations so that you can make an adjustment in your posture or you can make an adjustment and how tense your muscles are. Because those are all things that we can do. Even something as profoundly simple as just monitoring your own breathing, which is an essential part of any kind of meditative yogic practice. And we’ve I don’t know Why but we’ve all become really disconnected from something as simple as proper breathing techniques. So calling attention to your body so that you can both be attentive, but also try to change some of those things to start, you know, changing that feeling of anxiety. And then, you know, it also opens up your ability to pay attention to what’s happening in your head in a different kind of way.

Jessica Flint 30:24 Yeah, and I think that’s why yoga was so helpful because of that breathing, but just getting the body like into the body and feeling grounded and relaxing your shoulders and relaxing your muscles at the same time focusing on them.

Norman Kim 30:39 Yeah, you know, I think it makes a lot of sense, because most people think about yoga has, you know, there’s that kind of meditative, relaxing association we have with you, right. But any kind of physical activity is you’ve got to start with good breath control. And, you know, breathing gives your muscles oxygen, there’s no physical activity that doesn’t involve at its core, proper breathing technique, no matter what you’re doing. strength comes from proper breath. There’s nothing that’s not connected to our breath. And this is something that I think the ancient world knew that we’ve kind of lost touch with.

Jessica Flint 31:20 Yeah. So do you have a breathing practice yourself?

Norman Kim 31:26 I do. Not as much as they’d like to, obviously. You know, I think this is probably a common common ailment of of all of us that we should we could all stand to do better stance to do more of what we preach in our own practice. But But yeah, I think I mean, probably more, because I’ve been a singer for most of my life. It’s something that I’m certainly very conscious of. I try to pay a lot of attention to. But yeah, I could definitely stand to do more of it in my own life just as, like centering myself for the day.

Jessica Flint 32:01 Yeah. And it doesn’t have to be, you know, a lot of time either. It really can be just a few minutes, or even a few breaths, just okay, like recentering getting back. I know a lot of my listeners listen to a lot of podcasts. And there’s always this a lot of inspiration in their ears about people who do this and that you end up feeling like you’re falling short, because you’re not doing all of that. I think sometimes you have to say we’re doing enough, just then just add on as as you can add protection. Yeah. Yeah. All what’s been so great talking with you, Norman. I love it. Before we wrap up the show, I just want to take a minute and acknowledge you for being such a strong advocate and a pioneer in the field of eating disorder treatment, helping people find meaning and integrity in their life free from eating disorder thoughts and behaviors. And I just think it’s amazing work. It’s so thank you.

Norman Kim 32:53 Thank you. I mean, thank you for being a great friend. And for what you’re doing. There’s almost nothing more important than, you know, your kind of advocacy and reaching out. And, you know, maybe you don’t, but you’ve been a tremendous and very direct impact on people’s lives. So I’m very proud to be your friend.

Jessica Flint 33:14 Colvin mutual reception, and thanks so much for coming on the show Norman and sharing all this great insight with us.

Norman Kim 33:21 Thank you for having me. It’s been a pleasure.

Jessica Flint 33:33 Thank you, Dr. Norman Kim, you can find out about the great work Norman is doing in the social justice and diversity, equity and inclusion space of mental health by going to his LinkedIn page.