Acknowledging you have an eating disorder is hard. Even if you know the facts. So then how do you overcome an eating disorder when you are not even sure you have one?
Complicating this process even more is that a person with an eating disorder rarely recognizes the dangerousness of the symptoms.
Head’s up: Expect denial.
Denial is that common. Especially when you know the facts.
An example of denial is “that (fill-in-serious -medical-consequence, such as a heart attack) won’t happen to me. Maybe to other people, but not to me.”
Recovery is difficult, uncomfortable, and at times painful.
However, recovery is 100% possible. ONE HUNDRED PERCENT. (And, I have never heard of anyone who regrets recovery.)
For sure, how to overcome an eating disorder when you are not even sure you have one is no easy task.
There is no script, set of instructions, or do-it-yourself manual. Self-help is rarely enough for overcoming an eating disorder.
Part of you at times may not want to say goodbye to the disorder. That is normal. After all, the eating disorder has played a role in helping you to cope with feelings, relationships, and events in your life.
If eating disorder behavior were not helpful, you would not have an eating disorder.
On a basic biological level, you know you need food to survive. And that your eating disordered relationship with food is neither natural nor friendly.
Even though it might make you feel virtuous, special, or safe.
Food is not for nourishment for a person with an eating disorder. Instead, it’s something to restrict, binge. or binge/purge. The relationship with food is used as a way to communicate feelings.
Food becomes the enemy. You versus Food. Sometimes it is also a best friend.
To overcome an eating disorder, your relationship with so many things has to change, not just your relationship with food.
For example, a common tendency in the relationship with food is to categorize food as ‘good’ or ‘bad’. Doing so is problematic and adds momentum to an already adversarial relationship with food. Another reason it’s problematic is the implication that if you eat “bad” food, you are “bad”, and if you eat “good” (or no) food, you are “good”.
(Unfortunately, our culture regards food in an all-or-none kind of way based on nutrition content. And, in Diet Culture, worth as a human being is based on food choices and body size/weight. Someone with an eating disorder has taken what is considered normal in Diet Culture to an extreme.)
The truth is that food has no moral quality. Actually, the only ‘bad’ food is food that has spoiled!
All food is just food.
Diet Culture infuses morality with food, as if an apple is ‘good’ and brownies are ‘bad’. Are rotten apples with a worm “good”? Are fudgey, warm brownies ‘bad’? Nope.
“Rotten”, “wormy”, “fudgey”, and “warm” are descriptions, not value judgements. “Good” and “bad” are value judgments. As if you are a “good” or “bad” human being depending on your food choices. Hardly!
Social media and other sources promote the belief that food, weight, and morality are linked. They are not.
Diet Culture is sneaky and wants you to be at its mercy so it can sell you stuff.
Overcoming an eating disorder is hard enough, especially because you don’t live in a vacuum. Triggering messages are everywhere. Some are obvious, and some are more subtle.
Any discussion of overcoming an eating disorder must at least reference Diet Culture. Why? Because it is the air you and most other people you know (and those you don’t) breathe. I like to say fish don’t know they’re wet.
Overcoming an eating disorder with Diet Culture as backdrop everywhere is extra challenging.
(Beware of Diet Culture in disguise, co-opted as “Healthy Lifestyle”, “Clean Eating”, or otherwise packaged as health.)
There are concrete ways to overcome an eating disorder, though, even if you are not sure you have one.
Or even if you are not totally sure that you want to overcome the disorder.
The specifics of treatment vary, depending on the nature of your symptoms and which eating disorder diagnosis you have.
Here are 11 general tips:
Create a treatment team.An example of a treatment team is: An eating disorder specialized psychologist, anti diet registered dietician, and eating disorder informed primary care physician. Maybe a family therapist too.
You are the center of the treatment team. The other experts are there to support, guide, and make recommendations.
They are on your side. The goal for everyone on the team is to help you take steps toward well-being.
Be patient with yourself.Overcoming an eating disorder does not occur overnight. Progress takes time. And the trajectory is not linear. It is more of a squiggle.
You are not a problem that needs to be solved.Eating disorders do not occur in a vacuum. There are socio-cultural, biological, metabolic, historical, and political forces at play. For true change to occur, Diet Culture has to be eradicated.
But You and only You are the only one who can ‘do’ your recovery. You have support (remember the first tip?) but YOU do the work.
Recovery is unlikely if other people work harder than you in your recovery.
Discover new ways to cope.Find other methods of managing feelings so there is less need (or no need at all) to rely on the eating disorder.
One of the ways an eating disorder serves as a coping method is by numbing your feelings.
Learn strategies to tolerate and express feelings. There are therapies designed for exactly that purpose. Dialectical Behavior Therapy is an example. Two of the four areas of focus are emotion regulation and distress tolerance.
A mnemonic that can be helpful in this pursuit is “NCFA”, or Name your feeling, Claim your feeling, Frame your feeling, and Aim your feeling.
In other words, learn the name of your emotions, validate your feeling, understand why you are feeling the emotion, and then do something with the feeling to express it in a way that is more aligned with well being.
- Find your tribe.
Connect with people who are further along in overcoming an eating disorder than you are. Be sure your relationship is not based on exchanging eating disorder tips! Follow Instagram accounts of inspiration for recovery. (Instagram can also be problematic, so curate carefully! See Tip #6!)
Another idea is to connect with an online recovery group, some of which are low cost or no cost.
- Curate social media.
Eliminate triggering images. They are all over the place. Lots of research confirms what you may already know, first hand: Social media, and Instagram and Snapchat in particular, set up unrealistic expectations and lower self esteem and worsen body image.
If you feel worse about yourself, your body, or your life after you are on social media, consider deleting those accounts – or at least be super selective with whose accounts you follow.
- Learn and practice self-compassion.
Be on your own side, and try to support yourself as you would a dear friend or other loved one. Or your puppy!
Self-compassion is not laziness, self indulgence, pity party time, or woe is me.
It is the opposite. In fact, hundreds of peer reviewed research has been conducted demonstrating the benefits of self compassion.
Here are a bunch of self-compassion practices to try. Check them out! A formal self compassion practice is a great investment of time – it can take just 5 minutes.
Practicing self-compassion strengthens resilience.
- Explore ways to express yourself
So many other ways than through eating disorder symptoms are available for expression. Get creative and honor who you are.
Learn to play an instrument! Find a hobby! Learn a foreign language!
Random ideas include playing the ukulele, creating inspirational quotes for tee shirts, or learning Japanese.
- Learn about Health At EverySize (HAES) and Intuitive Eating (IE) approaches.
They are empowering alternatives to living in Diet Culture. (Ever notice ‘Diet Culture’ contains the words “die” and “cult”?)
HAES is based on celebrating diversity in body size and shape and honoring all human attributes. HAES is a social, cultural, political movement.
IE is another great resource in overcoming an eating disorder. Intuitive Eating’s 10 principles provide a philosophy for nourishing a healthy, happy relationship with food and your body. With exercise too!
- Practice new ways of thinking.
Notice when you hear yourself say/think mean things to and about yourself. If you would not speak that way to a friend, do not speak that way to or about yourself.
A form of therapy called Cognitive Behavior Therapy emphasizes identifying dysfunctional ways of thinking and teaches you how to reframe negative thoughts into accurate, neutral thinking.
- Keep your values in mind.
Mind-body-spirit well-being is most likely to occur when what we think, believe, say, and do are aligned. Eating disorder behaviors such as lying, avoiding, and hurting yourself are probably not congruent with your values. How do you reconcile this disconnect? One way is to identify your values, and work toward aligning them with the way you live your life. (The link is to a national survey. If you complete it, a copy of your results will be sent to you.)
The line between eating disorder behavior and what is culturally normal eating behavior is becoming harder to pinpoint.
This in and of itself is a problem and makes it harder to figure out how to overcome an eating disorder, especially when you are not even sure you have one.
Even for people who do not have an eating disorder, dieting is not a natural, helpful for weight, or attuned way to eat.
The only way the blurred line will become clear is by recognizing Diet Culture for what it is and intentionally turning your attention inward to your body’s signals. HAES and IE will support your efforts.
Sometimes you might wonder if treatment and recovery are better than life with the eating disorder. At times you might even miss the eating disorder.
This is all normal, rather than a sign that you’re not meant to recover.
If you get only one thing from this article, let it be this message, loud and clear:
Overcoming an eating disorder is absolutely possible.
In the words of Sarah Silverman,”Mother Teresa didn’t walk around complaining about the size of her thighs. She had shit to do!”
And so do you.
You and I know you can access more meaning in life than a number on the scale could ever provide.
I am Dr. Elayne Daniels, a Yale-trained clinical psychologist whose book smarts are augmented with firsthand experience. If you wonder if you have an eating disorder, or are concerned about a loved one, please reach out to me with any questions.
What images come to mind when you think of all eating disorders? How about when you think about what they have in common?
Perhaps you think of a skinny white teenager? Or a young, rich woman purging? And/or a middle aged woman in a large body eating from ice cream cartons and potato chip bags?
Oversimplified and misrepresentative images of people with an eating disorder are typical in the media.
One teeny kernel of truth is that all eating disorders aren’t the same. Yet, they share some overlap and in ways that may be surprising.
The most well-known eating disorders are Anorexia, Bulimia, and Binge Eating Disorder. There are others, but let’s focus on the main three for now.
Anorexia is when a person has an intense fear of weight gain and a distorted view of their own body weight and size. In addition, people with this condition go to extreme efforts, such as semi-starvation, to lose weight. The disorder can easily take over a person’s life and have severe medical complications.
Bulimia is diagnosed when someone regularly binges and purges. More specifically, binges are defined as a large amount of food, eaten secretively, and usually quickly. A core feature of a binge is feeling out of control. Loss of control can also occur when eating small amounts of food.
What makes a binge a binge is not necessarily the amount of food but more so the loss-of-control feelings of the person who is bingeing.
After the binge, unbearable guilt and disgust flood in. The sufferer then gets rid of the food by purging, which may include over-exercising, restriction, or laxative use.
Binge Eating Disorder is the most common of the three disorders. The primary symptom is recurrent binge eating without any method to compensate for what is eaten. Feeling out of control and a lot of shame are part of the suffering from BED.
These three eating disorders are the most commonly known. Though they each have distinct symptoms, the disorders have overlapping causes and treatment implications.
What all eating disorders have in common:
1. There is no ONE cause.
Years ago, kids’ problems were blamed on the mother. Schizophrenia? Mother’s fault. Depression? Mother’s fault. The same was true with eating disorders. Yep, Mother’s fault. The blame then shifted to genes, and then onto societal pressure for thinness.
It is not that simple.
Fortunately, science has advanced!
Researchers and treatment providers know that all eating disorders occur due to a complex interplay of five fundamental factors – biological, emotional, interpersonal, social, and psychological.
Take home message: The particular interaction of the contributing factors differs, but all five factors are implicated in all eating disorders.
2. Appearances can be deceiving.
You can’t tell by appearance if someone has an eating disorder. That is right — there is no way to know if someone suffers from an eating disorder just by looking!
The size of a person’s body is NOT an indicator, nor is gender, sexual orientation, or race, of an eating disorder.
A perfect example: Anorexia used to be thought of as a rich white girl’s disease. We now know that Anorexia affects people of all economic means.
Boys and men, LGBTQs, and BIPOCs are not eating-disorder-immune, either. In fact, rates of eating disorders are higher among the transgender community than in the nontransgender community.
One of my pet peeves is the stereotyping by size of all eating disorders. You can’t tell if someone has an eating disorder by judging their body.
Please do not assume a person in a large body has Binge Eating Disorder, or any disorder for that matter. Someone with Binge Eating Disorder may be in an average size body. A thin body doesn’t equal Anorexia.
You can not tell by looking at a body what is going on inside the person’s head — or their body.
3. Reaction to diet culture
We live in diet culture, a belief system that equates weight and food with morality and virtue. Thinness is the end all be all.
Furthermore, You and I and everyone are influenced by it, even if not on a diet. Sneaky ways diet culture disguises itself are as “clean eating,” “healthy lifestyle,” or “wellness.” (If it walks like a duck and quacks like a duck….)
“Fish don’t know they are wet” applies here. Not to fish but to you and me. We are so surrounded by diet culture that we may not even realize it. Despite the fact that it is a $70 billion/year industry.
More often than not, all eating disorders innocently begin with a diet.
Intentional weight loss efforts conflict with the body’s natural set point range of weight. The diet then gets out of control and spirals into an eating disorder.
If there were no diet culture, eating disorders would be very rare.
4. Interoceptive awareness derailed
Interoceptive awareness is your ability to perceive sensations from your body, in the present moment.
So if you notice you have a full bladder and have to use the bathroom, interoceptive awareness is to thank. When you notice hunger and fullness cues, you’re having a felt sense in the moment of your direct experience of hunger or fullness. Thank you, interoceptive awareness.
Another aspect of interoceptive awareness is emotions. How cool is it that every emotion has its own unique physical sensation or ‘autograph’ in the body? Anger, for example, may show up in your body as tension. Happiness as levity. Sadness, for instance, as a heaviness.
The wiring of the mind and body is designed so they can communicate with each other.
To reiterate, noticing bodily sensations provides key info to assist with meeting biological and psychological needs. There is a definite evolutionary advantage to this default mechanism.
Diet culture, unfortunately, messes with the innate, attuned interoceptive awareness mechanisms we are born with.
In other words, diets are all about rules, not about attunement with your body’s exquisite signaling system.
When on a diet, making decisions about what and when to eat are based on external methods (e.g. counting calories, following rules) rather than on trusting and valuing body sensations.
So, what happens is a disconnect from your body’s perfect system of communicating hunger/fullness to you.
Keep in mind that diets emphasize the external — weight, appearance, and rules, often determined and designed by someone you don’t even know. And created by someone who doesn’t know you or what you need nutritionally for optimal well being.
Unfortunately, external persuasion occurs at the expense of interoceptive awareness.
Your body’s capacity to communicate with you is a glorious built-in system. Dieting trashes it.
Fortunately, interoceptive awareness can return online and is an important ingredient of treatment and recovery.
5. Walking heads – “I would rather not have a body”
With all eating disorders, there is a disturbance in how you experience your own body.
More specifically, you have lots of negative thoughts, feelings, and sensations about your body and yourself.
The eating disorder solution is to sever ties with your body, and to end the mind/body relationship. In other words, to function as if your body weren’t there.
The idea is that it would be better not to have a body than to live in a body that feels like a nuisance, hindrance, or source of all things negative.
When your body feels like a receptacle of yuckiness, it’s no wonder being body-less seems like a better alternative.
Another factor in the walking head phenomenon is low interoceptive awareness. All eating disorders are associated with a huge disconnect from the body as if the body were nonexistent. Further, semistarvation, bingeing/purging, and other eating disorder behaviors can cause dissociative states, whereby you might not even feel like you are in a body.
6. All or none thinking, aka stinkin’ thinking
Also known as black/white thinking, good/bad, or dichotomous thinking. This is the tendency to think in extremes as if there are no shades of gray.
Words that may indicate all/none thinking include: always/never; good/bad; all/none.
For all eating disorders, good/bad thinking is the hallmark. Here are examples :
- I ruined my diet today by eating 5 m&ms, so I may as well eat the whole bag and start my diet tomorrow. Or purge after I’ve eaten the rest of the m&m’s. Or not eat until tomorrow night.
- Bread is bad. Fruit is good. I can’t eat carbs.
- I will never find a romantic partner until I am thin. Being thin is my #1 goal.
- Being thinnest among my friends is all that matters.
- If I eat a sandwich, I will get fat.
Cognitive behavior therapy teaches you how to identify distortions by evaluating their validity and offering reframes. You also learn about your underlying belief systems.
Reframing distortions and addressing underlying belief systems is key to healing.
We tend to believe what we think, even if what we think is not true.
Thoughts are super powerful; they determine feelings and behaviors. Often, thoughts are so automatic we may not even know we are having them. Therapy provides a method for identifying distortions and restructuring them to be accurate.
In the examples above, the thoughts are deemed fact by the person thinking them. Consider the impact on the person’s feelings and behaviors. Distortions are fuel for and characteristic of all eating disorders.
7. It is all about food
Eating disorders are called eating disorders because of a disturbance in eating behavior. The eating disturbances differ, depending on the disorder. Food may be withheld, restricted, eaten in large quantities, or purged.
Interoceptive awareness goes offline, and people’s well being overall suffers.
An anti-diet Registered Dietician can offer humongous help with nutrition restoration.
The anti-diet training and philosophy are key; otherwise, nutrition support is likely to make matters worse.
8. It is not about food
Recovering requires more than nutrition restoration because all eating disorders have a mental health aspect.
Addressing and resolving mental health problems is essential to full recovery.
Granted, as a psychologist I am biased. But I can tell you I’ve never heard of anyone fully recovering without psychological guidance and support.
Common treatment issues in all eating disorders include: body image, shame, self-esteem, anxiety, perfectionism, relationships, and value systems. None of the key psychological causes are about food.
9. Social Forces
We live in a culture of rampant weight bias, patriarchy, racism, classism, homophobia, and other social problems. The inequities are vast. All eating disorders occur in a socio-political context.
White privilege translates to the fact that Caucasians typically have greater access to resources than do people whose skin is not white.
Another form of privilege is thin privilege. Just because of their (highly desirable and socially sanctioned) thin body size, some people have greater access to resources and less discrimination than people deemed to be in a body that isn’t thin or that doesn’t meet the cultural ideal.
All eating disorders are affected by culture and the associated stereotypes, biases, and discrimination.
10. Myth city
Common ones are that all eating disorders are:
just a phase
a way to get attention
a lifestyle choice
forever; once you have one, you have one for life
One thing I’ve learned from 25 years of working in the field of eating disorders is that recovery is ABSOLUTELY possible and a worthy investment of time, energy, and other resources.
I know in my heart that full recovery is possible.
I also know that not everyone recovers.
(Access to and participation in effective treatment is more challenging depending on location. Telehealth has helped to level the playing field a bit.)
One of the things I remind people of is that recovery is one of THE hardest things. Blood, sweat, and tears don’t even come close to describing the physical and emotional pain of recovery.
Recovery is also one of THE most rewarding things in life.
I have yet to hear anyone say they wish they still had an eating disorder.
I do hear the opposite. Something like “I had no idea how much happier life could be without an eating disorder.”
Suffering from an eating disorder is like living in prison. There is no freedom, but a lot of darkness. It sucks.
You are worthy of nourishment — physically, emotionally, relationally, and beyond. Reclaim eating as a source of pleasure and your body as the wonderland it is.
Dr Elayne Daniels is a Yale-trained clinical psychologist in private practice. She specializes in the treatment of people with eating disorders using innovative and empirically based methods. Humor and connection are central to her treatment approach. You can contact her here.
“To the Bone”, a recently released Netflix movie, has generated discussion on the topic of eating disorders. The New York Times reviewed this movie. Anything that promotes awareness is a plus.
The movie itself is no Academy Award winner. It reminds me of an after school special from the 1980s.
In a separate blog I will review the movie. For this blog, I have only one message.
One of the most heinous sentiments in the world is “I wish I had the discipline to have Anorexia.”
No, you don’t. Do not wish you had Anorexia.
Ask anyone with Anorexia or who has recovered from it, and you will know why it is nothing to wish for and glorify.
Why do I say this?
kills up to 18% of its sufferers,
takes a humongous toll on families,
completely sucks all the joy out of life,
causes the body to self cannibalize,
and takes over the mind, as in a TOTAL HIJACK.
Anorexia is NOT:
due to vanity,
a diet. (Although it often starts as a diet.)
I had Anorexia over thirty years ago. It was HORRIBLE.
Hope is valuable. So is proper medical, psychological, and nutritional treatment.
I am dedicated to being the change I want for the world, as hokey sounding a vision as that might be.
Today is the birthday of the guy who invented the graham cracker. His invention of the graham cracker wasn’t for the creation of S’mores, or for dunking in milk. In fact, the dude created graham flour, which later turned into graham crackers, with the hope of killing the sex vibe among teens and adults. He thought peeps needed to be sexually tamed because they were ADDICTED to sex, gluttony, and all things material.
The year? 1830…
Sylvestor Graham was a Massachusetts minister, born in 1794. His fellow evangelicals were focused on social issues like suffrage, slavery, and tobacco consumption. Graham’s mission was to eradicate carnal desire. Yes, his evangelical stance was that American’s desires were animalistic, and he had the solution.
Graham was certain that people were sex crazed, and their diet and sex lives were to blame. So, based on his whole grain “graham” flour, he prescribed a particular way of eating. By the way, this is also why he is sometimes known as the “Father” of dieting. Booooooo! (Two thumbs down.)
His diet recommendations called for very little meat and butter; no alcohol; no flavorings or spices; only the most minimal amount of milk and eggs; and cold, hard-to-chew food. He believed this type of diet, along with particular ways of bathing and sleeping, would keep internal organs healthy. The alternative was considered immoral activity (ie eating tasty food and having sex) and would cause poor health.
Graham was certain that sex more than once a month or any masturbation damaged the brain, and that recreational sex caused illnesses such as pulmonary problems, spinal disease, epilepsy, and insanity.
His bottom line: If people’s drive for sex and tasty food could be quelled, they would have better self-control and overall health. Society would be a better place for all.
So there is lots of irony here. One: When Nabisco began to mass produce the graham cracker in the 1930s, it contained both processed flour and sugar. Graham touted these two ingredients as causing sex addiction and insanity. Two: What he thought would cause the demise of society is responsible for the popularity of his cracker: mass production, sugar and ‘impure’ ingredients. Third: In 1878 Dr. John Harvey Kellogg, a Graham disciple, created cereal. Following its success, Kellogg formulated his recipe. The breakfast cereal industry was launched!
Let’s cut to the chase: To celebrate Sylvestor Graham’s birthday today,
- Have sex
- Eat some more s’mores!
- With extra chocolate and marshmallow!
- And maybe with some Trix (from a cereal box or in the bedroom) on top!
A recent study in the journal Appetite examined the effect of eating chocolate cake. In particular, the researchers were interested in understanding the association of either guilt or of celebration with eating chocolate cake. In other words, when eating prototypic forbidden food like chocolate cake, were women likely to feel helpless and out of control (ie guilty) OR to experience pleasure and enjoyment (ie celebration)?
The study had two parts:
The first was to evaluate attitudes, perceived behavioral control, and intentions to eat healthily and their effect on a person’s reaction to eating chocolate cake.
The second was to evaluate if the association of guilt or of celebration was related to weight change over a period of time (6 or 18 months).
This study did not find any evidence for adaptive or motivational properties of guilt.
In other words, guilt is not a helpful motivator! That is worth repeating: Guilt is not a helpful motivator.
Participants who associated eating chocolate cake with guilt did not report more positive attitudes or stronger intentions to eat healthy than did those associating chocolate cake with celebration.
Instead, they reported lower levels of perceived behavioural control over eating and were less successful at maintaining their weight over an 18 month period.
Participants with a weight-loss goal who associated chocolate cake with guilt were less successful at losing weight over a 3 month period compared to those associating chocolate cake with celebration.
The take home messages:
- Have your cake and enjoy it too!
- Feeling guilty after eating ‘forbidden food’ is associated with gaining (nearly seven times) more weight over an 18 month period of time than among those who do not report feeling guilty
- Guilt and regret often have a “What the hell effect” or what is known among psychologists as the “Abstinence Violation Effect”. This attitude justifies giving up on intentions. It is the classic, “I already ate four cookies I mine as well eat the whole sleeve of cookies”. It could also be in the form of “Oh well. I already blew it. I will start again on Monday.”
- To let go of guilt, treat all dessert like birthday cake. And treat birthday cake like the celebration it is!
Food is a wonderful source of pleasure, balance, and vitality.
Enjoy food. Savor. Trust yourself and your (taste) buds!
Avoidant/Restrictive Food Intake Disorder (ARFID) has replaced Feeding Disorder of Infancy and Early Childhood.
The DSM-Vis the manual used for diagnosing psychiatric problems. It stands for The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. The Fifth edition has been out since May 2013 and includes changes to how eating disorders are categorized and diagnosed.
This post will address one of those changes, which the new diagnosis is called Avoidant / Restrictive Food Intake Disorder (also known as ARFID).
When people are diagnosed with any type of mental health disorder by a psychologist, it essentially means they meet diagnostic criteria set forth by the DSM-V, just as someone would meet criteria and be diagnosed with a medical problem like high blood pressure. An important goal of diagnosing specific disorders is to develop the best possible treatment plan and apply evidence-based interventions.
According to The DSM-V, ARFID includes:
A.An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following:
1. Significant weight loss (or failure to achieve expected weight gain or faltering growth in children).
2. Significant nutritional deficiency.
3. Dependence on enteral feeding or oral nutritional supplements.
4. Marked interference with psychosocial functioning.
B. The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice.
C. The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced.
D. The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder. When the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention.
Can you say that in English please?
Basically, what the DSMV says is that individuals who meet the criteria for ARFID have developed some type of problem with eating. As a result of the eating problem, the person isn’t getting adequate nutrition. There are many forms the eating problem could take – trouble digesting certain foods, avoiding certain colors or textures of food, eating only very small portions, having no appetite, or being afraid to eat after an episode of choking or vomiting.
In my private practice, the most common form of ARFID I diagnose and treat is when a child is afraid to eat due to fear of vomiting. This usually develops after an episode of vomiting at a time or location that was embarrassing or frightening to the child.
Sophie (not her real name) felt sick at school a few months prior to her meeting with me for the first time. She had tried to ignore the nausea, and went to lunch in the cafeteria with her friends. When at the lunch table with her peers, she vomited. Everyone saw. She felt humiliated. As a result of the scene in the cafeteria, Sophie was afraid to eat because she worried she would throw up. Her friends and parents were worried because Sophie was losing weight and eating very little.
Because kids with ARFID don’t derive enough nutrition through their diet, they may end up losing weight. Or, younger kids with ARFID might not lose weight, but rather may not grow as expected. Other individuals with ARFID might need supplements (like Ensure or Pediasure) to get enough nutrition.
Kids with ARFID may have problems at school or work because of their eating issues. They may avoid lunch with peers, not get schoolwork done because of the time it takes to eat, or even avoid seeing friends or family at social events where food is present.
A good example is of a ten year old boy, “Luke”, who almost choked on chicken nuggets one time, and now refuses to eat any type of solid food. He can’t eat school lunches or even enjoy a taste of his favorite snack.
How is ARFID different from anorexia or other eating disorders?
People with anorexia or bulimia struggle with distortions in how they see their body. Kids with ARFID typically don’t FEAR weight gain and don’t have a distorted body image.
Filling in the gaps
Although ARFID is considered a new diagnosis, it is just a way of describing symptoms more specifically. A lot of people with eating disorders don’t “fit” perfectly into a diagnosis of anorexia nervosa or bulimia nervosa. Before the release of the DSM-V, clinicians would often give the diagnosis of Eating Disorder, Not Otherwise Specified (EDNOS). Unfortunately, if you say that someone has EDNOS, it doesn’t really give us much information about the person’s symptoms, other than that they have some kind of eating disorder.
In the past, before the DSM-V, kids with ARFID might have been diagnosed with EDNOS. They also could have been given another diagnosis called “Feeding Disorder of Infancy or Early Childhood” (although most clinicians didn’t use that diagnosis especially since one of its requirements was that the age of onset has to be before age six).
But what about children or adults with restrictive eating NOT related to fear of weight gain, who may or may not be a normal weight, and whose lives are impacted by their symptoms? This is where ARFID fills in the gaps and helps us to better understand those individuals.
As ARFID is officially a new diagnostic category, there is not much data available on its development, course, or prognosis. We do know that symptoms typically present in infancy or childhood, but they may also present or last into adulthood (especially if untreated).
It is possible that some individuals with ARFID may go on to develop another eating disorder, such as anorexia nervosa or bulimia nervosa, but again, no research is available yet to give a clear picture of what happens down the road for these individuals. We also are still learning about treatments for individuals with ARFID. Although research is just beginning, it is likely that behavioral interventions, such as forms of exposure therapy, may be useful. And of course, as in other eating disorders like anorexia or bulimia, treatment of underlying conditions such as anxiety or depression is crucial.
Many kids develop different or strange patterns of eating at some point in their life – refusing to eat vegetables for a few months, or wanting to eat only chicken nuggets for dinner – but for most individuals, the patterns eventually resolve on their own without intervention. For the small subset of individuals who have persistent or worsening problems with food ingestion, however, the introduction of ARFID means we are now able to better diagnose and describe their symptoms. This should result in better clinical outcomes.
Dr Daniels, I never really know if I am hungry or full, and sometimes eat so much that I feel uncomfortable afterward. Do I have Binge Eating Disorder?
Overeating: What is it?
Overeating at times is part of normal eating. Examples of overeating include having an extra helping at a meal because something tastes soooo good, or eating beyond fullness at a special holiday meal or celebration.
Binge Eating: What is it?
The American Psychiatric Association defines Binge Eating Disorder (BED) as eating significantly more food in a short period of time than most people would eat under similar circumstances. The key is feeling a loss of control.
Disgust, guilt, or embarrassment are also common, as is eating in secret. While overeating may happen at times for everyone, a person with BED has recurrent episodes of bingeing without purging.
There is often emotional and physical distress. Episodes occur at least 1x per week for 3 months
BED is more common than Anorexia Nervosa or Bulimia Nervosa; 5 million women and 3 million men in the United States struggle with this disorder. Though this eating disorder is prevalent in our country, it can easily go undiagnosed.
If you are unsure if you or a loved one may have BED, seek professional help from an Eating Disorder expert. BED is unlikely to go away on its own. With proper treatment, recovery is completely possible!
The year was 1986. Meredith Baxter Birney played a Step-ford wife named “Kate”, who was married to a handsome successful attorney. The name of the movie is “Kate’s Secret”.
When the film aired, bulimia was taboo. While bulimia may be less of a taboo topic now, there is still a lot of shame associated. And lots of misunderstanding.
It is not unusual for men and women who suffer from bulimia to feel embarrassed and disgusted about their behavior and about themselves. They may develop secretive habits to hide their behavior.
Questions parents ask when their child is diagnosed with bulimia include: What is bulimia? Is it treatable? How many people have it? Is it contagious? Is it our (parents’) fault?
Bulimia is an eating disorder categorized by eating large amounts of food and then compensating to ‘undo’ the binge. The compensation can be by inducing vomiting, fasting, and/or compulsively exercising. It becomes a very entrenched cycle that is hard to break.
But the cycle can be fully broken, with the right kind of treatment.
Treatment may involve psychotherapy, taking medication, and/or family therapy. The goal is develop a healthy relationship with food and the body, and to overcome feelings of anxiety, guilt, and shame.
Bulimia affects males and females.
It is not contagious.
There is no single cause of bulimia.
Poor self-esteem and concerns about weight and body image play major roles, and there are many other contributing causes. In most cases, people suffering with bulimia—and eating disorders in general—have trouble managing emotions. Eating can be an emotional release, so it’s not surprising that people binge and purge when feeling angry, depressed, stressed, anxious…or when feeling anything. Eating and purging numb emotions.
One thing is for sure. Bulimia is a complex emotional issue. Major causes and risk factors for bulimia include:
- Negative body image: The emphasis on thinness and beauty can lead to body dissatisfaction; all of us are bombarded with media images of an unrealistic physical ideal.
- Low self-esteem: Women or men who think of themselves as inadequate, unattractive, or inferior to others are at risk for bulimia. Contributors to low self-esteem include perfectionism, comparisons, and a critical home environment.
- Transitions: Bulimia can be triggered by stressful changes or transitions, such as the physical changes of puberty, going away to college, starting at a new school, a pet’s death, or the breakup of a relationship. Binging and purging may be an attempt to cope with stress that would otherwise overwhelm
- Appearance-oriented professions or activities: People who are involved in activities where there is pressure to look a certain way are more vulnerable to developing an eating disorder.
If you are living with bulimia, you know it feels very scary to feel so out of control. But hear this: change is possible.
Taking steps toward recovery is tough. It’s common to feel ambivalent about giving up binging and purging.
Treatment for bulimia is much more likely to succeed when you stop dieting. Once you stop trying to restrict calories and follow strict dietary rules, you will no longer be overwhelmed with cravings and thoughts of foods.
The secret to recovery is to learn how NOT to diet and how to effectively manage emotions.
By learning these skills, “Kate” no longer has a secret.
For more information about bulimia, please contact me or check out www.nationaleatingdisorders.org
“Dr Daniels, when you give talks on anorexia please let people know it really sucks to have this problem. I hate when I hear people say they wish they had anorexia. Do they wish to think of nothing but food 24/7? Do they wish for self hatred and disgust? Do they wish their brain would shrink, their organs would shut down, and they would feel cold all the time? Tell them anorexia is a monster that takes over the mind and body.”
—-a 29 year old woman in treatment for anorexia nervosa
(Who by the way is doing great in treatment! Anorexia is completely 100% treatable with the proper treatment.)
What is anorexia?
It is the most deadly mental illness
It is NOT just about looking thin.
A person never chooses anorexia.
Anorexia accounts for more deaths than any other type of mental illness.
The person with anorexia says she’s “fine”. But her brain has shrunk, and she’s in denial about the seriousness of her condition. She may not even believe or acknowledge that she has anorexia. (Denial of the diagnosis and its seriousness is one of anorexia’s main symptoms.)
Families often feel angry with the person suffering from anorexia. They see her hurting herself and the people who love her. They may consider her to be a ‘selfish, stubborn, vain girl’ who won’t eat. That is not what she is.
What is she? She’s sick, with a mental illness.
She didn’t choose this any more than someone chooses cancer.
Family members and friends feel frustrated that their efforts to help are often unhelpful. “Why can’t she just eat?” is a common sentiment of family and friends. It is akin to asking why someone without anorexia can’t just eat a sneaker.
Anorexia – as all eating disorders – is a complex disease. There’s no one cause. It is no one’s fault. It is not that simple.
Current research reveals that anorexia can be inherited. Not everyone with the genetic predisposition will develop anorexia, though.
Environmental influences can trigger, and worsen, anorexia. Such triggers include: society’s obsession with thinness; puberty; dieting; going away to college; major life transitions; a loss/death; a traumatic world event, or a more personal one, like a breakup.
There are still a lot of misunderstandings about anorexia, even among health professionals.
Treatment can be hard to find. Ideally, treatment is multi-disciplinary: on the treatment team are a psychologist, a physician and a nutritionist.
Risk factors for anorexia include:
- Worry about weight, shape
- Parents’ body dissatisfaction
- Family emphasis on appearance
- Childhood anxiety
- Harm avoidance
- Negative self-image
- Goal-oriented family or personality
- Being considered “sensitive”
Signs of anorexia could include:
- Cutting food into small pieces or moving them around the plate instead of eating
- Exercising all the time, even when the weather is bad, they are hurt, or their schedule is busy
- Going to the bathroom right after meals
- Refusing to eat around other people
- Blotchy or yellow skin that is dry and covered with fine hair
- Confused or slow thinking, along with poor memory or judgment
- Dry mouth
- Extreme sensitivity to cold (wearing several layers of clothing to stay warm)
- Wasting away of muscle and loss of body fat
The key take home message here is that ANOREXIA IS COMPLETELY TREATABLE….and is unlikely to go away on its own.
Contact www.medainc.org or www.nationaleatingdisorders.org for more information.
Consider me a resource too!
People who obsess about food and have otherwise healthy eating may be suffering from “orthorexia nervosa,” a term that literally translates to “fixation on righteous eating.” Orthorexia may begin as a well intentioned attempt to eat more healthfully, but the intention morphs into a preoccupation with food quality and purity. People with this condition become consumed with what and how much to eat, and how to deal with “slip-ups.” An iron-clad will is needed to maintain this rigid eating style. Every day is a chance to eat right, be “good,” rise above others in dietary prowess, and self-punish if temptation wins (usually through stricter eating, fasts and exercise). Self-esteem becomes wrapped up in the purity eating behavior, which then becomes part of feeling superior or virtuous compared to other people who eat a wider range and larger amount of food. Eventually food choices become so restrictive, in both variety and calories, that health suffers – an ironic twist for a person so completely dedicated to healthy eating. Eventually, the obsession with healthy eating can crowd out other activities and interests, impair relationships, and become physically dangerous.
Is Orthorexia An Eating Disorder? Orthorexia is a term named by Steven Bratman, MD to describe his own experience with food and eating. It is not an officially recognized disorder, but is similar to other eating disorders – those with anorexia nervosa or bulimia nervosa obsess about calories and weight while orthorexics obsess about healthy eating (not about being “thin” and losing weight).
Why Does Someone Get Orthorexia? Orthorexia appears to be motivated by health, but there are underlying motivations, which can include compulsion for complete control, escape from fears, wanting to be thin, improving self-esteem, searching for spirituality through food, and using food to have an identity.
Do I Have Orthorexia? Consider the following questions. The more questions you respond “yes” to, the more likely you are dealing with orthorexia.
- Do you wish that occasionally you could just eat and not worry about food quality?
- Do you ever wish you could spend less time on food and more time living and loving?
- Does it seem beyond your ability to eat a meal prepared with love by someone else – one single meal – and not try to control what is served?
- Are you constantly looking for ways foods are unhealthy for you?
- Do love, joy, play and creativity take a back seat to following the perfect diet?
- Do you feel guilt or self-loathing when you stray from your diet?
- Do you feel in control when you stick to the “correct” diet?
- Have you put yourself on a nutritional pedestal and wonder how others can possibly eat the foods they eat?
So What’s The Big Deal?The eating behavior of people with Orthorexia can actually be unhealthy, with nutritional deficits specific to the diet they have imposed upon themselves. These nutritional issues may not always be apparent. Social problems are more obvious. People with this disorder may be socially isolated, often because they plan their life around food. They may have little room in life for anything other than thinking about and planning food intake. Individuals with orthorexia lose the ability to eat intuitively – to know when they are hungry, how much they need, and when they are full. Instead of eating naturally they are destined to keep “falling off the wagon,” resulting in a feeling of failure familiar to followers of any diet.
When Orthorexia Becomes All ConsumingDr. Bratman, who recovered from orthorexia, states “I pursued wellness through healthy eating for years, but gradually I began to sense that something was going wrong. The poetry of my life was disappearing. My ability to carry on normal conversations was hindered by intrusive thoughts of food. The need to obtain meals free of meat, fat, and artificial chemicals had put nearly all social forms of eating beyond my reach. I was lonely and obsessed. … I found it terribly difficult to free myself. I had been seduced by righteous eating. The problem of my life’s meaning had been transferred inexorably to food, and I could not reclaim it.”
Are You Telling Me it is Unhealthy to Follow a Healthy Diet?Following a healthy diet does not mean you are orthorexic, and nothing is wrong with eating healthfully. Unless, however, 1) it is taking up an inordinate amount of time and attention in your life; 2) deviating from that diet is met with guilt and self-loathing; and/or 3) it is used to avoid life issues and leaves you separate and alone.
What Is The Treatment for Orthorexia?Society pushes healthy eating and thinness, so it is easy for many to not realize how problematic this behavior can become. Even more difficult is that the person doing the healthy eating can hide behind the thought that they are simply eating well (and that others are not). Further complicating treatment is the fact that motivation behind orthorexia is multi-faceted. First, the person with orthorexia must admit there is a problem, and then identify what has led to the obsession. She or he must also become more flexible and less dogmatic about eating. Working through underlying emotional issues makes the transition to normal eating easier.
While orthorexia is not a condition your doctor will likely diagnose, recovery can require professional help. A practitioner skilled at treating eating disorders is the best choice. In my practice, I have successfully treated many men and women of all ages with symptoms of orthorexia.
RecoveryPeople in recovery from this disorder will still eat healthfully, but there will be a different understanding of what healthy eating is. They realize that food will not make them a better person and that basing self-esteem on the quality of their diet is irrational. Their identity shifts from “the person who eats health food” to a broader definition of who they are – a person who loves, who works, who is fun. The recognize that while food is important, it is one small aspect of life, and that often other things are more important!
More information is available at www.orthorexia.com
Trauma and Eating Disorders (Source: National Eating Disorder Association)