Eating disorders are complex conditions that arise from long-standing behavioral, emotional, psychological, interpersonal, and social factors. People with eating disorders often use food and control of food to cope with overwhelming feelings and emotions. While dieting, bingeing, and purging may begin as a way to cope, these behaviors ultimately damage physical, emotional, and mental health. Common eating disorders include anorexia nervosa, bulimia, and binge eating disorder. Friends and family should express concerns for a loved one's eating behaviors in a caring, supportive way and encourage seeking help from medical professionals.

1. Eating Disorders

2. What are eating disorders?
 Eating disorders are complex conditions
that arise from a combination of long-
standing behavioral, emotional,
psychological, interpersonal, and social
factors.

3. What are they?
 People with eating disorders often use food
and the control of food in an attempt to
compensate for feelings and emotions that
may otherwise seem over-whelming.
 For some, dieting, bingeing, and purging may
begin as a way to cope with painful emotions
and to feel in control of one’s life, but
ultimately, these behaviors will damage a
person’s physical and emotional health, self-
esteem, and sense of competence and
control.

4. Disorders
 Anorexia Nervosa
 Bulimia
 Binge Eating Disorder

5. Describe
 Most of you know someone that has
struggled with their eating -- make a
group of 3 or 4 and describe the person
to the rest of your group.
 Did you describe the person or their
behavior?
 Common themes?

6. Anorexia nervosa
 Characterized by self-starvation and excessive weight loss.
 Symptoms include:
 Refusal to maintain body weight at or above a minimally normal
weight for height, body type, age, and activity level
 Intense fear of weight gain or being “fat”
 Feeling “fat” or overweight despite dramatic weight loss
 Loss of menstrual periods
 Extreme concern with body weight and shape

7. Bulimia
 Characterized by a secretive cycle of binge eating followed by purging.
Bulimia includes eating large amounts of food--more than most people
would eat in one meal--in short periods of time, then getting rid of the
food and calories through vomiting, laxative abuse, or over-exercising.
 Repeated episodes of bingeing and purging
 Feeling out of control during a binge and eating beyond the point of
comfortable fullness
 Purging after a binge, (typically by self-induced vomiting, abuse of
laxatives, diet pills and/or diuretics, excessive exercise, or fasting)
 Frequent dieting
 Extreme concern with body weight and shape

8. Binge Eating Disorder/
Compulsive Overeating
 Characterized primarily by periods of uncontrolled,
impulsive, or continuous eating beyond the point of
feeling comfortably full.
 While there is no purging, there may be sporadic
fasts or repetitive diets and often feelings of shame or
self-hatred after a binge.
 People who overeat compulsively may struggle with
anxiety, depression, and loneliness, which can
contribute to their unhealthy episodes of binge eating.
 Body weight may vary from normal to mild, moderate,
or severe obesity.

9. Factors
 Disordered eating is NOT just about
food and diets…
 Can you list the other factors that play a
role in the development or continuation
of disordered eating behaviors?
 See how many your group can come up
with.

10. Psychological factors
 Low self-esteem
 Feelings of inadequacy or lack of
control in life
 Depression, anxiety, anger, or
loneliness

11. Interpersonal Factors
 Troubled family and personal
relationships
 Difficulty expressing emotions and
feelings
 History of being teased or ridiculed
based on size or weight
 History of physical or sexual abuse

12. Social Factors
 Cultural pressures that glorify "thinness" and
place value on obtaining the "perfect body"
 Narrow definitions of beauty that include only
women and men of specific body weights and
shapes
 Cultural norms that value people on the basis
of physical appearance and not inner
qualities and strengths

13. Other Factors
 Scientists are still researching possible
biochemical or biological causes of
eating disorders. In some individuals
with eating disorders, certain chemicals
in the brain that control hunger,
appetite, and digestion have been
found to be imbalanced. The exact
meaning and implications of these
imbalances remains under investigation

14. Behavior
 Share some of the behaviors that you
have witnessed from people struggling
with and ED regarding food and
exercise.
 What is the common theme for these
behaviors?

15. Food Behavior
 Anorexic
 The person skips meals, takes only tiny portions, will
not eat in front of other people, eats in ritualistic
ways, and mixes strange food combinations. May
chew mouthfuls of food but spits them out before
swallowing.
 Grocery shops and cooks for the entire household,
but will not eat the tasty meals.
 Always has an excuse not to eat -- is not hungry, just
ate with a friend, is feeling ill, is upset, and so forth.

16. Food Behavior
 Bulimic
 The person gorges, usually in secret, emptying
cupboards and refrigerator. May also buy special
binge food.
 If panicked about weight gain, may purge to get rid of
the calories. May leave clues that suggest discovery
is desired -- empty boxes, cans, and food packages;
foul smelling bathrooms; running water to cover
sounds of vomiting; excessive use of mouthwash and
breath mints; and in some cases, containers of vomit
poorly hidden that invite discovery.

17. Exercise
 The person exercises excessively and
compulsively. May tire easily, keeping up a
harsh regimen only through sheer will power.
As time passes, athletic performance suffers.
Even so, s/he refuses to change the routine.
 May develop strange eating patterns,
supposedly to enhance athletic performance.
May consume sports drinks and
supplements, but total calories are less than
what an active lifestyle requires.

18. Exercise
 Up to five percent of high school girls and seven
percent of middle-school girls have tried steroids in
attempts to get bigger and stronger in sports and also
to reduce body fat and control weight.
 Some say they don't mind gaining weight as long as
it's muscle weight, not fat.
 Male abuse of steroids is also well documented.

19. Thoughts and Beliefs
 In spite of average or above-average intelligence, the person thinks in
magical and simplistic ways, for example, "If I am thinner, I will feel
better about myself." S/he loses the ability to think logically, evaluate
reality objectively, and admit and correct undesirable consequences of
choices and actions.
 Becomes irrational and denies that anything is wrong. Argues with
people who try to help, and then withdraws, sulks, or throws a tantrum.
Wanting to be special, s/he becomes competitive. Strives to be the
best, the smallest, the thinnest, and so forth.
 Has trouble concentrating. Obsesses about food and weight and holds
to rigid, perfectionistic standards for self and others.
 Is envious of thin people in general and thinner people in particular.
Seeks to emulate them.

20. Feelings
 Has trouble talking about feelings, especially anger. Denies anger,
saying something like, "Everything is OK. I am just tired and stressed."
Escapes stress by turning to binge food, exercise, or anorexic rituals.
 Becomes moody, irritable, cross, snappish, and touchy. Responds to
confrontation and even low-intensity interactions with tears, tantrums, or
withdrawal. Feels s/he does not fit in and therefore avoids friends and
activities. Withdraws into self and feelings, becoming socially isolated.
 Feels inadequate, fearful of not measuring up. Frequently experiences
depression, anxiety, guilt, loneliness, and at times overwhelming
emptiness, meaninglessness, hopelessness, and despair.

21. Social Behavior
 Tries to please everyone and withdraws when this is not possible. Tries
to take care of others when s/he is the person who needs care. May
present self as needy and dependent or conversely as fiercely
independent and rejecting of all attempts to help. Anorexics tend to
avoid sexual activity. Bulimics may engage in casual or even
promiscuous sex.
 Person tries to control what and where the family eats. To the dismay of
others, s/he consistently selects low-fat, low-sugar non-threatening --
and unappealing -- foods and restaurants that provide these "safe"
items.
 Relationships tend to be either superficial or dependent. Person craves
true intimacy but at the same time is terrified of it. As in all other areas
of life, anorexics tend to be rigidly controlling while bulimics have
problems with lack of impulse control that can lead to rash and
regrettable decisions about sex, money, stealing, commitments,
careers, and all forms of social risk taking.

22. Judy’s Story
 My name is Judy Sargent. I
am 37 years-old and a
recovered anorexic. I
suffered from severe
anorexia nervosa for 10
years, was hospitalized 26
times, and landed myself in
intensive care units on
multiple occasions. You
would never guess any of
these things looking at me
today.
 http://www.angelfire.com/ms/anorexianer
vosa/images/then.gif

23. Story
 Did you get good grades in school?
 Yes, I was a straight "A" student. My father is
a professor, so there was always pressure to
perform. If I got an "A," my father said that I
didn't challenge myself enough. If I got an
"A-," my father said that I didn't apply myself
hard enough. I couldn't ever seem to "win"
the approval I so desired from my parents.

24. Did you feel as if you were not perfect
compared to your peers?
 I guess you could say I'd always been a
perfectionist (striving for perfection in
everything that I did), but the pressure was
internal (competing with myself and nobody
else). In terms of my peers, I felt inferior. I
had HORRIBLY low self-esteem. I never felt
"better than" my peers, nor did I do things to
make myself feel that way. In my minds eye, I
knew that I was inferior. Socially, I felt like a
misfit (even though I was on the cheerleading
squad and outwardly looked like "I had it all").

25. Why did you decide to stop eating
rather than something like become
bulimic?
 It all started as a simple "diet" (as part
of my self-devised, self-improvement
plan), but it snowballed out of control.
Eventually, I became afraid to eat (and
even, at times, to drink water). It was
like a phobia (fear) of weight gain and
food.

26. What made you look at yourself as not
a thin enough person?
 Contrary to popular belief, I
saw myself as thin, although
I told people that I was "fat."
For me, the word "fat" took
on a whole new meaning.
 When I looked at myself in
the mirror, I saw the
protruding bones and the
greyish blue skin. In my
mind, I was still "fat"
because I was still less than
perfect and still unhappy.

27. How did your friends cope with the
problem?
 My friends quickly dissipated and then
disappeared completely. The anorexia
became all consuming. I spent hours
exercising, and I avoided any social
gatherings that had anything to do with
food.

28. I never imagined….
 I started losing weight, never
dreaming that I'd become
anorexic, that I'd lose control
over my life and almost wind
up dead. I began my diet as
a simple self-improvement
campaign, as an attempt to
"feel better" about myself.
Initially, I felt better...so I lost
more weight...quickly it
became a trap and spiraled
out of control.

29. Inside the ED’s mind
 Anorexia nervosa is not really about
losing weight, eating or not eating,
exercising like a maniac or not. It is
about self-esteem. It is about how you
feel about yourself. True happiness
comes from within, it cannot be gleaned
from reading the numbers off of a
bathroom scale.

30. Behaviors
 Restaurant Rules:
 Before ordering, ask for a full glass of ice water (with lemon,
optional) and consume it. Get a refill when the waiter comes to
take your order.
 Get nutrition information ahead of time if you can. Surf the 'net
or call the restaurant (just tell them you have "health issues")
and ask about the calorie, fat and carb content of their dishes.
Then you will know what to order -- or whether to even bother
going there.
 Avoid all breaded or battered items, fried items, sauteed items,
breads, pasta, rices, sweetended drinks, and of course,
desserts.

31. More “Rules”
 Get the simplest foods in their
most natural form available,
such as grilled fish and a tossed
salad. Lean proteins like shrimp
are best. (You don't NEED the
cocktail sauce, ignore it!)
 When given a choice, always
lunch portion, never dinner
portion.
 Request all sauces and
dressings on the side. That
way you retain control over how
much you consume. Nearly all
the excess calories, fats and
carbs are in restaurant sauces
and dressings.
 Have your water glass refilled
when the food arrives.
 One or two sips of water
between bites.
 Set down fork after each bite.
 Chew slowly and thoroughly.
 Be discreet; don't make a
spectacle of yourself. You are
there to survive the experience,
savour your sense of control,
and enjoy your time out -- not to
draw attention to how weird you
can be with food.

32. Excuses?
 "Oh, thank you, but I already
ate at work (school, friend's
house, on your way home,
etc. wherever you just came
from)."
 "Well, I haven't really been
feeling well today. My
stomach is kind of queasy;
maybe I'll just have some hot
tea and see if it settles for
now."
 "Man, I've got a massive
headache -- I'll just take a
big glass of water and an
aspirin (tylenol, ibuprofen,
whatever) if you don't
mind ..."
 "Well, I had a really HUGE
breakfast (lunch, snack,
whatever) and I'm still full
from that ... maybe later."

33. Reality?
 "My favorite safe food is egg
whites. 15 calories each and
pure protein, no fat. 4 are
just 60 cal. total and you will
think you just had an omlette
at perkins. My second fav is
canned chicken broth. 20
cals in the whole can (fat
free kind of course) warms
you up and no guilt."

34. Helping
 If you are worried about your friend’s
eating behaviors or attitudes, it is
important to express your concerns in a
loving and supportive way. It is also
necessary to discuss your worries early
on, rather than waiting until your friend
has endured many of the damaging
physical and emotional effects of eating
disorders.

35. Judy’s advice
 I usually encourage people to voice their
concern to their friend by saying something
like, " ___ (name), I'm concerned about you.
I've noticed that you've lost a lot of weight
lately. I really care about you and I'm afraid of
losing you. Would you consider going to get
help?" Denial and resistance is common in
the early stages of an eating disorder, so this
approach may not work.

36. Communicating
 Set a time to talk. Set aside a time for a
private, respectful meeting with your friend to
discuss your concerns openly and honestly in
a caring, supportive way. Make sure you will
be some place away from other distractions.
 Communicate your concerns. Share your
memories of specific times when you felt
concerned about your friend’s eating or
exercise behaviors. Explain that you think
these things may indicate that there could be
a problem that needs professional attention.

37. Communicating
 Ask your friend to explore these concerns with a
counselor, doctor, nutritionist, or other health
professional who is knowledgeable about eating
issues. If you feel comfortable doing so, offer to help
your friend make an appointment or accompany your
friend on their first visit.
 Avoid conflicts or a battle of the wills with your
friend. If your friend refuses to acknowledge that
there is a problem, or any reason for you to be
concerned, restate your feelings and the reasons for
them and leave yourself open and available as a
supportive listener.

38. Communicating
 Avoid placing shame, blame, or guilt on your friend regarding
their actions or attitudes. Do not use accusatory “you”
statements like, “You just need to eat.” Or, “You are acting
irresponsibly.” Instead, use “I” statements. For example: “I’m
concerned about you because you refuse to eat breakfast or
lunch.” Or, “It makes me afraid to hear you vomiting.”
 Avoid giving simple solutions. For example, "If you'd just
stop, then everything would be fine!"
 Express your continued support. Remind your friend that you
care and want your friend to be healthy and happy.

39. Body Image
 Body image is . . .
 How you see yourself when you look in the mirror or when you
picture yourself in your mind.
 What you believe about your own appearance (including your
memories, assumptions, and generalizations).
 How you feel about your body, including your height, shape, and
weight.
 How you sense and control your body as you move. How you
feel in your body, not just about your body.
 3 D’s
 Dieting, Body Dissatisfaction, Drive for Thinness

41. Dieting
 Americans spend more than $40 billion dollars a year on dieting and
diet-related products.
 That’s roughly equivalent to the amount the U.S. Federal Government
spends on education each year.
 It is estimated that 40-50% of American women are trying to lose weight
at any point in time.
 One recent study revealed that 91% of women on a college campus
had dieted; 22% dieted "often" or "always."
 Researchers estimate that 40-60% of high school girls are on diets
 Another study found that 46% of 9-11 year olds are sometimes or very
often on diets
 And, another researcher discovered that 42% of 1st-3rd grade girls
surveyed reported wanting to be thinner

42. Media
 All media images and messages are constructions.
They are NOT reflections of reality. Advertisements
and other media messages have been carefully
crafted with an intent to send a very specific
message.
 Advertisements are created to do one thing: convince
you to buy or support a specific product or service.
 To convince you to buy a specific product or service,
advertisers will often construct an emotional
experience that looks like reality. Remember, you are
only seeing what the advertisers want you to see.

43. Too rich? Or just too thin?

44. Media
 Advertisers create their message based on what they think you
will want to see and what they think will affect you and compel
you to buy their product. Just because they think their approach
will work with people like you doesn’t mean it has to work with
you as an individual.
 As individuals, we decide how to experience the media
messages we encounter. We can choose to use a filter that
helps us understand what the advertiser wants us to think or
believe and then choose whether we want to think or believe
that message. We can choose a filter that protects our self-
esteem and body image.

46. Actress Jennifer Aniston for Vanity
Fair, May 2001
 "The media create this
wonderful illusion-but
the amount of
airbrushing that goes
into those beauty
magazines, the hours
of hair and makeup!
It's impossible to live
up to, because it's not
real."

47. - Elizabeth Hurley for Details magazine
 "On my last Cosmo
cover," she
explains, "they
added about five
inches to my
breasts. It's very
funny. I have, like,
massive knockers.
Huge. Absolutely
massive."

48. Christy Turlington
 Christy Turlington explains to
Elle magazine... "Advertising is
so manipulative," she says.
"There's not one picture in
magazines today that's not
airbrushed." ... "It's funny,"
Turlington continues. "When
women see pictures of models
in fashion magazines and say, 'I
can never look like that,' what
they don't realize is that no one
can look that good without the
help of a computer.

49. Reverse triggers
 From the website…
 “These images represent what we
never want to become. If you
want to know why ... just look
around you at how these people
too often end up being treated.
Perhaps you yourself have been
guilty of this at times. For the
record, this site does not
condone bashing fat people. We
just choose not to be among their
number, is all. “
 http://www.plagueangel.net/grotto/id11.html

50. Pro-Anorexia?
 "Pro-ana" thus becomes short for proactive, volitional anorexia.
It refers to actively embracing the concept of anorexia as a
lifestyle choice rather than an illness.
 Philosophy: There are No Victims Here
 Volitional, proactive anorexia is not a disease
or a disorder. It is not to be confused with
ED-anorexia; it is not something invasive which
one "suffers from." There are no VICTIMS here.
It is a lifestyle choice that begins and ends
with a particular faculty human beings seem in
drastically short supply of today: the will.
 http://www.plagueangel.net/

51. Dealing with clients
 What do you need to learn to effectively
and compassionately deal with ED
patients and clients?