My Friend ED: The Complex and Challenging World of Treating Eating Disorders

Bulimia. Anorexia.  Purging. Orthorexia. EDNOS. ED.  An eating disorder by any other name still sucks. 

Eating Disorders have the highest mortality rate of all psychiatric illnesses yet despite their prevalence, talking about them remains terrifying, taboo, and to be avoided at all costs. 

And why? 

There is a major lack of understanding – conflict inevitably arises when there is a lack of communication and therefore clarity

For insight, I interviewed Kelly Lavender, a private counsellor who has been helping patients recover from eating disorders for the past 20 years.  

ME: Thanks so much for agreeing to be interviewed. Would you mind telling me about your background, what do you do and what is your goal for patients?

KELLY: I’m a Registered psychotherapist operating out of a private practice in Auckland who specialises in eating disorders. The goal for all the clients I see is for them to become fully recovered from an eating disorder –  but I think goals also need to be individualised on a case by case basis. While it’s ideal that everyone would be one hundred percent better, because of the vicious nature of these kinds of diseases, it’s just not always the reality. But, I always hope that my clients will be happy and live a fulfilling life. 

That’s so great- I love that counsellors are beginning to embrace the idea that there is no one treatment plan that will work for everyone. But I understand that hasn’t always been that way?

Yes, ideas about EDs have changed a lot over the years. Years ago, there was some very archaic thinking that shaped treatments in a not-so-positive way. Patients would be treated on their own, without family involvement, and it was believed that hospitalisation was the best treatment.  Eating Disorder treatment has come a long way and there are clear evidenced based treatment available. In particular, Family Based Treatment. . The family is much more involved, in fact are seen as a key resource, particularly in adolescent  and young adult populations. In the past, parents or the family environment were often viewed as contributing in some way to the development of the ED, which we now know is incorrect and can actually be a damaging view to take. We also know that eating disorders are serious psychiatric illnesses and not something that someone can be reasoned out of or something that occurs by choice.

That’s so sad. Why were parents left out of the treatment plan? 

In the past there was a strong idea that the family was the cause of the ED, and therefore the only way a person could recovery was to be away from the family environment. EDs were very often attributed to bad parenting, either overbearing or inattentive mothers, absent fathers of perhaps in relation to a traumatic event. 

Now of course we know that’s not the case and is far more complicated. ED’s are brain based illnesses and although environment can play a part in the illness, it is not the cause. ED’s are not a cry for help or attention or only because someone wants to be thin. They are very real, very serious, psychiatric illnesses. It’s not the parent’s fault any more than it is the patient’s fault. Anyone can get an ED, and I think that’s a big problem; many people still believe that EDs are intentional.

Thankfully, in the clinical world, that’s changing as is our understanding that it’s not parents who cause an ED. We also know that they are vital to the treatment plan. In most cases, parents are essential resources and no blame is attributed. Unfortunately, some clinicians still think I the old way- they attribute blame the parents- but here in New Zealand, I’m glad to say, that is mostly not the case, especially as FBT is a well known therapy here, However, we’re still a long way from perfect and FBT does not work for every family. There is more research needed in the field 

How do you think the way EDs are treated needs to change? 

Well, one way is that we don’t yet have a good set of guidelines when it comes to involving parents in the recovery plan for patients who are 18 years and older. In many cases, patients who are legally adults are still living with family because they’re unable to live alone, but legislation states that we can treat them without parental involvement if they so choose.  

I think it’s so important that this is changed because someone suffering with an ED is often ambivalent about change or treatment or can be in denial about the seriousness. It is often peole around them who are worried the most or are the first to notice the negative patterns.  Their brain is literally starving and this reduces their capacity to make logical decisions and to look after themselves. If they refuse treatment and parental involvement we can’t do anything about that, despite the increased likelihood of recovery with parental involvement.

It sounds so difficult- I really hope that legislation is changed so that people can get the help and support they need because the long term prognosis is so scary. From my understanding, it’s clear that an ED doesn’t go away just because a patient is medically stable. Digestive issues, osteoporosis, chronic pain and fatigue- these all play in. Can you share some the long term effects of an ED? 

Yes, and there are a lot, you’re right. There are physical, mental and psychological effects if full recovery is not achieved. Physically, for patients with anorexia, fertility, osteoporosis and ongoing mood related issues are some of the main ones. For bulimia, the vomiting can cause teeth erosion and also affect blood stability and lower potassium levels, which is very dangerous. If someone is starving, there are physical changes in the brain which have ongoing detrimental affects but there’s clinical evidence to prove that these changes recover with normal weight, so all hope is not lost. 

Psychologically, there’s an ongoing risk for increased anxiety, suicide, OCD, and depression. When someone is trapped in the ED, this affects their ongoing sense of self change and . This destroys self-worth and can affect their ability for a meaningful quality of life as an adult.

Continuing in the ED behaviour leads to new neural pathways, which means that the eating disorder cognitions become more entrenched and difficult to change. 

From my perspective, one of the big barriers to them having that support- not just at home or in care but also in society- is that lack of understanding about the types of EDs. There are so many and they all express themselves in different ways in different people. From a clinical perspective, can you define the different types of Eating Disorders for me?

Sure. The Diagnostic and Statistical Manual version 5 (DSM 5)  defines them. The definitions are quite long but I can give you the quick version of the two most common- Anorexia and Bulimia. Though I would advise anyone who needed to know more to go to someone who is trained to make a clinical diagnosis. Self diagnosis is never advisable.

Anorexia Nervosa is characterised by significantly low body weight, an intense fear of gaining weight, efforts to prevent this from happening, and a dysmorphic perspective of one’s body.  

Bulimia Nervosa is characterised by eating a large amount in a comparatively short period of time, a lack of control over eating during this time, with compensatory methods to ‘rid’ calories consumed, such as vomiting, fasting, or exercise, The persons sense of self is also  influenced by their perception of their weight and shape.

These feel like very prescriptive definitions but the DSM really has improved in the latest addition (DSM5) There used to be a very narrow set of criteria for what an ED was but now, thankfully, we know more about the infinite variations and the criteria has widened to reflect that. For example, a patient can still have anorexia and yet still be at a normal weight- it used to be that they had to fall under a certain BMI before they could be treated for their ED. It is important this information is understood and disseminated so that GPs and the wider population can detect EDs sooner. The sooner any ED is recognised, they sooner people can get the help they need.

That’s so true. If there’s more acceptance and understanding around EDs, I hope people will be more likely to be offered help- I know that for many people, they’re so ashamed of their ED that they put off asking for help. Exactly how common are Eating Disorders in University Students? What are some of the risk factors?

Unfortunately there are no statistics for the prevalence of eating disorders in NZ. An excellent PhD project if anyone’s interested! As for how many people have an ED- overall, internationally, it’s estimated that about 2-3% of the general of population have bulimia, 3-4% have binge eating disorder, 4% with Avoidant Restrictive Food intake Disorder and 1% for anorexia. Approximately 10% of the population have diagnosable EDs and as many as one in four teenage girls may suffer from the symptoms of an eating disorder at some point. These percentages do not include the proportion of the population, males and females, struggling with disordered eating of some kind or/or body image concerns.

How can someone tell if a friend or family member may have an eating disorder? And if they’re worried what should they do? 

The very nature of many EDs is that they’re secretive. They lead to clients hiding because they’re sacred of someone making them change and taking away this coping mechanism or sense of control they’ve developed. This shame stops people from reaching out, and if someone asks them if they’re okay, it’s so much easier to say they’re anxious, which means our ability to know if it is an ED or not is restricted.However, there are a few hallmark signs. Things like rapid weight loss, withdrawal from family gatherings, avoiding going out with friends, eating less, increased exercise, and a change in diet, like going gluten free, vegetarian or vegan. It won’t be just one of these things, it will be a combination of many of them- I don’t want people to think that just because their friend or child goes vegan that they have an ED

But knowing if someone’s making a lifestyle change or has a genuine ED is hard, especially for friends who aren’t living with that person and can’t see their day to day activities. If you notice something’s off, ask if they’re okay. Persist if they deny it but you keep seeing any of those criteria I mentioned before, especially if there’s four or five of them. Come back and keep asking, keep caring without judgement. 

If you still have severe concerns, just be honest. Tell the person you’re worried. If they still deny it, I’d suggest you go to the university counsellor and ask for some advice- you might be able to go in together and have a talk.  

And what about for people who worry sometimes about their eating and the thoughts they have around food. How can someone tell if their own eating habits are unhealthy?

Generally, if food causes anxiety- or more anxiety than they’ve had previously, if they notice increased time devoted to thinking about food, if they find themselves skipping social opportunities because of stress about what food might or might not be there, and if they have no flexibility about what they will or won’t eat, then there’s a possibility that they might have some disordered thinking about eating and I’d encourage them to approach their GP or a specialist. If they feel nervous that if they come forward they’re going to be made to eat things that make them anxious, or that their habits are going to be ‘taken away’ from them, then this is an even bigger red flag and they definitely need to talk to someone- either a professional or a family member or friend that they trust.  It’s okay to be afraid, just don’t be silent.  

That’s so helpful, Kelly, thank you. Any final thoughts you want to add on? 

I just want to stress that EDs are not a choice. They are brain-based illnesses that deserve and need compassion, support and understanding. It is not a vanity issue.