Questions and answers about identifying and supporting people with possible eating disorders

An eating disorder is more than just losing or gaining weight; it’s about the thoughts and feelings that are going on inside the person’s head. Below are some lists of the different signs that may indicate your friend or family member has an eating disorder. Please note that not everyone will display all signs and there could be some that we have missed.

If, after reading this page, you think your friend or family member does have an eating disorder, it’s very important that you talk to them about it and try to get them to talk to a professional. No one is to blame for having an eating disorder but it is unlikely to go away without help from a professional.

Eating disorders are usually very secretive and you may find that you haven’t noticed many of the signs below. Some of these signs will only be visible if you live with your friend or family member and even then, someone with an eating disorder may be very clever at hiding it from you. You may want to talk to another friend or family member and see if they’ve noticed anything. The more people that are concerned for your friend or family member, the more likely it is your friend or family member will realise they have a problem.

Behaviours around eating

Often people with eating disorders display very specific behaviours around meal times. Do they…

• refuse to eat with others
• feel very anxious about eating in public
• eat different foods from everyone else
• eat food at different times to everyone else
• not talk much (or talk heaps) during meals
• leave the table frequently during meals (especially to go the bathroom)
• secretly dispose of food during the meal (wrapping it in a napkin, wiping it on the underside of plate, putting it in pockets)
• drink an excessive amount of water (at meals, before meals or during the day)
• lie to people about how much they have eaten

Behaviours around food

If they are restricting their intake (not eating much) you may have noticed the following behaviours. Do they?

• refuse to eat or only eat tiny amounts
• say they feel full after eating only a small amount of food
• frequently say they are not hungry
• seem obsessed with food
• spend lots of time looking at recipes
• cook for others but not eat themselves
• become very concerned and ‘worried’ about what others are eating
• count calories or measure food quantities
• talk about food a lot
• only eat particular types of food or at certain times
• claim they have a dislike of or are allergic to particular foods (e.g. red meat, carbohydrates, gluten) so they don’t have to eat them
• only eat diet or non-fat foods
• have difficulty choosing foods to eat
• prefer foods of a certain colour or texture
• compulsively arrange their food before eating it
• cut food up into tiny pieces
• eat with a teaspoon
• mix their foods together before eating them
• only eat one type of food at a time
• add lots of condiments (salt, pepper, relish, mustard, vinegar) to their food
• eat extremely slowly
• eat food in a specific sequence

If they are binge eating you may have noticed the following behaviours. Do they?

• hide food in their room or a separate cupboard
• hide food wrappers around the house so no-one finds them
• find it hard to explain where money in the flat account went
• often go for walks to find, buy or steal food
• fast or restrict food between binges

If they are purging you may have noticed the following behaviours.

Do they?

• vomit after eating ie. go the bathroom immediately after meals
• use laxatives, diuretics or enemas to try to lose weight
• feel anxious if they are unable to vomit after eating

Emotions and thoughts

Do they?

• believe they are fat when they are not
• wish they were thinner or a different shape
• have black and white thinking about food. ie good food & bad food
• have low self esteem
• have a need for perfection
• have periods of depression
• become very irritable and argumentative – especially around food and meal times
• think in extremes e.g. “if I’m not thin, I’ll be grossly obese”
• seem very anxious around food
• deny or minimise the seriousness of their behaviour
• seem unhappy about their current size or body shape

Are they?

• over-sensitive to criticism
• extremely concerned about their appearance, both physical and behavioural
• more anxious than in the past (especially around situations that include eating)

Physical signs of starvation

Have you noticed?

• a significant weight loss (although this doesn’t always happen)
• the hair on their head thinning or losing more than normal eg. More hair than usual in the shower after washing their hair
• the appearance of fine raised hair on their body (lanugo)
• their skin being pale and dry
• their periods being irregular or have stopped all together

Physical signs of bingeing and purging

Have you noticed?

• their weight fluctuating up and down
• their cheeks being puffy
• their eyes being red
• scars on their knuckles from making themselves sick (having their fingers down their throat)

Other signs

Finally you may have noticed the following signs. Do they?

• deny being ill or underweight
• frequently weigh themselves
• avoid social interaction so as to avoid food
• exercise excessively
• get upset when things aren’t how they’d like them to be
• wear baggy clothes
• abuse alcohol or drugs
• buy diet books or get them out of the library
• seem very secretive (esp around what they have eaten)
• have a decreased interest in sex
• have trouble sleeping
• have problems concentrating
• have memory problems
• have difficulty comprehending information
• have difficulty making decisions
• have difficulty with money from spending lots on food
• shoplift food or laxatives or steal money to buy food

Please remember that there are many different types of eating disorders. Every person’s pattern and experience of an eating disorder is unique.

Anybody can develop an eating disorder, although there are some groups of people who have a higher risk.

Females

About 90% of people with eating disorders are females, however they are becoming more common in males.

Teenagers

Anorexia and Bulimia commonly begin in the teens, although cases have been recorded in children as young as six years old. Anorexia often begins in teen’s aged 13-18 while bulimia often starts later, in the late teens or early twenties.

Particular families

While once eating disorders were mainly only seen in middle to upper class families who were extremely close and over protective this is not so much the case anymore and eating disorders are seen in all socio-economic groups and all types of families. However, there is an increased risk if a parent or sibling has had an eating disorder, mood disorder or alcohol or drug problem.

Particular countries or ethnic groups

Eating disorders are more common in industrialised societies where there is an abundance of food and where there is a cultural ideal for women to be thin. While this used to be mainly white societies, eating disorders are now occurring in almost every culture and ethnic group.

Growing up in a society that places a high value on women being thin

Societies that believe women should be thin often give out very conflicting and confusing messages to young women about their size, food, diets, health and the roles they should have. These conflicting messages can contribute to the development of an eating disorder.

Particular groups of individuals

Eating disorders are more common in adolescent females and young women, women at university, individuals in sports or professions where there is a high value on being thin (eg. Ballet, gymnastics, running, modelling)

Individual characteristics

Eating Disorders do tend to be more common (although not exclusive) in people who:

• Are perfectionists – both physically and academically
• Have low self-esteem
• Have high body dissatisfaction – don’t like the way they look
• Have difficulty naming their emotions
• Have periods of depression

Sexual abuse

Being sexually abused as a child is often a contributing factor to the development of eating disorders

Dieting behaviour

While not every dieter will develop an eating disorder, nearly every eating disorder begins with some kind of attempt at weight loss.

Helping someone with an eating disorder can be very difficult. Below are a number of things that can make the process easier for the both of you:

• Be patient. Recovery from an eating disorder can be a long process. Do not expect overnight recovery even if the person is seeing a counsellor or attending a group. Support them in making changes in their own time.
• Accept and validate the feelings they have, rather than telling them how they should feel.
• Do not lay blame. This only reinforces the person’s feelings of shame.
• Encourage discussions about feelings (if they won’t talk to you try to suggest someone else they might talk to).
• Spend time listening.
• Show that you care. Be as warm and supportive as you can without making them the focus of your attention.
• Avoid food related discussions or discussions focusing on weight or body size. These can reinforce the persons feelings of inadequacy. Focus your attention as well as your comments on things other than appearance. Eg “I like the way you laugh/handle your work/talk to your friends”.
• Let them maintain control over their life/activities and take responsibility for their actions as much as possible, and try not to make decisions for them (this will depend on how worried you are about her physical and mental health).
• The person must feel that they are making their own choices regarding the time, speed and resources they use in their daily routine. This can be frustrating for supporters, however the situation may become worse if the person feels that they have lost control. Treating them with respect, and allowing them to take responsibility for their actions will support and increase their sense of self worth.
• Look at your family’s/flat’s rules, behaviours, and beliefs around food. Try to be consistent in family/flat approaches (i.e., ensure you are all saying the same thing to the person).
• Give them the help they want. If they don’t want you to buy them certain foods for a time, not to ask parents/friends to visit etc, respect this. Don’t “know better” than them.
• Learn everything you can about eating disorders, the more you know the more you can understand. Understanding is a key to coping. We have a list of books that you may find helpful.

Seek support for yourself also

It is vital that you care for yourself when giving support to others. Seek some outside support, find a family member, friend or support group where you can talk about your feelings and frustrations. Most importantly, continue to have your own life and do the things that matter to you.

An eating disorder is difficult to cope with – especially when it strikes someone you love. It is important to remember that you cannot solve it alone, you didn’t cause their eating disorder and you can’t make them better, but you can probably help. Friendships and families are all different and you will find your own unique way through this time. Dealing with an eating disorder is very exhausting, you may feel unwanted and out of line, you might even feel guilty. That’s okay – you’re doing your best.

Remember that it is the disorder that you are both struggling with, not each other. It is very important to get support for yourself if you are supporting someone with an eating disorder, as it is easy to get overwhelmed by it. An eating disorder affects more than the person who is experiencing it.

The earlier that someone can receive professional support, the better the outcome will be.

The level of intervention that a person with an eating disorder needs depends on their ability to maintain a balanced physical state.

A balanced physical state is where the person is able to maintain their physical health at a level at which they can survive and live reasonably. This includes maintaining their natural weight. Obviously this is hard to determine. Examples of “living reasonably” would be the absence of feeling faint, dizzy, difficulty concentrating, heart palpitations, always feeling cold and shaky. See a doctor if you are concerned with any physical symptoms.

Sometimes an eating disorder is so powerful that it is impossible for the sufferer to make good choices for themselves. Decide whether they can control their own eating on this basis.

If they cannot maintain a balanced physical state, you (or someone) need to take charge of this for them as much as you are able.

If they can maintain a balanced physical state, support them to start challenging the eating disorder and the ways that it impacts on their life, but let them lead this process.

If they cannot maintain a balanced physical state themselves, what should I do?

Ideally the person should be encouraged to make as many choices and decisions as possible (with guidance and encouragement), however depending on their physical state, their age, whether they are living with you and whether you are able, some suggestions are:

• Take them to a professional mental health clinician or GP or go yourself
• Be aware of the symptoms of the eating disorder and know when to seek professional help
• Take control of their eating and exercising routine, but leave them in charge of the rest of their life as much as possible
• Spend quality time with them away from food issues
• Talk with them about the things you can do that will help
• Limit activity according to the amount of food they are eating or keeping down
• Find a way for them to eat – this will be unique to your family/friendship, they may need you to sit with them, or to have specific food (that is less scary to them) at specific times etc
• Do not give them options about whether they eat, but they may have options about what, when and how much, within the limits of safety.
• Do not enter long negotiations about food
• If they are vomiting, make sure they are with someone for at least half an hour after eating; reduce the opportunities for them to vomit or binge
• If they are vomiting or using laxatives challenge this and encourage them to cut down their use of them, with a doctor’s advice.
• Make sure there is food in the house that they like to eat

• Join a support group – by sharing experiences within a group you can learn new ways of coping.
• Read – study the subject. We can suggest books that you might find helpful.
• Don’t focus on food, talk about other things.
• Don’t put the blame on the sufferer – this only makes things worse.
• Use “I” statements rather than “you” statements – for example, “I am upset” rather than “you are making me get upset”.
• Listen – spend time listening, avoid speaking about your own experiences.
• Remember, you are an individual too and have your own life. If the person with the eating disorder seems to be controlling your life as well as theirs, take time out and try and see why this is happening.
• Encourage openness within your family or social group – look at the rules and norms – are they positive? Are they too rigid?
• Treat the anorexic/bulimic person with respect and stand back, allowing them to take responsibility for their actions.
• Accept and love the person for what they are and not what you would like them to be of who you think they ought to be.

Remember: RECOVERY IS POSSIBLE; it takes time and hard work. Don’t give up.

If you think your friend or family member may have an eating disorder it is important that you seek help from a professional. This could be the hardest thing they have ever done and persuading them they should talk to someone will not be easy. Be prepared for denial and refusal to admit or acknowledge they have a problem. Remind them that you know it is difficult and scary but also very important. No one is to blame for having an eating disorder and they seldom go away without professional help.

Here are some suggestions on who you could get your friend or family member to talk to – or you could contact them for some information about how they can help you. Remember though it is better if the person is able to contact the agency themselves. You can always go with them for support.

For anyone

• Talk to your local doctor
• Call your local Citizen Advice Bureau for your local counselling services
• Look in your local phone book under counselling services or psychotherapist and psychotherapy services
• Contact NZAC (New Zealand Association of Counsellors on 07 834 0220 or execofficcer@nzac.org.nz) or NZAP (New Zealand Association of Psychotherapists on 04 475 6244, Mon – Fri 9am – 1pm) for a counsellor or psychotherapist in your area.

If they are still at school

• Talk to a teacher
• Talk to your school counsellor
• Talk to a GP / Doctor

If they are at university

• Talk to someone at student health
• Talk to someone at the student counselling service

If they are female

• Your town or city may have a women’s centre that offers counselling services or can refer you on to a doctor or therapist.

If they live in the Greater Wellington Region

• Have a look at the services we provide and contact us

There are many types of therapeutic tools. There’s talk therapy – where you talk about your experiences and express your feelings. There are counsellors who take this approach and also incorporate massage, breath work, body work, movement or role-playing. Some counsellors use art, writing or theatre – others use hypnosis.

If you start working with someone and the counselling doesn’t meet your needs – change to a new therapist.

Be willing to do a fair amount of work to find a counsellor – you don’t have to go to the first person you find. Speak to prospective counsellors on the phone, compare their orientations, and how you feel when you talk to them. Also consider the cost.

Questions you may like to ask

• Have you ever worked with women with eating difficulties? What kind of training do you have in this work?
• How do you work with people who have eating disorders? What are the techniques you use?
• What do you think are some of the contributing factors in how we develop issues around food?
• Do you think self-help / support groups are useful for people with eating issues?
• How much do you charge? Do you have a sliding scale of fees?
• Do you have experience in working with bi-sexual people, homosexual people, sexual abuse, alcohol related issues, marriage guidance? (include any other issues that may be relevant to you).

You may also wish to work with only women or only men, and may want to make choices around the race, socio-economic background, sexual preference and religion / spirituality of your counsellor. Don’t be afraid to make these preferences.

What does effective counselling feel like?

You should feel understood and supported, warmth between you and your counsellor.

Counselling may not always feel comfortable, but you know when you’re with someone who is right for you when you feel that you are developing more skills to heal yourself as time goes on. You become able to recognise your own patterns and to feel and interpret your own emotions, as time goes on you may look to develop more independence.

References

American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders (4th Ed.) United States of America: American Psychiatric Association.

Bulik, C, (1994). Eating Disorders: Detection & Treatment. New Zealand. Dunmore Press Limited.

Leon, G.R., Fulkerson, JA., Perry, CL, Cudeck, R. (1993). Personality and Behavioural Vulnerabilities Associated with Risk Status for Eating Disorders in Adolescent girls. Journal of Abnormal Psychology. 102.(3) 438-444.