All About Eating Disorders

There is no one weight or shape associated with an eating disorder - eating disorders are mental illnesses not weight disorders

Fast Facts (from the Academy of Eating Disorders)

• Eating disorders are serious mental illnesses. They are treatable, and the sooner someone gets the help they need, the easier recovery can be. That said, a better life is always possible no matter how long someone has struggled.

• Eating disorders are NOT choices, passing fads or phases.

• Eating disorders occur all over the world, especially in industrialized regions or countries. They affect people of all gender, ethnic background, socioeconomic status, age, sexual orientation, etc.

• Eating disorders have the highest mortality rate of any psychiatric illness (Eating Disorder Hope).

• Although there are formal guidelines that health care professionals use to diagnose eating disorders, unhealthy eating behaviors exist on a continuum. Even if a person does not meet the formal criteria for an eating disorder, they may be experiencing unhealthy eating behaviors that cause substantial distress and may be damaging to physical, psychological, social, and spiritual health.

Types of Eating Disorders (Eating Disorder Hope)

The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association (APA), offers a common language and standard criteria for the classification of mental disorders. It is used, or relied upon, by clinicians, researchers, psychiatric drug regulation agencies, health insurance companies, pharmaceutical companies, the legal system, and policy makers together with alternatives (such as the ICD-10 Classification of Mental and Behavioural Disorders, produced by the WHO.) The DSM is in its fifth edition, the DSM-5, published on May 18, 2013. In this most recent edition, several distinct categories of eating disorders are recognized:

• Binge Eating Disorder - is defined as recurring episodes of eating significantly more food in a short period of time than most people would eat under similar circumstances, with episodes marked by feelings of lack of control. Someone with binge eating disorder may eat too quickly, even when he or she is not hungry. The person may have feelings of guilt, embarrassment, or disgust and may binge eat alone to hide the behavior. This disorder is associated with marked distress and occurs, on average, at least once a week over three months.

• Pica - describes a disorder in which a person consumes non-nutritive items over a period of at least one month. This consumption of non-nutritive items is inappropriate to the person’s developmental level, culture, and may occur in the presence of another mental disorder associated with impaired functioning.

• Rumination Disorder - involves repeated regurgitation of food for a period of at least one month Regurgitated food may be re-chewed, re-swallowed, or spit out. The repeated regurgitation is not due to a medication condition (e.g. gastrointestinal condition). The behaviour does not occur exclusively in the course of Anorexia Nervosa, Bulimia Nervosa, BED, or Avoidant/Restrictive Food Intake disorder. If occurring in the presence of another mental disorder (e.g. intellectual developmental disorder), it is severe enough to warrant independent clinical attention.

• Avoidant-Restrictive Food Intake Disorder - is manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following: significant loss of weight (or failure to achieve expected weight gain or faltering growth in children), significant nutritional deficiency, dependence on enteral feeding or oral nutritional supplements, marked interference with psychosocial functioning. The behavior is not better explained by lack of available food or by an associated culturally sanctioned practice. It is important to note that the behavior does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way one’s body weight or shape is experienced. The eating disturbance is not attributed to a medical condition, or better explained by another mental health disorder. When is does occur in the presence of another condition/disorder, the behavior exceeds what is usually associated, and warrants additional clinical attention.

• Otherwise Specified Feeding and Eating Disorders (OSFED) - is a catch all diagnostic category that includes atypical anorexia, purging disorder, binge eating disorder (where not all the criteria for a stand-alone diagnosis are met), bulimia nervosa (where not all the criteria for a stand-alone diagnosis are met), and night eating syndrome.

• Unspecified Feeding and Eating Disorder - this category applies to where behaviours cause clinically significant distress/impairment of functioning, but do not meet the full criteria of any of the Feeding or Eating Disorder criteria. This category may be used by clinicians where a clinician chooses not to specify why criteria are not met, including presentations where there may be insufficient information to make a more specific diagnosis

• Bulimia Nervosa - is characterized by frequent episodes of binge eating followed by compensatory behaviors such as self-induced vomiting to avoid weight gain.

• Anorexia Nervosa - is characterized by distorted body image and excessive dieting that leads to severe weight loss with a pathological fear of becoming fat. There are two sub-types: A) restrictive type (AN-R), and B) binge-purge type (AN-BP).

Canadian Statistics (National Eating Disorder Initiative, 2017)

• Research indicates that the prevalence rate of eating disorders is between 2% and 3%. Based on Statistics Canada population data (Statistics Canada 2016), an estimated 725,800 - 1,088,700 Canadians will meet the diagnostic criteria for an eating disorder. Many more may be on a spectrum of disordered eating.

• As described by Pinhaset al., (2011), very little quantitative information exists on the outcomes or co-morbid diagnoses of Canadian ED patients. The large Ontario Mental Health Survey (Garfinkelet al., 1995; Woodside et al., 1996) provided information on co-morbidity in eating disorders where 34% of women and 15% of men with an eating disorder had a lifetime diagnosis of major depression; 37% of men and 51% of women had a lifetime diagnosis of anxiety disorders and 45% of men and 21% of women had a lifetime diagnosis of alcohol dependence. In a cohort study of cases from the only adult tertiary care ED program in British Columbia (954 consecutive patients referred to the only adult tertiary care eating disorders program), the standardized mortality ratio for AN was 10.5 (Birmingham et al., 2005) with a life expectancy reduction of 20-25 yrs (Harbottleet al., 2008).

• 70% of doctors receive 5 hours or less of eating disorder-specific training while in medical school (Girz, LafranceRobsinson, & Tessier, 2014). In 2004, only 6.3% of psychiatry residents felt they had spent enough time with ED patients to work effectively with them in clinical practice (Williams & Leichner, 2006)

• While financial data is not available in Canada on a national scale, a study conducted in British Columbia in 2003 reported the provincial costs of those with anorexia nervosa on long-term disability may be as high at $101.7 million/year, up to 30 times the cost of all tertiary care services for eating disorder treatment in the province (Su & Birmingham, 2003). It is important to consider that there are hidden costs associated with eating disorders, including lost earnings of sufferers and carers (PricewaterhouseCoopers, 2015)

Behaviours

Eating disorders may include individual or multiple combinations of behaviours, which may change over time, but the thought processes often remain the same for people who struggle over a number of years. Behaviours may include restriction (limiting variety and/or quantity of food eaten), bingeing (eating a significantly larger portion of food than would be considered reasonable for a non-eating disordered person, purging (using behaviours to compensate for calories consumed, including self-induced vomiting, misuse of laxatives, restriction, or compulsive exercise).

While some may find it useful to put a label to what they are struggling with, it is perfectly normal for individuals to go through changes in behaviours over the course of their illness and recovery. For example, someone who has struggled with restriction may begin to struggle with bingeing and/or purging or vice versa. This can be extremely distressing to the individua,l but highlights the point that in the end, eating disorder behaviours (whatever form they may take) are coping mechanisms. The emphasis needs to be placed on how the behaviour impacts the person’s life rather than what the individual behaviour is and how that might be used to categorize a patient into an overall diagnosis (which is only useful in so far that it directs the course and type of treatment).

Bingeing

Bingeing is generally defined as consuming, or engaging in some activity, in a large quantity over a relatively short period of time. In terms of eating disorders, this amounts to eating a lot in a short period of time. It is categorized as either objective (something most people would agree, is a large quantity of food as compared to "normal") or subjective (the individual feels they are eating a large quantity of food, but is not in fact consuming any more than is "normal.")

It is important to note that "normal" is a relative term which makes definitions more difficult.

Bingeing can occur as a coping mechanism in itself, but it can also occur in response to deprivation. Deprivation does not strictly mean starving, it also applies to something as simple as labelling a food item “bad” and treating it and our relationship with it and other foods as such.

Bingeing can occur with any eating disorder or disordered eating. There is often much more shame associated with this behaviour, but whatever your struggle looks like know you are not alone and you deserve recover. Sufferers of binge eating disorder often face a great deal of stigma in our diet-and-weight-loss-centric culture. However, dieting is not a successful solution to bingeing as it does not address the underlying issues and cycles of restrictive eating will only perpetuate the behaviour.

Purging

To purge something is to get rid of it, in the case of eating disorders, to get rid of food that has been ingested either by self-induced vomiting, laxative abuse, enemas, and/or exercise. Restriction can also perform the same functions as purging for some people.

Purging can result in serious, sometimes fatal, physical complications including: electrolyte imbalance (which can lead to sudden cardiac arrest), dental erosion, esophageal tears, and/or Barrett's esophagus (a condition in which the lining of the esophagus is damaged by repeated exposure to stomach acid, which changes the nature of the cells, and can potentially lead to adenocarcinoma.) Laxative abuse can also severely alter the bowel's ability to function. Chronic use of diuretics can also lead to hypotension and kidney failure as well electrolyte disturbances (Psych Central, Binging & Purging.)

Bingeing and purging often go hand-in-hand, as is seen bulimia nervosa, but that is not always the case. Purging can occur with any eating disorder diagnosis.

Restriction

Restriction involves limiting the variety of foods eaten and/or nutritional intake. It can occur in any eating disorder and can lead to health consequences such as depression, insomnia, anxiety, bradycardia, electrolyte deficiencies, vitamin and mineral deficiencies, osteopenia and osteoporosis, diminished concentration and cognitive abilities, hypotension, and hypoglycemia.

Long-term restriction can lead to (though not necessarily) weight loss; however, serious and potentially fatal consequences from restriction can occur at any weight. The body slows metabolism to compensate as best it can, but eventually it will consume its own tissues in order to come up with needed nutrients to keep the vital organs functioning as long as possible. Lab values (blood work) may appear normal in many cases even when severe deficiencies are present in the body's cells, critical nutrients and electrolytes are "stolen" from the intra-cellular spaces in order to keep the blood levels as stable as possible. Even in cases of severe malnutrition, lab values can remain within normal limits over 50% of the time, this can be misleading, invalidating, and even delay care and necessary treatment (NCBI article on the usefulness and limitations of lab values in the assessment of eating disorders.) It is quite common for restriction to lead into bingeing, becoming a cycle of behaviours that can be quite distressing to the individual.

Restriction is often viewed favourably or as a manifestation of self-control and this is a dangerous idea that stems from a very diet-focused. Restriction is not synonymous with control, there is no hierarchy of eating disordered behaviours, nor does restriction serve as way to calm oneself effectively. Restricting actually increases general anxiety in individuals (though they may find they feel more detached and "calm" due to physical exhaustion); their body is on alert for food and is in a threatened state so long as the deprivation continues.

Other forms of restricting

CHEWING & SPITTING

Chewing and spitting is a less discussed eating disorder behaviour, but does occur with eating disorders. Chewing is the first step in the digestive process and sets into motion a whole cascade of hormonal and chemical signals in the body.

People who chew and spit out food can end up with dental problems, including cavities and gum disease. Chewing food also signals stomach acids to kick in, ready to do their job of digesting food. But without the actual food to digest, this may cause stomach problems.

Though studies are limited, there are questions around insulin release and potential insulin resistance in patients who chew and spit.

ANOREXIA ATHLETICA & COMPULSIVE OVER-EXERCISE

Anorexia athletica is not formally recognized in the current DSM (V), but is often discussed in relation to eating disorders. It is similar to, though distinct from, other eating disorders and the use of exercise as a disordered behaviour. Anorexia athletica is more common in those who participate in sports, exercise and physical fitness where leanness is the primary focus, though calorie restriction and a dietary focus can come into play as well.

Compulsive exercise can occur with any eating disorder and is challenging in that it is viewed favourably by the general culture which can normalize the behaviour for individuals struggling.

Exercise and dietary restriction have a number of health complications; a common occurrence in cis-gendered women with anorexia athletica is "female athlete triad syndrome" (FATS). The triad consists of low energy availability (especially in relation to high levels of activity) leading to amenorrhea or oligomenorrhea (period loss or disruption to the normal menstrual cycle) and osteopenia/osteoporosis.

The following article is written by Gwyneth Olwyn. It outlines some ways in which to assess one’s relationship with exercise and the purpose it is serving in one’s life.

"Here are the six facets that are used to determine whether anything has become an addiction (including exercise):

1. Salience: does the activity become the most important one in a person’s life? Do they think about it more than anything else? Do they crave it or feel they are suffering without it? As soon as they are not doing the activity are they planning when they can next do the activity? Do they forego other previously pleasant activities in their lives so they can do the activity in question?

2. Mood modification: That’s the subjective feeling of the “high”. The feeling of “in the zone” or “meditative” or “calming”, “neutralizing other stresses”.

3. Tolerance: Needing to increase the amount and time dedicated to the activity to get the same levels of mood modification.

4. Withdrawal Symptoms: Irritability, short-tempered, jumpiness, anxiety when unable to do the activity in question.

5. Conflict: Interpersonal issues arising with loved ones and friends as a result of the activity. Family and friends expressing their anxiety, concern or irritation with the person’s focus on the activity. Intrapersonal conflict where the person experiences guilt or anxiety that she is harming herself and others with her focus on the activity.

6. Relapse: Attempts to avoid or moderate the involvement in the activity are punctuated with repeated returns to the activity at a quickly restored or even heightened level than before.”

ORTHOREXIA - “CLEAN EATING”

While not in the current DSM (V), the psychiatric Bible of diagnoses, orthorexia is a commonly referred to issue in the context of eating disorders. The term "orthorexia nervosa" literally means "a fixation on righteous eating" (NEDA, orthorexia nervosa.) The obsession in this situation is related to eating what is deemed "healthy" (good) food versus food's that are generally considered indulgent or "unhealthy" (bad.)

Of course there is no inherent morality in food, there are just strong cultural attitudes that influence our thinking about healthy eating and villainize certain foods and/or food groups. The increasing attention on obesity, diabetes, heart disease, and cancer contributes to an increasingly diet-focused culture. Research is ongoing, but headlines are often created from incomplete and/or biased studies which are taken up in the media and spread widely without complete understanding or all the facts.

Following a healthy diet in itself, does not mean you are suffering from orthorexia, and there is nothing wrong with eating healthily. Unless, however, 1) it is taking up an inordinate amount of time and attention in your life; 2) deviating from that diet is met with guilt and self-loathing; and/or 3) it is used to avoid life issues and leaves you isolated and unhappy.

Health Effects of Eating Disorders

Eating disorders impact every aspect of a person’s life - their mental, social, physical, and spiritual well-being. beyond the individual, eating disorders impact the loved ones who gather around to support the person struggling.

Mental, Spiritual, & Social Health Effects:

Eating disorders can affect individuals and families ability to work and/or attend school, participate in activities of daily living (ADLs), connection to their faith or spirituality, result in loss of relationships (romantic, familial, friendship, or otherwise).

Beyond physical health (discussed below) these illnesses significantly reduce persons quality of life.

Physical Health Effects:

Dental Problems & Tooth Decay

Purging in the form of vomiting is the most obvious reason for dental problems and tooth decay to occur in the context of an eating disorder. Stomach acid that is regurgitated can cause serious damage to the teeth, gums, and other tissues (such as the lining of the espohagus.)

However, nutritional deficiencies can also affect the integrity of the teeth. Lack of calcium, iron, and certain B vitamins can lead to gingivitis, canker sores, angular chelitis (inflammation at the corners of the mouth,) gingivitis, and dental erosion.

Dehydration may lead to impaired saliva production which can exacerbate dental erosion.

Finally, estrogen deficiency has been linked to receding gums due to bone loss in the jaw, heightened sensitivity, and the risk of infection (as estrogen plays an important role in the immune system of women.)

Other Health Effects Associated With Purging Behaviours

Purging behaviours can take several forms, all of which can have many, serious consequences.

RISKS ASSOCIATED WITH SELF-INDUCED VOMITING

• Electrolyte imbalances (particularly potassium) and possible sudden cardiac death

• Dehydration

• Dental erosion, gum irritation

• Sore throat, swollen salivary glands

• Stomachache, heartburn, and acid reflux

• Barrett's esophagus and an increased risk for the development of cancer in the esophagus

• Torn esophagus (Mallory-Weiss syndrome)

• Ruptured esophagus (Boerhaave syndrome)

• Scarring on the fingers and hands (Russell's sign)

• Digestive problems

• Disruption to the electrical and chemical signalling/feedback systems in the brain and digestive tract.

RISK ASSOCIATED WITH LAXATIVE ABUSE

• Electrolyte imbalances (particularly potassium) and possible sudden cardiac death

• Dehydration (and related low blood pressure, fainting, etc.)

• Lazy bowel, or loss of bowel function entirely, requiring medical assistance to pass fecal matter

RISKS ASSOCIATED WITH OVER-EXERCISE:

• Arrhythmias and potential sudden cardiac death

• Injuries & reduced healing

• Amenorrhea and the subsequent increased risk of osteopenia and osteoporosis

Osteopenia & Osteoporosis

Osteopenia ("pre-osteoporosis” or lower bone mass than is expected for a person’s age) and osteoporosis (serious loss of bone mass) are serious complications that can occur as a result of an eating disorder. 

Calcium, vitamin D, magnesium and other vitamins and minerals are crucial in the formation and maintenance of healthy bones. A lack of these critical nutrients can increase the risk of developing osteopenia and osteoporosis.

Furthermore, secondary amenorrhea due to impaired hormone production and function can lead to massive bone loss. The estrogen hormones that are involved in the menstrual cycle are crucial for bone health in cis-gendered females as these hormones "play a key role in regulation of bone mass and strength by controlling activity of bone-forming osteoblasts and bone-resorbing osteoclasts" (NCBI, 2009).

Reproductive Health Issues

I imagine most people know about the basic impacts on reproductive health; in those with eating disorders reproductive is often disrupted due to hormone imbalances caused by malnutrition.

• Anovulation and amenorrhea can impair or complicate sexual health, libido, and potential pregnancy.

• Infertility and miscarriages are more common in the eating disorder population (Science Daily, 2013.)

• Loss of pelvic musculature can increase the risk of uterine prolapse.

In a more detailed explanation, this article Jessica Baker points out that all eating disorders, including (using the DSM-5 definitions) anorexia, bulimia, otherwise specified feeding and eating disorders, and binge eating disorder can al cause damage to reproductive health, at any age.

While loss of one's period or irregularity is more common with anorexia, it can also strike people who struggle with bulimia or otherwise specified feeding and eating disorders.  Ovulation may cease for those actively struggling with an eating disorder of any kind.  Aside from potentially making conception difficult, eating disorders can also affect birth outcomes:

...women with AN have an increased risk of low weight babies, preterm birth, and a C-sections. Women with BED are at increased risk for maternal hypertension, large-for-gestational-age babies, and a longer duration of labor. 

In addition, the article cited above cites the effects on older women with eating disorders, noting:

...midlife women (age 40+ years) with an eating disorder have worse medical profiles compared with young adults.

Please take the time to have a look at the linked article:  Eating Disorder Can Do Real Damage to Gynecological Health - At Any Age .  

Gwyneth Olwen (a Canadian blogger) covers more extensively issues of fertility and pregnancy, restriction and fertility, two types of fertility, intervention to induce fertility, the un-recovered or partially recovered patient, all in great detail which includes what data we have on men and on fertility, pregnancy, and post-partum health during or after recovering from an eating disorder.  Check out her blog at Reproductive Health 1: Fertility and Pregnancy.

However, fertility and pregnancy are not the only two reasons to recover from an eating disorder: eating disorders also affect menstruation (which can, in turn, cause bone thinning, among other things) and implications for me, which she explains in Reproductive Health II: Kids or not, it's still important.

Organ Damage

When we lose weight, we do not selectively lose weight from only certain stores. The body takes what it needs from various sources, as needed. Extensive and enduring malnutrition depletes the body of reserves and leads to the breakdown of even crucial organs (such as the brain, heart, liver, and kidneys.) Severe organ damage can result in death. Most of the changes that occur can be reversed with proper nourishment, but it takes time and we have to remember our bodies are all very different and thus tolerate severe stresses differently.

Premature Death

Premature death is the ultimate outcome of an untreated eating disorder.  All of the damages listed above finally come together, and death ensues, either due to medical complications or suicide.  One meta analysis found the following  “...mortality rate of 5.0” – that is, they were five times more likely to have died over the study period than age-matched peers in the general population. Mortality rates are age and treatment related.  The sooner a diagnosis and treatment occur, the higher the recovery rate.  

According to one study, the mortality rate for anorexia nervosa patients aged 25 to 44 followed after hospital discharge was 14 times that of age-matched non-eating disordered peers.

Read more here and never underestimate your risk of a catastrophic medical event at any age.

Demographics

General

There are a lot of stereotypes that surround eating disorders and these stereotypes harm patients who feel they do not fit the typical representation of an eating disorders. The truth is, eating disorders do not discriminate, they affect people of all ages, genders, sexual orientations, ethnic backgrounds, body sizes, and socioeconomic statuses.

Men With Eating Disorders

Eating disorders are commonly thought to be a problem affecting girls and women.  This gender difference may reflect our society’s different expectations for men and women. Men are generally expected to be strong and powerful. They often feel ashamed of skinny bodies and have the desire to achieve bigger and more powerful bodies.

However, eating disorders among boys and men are on the rise. A broadening definition of what constitutes an eating disorder and the evolving cultural norms regarding the male physique may both account for greater recognition of eating disorders in males.  Just like females, males can be at risk of developing all forms of eating disorders. When investigating the risks for men, many studies have found a positive correlation between the development of an eating disorder and athletic performance. This is likely due to the focus that is placed on body fat percentage in certain sports (such as body building etc.) that leads these individuals to heavily restrict or alter their diets based on which foods they believe will or won’t give them a competitive edge. It is also not uncommon for men fixated on athletic performance engage in other drastic behaviors such as steroid use and compulsive exercise.  This is only one example of how men are at risk of developing a life threatening and debilitating eating disorder.

In a society that lacks support and treatment for eating disorders, there is even less available that is tailored for boys and men who struggle. In the United States, some residential treatment facilities only accept certain percentages of male patients as admissions, and even fewer offer male-only groups (Frisch, M.J., 2006).  Most therapeutic groups that do include men are composed primarily of females and are often lead by female therapists which can make it more challenging for men to feel included and connected to groups and therapists.  Males may feel significantly different experiences regarding body image, sexuality, co-morbid conditions as well as coping mechanisms and means of expression. Given these gender differences, it is beneficial to allow males the opportunity to discuss such topics in a single gender setting with a more behavioural and active approach to group therapy (Weltzin, 2012). Groups that tend to focus on perceived pressure to be thin, body dissatisfaction, and the cultural thin ideal may not necessarily be efficacious for males. Rather, it is suggested that eating disorder prevention programs for males focus on lowering levels of body dissatisfaction addressing subjects such as body size and shape, muscularity as well as other physical areas of concern (Vo, M., 2016).

There is a great deal of work to be done before males can comfortably access the supports they need when dealing with a debilitating eating disorder. Hopefully as awareness around male eating disorders grows in society, so will the treatment and therapeutic resources for men.

Further Reading:

• Men Get Eating Disorders Too; this resource includes an online peer support page that might be helpful for adult males seeking an environment that can truly understand their struggles. 

• https://www.psychologytoday.com/blog/eating-mindfully/201412/eating-disorders-in-boys-and-young-men

This article focuses on some research finding on eating disorders in the male population and goes into some detail around the different types

• https://www.childrens.com/specialties-services/specialty-centers-and-programs/psychiatry-and-psychology/conditions-and-programs/eating-disorders/conditions-and-treatments/eating-disorders-in-younger-children

This article discusses programs for younger children including boys who struggle with disordered eating

• https://www.healthyplace.com/eating-disorders/articles/men-with-eating-disorders

SOME OTHER HELPFUL AND INTERESTING READS:

• Atlantic Magazine blog, “Body-image pressure increasing affects boys.” March 10, 2014.

• Bunnell, D. & Maine, M. (2014) “Understanding and treating males with eating disorders” in Cohn, Lemberg.

• Field AE, Sonneville  KR, Crosby, RD, et al. Prospective Associations of Concerns About Physiqueand the Development of Obesity, Binge Drinking, and Drug Use Among Adolescent Boys and Young Adult Men. JAMA Pediatrics, 2014, 168 (1): 34-39. 

• Weltzin, T. Carlson, T., et al. (2014) “Treatment Issues and Outcomes for Males with Eating Disorders” in Cohn, Lemberg.

• Wooldridge, T. (2017, in press) Understanding Anorexia in Males: An Integrated Approach. Philadelphia, PA: Routledge.

People of Colour

The typical representation of an eating disorder is of a young, white, middle-class, female, but such a stereotype leaves out other important demographics, such as people of colour. Eating disorders occur in other cultural contexts and in people of every ethnic background, though there may be important, and often understudied, differences in terms of influencing factors and manifestations.

It may be important to consider: under-reporting, treatment options in various places, cultural and socioeconomic intersections, cultural standards, and post-colonial factors. For example, Western society and the media often display European traits as a standard for beauty and it should be considered that diversity does not have proportional representation in public spaces, which may contribute to body image pressures and low self-esteem in groups that are poorly represented with limited role models. This is a noted factor in the causation of eating disorders, but not the only factor.

The Science of Eating Disorders blog has a five-part series of articles where they dissect and discuss eating disorders and culture (Whose Culture is it Anyway? Disentangling Culture and Eating Disorders 1-5/5)

While the following article focuses on the U.S., the situation in most parts of Canada is quite similar.  Be aware that you might find parts of the article triggering as there are a few mentions of weights and behaviours.  Take care of yourself if you are feeling vulnerable: America is Utterly Failing People of Colour with Eating Disorders.

LGBTQ+

Research with a specific focus on eating disorders in relation to the LGBTQ+ community is lacking. What research there is, generally reaches similar, common-sense conclusions: 

1. That individuals in the LGBT+ community face more discrimination overall which can tie in to some of the psychological and sociological pressures that contribute to eating disorders. 

2. Individuals who identify as transgender, gender-fluid, or non-binary, may struggle with significant gender dysphoria. In the context of an eating disorder, this will complicate already challenging body image issues. It should, however, be recognized that body dissatisfaction is not always resultant in a drive for thinness (Science of Eating Disorders, Impossible Binaries: Eating Disorders Among Trans Individuals), as there are different cultural attitudes towards "male" and "female" bodies in terms of what is seen as desirable. Male and female bodies both face certain pressures, that contribute to body image issues, but these pressures often differ. The male body is typically expected to be "muscular" and/or "hyper-masculine" and the female body is typically expected to be "thin and fragile" whilst retaining secondary sex characteristics.

What studies there are in this area, emphasize the sociological factors that contribute to eating disorders, and while these are important and do play a role in the development and maintenance of these illnesses; many of these studies fail to appreciate the genetic, biological, and other psychological factors that contribute to eating disorders (e.g. other mental illnesses, childhood upbringing, trauma etc.)

Some studies have found that eating disorders are less common in lesbian and bisexual women, others have found they share roughly the same prevalence (Science of Eating Disorders, Eating Disorders Among Lesbian and Bisexual Women.)

The Journal of Eating Disorders as well as the Science of Eating Disorders blog, have some useful articles and reviews on the subject.

Older Adults

We commonly associate eating disorders with youth and are not aware of how many older adults are also struggling and are unable to access age-appropriate services or services that last long enough to support someone who may have had an eating disorder for decades.  Accurate, thorough, and up-to-date statistics are hard to find, but the National Association of Anorexia Nervosa and Associated Disorders (ANAD) cites one study that estimated 13% of women age 50+ struggle with eating disorder behaviours.

Older adults are thought to develop eating disorders in the following instances:

• They experience a major mid-life change (separation or divorce, job loss or change, moving, looking after elderly parents, and so forth), and begin changing their patterns of eating.  Since most eating disorders are genetic in nature, a combination of stress and changing eating habits can result in development of an eating disorder.

• They had an eating disorder as a youth, and major mid-life changes resulted in relapse, although they may struggle with different symptoms than those they experienced when younger.

• They have struggled with an enduring eating disorder, either without diagnosis and treatment, or having been diagnosed and treated, remain afflicted.

Older adults require different approaches to treatment, but research and evidence-based practice based on the unique population of older adults is still lacking.

Further Reading:

• This article provides a brief, personal account of what life is like as an older adult with an eating disorder: Eating Disorders Deadly for older adults, too.  

• Science of EDs: Not just for Kids: Disordered Eating and Body Dissatifaction in Midlife.

• Science of EDs: Charateristics of Women With Mid-Life Onset of Eating Disorders.

Readiness & Recovery

readiness vs. willingness

(by Sally Chaster)

This is an important discussion to have: will you ever be "ready" to do what it takes to recover? Tackle behaviours head on? Use coping skills instead of those behaviours.  Find out who the real you is behind the curtains of the eating disorder?  For many, the answer is often "No! No, I am not ready. But I am willing..."  

Willingness is so much more important than readiness.  Willingness is what gets us moving in a direction. There is such power in the words "I am willing to try. I am not certain of the outcome, but I am willing to try."

We would argue that there is a third dimension to this dichotomy of readiness and willingness: the desire to recover.  Many of us feel the weight of our eating disorders, interfering with everything we do, crushing us with its incessant demands. Our eating disorders convince us that even though friends and others with eating disorders have lost their lives or have suffered serious physical, emotional, or social consequences, we are somehow different. We are somehow invincible.  It will never happen to us because we do not feel we are "sick enough.” In the face of that brick wall of demands, we may be willing, but we also need desire to recover. With only willingness, we may be stabilized while inpatient, but without desire we may be prone to relapse when more intensive supports are no longer in place.

Eating disorders take over our lives and we are called (by parents, clinicians, other family, or a sudden health crisis as a result of our EDs) to do more than they we might be ready to do.  It is at time that it becomes important to to look within and see if we can muster even a small shred of willingness to try something new. 

ARE YOU WILLING?
The following was originally written by "Keeker" (unfortunately the URL to her site is no longer valid.)

I don’t believe in being “ready” to recover. I believe in being willing to recover, but ready? Who is ever ready to gain [weight], give up purging, or forfeit bingeing? Who is ever ready to give up their illusion of control, the only coping mechanism (albeit negative) that they know?

If everyone waited until they were ready to recover, very few would ever recover. Recovery is scary as hell. Recovery means facing the unknown and, likewise, giving up on the known. If I sat around waiting to feel ready to recover, I’d never move forward. I’d be consumed by my disease.

Because of the nature of eating disorders, I believe most people will never feel entirely ready.

But what they can be is willing. Yes, I will eat this and nourish my body. No, I will not purge even though I’m full and uncomfortable. Yes, I will continue to get back up after every relapse. No, I refuse to give up on recovery. Yes, I will continue to fight that disordered voice for as long as I live. Yes, I am in this for the long run. I may hate recovery, but I hate my eating disorder more, so I will move forward. Because I am willing.

For the time being, I can be willing to go through the recovery motions, and hope that in time I will learn to embrace them with all my heart. I do so for my health. I do so for those who love me. But most of all, I do it for myself.

My eating disorder will never be ready to stop controlling me. It will never be ready to shut the hell up. Which is why, despite my lack of readiness, my willingness must prevail.”

Coping skills

at the root of it, an eating disorder is a coping mechanism

Eating disorders serve as a means of coping that an individual has learned through experience. Recovery then, requires learning and practicing new coping methods in the face of distress. The following is an introduction to concepts and coping skills that can be useful in recovery and may be practiced alone or may be encountered in a more therapeutic setting.

The Function of Emotions

Oftentimes, people with eating disorders experience emotions as unpleasant and one effective way of numbing those unpleasant emotions is by engaging in eating disordered behaviours.

While emotions can be unpleasant at times, they serve an important purpose. The classical theory of emotions purports that they are important for communicating with and influencing others: they prepare us for ,and motivate us to, action, and they can be self-validation (meaning they give us information about a situation or event). These needs are explained in more detail in The Functions of Emotions.  An alternate theory, the theory of constructed emotion developed by Feldman-Barrett purports that emotions construct our reality. Regardless of differing theories, emotions serve an important purpose in our everyday experiences of the world.

While it’s all very well to learn the functions of emotions, sometimes it is a struggle to know what one is feeling as sometimes we may be experiencing multiple emotions simultaneously; some can even be contradictory to one another. All-in-all it can be quite confusing especially in a culture that focuses very little on learning and practicing emotional intelligence (that is “the capacity to be aware of, control, and express one's emotions, and to handle interpersonal relationships judiciously and empathetically.”)

In lieu of professional therapy to help you learn to identify and navigate your emotions, feeling charts can be quite useful in helping one identify a feeling based on its intensity in a given moment.

Radical Acceptance

Radical Acceptance is the skill of accepting non-judgmentally the things you can't change.

You need RADICAL ACCEPTANCE in order to make a change.
We cannot change that which we don't first accept.

ACCEPTANCE is seeing reality for what it is, even if you don't like it.
ACCEPTANCE does NOT mean giving up or giving in.
ACCEPTANCE can be to acknowledge, recognize and endure.
Deciding to tolerate the moment is ACCEPTANCE.
ACCEPTANCE turns suffering you can't cope with into pain you can cope with.
ACCEPTANCE is the only way out.

Three Myths about Acceptance:

1. IF YOU REFUSE TO ACCEPT SOMETHING, IT WILL MAGICALLY CHANGE.

2. IF YOU ACCEPT A PAINFUL SITUATION, YOU WILL BE WEAK

3. IF YOU ACCEPT YOUR PAINFUL SITUATION, YOU ARE ACCEPTING A LIFE OF PAIN.

What makes it so difficult to Radically Accept?
WILLFULNESS

• Imposing one's will on reality.

• Refusing to tolerate a situation.

• Trying to change or fix a situation that cannot be changed or fixed.

• Refusing to do what is needed.

• Sitting on the sidelines of life and refusing to play.

• It is the "terrible twos" - "No! No! No!" [as if refusing to accept a situation, it will magically change.]

WILLINGNESS

• Accepting what is.

• Responding effectively or appropriately to the current situation.

• Doing what works.

• Doing just what is needed in the current moment. EVEN IF IT SUCKS.

Steps to take when willfulness holds you back.

1. Notice it.

2. Radically accept it.

3. Turn your mind towards acceptance and willingness.

(TURNING THE MIND has to happen over and over again - you can't "radically accept" that you're sick once and then you never have to struggle with nonacceptance and willfulness again. Turning the mind is just noticing that you've been distracted and turning back again to what you know.)

• This article on Radical Acceptance below explores radical acceptance with examples of how it supported the author in her own life, and reiterates that we can choose pain by choosing to radically accept a difficult situation, or we can choose suffering by refusing to do so. Suffering is pain that does not diminish.  Acceptance of pain allows it to fade; perhaps never to disappear, but eventually, to not occupy our every waking thought.  

• This article on Radical Acceptance explores the options to radical acceptance, and how some choices cause suffering, which lasts as long as you refuse to accept something you do not like, or that isn't fair, or you weren't expecting, and so forth.  Practice radical acceptance, allow yourself to feel the pain, and sooner or later, you can let your mind touch that pain without being hurt anymore.

Self-Compassion

Self-compassion is a really important skill to learn and practice consistently in your life, not just when you are struggling with your eating disorder.  Are you feeling badly about your grade on a paper?  Self-compassion.  Was someone rude to you?  Self-compassion.  Are you feeling left out?  Self-compassion.  Are you just feeling blue?  Self-compassion.

Okay, okay, but just what is self-compassion?  It is the sharing of love, empathy, support and kindness that you would offer a friend or loved one in pain, except that you offer it to yourself.  It is treating yourself kindly and gently, and validating your feelings whether or not they are actually true.  

Kristin Neff, a leading researcher in the area identifies three components of self-compassion:

1. Self-kindness vs self-judgment

2. Common Humanity vs isolation, and

3. Mindfulness vs over-identification.

Ms Neff describes on her website that self-compassion is:

...having compassion for oneself is really no different than having compassion for others. Think about what the experience of compassion feels like. First, to have compassion for others you must notice that they are suffering. If you ignore that homeless person on the street, you can’t feel compassion for how difficult his or her experience is. Second, compassion involves feeling moved by others’ suffering so that your heart responds to their pain (the word compassion literally means to “suffer with”). When this occurs, you feel warmth, caring, and the desire to help the suffering person in some way. Having compassion also means that you offer understanding and kindness to others when they fail or make mistakes, rather than judging them harshly. Finally, when you feel compassion for another (rather than mere pity), it means that you realize that suffering, failure, and imperfection is part of the shared human experience. “There but for fortune go I.”

Fine so far, right?  But how do you actually treat yourself with self-compassion when you hear that little voice that pipes up when you feel like you are a failure because? Try being kind to yourself instead.  Reassure yourself that nothing takes away your integral worth and that you deserve to be treated with the same gentle compassion you would give to anyone else. Instead of punishing yourself, talk to yourself the way you would talk to a friend or a child in similar circumstances: would you tell them they deserve to "fail" or they deserve to be punished?  Probably not, so why are you any different?

Head over to self-compassion.org for more information, and also, for a short test that identifies your own self-compassion in five spheres.

Managing Anxiety, Distress, & Worry (by Sally Chaster)

Anxiety is one of the emotions that can keep us trapped in our eating disorder: food anxiety, weight anxiety, family dinner anxiety, restaurant/food court anxiety, work/school anxiety, life and death anxiety.  It is important to work on changes you can make to your surroundings, routine, and emotion management to develop the resilience that will support your recovery efforts.  

Technically, anxiety is apprehension over an upcoming event. We anticipate the future with sometimes scary predictions that don’t necessarily have any basis in truth. In everyday life, anxiety’s physical and emotional symptoms can mean an increased heart rate, poor concentration at work and school, sleeping problems, and just being a total Crankasaurus Rex to family, friends, and co-workers.

Everyone feels anxiety about something at some point in their lives; anxiety is the perception of danger(s) that doesn't really exist.  Anxiety, and all emotions are a way of communicating with the world around us to receive input on what is happening. But an emotion is not a fact, and anxiety is not a guarantee that something awful might happen to you if you do/don't do whatever anxiety is telling you to do.  

In 15 Ways to Beat Anxiety Now, author Giuliana Hazelwood provides concrete and longer term ways to reduce anxiety.  

But what about those days when you are in the middle of overwhelming anxiety?  What do you do then? I try to work on bringing myself back into the present, away from the worrying and bickering going on inside my head. I start by assessing what is going on with my body.  Typically, my shoulders are tense, and my abdomen, too.  I make a conscious effort to lower my shoulders, and try to relax both my shoulders and abdomen.  I also tend to notice that my breathing is shallow, and rapid. While it is one thing to tell you to breathe deeply in and out, that can be a bit difficult when you feel immobilized by anxiety.   

Paced breathing is one of the skills I try to practice to control my breathing; it not only gives you something different to focus on, it can also be quite effective at reducing anxiety.  In essence, paced breathing is about breathing in deeply - say to 4 deep breaths - and breathing out for longer than you breathed in, in this instance five breaths.  Or you could use five in/six out.  One way to practice this skill so it comes more naturally to you is, where possible, to "walk" your breathing'; that is, to count your breathing by the number of steps you take (don't hurry or run).  So, take five breaths to five steps and breathe out over the course of six steps, as an example.  

Paced breathing still works if you are not able to move around. If seated or lying down, make sure your entire body is relaxed.  From there, count inside your head to four or five breaths in, and five or six breaths out.  Practice this meaningfully and without judgment; just focus on your breathing and counting.  You can download a paced breathing app on to your cell phone, like this one, and numerous others listed on Google.

Another thing I do when anxious is the 5-4-3-2-1 sense inventory.  Start off by naming five things you can see, four you can hear, three you can smell, two you can touch, and if possible, one you can taste.  After five, do it again, but to the count of four (yes, you can count ones you counted before, but also let new experiences into your senses). Then three, two, and one, and do an inventory of how anxious you are.

My final advice that I use for grounding myself is to look around my surroundings and name the items my eyes fall on; I might notice the chair sitting across from me, some ceramic art my daughter did when she was very young, my cat, the silver box we use to store cards in, and so forth. In a sense, naming them is owning them, or re-claiming my surroundings, and it brings me into the present moment where I am better able to quiet those "voices" in my head that tell me lies that "this" will happen if I do "that".

Remember, all anxiety reduction methods should be tried with curiosity, and not with judgment. These are skills, and like any skill, they require practice over and over, even when you are not anxious, so that you have learned the skill for when you really need it.

To get some more ideas from experts, you can check out these sites: Ten Tools That Help Relieve Panic Attacks, and Driving Peace. 

Setting Healthy Boundaries

"Boundaries are not selfish. They aren’t overindulgent or evidence that you’re too sensitive, and they aren’t weakness. Boundaries are conditions that allow you to take care of yourself; conditions that give you the means to survive and keep from sinking. They’re circumstances that honor your needs and respect your feelings. Limits that YOU get to decide on; limits that are inherently valid, regardless of how they compare to anyone else’s. You deserve to create a space for yourself that feels safe and supportive. You deserve to exist under terms that don’t harm you; terms that allow your best self to come through. Even if other people don’t understand; even if it makes them feel angry or rejected or sad — your boundaries are necessary and they matter. Their needs matter too, and it’s not wrong to want to make shifts to accommodate both — but the truth is that you can’t take care of anyone else if your own needs aren’t being met. You don’t have to explain your boundaries. You don’t have to justify them, and you don’t need anyone’s approval. You need to believe that you’re someone worth taking care of, and you need to trust that if anyone is entitled to your protection and care, it’s you." — Danielle Koepke

WHAT ARE BOUNDARIES? 

Boundaries are rules or limits we set in relationships with others that are specific to each individual (i.e., one person may give hugs to people they may have just met, but another person prefers to hug only people they are close to, still others do not wish to be touched or hugged at all). Someone with healthy boundaries is able to say no, or yes, depending on what they need. They recognize their boundaries and honour them. Someone with unhealthy boundaries may look two ways: they say yes when they really want to say no and vice versa, or they keep people at such a distance that they struggle to form close relationships. 

Healthy boundaries are essential not only to having healthy relationships, but also to our happiness.

The first step to honoring your boundaries is to identify what kind of boundaries you tend to have. In order to grow, it is important to be honest with yourself.

TYPES OF BOUNDARIES

1. Porous Boundaries: Difficulty saying no to others, oversharing personal information, overly dependent on the opinion and validation of others, over-involvement in others’ problems, accepting of abuse and disrespect, fearing rejection when you act against another’s wishes. 

2. Rigid Boundaries: Avoids intimacy and close relationships, feels uncomfortable with closeness and asking for help, holds few close relationships, very protective of personal information, often detached from others, keeps others at a distance to avoid possible rejection.

3. Healthy Boundaries: Recognizes their limits and values and does not compromise on them, values own opinions, can communicate needs and limits to others, accepting of others and their expressed boundaries.

DEFENSES VS. BOUNDARIES

• A boundary lets positive things through and keeps harmful things out. A defense indiscriminately keeps things out.

• Setting a boundary is a conscious and healthy way to protect ourselves from emotional harm. Being defensive can lead us into unhealthy and unproductive behavior.

• Boundaries derive from love and self-worth. Defenses derive from fear and the belief that you are worthless.

BOUNDARY ERRORS VS. BOUNDARY VIOLATIONS

• A boundary error occurs when a person crosses a boundary accidentally or out of ignorance.

• A boundary violation is when a person disregards us when we tell them that a boundary exists.

These are some websites which provide more information about healthy boundary setting and maintenance:

• Serenity Online Therapy

• 10 Ways to Build and Preserve Better Boundaries

• 5 Ways to Maintain Boundaries with Difficult People

Practicing a Non-judgmental Stance

Exercises for Non-judgmental Thinking (by Christy Matta)

“Cultivating non-judgmental thinking is taught in Dialectical Behavior Therapy (DBT) Skills Groups as a part of the Mindfulness Training.  Mindfulness teaches individuals to observe and describe their own behavior, which is necessary when any new behavior is being learned, when there is some sort of problem, or a need for change.

In DBT, mindfulness skills are intended to improve an individual’s abilities to observe and describe themselves and their environment non-judgmentally, which enhances the ability to participate in life effectively.

• A NON-JUDGMENTAL STANCE: Judging something as neither good nor bad. Everything simply is as it is. Focusing on just the facts.

Judging is often a short hand way of stating a preference. In my recent post “Why Not Judge” I discuss judgmental thinking in greater detail and mention that “judgments are spontaneous and often inaccurate interpretations of our environment that influence our thinking and behavior.”

For example, if we judge a piece of clothing as pretty or beautiful we are stating a preference for that thing.  If we say it is ugly, then that is short hand for “I don’t prefer that.”  The problem is that we sometimes forget that our judgments are not facts, but are only our own preferences and opinions based on our own experiences.

Forming judgments is a spontaneous process and there are times when we need to make judgments.  However, in order to reduce emotional reactivity, it’s important to become aware of your own judgmental thinking and to develop the ability to think non-judgmentally.

EXERCISES IN CULTIVATING A NON-JUDGMENTAL STANCE

Focus on Language

Because it is so difficult to maintain a non-judgmental stance during times of stress and crisis, you may want to identify certain common judgmental words and phrases that trigger you to stop and observe your thinking.  Frequently used judgmental words include: “right,” “wrong,” “fair,” “unfair,” “should,” “shouldn’t,” “stupid,” “lazy,” “wonderful,” “perfect,” “bad,” and “terrible.”

Identify your common self judgments. (I’m bad, stupid, lazy, weak, not worth it etc.).

Turn that self judgment into a nonjudgmental descriptive statement.

When X happens (describe the situation).

I feel X (use a feeling word) e.g. “when someone yells at me, I feel helpless and afraid.” Or “when I make a mistake, I feel anxious and ineffective.”

Focus on Breathing

Bringing your focus to your breathing helps you calm, relax and slow down your thinking.  It enables us to get in touch with the present moment and let go of all the thoughts and judgments about the past and future.

Notice Your Thoughts

Bring your attention to your thoughts and judgments when you are doing simple activities, like eating.  Notice the thoughts you have about the food, as you eat it.  Don’t try to counter your judgments, just notice that they are there.

Judgments tend to activate extreme emotions.  If you want to live a less judgmental life, you must first become aware of your own automatic thoughts and judgments.  Learning to think non-judgmentally takes practice.  You have to be aware of when judgmental thinking occurs and practice bringing your attention to just the facts.”

Pros & Cons Lists

Pros and cons lists can be a helpful way to process ambivalent thoughts and assist in considering and/or making decisions. Should I pursue more formal treatment? Should I engage in this behaviour? Do I want to hold on to my eating disorder or do I want change?

There are often conflicting emotions around these kinds of decisions even if they feel like they "should" be straightforward. Ambivalence is a normal (and well-documented) aspect of eating disorders. We have to remember that our eating disorders give us something, they serve a purpose in our lives.

Writing a pros and cons list around decisions can help you put your thoughts onto paper and create a visual to refer back to. It's helpful to avoid looking at things in black-and-white terms such as "good" or "bad." It's more important to simply step back and look at consequences and whether these outcomes match up with your personal values and hopes for the future.

One really helpful example of  different way to look at pros and cons is the format used in DBT shown here and here.

Learning How To Tolerate, Accept, and/or Love Our Bodies

The body positive movement has been growing in recent years. This is encouraging, but for some of us it can feel so impossibly far away. We live in a culture that teaches us from an early age to pick apart our flaws, to hate our bodies, and to change them to suit what society deems as "ideal."

If you can reach a place of loving your body, that is wonderful, but sometimes it's a long process and the place to start is simply learning to tolerate your body and potentially moving on from there. If you only learn tolerance, that's okay too. It's just about putting down our weapons and refusing to fight with our bodies any longer.

Sometimes focusing on what our bodies allow us to do can be helpful. If you love gardening you practice appreciating the feel of the sun on your skin and your hands working in the soil, the strength in your arms to pull and to plant. Your body allows you those experiences.

Finally, surround yourself with body positive role models like Sonja Renee Taylor, Megan Jayne Crabbe, and Jen Bretty.

Opposite Action

Opposite action is another helpful DBT strategy. It involves recognizing an urge and going against it. This skill is relevant to eating disorders, impulsive behaviours, anxiety, and depression.

The following is taken from an article on Psychology Today written by Jennifer Rollin:

"The first step is to identify and name the emotion that you are experiencing. The next part is to determine whether the emotion (including it’s intensity and duration) “fits the facts of the situation.” Additionally, a person can ask themselves whether acting on the urge will be effective in the long-term. Then, based on these answers, a person decides whether to act on their urge or to do an action that is opposite to the urge.

AN EXAMPLE OF OPPOSITE ACTION

Emotions are important in that they provide us with information and signals about things to pay attention to in our lives. There are times when an emotion “fits the facts of a situation” and motivates us towards effective action. For instance, feeling anxiety about an important exam could serve as a motivator to study. Or feeling anxious while walking home alone at night could help someone to maintain a better awareness of their surroundings.

However, there are times when an emotion “does not fit the facts of the situation” and when acting on an emotional urge is not effective. For instance, feeling intense anxiety about eating dinner at a restaurant does not “fit the facts of the situation,” and could cause someone to feel the urge to avoid socializing and going out to eat. Over time, this avoidance behavior only serves to make the anxiety worse. Additionally, it could start to negatively impact an individual’s relationships. In this instance, it would be helpful to note that you are experiencing the urge to avoid eating out and to the take an “opposite action,” which is more in alignment with your life values. For instance, pushing yourself to have meals out at a restaurant (despite feeling afraid), would be taking an opposite action.

It's a skill that takes practice as it involves distancing oneself from sometimes very intense emotions in the moment.”

Trigger Management

Triggers are everywhere in the world around us. Some are avoidable and some are not. Some are specific to your individual experience and some are broader.

There are certain steps you can take to avoid some triggers which can be a helpful way to support your own recovery and well-being. You can do your best to avoid situations where you might be triggered (e.g. large crowds and close proximity to others). You can avoid looking at harmful online images and content in certain "pro" communities. You can steer yourself (to some degree) away from harmful media content (e.g. shows that depict sexual violence - there's actually a great website called Unconsenting Media that works with a list of media that has suggestions of or actual depictions of sexual violence).

Love Our Bodies Love Ourselves has featured a few articles on taking care around social media and managing triggers

• Nutritionists Social Media Strategies for Preventing Food Obsessions

• How Social Media Can Harm Body Image

• Eating Disorder Accountability: The Media Indirectly Says Lose Weight

The other side of trigger management is that the world is full of them and sometimes challenging yourself to work through those triggers can be an important part of your recovery (especially in regards to weight, body shape, and imagery). Determining whether that's where you're at is an individual process.

Relapse Avoidance

Relapse happens; it's a normal part of recovery. That said, there are steps we can take to avoid relapses and to get back up from them when they do occur.

The following is an excerpt from Kelty Mental Health:

"It takes a lot of courage, hard work, strength and support to recover from an eating disorder. Most people can’t reach this point without a few slip ups and minor setbacks. Relapse is when a person who is in recovery goes back to disordered eating behaviours or negative thoughts about food, weight, and body size. The way to prevent a relapse is to recognize and deal with some of the things that could get in the way of recovery.

“So the more I learned what my triggers were, what I was good at and where my vulnerabilities lied – the easier it was for me to adapt. Likewise, the more I knew what strengthened me and the support and resources I possessed, the easier it was to adapt.” ~ Amy

STRATEGIES FOR PREVENTING A RELAPSE:

1. Develop a support system – and use it! - it is very important to surround yourself with people who love, support and encourage you. These people can be members of your family, your friends, or your care providers. They will be there to help you when you are struggling with a difficult situation or experience. It’s not always easy to reach out, but you should feel comfortable asking for help when you need it. Some people find it useful to make a list of names and phone numbers to call if they start to slip back into old thought patterns or unhealthy eating behaviours.

2. Reduce negative influences - try to identify the negative influences in your life, and find ways to reduce or avoid these unhelpful situations. These negative influences might include people who make unhelpful comments about their own weight and appearance, or trigger you to make unhelpful comparisons about your weight or shape. Your own thoughts can also be unhelpful! Learn to challenge any destructive thoughts you have about yourself. Make a list of all of your good qualities and use it when you feel critical or negative.

3. Identify your “triggers” - a “trigger” is anything that can cause you to return to disordered eating behaviours or thoughts. Each person has their own triggers. They often include feeling stressed, anxious, depressed or lonely. Sometimes an upsetting or traumatic experience can be a trigger. Some people are more likely to relapse at certain times of the year, for example during holidays or exams. To identify your triggers, think of times when you were tempted to act on eating disorder urges. Try to figure out what contributed to these urges.

4. Make a personal coping plan - make a list of different triggers that could cause you to act on eating disorder urges. Then, come up with a plan for dealing with each of these triggers in a healthier way. Your coping plan might include calling a friend, taking a walk, or writing in a journal.

5. Eat snacks and meals regularly - a meal and snack schedule can prevent you from going back to disordered eating or unhelpful eating behaviours. Plan your meals and snacks ahead of time, and stick to your plan! Eat three meals a day, plus snacks, at regular times (about every 3 hours). A consistent schedule will be good for both your emotional and physical health. Your family may be able to help by eating meals together with you as often as possible.

6. Keep busy and stay involved - get involved in a hobby or activity that you enjoy. It can be anything from arts & crafts, to volunteering, to nature walks, to joining a club. If you make time to do the things you enjoy, or to do nice things for others, your focus will shift away from your eating disorder. It can also help to keep you motivated to recover and to stay connected to your surroundings and the people in your community.

7. Make time for yourself - it is important to take time to do something good for yourself every day. Some people find it helpful to use this time to relax or reflect. Some do yoga or meditation. Others draw, paint, write, or listen to music. No matter what you choose, remind yourself that you are important. You deserve to take this time to do something that is just for you!

Signs of Relapse
It is important to remember that recovery is possible, even for those who have struggled with eating disorder symptoms for a long time. If we know some of the signs of relapse, we may recognize when someone is returning to eating disorder patterns. Then, there is a chance to prevent a slip from turning into a relapse.

Examples of warning signs include:

• checking weight daily

• skipping meals

• over exercising

• needing to be perfect

• increased need for control

• difficulty coping with stress

• feeling sad or hopeless

• wearing loose-fitting clothing

• worrying about weight

• avoiding situations that involve food

• looking in the mirror a lot

• spending a lot of time alone

If you notice some of these signs in yourself or a loved one, and are worried that a relapse may happen, it is important to get help right away. The support of a mental health professional can be very important in preventing relapse. This is especially true during the early stages of recovery and/or relapse.

Articles

A collection of articles on recovery, diet-culture, mental health, and more!

RECOVERY AS A JOURNEY OF THE HEART

While this article is not specific to eating disorders, it is an excellent article about mental health for all to read (clinicians working in the field especially).

WHAT THIS WOMAN NOTICED AT A BOOKSTORE SAYS SO MUCH ABOUT SOCIETY'S OBSESSION WITH WEIGHT

An article by Refinery29 that explores eating disorders and society's obsession with weight loss.

5 THINGS YOU SHOULDN'T SAY TO SOMEONE WITH AN EATING DISORDER

It can be hard to know what to say to your loved one, friend, colleague, etc. who is suffering. This article provides a little bit of guidance.

Of course, it's always important to check-in with the individual person because everyone's different.

THE WEIGHT-INCLUSIVE VERSUS WEIGHT-NORMATIVE APPROACH TO HEALTH: EVALUATING THE EVIDENCE FOR PRIORITIZING WELL-BEING OVER WEIGHT LOSS

This article is an excellent exploration of weight stigma in health care and the outcomes of such stigma.

HERE’S HOW FATPHOBIA IS BEING MARKETED TO YOU – AND WHY SO MANY OF US BUY INTO IT

An Everyday Feminism article that explores how profitable fatphobia is: “...nearly half (47.4%) of overweight people and 29% of obese people were, from a metabolic standpoint, quite healthy.” On the flip side, more than 30% of individuals with “normal” weights were metabolically unhealthy."

Fat is not the problem; stigma, misleading "facts," and diets are.

101 SELF CARE TIPS

Because eating disorders are often too much about shame and guilt, self-hatred, and low self-esteem, it is really important to learn skills like self-care, both in terms of learning to be mindful, but also to provide counter-point to the harmful messages and emotions that come with being eating disordered.

This article by The Mighty lists 101 self-care tips you can explore when it all feels like too much.

THE BIG FAT TRUTH

A news feature from the journal Nature that explores some of the misconceptions around obesity and health that run rampant in our society.

The author, Virginia Hughes, explores several articles that offer evidence that obesity is not what it seems, or at the very least, much more complex than various news headlines would have us believe.

WHAT I HEAR WHEN YOU SAY I'M DOING WELL IN RECOVERY

This piece from The Mighty looks at the mixed feelings that come with recovery from an eating disorder and hearing those words "you're doing well."

"There is nothing harder for me to hear in recovery than hearing I am doing well. It doesn’t make sense, I know. Wouldn’t I want to be told I’m succeeding and making progress in recovery? The truth is, it feels awful because recovering from an eating disorder isn’t a victorious process. It is agonizingly painful and terrifying."

GRAND UNIFIED THEORY OF FEMALE PAIN

Leslie Jamison is the author of the Empathy Exams, a book that looks at the concept of empathy and pain. Beginning with her experience as a medical actor who was paid to act out symptoms for medical students to diagnose, Leslie Jamison’s visceral and revealing essays ask essential questions about our basic understanding of others: How should we care about each other? How can we feel another’s pain, especially when pain can be assumed, distorted, or performed? Is empathy a tool by which to test or even grade each other? 

The Grand Unified Theory of Female Pain is the final essay in the book. It is a long, but excellent read.