Health

As the years have gone by, the diagnosis of eating disorders has gotten more and more complicated because new ones keep popping up. There are still the three basics: anorexia nervosa, bulimia nervosa, and binge eating, but the most common diagnosis is EDNOS (Eating Disorder Not Otherwise Specified). This can be somebody who practices abnormal eating behaviors that are not in the diagnosis of any of the other three conditions, or somebody who has some but not all symptoms of anorexia, bulimia, or binge eating. Although some people who diet in unhealthy ways may overlap with eating disordered individuals in symptoms, such as restricting and then binging or false belief that one is overweight, they do not necessarily have eating disorders—this is often referred to as “disordered eating.” In the following list I will further explain each condition.

Anorexia Nervosa

In order to meet the diagnosis for this disease, one must exhibit: Refusal to maintain a weight over 85% of recommended body weight; intense fear of becoming fat or gaining weight; distorted view of body shape and size; loss of menstrual cycle for at least 3 consecutive months. There are two types: the restricting type, including those who lose weight simply by restricting food intake, and the binging/purging type, consisting of people who display the characteristics of anorexia and also either binge or engage in “purging” activities like vomiting, use of laxatives, or excessive exercising. Although it is very common for anorexics to induce vomiting in order to get rid of food they have consumed, this is different and separate from bulimia (for bulimia diagnosis, see below).

It should also be noted that while restriction of certain types of food, severe restriction of food, excessive exercise, drastic weight loss, excessive exercise, eating and dieting rituals, preoccupation with and distress over body weight and shape to the point of withdrawal from other activities are very common characteristics of anorexics, one does not have to display either of these to be diagnosed with the disease (the only characteristics required are those listed above).

I emphasized this because I was surprised to learn that fasting was not necessarily a characteristic of anorexia. I learned this when I told my psychiatrist I didn’t think I was ever anorexic because I rarely skipped meals. He informed me that the amount of food eaten is not part of the diagnostic criteria. One of his patients, in fact, had the same seemingly harmless ritual each day: a bagel for breakfast, a 6-inch sub for lunch, and pizza for dinner. Given her body type and physical activity, this was not enough to maintain her weight, and she met all the criteria for anorexia.

Anorexia has an extremely extensive history, although there is much debate about when the official disease anorexia nervosa originated. During the Middle Ages, there was a condition called anorexia mirabilis in which a girl or woman, such as Catherine of Sienna, claimed that their ability to go without eating was an indication of divine privilege and spiritual power. This phenomenon lasted through the 19^th century, until people stopped believing in the religious implications of this behavior, and furthermore, scientists proved that although these women severely restricted their food intake, they did not survive entirely on God’s divine love as they had claimed. The term anorexia nervosa was coined in the early 20^th century when doctors noticed anorexia (which means lack of appetite) linked to no other condition, such as digestive problems or mental illness. Those with this new disease severely restricted their food take solely because they experienced discomfort around food. Since then, there has been a growth in diagnosed anorexics, especially in the past few decades, almost one quarter of whom are male, which defies the stereotype that eating disorders are “girls’ diseases.”

Treatment includes giving parents total control over the child’s meals and insisting that they must eat or else be hospitalized (known as the Maudsley Method), taking in a high calorie diet, nutritional counseling, cognitive behavioral therapy (a fancy term for therapy), psychiatric counseling if needed, and in severe cases, hospitalization and/or tube feeding. Even so, about one tenth of anorexics die because of complications related to anorexia nervosa or suicide, which attests to how difficult it is to live with this disease.

Bulimia Nervosa

Bulimia is characterized by consumption of an abnormally large amount of food in a short period of time followed by some purging activity, such as self-induced vomiting, use of laxatives, diuretics, enemas, excessive exercise (often known as “exercise bulimia”), or fasting. These individuals evaluate themselves largely based on their body weight and size.

Bulimics are different from anorexics in that, although many anorexics exhibit binging and/or purging behavior, this behavior occurs more recurrently in bulimics. Bulimics often restrict food intake like anorexics do but then shortly follow these dieting periods with a binge-purge episode. Anorexia and bulimia each inflict 1-4% of the population.

Bulimic practices also date back many years. In ancient Rome, there was even a room called the vomitorium in feast halls. It was common practice for guests to eat huge amounts of food and then vomit it out before their next course (if you think I’m making this up, google it). It was also a regular ritual for members of this society to eat copious amounts of food one night and then fast for several days.

Although I am not a bulimic, I can attest that purging behaviors bulimics and some anorexics engage in are as ugly as they sound.

Treatment is similar to that of anorexia nervosa. In severe cases, the individual is taken to a hospital, where he/she is re-hydrated and given supervised meals. Some facilities monitor showers and bathroom visits; others simply force patients to wait a certain period of time after meals before using the bathroom. The Maudsley Method described earlier also applies to bulimic cases. Usually, parents’ normalizing their children’s eating and eliminating dieting rituals decreases the desire to binge and purge. Although bulimia is not as deadly or as noticeable as anorexia (bulimics are usually at normal weights), it brings about severe health complications that can lead to death.

Binge Eating Disorder

The most common of clinical eating disorders, binge eating disorder is characterized by consumption of excessive amounts of food in short periods of time and a feeling of being out of control of one’s eating. Again, many individuals with other disorders exhibit behaviors associated with Binge Eating Disorder, but not as frequently and usually combined with other behaviors. The binge eating is often overweight and often has low self-esteem and uses food to cope with emotional problems. Clearly, this disease has significant medical consequences because it can bring on obesity and the complications that arise because of it. I should emphasize, though, that any eating disorder has, in addition to medical consequences, severe psychological ones like obsession with food, inability to concentrate, body dysmorphia, intense self-loathing, and social withdrawal.

Binge eating disorder in children can also be treated with the Maudsley approach. Normalizing eating often decreases the desire to binge. Many binge eaters work through their problems on their own through therapy, seeing dieticians, and exercising and decreasing food intake in order to lose weight. Others don’t. Some go too far the other way and become anorexic or bulimic.

Parents should know that, although they may be concerned about their children’s weight, giving them restricted access to food and pushing “healthy” foods while prohibiting “junk” foods is actually harmful, not helpful. This approach does not decrease a child’s desire to eat “unhealthy” foods. Furthermore, it makes these foods something they turn to for emotional reasons because it is “special” or “prohibited” and because of this can lead to binge eating disorder (or any other disorder).

Eating Disorder Not Otherwise Specified (EDNOS)

Although not specified in the DSM (Diagnostic and Statistic Manual), EDNOS is the most common eating disorder and requires treatment just like the other ones. Some EDNOS patients have begun developing anorexia or bulimia, or have some symptoms, but do not fit all the criteria. Some fit certain criteria from each of the three main eating disorders but do not fit one exactly. Others display entirely different symptoms from a classical anorexic, bulimic, or binge eater. For example, some habitually chew food and then secretively spit it out. One girl I was in treatment with had significant trouble eating solid food because she was afraid of choking, although ingesting high-calorie liquids, soup, or other “less dangerous” foods like ice cream did not faze her. Often, an EDNOS patient is one who has partially recovered from an eating disorder but still meets some criteria. For example, I have restored most of my lost weight and regained my period, but still struggle with the desire to go back to my old behaviors and exhibit the other diagnostic criteria for anorexia (intense fear of becoming fat or gaining weight; distorted view of body shape and size).

Eating disorders are varied and complex, and it is important not to get too caught up in the specific diagnosis and instead focus on treatment. Whatever the physical consequences, all these disorders have severe mental and emotional ones. If one catches the eating disorder while it is first developing and still in the EDNOS stage, this is an advantage, but the person still must undergo one or several of the types of the treatment listed in order to halt the eating disorder before it entirely consumes his or her life (if it hasn’t already).

Despite the length of this article, there is much left unsaid, but this should provide you with a few basic ideas.

A girl recently wondered out loud what people did in an inpatient or day-long program for anorexia or bulimia. I thought for a long time about how I would describe the whole experience to someone. It was the most educational and intense three weeks of my life, and this is what it is.

It’s difficult, and it’s rewarding. It’s depressing, and it’s elating. It’s smiling, and it’s frowning. It’s looking in the hospital window and hating your stomach for being so huge, but also occasionally believing that you wouldn’t be here if overweight were your problem. It’s struggles and tears, staring down at your plate unable to believe you can eat all that. It’s staring down a seemingly bottomless bottle of Ensure and picturing your head on the body of a pig. It’s sometimes sneaking to the bathroom to throw up your meal after saying you have to “call your parents” or something, but it’s usually hanging in there and staying still and knowing you were strong enough to keep the food in your stomach, as uncomfortable as it seems. It’s feeling a comforting, uplifting rush of nutrients to your brain after you get some fat in your diet after months of fat-free living.

If you work hard enough, it’s usually also horrible, nasty fights with your parents (pretty much as bad as it gets if you’re me). It’s ignorant psychiatrists and annoying nurses who misdiagnose you and try to put you on unnecessary medication and baby you to the point that you really just want to smack on of them right in the middle of her snaggle tooth—but instead you just vent to the other people in the program because most likely they feel the same way.

At the same time, it’s intelligent, respectful, and wise staff who will come in just to give you advice about spending time in nature and reading and self-soothing techniques and believing in yourself, and even read you Dr. Seuss’s “Oh the places you’ll go.” It’s therapists who point out flaws in yourself that you haven’t seen before. It’s friends who support you in ways only possible when people can read one another’s minds. It’s patients who finish one another’s sentences. It’s girls who collectively agree that they will gain ten pounds after eating a cookie and then laugh out loud at their ludicrous but real consensus.

It’s having to tell your teachers and friends why you are missing so much school. It’s being so behind in chemistry that you have to go to extra help every day for two weeks to catch up. It’s returning to your small school and knowing that everybody knows where you were, but then seeing their smiling and welcoming faces.

It is watching eleven-year-olds with eating phobias that they cannot understand, that nobody can really understand, and feeling sorry for them at first but then just simply growing tired of the ones who constantly complain because you all are going through the same thing and you have to try to keep your cool.

It is when your eyes fill up with tears as the girl across from you in therapy talks about her dream to become a pediatrician, or her experience at the art school she had to drop out of, or her vision of herself as a cat who falls out of a tree and gets back on her feet. It is praying that your friends will keep their balance, or at least land on their feet after they fall.

It is watching your weight increase and feeling helpless, knowing that whatever you lose you’ll just have to gain back. It is crying but it is also laughing. It is the time you peed in the cup and put on your hospital gown to get weighed and then heard there was a fire drill and had to wait in the day room in your hospital gown holding your cup of pee for half an hour while watching ABC News until it was declared “safe” to resume your activities.

It’s having to deal with girls who are thinner than you, and not wanting to go back after your first day when another patient makes the comment, “You don’t look very underweight.”

It is witnessing at least one person completely lose it every Wednesday, the dreaded “pizza day.” It is watching your friend surreptitiously throw cheese on the floor and wishing she could be as rational and sane at meal times as she is the rest of the time.

It is watching You, Me, and Dupree or doing “music therapy” (there’s another funny story attached to that . . .) or drawing in your sketchbook with the other patients during breaks. It is helping a younger girl with her chemistry homework at ten o’clock every morning and feeling really good when she says, “I finally get it.” It is drawing a picture of Miley Cyrus of another younger girl and watching her pride as she hangs it in her room.

It is going home and venting to your parents about how gross you feel after eating ice cream, or perhaps how strong you feel, all depending on your mood. It is petting your cat for comfort and trying to concentrate on his serene and mesmerizing purring and not your own thoughts.

It is being discharged and having the other girls hug you and say they don’t want you to leave. It is not wanting to leave yourself, but also knowing you need to get back into the real world. It is ultimately recognizing that you don’t want to be stuck in the shadows of this disorder, and that there is no shame in moving on. It is actually wanting the emotional and physical comfort and strength that your new, proper eating regimen brings you. It is feeling fat and looking around and knowing you’re not the only one, but also realizing that if you let this thought define your actions, you are being weak, not strong. It is learning that it doesn’t take discipline to give into a disorder; it doesn’t make you a failure to succumb to the temptations of food. Instead, you are strong for doing what you think you cannot do; disciplined for being able to regain your health.

It is finally understanding that if you keep your old ways and old goals, you have entered into a contest you can’t win. It is observing that there are no “best anorexics” except those who are dead, and that even those who get so thin they die don’t feel successful. It is being able to say that the glimmering prize of total control and happiness awaiting you at the end of a never-ending marathon of obsessing, restricting, exercising, and purging is a mirage. It is acknowledging that, in this one case, the only way to win is to quit the race. The only way to say “yes” to yourself is to say “no” to this disorder. The only way to get ahead is to walk straight out. It is wanting to deal with your actual problems; wanting happiness that is lasting, accomplishments that are meaningful, and relationships that are real. It is rejecting denial and fear. It is being proud to keep on fighting the good fight.

            My nutritionist has me email her a record of what I eat every day to make sure I’m staying on track, as well as an “inspirational quote” to keep me going in recovery.  Over time, I have collected these favorites, and now I will share them with you (I believe that they can apply to many situations).

“You can’t get healthy answers without healthy questions.” –My therapist, on challenging your own thoughts and beliefs

“Use every resource available to you.  Ask tons of questions.  Find out the stories of everyone else.  Open up in groups.  Share your fears.  Form friendships.  Trust people.  Be honest with yourself and with others.  That’s all I can tell you . . . .  You are trying to avoid something with your eating disorder.  You’re running and running in one direction, but you’re not going anywhere.  I hope one day you can stop, look around, and realize that life is beautiful right where you are, with all its imperfections.” –Me, advice to a friend from treatment when she had to go back inpatient

“Suzy, there is so much out there for you in the world. And I can hear in your letters, that you really want it bad. You don’t want this stupid illness messing up your life anymore. You know in your heart that you aren’t fat or ugly or stupid or any of the other mean things anorexia tells you. Anorexia is a parasite, a bully. You can’t let it make you back down into a corner and let it steal your lunch money and your sanity. You have the power to stand up and fight. And nothing is worth more than your life, the life you could lead that is happy and not controlled by fears and self-consciousness. I know you have the strength in you, and the intelligence. All you need to do is believe that you can do it.” –Another friend from treatment

“When I speak to a group, I often site the statistic: Eating disorders have the highest mortality rate of any psychiatric illness.   I just came face to face with how true that fact is. The statistics are real. They are not just numbers. All of the numbers represent real people with real families.  Today I found out that a dear friend passed away from her eating disorder . . . .  Let her story inspire you to eat that meal you don’t want to eat. Let her story guide you to do the next right thing for your recovery — for your life.” –Jenni Schaefer, author of Life Without Ed

“You must do the thing you think you cannot do.” –Eleanor Roosevelt

“I want people to know, it’s OK to talk about it. It’s hard, but it’s OK to talk about it.” –Gary Grahl, author of Skinny Boy

“After seven years of fighting this battle on my body, I decided to fight for myself. I was tired and I couldn’t continue doing back flips, trying to be who I thought this culture was telling me I should be . . . . I’ve done better as a ‘big’ girl than most ‘skinny’ girls do as skinny models, so it’s been amazing.  But what’s more amazing is that I did it on my own terms.”  –Kate Dillon, on forgoing her status as “the next Cindy Crawford” to overcome her eating disorder and become a plus-size model with her natural body type

“If you live your life with a shield up, even the good things in life will pass you by.”
-- Anonymous

“The greatest weapon against stress is our ability to choose one thought over another.”
- William James

Before I started a day treatment program at the hospital, my therapist suggested I write a “declaration of independence” from my eating disorder to inspire myself to leave behind this “abusive relationship,” as she calls it.  Recently when I went to see her, she read it back to me.  It was very empowering to hear my own words of wisdom and advice to myself.  I also realized that when I wrote it I was very unsure of what I was saying and doubted myself, but now after being through treatment and reading it the ideas I express make total sense.  Please consider, however, that this disease is not rational and there was and is still a part of me that wants to hang onto Ed.  However, to quote a song from The King and I that my choir teacher shared with me to help me get past performance anxiety, “Make believe you’re brave and the trick will take you far. You may be as brave as you make believe you are.”  I made believe I was brave enough to let go of my eating disorder once and for all, and hopefully this Declaration of Independence will inspire courage within me in the future. Declaration of Independence Dear Ed, 

You have made me feel inferior in every way, and all for being less than perfect.  Your motto is always “become better,” which also means “become thinner,” but I am never good enough or thin enough for you, and I don’t think I ever will be.  So what’s the point of staying with you if we’re never going to make it work?

            Let me list the things I can do without you.  First of all, I can do something because I feel like it.  I can walk outside and run through the leaves and lie on the hammock and trek through the trail in the woods and do flips on my trampoline and swim in the pool and plant the garden and draw each intricate detail of the back of my house.

And breathe in the fresh air.

Second of all, I can excel without starving myself.  I can engage in class discussions without thoughts of food or eating or binging or starving or purging or looking in the mirror interrupting me.  Imagine!  I can succeed even more in every little calculus problem.  I can take on the worlds of mathematics, Spanish, theater, English, orchestra, art history, and chemistry and enjoy it the whole way without feeling fatigued or feeling “fat.”  I can actually immerse myself in my school work, rather than just seeing it as a way to pass the minutes before the next meal I will allow myself because I haven’t eaten in twelve hours and I can’t feel anything or talk to anyone or do anything but lie on my bed, half-absorbing what’s on the page in front of me.

Lastly, saying “no” to you means saying “yes” to myself.  You tell me that if there is ever an ounce of happiness in my life, I am a hugely obese pig and deserve to suffer.  You tell me I consequently need to feel the pain in my body after going through school and practice without food so that you can teach me a lesson about discipline. 

Why do you put me through so much pain?  Don’t you realize what I could be without you?

Maybe I’m unsure of who that person is, but it’s a risk I’m willing to take.  If I say “yes, yes, yes” to myself, this is the magic I need to succeed to my fullest.  There are things we need to give ourselves in order to be happy—food, water, shelter, relaxation.  Passion.  Friends.  Family.  Love.  Others  can’t provide them.  You can’t provide them.  And I can’t provide them unless I’m free of your influence.

You’re probably protesting now, shouting that I don’t deserve to be happy or succeed.  But this is an ongoing cycle.  When you deprive me of food, social interactions, etc. you make me less fit to succeed.  Then you starve me more.  You’re not helping me accomplish anything, Ed.  Truth be told, if you look in the mirror someday, you’ll see somebody pretty weak and useless.  You say I’m the worthless one, but Ed, you’re worthless to me and everyone else you’ve tormented in the past.

Without much love,

Suzy