Ending the stigma of eating disorders is the first step toward treatment and recovery; meet several survivors who share their stories.
Meredith Dales sits across from me, her tall, willowy form sitting straight, her long arms folded in her lap. Tattoos trace a path down her neck, sheathing her arm and snaking along her wrist to her fingers, where artful birds seem to flutter in flight each time she shifts her hands to better emphasize her thoughts.
Dales is still and ostensibly serene. A closer look uncovers a study in quiet, subtle, but meaningful motion. Thoughts and feelings drift across her face, altering her posture and intensity. She agreed to meet me in a crowded restaurant in Annapolis to tell me the scary and intimate details of her personal experience with an eating disorder. A happy, academically- and athletically-gifted child from a loving family, Dales in her teen years suffered deeply from anorexia, at times turning to drugs and alcohol to ease the pain. As Dales grew into a young woman, her battle with anorexia exploded, impacting her family, her only child, and her friendships, eventually rendering her homeless. At fourteen years old, Dales, who is 5’9, weighed 72 pounds. By the age of 23, she was at times addicted to drugs or alcohol, had attempted suicide, or was homeless.
Dales’ singular goal for opening up to a complete stranger about her painful past is to eliminate the stigma that surrounds eating disorders and to offer a glimpse of hope for an optimistic future to the families—adults and children alike—who suffer from this grave disease.
A Very Real Affliction
Eating disorders are one of those diseases people might stare at, or shamefacedly look away from, but not want to talk about. In fact, I was inspired to accept the assignment to write about eating disorders after the shocking death of my friend Ginger Doyle, a much-loved woman and writer from Annapolis who died from complications of her eating disorder two summers ago, much too young, at just 39 years old.
What I’ve learned through talking with Dales and others plagued by eating disorders, as well as in interviews with doctors and therapists, is that this disease is infinitely complex and deeply connected to mental health. It impacts strong children, financially successful adults, and tough athletes. It is intricately linked to how body shape is defined, dictated, and distorted by social trends and cultural norms. At their most trite, eating disorders blur the thin, gray line between “being in shape” and being “too skinny.” At its most complex, the disease is an intentional—though to the suffering, seemingly unavoidable and even empowering—form of self-harm.
Eating disorders are pervasive, appearing across all ages, ethnicities, and nationalities. While girls and young women are more likely to be afflicted and seek treatment, boys, young men, and even older adults of both genders suffer from the disease. A 2007 study asked 9,282 English-speaking Americans about a variety of mental health conditions, including eating disorders. The results, published in Biological Psychiatry, found that nearly 10 percent of women and three percent of men had anorexia during their lifetime. A 2012 study in the International Journal of Eating Disorders found that 13 percent of women over age 50 engage in eating disorder behaviors.
Eating disorders are more than an unhealthy obsession with nutrition: they are deadly. Statistics show that every 62 minutes, someone dies as a direct result of an eating disorder. But what exactly is an eating disorder? What causes it? How can you detect it? And what can you do to help a loved one? These are the questions Dales discusses with me at length, revealing piece by piece how she went from healthy to frail and back again, and of how modern medicine offered her a path to management of the disease.
Social and Medical History of the Disease
There was a time, not too long ago, when eating disorders were, in the eye of the public, known mostly as “anorexia,” a sickness thought to be caused simply by refusing to eat. We now know that most of this statement is not true.
History tells us that eating disorders have always been present in the human condition. Researcher Robert Vaughn wrote, “whether the mental illness known as Anorexia Nervosa is a true disease of modernity or a manifestation of an illness that has existed throughout human history is indeed ambiguous. What is certain however, is that volitional self-starvation…is nothing new at all.”
In the 12th and 13th centuries, ascetic nuns admired for their abstinence from earthly pleasure and their refusal to eat earned their way into sainthood. Saint Catherine of Siena was just one of the faithful who routinely starved themselves for weeks or months at a time in a belief that they could better understand and appreciate the suffering of Jesus. For them, fasting wasn’t necessarily a way to get thin—though this would be a physical manifestation of suffering—but rather an expression of devotion to God.
Doctors label this eating behavior anorexia mirabilis (mirabilis meaning “miracle”), and many are quick to distinguish it from anorexia nervosa. The difference, in laymen’s terms, being that anorexia mirabilis is a choice not to eat in pursuit of spiritual perfection, while anorexia nervosa is a mental illness untreatable without therapy and often associated with self-destruction in the pursuit of physical perfection.
Incidence of eating disorders began to show up more often in medical literature by the mid-1800s and can be correlated to an increasing fascination and romantic view of thinness. Queen Elizabeth of Austria, revered to this day throughout Europe for her beauty, independence, and personal discipline, was known to fast and exercise to emaciation during her time on the throne. Interestingly, Sisi, as she was known, was assassinated on the shores of Lake Geneva, where a wispy statue, still there today, shows just how incredibly thin she was.
In 1859, a French doctor, Louis-Victor Marcel, diagnosed patients found to have “obstinate refusal of food” and a “hypochondrial delirium,” which he noted had high risk of relapse after treatment and a poor outcome. In 1874, an English doctor, William Tuthey Gull, described patients with peculiar restlessness, amenorrhea, and emaciation. He diagnosed them with what he termed anorexia nervosa, or “a nervous loss of appetite.” The term remains in use today and reflects the physical and mental components that combine as powerful symptoms of the disease.
Eating Disorders Today
Cases of anorexia became markedly more apparent after 1960, and eating disorders became a major area of study after that time. There is some discussion amongst specialists about the root cause for the distinct rise in cases of anorexia in the past 50 years, with some pointing to affluent, Western diets laden with fats and sugars that make maintaining a healthy weight via balanced eating difficult. Others point to social norms, to an infatuation with celebrity and to media that glorifies thin, sometimes emaciated, body types.
Dr. Lisa Hill, Psy.D., practices in Annapolis and specializes in eating disorders. She studied meta-analysis on if media exposure alone increases body image dissatisfaction, one of the leading motivations for food deprivation, though not it’s root cause. “What I found was that we can’t pinpoint one source: body dissatisfaction comes from moms talking about their own weight, from peers at school, from teachers talking about how they’ve lost body fat. Dissatisfaction and dysmorphia starts as young as age four.”
Dr. Hill notes that social comparisons are only worsened by instantaneous delivery of visual images through social media. “Even as a healthy, secure adult we look at people on our social media accounts, which set us up for an upward social comparison. When you compare yourself to someone else that you think is better than you, there is no way to recover or come out on top.”
Dr. Marla Sanzone, PhD, MP practices psychology out of her cheery offices in the loft-like second floor of a bungalow in West Annapolis. Dr. Sanzone has focused on eating disorders for much of her 30-year career.
In our conversations, Dr. Sanzone confirmed the correlation between modern social pressures that drive extreme views of physical perfection and the rise in cases of life-threatening disordered eating, especially among young women. “Our children see and hear about other young people having plastic surgery in the tween and teen years,” she says. “They might hear their moms complaining about how they are unhappy with their aging bodies. That’s very confusing for kids at a time when it’s hard enough just trying to fit in.”
What is an Eating Disorder?
Today, doctors and therapists know that eating disorders are a form of mental disease. Many people tend to think that anorexia is the only or most severe form of an eating disorder. Anorexia is inappropriately painted as the poster child for eating disorders, but with good reason. For females between age 15 and 24 years who suffer from anorexia nervosa, the mortality rate associated with the illness is 12 times higher than the death rate of all other causes of death.
In fact, though, there are a plethora of eating disorders. All are characterized by an unhealthy, imbalanced regard for food and nutrition. People who have an eating disorder focus on food as a maladaptive way to cope with emotional stress or trauma.
The symptoms of eating disorders (namely depression, anxiety, and mental health issues) may be genetic. “It’s important to know that there is not one factor that causes an eating disorder,” Dr. Sanzone says. “We know we are born with genetic predisposition to particular diseases, many of which we will never know we are carrying, because we aren’t triggered by a particular trauma. It’s the same with this disease.”
With the rise of identified cases of eating disorders since the mid-20th century (especially since the 1970s), and more attention on the epidemic, multiple studies have identified a cluster of conditions shared by sufferers. “There are common temperamental or constitutional personality traits,” Dr. Sanzone says. These traits may include compulsive behaviors, all or nothing thinking, an intrinsic sense of not being good enough, a need to be noticed and highly regarded, emotional sensitivity, and being highly perceptive.
Eating disorders are more likely to develop in cases where there is a family history of anxiety, depression, or any kind of addictive behaviors. “Often times, the personalities able to implement the extreme discipline required of an eating disorder are very capable. They are often strong leaders and high achievers,” Dr. Sanzone says. “But most, especially the children, don’t have the emotional maturity or life experience yet to balance all the incoming data from the broad emotional range they experience. They can’t contextualize it, so they internalize it.”
Personal Stories
Meredith Dales takes a deep sigh as she dives into her story. “I felt like I wasn’t good at anything, I couldn’t succeed at anything. I had all these adult voices floating inside my head—my coach who preached about food and how to eat right, and my grandmother who’s so proper and has this idea of perfect beauty, and my dad who was critical and unemotional,” she explains. “I thought…I don’t want to feel this way, and no one is helping me, so I just turned it inward.
Dales has come to the other side of her journey through years of inpatient and outpatient therapy, but looks back at her darkest moments with a clear view of the journey. “I thought to myself my body is the only thing that’s really mine. My low moments turned to self-loathing. I thought, instead of loathing, I could empower myself. I explored my capability of mastering things, and I thought I was very successful. And because of my anorexia, I truly thought I had a personality and a physicality I could respect. In fact, I was very successful doing things that were very destructive.”
Dales’ story began in a deep, dark well of emotional pain and trauma that impacted her mental health. Others begin with discipline. For example, eating disorders are prevalent in the military, especially among women. Research suggests female service members are four percent more likely to develop an eating disorder than females not in the service.
One woman I interviewed, a graduate of a service academy who asked not to be named, described her extreme weight loss during her years in the military, couching it in terms that exactly match Rice and Sanzone’s description of people whose core personality traits might make them more susceptible to the disease. “I was highly disciplined, geared to achieve, and forced to perform at the highest level. Between sports, academics, and trying to function in this highly competitive environment, I was exposed to all the triggers for my eating disorder. I thought I could be the best, and be regarded as the best, if I showed that I was disciplined.”
A review of records obtained over eight years (1998–2006) by the Defense Medical Epidemiology Database indicated that 0.3 percent of all military members were diagnosed with an eating disorder during that time. Eating disorders were diagnosed more in 2006 (0.41 percent) compared to 1998 (0.23 percent), suggesting eating disorders among service members doubled, mostly in the Marines. The National Eating Disorders Association notes on their website that studies on incidents of eating disorders among women in the military are nearly epidemic. A survey of 3,000 women in the military found that over 60 percent of respondents had an eating disorder, and in the Marine Corps alone, 97.5 percent met the criteria for an eating disorder.
Neither the military, nor this woman’s family acknowledged her illness, which they might have considered a sign of mental or physical weakness. It was her friends who intervened, and her own desire to be healthy and balanced, that finally helped her move beyond anorexia.
This was the case too for Christine Feldmann of Annapolis. Feldmann, who works in marketing, appears to be a self-confident, successful professional and dedicated mother who is somehow managing to juggle more than her fair share. But there was a time when she didn’t feel so strong.
Feldmann described for me a lifetime of struggle with her body image, self-assurance, and self-acceptance. When she was in elementary school, she says, she looked up to her sister, a petit and pretty teen, as an ideal physical shape that as a lanky girl she could never achieve. Throughout her teens she would occasionally binge, often being restrictive, but not drastic enough for others to notice. In college, she became much more obsessive, thinking that she wasn’t pretty enough, not smart enough. By the time she was out of college and working her way into a career, she was fully exposed to the triggers that would send her deep into her disease. She relied on laxatives to purge, sometimes taking up to a dozen each day. “I thought maybe if I lose some weight my boyfriend won’t leave me, and I will be worthy. If I can just lose some weight, this will all be better,” she explains.
It wasn’t until Feldmann went to the Shepperd Pratt Center for Eating Disorders in Towson, Maryland, for inpatient care that she finally decided to break her addiction to purging and survive her disease. “I was 23 years old and was in with people who were 40 and 50 years old; I thought to myself, ‘Do I really want to spend my entire life being consumed with this? Do I want food, and what I eat and how I get rid of it to be the only things I think about every day?’ I decided I just couldn’t do it.”
Family Awareness at Home
When I asked Dr. Sanzone the one thing she would like parents to know about how to prevent or identify an eating disorder for their children, she didn’t hesitate for a second. “As parents we create the factors that come together into the petri dish of social pressures the child lives in, which create the perfect storm for these kinds of disorders,” she says. “Parents need to know that they play a significant role in their child’s mental health. Certain attitudes and behaviors they model can factor into a child’s propensity for developing an eating disorder.”
Dr. Sanzone suggests parents should look inward, asking themselves if they are mirroring the values or the life they want their child or loved one to emulate. “If you are emitting or modeling anxious, self-conscious, never good enough, competitive, or a push, push, push for the future orientation, you are setting [your children] up to internalize these traits.”
Dr. Sanzone says that the self-centered and ego-driven values of western cultures drive people to think they must excel more than the next person, to have what she calls a competitive attitude with an adversarial edge. “By this I mean, we might feign admiration for a neighbor’s new car or promotion, and want to be happy for them, but inside our ego asks what did I do wrong or what can I do to surpass them. When ego takes over our true inner self and surpasses who we are, it prevents contentment.”
She says parents should pause to reflect on the question: how much of yourself are you putting into your kids, instead of letting them develop their own sense of self? For people with a predilection for mental health issues, parents striving for perfection could instead be driving their children toward a deadly disease.
She also wants parents to know that an eating disorder is indeed, a deadly disease. “Take it seriously, patients can’t just get over this disease on their own, it needs treatment. Check in with your general practitioner, see a specialist, seek a mental health professional, do not try to do it on your own.”
Treatment Options
Modern treatment for eating disorders has seen much progress. Treatment is more holistic, evidence and data based, and better grounded in the science of mental health. Dr. Terry Griffith, Psy.D. is Clinical Coordinator for the Intensive Outpatient Programs at the Center for Eating Disorders at Sheppard Pratt. She says that eating disorders are among the most difficult mental diseases to treat due to their complexity and the havoc they wreak on patients’ emotional and physical health. “People think you can just heal from this illness. We don’t use the word ‘cure,’ instead we help patients discover ways to treat and manage the symptoms of the disease so they can sustain and maintain without binging, purging, or restricting.”
Treatment options at various treatment facilities can range from 24/7 inpatient care, to partial hospitalization (seven days each week, 12 hours each day, 7 a.m.–7 p.m.), and intensive outpatient care (four days each week, for four hours each day). Patients might also participate in residential programs. All patients at Sheppard Pratt, for example, also receive cognitive behavioral therapy. “Our goal is to replace maladaptive coping with adaptive ways of coping. We help and empower patients to use the proper tools to manage their eating disorder and we rely on a team to help people not be triggered by their difficulties,” Dr. Griffith says.
Sara Heilman is a Certified Personal Trainer, Health Coach, and Fitness Nutrition Specialist with a survival story of her own. “Growing up, my family would talk about losing weight and being healthier, but there was something missing and as a bigger girl, I found comfort in food.” From age 14 to 21, Heilman engaged in active disordered eating as a bulimic and binge eater. Depressed and anxious, she decided to take a semester off from college to change her life. In therapy, Heilman was able to address her family, and to reveal the secret pain she carried. “I was in therapy for two years and was able to learn how to process my emotions and live in a balanced way.”
Today, Heilman uses her expertise in exercise to help teens and young women with severe disorders, often in conjunction with a medical team, to move from obsessively using exercise and food as tool to manage weight toward relying on them as modalities for maintaining mental and physical health. She often works with doctors and patient treatment centers.
Another modality for treatment is occupational therapy, which can range from art classes that seek to correct body dysmorphia, to equine therapy that helps with depression and anxiety. In art therapy, an artist outlines the patient’s body. Then the patient draws what they think their body looks like. Together, the therapist and the patient compare the images and talk about how to manage distortions. Wearing clothes that are too big to hide having to look at their bodies is a commonality amongst patients. Demonizing one food or food group over another is another commonality. Occupational therapists can take patients shopping for clothes and for food. They can show them how to accept their bodies and how to have balanced meals. “The goal of healthy body image is to not have them love or admire their body but to accept and tolerate this body. It’s not realistic for some patients to love their body, but we can teach them to accept it enough that you don’t abuse it,” Dr. Griffith explains.
In many residential and hospital treatment centers, patients participate in groups that support difficulties. A self-esteem group will use cognitive behavioral therapy to help patients learn self-worth and self-efficacy. Another group might address substance abuse or trauma, and how these things impact an eating disorder. Still others might help rigid thinkers or perfectionists to address a cognitive deficit that impacts their disorder.
Recovery is Possible
Dales was homeless and alcoholic, wandering in and out of alleys and byways until she stumbled into the Lighthouse Shelter one cold and rainy night. In order to get a bed, she had to be and stay sober. It was in the moment when the woman at the front desk said “Come in, I know you can do this,” that Dales felt for the first time in a long time, that she was meant for more than the streets.
These days, Dales is the proud owner of a skincare and Reiki clinic in Annapolis. Instead of restricting, Dales balances and enjoys. Instead of indulging, she maintains a healthy lifestyle with exercise, mental health therapy, and spiritual practice. Dales’ journey with an eating disorder is one of too few that end well. If you think you have an eating disorder, or even that your eating might simply be disordered, put aside the stigma, reach out for help, and give yourself the assistance you deserve.
Types of Eating Disorders
Anorexia nervosa is characterized by extreme weight loss, an intense fear of weight gain, food restriction, inappropriate or unbalanced eating habits, and obsessing over a thin figure. People suffering experience body dysmorphia, or a distorted body image. As the person becomes more emaciated, the mental symptoms of the disease spirals downward, and their image of themselves becomes more distorted.
Bulimia nervosa is characterized by episodes of consuming an excessive amount of calories in a restricted period of time then undoing the binge by purging. Most common is self-induced vomiting, meanwhile others are overdosing on laxatives and excessive exercise. Bulimia is often associated with secretive behaviors due to shame and fear.
Binge eating describes consuming an abnormally large amount of food in a short period of time. During the binge, the person feels out of control, and can’t stop eating. Binge eaters don’t purge. Afterwards binging, they feel shame and guilt, though these negative emotions become coping mechanisms that hide deeper mental health issues like depression and anxiety.
ARSID is characterized by a refusal to eat specific foods or refusal to eat any type of food due to a negative response from certain colors, texture, or smell. Often associated with children, this is a problem for adults as well. ARSID prevents access, ingestion, and absorption of key nutrients.
Helpful Resources
If you think you might need to reach out to a mental health professional about an eating disorder, seek education.
Visit the Center for Eating Disorders at Sheppard Pratt’s website to learn more about the definitions and complexities of eating disorders. www.sheppardpratt.org/the-center-for-eating-disorders-at-sheppard-pratt
Visit the National Eating Disorders Association website. This organization exists to support families and individuals impacted by eating disorders. www.nationaleatingdisorders.org
Considering joining Eating Disorders Anonymous, a Twelve-Step fellowship of individuals who share their experience, strength, and hope with each other that they may solve their common problems and help others to recover from their eating disorders. To find an online or in person meeting near you, visit www.eatingdisordersanonymous.org
Visit your insurance company’s website to find psychologists, psychiatrists, and therapists who are trained in treating eating disorders in your area.
