Friends Helping Friends:A Guide to Approaching Peers About Their Potential Eating Disorder By Allison K. Spivack, B.A. with Amanda J. Roberts, Ph.D.

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FRIENDS HELPING FRIENDS A Guide to Approaching Peers About Their Potential Eating Disorder

By Allison K. Spivack, B.A.With Amanda J. Roberts, Ph.D

Copyright © 2011 by Allison K. Spivack, B.A. and Amanda J. Roberts, Ph.D. All rights reserved. No part of this publication may be reprinted, reproduced, transmitted, or utilized in any form or by any electronic, mechanical, or other means, now known or hereaft er invented, including photocopying, microfi lming, and recording, or in any information retrieval system without the written permission of University Readers, Inc.

First published in the United States of America in 2011 by Cognella, a division of University Readers, Inc.

Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identifi cation and explanation without intent to infringe.

Photography by: Sarah M. Mohler, B.S.

15 14 13 12 11 1 2 3 4 5

Printed in the United States of America

ISBN: 978-1-609279-74-5

For Abby, Mom and Dad, and my endless list of genuinely remarkable friends.

Love Always, Allison

Dedication

Contents

Introduction 1

Loving Your Body and Society’s Impact: Body Image and Cultural Perspectives 3

WHAT QUALIFIES AS AN EATING DISORDER?

The Diagnostic and Statistical Manual (DSM-IV) Criteria for Eating Disorders 11

WHAT SHOULD I LOOK FOR? WHAT ARE THE “SYMPTOMS”?

Warning Signs of Eating Disorders 17

WHAT RISK FACTORS AND POTENTIAL MEDICAL COMPLICATIONS ARE INVOLVED IN EATING DISORDERS?

Risk Factors and Medical Complications 21

WHAT ARE THE CAUSES OF EATING DISORDERS? HOW DO THEY COME ABOUT?

Potential Causes of Eating Disorders 27

ARE THERE ANY OTHER IMPORTANT NOTES ABOUT EATING DISORDERS THAT HAVE NOT YET BEEN MENTIONED?

Other Brief but Important Notes About Eating Disorders 33

WHAT’S THIS ABOUT TRIGGERS?

Triggers 37

MY LIFE FEELS LIKE IT’S FALLING APART. HOW CAN I HELP MYSELF AND STILL BE A GOOD FRIEND?

Taking Care of Yourself and Fighting Your Own Battles 41

I’M CONCERNED ABOUT A FRIEND. NOW WHAT SHOULD I DO?

Taking Care of Others/Friends and How to Deal with the Situation 45

OK, THIS TIME I’M REALLY GOING TO APPROACH MY FRIEND. HOW EXACTLY SHOULD I GO ABOUT THIS?

How to Approach a Friend You Think May Have an Eating Disorder 49

WHAT SHOULD I ABSOLUTELY NOT DO WHEN APPROACHING A FRIEND ABOUT THIS ISSUE?

What NOT to Do When Approaching a Friend About an Eating Disorder 53

WHO CAN I CONTACT?

Resources 57

MY FRIEND WANTS HELP. WHAT ARE THE TREATMENT OPTIONS?

Treatment Options 63

GOOD BOOKS, MOVIES, AND WEBSITES

Useful Readings, Films, and Websites 71

HEY, WHERE’D YOU COME UP WITH ALL THAT INFORMATION?

References 77

Acknowledgments 79

WORKSHEETS AND NOTES

Conversation Starters 85

All About Me: Self Evaluation/Refl ection (2 parts) 91

Notes 99

Introduction 1

Introduction

Over the course of my junior year of college, one of my clos-est friends developed an eating disorder. Th is was further perpetuated and complicated by her severe swings in and out of depressive states. Although the disorder did not manifest fully until the summer, she demonstrated many of the classic warning signs such as poor body image, denial of hunger, and irritability.

She would return from weekends at home or simply a day of class and tell me she had not eaten. At fi rst I did not think her behavior was too unusual because when my life becomes extremely busy, I have a tendency to skip meals. But her actions continued and hints about her declining well-being were dropped frequently. In addition, personal traumas had worsened and taken a toll on her to such an extent that I found her crying on the fl oor of her closet one night in a frightening catatonic state.

Th is was not the fi rst time I had seen her behave this way, and aft er much discussion and demonstration of exactly how terrifi ed I was she fi nally agreed to go to therapy. Showing your friends and family how much you care about and love them is a huge aspect in their recovery. I think the one thing that scared my friend the most was when I told her about my sister’s death 2 1/2 years earlier and how my mom had found her in bed and not breathing. I looked my friend straight in the eye and told her I refused to go to another funeral that year and that anorexia nervosa is the deadliest psychiatric disorder. I also told her I was terrifi ed of returning home one aft ernoon only to fi nd her just as my mom had discovered my sister.

2 Friends Helping Friends

Ultimately her story of trauma and current recovery is what in-spired me to compile information and assemble this guide. She is still one of the most amazing people I know and I am extremely proud of her for taking care of herself. I hope this guide serves as a helpful tool and that you too can help a friend in need. I created it because I lacked the resources and reference guides to help me navigate this life experience. Th ank you for taking the time to read this through. I hope you learn a great deal and gain the confi dence and courage to approach a peer about her or his behavior. Most important, though, be supportive and be a friend.

Loving Your Body and Society’s Impact 3

Loving Your Body and

Society’s Impact: Body Image

and Cultural Perspectives

Modern American culture portrays mixed messages about the human body. Our society oft en projects the “coat-hanger-thin” image of a catwalk model as the ideal repre-sentation of health, success, and happiness for women. Th e “ideal” man is oft en thin, but very muscular or sometimes also very thin. Th ese images combined with numerous advertisements for diet and exercise programs following those for fast foods, sugary cereal, and soda cause much confusion in people’s minds. Th e intense focus on body image in American culture pushes into the American consciousness food, dieting, exercise, and the fact that a person working incredibly hard to lose weight is not good enough because that person will never be as thin as the models they watch in haute couture runway shows. Our society oft en encourages the achieve-ment of this thin ideal since the message of thinness’ inextricable link to happiness, success, wealth, love, and intimacy remains at the heart of what is conveyed to the population. Advertisements rely on the fact that sex sells. Th ey also tend to toy with their audiences in eff orts to make them believe that consuming a particular food item, like Paris Hilton does in a Carl’s Jr. television ad, will bring about one’s good fortune. Th us dieting and this thin ideal remain focal points in the American cultural perspective.

Americans are taught to pursue the thin ideal while simultaneously being bombarded by media messages demonstrating the convenience, low cost, and high availability of fast food. Th is constant barrage of advertisements reinforces our focus on the “skinny” of things and our

4 Friends Helping Friends

desire to be categorized as thin that only serves to spark or further perpetuate a dangerous obsession with all things food-related. Th is phenomenon even infi ltrates our manner of ordering coff ee in that people now order “skinny” beverages of skim milk and sugar-free syrup. In this sense “diet” has fully risen to the center of our thinking and oft en consumes a good portion of our daily thoughts and actions.

Dieting has evolved into somewhat of a religion within modern American culture seeing as so much of our time, eff ort, and money is spent altering ourselves to match a prescribed image that only a very small percentage of the world naturally fi lls. Food is used to mark every occasion from joyous to sorrowful. It is used as a source of comfort and of love. While food is essential and to be enjoyed, some take it to an extreme and use the restriction or overindulgence of food with or without compensatory behaviors, as coping mechanisms. Sometimes this is done as an act of defi ance, a call for attention, or because some other trauma triggered it. While eating disorders do not solely arise out of genetics, those with parents or siblings aff ected by such psychopathologies remain in a higher risk category for having this type of disorder. Ultimately it is a combination of one’s biology and environment that determines whether or not they will develop an eating disorder.

Th at said, it is important to break down what qualifi es as “non-disordered” eating. Is it actually possible? Who doesn’t have a specifi c way they like a dish prepared or certain ingredients they prefer (for example the use of non-fat milk instead of 2-percent or whole milk)? Every culture has specifi c dietary rules and means of eating. Some cultural diets focus on meat, others on no meat at all, and some on a mixture. However, human cultural evolution produced a crude shift in our thinking about food. Th e ideas that initially laid the foundation for a survival-based focus morphed into a desire-based focus in which humans eat for many more reasons than actual physical hunger.

Th is focus shift coincides with the cultural change in perspectives on body image. While individual experiences tailor a person’s beliefs,

Loving Your Body and Society’s Impact 5

ideas, and self-image, the overall cultural “skinny/thin” and “muscu-lar/six-pack abs” ideal is the ultimate rule by which many women and men measure themselves. Th e search for perfection, rooted in severe disturbances and distortions in one’s perception of their appearance combined with their overall body dissatisfaction, is oft en one of the main catalysts that ultimately contributes to the development of an eating disorder. Th ese disturbances and distortions that fuel body dis-satisfaction also infl uence self-evaluation, which is oft en aff ected by a person’s body shape, weight, and investment in these things.

Body size distortion is measured by asking a population of healthy, recovered, and ill subjects what they believe to be their body’s size versus their actual size using a pictorially based scale. Results taken from studies employing this technique demonstrate that anorexic and bulimic patients tend to overestimate their size, indicating they perceive themselves to be larger than they are. For example, one study conducted by Zelner et. al 1989, utilized silhouettes and asked those with eating disorders to rate themselves in three categories: current body shape, ideal body shape, and what they believe the opposite sex would fi nd most attractive. Th e startling discovery in this study can be found not only in the vast distance between where female eating disordered participants placed the marker for their current silhouette and their ideal, but also in the distance between their own ideal and what they believed men found attractive. Even females without eating disorders marked their places on the same scale to indicate a drive to be thinner than they currently stood; however, not to the same extent as those who were currently ill with an eating disorder.

Levels of dissatisfaction measured using body weight, image, and self-esteem evaluation scales are typically extremely elevated in those with eating disorders. Th ese peak scores typically correspond with highly motivative and self-evaluative salience especially when exam-ining engagement in appearance-management behaviors. Th is occurs because many base their self-defi nition on their physical appearance. Like those with eating disorders, chronic dieters also display elevated

6 Friends Helping Friends

concerns about their physical appearance, overestimations of their body weight, and lower satisfaction rates with their current bodies. Th is is one reason that dieting is probably the most critical risk factor for the development of eating disorders.

Possible contributing factors to these issues are the media and fashion industry, which reign supreme in social infl uence and pressure regarding a person’s body, despite the “love-your-body” campaigns. Th ey proclaim a message of thinness that is fundamentally linked to beauty, success, wealth, love, sex, and health. Being thin is con-stantly portrayed as the ideal, oft en forcing health to take a backseat to beauty, and resulting in a society and culture rooted in skewed body perceptions. Th e media understands their substantial infl uence on society and uses their knowledge to subliminally exploit by reinforc-ing messages of thinness in the selling of children’s toys like Barbie and G.I. Joe, which teach kids and parents alike what is and is not an acceptable body type. Barbie’s proportions are humanly impossible. A woman died who actually tried to become this thin using a corset she tightened every day. Although subconsciously, people spend hours in the gym attempting to become as ripped and trim as action fi gures and superheroes, when oft en, these proportions are impossible.

Th e toy industry is not the only one hurting our self-image and perception; magazines play an enormous role as well. Magazine covers, advertisements, and billboards alike are oft en airbrushed or computer-enhanced. Sometimes, the models we see on magazine cov-ers are either a collage of many diff erent people or someone has edited the original image fi le so that certain lines are more distinct and the person appears to be thinner, taller, and more curvaceous. We are made to believe that the fi gures set before us are actually attainable. But due to America’s toxic love aff air with fast food and sugar that is endorsed by the media, our ability and strength to overcome these food obstacles is a much bigger task than perhaps initially imagined. In other words, we internalize the standards set forth by the media and sacrifi ce everything to obtain “perfection”. Some even give their

Loving Your Body and Society’s Impact 7

lives, such as those who have died from anorexia nervosa. As one can see, people will sacrifi ce a great deal to be considered beautiful and to gain control over at least one aspect of their lives.

Control plays a lead role in eating disorders. Th eir development oft en coincides with a need to establish or reassert control over life experiences that have left an indelible mark on a person. Sometimes they also serve as cries for attention or contents to fi ll a void. Th e bottom line is that a person’s body is something viewed as belonging only to them and to no one else. As a result, many decide that this is the one thing they can grasp despite the intense chaos surrounding every other aspect of their lives.

Th e lack of control or desire to establish it within one’s life may originate from two important concepts that are oft en confused: hun-ger and satiety. People will eat, not because they are actually physically hungry, but because they are bored, stressed, upset, or just attempting to fi ll a void. Satiety keeps our hunger drive in check and alerts us when we are full so we may stop eating for a while. Th e problem arises when we misinterpret the signals our bodies send. Th e hunger we feel may not in fact be physical hunger, rather it may be a need for power, sex, love, belonging, or just fi nding that missing piece in our lives. Th is is what drives us as a food-centric culture: our constant need to eat, regardless of the occasion, and the fact that we can never satisfy ourselves with anything. We are taught from a young age to want more and not to settle. Consequently we continue to strive toward goals that leave us famished and unsatisfi ed. Eating disorders may develop from internalized concepts like this.

What Qualifi es As

an Eating Disorder?

DSM-IV Criteria for Eating Disorders 11

The Diagnostic and Statistical Manual (DSM-IV) Criteria for Eating Disorders

ANOREXIA NERVOSA (AN)

• An absolute refusal to maintain body weight at or above a mini-mally normal weight for their age and height º For example, weight loss leading to maintenance of body

weight less than 85 percent of that expected or failure to make expected gain during period of growth leading to body-weight less than 85 percent of that expected

º Intense fear of gaining weight or becoming fat even though they are underweight

º Disturbance in the way in which one’s body weight or shape is experienced

▪ Body image distortion and dissatisfaction ▪ Undue infl uence of body weight or shape on self

evaluation ▪ Denial of the seriousness of the current low body weight

º In postmenarchal (period started or should have started) females, amenorrhea (absence of at least three consecutive menstrual cycles)

▪ I.e., if you are not taking estrogen, you would not have a period

• Subtypes º Restricting type (AN-R)

▪ Severe restriction of food intake• Major control issue

12 Friends Helping Friends

• During current episode of AN, the person has not regularly engaged in binge eating and/or purge eating

• Th ese behaviors include self-induced vomiting, excessive exercise, misuse of laxatives, diuretics, and enemas

º Binge/Purge type (AN-BP) ▪ Engagement in binge eating (eating more than one nor-

mally would in a two-hour period) huge amount of food feelings of shame and guilt, which in turn cause the feeling of needing to compensate

BULIMIA NERVOSA (BN)

Oft en hidden, person will typically fl uctuate in weight; feel-ings of guilt and shame associated with their actions as well as feelings of hopelessness

• Recurrent episode of binge eating (an episode of binge eating is characterized by the following: º More food, faster than most people º Sense of lack of control during the episode º Recurrent inappropriate compensatory behavior in order to

prevent weight gain º Abuse of diuretics, laxatives, other emetics, and like sub-

stances as well as self induced vomiting º Fasting or excessive exercise following the binge º Must occur at least two times a week for three months º Self-evaluation is infl uenced by weight º More time spent invested in body image than others º Behavior doesn’t exclusively occur during episodes of AN º Compensatory action accompanies a binge º AN-BP if below 85 percent of body weight

• Subtypes º Bulimia Nervosa-Purging (BN-P)

DSM-IV Criteria for Eating Disorders 13

▪ Person engages in self-induced vomiting, emetics, laxa-tive abuse, etc.

º Bulimia Nervosa-Non Purging (BN-NP) ▪ Person still engages in obvious compensatory behavior,

but uses fasting and/or exercise

EATING DISORDER NOT OTHERWISE SPECIFIED

• Partial AN º Normal criteria with the exception of regular menses º Normal criteria with the exception that weight is still in the

normal range • Partial BN

º Binge and compensation still occur, although fewer than twice a week or for a duration of less than three months

º Compensatory behaviors aft er eating small amounts of food, but still at a normal weight

• Binge-Eating Disorder (BED) º Th ought to be the most common eating disorder in males

(possibly most common eating disorder in females as well) º Research Criteria

▪ Eating within a discreet period of time an amount of food that is defi nitely larger than most people would eat in a similar period of time

▪ Sense of lack of control over eating during the episode ▪ Episode is associated with three or more of the following:

• Eating much more rapidly than normal• Eating until feeling uncomfortably full• Eating large amounts of food when not feeling

hungry• Eating alone because of being embarrassed by how

much one is eating

14 Friends Helping Friends

• Feeling disgusted with oneself, depressed, or very guilty aft er over eating

• Marked distress regarding binge eating º Binge eating occurs on average at least two days a week for

six months º Binge eating is not associated with the regular use of inappro-

priate compensatory behaviors and doesn’t occur exclusively during the course of AN or BN

• Chew and Spit º Insulin levels rise to compensate for incoming food, but then

fall because no digestion occurs º Spikes in insulin make it more diffi cult to lose weight º Warning sign of self-destructive behavior, possibly a precur-

sor to AN and BN ▪ Can potentially develop BP subtypes of the umbrella

disorders ▪ Prepares the body for food, then deprives ▪ Can produce ulcers

CHARACTERISTICS OF A BINGE

• Typically occur in secrecy • Person is oft en in a “trance,” “zone,” or “numbed-out” • Rapid consumption • Continues until painfully full or interrupted • Can be triggered by emotions • Feels out of control • Temporary increase in mood • Followed by a depressed mood (as one realizes what they’ve

done—again) • Usually high-calorie or simple carbs like cake, ice cream, breads

º Easy to eat, full of fl avor, associated with comfort

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