Eating disorders can be very scary, confusing and anxiety provoking illnesses for everyone involved. This includes friends and relatives. It is unusual for a week to go by without us being asked for advice on how to help, support or confront a friend or relative who has or might have an eating disorder For that reason we thought we’d make that the topic of our latest blog: how to help a friend.
The first essential thing to remember when talking to or supporting a friend with an eating disorder is that it is pretty much impossible to always say the right thing. Expect to get it wrong sometimes and don’t let this put you off trying to help. At some point your friend will probably need to see a professional who is trained in supporting people to over come an eating disorder. You should never try to take responsibility for helping your friend alone.
Below we have tried to offer some guidance about what to do and what not to do to best support a friend.
Remember, you don’t have to know all the answers. Just being there is what’s important. This is especially true when it feels like your friend or relative is rejecting your friendship, help and support.
There are a multitude of physical, emotional and psychological consequences of eating disorders. One of the issues that we commonly get asked about is what impact eating disorders have on fertility – both short term and long term.
Concern about fertility is one of the most common reasons that women cite for seeking treatment for an eating disorder. Whilst we still don’t feel that there is enough research in this area to be able to give a definite statement about the long term impact of either anorexia or bulimia on fertility, we do know that women with current eating disorders are more likely to experience fertility problems.
It is fairly well known that in restrictive eating disorders, where periods stop due to low weight, fertility issues are very likely. However studies have also identified fertility difficulties in women with eating disorders who are at a healthy weight.
A research study done in 2013 (Int J Eat Disord 2013; 46:826–833) is the most recent study that we are aware of that investigated the impact of a current eating disorder on fertility. The researchers compared 2,257 women with a current diagnosis of an eating disorder with 9,028 women without an eating disorder. An advantage of this study is that it explored fertility issues in women across all eating disorder diagnoses: anorexia nervosa, bulimia nervosa, atypical eating disorder and binge eating disorder.
The researchers found that across all eating disorders, women were more likely to be childless. Whilst this doesn’t necessarily point to fertility problems in itself, it does support previous research in highlighting the presence of increased fertility difficulties in women with eating disorders. This research also found that women with bulimia nervosa or binge eating disorder were at increased risk of miscarriage.
Previous research has also found that in restrictive eating disorders with resulting low weight, up to 1/4 of patient may never regain normal menstruation cycles, suggesting that fertility may be affected even following successful treatment. In women that do become pregnant there is a known increased risk of complications like miscarriage, birth defects and low birth weight babies, Cesarean section, and postpartum depression.
We would reinforce that we don’t feel there is enough research at present to know what the long term fertility implications for people in recovery from an eating disorder are. There is some evidence though that fertility may not always return to normal once a person has fully recovered from an eating disorder. We would suggest that this is more likely if the eating disorder has been severe and long term.
I you are concerned about the impact of an eating disorder on your fertility, we would encourage you both to seek professional help and to be open about your eating disorder history with your GP or any other professional involved in your fertility care.
The Unspoken Effects of Dieting
It seems that dieting has almost become a ‘normal’ activity amongst individuals in the UK. Every magazine we open shares diet details, every celebrity seems to endorse a different one, and it seems almost a rarity amongst certain groups not to discuss dieting. Of course, dieting can be done in a healthy way when it involves a balance of food groups, regular healthy eating and combined exercise to achieve weight loss goals. However many of the ‘fad’ diets that we read about do not seem to work on these principles. Very few women who diet realize that dieting itself causes severe psychological and physical changes. Dieting, even in women without eating disorders, often causes depression and irritability. When you diet, your metabolism slows down in order to conserve the small amount of food available. This is an intelligent move on your body’s part, and probably has helped people to survive in times of famine. The problem is that when you stop dieting, since your metabolism has slowed down, it becomes easier than ever to gain weight and you put weight on faster and more easily. Each time you go through another diet, this cycle continues. The only way to speed up your metabolism again is to eat.
Your body is like a wood-burning stove. It needs fuel to keep warm. The fuel intake needs to be regular through the day. The fire inside the stove is like your metabolic rate. It will burn the hottest when it has plenty of fuel. When we limit the amount of energy or ‘fuel’ we are giving our body, we will undoubtedly experience a number of physical consequences:
In women who are dieting healthily these effects may be mild and short-lived. When dieting is extreme however, as in anorexia nervosa, a state of chronic starvation is evoked meaning that these effects are likely to be ongoing, potentially causing serious longer term consequences.
Thinking traps may also be referred to as ‘thinking errors’ or ‘cognitive distortions’. Most people use thinking traps from time to time, however they tend to be more common in people who experience psychological distress such as anxiety or depression. They are also very common in people with disordered eating. Often people will use these thinking traps so often they they will not be aware that they are using them. However, awareness of these thinking styles can be an important stop in understanding and changing unwanted moods and behaviours.
Here are eleven of the most common thinking traps that you might have experienced:
1. Mental Filter
Mental filtering is when we focus exclusively on the most negative and upsetting features of a situation, filtering out all of the more positive aspects.
Example: You undertake a performance review at work which is ninety-five percent positive and complimentary – but you dwell and focus exclusively on the five percent of the review that mentioned ways in which you could have performed better. This leaves you feeling that you are a failure, that you haven’t done well enough and that your boss sees you in a negative way. The impact of this mental filter may be that you not only don’t recognise the praise that you were given but that you start to feel anxious or low when thinking about your job.
2. Disqualifying the Positive
Disqualifying the positive is when we continually discount and dismiss the positive experiences we encounter, by deciding they are unimportant or ‘don’t count’. Positive information or experiences may be seen as a fluke.
Example 1: A friend compliments you on a dinner you made, but you decide that “they are just saying that to be nice” or “they are trying to get something out of me”.
Example 2: “I know I wear a size 10-12, but my thighs are too big”, “He only asked me out because he was lonely or feels sorry for me, he doesn’t really like me”.
3. ‘Black and White’ or ‘All or Nothing’ Thinking
This involves thinking in extremes, with no middle ground. These types of thoughts are characterised by terms such as or ‘every’, ‘always’, or ‘never’ . Everything is seen as good or bad or a success or failure. It is generally the negative perspective that is endorsed, discounting all the shades of grey that lie in between the two focussed on choices.
Example 1: If you get eighty per cent on a test, you feel like a failure that you didn’t get a perfect score.
Example 2: People with eating disorders often believe that if they can’t be ultra-thin, they will be obese, and that they must be completely in control of their eating or there will be chaos. You may believe that if you begin eating normally you will lose all control and end up extremely overweight. When you think this way you are thinking in extremes; ultra thinness and obesity are not the only alternatives, in fact your body functions best within a natural weight range, which is somewhere between these two extremes.
To avoid black and white thinking it is often helpful to look for the grey area in between. Look for all the possible alternatives. For example “Getting a mix of As, Bs and Cs for my exams is fine and does not mean I am a failure” or “Obesity is not the only alternative to thinness, it is more likely that I will be in a healthy weight range”.
Thinking in an over-generalising way means we will often see a single unpleasant incident or event as evidence of everything being awful and negative, and a sign that now everything will go wrong.
Example 1: If you fail to get a job you interview for, you decide you are never going to get a job.
Example 2: If you go on one unsuccessful date, you decide you are never going to find a partner.
Example 3: Believing that if something turns out badly once, then it will always happen that way. For example, failing your driving test and believing you are totally inadequate in all areas of your life.
For people with eating disorders a common generalisation is thinking that because I have put on some weight, I am just going to continue to put on weight forever. However, the facts show us that initial weight gain following re-introduction of regular eating is your body counteracting effects of past deprivation or starvation.
5. Jumping to Conclusions
This thinking trap involves making a negative interpretation or prediction even though there is no evidence to support this conclusion. This type of thinking is often made when thinking about how others feel towards us. It can show up as either ‘mind reading’ (assuming the thoughts and intentions of others) or ‘fortune-telling’ (anticipating the worse ad taking it as fact).assuming the worst even when there is no reason to.
Example 1: “People are staring at me because I am so fat” (mind reading).
Example 2: “My boss wants to speak to me – I must have made a massive mistake and I’ll get the sack” (fortune telling).
Example 3: “Sarah didn’t call – I must have done something to upset her” (mind reading).
Example 4: You are at a party and you don’t like what you are wearing and you decide ‘everyone is laughing at me’ (mind reading).
Example 5: You are going to take your drivers test and ‘know’ that you are going to fail (fortune-telling).
6. Magnifying or Minimising (Also referred to as “Catastrophisation”)
Thinking in a magnifying or minimising manner is when we exaggerate the importance of negative events and minimize or downplay the importance of positive events. In depressed individuals, it is often the positive characteristics of other people that are exaggerated and the negatives that are understated (and then when thinking of oneself, this is reversed).
Catastrophising is only paying attention to the negative side of things or overestimating the chances of disaster. When we think catastrophically we are unable to see any other outcome other than the worse one, however unlikely this result may turn out to be.
Example 1: “I had one binge – I am back to square 1 – I’m never going to get better”. “Nothing ever works for me – I may as well give up now”.
Example 2: You send out the wrong letter to a client at work, and this turns into “I will now lose my job, and then I won’t be able to pay my bills, and then I will lose my house.”
A person engaging in personalisation will automatically assume responsibility and blame for negative events that are not under their control. This is also called ‘the mother of guilt’ because of the feelings of guilt, shame, and inadequacy it leads to.
Example: You feel it’s all your fault that your dog injured his foot even though you weren’t at home when it happened but were out shopping. Your thoughts might be ‘if only I didn’t go out’ or even ‘maybe when I came home I accidentally stepped on the dog and hurt him’ even though this is entirely unrealistic.
8. Shoulds and Oughts
Individuals thinking in ‘shoulds’, ‘oughts; or ‘musts’ have an ironclad view of how they and others ‘should’ and ‘ought’ to be. These rigid views or rules can generate feels of anger, frustration, resentment, disappointment and guilt if not followed.
Example: You don’t like playing tennis but take lessons as you feel you ‘should’, and that you ‘shouldn’t’ make so many mistakes on the court, and that your coach ‘ought to’ be stricter on you. You also feel that you ‘must’ please him by trying harder.
9. Emotional Reasoning
Emotional reasoning is when we assume feelings reflect fact, regardless of the evidence. The idea here is “I feel it, therefore it must be true”. Such thinking can lead to self-fulfilling prophecies whereby our thoughts can end up eliciting the very behaviour we predicted, just because we changed our behaviour in accordance with that thought.
Example 1: if you think “I feel ugly and stupid, so then I must actually be ugly and stupid” you might then stop buying yourself new clothes and start doing poorly at the course you are taking at university, even though you look fine and were doing very well at school.
Example 2: Taking your emotions as an accurate reflection of what is happening. For example, “I feel fat therefore I am fat”, even when you are actually underweight.
Labelling is an extreme form of ‘all or nothing’ thinking and overgeneralisation. Rather than describing a specific behaviour, an individual instead assigns a negative and highly emotive label to themselves or others that leaves no room for change.
Example: You make a mistake on a form you filled out and it’s sent back to you in the post. So you decide “I’m such a loser” or “I’m so stupid” rather than thinking “I made a mistake as I had a busy day when I was filling this out”.
11. Expecting perfectionism and having double standards
These two often go together. People with eating disorders often expect themselves to be perfect and anything less than excellence equals failure. They judge themselves by what they achieve and expect others to judge them in the same way.
Additionally, they may have double standards, for example, thinking it is OK for other women to be a normal weight, but that they will only look good at X weight. It may be OK for other people to make mistakes but unacceptable for them.
The Sunday times this week released an article detailing concerns of occurrences of anorexia increasing in school age boys. These concerns came from a head teacher at a private school in the North of England who believed pressure to achieve academically and anxiety over school performance was at the root of this increase. The Royal Grammar School (RGS) in Newcastle is pioneering in its efforts to reduce school related stress and address mental health issues by hiring dedicated counsellors and holding a conference for teachers on helping pupils to cope with stress.
A recent report from NHS England suggests that rates of anorexia in school age children are indeed increasing. It is now estimated that 1 in 10 children will experience a mental health condition at some point during their school career.
The London Centre for Eating Disorders and Body Image has also seen an increase in schools sharing concerns over male pupils and is increasingly being asked to run their education and awareness sessions to boy only groups. Dr. Bryony Bamford of The London Centre says “We are pleased that schools are picking up that anorexia is not a female only illness, but equally concerned at the increasing rates of emotional stress and distress that we are seeing in very young children. Both parents and teachers need to be fully aware of how to support children to cope with pressure and anxiety in as well as outside of school”.
Recent data published from 35 NHS hospitals in England over the past 3 years showed that more than 2,100 children were treated for eating disorders before they reached their sixteenth birthday. Of these, 197 children were under the age of nine and almost 400 were between the ages of 10 and 12. A further 1,500 children were aged between 13 and 15 years old. Given that this data is taken from only 35 hospitals within England, and that anorexia in young children is not always detected, these figures are likely to be well below the actual number of young children suffering from anorexia within the UK.
There are a range of eating disorders that can be diagnosed in childhood, anorexia nervosa being the most serious of these disorders. Anorexia is a psychological diagnosis where the sufferer will restrict their food intake and fluids. They may also exercise in response to consuming food. Anorexia almost always results in a weight loss, although in young children whose weight should be increasing, it may result in lack of weight gain rather than noticeable weight loss.
Here is what to look out for if you are worried that your child is restricting his/her diet and could be displaying early signs of an eating disorder.
My child hasn’t lost any weight so I don’t need to worry
If your child is displaying the warning signs, but seems not to have lost any weight, there could still be cause for concern. It’s important to remember that children are growing and should be putting on weight. A child’s weight shouldn’t be stagnant. On average children gain about 2-3 kg (5-7 pounds) per year between the ages of 6- 10 years old.
My GP says not to worry…
If you take your child to your GP, and they consistently dismiss problems with your child’s eating behaviour, it is worth seeking the advice of an eating disorder expert. Childhood anorexia is still relatively rare and it may not be spotted by your GP. If you know there is something wrong with your child’s eating behaviour, it is always worth seeking the advice of an eating disorder expert.
Remember, the earlier the diagnosis, the better the chances of a full recovery. Anorexia is a particularly difficult illness to overcome when it has become entrenched in a young person’s mind over a number of years. The sooner your child can receive help, the sooner your child will overcome their disorder and go on to live a happy, healthy life.
Teenagers do not need to be dangerously underweight to be practicing the dangerous eating behaviors associated with anorexia.
A recent Australian study noted that a drastic drop in weight carries the same risk for life-threatening medical problems even if the patient is a normal weight.
Anorexia nervosa is a mental illness characterized by excessive weight loss and psychological symptoms that include a distorted self-image and fear of weight gain. In some patients, this can also include depression and anxiety. Using current diagnostic guidelines (set to change in 2015), those who have these symptoms but are not underweight enough to qualify for the definition of anorexia fall under a different diagnosis, known as Eating Disorder Not Otherwise Specified (EDNOS).
“Emaciated bodies are the typical image portrayed in the media of patients with restricting eating disorders such as anorexia nervosa,” said lead researcher Melissa Whitelaw, a clinical specialist dietitian at The Royal Children’s Hospital in Melbourne, Australia. “This paper highlights that it is not so much about the weight but the weight loss that can lead to a serious eating disorder. The complications of malnutrition can occur at any weight.”
In her study, which included 99 teens aged 12 to 19, Whitelaw found only 8 percent of the patients had EDNOS-Wt in 2005, but more than 47 percent of the patients had it in 2009.
“I was surprised to see how much it increased,” Whitelaw said. “I was also surprised at how similar they were not only physically but also psychologically. Everything about them was anorexia except that they don’t look really skinny.” Both groups had even lost a similar amount of weight: a median 28 pounds for those with anorexia and 29 pounds for those with EDNOS-Wt.
Other experts noted that it can be difficult to spot this less obvious eating disorder.
“We are conditioned to think that the key feature of anorexia nervosa is low body mass index [BMI],” said Cynthia Bulik, director of the Center of Excellence for Eating Disorders at the University of North Carolina at Chapel Hill. BMI measures whether a person is a healthy weight for their height.
“In fact, we miss a lot of eating disorders when focusing primarily on weight,” Bulik added.
Leslie Sim, an assistant professor of psychology at Mayo Clinic Children’s Center in Rochester, Minn., said, “People are calling it atypical anorexia, but we see it every day. We see people who have all the psychological, behavioral, cognitive and physical symptoms of anorexia nervosa, but the only difference is their weight.”
In this study, the side effects of having an eating disorder were also very similar. Dangerously low phosphate levels occurred in 41 percent of anorexia patients and 39 percent of EDNOS-Wt patients. The lowest pulse for the teens was 45 beats per minute (bpm) for those with anorexia and 47 bpm for the other group. Meanwhile, 38 percent of the EDNOS-Wt patients and 30 percent of the anorexia patients required tube feeding.
“[Normal-weight patients with anorexia symptoms] were becoming medically unstable, despite the fact that they had what you would call a normal body weight,” Whitelaw said.
The reasons for the apparent increase in these patients is less clear, but both Sim and Whitelaw said it is likely a combination of increased awareness of the problem and an increased focus on obesity. One tricky aspect of identifying these patients, Sim said, is that the weight loss appears at first to be a positive development.
“These patients just fly under the radar and when they’re in that earlier stage, it’s harder for people to see it,” Sim said. “Parents say to me every day, ‘I thought my daughter was doing something good and making healthy choices until it got out of control. We didn’t know it was a problem until she couldn’t eat the cake at her birthday party.’ “
The experts emphasized that eating disorders are not parents’ fault. Instead, parents can play an important role in identifying the symptoms of an eating disorder, especially in its early stages, said Jessica Feldman, a licensed social worker and site director of The Renfrew Center in Radnor, Pa. Symptoms include significant changes in eating patterns, excessive exercising, a teen’s negative statements about their body image, an increase in depression or anxiety, and a loss of interest in previously enjoyable activities.
“No one chooses to have an illness. We would never tell someone with allergies to ‘just stop sneezing,'” Bulik said. “Although dieting might be a first step, the illness takes over and develops a life of its own — sufferers often cannot eat, even if they want to.” (Source: WebMD; posted by: Dr Bryony Bamford)
In what would be a landmark move, Italian officials are proposing that owners and publishers of pro-anorexia or pro-bulimia websites be subject to jail time or fines. The legislation would work by adding a clause to an existing law that makes it illegal to assist or instigate suicide, reports Yahoo Health. The Italian government is worried that the rise of pro-ana types of websites is promoting eating disorders as positive lifestyle choices and that they pose a public health threat. Yet critics of the bill say that targeting website owners would mean targeting many young people who are suffering from eating disorders – and who may already be in a vulnerable state. “People who create and consume this content are not villains; they are struggling, and sometimes they are very sick,” said Claire Mysko, teen outreach coordinator for the National Eating Disorders Association. “That’s why we believe so strongly in providing a positive alternative.” If the bill is approved, offenders could face up to two years in jail or fines of $10,000 to $100,000 euros. The fines would double if the website in question was found to have influenced the behavior of a person 14 years old or younger. Critics are calling the move ultra-conservative, stating that the law would only punish those that truly need help. The law has yet to be voted on, but both houses of parliament must approve the legislation in order for it to pass. Source: yahoo health
We praise the recognition among schools that encouraging pupils to strive for perfection in all areas can increase the risk of mental health conditions including depression and eating disorders.
Unrelenting standards and a core sense of failure or not being good enough are common difficulties among people who present to us for treatment. Targeting these issues at a younger age and encouraging people to resist the urge to need to be perfect at all times is crucial to good mental health. We hope to see more schools following this example.
1. You constantly try to restrict the amount of food you are eating.
2. You have ‘banned food’, usually carbohydrates or high calorie foods that you never allow yourself to eat.
3. Your weight has dropped to the point where others can notice that you have lost weight.
4. You experience an intense or persistent fear of putting on weight.
5. You find it difficult to concentrate and spent a lot of time feeling distracted by thoughts about food, weight or eating.
6. You have experienced mood changes or mood swings, or you may experience a very flat mood, with loss of recognizable mood states.
7. You find it difficult or anxiety provoking to eat with other people.
8. You always notice what other people are eating and would never consider eating more than they are.
9. You feel cold often, even when others around you aren’t.
10. You have noticed changes to your hair or skin such as hair loss, dry skin or weak nails.
By Dr Bryony Bamford