In the second half of our interview, Sari Fine Shepphird, Ph.D, clinical psychologist and author of 100 Questions & Answers about Anorexia Nervosa, offers important information about eating disorders and their treatment. For more information about Shepphird and her book, please visit her website.
Q: Can you talk about the warning signs for eating disorders?
A: Some of the more obvious signs include: the person avoids eating with others; starts to restrict the types of foods they eat (not just the quantity); becomes secretive (e.g., is evasive when asked what they had for lunch); skips meals; makes frequent trips to the bathroom after meals; starts to exercise excessively; begins to weigh themselves frequently; makes negative comments about their own bodies or other people’s bodies; seems to idealize thin celebs or thin friends; compares themselves to others (which actually isn’t a normal thing to do, even though we’re conditioned to do this by our society); starts to count calories frequently; comments about certain foods being “bad” foods and feels like a “bad person” for eating these foods.
The more subtle signs include: the person starts to dress in very baggy clothes to hide their frame; develops strange behaviors around food (e.g., only eats at a certain time of day, or in a certain order); shows great concern about weight gain and makes a lot of weight-related comments; loses or gains a significant amount of weight; begins to make general self-critical comments; develops perfectionistic tendencies; shows signs of low self-esteem; is embarrassed or ashamed after eating; puts pressure on themselves to exercise, even when they’re tired or injured.
Q: Recently, the news has reported that kids as young as five are being diagnosed with eating disorders. Why do you think patients are getting younger? Aside from general warning signs, are there specific things to watch out for with kids?
A: It is disconcerting indeed that patients with eating disorders are seemingly getting younger. Interestingly, older patients are being diagnosed with greater frequency as well. The emphasis on thinness in our culture has only gotten stronger in the past decade. Children are exposed to greater amounts of media and role models, including children’s role models, are themselves feeling a greater pressure toward thinness. Parents also feel that pressure to a greater degree and perhaps unwittingly convey their own body image concerns to their kids through their actions and words.
Parents may want to let their child’s pediatrician know if they notice any unusual behaviors around food. Picky eating is normal for children, but any behaviors that persist or seem odd or extreme should be brought to their doctor’s attention. Feeding disorders of childhood can be ruled out by their doctors, and treatment is important. Such disorders can also be precursors to later eating disorders.
Parents should be sure to start their kids off early with a healthy approach to eating, rather than a restrictive one. Children naturally have hunger and fullness cues that help to regulate their eating. These cues can become skewed if children are made to feel guilty for eating a healthy diet, or if unhealthy behaviors around food are modeled in the home.
Q: What are some ways family and friends can approach their loved one if they notice warning signs?
A: It’s difficult to approach someone who has an eating disorder. Most people are afraid that they’ll lose the friend or the loved one will be angry with them or defensive. But it’s worth the risk to express your love and concern. One thing I recommend is that people use “I” statements, so it doesn’t seem like you’re somehow attacking their behavior. This way, you come across like you’re expressing your concern. I suggest this formula, “I feel ___ when ______ because ____.” For instance, “I feel frightened when I see you skip meals, because I’m concerned that you’re losing too much weight.” Start by talking about how you feel rather than accusing the person, which is more likely to make them defensive.
I also recommend this often: You may wish to avoid addressing the eating disorder directly if you feel they may become defensive, but instead talk about something related, such as “I’ve been noticing you’re under a lot of stress lately. I can see it in your behavior. Can I help?” This approach becomes sort of a dance, take a step forward, and take a step back and perhaps even let it be for awhile. Give your loved one time to absorb what has been said, time to react and think about it. Be caring and very gentle, without feeling like you need to hammer in the point. Instead of saying, “You have a problem. You have to get help or I can’t be your friend anymore,” you can say, “If you’d like to talk more, I’m here for you.”
Q: What can you do if a loved one refuses treatment?
A: A child can be brought by their parents for involuntary treatment. However, it is difficult with an adult, because you cannot force someone into treatment unless perhaps they are gravely disabled. People with an eating disorder often feel that their eating disorder has benefits, or fear the thought of recovery. This fear of not wanting to recover is actually a symptom of the illness. The person isn’t necessarily going to consider change when they might not see the need for it.
One thing that a person can do is to point out how their (loved one’s) life would improve if they were to get treatment. Perhaps they’d have more energy to meet their goals, feel a greater sense of calm or improve their sense of self-esteem and self-worth. People with eating disorders are under a great deal of stress. Getting help will allow them to develop other kinds of coping skills to reduce stress and improve their lives. I have many patients who start going to therapy for depression, anxiety or stressful life circumstances. They don’t tell me about their eating disorder at first, or don’t want to talk about it. At a later point in treatment, they’re ready to address it. So, a great way to get someone to seek help is to offer help for or suggest discussing a different issue. Once they’re in treatment, they might be more open.
Q: Finding out your child has an eating disorder can be incredibly overwhelming and parents might not know where to start. Can you take us through the steps in finding a treatment team and helping your child through recovery?
A: It can be hard to know where to find a good professional. Oftentimes the best thing to do is to ask your primary care doctor if they know someone who specializes in eating disorders. Or, ask another trusted source, such as a religious leader or a close friend, for a recommendation. There are also specialized treatment Web sites that list people who are specifically trained in eating disorders, including: ED Referral, the Gurze Website, National Eating Disorder Association, and the National Association of Anorexia Nervosa and Associated Eating Disorders.
Even when you find a recommendation for a professional, it’s best to ask a series of questions to make sure they’re a good fit for you. Just because they’re trained in eating disorders doesn’t mean they’re automatically a good fit. Have an initial phone call to get a sense of the practitioner’s personality; ask about training and level of experience; and practical things like whether they accept your insurance, how long they’ve been treating eating disorders and if they treat your child’s specific type of eating disorder. (For questions to ask your therapist, download Shepphird’s form here.)
The best way to approach treatment is through a team approach, so make sure that person usually works with a multidisciplinary team of professionals.
If you need to find a treatment center, the same suggestions apply. You may even want to visit the treatment center and ask questions about their approach to treatment. If a treatment center has a policy that doesn’t allow parents to visit, then I would generally not recommend that center.
Once a child starts treatment, then the parents can choose various forms of support. For an adolescent or child with an eating disorder, one of the best ways we know through research for parents to be involved is a very hands-on approach. For instance, in the Maudsley approach, parents take an active approach in helping to re-feed their child and teach them about being healthy. Before, parents used to be on the sidelines, but now for younger patients, parents are encouraged to be part of the recovery.
For an older patient, Maudsley doesn’t necessarily apply. However, loved ones are still encouraged to be supportive and compassionate. It means a great deal to patients to know that people love and support them, even though they may seem uninterested or unfazed by the offer of support.
Further along the process, once a loved one is in recovery, there are some things to keep in mind. Unless it’s Maudsley therapy, where parents encourage weight gain directly, refrain from making comments about a person’s weight, such as “You’re losing weight. Are you sure you’re eating enough?” or “You look like you’ve gained some weight.” Instead, comment on other changes: “You seem happier, more energized.” “I’m so proud of you for all your hard work.”
One thing you want to avoid with adult friends and loved ones is a power struggle about recovery. While you can encourage your loved one, criticizing, blaming or berating them for not taking recommendations is probably doing them a disservice. Patients are likely already doubting themselves and feeling like a failure. Criticism can serve to set them back rather than help them along.
Also, loved ones should avoid commenting about their own weight. I’ve seen kids who’ve made progress in recovery go home to see their parent is on a diet or is being picky with food. This reinforces what the patient has worked so hard to unlearn. Having your own healthy body image can be a means for supporting a loved one who is in recovery.
Another important thing is for loved ones to find support for themselves. Studies show that having a loved one with an eating disorder can be just as difficult if they had cancer or some other serious, chronic illness. This can cause personal and marital stress, financial difficulties and jealousy among siblings. There is no shame for parents to be in therapy themselves. Therapy is a supportive place where you can gain strength and tools for managing your life.
Q: You mention in your book that anorexia isn’t all about food and weight; that these are symptoms of underlying issues. What are some of these underlying issues?
A: Although the symptoms of anorexia largely surround food and eating, the truth is that at its core, anorexia and other eating disorders do not solely have to do with food. Often we find that people with eating disorders are experiencing underlying emotional distress, relationship or psychological conflicts, difficult life transitions or past trauma. Eating disorders can be part of an overall picture of struggle in a person’s life. When combined with genetic and biological factors, these struggles can sometimes be a precursor to eating disorder symptoms. For some people, anorexia serves as a complex distraction from other painful, seemingly unmanageable feelings or life events. Part of the recovery process from anorexia is learning other, more healthy ways of coping with life’s challenges.
Q: We’re only recently discovering that anorexia occurs in men and older women. What are some key points about anorexia in these populations?
A: Anorexia does occur in males! There is a common stereotype that anorexia is a female illness; however, that is not the case. We know that 10% to 15% of anorexia cases are diagnosed in males, and those are just the cases that go reported. Experts feel the rate may be significantly higher; however, many men feel a greater stigma about eating disorders, so they may not seek treatment. When they do, they will unfortunately find that there are far fewer treatment programs available to men than to women. Some co-ed programs do offer specially designed treatment “tracks” that address uniquely male concerns, but there is a need for many more such programs.
Male athletes have a higher reported rate of eating disorders than the general population, due in part to the belief that weight loss is a necessary requirement for peak athletic performance in their sports, and a higher rate of anorexia has also been reported in homosexual and bisexual males.
We know from recent research that eating disorders occur across the lifespan, not just among young women, as many may presume. Body image dissatisfaction is fairly stable across the age span, and many of the same risks for eating disorders in younger women can be precursors for older women as well.
While health care professionals may be less likely to suspect an eating disorder in an older woman, the risks are real nonetheless. Factors such as growing public awareness, social pressure to be thin and an aging population of “image conscious” baby boomers may be some of the contributing factors for more cases of eating disorders among older women. And challenges such as divorce, childbirth, widowhood, menopause, chronic dieting and other age-related changes are examples of later-life events that may represent an increased vulnerability for the onset of anorexia at a later age. Complications of eating disorders can be greater for an older person, so it is important for older men and women to see a doctor soon after symptoms appear.
Q: Anything else you’d like readers to know about anorexia or eating disorders in general?
A: One of the main things that more people need to realize is that eating disorders are serious, often debilitating medical and psychiatric illnesses. Many times we do not realize how serious these illnesses are. I don’t think it’s been said enough how high the death rate is from eating disorders or how debilitating the complications can be.
Also, sometimes people think that anorexia and bulimia are the only forms of eating disorders. However, there are also non-classified eating disorders, which are just as serious. In fact, someone can die from a short-term eating disorder. One of my colleagues lost her daughter to bulimia after just one year of symptoms. You don’t have to have an eating disorder for five to seven years in order for it to be serious.
Unfortunately, because of the media, eating disorders sometimes seem as though they are almost encouraged and admired. Yet this is unfortunate as they’re serious, devastating illnesses that need to be treated. A person can lose their health, their family, their motivation for living and ultimately their life.