The key to the successful treatment of eating disorders is early diagnosis and competent, intensive, aggressive care.

What are the Risk Factors for Eating Disorders?

There are more than just one or two risk factors that can lead to a disorder. Although there are always exceptions and many permutations, those at greatest risk have at least 3-4 of the following characteristics:

Genetics: It has been shown that a single dopamine receptor gene may lie behind an addiction to alcohol, drugs, or food. Some people carry a rarer form of this pleasure gene, with fewer dopamine receptors. People with fewer dopamine receptors "may begin to use substances to satisfy the inherent deficit." *1 Just as alcohol and cocaine boost the level of dopamine in the brain, so do carbohydrates. *2 This, as well as research implicating dysfunctional serotonin levels in the brain, point to a possible genetic "predisposition" toward the development of an eating disorder.

Temperament: Specific personality types seem more predisposed to the development of a disorder than others: Perfectionists and Dichotomous Thinkers (no gray areas: good/bad; fat/thin), those who display a tendency towards depression and anxiety, as well as those with obsessive-compulsive disorder.

Extreme sensitivity and vulnerability: Those at risk often care for others before taking care of themselves. They can take an offhand, benign comment that most others would ignore or be unaffected by and allow it to warp their sense of self. They can often tell you the person who made the life-altering comment, as well as the date and time of day the comment was made, such as: "It seems that you've put on a few pounds," "You better watch what you're eating, you don't want to get fat." etc.

Familial: Often the parents/family in a disordered eater's life may demonstrate the following characteristics:

Cultural: "Through the media, in our culture, women are often portrayed as expensive toys, the ultimate recreation. The beauty standards are so narrow that many women seem to look alike: hollow-cheeked, passive, focused on their appearance, vulnerable and extremely thin. They appear as decorative or sexual objects to be admired, used or discarded. It's a stereotype that starts 9-year-olds dieting and teaches adolescent girls that their developing bodies will never be good enough. It compels young adults to live as if they are being constantly watched, desired and judged, especially when the males they know openly denigrate large women and admire thin women."*3

How should I approach a friend whom I suspect may have an Eating Disorder?

• Increase Your Knowledge about eating disorders (request information packets from health centers, national or local organizations, visit other web sites, read books, attend seminars: see "Resources" page for suggestions)
• Don't be scared to talk with her/him.
• Prepare Yourself: Write down specific behaviors you have witnessed that concern you ahead of time.
• Pick a Time and Place that is quiet, private and comfortable. Be sure you're calm and not under stress. Don't confront your friend with a group of people or in front of a group of people
• Explain Your Concerns: Use specific "I" messages utilizing examples of behaviors you have seen or changes in your relationship: Avoid ANY mention of weight or appearance! For example, "I feel angry and hurt when I hear you say terrible things about your body. Yesterday you called your thighs obnoxious;" "It makes me afraid to hear you vomiting;" "I'm scared, can I make an appointment for you at the Health Center? I'll go with you."
  • Avoid accusational "You" statements, i.e. "You have to eat something!" "You must be crazy!" "You're out of control!"
  • Don't focus on the physical perils of an Eating Disorder. Your friend is probably painfully aware of the damage being done and this can cause you to forget about their underlying feelings.
  • Remember your motivation: Your friend's health and happiness...not to accuse, blame, or shame. Listen with a nonjudgmental ear.
  • Encourage the person to seek professional help as soon as possible. Suggest that s/he see someone who specializes in eating disorders [if possible, have a few local names and numbers handy to share or call together right then]
• Expectations and Needs:
  • Expect a guarded or angry response. Your friend is doing their darndest NOT to feel...so...as their friend YOU are going to feel their fear, their anger, their "out of controllness."
  • Don't expect any thanks
  • If your friend rejects help and you believe s/he is in immediate danger, seek professional assistance after first notifying him/her of your intent...I have even heard of someone successfully dragging their friend to the health center saying, "For my sake. I need you to go to the health center. I must do this." If your friend is under 18, his/her parents need to know immediately.
  • Don't try to solve her/his problems or help with the eating disorder on your own. Get help from others.
  • Don't expect to be the perfect friend--reach out for support when you need it. This is not only healthy for you but provides a helpful model for your friend.
• Future Times Together
  • Don't talk about weight, food, calories, or appearance. Do not make any comments on what she/he looks like. Instead, speak to changes you've noticed in terms of mood, wellness and functioning.
  • Do not get into power struggles or try to force or encourage your friend to eat.
  • Don't allow her/his peculiarities to dominate you or manipulate you.
  • Don't expect your friend to be "cured" after treatment. Recovery can be a long process.
  • Recognize that the Eating Disorder is only one aspect of your friend. Get to know the inner part of your friend by getting to know what they think and feel. Let them know "it's what's inside that counts" and that you want to be there to listen to them.
  • If you tried and missed the boat the first time, go back. "I think I missed the boat. I don't know how or if I can help, but I'm going to try."
  • Stop engaging in "bad body talk" with all your friends
  • Be available when your friend needs someone, but remember, it is okay to set limits on what you can and cannot do.
  • Hang in there! It won't be easy and most importantly...
  • Don't keep this a secret for your friend. [How I wish that every one of Andrea's friends had voiced their concerns with her and called us with their worries...with numerous compelling "reality bites," it would have been difficult for any of us to remain in denial. One recovered young woman told us that it was her friend's statement that she "would rather have a live enemy than a dead friend" that helped nudge her toward recovery]

For additional helpful tips, please see NEDA's [http://www.nationaleatingdisorders.org/p.asp?WebPage_ID=337] booklet, How To Help A Friend With Eating and Body Image Issues 800-931-2237 or The Alliance for Eating Disorder Awareness at http://www.eatingdisorderinfo.org/

How do Eating Disorders begin? What are the warning signs?

"Eating Disorders come into being through a combination of biological and sociocultural factors set off by some sort of stressful precipitant, or trigger. All these factors must be in place for an eating disorder to develop. Sociocultural factors have nowhere to set down roots if the genetic soil is not fertile, and vice versa." *2 Once all the factors are in place and stress is applied, the Disorder often begins very innocently with the individual cutting out some meat and then some fats from their diet. Slowly, the diet becomes more severe and calories are counted continually. The diet is not only a means to become thin, or to NOT become fat, but it numbs and diverts attention from the underlying issues that one would rather not face (angers, fears, loneliness, etc.). "The Eating Disorder becomes a survival tool--a stabilizer in an otherwise chaotic world." *2

As the diet progresses the scale becomes the judge and jury and can be used 20-30 times a day. Waking hours (and often dreams as well) are consumed with thoughts of food and feelings of hunger, and superiority often followed by regression and guilt. Social isolation begins to intensify. There is no peace. There are only thoughts of the battle in which one is engaged. Those who suffer from Anorexia tend to be very proud of the control they exhibit. Those who suffer from Bulimia and Binge Eating Disorder tend to be very shameful of their behavior. Often sufferers pick one body part to HATE. It is an abnormal and overriding hatred that includes the belief that, "If only my stomach (or whatever body part is chosen) were flat (or whatever attribute is desired), I could be happy and whole and finally rest."

Some additional warning signs of danger:

If you have an Eating Disorder, are there tests to see if you are in danger? When is hospitalization necessary?

There are many tests that can and should be done to detect whether or not a disordered eater needs hospitalization. The problem with physiological/vital sign instabilities is that they often cannot be felt or detected by the person experiencing them.

You can feel and look perfectly fine and be close to death.

• Bradycardia: a pulse rate less than 60 beats per minute, in youth ages 14-21, is NOT NORMAL. A pulse with fewer beats is not an indication of physical fitness—even elite athletes in this age group who are in the very best of shape rarely have a pulse rate less than 50 beats per minute. A pulse rate from 50-60 may indicate a need for careful weekly monitoring (six months before her death, Andrea's pulse rate was 58). A pulse rate below 50 is DANGEROUS!
• Hypotension: low blood pressure, low heart rate
• Hypothermia: cold intolerance. You are cold most of the time, you feel it and so does someone who holds your hand. You are putting on a sweater when others around you are comfortable.
• Orthostatic changes: Changes in blood pressure from lying, sitting and standing positions. This is an easy test that can often show whether or not there is a serious problem.

Other signs indicating hospitalization is necessary (again, only one sign is needed to be in critical condition):

• Acute food refusal
• Uncontrollable bingeing and purging
• Dehydration (pinch your child’s skin on their hand, if it remains pinched for any length of time: get a physician’s opinion)
• Electrolyte disturbances in the blood (sodium or potassium)
• Severe malnutrition, i.e., weight less than 75% of ideal body weight
• Cardiac Dysrhythmias
• Failure of outpatient treatment—you’ve been trying the TEAM approach but it is not working. Something more serious must happen.
• A diagnosis such as severe depression, obsessive compulsive disorder, or severe family dysfunction, that interferes with the treatment of the eating disorder.

When signs or symptoms of an eating disorder are suspected, the possibility of other medical (brain abnormalities, thyroid disorders, diabetes, etc.) and psychiatric causes (psychosis, depression, obsessive-compulsive disorders and post-traumatic stress disorder) need to be considered. Treatment would obviously then be focused on the primary cause in conjunction with the eating disorder.

What does healing look like?

There is a model that suggests six stages of change [Prochaska, Norcross & Diclimente, 1994]. It describes healing as a process where progress is not necessarily linear--it can include starts and stops, steps forward and back, eventually leading to mental and physical health.

The six stages include: Precontemplation (Denial) (I don't have a problem--you're the one with the problem); Contemplation (Something is not right with me, but I'm not sure I want to give it up just yet.); Preparation (I may be ready to seek help); Action (I began seeing a therapist today. My next appointment is in three days); Maintenance (This process is so very hard! It's taking more time than I ever thought possible. I WILL keep going. I must keep going!); and Termination (I am recovered!). The process is often a slow one. It can take an average of 3-5 years to arrive at the stages of preparation and action.

 

What kind of treatment is recommended?

TREATMENT NEEDS TO BEGIN AT THE FIRST SIGN OF A PROBLEM (as soon as behaviors leave the realm of "moderation") EARLY and COMPETENT, INTENSIVE, AGGRESSIVE INTERVENTION IS PARAMOUNT. Treatment should have these components:

Medical Guidance (working with a medical care provider experienced with eating disorders and either well informed or willing to become informed on the topic)

Nutrition (working with a nutritionist/dietitian well informed and/or experienced with eating disorder)

Individual Therapy (again, with a therapist experienced with successful treatment of eating disorders) including a Group Therapy component if indicated.

Family Therapy (a must for optimum success but especially important if the disordered eater is still living at home)

Today, I would seek an even broader path, making sure that the therapist had experience beyond a cognitive behavioral model including alternative holistic therapeutic practices and perspectives interwoven with a protocol that contained alternative methods of healing such as, hypnosis (only with trained and certified practitioners knowledgeable with its applicability in treating disordered eating), massage, Healing Touch Therapy (for more info, please see http://www.heartofhealing.net), meditation (such as that offered by Pema Chödrön, American-born Tibetan Buddhist nun whose teachings include the meditative practice of tonglen (found in her Good Medicine audio tape or CD available through Sounds True, 1-800-333-9185/ www.soundstrue.com), acupuncture, yoga and/or any other valuable adjuncts to treatment recommended by the treatment team.

dieting, perceiving intense body dissatisfaction and/or preoccupied with weight, especially with a perfectionistic, driven, achievement-oriented personality, you may be at risk for developing an eating disorder. If you are experiencing marked changes in weight, imbalanced eating habits, depression and/or feelings of alienation, please, get treatment NOW and stay in treatment. Andrea thought she was not at risk because she did not, at first, fit into the specific definitions of eating disorders. We did not understand that as soon as her attitudes, self-perceptions and behaviors left the realm of moderation she was in need of immediate, competent, professional intervention.

Just like a drug addict, a disordered eater often must have, not one, but two or three serious scares before convinced that they have a problem that requires a commitment to treatment.

Andrea ignored many warning signs her body was giving and died during her first serious scare. She thought it COULD NOT kill her ~ she thought she had time.