Unlike the other issues that I treat in my practice, I have included this section because many of the individuals referred to me for eating disorder treatment – nor their families, partners or friends – are well-versed with the facts.
I have also included links to pages about the most commonly asked questions about my experience and approach to working with adolescents and adults struggling with eating disorders, as well as to some great resources and videos. I hope that this section helps to begin to demystify the complexity of eating disorders.
What are eating disorders?
- Eating disorders are serious mental disorders that occur all over the world, particularly in industrialized regions or countries. They are NOT choices, passing fads or phases and they can be severe and fatal. They are treatable, and the sooner an individual gets the treatment he or she needs, the better the chance of a good recovery.
- The three main categories of eating disorders are anorexia nervosa, bulimia nervosa and binge eating disorder. Eating disorders can be recognized by a persistent pattern of unhealthy eating or dieting behavior that can cause health problems and/or emotional and social distress.
- Although there are formal guidelines that health care professionals use to diagnose eating disorders (DSM-5; APA, 2013), unhealthy eating behaviors and disordered eating exist on a continuum. Even if a person does not meet the formal criteria for an eating disorder, he or she may be experiencing unhealthy eating behaviors that cause substantial distress and may be damaging to both physical and psychological health (AED, 2014).
- Anorexia nervosa is characterized by a significantly low body weight and an intense fear of gaining weight or becoming fat. It is also distinguished by a disturbance in the way in which one body’s weight or shape is experienced, an undue influence of body weight or shape on self-evaluation, or the persistent lack of recognition of the seriousness of the current low body weight.
- There are two subtypes of anorexia nervosa. In the restricting subtype, people maintain their low body weight by restricting food intake and, sometimes, by exercise. Individuals with the binge-eating/purging type also restrict their food intake, but regularly engage in binge-eating and/or purging behaviors such as self-induced vomiting or the misuse of laxatives. Many people move back and forth between subtypes during the course of their illness (DSM-5, APA, 2013).
Bulimia nervosa is characterized by recurrent episodes of binge eating, in a discrete period of time (eg, 2 hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances. These episodes are marked by a sense of lack of control. These binge eating episodes are followed by inappropriate compensatory behaviours in order to prevent weight gain, such as self- induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.
Binge eating and inappropriate compensatory behaviour both occur, on average, at least once a week for 3 months and the individual’s self-evaluation is unduly influenced by body shape and weight (DSM-5, APA, 2013).
Binge Eating Disorder
- Binge eating disorder is characterized by recurrent episodes of binge-eating (same as bulimia nervosa), but is not associated with the recurrent use of inappropriate compensatory behaviours to counteract the binges.
- Binge eating episodes are associated with three or more of the following:
eating much more rapidly than normal; eating until feeling uncomfortably full; eating large amounts of food when not feeling physically hungry; eating alone because of embarassment; and/or feeling disgusted with oneself, depressed, or very guilty after overeating. Binge eating disorder is marked by distress regarding the binge eating and these episodes occur at lease once a week for 3 months (DSM-5, APA, 2013).
Other Specified Feeding or Eating Disorder (OSFED)
OSFED would include: atypical anorexia nervosa; subthreshold bulimia nervosa; subthreshold binge eating disorder, purging disorder and night eating syndrome (DSM-5, APA, 2013).
Avoidant/Restrictive Food Intake Disorder (ARFID)
ARFID, which may be diagnosed in children, adolescents or adults, is characterized by an eating or feeding disturbance as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one or more of the following: a significant weight loss (or failure to achieve expected weight gain or faltering growth in children); a significant nutritional deficiency; a dependence on enteral feeding or oral nutritional suppliments; and/or a marked interference with psychosocial functioning. ARFID is not better explained by a lack of available food or culturally sanctioned practices, or by another medical condition or mental disorder. It is not AN or BN and there is no body image distortion (DSM-5, APA, 2013).
Early signs of eating disorders
- Fear of gaining weight
- Preoccupation with food
- Feeling out of control while eating
- Intentionally vomiting after eating
- Eating in secret
- Feeling intense guilt after eating
- Using laxatives or diuretics
- Excessively exercising
- Body checking
- Chronic dissatisfaction with one’s appearance
Who may be affected by eating disorders?
- Anyone can be affected. Eating disorders do not discriminate on the basis of sex, age, or race. They can be found in both sexes, all age groups, and across a wide variety of races and ethnic backgrounds around the globe. But there are groups who display an increased risk for eating disorders (AED, 2014).
Who is at increased risk for eating disorders?
- Eating disorders are more common in women, but they do occur in men. Rates of binge eating disorder are similar in females and males.
- Athletes in certain sports are at particularly high risk for eating disorders. Female gymnasts, ice skaters, dancers, and swimmers, to name a few, have been found to have higher rates of eating disorders. In a study of top student athletes, over one-third of female athletes reported attitudes and symptoms placing them at risk for anorexia nervosa. Male athletes are also at increased risk especially those in sports such as wrestling, bodybuilding, crew, running, cycling, climbing, and football (AED, 2014).
How common are eating disorders?
- Anorexia nervosa: Between 0.3 and 1% of young women have anorexia nervosa.
- Bulimia nervosa: Around 1 to 3% of young women have bulimia nervosa.
- Binge Eating Disorder: Around 3% of the population has binge-eating disorder.
- Between 4% and 20% of young women practice unhealthy patterns of dieting, purging, and binge-eating.
- Currently, about one in 20 young women in the community has an eating disorder (AED, 2014).
What causes eating disorders?
- Eating disorders are complex and are influenced by BOTH genetic AND environmental (i.e., pressure to be thin, trauma, etc.) factors. Eating disorders are NOT simply caused by Western cultural values of thinness although those factors are operative.
- While the current Western obsession with slimness and the glamorous portrayal of emaciated women in the media may play a role in the recent increase of eating disorders, genetic vulnerability, personality, psychological and environmental factors all contribute to the causes of eating disorders (AED, 2014).
How devastating are eating disorders?
- For women aged 15-24, eating disorders are among the top four leading causes of burden of disease in terms of years of life lost through death or disability.
- Anorexia nervosa has one of the highest overall mortality rates and the highest suicide rate of any psychiatric disorder. The risk of death is three times higher than in depression, schizophrenia or alcoholism and 12 times higher than in the general population. Up to 10% of women with anorexia nervosa may die due to anorexia-related causes. Early recognition of symptoms and proper treatment can reduce the risk of death. Deaths in anorexia nervosa mainly result from complications of starvation or from suicide.
- Health consequences such as osteoporosis (brittle bones), gastrointestinal complications, and dental problems are significant health and financial burdens throughout life. Furthermore, quality of life is severely impaired in all eating disorders (AED, 2014).
Can one recover from an eating disorder?
- In general, early detection and treatment are associated with a better chance of recovery. One reason for this may be that brain development is not complete until about age 20 and the effects of starvation on the developing brain are particularly noxious.
- Anorexia nervosa: Over a 10-year period, about half of those with anorexia nervosa recover fully, a small percentage continues to suffer from anorexia nervosa, and the rest develop other eating disorders. Even among those individuals who recover from an eating disorder, it is common for them to continue to maintain a low body weight and experience depression.
- Bulimia nervosa: More than half of those treated for bulimia nervosa have recovered at follow-up (AED, 2014).
Understanding the stages of change in the recovery process
Recovery from an eating disorder can be a long process that usually requires not only a qualified team of professionals, but also the love and support of family and friends. It is not uncommon for someone who struggles with an eating disorder to feel uncertain about their progress or for their loved ones to feel disengaged from the treatment process. These potential roadblocks may lead to feelings of ambivalence, limited progress and treatment drop out. Therefore, knowing about the Stages of Change Model, as defined by Prochaska and DiClemente, will help everyone involved better negotiate the road to recovery.
The Stages of Change in the process of recovery from an eating disorder are a cycle rather than a linear progression. The person may go through this cycle more than one time or may need to revisit a particular stage before moving on to the next. They may also go through the stages for each individual eating disorder symptom. In other words, if they are recovering from anorexia, they could be in the Action Stage for restrictive eating (e.g., eating three meals a day along with snacks, engaging in social eating, and utilizing support system) while, at the same time, they could be going through the Contemplation Stage for body image and weight concerns (e.g., becoming aware of how body image is tied to self-esteem and self-worth, defining oneself as a body or number, and identifying the negatives of striving for the “perfect body”). This is precisely why recovery from an eating disorder is complex and individualized.
The following is a general breakdown of the Stages of Change for someone who is recovering from an eating disorder. If you are a parent, partner or friend of someone struggling, you no doubt struggle right along with them, so it is crucial for you to pay attention to your own needs as well as be present for your child or friend during her recovery process (NEDA, 2021).
What are the stages of change?
There are five Stages of Change that occur in the recovery process: Precontemplation, Contemplation, Preparation, Action and Maintenance.
The Precontemplation Stage is evident when a person does not believe they have a problem. Close family, partners and friends are bound to pick up on symptoms such as restrictive eating, the binge/purge cycle, or a preoccupation with weight, shape and appearance even before the individual admits to it. They may refuse to discuss the topic and deny they need help. At this stage, it is necessary to gently educate the individual about the devastating effects the disorder will have on their health and life, and the positive aspects of change.
Do not be in denial of your child, partner or friend’s eating disorder. Be aware of the signs and symptoms. Avoid rationalizing their eating disordered behaviours. Openly share your thoughts and concerns (NEDA, 2021).
The Contemplation Stage occurs when an individual is willing to admit that they have a problem and are now open to receiving help. The fear of change may be very strong, and it is during this phase that a psychotherapist should assist the individual in discovering the function of their eating disorder so they can understand why it is in their life and how it no longer serves them. This, in turn, helps the individual move closer toward the next stage of change.
Particularly if your child is under the age of 18, be more proactive in encouraging them to seek professional help from a qualified eating disorder specialist. Educate yourself about the disorder. Be a good listener. Do not try to “fix” the problem yourself. Seek your own encouragement from a local eating disorder support group for family and friends (NEDA, 2021).
The person transitions into the Preparation Stage when they are ready to change, but are uncertain about how to do it. Time is spent establishing specific coping skills such as appropriate boundary setting and assertiveness, effective ways of dealing with negative eating disorder thoughts and emotions, and ways to tend to their personal needs. Potential barriers to change are identified. This is usually when a plan of action is developed by the treatment team (i.e. psychotherapist, nutritionist, and physician), as well as the individual and designated family members. This generally includes a list of people to call during times of crisis.
If supporting a loved one in their recovery, identify what your role is in the recovery process. Explore your own thoughts and beliefs about food, weight, shape and appearance. Ask your child, partner or friend and the treatment team how you can be best involved in the recovery process and what you can do to be supportive (NEDA, 2021).
The Action Stage begins when the person is ready to implement their strategy and confront the eating disorder behaviour head on. At this point, they are open to trying new ideas and behaviours, and are willing to face fears in order for change to occur. Trusting the treatment team and their support network is essential to making the Action Stage successful.
Follow the treatment team’s recommendations. Remove triggers from your environment: no diet foods, no scales and no stress. Be warm and caring, yet appropriate and determined with boundaries, rules and guidelines. Reinforce positive changes without focusing on weight, shape or appearance (NEDA, 2021).
The Maintenance Stage evolves when the person has sustained the Action Stage for approximately six months or longer. During this period, they actively practice new behaviours and new ways of thinking as well as consistently use both healthy self care and coping skills. Part of this stage also includes revisiting potential triggers in order to prevent relapse, establishing new areas of interests, and beginning to live their life in a meaningful way.
Applaud the individual’s efforts and successes. Continue to adjust to new developments. Redefine the boundaries at home as necessary. Maintain positive communications (NEDA, 2021).
A possible sixth stage
The Termination Stage and Relapse Prevention. Relapse is sometimes grouped with the maintenance stage since recovery in nonlinear and it is not uncommon to return to old behaviours during the overall recovery process. So, how do you know when it is time to discontinue treatment? With the understanding that this decision is best made in consultation with your treatment team, ask yourself the following questions:
Have I mastered the Stages of Change in the major areas of my eating disorder? Do I have the coping skills necessary to maintain these changes? Do I have a relapse prevention plan in place? Am I willing to resume treatment in the future if necessary?
To prevent relapsing do not forget to ask for help, communicate your thoughts and feelings, address and resolve problems as they arise, live a healthful and balanced life, and remember that you would not have made it this far if it were not for your strong determination and dedication toward recovery (NEDA, 2021).