Body Checking: Safety Behaviors In Recovery

Like many things, body-checking behaviors happen for almost all human beings. It’s the degree to which they occur and how they become linked to the drive to create energy deficits in the body that distinguishes the behaviors as being quality-of-life reducing in those with eating disorders.

What are body-checking behaviors? I would prefer not to go through the list because it’s a bit like firing up a flame thrower in a moth-filled sky—those carefully navigating their recovery efforts don’t need exposure to the list of behaviors. Suffice to say that for a person who has no eating disorder, body-checking behaviors are fleeting and involve a passing conscious observation of the body’s shape. The behavior might involve tactile confirmation of the body’s shape (using hands to smooth clothes, grab loose flesh etc.) or it may simply involve a visual assessment (reflection in a full-length mirror from different angles).

The behaviors themselves do not suggest the presence of an eating disorder. Instead these behaviors are co-opted by the presence of an active eating disorder to serve as avoidant safety behaviors to try to alleviate the threat response associated with approaching and eating food.

They are similar to going back to check if you left the oven on. Again, everyone has experienced a time where they return home because they cannot recall turning off the curling iron, stovetop element, etc. But for those with obsessive-compulsive disorder, the act of going to check becomes itself an anxiety-avoidant behavior that only serves to keep ratcheting up the anxiety with each check-again loop.

Body-checking behaviors begin pretty much from day one. A baby will be fascinated by her own toes and a toddler will gleefully lift up her shirt to show everyone her amazing belly “My belly!” All these interactions with their own bodies allow children to develop their brain’s ability to interpret stimuli from the senses: sight, hearing, taste, smell, touch, heat, pressure, pain, balance, vibration, movement, and internal status.

Body-checking behaviors in adults who are not dealing with an anxiety disorder may not occur with the same frequency or absorption as they do when the brain is developing, but they still occur and likely provide updates to allow the brain to maintain an accurate connection with all the sensory stimuli it receives.

When these behaviors get co-opted by the threat response system, that’s when the quality-of-life goes in the toilet. The dominant initial hypothesis in scientific literature for this eventuality in those with eating disorders was that body checking magnifies perceived imperfections, serving to maintain body size preoccupation and the fear of losing control (thus maintaining dietary restriction). 1 This hypothesis arose from the post-hoc rationalizations provided by patients: “Body checking helps me to control my weight.” Further investigations identified that eating disorder patients tend to veer back and forth from intense body-checking behaviors to avoidance of those behaviors. 2

Imagine you had an intense phobia of birds but had to work in a wild bird sanctuary or end up on the streets with no shelter or food. Your job is to sweep out the birds’ enclosures and restock their feed and water. The feed and water is handled first. The birds come to the feed area when you refill it, and you close them off in that area so you are able to enter their main enclosure safely to sweep it out.

Now imagine the number of avoidant safety behaviors you might develop in that circumstance to try to get through the day. You have to approach the very thing that sends your threat identification system into absolute chaos every single day. Without some specific guided support from a trained exposure and response prevention (ERP) therapy provider, your world would careen from hyper-vigilance to avoidance and back again. The phobia would inexorably increase in intensity and each moment of your day would be chaotic and traumatizing.

Whereas your non-phobic colleagues are careful (these are raptors with sharp claws and beaks), you are mired in multiple steps to keep checking that the birds are safely stowed in the feed area. You try to avoid looking at the birds at all but then are forced to keep checking where they are in the feed enclosure before you enter the main enclosure. It’s a circular nightmare.

For someone with an active eating disorder, approaching food multiple times a day to survive is like cleaning out those wild bird enclosures. It’s not surprising that all manner of sensory update behaviors that are normal to all human beings get co-opted as a way to try to get the threat response to ease up just enough to get the job done of eating to survive another day.

So what do you do with these behaviors in recovery? Body checking is normal; but how it’s been co-opted to reinforce anxiety is disordered.

I’ve mentioned choosing the battles in recovery when it comes to not weighing yourself in the blog post Weighing Yourself: Don’t Do It. The fundamental focus for the brain retraining facets of recovery is to apply therapy efforts on approaching and eating the food.

You might think you are afraid of losing control of your weight or size, or your health or identity, but that’s the conscious mind conjuring up reasons for why the threat response has fired up in the first place. That your threat response has misidentified food as a threat is an anomaly—a not fully understood set of connections that your brain is predisposed to make and reinforce. You are compelled to explain that strange anomaly using sociocultural frameworks.

Most of us have experienced déjà-vu—a distinct sense that we have experienced before the exact scene or conversation that we are having now. Déjà-vu occurs for migraineurs, those under stress or fatigue, during neural development between the ages of 15-25, and the instances decrease with age. The most recent hypothesis for this is that there may be fleeting delays between sensory input and interpretation that create a double-input experience for the brain. 3

There are also many ingenious (and disturbing) experiments that will mess with proprioception (the sense of our own body in 3-dimensional space) where we can extend the sense to treat a rubber hand as our own or experience a sense that our own hand is not ours. 4 What is interesting with these experiments is that our conscious mind does phenomenal contortions to try to explain the aberrant sensory inputs we experience. Your explanation of the reason for avoiding food is no different—just the creative conscious mind trying to make meaning of an anomalous and fundamentally meaningless set of stimuli inputs (in this case the threat identification system going on high alert because you are approaching food).

When you find yourself locked in body-checking behaviors, or desperately trying to avoid applying them, you can use your creative conscious mind to help you maneuver these behaviors back into their normal range of application. Identify either the repetitive application or avoidance of these behaviors as the co-option of normal brain-stimulus-interpretation updates for the purpose of trying to lower the threat response to food. Brining it to your conscious attention might look something like this:

“I am not afraid of losing control of my weight, shape, health, or identity. I am not going to feel any more at ease when it comes to eating whether I avoid the mirror or spend time squeezing my thighs to see if they have changed in shape at all or not. I will feel more at ease with eating by practicing my eating. I will go eat.”

For the woman working in the wild bird sanctuary with a phobia of birds, she won’t resolve the panic by either calling in sick or spending an extra ten minutes repeatedly checking that the feed enclosure really is locked off and all the birds really are in that feed enclosure before she enters the main enclosure. She will make progress when she decides to hire an ERP therapist who will help her to specifically to address the phobia itself. And yes of course as part and parcel of that work, she will be addressing the conscious decision not to apply repetitive safety or avoidance behaviors while in the presence of the birds. However, this therapeutic approach is done in a very methodical and stepped process to ensure success.

An active eating disorder has much in common with an active phobia. The application of ERP for the treatment of eating disorders is something a team of researchers at Columbia Psychiatry have been investigating in the past few years and I have referenced their work in other blog posts here well. 5

As the research chasm delays the transition of new treatment options from research validity to wide-spread practitioner application, it’s not easy to find an ERP practitioner who will be familiar with using the approach to help those with active eating disorders. 6 Nonetheless, ERP is an established treatment approach for PTSD and phobias so it will be possible to find a competent practitioner even if she is not familiar with its application for eating disorders specifically.

If body-checking and avoidance behaviors have been co-opted by an active eating disorder as a bunch of spiraling safety and avoidance behaviors to try to manage eating the food, then see if you cannot find an ERP practitioner to help. In the meantime remind yourself that the behaviors will not alleviate the underlying panic around eating. Only approaching and eating the food will alleviate the panic over time.

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1. Mountford, Victoria, Anne Haase, and Glenn Waller. "Body checking in the eating disorders: Associations between cognitions and behaviors." International Journal of Eating Disorders 39, no. 8 (2006): 708-715.

2. Shafran, Roz, Christopher G. Fairburn, Paul Robinson, and Bryan Lask. "Body checking and its avoidance in eating disorders." International Journal of Eating Disorders 35, no. 1 (2004): 93-101.

3. Brown, Alan S. "A review of the deja vu experience." Psychological bulletin 129, no. 3 (2003): 394.

4. Nishiyama, Yuta, Shinpei Tatsumi, Shusaku Nomura, and Yukio-Pegio Gunji. "Ghost hand: My hand is not mine." (2009).

5. Steinglass, Joanna E., Robyn Sysko, Deborah Glasofer, Anne Marie Albano, H. Blair Simpson, and B. Timothy Walsh. "Rationale for the application of exposure and response prevention to the treatment of anorexia nervosa." International Journal of Eating Disorders 44, no. 2 (2011): 134-141.

6. Glasgow, Russell E., Edward Lichtenstein, and Alfred C. Marcus. "Why don't we see more translation of health promotion research to practice? Rethinking the efficacy-to-effectiveness transition." American Journal of Public Health 93, no. 8 (2003): 1261-1267.