For over two decades, people have been coming to my office to change. My job is to ask important and meaningful questions and to try and understand the answers that I receive. I have needed to know how to closely look for unknown truths never confessed that lead to growth and hope. Livingston (2012) argues that one of the greatest risks in life is to be honest with ourselves. Secrecy is frequently at the core of all eating disorders.
Early assessment of the warning signs of anorexia nervosa, bulimia nervosa, binge eating disorder (BED) and eating disorder not otherwise specified (EDNOS) is essential in preventing the downward spiral of lethality. We know that timing is everything. The earlier we intervene, the greater the clinical success and prevention of a runaway train of self-destruction. Eating disorders are extremely serious and when untreated can be deadly. We know that anorexia has the highest mortality rate of any mental illness. The prevalence of eating disorders is significant. Currently in the United States we know that 20 million women and 10 million men will suffer from an eating disorder at some time in life. Clinicians need to first rule out organic causes of multiple medical conditions that may be misdiagnosed as eating disorders (Lyme, Addison’s Disease etc.). In addition, there is a risk of complications from coexisting conditions like anxiety, depression, attention deficit disorder, addictions, trauma and personality disorders, which can interfere with a practitioners thorough eating disorders assessment. If you don’t look closely and thoroughly to investigate relevant clinical symptomatology, it is easy to miss the complex interaction of genetic, biological, psychological, family, social and environmental factors. Every treatment needs to be individually tailored to be most effective.
No psychotherapy is consistently an effective treatment for adults with anorexia and there is a need for further research on predictors of treatment acceptance and completion. (Halmi). Clinicians need to look closely and find out about recent weight loss and dramatic changes in eating habits. Self-imposed starvation and extreme dieting is the most common eating disorder. Anorexia is more prevalent in over-achievers, outstanding athletes and individuals with perfectionistic features. The mirror is an enemy reflecting an individual who is always “too fat.” Even when dangerously underweight, there is still a wish to lose more. There is an individual trying to hide in baggy clothing, a cycle of self-hatred, the wish for control, caloric restriction, over exercise, self-induced vomiting, laxatives, diuretics, enemas, diet pills, zero calorie beverages, secretive or ritualistic eating patterns, and an avoidance of social gatherings when food is served. When asked “How would you feel if you lost or gained 15 pounds?” the answer is linked to self-esteem and self-worth, shame, humiliation, and urges to self-harm (cutting, burning etc.). Ask about the relationship to the scale. How often do you weigh yourself? It might be never, for fear of a bad number, multiple times a day, recorded by a nutritionist, nurse or doctor when they are standing on the scale backwards and determined that the weight not be stated. Does the individual sit down for meals or is the role of host or hostess being played with the goal of meal avoidance? When at the table, is food cut into a variety of small pieces, moved around the plate, flattened or smashed, but not eaten. We see that identity is not defined by achievements, interests, accomplishments and relationships. Instead the primary focus is on appearance, weight, make-up, and jewelry. Distorted body image is a constant with a rigid conviction of being fat with no change in self-perception through reality testing from clinicians, friends and family. We might see aversions to favorite foods or avoidance of foods high in fat, calories, oils or significant dietary changes like meat lovers transforming into vegetarians over night or a new pattern of eating food that is not liked or keeping old rotted food to create nausea or the loss of hunger. Reports of severe constipation, thinning hair dizziness/fainting, brittle nails, irregular periods or amenorrhea, complains of constant coldness with a drop in internal body temperature, baby fine hair covering the face or body (lanugo). Is pregnancy avoided due to fear of weight gain? Is breast feeding refused solely because of the need to immediately return to pre-pregnancy weight. Is there a family history of eating disorders or significant psychiatric illness? Do adults want or need to buy clothing in the children’s department? Are only certain sizes of clothing acceptable for purchase? Are size tags quickly removed from garments? Is summer dreaded due to wearing shorts, bathing suits, sleeveless blouses or dresses? Do we see that salad dressing or sauces are ordered on the side and food secretively being thrown away or fed to pets? Are lunches, protein bars or shakes forgotten at home or quickly ditched?
Clinicians find that there are periodic episodes of binge eating with compensatory food restriction or purging. It can be easy to miss the signs given that weight is normal or even over the desired weight range. There can be hoarding of food in rooms, gastrointestinal problems, severe dehydration, electrolyte imbalance, discoloration of teeth or poor enamel due to exposure to stomach acids. Swollen salivary glands (chipmunk cheeks), complaints of sore throats, mouth sores, or long periods of alone time sought to allow for episodes of bingeing or purging with complaints of low energy or chronic fatigue. It is not uncommon for dental checkups being avoided so that the signs and symptoms of illness are not revealed. Is there a new use of candles, air freshener or fresh flowers in order to hide the smell of vomit? Is there a quick escape to the bathroom after meals with doors locked and loud running of water or radio use to prevent outsiders hearing vomiting? Is there a feeling of being invisible or unnoticed except when in the hospital? Is there a feeling of disconnection and out of body experiences associated with periods of binge eating or purging? Do we see recurring patterns of mood instability, impulsivity, addiction and feelings of numbness?
Recent reports from the Mayo Clinic indicate that BED affects almost as many males as females. Do we see individuals desperately seeking periods of free alone time to purchase high caloric junk food to ingest quickly? Is there evidence of weight gain or obesity? Do feelings of shame, doubt, embarrassment, avoidance of hobbies, not sharing meals with family or friends and ongoing patterns of social withdrawal. The challenges of recovery are greater given the length of time that the individual is symptomatic. There is a need for physical, spiritual, emotional, social reconstruction. Given longstanding obesity, high blood pressure and the development of cardiovascular problems is not uncommon.
Eating Disorder NOS
EDNOS is the most common diagnosis. However, it is frequently missed given individual variation in symptomatology. Chronicity is on the rise given difficulties in creating a routine of balanced healthy meals and the shift in focus on weight and appearance to relationships and emotional feeling states. Eating of non-food items is not uncommon. These disorders are often overlooked medical illnesses due to co-morbidity. The complexity of chief complaints and differences in presentation can leave a clinician feeling de-skilled. There is a sense that nothing is routine or predictable given that important pieces of the clinical picture are missing.
Future Treatment Planning
By tuning into the warning signs of eating disorders earlier, we increase our ability to effectively prevent and treat eating disorders with psychotherapy (individual, family and group), nutritional consultation, pharmacotherapy, medical and dental follow-up care is no longer avoided when healthy weight is achieved and maintained. We can prevent relapse by extending periods of stability and the development of positive feelings associated with food, meal sharing, regular exercise, health and wellness. Ideally, we will see greater productivity at work, relational connectedness and the true ability to fully care and love others and self. During my work in clinical practice I have been continuously filled with hope and impressed by my patients’ capacity for positive change.
For further information, visit The National Eating Disorders Association website at www.nationaleatingdisorders.org. NEDA is the leading non-profit organization in the United States advocating on behalf of and supporting individuals and families affected by eating disorders. The mission of NEDA is prevention, improved access to quality treatment, and eating disorders research.
Rachel W. Bush, PhD, is a licensed clinical psychologist with a private practice in Pound Ridge, New York. She can be reached by phone at (914) 764-1440 and by email at Rbushphd@yahoo.com.