How Do Eating Disorders Develop?

A school of orange fish representing the idea that fish dont know their wet in the same way as we often dont realize what could be causing an eating disorder

No one thing causes eating disorders to develop. It’s more like a perfect storm of genetics, biology, psychology, culture, and environment. Lots of factors merge together around the same time.

Genetics is one of many factors in how eating disorders develop

Genetics contribute for sure! In fact, they predispose individuals to eating disorders.

Eating disorders tend to run in families. And, the rate of eating disorders is higher in identical twins than in fraternal twins or other siblings.

Biochemistry is a factor in how eating disorders develop

Certain neurotransmitters, hormones, and other chemicals are out of range among people with eating disorders. The levels are either too high or too low. These chemicals in our body are what regulate appetite, stress, mood, and sleep.

Among cis-gender girls, early menarche (compared to peers) can be part of the perfect storm.

Psychology is too

Psychological factors contribute to eating disorders. People with an eating disorder often also struggle with depression and/or anxiety. Obsessive Compulsive Disorder is particularly common, occurirng in 25% – 69% of women with anorexia . Other psychological factors include:

  • Poor self esteem
  • Feeling a sense of hopelessness
  • Perfectionism

Certain personality temperaments put a person at higher risk for an eating disorder. Traits like reward dependence, harm avoidance, sensation seeking, and obsessive-compulsiveness may be part of that perfect storm.

Culture is another contributor in how eating disorders develop

We live in Diet Culture. It is so pervasive and sneaky. In fact, we often don’t even realize how very much we’re impacted by its toxicity. It’s omnipresent. Ubiquitous. The lens through which we see ourselves and the world.

Dieting, body dissatisfaction and a drive to be thin increase the risk for an eating disorder. Diet Culture encourages all three.

Diet Culture is sneakily disguised as ‘a healthy lifestyle’, ‘clean eating’, or as a trendy way to eat. Like Whole30, Keto, or Noom.

If it has rigid rules to follow or involves arithmetic, it is probably a diet.

Diet Culture contrbutes to eating disorders in many ways:

  • An over-emphasis on appearance, at the expense of valuing inner qualities, like kindness
  • Societal standards that promote an unrealistically thin body shape
  • Associating thinness with positive qualities like attractiveness, health, success and love
  • Media’s focus on dieting and striving for a slim and toned body for women
  • Messages that perpetuate a fear of fat and food; viewing fat as undesirable or foods as “good,” “bad” or “sinful”

Intuitive Eating is such a better alternative, on all fronts. Its first of ten guiding principles is to ‘reject Diet Culture’. Mind you, the principles are not mandates. They are gentle steps. And, they’re associated with improved well being – physical and psychological. Unlike anything in Diet Culture!

Environment is important to understand in how eating disorders develop

Your environment also plays a role in how eating disorders develop.

For example, what was your home environment like? How did family members communicate feelings? Did family members diet? Were/are they weight conscious?

What kinds of extracurriculars did you participate in? How about the kind of friend group you were part of?

Aspects of an environment that may be relevant to how eating disorders develop:

Family conflict
Physical or sexual abuse history
Activities that focus on weight, such as gymnastics, dancing, running, wrestling
Peer pressure
Being bullied because of weight or appearance in general

You have agency over some factors associated with how an eating disorder develops. But not all. Fish do not know they are wet. In the same way that you may not realize the extent to which you are immersed in Diet Culture.

However, you do have agency over many aspects of recovery.

With support, you can emerge. And you will. Stronger than ever. And as a true power source.

You will be the fish that went to school (pun intended), recognizes Diet Culture, and knows your way out of the storm.

I am Dr Elayne Daniels, a MA based psychologist specializing in the treatment of eating disorders and negative body image. Contact me for more information.

How Do I Know If I Have An Eating Disorder?

A photo of a woman folding clothes, with only her arms visible.

There are lots of signs of an eating disorder, yet how to know if you have one can be tricky. One of the main reasons you may not know if you have an eating disorder is due to Diet Culture. More about that in a moment.

How to know for sure if you have an eating disorder? Ideally, an informed physician or psychologist would conduct an evaluation of your symptoms. Unfortunately, education and training for eating disorder treatment is woefully inadequate, especially among medical doctors.

Even worse is that a lot of medical professionals don’t actually know how to correctly diagnose an eating disorder. Instead they resort to stereotypes and myths, such as using weight as a main indicator. Or believing that only white teenage girls develop eating disorders.

By the way, in the United States, an estimated 30 million people of all ages and genders have an eating disorder.

So, how do you know if you have an eating disorder?

Knowing if you have one is complicated. Being diagnosed with one can be even more complicated. Again, eating disorders are easily misdiagnosed. And often overlooked by professionals. Many in the medical and psychiatric field do not have training in eating disorders. Or in nutrition. (Can you tell it’s a pet peeve of mine?)

Consider too that an eating disorder is often downplayed by the person suffering from one. S/he may not want it to be identified. Or not recognize that her thoughts and behaviors are part of a bona fid eating disorder.

By the way, you can’t tell by looking at a person if she has an eating disorder. Body size is not an indicator, nor is any specific sign a slam dunk indicator. Girls and boys, nonbinary people, women and men suffer from eating disorders.

You definitely can’t tell by looking at yourself in the mirror if you have an eating disorder. Often your own perception of your body size and shape is distorted.

What is the main challenge of knowing if you have an eating disorder?

A huge challenge for how you know if you have an eating disorder is Diet Culture.

In reality, Diet Culture makes it nearly impossible to distinguish between “normal” and “abnormal” eating and body image. What is considered ‘healthy’ in Diet Culture is often anything but.

Haven’t heard of Diet Culture before? It’s a system of beliefs that equates thinness with worth as a human being. Through the lens of Diet Culture, you’re taught to feel bad about your body. And to judge other people’s worth by their body too. Diet Culture is often disguised as “healthy lifestyle”, “eating clean”, or “Intermittent Fasting”.

No wonder eating disorders are so rampant. Or that what is and isn’t an eating disorder can be tricky to determine.

Diet culture’s solution to any problem is: “Lose weight and you’ll look better, feel better, and be better.”

Taking this insidious message to heart puts you on a fast(er) track to an eating disorder.

Of course more factors than Diet Culture are at play. Regardless, Diet Culture’s messages are pervasive and detrimental. To the point where you may be unaware you’ve internalized them and are being controlled.

A picture of a white plate and a fork and knife on it. There is a frown face  drawn on the plate.

Social media has fueled Diet Culture’s impact. (Instagram is considered the most influential. although I suspect TikTok is a contender for first spot.)

What follows is a list of potential indicators of an eating disorder. This is not a complete list! (Resources are also available online to help you determine if you have an eating disorder.)

Possible indicators that you may have an eating disorder include:

1. Preoccupation with food, weight and/or the shape of your body.

  • Thinking about food all day – what you ate, wish you could eat, wish you did not eat, and how to compensate for what you ate.
  • You’re constantly thinking about your body and comparing yourself to others, especially to people on social media.
  • You weigh yourself often, and the number on the scale determines your mood and how the day goes.

2. Not eating certain foods for fear that something bad will happen to you.

  • A common example is cutting out particular food groups out of fear that they will cause you to ‘get fat’.
  • Another example is believing myths, such as sugar is toxic or addictive.

3. Feeling out of control over the amount of food you’ve eaten, at least once a week.

  • You might have binges. If you feel a loss of control when eating, you’re bingeing.
  • Bingeing is usually secretive. And is inevitable after a period of restriction.
  • Sometimes you may think you’ve binged because you’ve eaten more than you planned.

4. Worrying about the nutrition and calorie content of foods.

  • People with an eating disorder tend to get stressed about eating out. They may look at menus online in advance of going to a restaurant.
  • More than others, people with an eating disorder are influenced by calorie information on menus.
  • Someone with an eating disorder is likely to avoid going to restaurants, or to compensate before and/or after they eat.
  • Avoiding social occasions if food is involved is common.

5. Feeling disgusted or anxious when looking at your body or seeing it in a mirror.

  • A person with an eating disorder is likely preoccupied with looking at herself in the mirror. Or may go out of her way to avoid seeing her reflection.
  • People with certain forms of an eating disorder may wear oversized clothing as a way to hide their size or shape.

6. Constantly comparing your body to friends’, social media influencers, and people you see at the gym.

  • And feeling worse about yourself, regardless of the comparison.
  • You long for your body to look more like so-and-so’s body. You may even think that if you could look like so-and-so, everything would be perfect! You’d be happy, then. (But not really.)

7. Feeling guilty after eating.

  • Food is often categorized as good or bad. In reality, all food is just food. It doesn’t have moral quality.
  • Having an eating disorder often means rigid rules.
  • Violating any rules leads to guilt. Especially when the rules involve food.
  • All-or-nothing thinking is common.

8. Intentionally making yourself vomit or exercise excessively so you don’t gain weight.

  • These are called compensatory methods. They’re habit forming. And dangerous.
  • The purging methods are secretive.

9. Being very aware of calories.

  • You’re vigilant about the calorie or macro content of food, and/or the amount of calories you burn.
  • You have rules about how many calories you’re allowed, and you may track the information in your head, on an app, or with pen and paper.
  • The less you’ve eaten, the better the day. And the more successful you feel.

10. Needing to check your body’s appearance throughout the day.

  • You may frequently mirror check, weigh yourself often, or pinch areas of your body to assess the amount of tissue.
  • These are called checking behaviors and can become automatic.
  • You engage in these behaviors for reassurance that body parts have not gotten larger.

11. Having other symptoms as a result of your behaviors.

  • There are a myriad of medical symptoms and risks involved.
  • “Everyday” physical consequences include headaches, fatigue, dizziness, light headedness, irregular heartrate, gi distress, and constipation.
  • Depression, anxiety, and other mental health problems are common. Or become worse.

12. Treating your body as if it is an object, rather than as a beautiful expression of your life.

  • When you focus on your weight, you are objectifying your body, as if it is a mold of clay to size and shape.
  • Withholding food from yourself is punitive.
  • What about practicing embodiment? BEING in your body as if your body were the instrument through which you live your glorious life?

Ok. So now what?

Early evaluation and diagnosis, as well as effective treatment, stack the deck favorably for recovery.

And, full, complete recovery is possible!

What if you’re still not sure if you have an eating disorder? Consider talking with a specialist on a hotline through one of the national organizations such as the National Eating Disorder Association.

Whether or not you have an eating disorder, educate yourself on topics such as fat stigma, privilege and other social injustices that make up Diet Culture.

For a new perspective, read about Intuitive Eating and body neutrality Both offer a refreshing alternative to Diet Culture.

Let’s ditch Diet Culture together. And delight in size and shape diversity.

Imagine actually enjoying food? Welcoming other pleasures? And feeling comfortable in your body?

This IS possible. As you learn to love yourself more, you’ll break free from the constraints of Diet Culture.

As you become more accepting of yourself, you teach others to be more accepting of you too. And of themselves. Before you know it, you’ll be teaching others to break free from Diet Culture too.

Greater inclusivity will reduce the rate and impact of eating disorders. And lead to unprecedented freedom FOR YOU to let your body be.

I’m reminded of Margaret Sanger’s words: “No one can consider [themselves] free who doesn’t own…. [their] own body.”

The first step toward freedom in your body is to admit having an eating disorder.

By letting go of the shackles of Diet Culture, you’ll be able to experience your life – “happiily full” and with abundance. .


Hi! I am Dr Elayne Daniels, a MA licensed psychologist with a passion to help people of all sizes and shapes improve their relationship with food and their body. If you’re struggling with an eating disorder, live in MA, and want help, please contact me here.

What’s the REAL Relationship Between Anxiety and Eating Disorders?

A photo of a woman seated at a table alone, eating soup, reading a book that she is holding in one hand and that is blocking her face.

Anxiety and Eating Disorders often co-occur. Anxiety can begin before an Eating Disorder, around the same time, or after the onset of an Eating Disorder. This chronology has led many to wonder about the real relationship between anxiety and Eating Disorders.

So, let’s unpack this. First, anxiety.

Think of anxiety as on a continuum.

On one end is minimal anxiety. On the other end is severe anxiety. As anxiety approaches the ‘severe’ end of the continuum, it becomes an Anxiety Disorder. To be a disorder means symptoms interfere with daily life and impair functioning.

There are many different kinds of Anxiety Disorders.

They include: Obsessive Compulsive Disorder, Generalized Anxiety Disorder, Simple Phobia, Panic Disorder, Social Anxiety Disorder, and Post-traumatic Stress Disorder.

To have an official disorder of any type means you meet specific criteria outlined by the Diagnostic and Statistical Manual (DSM). This is true for Anxiety Disorders and Eating Disorders. The DSM is THE official handbook that outlines and describes all psychiatric conditions.

In the DSM category of Eating Disorders, three main types include Anorexia nervosa, Bulimia nervosa, and Binge Eating Disorder.

Eating Disorder symptoms are challenging to treat. Plus, people with an Eating Disorder often have other psychological conditions too.

Guess which DSM diagnosis occurs most frequently among people with a DSM diagnosed Eating Disorder?

You guessed it: Anxiety!

Anxiety is the most common condition people with an eating disorder have.

In fact, 48-51% of people with anorexia nervosa, 54-81% of people with bulimia nervosa, and 55-65% of people with binge eating disorder are also diagnosed with an Anxiety Disorder.

Far more people with an Eating Disorder have anxiety, but to a lesser degree than someone with a DSM Anxiety Disorder.

By the way, there is little research on the prevalence of Eating Disorders among people with an Anxiety Disorder.

One of the most common forms of anxiety that co-occurs with Eating Disorders is Obsessive Compulsive Disorder (OCD). In fact, OCD usually occurs first and is considered by some a risk factor for developing an Eating Disorder.

Anorexia nervosa is the Eating Disorder than most often overlaps with OCD.

The other two Anxiety Disorders most often associated with Anorexia are Social Anxiety Disorder and Generalized Anxiety Disorder. (Social anxiety disorder is also more common in people with bulimia than in people without an Eating Disorder.)

Actually, Social Anxiety Disorder is the anxiety disorder that occurs most often among people with any type of Eating Disorder (not only Anorexia.).

Think about the implications of co-occurring Social Anxiety Disorder and Eating Disorders.

When someone has Social Anxiety Disorder, they may be that much more reluctant to seek treatment. Having Social Anxiety makes getting help for an Eating Disorder (and the for Anxiety Disorder for that matter) that much harder. And less likely.

Delaying or avoiding treatment worsens the prognosis for someone with an Eating Disorder. Or with an Anxiety Disorder. Or with both.

Let’s put the pieces together: Anxiety Disorders seem to occur more often in people with an Eating Disorder than in the general population. We also have evidence that Anxiety Disorders likely emerge before an Eating Disorder.

What does this mean?

The sequence suggests that early onset anxiety may increase the risk of developing an Eating Disorder. This is especially true of Social Anxiety Disorder.

The research on the relationship between Eating Disorders and anxiety is difficult to interpret. One reason is because of all the combinations of different Eating Disorder and Anxiety Disorder diagnoses. (As outlined in the beginning of this article.) There are methodological problems in some of the research that also makes it tough to evaluate.

So the inconsistencies complicate the understanding of co-occurring anxiety and Eating Disorders.

Regardless, though, treatment for one often benefits the other.

For example, Cognitive Behavior Therapy (CBT) is one of the treatments of choice for Eating Disorders and Anxiety Disorders.

CBT is based on the idea that psychological problems are the result of distorted ways of thinking and unhelpful behavior. Through the use of specific techniques, CBT helps people learn to cope better with everyday kinds of things. Improved coping decreases their need to use Eating Disorder behaviors. The same sort of techniques are useful in treating Social Anxiety Disorder.

Another plus to mention is that certain medications called Selective Serotonin Reuptake Inhibitors (SSRIs) can be helpful. They are often part of an effective treatment plan for Anxiety and Eating Disorders. SSRI’s were originally developed to treat depression. (They help treat depression too!)

So what is the REAL relationship between Anxiety and Eating Disorders? It depends on which research findings you read.

My professional experience is that anxiety is practically always present before an Eating Disorder develops.

Anxiety can be one of the reasons why an Eating Disorder develops in the first place.

How so? Well, in an attempt not to feel anxious, a person turns to Eating Disorder symptoms. Usually this is not conscious.

Anxiety may then decrease, but only artificially. It is still there. An Eating Disorder masks it. But, the person no longer feels as anxious. The more she relies on Eating Disorder symptoms, the less anxiety she feels. An entrenched cycle has begun.

Anxiety also occurs during an Eating Disorder. Maybe because of sneaky behaviors that are involved. Or due to malnourishment.

Anxiety also occurs after an Eating Disorder and as part of recovery. Why? Well, change can be scary. Feelings are no longer numbed by an Eating Disorder. Instead, CBT and medication provide more skillful ways to be in the world. But learning and changing take time. There is no quick fix.

Both Anxiety and Eating Disorders are treatable. To be you, without symptoms of Anxiety or of an Eating Disorder is possible. Whichever type of Anxiety Disorder or Eating Disorder you have, seek treatment that addresses both. Doing so will be one of the best investments you will ever make.

Dr Elayne Daniels is a private practice psychologist in Massachusetts, specializing in the treatment of people with Eating Disorders and co-occurring conditions of all types.

3 Reasons Poor Body Image And Eating Disorders Go Hand-In-Hand

A whimsical painting of a woman's face, surrounding by koi fish, as if underwater and swimming with them

Not everyone with an eating disorder has poor body image, and not everyone with poor body image has an eating disorder. However, poor body image and eating disorders often do go hand in hand.

Let’s start by defining body image.

Body image is the relationship you have with your own body. As with most relationships, body image is complex.

Body image is important because of how it impacts your physical and mental health, relationships, and self-esteem.

It includes how you see/perceive your body, what you think about your body, and how you feel about it. Body image also includes beliefs and behaviors, and is strongly influenced by Diet Culture.

Diet Culture influences everyone’s relationship with their body, even if they aren’t dieting. Sometimes it’s disguised as ‘healthy lifestyle’, ‘clean eating’, or other such euphemisms. It glorifies thinness and intertwines weight with worth.

In addition to making you feel bad about your body and self, Diet Culture demands you be vigilant about eating and weight.

It says that to be worthy, you must be thin. And if you’re not in a thin body, you are to blame.

Diet Culture shows up as all-or-nothing, perfectionistic thinking regarding food, body and health. Rules to eat “x” but not “y”. To “start Monday” if you ‘blew it”. If not thin, then you’re fat.

It promises that if you follow external rules, rather than trust your body’s wisdom, you will succeed.

This kind of messaging makes having a good relationship with your body almost impossible.

Poor body image often begins in childhood. Thanks to Diet Culture, growing up with a neutral or even positive body image is more the exception than the rule.

Parents are not immune either. They don’t live in a vacuum. Diet Culture is so insidious that even recognizing it is a challenge. Sort of like fish not knowing they are wet. They often unknowingly perpetuate Diet Culture messages, for they have also internalized them.

There’s no shame here- Diet Culture impacts US ALL.

The main points include:

1.Poor body image is due to the internalization of Diet Culture.

2.If there were no poor body image, there would be no dieting.

3.If there were no dieting, there would be no eating disorders.

(Except Anorexia nervosa, which recent research suggests has a prominent genetic component irrespective of cultural ideals.)

How does negative body image present in eating disorders? There are many forms: body dissatisfaction, overconcern with weight and shape, body-related checking, avoidance behavior, misperception of size, and body-related cognitive bias.

There are three basic ways body image and eating disorders go hand in hand.

First, research finds time and time again that poor body image is one of the most common precursors to eating disorders. Second, it is the main symptom of many eating disorders, including Anorexia nervosa and Bulimia nervosa. Lastly, recovery requires improved body image. Without it, recovery is incomplete and/or short-lived.

Let’s look at each of the three ways poor body image and eating disorders go hand in hand.

1. As mentioned, poor body image is a risk factor for eating disorders.

Eating disorder prevention programs often target body image for this very reason. Poor body image is a risk factor for other problems, too, including depression, anxiety, and low self-esteem.

Why is poor body image so strong a precursor to eating disorders?

One reason is poor body image can and does easily lead to dieting, disordered eating, and then to an eating disorder.

Negative body image is a logical risk factor in eating disorders because people who develop eating disorders tend to highly value body shape and weight. Especially to define their self-worth.

2. Poor body image is a criteria in the diagnoses of two well known eating disorders, Anorexia nervosa and Bulimia nervosa.

In the case of either disorder, poor body image presents as body shape and weight hugely influencing self-worth. People with Anorexia nervosa also have a disturbance in how they experience their weight or shape. Sometimes they’re unable to recognize the seriousness of their current (often low) body weight.

The most common eating disorder is Binge Eating Disorder. Body image related concerns are not part of the diagnosis. However, about 60 percent of BED patients endorse overconcern with weight and shape. And avoidance behaviors and body checking too.

3. Why does recovery from an eating disorder require improved body image?

People with an eating disorder sometimes fear they’ll never feel at peace in their body. Especially if they give up their eating disorder behaviors. They inaccurately believe that their only hope to eradicate negative body image is to lose weight and maintain a body size closer to Diet Culture’s ideal.

Surrendering eating disorder behaviors, including dieting/restriction, is especially difficult in the Diet Culture World we live in. An important facet of treatment is to help people learn self advocacy, social action, and how to be the change they want to see in the world.

The good news is that full recovery from eating disorders is possible. Which means that improving body image is also possible.

There’s no shame here- diet culture impacts US ALL.

To move toward healing and freedom from food and body concerns, we have to dismantle and question the ‘truths’ that Diet Culture has enforced from Day 1. And, to consider how buying into these beliefs and messages (most often over and over again) has been destructive to attuning to your body, your needs, your hungers and your trust in yourself.  

As you begin to do this important self-inquiry, externalize some blame you’ve put on yourself.

Join me as we take down Diet Culture, together. Only then will body image collectively improve and eating disorder rates plummet.

I am a non-diet, Certified Intuitive Eating specialist and clinical psychologist in MA. If you’re struggling with your body image and/or eating disorder, please contact me here.

Are Eating Disorders A Mental Illness?

A drawing of a young woman with a globe she is leaning on has an expression of concern.

Eating Disorders are a diagnosable mental illness. So says the Bible for diagnosing psychiatric illnesses, the Diagnostic and Statistical Manual of Mental Disorders (DSM).

Published by the American Psychiatric Association, the DSM includes hundreds of mental health disorders categorized by symptoms, for both adults and children. Updated every few years, the current version is DSMV.

Eating Disorders have their own DSMV category, Feeding and Eating Disorders, or “FED” for short.

I’m not sure if the APA intended the pun or not.

Eating Disorders’ inclusion as a mental illness in the DSM has advantages.

First and foremost, recognizing eating disorders as a mental illness adds legitimacy. As a result, eating disorders are less likely viewed as a rite of passage, fad, choice, or attention seeking maneuver.

Another plus of recognizing eating disorders as a bona fide mental illness is earlier diagnosis and treatment. (And insurance coverage.)

However, identifying eating disorders purely as a mental illness is oversimplified.

Here are three reasons why.

First, let’s look at the numbers. The National Eating Disorders Association reports 20 million women and 10 million men in this country will have an eating disorder in their life. That is a lot of people.

Speaking of a lot of people…

Imagine randomly asking people questions from a disordered eating screening tool. Questions like, “How afraid are you of gaining three pounds?” “Compared to other things in your life, how important is your weight to you?”

The results of this experiment? You’d most likely find people without a diagnosed eating disorder reporting eating disorder symptoms.

So if many people suffer from what is considered a disorder (knowingly or not), is the disorder a disorder?

This is where Diet Culture enters into the equation. Or, as I like to say, fish not knowing they’re wet.

And Diet Culture is the second reason there is more to eating disorders than what the DSM has to say.

What is Diet Culture anyway?

It’s a set of beliefs that worships thinness and equates it with morality and success. Diet Culture is the lens through which we define attractiveness, worth, health, and our own bodies. It’s the air we breathe and one of the main factors affecting how we feel about ourselves.

What does Diet Culture have to do with eating disorders?

Everything!

Diet Culture perpetuates eating disorders and makes recovery much more difficult. As activist, Dance Champion, and Marathoner Ragan Chastain says, Diet Culture is “particularly dangerous to those with a predisposition for, currently suffering with, or recovering from eating disorders.” (Again, that’s a lot of people!)

So, how are Diet Culture and eating disorders linked?

“Thinner is better, regardless of the mental and physical cost” is a Diet Culture belief. So is the premise that anyone can be thin if they just try hard enough. These are the ingredients in a recipe for an eating disorder.

We’re surrounded by images and messages that reinforce this premise and keep us hostage.

The message is clear. You have to have a certain size (thin) body, and follow a set of rules (e.g. fitness and/or meal plans) to be successful, attractive, and worthy.

Again, this is fertile ground for eating disorders. (And a dark parody of taking the messages too far.)

The third way to think about eating disorders beyond the DSM is as a Culture bound syndrome.

A culture bound syndrome is “a cluster or group of co-occurring, relatively invariant symptoms found in a specific cultural group, community, or context” (American Psychiatric Association).

What do culture bound syndromes and eating disorders have in common?

Research from 1995 on the island of Fiji addresses this very question. The mid 1990’s is when American television first began broadcasting in Fiji.

Prior to television, there was no such thing as eating disorders in Fiji. Even though there was a lot of emphasis on food.

But the food emphasis was on the joy of eating. And in delighting in the abundance of delicious food. The focus on pleasure is the opposite of Diet Culture messages.

By 1998, 3 years after “Friends” and “ER” were broadcast, that changed, especially for teenagers.

An astounding 11.3 percent of adolescent girls reported purging for weight loss. They said things like, “I want their (actresses’) body…I want their size.”

By 2008, 45 percent of girls had purged in the last month.

So, are eating disorders a mental illness? Yes.

But…

Complex biological, temperament, genetic, and sociocultural factors interact to yield an eating disorder. Diet Culture is a major player in that equation. Factor in Diet Culture messages, and eating disorders can be thought of as a Culture Bound syndrome.

Diet Culture harms you. Actually, it harms anyone with a body. That includes people who aren’t on a diet. And even people from a South Pacific island who until recently had a diagnosed eating disorder rate of zero.

So when thinking about eating disorders, please respect that many factors contribute to their development and maintenance. They are a mental illness, but so much more.

I am a MA licensed psychologist with a passion to help people of all sizes and shapes improve their relationship with food and their body. If you are struggling with an eating disorder and want help, please contact me here.

What Is Disordered Eating?

Four rows of food, witha woman's arm with fork in hand, demonstrating disordered eating.

Disordered eating is so common that it’s hard to identify and define. It’s just accepted as “normal”.

Kind of like fish not knowing they’re wet. It’s just how they live.

We’re born with all of the knowledge we need in order to eat well. But over time, the knowledge goes offline. Especially with our cultural obsession with thinness as our backdrop. And the tendency to categorize food as “good” or “bad”. As if food has a moral quality.

What is normal eating anyway? To define DISordered eating, we first need to know what ordered (“normal”) eating is.

Ellyn Satter, a registered dietician and family therapist, has an often cited definition. (She has lots of street cred as an internationally recognized expert on eating.)

She says normal eating is….

  • “… eating until you are satisfied.
  • Being able to choose food you enjoy and eat it and truly get enough of it – not just stop eating because you think you should.
  • Giving some thought to your food selection so you get nutritious food, but not being so wary and restrictive that you miss out on enjoyable food.
  • Giving yourself permission to eat sometimes because you are happy, sad or bored, or just because it feels good.
  • Mostly three meals a day, or four or five, or it can occasionally be choosing to munch along the way.
  • Leaving some cookies on the plate because you know you can have some again tomorrow, or it is eating more now because they taste so wonderful.
  • Overeating at times, feeling stuffed and uncomfortable. And it can be undereating at times and wishing you had more.
  • Trusting your body to make up for your mistakes in eating. Normal eating takes up some of your time and attention, but keeps its place as only one important area of your life.

In short, normal eating is flexible. It varies in response to your hunger, your schedule, your proximity to food and your feelings.”

Is it even possible to have a “normal” relationship with food these days?

My thoughts: “YES, but…”

“Normal eating” remains quite the oxymoron in our culture. As if the two words don’t belong together, side by side. And that an understanding of how the two words could possibly be a real thing is hard to believe. A common response is something like, “nondieting and normal eating may work for other people, but not for me. I could never do that.”

Indeed, nondieting (“ordered” rather than disordered eating) may seem like a radical act. To actually tune back into your own body’s natural signals. Not an easy thing to do – the signals have been derailed. Diet Culture’s rules of should’s and shouldn’ts have overridden your body’s inherent wisdom. BUT, you CAN reclaim that wisdom. Actually, to do so is your birthright.

Defining disordered eating is also difficult because there’s no specific criteria. In order to address a problem, defining it is helpful in order to know what it even is. And to understand why it is a problem in the first place.

The main reason disordered eating is hard to identify and define is because it is more the norm than not in our weight obsessed, diet oriented culture.

Consider the fact that disordered eating, Eating Disorders, and dieting are more common than normal eating. That’s disturbing.

So what are the signs and symptoms of disordered eating, and how do you distinguish it from Eating Disorders or dieting?

Signs of Disordered Eating:

Disordered eating takes a variety of forms. Examples include limiting intake to a certain number of calories or macros; eating only certain foods and avoiding others for weight related reasons; bingeing, purging, restricting, and/or fasting.

The mindset and behaviors that drive disordered eating can be hard to distinguish from cultural definitions of normal eating. And to distinguish from an Eating Disorder All of these behaviors are concerning. In time they can easily morph into a full blown Eating Disorder.

Disordered eating often has additional features, including:

  • Self-worth based on body weight and size
  • Body dissatisfaction
  • Exercise to compensate for eating
  • Preoccupation with food, weight
  • Compulsive use of scale to check body weight
  • Fad dieting
  • A rigid approach to eating, such as only eating certain foods, inflexible meal times, refusal to eat in restaurants or outside of one’s own home

There are also lots of side effects of disordered eating.

For example:

  • Decreased ability to focus because thoughts about food, body, and exercise get in the way.
  • Social activities are affected, especially if they involve eating in a restaurant. Or eating foods that aren’t part of the plan.
  • Using disordered eating rules to cope with stress.
  • Anxiety due to food, weight, exercise.

Treating Disordered Eating

Disordered eating impacts physical and psychological health and puts people at risk for a host of problems. And it takes away from quality of life. Big time.

The relationship we have with our bodies is complex. So is how we nourish ourselves.

Fortunately, it is never to late to improve your relationship with food or your body. And there is no better time than right now.

As a psychologist, I’m biased in favor of psychotherapy. At least to support you as you start on the path of improving your relationship with food and your body. Finding like minded people also helps. There are communities to join online for example that may empower you.

Psychotherapy is helpful because it provides an opportunity to understand complex relationships with food and body. Also, therapy helps people move toward body acceptance. In addition, a nutritionist who specializes in eating disorders and adopts a non-diet approach to food and exercise can also be a good resource. Particularly with respect to increasing attention to the body’s natural hunger/fullness cues.

Reclaim your natural default of Intuitive Eating. Eat unconditionally. In whatever way pleases your body. Food is meant to be a source of pleasure. Denying yourself of it does not make you virtuous. Fueling and nourishing yourself well provides a sense of freedom, energy, and limitlessness.

Consider being your own unique fish, and surround yourself with others who share your vision.

I am a psychologist with a passion! IF you would like to learn more about freedom to derive pleasure from food and to be comfortable in your own skin, please contact me here.

How To Heal From 3 Heartbreaking Side Effects Of Eating Disorders

A woman sitting on a chair eating a banana and reading demonstrates it is possible to heal from the side effects of eating disorders

Eating Disorders are serious illnesses that squeeze joy and ease out of your life. They take a huge toll on your body and mind and can shorten life span. Despite how damaging the effects can be, you can heal from (most of) the heartbreaking side effects of eating disorders.

Consequences of eating disorders vary, depending on which eating disorder you have, the duration and severity of the disorder, and a few other factors.

If you have an eating disorder, reading about the side effects is not likely to motivate you to recover. Education alone is not enough.

Upon learning about side effects, you might think “oh, that (side effect) won’t happen to me”. Or “if that happens, I will deal with it then.” Or even “I hope that (side effect) happens because I deserve to suffer.”

Separating the psychological and physical side effects is not completely fair, because the mind and body are connected to one another. One affects the other.

The psychological side effects of eating disorders are what I am going to focus on here.

You can read about the physical side effects here.

How do eating disorders cause psychological side effects?

Well, atypical eating behaviors, such as fasting or chronic dieting, impact your thoughts and emotions. (And, of course, your body.)

Dangerous patterns of compensation, such as self-induced purging or laxative abuse, do too. (And they affect your body as well.)

Even though your body and mind are resilient, the force of eating disorders is fierce and destructive. Withholding nourishment from and inflicting punishment onto yourself cause wounds. And some wounds leave scars.

The psychological impact of eating disorders can be complex. And less obvious than the physical side effects.

The psychological impact is less visible but no less serious.

For example, shame, loss of control, hyper-control, and body image problems are common. So are guilt and anxiety.

Other mental health side effects of eating disorders include:

  • major mood swings
  • depressive thoughts or actions
  • obsessive-compulsive behaviors
  • general anxiety
  • Isolation
  • impulsive behaviors, such as self-harm
  • low self-esteem

(Please note: Research has yet to determine exactly which psychological variables are linked to the cause and which are due to the effects of eating disorders.)

Three lesser known heartbreaking psychological side effects of eating disorders include:

  • Poor interoception
  • Self objectification
  • Psychological inflexibility

Let me explain what these fancy sounding concepts mean, why they’re important, and what you can do to heal them.

Interoception tells you what your body feels on the inside. Interoceptive awareness occurs when you recognize you have to empty your bladder (i.e. you have to pee), or that your heart is racing.

Interoception is also knowing when you’re feeling hungry and when you’re feeling full.

By definition, having an eating disorder means not eating when hungry (restriction/fasting), and/or eating beyond fullness (bingeing). Over time, your body’s hunger and fullness signals get dysregulated because they’ve been ignored. They get used to you overriding them.

Recovery involves improving interoceptive awareness by re-regulating your hunger and fullness signals.

Meeting with a registered dietician who specializes in the treatment of eating disorders can help you do this. The basic recommendation is to eat in a structured, consistent, patterned way each day: Meal, snack, meal, snack, meal, snack. And not to go 4 or more waking hours without eating.

As a bonus interesting fact: I have noticed that a lot of people in treatment for an eating disorder also tend to ignore other body signals, including the need to pee.

2. Self-objectification is a body image concept that has to do with seeing yourself as an object first, and a human being second.

Your experience of being female is defined by a culture that sexually objectifies women’s bodies.

So as a girl/woman, you naturally internalize an observer’s view of your body. This leads to ongoing monitoring of your body’s appearance. And of weight especially. It also increases shame, anxiety, and disgust toward yourself. Self objectification leads to eating disorders and remains a side effect.

Eating disorder recovery involves redefining your relationship with your body and seeing it through your own lens. Learning other ways to experience (see, feel, connect with) your body. And honoring your body as part of your human experience.

3. Cognitive inflexibility increases risk for eating disorders and is a side effect that’s hard to change. Especially for people who have Anorexia nervosa.

Cognitive flexibility refers to the ability to shift your thinking and/or your plan or strategy.

A lack of cognitive flexibility occurs during eating disorders and continues into recovery.

Cognitive Behavioral Therapy is a useful treatment approach. The focus is on helping you learn how to identify underlying thinking patterns that may be keeping you stuck. Meditation can also help.

Eating disorders are serious yet highly treatable. Yes, you can fully heal from an eating disorder – with treatment with a therapist trained in providing therapy to people with eating disorders.

The sooner you seek specialized help, the sooner you will heal from the symptoms and side effects of eating disorders.

And what a gift to yourself that is!

I am a clinical psychologist specializing in helping people recover from eating disorders. What that looks like is working alongside each person, as they discover true joy and passion in life, live fully embodied, and heal more and more each day.

20 Subtle Warning Signs of Eating Disorders

Graffiti of a black woman represents subtle risk factors for eating disorders

Someone you love has been diagnosed with an eating disorder. You Monday morning quarterback and rack your brain. Would your loved one even have an eating disorder if you had known about subtle warning signs of eating disorders? Maybe. Maybe not. In any event, please do not take on the eating disorder as your fault. Because it is not your — or any one person’s — fault.

One of the hard things when it comes to eating disorders is how to differentiate — in people of any sex, sexual orientation, age, or demographic — what’s normal and what’s considered clinical. You may wonder “is this part of being a fill-in-the-blank (teenager/woman/athlete)? Or, is it a sign of a problem?” The “this” could be just about anything – negative body image, certain eating behaviors, or various exercise patterns.

Diet Culture makes differentiating warning signs of eating disorder behaviors hard to evaluate. Especially when disguised as ‘clean eating’, ‘healthy lifestyle’, or ‘wellness.’ They all mean the same thing.

Remember, eating disorders are caused by a combination of biological, psychological, and socio-cultural risk factors — including genetics. In people who are genetically predisposed, subtle warning signs add up quickly and create the perfect storm.

Here are 10 subtle warning signs of eating disorders:

1. Bathroom use Discretely going to the bathroom after eating something is a common warning sign of eating disorders. Often the reason is to induce purging. Notice if you hear the water faucet running for an unusually long period of time. The running water sound is to drown out any evidence you might otherwise be able to hear.

2. Food rules This could be an entire book! There are so many. Here are some examples:

  • not eating after a certain time of day
  • waiting until a certain time of day before eating anything
  • eating only a certain number of calories or grams of a nutrient like fat
  • insisting that food can’t touch on the plate
  • at restaurants only ordering salad, with dressing on the side
  • declining any invitations that involve food, even with friends

3. Inflexible routines The eating disorder becomes the center, around which everything else revolves. This focus influences anything and everything else a person does or thinks during the day.

4. Unusual interest in what other people eat. Vicarious eating is common. In other words, eating ‘through’ watching or talking about what other people are eating.

5. Sudden interest in nutrition, food labels, additives/preservatives. And spending time scouring the nutrition information on products. Looking up nutrition information online before eating is another example.

6. Preoccupation with ‘clean’ eating, Aka dieting, ‘just being healthy’, or some other word that is a stand in for restriction.

7. Viewing Cooking shows, food related videos, or recipes on the internet becomes a regular part of the day.

8. Irritability, whether from the effects of restriction or due to having binged, she has mood fluctuations that are somewhat new.

10. Sneaking exercise, to compensate for what she’s eaten.

And 10 more….

11. Lying about food, exercise, and eating disorder behaviors. Denial of having a problem is common too.

12. Sudden decision to become a vegetarian/vegan, and the decision does not come from a place of animal rights.

13. Frequent use of scale to weigh self, or starting to use a food scale to measure the amount of food before eating it.

14. Excuses to avoid meals with family/friends, such as “Oh I already ate at Megan’s house”,

15. Wearing oversized/baggy clothing to camouflage body.

16. Monitors and compares own intake with others; “the rule” is to consume less than other people at the table.

17. Zoned out expression, due to hunger/malnutrition or preoccupation with eating disorder symptoms.

18. Strange combinations of food, including certain condiments.

19. Insistence on preparing all food herself in order to have complete control over ingredients and quantity.

20. Unusual forms of eating behavior, such as pulling food apart with fingers.

There are many other early warning signs, and the presence of any of the above does not mean the the person is necessarily destined to have an eating disorder.

Plus, the early warning signs for eating disorders vary depending on the type of eating disorder. Early signs of anorexia nervosa, for example, may be different from those of Binge Eating Disorder.

Regardless of the specific thoughts and behaviors, all disordered eating and eating disorders begin with some form of a diet. Or a decision ‘to eat healthy’. Or ‘to lose weight and get in better shape.” The diet could be recommended by a physician, family member, or friend. Even by a Health Education teacher. Or a coach.

Eating disorders are serious conditions, even at times deadly. The symptoms don’t go away on their own. Early recognition of subtle waring signs of eating disorders will shorten the duration of the disorder. And, early treatment is key in full recovery.

And with treatment, full recovery is absolutely possible.

I have specialized in treating people with eating disorders for over twenty years and know personally and professionally that recognizing warning signs can make a huge difference in whether a full blown eating disorder develops. Please contact me if you would like to know more.

10 Risk Factors For Eating Disorders That Every Parent Needs To Know

Three young girls at a table eating and are at risk for eating disorders.

Parents often blame themselves when their child has an eating disorder. Or they blame the child. The cause of eating disorders is way more complicated than faulting parents or the child. When parents know about risk factors for eating disorders, they recognize just how complex these disorders are.

Risk factors for eating disorders come from both Nature (genetics, biology) and Nurture (environment, culture).

The factors combine in a particular way that then leads to eating disorders.

So, the cause of an eating disorder is never just one thing. It is way more complicated than that.

That means there is no single gene that CAUSES eating disorders, nor are cultural pressures for thinness THE cause of eating disorders.

The three categories of risk factors for eating disorders that every parent needs to know come from:

1. Biology/Genetics (Nature)

2. Psychology (Nurture) and

3. Culture (Nurture)

Factors from all three categories combine and result in an eating disorder.

Triggering events distinguish why some people with risk factors from the three categories develop eating disorders and some don’t.

What’s a triggering event? Well, it could be something like a loss, such as the death of family member, friend, or pet. Or a parents’ divorce. Maybe a geographic move of a best friend. Or some other transition, such as to a new school. Even a medical problem, be it a chronic disease diagnosis, surgery, or an injury, can be a trigger.

BIOLOGICAL/GENETIC risk factors for eating disorders:

Biological risks predispose people to eating disorders. Genetics account for 40-60% of liability for eating disorders.

  1. Genetic relative: Having a first degree relative (e.g. parents, sibling) with an eating disorder is a risk factor.

2. Relative with a mental health condition: Having a relative with depression, anxiety, substance abuse, or other psychiatric illness increases risk.

3. Early menarche: Girls whose first period is earlier than their peers’ are at higher risk.

PSYCHOLOGICAL risk factors for eating disorders include:


1 Personality characteristics: Certain personality traits increase risk. The biggest one is perfectionism. Others include high sensitivity, low distress tolerance, and behavioral inflexibility.

2. Body Image: Negative body image is common. But not everyone with body dissatisfaction develops an eating disorder.

People who develop an eating disorder have even worse body image than the norm. They also tend to internalize societal ideals of weight and appearance more.

3. Anxiety Disorder: Anxiety symptoms often occur well before an eating disorder develops. More than 2/3 of people with anorexia have anxiety disorder symptoms first.

SOCIAL/CULTURAL risk factors for eating disorders include:

  1. Diet Culture: The number one risk factor in this category is the societal pressure to be thin. Diet Culture is the toxic system of beliefs that idealizes thinness and connects weight and morality.

    Weight discrimination is the norm in Diet Culture. So is categorizing food as good or bad.

    Living in Diet Culture negatively affects your relationship to your own body and your children’s relationship with their body.

    Dieting is ineffective for sustained weight loss in almost 100 percent of people. When dieting no longer works, eating disorder behaviors such as fasting, restricting, and purging can easily develop.

    2. Teasing: Approximately 60% of people report a history of being teased.

    3. Appearance ideal internalization. Striving to have the socially-defined “ideal body” is harmful. Dieting becomes normalized as a ticket to success.

Eating disorders develop for lots of reasons. Biological, psychological, and cultural factors, along with a triggering event, create a perfect storm.

There are little, everyday things you can do to decrease the risk of an eating disorder for your child. For example, don’t comment on your own or other people’s weight. Focus instead on non-appearance related qualities. Don’t label food as good or bad. Food is just food. Food doesn’t have morals attached to it. Eat a full range and variety of food, and enjoy it! Encourage your child to do so too.

If you yourself have an eating disorder, please get treatment. You deserve that, and so does your child.

While eating disorders may not be 100% preventable, you can absolutely decrease the risk for your child. And for yourself.

For more information, please contact me.

10 Things All Parents Must Know About The Prevention Of Eating Disorders (& Overcoming Them)

Two parents, their son and daughter on standing on a beach overlooking the ocean, representing the importance of recognizing early warning signs of eating disorders

Dieting triggers Eating Disorders. You and your family live in diet culture. Ut oh. How then as parents can you prevent eating disorders? What are some of the things for parents to know about the prevention of eating disorders?

Education for parents about the prevention of eating disorders makes a difference in the life of every family member. There is lots of hope!

Here are ten things for you as parents to know about the prevention of eating disorders.

1. The most common way Eating Disorders start is as an “innocent” diet. (Which is an oxymoron.)

More than 40 BILLION dollars is spent each year on dieting. From an early age, children receive the message that being in a socially acceptable size body (e.g. thin) is essential for happiness. The diet industry, fitness industry, and even the medical field promote unhealthy weight practices (aka dieting), often disguised as ‘healthy lifestyle’ or ‘clean eating’.

Why is this relevant?

The most fundamental way to prevent Eating Disorders is through teaching and modelling nondieting. Dieting is not innocent; it is a significant risk factor for Eating Disorders. And, it promotes mistrust of the body, as well as weight cycling and preoccupation. Dieting interferes with quality of life and is not sustainable. Research since 1959 has demonstrated the futility of dieting over and over and over again. And the dangers associated with it.

I discourage dieting, and so should you. It can lead to an Eating Disorder, especially for susceptible children.

So what can you do instead?

Teach your children how to trust their body, appetite, and needs. Be aware of what you are modelling for them, through your words and actions.

A child delighting in sitting at a table about to eat a delicious looking donut.

For example, eliminate (ideally) or limit your purchase of diet/low calorie foods. Do not speak disparagingly about your or someone else’s body size or weight. Educate your children that no food is “good” or “bad”. Food is food and does not have a moral quality.

Emphasize Intuitive Eating, movement for pleasure, and your child’s many awesome qualities beyond appearance.

Encourage your children to be in tune with the physical sensations in their body. Teach them the skills of Interoceptive Awareness. This education will also help them to regulate their feelings.

One of the best resource for parents of infants all the way through adolescents is Ellyn Satter’s website. It is a rich source of gold standard information for families on eating competence, feeding dynamics and division of responsibility.

2. Learn the basics about eating disorders.

There are tons of free resources online. Prevention is easier if you know the facts. Recognize too that Eating Disorders include more than the two most commonly known (Anorexia nervosa and Bulimia nervosa), and sub threshold forms of Eating Disorders are serious too.

Here are more of the basics:

a. Genetics increase risk. If a biological relative has/had Anorexia, for example, risk increases eleven times. However, an eating disorder is not inevitable. Genes predispose but are not a slam dunk.

b. Eating Disorders rarely get better on their own. With proper treatment, though, they are completely treatable.

c. Eating Disorders occur among boys/men, people who are transgender, and girls/women. People of color, of any socioeconomic status or religion, and of all ages develop Eating Disorders.

Two tween girls are on a hammock enjoying nature.

3. Teach media literacy. Especially with social media. Doing so will buffer against appearance based comparing.

Research studies confirm what you likely already know: Social media usage can promote body dissatisfaction, depending on the images you are looking at. The number of likes you get on your posts also factors into how you feel after spending time on Instagram. More often than not, you feel worse about yourself after spending just ten minutes scrolling on Instagram.

4. Be a role model in as many ways as possible. Both on the inside and outside.

Live your life in a way that is aligned with your own values. When day to day choices are based on your own set of values, you are also instilling the values into your children’s life. Healthy values can be key in the prevention of eating disorders.

5. Teach and model self-compassion to your children.

Being self compassionate is similar to showing other people compassion. Self compassion means you accept imperfection. Life can be hard, filled with frustration, loss, mistakes, and limits. This is what it means to be human. Ups and downs in life are to be expected, and are what connect us as human beings. In this way self compassion strengthens resilience.

6. Eating Disorders are not caused by just one thing.

There are many genetic, biological, behavioral, psychological, and social factors that combine and create the perfect storm. Eating disorders do tend to run in families. Exciting research in the last decade or so using brain imaging will probably provide additional guidelines for the treatment and prevention of eating disorders. Good news!

7. You can not tell if someone has an Eating Disorder by looking at them.

Someone with an Eating Disorder may appear “healthy” but be ill. In general, do not comment on people’s weight or food choices. And, never tell someone with an Eating Disorder they look “healthy.” To that person, “healthy” is code for “you look fat” or “you have gained weight.”

8. People with Eating Disorders are at higher risk for suicide, medical complications, and psychological disorders, such as depression or anxiety. Sometimes they also have substance use problems. Including diet pill abuse.

Eating Disorders can be fatal.

9. Eating Disorders are not a phase, choice, or resolved by a mandate to ‘just eat’.

They are legitimate, serious conditions that require specialized treatment. The typical approach is to have a medical doctor, registered dietician, and a psychologist working as part of a team with you and your child. Sometimes a family therapist is also involved.

10. Parents are not to blame when a child develops an Eating Disorder.

The reasons for why the Disorder developed vary for each person. Further, there is no one set of guidelines for parents to absolutely guarantee the prevention of an eating disorder in their child.

The great news is that there are things every family member can do to create a recovery-promoting environment.

Including parents in the prevention of eating disorders and in the treatment process is especially important.

Eating disorder prevention is critical. As parents, you may not be able to prevent your children from developing an eating disorder. However, please recognize that there are many action steps you can take to protect your kids. And to stack the deck more favorably.

Educate yourself and be mindful of what you are teaching your children.

Your children soak in your comments and behaviors, everyday. You have agency over the messages your children absorb. Use that to your and their advantage.

I have specialized in the prevention and treatment of Eating Disorders for over 20 years and have seen the Disorder’s toll on a family. Full recovery is available to anyone suffering from an Eating Disorder, and for their family too.