Some information on common eating disorders

Quick note:  Current and past sufferers of one or more of the disorders mentioned, I am interested in your feedback on what I have written.  Any feedback is welcome, but I am especially interested in your thoughts on how someone who loves you can be helpful.  Please feel free to provide your feedback anonymously here:
http://www.surveymonkey.com/s/DL7QZM2

Considering I work in mental health, and especially since I work with primarily women, I want to bring to the forefront that this is National Eating Disorders Awareness Week.  Eating disorders are common, and while there is a lot of common knowledge about them, there are also many misperceptions about them, and a lot of mystery remains around how to help when someone you love is struggling with one. 

Three common eating disorders can be thought of as falling somewhere along a continuum, but for purposes of this post today, I am going to refer to them in these three separate categories.  There are other types of eating disorders that do not fall along this continuum which are more rare or not well-researched yet (for instance, pica which is the eating of substances not thought of as food such as paper or dirt, and orthorexia which is an obsession with eating certain kinds of foods) which I am not going to cover here, largely because I know little about them and their causes and treatments.

The three eating disorders that I am going to write about here are Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder.

Binge Eating Disorder

Binge Eating Disorder is the most common of the three, and the one in which there is more equality between men and women in who suffers from the disorder.  An important thing to recognize about this disorder is that not all (by a long shot) overweight people have it.  Conversely, not all people who have it are even overweight.  BED is characterized by having at least 2 episodes per week of binge eating.  Binge eating means that a person is eating out of control, long past the point of being satiated or even over-full.  (To contrast, the majority of people who become overweight do so over long periods of time by eating just a little too much here and there.)  BED is also characterized by an obsessive fixation on food; thinking about it throughout the day, thinking about when they can be alone and get enough food so they can binge.  The inception of the disorder may actually be brought about by overly stringent dieting.  There are many causes of the disorder, but often it comes down to seeking comfort from either the food itself or the ritual of binging, or both.

If you suspect someone you love is suffering from the disorder, it can be difficult to bring it up because of the emphasis our culture puts on being at a low weight.  It is important to know, however, that eating thousands (or tens of thousands) of calories in a short period of time, especially when repeated with frequency, is dangerous.  It puts a lot of strain and pressure on several different body systems, most notably the digestive system and even the cardiovascular system.  While the weight gain that is likely to be caused by the disorder can be hard on the body, the overall practice itself is unhealthy.  If you know for sure that someone you love is binging, either because you have seen it or because that person tells you, you can focus on the binging behavior itself as harmful without lecturing the person about the effects of weight gain and obesity.  (Chances are, they are probably well aware of both, but you can more easily align with them if you can support them in changing the behavior rather than pressuring them to lose weight.)  As with anything, it is important to take a supportive, rather than a controlling stance.  Leave the lifestyle and medical decisions up to a professional.  Unless you are the parent of a minor child, or unless you have permission/instructions from the person and/or their therapist/medical professional, do not attempt to put them under surveillance to minimize the likelihood of the binge behavior occurring: this is likely to alienate them.  What you can do is encourage the person to become involved in counseling.  It is likely that their self-esteem has been damaged by the disorder, and that they feel shame surrounding their binge behavior.  It will be helpful for them to meet with a professional who can help them uncover the need that is being met by this behavior (and there is a need being met, otherwise they wouldn’t be doing it), and explore healthier ways of meeting the need.  The experience can also help them normalize the behavior, thereby reducing the shame around it.

Bulimia Nervosa

Bulimia is akin to the unhappy median of Binge Eating Disorder and Anorexia Nervosa.  A key aspect of Bulimia that must be present in order to diagnose the disorder is binging.  Eating a normal or small amount of food and then being scared of gaining weight from it, then attempting to vomit is not Bulimia Nervosa.  In combination with some other behaviors it may be Anorexia Nervosa, or it may be a category known as ED-NOS (Eating Disorder-Not Otherwise Specified), which may fall anywhere along the continuum described here.  No, characteristic of Bulimia Nervosa is binging and purging.  Purging itself may also take several forms.  It is most commonly thought of as a forced vomiting of food, but it can also materialize as laxative abuse or excessive exercise.  But the bottom line is, for it to be bulimia, binging AND purging must occur.

Sufferers of bulimia are quite commonly at a normal-looking weight, but can sometimes be slightly under- or over-weight.  Sufferers are, like sufferers of anorexia (which is covered below), normally fixated on weight, appearance, calories, consumption and subsequent expulsion of food/calories.  Bulimia has a high comorbidity rate, which means that sufferers of bulimia are likely to be concurrently suffering from another psychiatric disorder such as anxiety, substance dependence, and impulse control difficulties. 

Bulimia Nervosa may be difficult to detect in a loved one based on body size, but it is likely that you will notice evidence of the person being overly harsh or critical of his or her size or figure.  Dissatisfaction with self can be difficult to hide when a person is also focusing on many other things.  The person may be very ritualistic about his or her eating habits, and may eat very little when in the presence of others in preparation for a binge.  If you are concerned that someone you love may be suffering from this disorder, realize that while you can be compassionate and caring, you cannot change their behavior and you should not try unless the sufferer or their doctor or therapist ask for your intervention/accountability.  The best thing you can do is to gently voice your concern, and offer your support.

Anorexia Nervosa

Anorexia Nervosa is characterized by a refusal to consume sufficient amounts of sustenance (food) in order to either lose weight or maintain a very low body weight.  There are several diagnostic criteria that must be met in order for a person to be diagnosed as “anorexic” (such as a loss of menses in women, body weight that falls below a certain point, as well as the obsession with food/calories and exercise, and an unrealistic expectation for the sufferer’s own body weight), but a person can be suffering from anorexia before the exact weight or loss of menses occurs.

A person suffering from Anorexia often believes that as he or she becomes further removed from food, that the person’s thinking becomes clearer.  There are physiological reasons for this.  Starvation is likely to cause a “high” feeling, or a feeling of elation or happiness.  Also, because the body has gone into “survival mode,” thinking becomes more “black and white” to simplify things.  Therefore, the person is not thinking more clearly, but sees things as black and white, which makes decisions easier.  (And for a person who already associates food with fat, and fat with “bad,” it further solidifies the resolve to avoid food.)

If, in someone you love, you notice a steep drop-off in their weight, or an obsession with going to the gym, or if they are finding all sorts of excuses to skip meals, it is worth looking into whether they may be suffering from this eating disorder.  As with sufferers of Bulimia Nervosa, it is important to keep in mind that you cannot change their behavior, and that you should only try to when and where your intervention is asked for.  Until then, it is ok to let a person know that you are concerned.

The bottom line: How to help

If you do not know anybody who is suffering from an eating disorder, perhaps the most important thing you can do is to think about your own attitude, and try to be a part of a cultural change that shifts us all from equating a very low body weight with attractiveness.  Have you ever said something akin to “She’s so pretty, especially for a heavy girl!”?  Statements like that are part of the problem.  Another problem is making fat jokes, even to people who are slender or average weight.  This reinforces that being fat is somehow “less than,” and something to be avoided at all costs.

If you know someone personally whom you are concerned about, I would encourage you to gently approach them.  You may want to avoid explicitly asking if they have an eating disorder, and instead just observe what you have noticed.  For instance, you might say “So, I’ve noticed that you are very preoccupied with fitting into a smaller dress size, and you are already attractive at the size you are.  I’ve also noticed that anytime I invite you to dinner, you seem to have other plans or if you come, you pick at your food and say you’ve already eaten.  Are you ok?  Is there something going on with you?”  If they aren’t fully aware of what is going on with them, you may bring some awareness with your objective observations.  If they are fully aware, they may deny that there is a problem, but you have at least shown concern and love and opened the door in case they would later like your support.

The most important thing to remember is to be non-forceful and non-judgmental.  Arguing will get you nowhere and it may alienate you.  If you are observing new symptoms, it is ok to bring them up at another moment, but “hounding” someone regularly can also lead to alienation (especially if these symptoms are being caused by something else, and not an eating disorder!).  However, a loving, gentle, and open approach may be a person’s first stop on the road to healing.

And if you are a current sufferer, know that I am here if you want to talk.