I studied psychology at the university and learned something about it and want to share the knowledge. A friend of mine teaches aerobics classes and fitness in a gym and in her job she meets a lot of women struggling with weight and body image issues. She wanted to know how eating disorders work and how to approach people who suffer from Anorexia. This post is my attempt to make some educated suggestions. I know part of a psychological treatment focusses around the approach I’m suggesting here.

This is the third blog in a series of blogs about eating disorders. The fist one was about ED in general, the second one about Bulimia Nervosa. This one about Anorexia Nervosa is written to give some information on what anorexia is and what impact it makes. These are not my own insights, but the insight psychologists and other professions have in the field. I’ll link to the sources at the bottom of this blog. I also try to create understanding for those who suffer from it. I often notice people saying very harsh things about anorexics “Just give the girl a sandwich”, or “Just eat more”. They blame anorexics for not eating and think not eating is the core problem. In this article I try to explain why this is an oversimplification of the problem and suggest another approach.

What is Anorexia Nervosa (AN)?

Someone who suffers from AN is excessively preoccupied with his or her figure and weight. The sufferer’s thoughts focus on the will to lose weight, causing a restriction in food intake and thus reducing the variation in food.
The treacherous part of the disease is that these strategies don’t have an immediate effect. In the beginning there is no loss of weight, any loss of weight goes very slowly. People with AN have often a negative image of their selves and as a result they isolate their selves from their surroundings. This is also partly caused by their preoccupation of food.

I blogged about bulimia before, the difference between Bulimia Nervosa and AN is that a bulimic suffers from uncontrollable cravings and binges/purges after such an episode. Bulimics aren’t necessarily thin either, most of them have normal weight or are overweight. It is possible though to be seriously underweight as a bulimic, but it’s not very common. Anorexics starve themselves and are often seriously underweight. This is a hallmark for anorexia: refusing to maintain an healthy weight of BMI = 18 or higher. Bulimics usually don’t have this.

Most anorexics are in denial of their condition. This makes it very hard to get them seek help. In their eyes they don’t have a problem. Even when rushed to the hospital for emergency tube feeding, they think they are overweight. It’s perfectly possible to hear someone with a body mass index of 13 claiming to be overweight. So the problem is a mental (psychiatric) problem in the first place, but this condition is a result from starvation. Even after being released and having an acceptable body weight, it’s possible that they will be back in a few months because they still ‘feel fat’. Therefore, the problem isn’t solved with force feeding people. You do something about the symptoms, but you don’t handle the cause of the problem: a psychiatric condition. People start to diet because they want to slim down, they get underweight and due to altered physiological conditions their brains change, too. When this is reversed, the brain changes (metabolism, connectivities) isn’t changed back, because the brain doesn’t work that way. Scientists found this out in the Minnesota Starvation Experiment. In a Scientific American Podcast (links to mp3), Dr. Trisha Gura cites this too.

So, “Just give the girl a sandwich” is an oversimplification of the problem. I know some girls I met when we had a class about the neurobiology of eating disorders, who really want to get rid of ‘ana’ after they saw what it was doing to them. Their denial was broken. They know rationally they have to gain weight, they are underweight, they will die etc. etc. So normally you would expect their recovery was imminent, but it wasn’t. They know rationally they have to eat, they have to sport less. They know, they really do! But they FEEL fat still, they FEEL like they have to lose weight, they still don’t LOVE their bodies. When eating some have to vomit involuntary: they are not able to eat enough calories, because their bodies refuse to take it. There is still a conflict between what they are feeling and what they want voluntary (with their will). The girl really wants a sandwich, but “Ana” doesn’t want it. Yes! They can talk about it like it is another person. You want to get better, but the disease doesn’t want you to get better. You have to win the battle every day to survive. So to the people watching anorexic girls, please don’t say: “You just have to eat more!” You don’t help them with such a remark… in the contrary.

There are a number of features that are often present in eating disorders. This means the features can be present in any type of eating disorder, including anorexia nervosa. For a complete list of them including the DSM-IV-TR criteria see Wikipedia.

Treatment

There are very few people who overcome this disease them selves. The description above shows why. The vast majority of people need treatment in specialized eating disorder clinics. Treatment usually consists of cognitive behavioral therapy aimed at a change in body image and group therapy. Another possibility is a psycho-dynamic therapy. However, a lot of people relapse and become regular clients of eating disorder clinics (this resembles the relapse rate of drug addicts). Others commit suicide or die as a result of irreversible physical damage caused by the disease (e.g. cardiac arrest).

I wrote about it before, but I want to say it again here: given the fact that it’s almost impossible to overcome this disease alone, and the high relapse rate found after treatment, you cannot say that someone who has been treated for and eating disorder and has no (or sub-clinical) symptoms at the present time of the disease is ‘cured’. Someone who is symptom free can relapse after years due to ‘life events’. So you have to be careful for the rest of your life and be watchful to stay symptom free. Seek help immediately if you see some symptoms returning. I can really recommend the book “Lying in Weight” by Trisha Gura to those who recovered from a eating disorder in puberty, I used the book as a source for this blog.

The biggest problem with a lot of (teenage) anorexics is to get them seek help, hoping they get insight in their condition. Most of them don’t want to see a doctor, most of them claim that they’re fine. When I read some of the so called “pro-ana” weblogs, there were several tips given to fool everyone and how to lie to medical and psychological professionals. They are clearly in denial. Putting them in front of a mirror doesn’t help, they see a fat person. They will not seek help themselves. Forcing someone into an eating disorder clinic to undergo psychiatric treatment who denies to have a problem doesn’t work either. You can ask them to seek help and guide them, but you have to hope they’ll get insight in their disease, that’s crucial.

Usually they go there because their family wants it, walk through the program and carry on starving themselves again after release. That’s because they aren’t motivated to do something about the disease, because they don’t think it’s a problem or when they do, ‘Ana’ takes over again. They relapse and want to lose the weight they gained there when they got out. This makes it very hard for the people surrounding the patient, they see someone destroying him/herself and it seems like there’s nothing you can say or do that helps.

It’s interesting to see how members of a “pro-ana” community react to fellow-members being admitted to hospital: it’s bad, they feel sorry for that member, but the curious thing is they see it as a conspiracy of their families and friends to prevent them getting thin. That’s the brain alteration kicking in: they are getting a little paranoid. When you as a family member or friend try to force them and criticize them on their eating behaviors, they withdraw even further. It’s a logical step, when you try to see it through their eyes. Therefore it’s crucial to support them, to show you care about them, give them affection even when they make bad decisions. For family members and friends it’s very hard to find the right balance. You don’t want to be pro-ana, but you want to help them. I think shifting the attention to the relationship you have with the anorexic instead of the disease might help. This is one of the tips health care professionals give, too. See the links at the bottom for some books and web sites with tips for friends and family members of sufferers.

It seems s logical step to try to find out why they think they have to be thin and what they are missing. What ‘hole’ they try to fill by slimming down. If they feel rejected for instance and think being thin makes them accepted by the society, it might help to show a lot of acceptance. Showing you accept and love them because you love who they are, no matter what. They don’t have to do anything to get acceptance, they have it already.
Of course you want them to eat more, I don’t want to say you shouldn’t comment on that, but telling them “Just to eat more” or “Eat everything on your plate, or else…” doesn’t work. You could ask them to have a cup of soup filled with vegetables and nutrients to start with and try to get them professional help, but gently, hoping they get the insight. An eating disorder isn’t the problem, it’s a coping mechanism for something else that doesn’t work. People have eating disorders for a reason, that’s why understanding anorexics is so important.

When they do get that insight, the battle isn’t over yet, it has just begun. As a friend or as a parent you can affirm them by helping them, supporting them in this battle. Instead of ‘Just eat more’ comfort them when they are so sad, make them feel safe, don’t judge them when they lost weight again, better not comment at all at any weight change. If you are religious, pray for them. Show as much as support and love as you possibly can, they need it so badly!

I really hope the media will take it’s responsibility and try to change the thinness ideal, there’s a start already. But as long photos in magazines are ‘digitally enhanced’ and slimness is promoted, there will be young girls being pushed over the border. These young girls are in the beginning of puberty with changing bodies, mentally unstable and often afraid of all the things happening to them. And instead of protecting them, the society pushes them over the limit with this insane body ideal. The thing that frightens me is that if I look at the two photographs on this blog, I notice the models being thin, but not alarming thin. Apparently I grew used to these kind of pictures, they look ‘normal’ to me. Both models died of anorexia however. The bottom picture was taken one day before Luisel Ramos died. This is how far we already got. Please wake up! Don’t let Ana win the war we are in!

Links to some good sites for more information

• Mayo Clinic
• Reach Out! (Australian website) with more information and how to seek help
• Eating Disorder Referral and Information Center
• Lying in Weight, a book by Trisha Gura (via Amazon.com)
• Model in the top right picture: Ana Carolina Reston, died November 15 2006 due to Anorexia Nervosa, source.
• Model in the bottom left picture: Luisel Ramos, died August 2, 2006 due to Anorexia Nervosa, source of the picture.

Resources for friends and family members of sufferers:

• Tips from RenfrewCenter.com (an eating disorder clinic)
• Tips for Friends and Family of Someone with an Eating Disorder (by Jane Framingham, Ph.D. on Psych Central)
• Anorexia Nervosa: A survival Guide for friends, families and sufferers (by Prof. Dr. Janet Treasure, via Amazon.com)
• Talking to Eating Disorders: Simple Ways to Support Someone With Anorexia, Bulimia, Binge Eating, Or Body Image Issues (Paperback) by Jeanne Albronda Heaton (Ph.D) via Amazon.com.

Posted under Psychology