When food becomes the only control: eating disorders and anxiety

“I know this isn’t normal. But it’s the one thing in my life I actually have a handle on.”

Someone said that to me in our second session, once we knew each other a little. He wasn’t talking about food, even though food was ostensibly what we were discussing. He was talking about what it is like when everything else is uncertain — work, a relationship, the future, whether he is good enough — and there is one single area where it is clear what counts as right and what counts as wrong, and where the answer arrives immediately.

I hear that sentence often. That is why I am writing about it. Not because it is unusual, but because it is so common that we have almost stopped noticing it.

The anxiety was often there first

One of the most persistent findings in eating disorder research is that anxiety disorders often do not follow the eating disorder — they precede it. In a large study, Kaye and colleagues found that a substantial proportion of people with anorexia or bulimia had already met criteria for an anxiety disorder in childhood, most often obsessive-compulsive disorder or social anxiety, years before any difficulty with food appeared.

That is not proof of causation. It is a strong hint that food is not the starting point. The starting point is a nervous system already tuned to danger, and a child who very early on looked for a way to settle that inner restlessness.

Many of these people were described as good, precise, reliable. As someone who causes no trouble. Perfectionism that the world praises and anxiety that nobody sees are often the same thing viewed from two sides.

Why the restlessness attaches itself to food

Because food is the one area that is at once necessary, daily, measurable and socially approved of when you restrict it.

Nobody will tell you it is strange to decide to look after yourself more carefully. Quite the opposite — you will probably be praised. And because the body responds, you get something that is extremely rare in anxiety: evidence that your actions change something. When everything else offers no feedback at all, that is powerful.

In other people the same anxiety attaches itself to something else — cleanliness, the schedule, work, checking. In some it attaches itself to food. Which door opens is often a matter of circumstance rather than character.

There is usually something else alongside it: a period when something in life came loose. A move, parents separating, illness in the family, a change of school, a first real loss. It need not be dramatic. It is enough that the person felt at the time that they had no influence over anything that mattered. Control over food then entered as something that was entirely theirs.

In the short term it genuinely works

This is the part an outside observer finds hardest to accept. Control over food is not senseless behaviour. It is behaviour that does its job — just not the job it appears to be doing.

When the body is in a state of arousal, attention narrows. Focusing on one concrete, manageable rule is a rest for a frightened nervous system. Instead of diffuse, shapeless worry (“am I enough”, “will they leave”, “what about five years from now”) you get one question with a clear answer. The worry acquires a shape. Shaped worry is less unbearable than shapeless worry.

This is exactly why I talk about food as a symptom that is doing something rather than an error to be removed. If you take away the solution without touching the problem, all that remains is the problem.

A loop that keeps itself running

The trouble is that the relief does not last. And every time the anxiety returns, it returns with a small addition: now you know what settled it last time.

This is the same mechanism that keeps compulsions alive in obsessive-compulsive disorder. Every avoidance teaches the brain that the danger was real and that you dodged it just in time. Because the fear never meets an outcome that would disprove it, it remains untouched — and the rule that settled it becomes obligatory.

Each turn of the loop makes the rule a little stricter. Not because anyone wants that, but because what settled things last time stops settling them after a while. People do not describe this as escalation. They describe it as “I’ve just become a bit more consistent”.

The rules multiply beyond the plate

With the people I see, it rarely stops at food. The control spreads — to the schedule, to movement, to when someone may visit, to which social events can be accepted. Each new rule is an attempt to extend the feeling of safety a little further.

What is striking is that people rarely feel safer as a result. They feel more tired. Maintaining rules is work. It demands constant attention, planning ahead, quiet calculation in the middle of a conversation with someone else. One person told me it felt as though a programme were running in the background all day that he could not close.

The consequence is that life shrinks. Not all at once, but one cancelled evening at a time. And because every withdrawal lowers the anxiety, the shrinking does not feel like a loss. It feels like reasonable caution.

This is the same pattern I describe in the piece on catastrophising: the mind offers the worst-case scenario, and the behaviour makes sure it never meets reality.

What is happening in the brain

To simplify: in anxious people, the system that predicts what is about to happen is set up to treat uncertainty itself as a threat. The danger does not have to be real — it is enough that the outcome is unknown.

Work by Frank’s group and others has shown that people with eating disorders often have heightened sensitivity to prediction error and markedly low tolerance of uncertainty. That is why a rule that fixes the outcome in advance is so appealing. It does not remove the fear — it removes the unknown, and for such a nervous system that is almost the same thing.

I have written more about what an aroused system looks like from the inside in the piece on anxiety in the brain.

What therapy does with this

The first thing that happens in serious treatment is not a conversation about meaning. It is establishing physical safety and regular eating. As long as the body is in deficit, thinking narrows, mood drops, obsessionality rises — and any deeper conversation rests on poor foundations. That is not a psychological aside; it is physiology.

Only then does the actual work begin: learning to tolerate uncertainty without immediately shutting it inside a rule. This is slow. It proceeds in small steps that look unimportant from the outside and are anything but from the inside.

In practice this means I do not work on making the anxiety disappear before the person takes a step. I work on them taking the step while the anxiety is present, and staying long enough to see what happens. Almost always, less happens than they expected. Not the first time, and not the second. Somewhere after many repetitions, the body starts to believe what words could not persuade it of.

Alongside this, the question of what the control was for opens up. What could be managed in the family and what could not. Where having a need was forbidden. Here I work with a genogram and with the body’s response, not only with thoughts.

Where this explanation breaks down

Now I have to say where my own explanation lets me down.

First: anxiety is not the only route. There are people in whom an eating disorder did not grow out of anxiety but out of prolonged restriction that was initially entirely external — a sport, a profession, a piece of advice someone took too seriously. For them, anxiety arrived later as a consequence rather than a cause. If I offer them “there’s anxiety underneath”, I am offering them somebody else’s story.

Second: the explanation “food is only a symptom” can become an excuse for delay. I have heard it used like this: until we understand the deeper cause, there is no point addressing eating. That is wrong, and it can be dangerous. Nutritional rehabilitation does not wait for psychology to catch up with it.

Third: in a body that is in deficit, a great deal of what looks like personality — rigidity, obsessionality, social withdrawal — is not personality at all. It is a consequence of the state. The classic Minnesota starvation study demonstrated this in volunteers with no disorder of any kind. If I ignore that, I will be interpreting character where I should be interpreting physiology.

When the first address is a doctor, not a therapist

An eating disorder is not only a psychological matter. It has physical consequences that can be serious and that remain invisible from the outside for a long time. If fainting, disturbances of heart rhythm, marked loss of periods or rapid deterioration appear, the first step is a doctor, not a therapy room. That is not a departure from therapy but its precondition — I write about the order in which help should come in the piece on when a doctor comes first.

With adolescents, something else applies: guidelines recommend family-based treatment as the first choice. Not individual therapy with the parents waiting outside, but treatment in which the family is part of the solution. The research by Lock and Le Grange supports this firmly enough that we should not depart from it without a reason.

What helps the people close by

If this is your person rather than you: arguing about the plate almost never helps, because the argument speaks to the symptom rather than to the person. What matters more than the content is that you stay in contact at the moments when contact is uncomfortable.

It also helps to remember that the control is not aimed at you, even though it often feels that way. Someone who narrows their life under distress is not pushing you away. They are pushing away the feeling that the ground has gone — you simply happen to be nearest to what they are pushing.

What genuinely helps, and where the people close by most often exhaust themselves, I have set out separately in the piece on setting a boundary without closing the door.

And you do not need to be a therapist. You need to be someone who does not disappear. That is less than you imagine and more than it seems.

What to remember

Control over food in anxiety is neither foolishness nor a bad habit. It is the best solution someone found, at a given moment, for the sense that the ground was slipping away. It works in the short term, and that is precisely why it repeats.

The loop does not break by forcibly removing the rule. It breaks when a person gradually discovers that they can bear uncertainty without it — and that other ways of settling themselves are available.

The body comes before meaning. A doctor comes before a therapist whenever the body is at risk. With an adolescent, the family is part of the treatment, not an obstacle to it.

And if you recognise yourself here: understanding what the control was for is not the same as giving yourself up. It is the beginning of a conversation about what might serve you instead.