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Eating disorders (EDs) are among the deadliest psychiatric illnesses people face. Defined by the American Psychiatric Association (APA) as “illnesses in which people experience severe disturbances in their eating behaviors and related thoughts and emotions” and characterized by preoccupation with food and body shape and weight, people of all demographics can experience EDs. According to the National Association of Anorexia Nervosa and Associated Disorders, EDs affect 9 percent of the U.S. population. Despite this global prevalence, however, different groups face disproportionate barriers to care–even groups that may be at higher risk than others. Black, Indigenous, and People of Color (BIPOC) people, for example, are significantly less likely to be asked by their doctors about eating disorders, and transgender children are at greater risk of developing EDs than their cisgender peers.
With a complex range of symptoms, triggers, and the potential for lasting damage to people who experience them, EDs require multi-disciplinary and specialized treatment. With the onset of COVID-19, it’s become harder to manage eating disorders, as typical coping tactics and strategies–such as indoor hobbies and social support networks–are less accessible amid shut-downs and isolation. As a result, more people are experiencing some EDs, like anorexia. And in addition to pre-existing cultural and societal pressures to diet, memes and jokes around weight-gain during COVID-19 have rampantly spread throughout the internet.
As a mental health care provider, it can be difficult to know what ED warning signs to look for when treating clients, especially amongst those with no previous history of eating disorders. And while it can be difficult to treat a client who presents symptoms of an ED if you do not specialize in its treatment, there are certain phrases, thought patterns, and beliefs that can indicate a client is suffering from an eating disorder, and may need further assessment and specialized treatment for it.
What follows are some common signs that a client may have an eating disorder.
While this can be mistaken as having healthy living habits, rigid rules around food and exercise can actually signal an eating disorder. Clients who have inflexible mindsets related to food and exercise may say things like, “I can only have a certain amount of calories per day,” or, “If I eat this, it means I have to exercise for a certain amount of time.”
This type of sign can be especially difficult to notice when your client’s conversations around food focus on a strong drive for healthy eating–a more recent phenomenon that has developed with the rise of the wellness industry. Phrases like, “I only eat fruits and vegetables,” or, “I just went on a cleanse,” can be indicative of disordered eating disguised as wellness. These types of statements may be a sign that a client has a condition referred to as orthorexia, characterized by an obsession with the quality and purity of food rather than weight loss and body changes. While neither the APA nor the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) have officially defined orthorexia as an eating disorder, it has gained recognition in the medical community.
Research has consistently shown that diets do not work, and that long-term weight loss is more likely to occur when a person practices habits like intuitive eating, a philosophy focused on empowering someone to make healthy choices for their body without imposing the restrictions and shame typically associated with diets.
It’s also important to note that you cannot tell if someone has an eating disorder just by looking at them. Only 6 percent of people with eating disorders are medically diagnosed as underweight, and someone can be any weight or body shape and suffering from an ED. So if your client mentions that they are on a diet, it’s important to assess their dieting history. It can be helpful in this case to ask how many diets the client has tried, what kind of diets, and if their physician has recommended weight loss or any specific diets.
Clients with eating disorders will often have a list of “fear foods,” or foods that can create anxiety, fear, or discomfort due to their calorie content, texture, or association with a bad experience. This pattern of avoidance can extend to other aspects of clients with EDs’ lives, including clothes and places that may trigger distress.
Someone with an eating disorder may say things like, “I don’t wear shorts or tank tops because I don’t feel comfortable with the way this looks,” or “I don’t eat carbs.” These avoidance behaviors will also frequently impact the person’s quality of life, causing them to avoid social interactions, among other things. A revealing sign of this could include statements like, “I never eat in public or around other people” and “I don’t leave my house when I feel fat”
Some people with EDs may use the term “emotional eating” to describe binge eating or limiting their food intake when they are stressed or overwhelmed. Emotional eating, which is defined by Mayo Clinic as a coping mechanism for suppressing or soothing negative emotions, is used as a form of comfort in times of stress, and in the case of eating disorders is often done in secret and can elicit a lot of feelings of shame.
When a client says they are emotionally eating, a therapist needs to get a strong sense of their client’s eating habits, as emotional eating is often linked to limiting or restricting food intake, a serious eating disorder behavior.
While exercise and commitment to physical fitness can be fun and healthy, people with EDs often use exercise as a form of purging, as a weight loss tool, or punishment for eating.
There are notable differences between someone who is trying to become an athlete or get into better shape and someone who exercises excessively. The key component to identify is self-hatred–or whether a person is exercising to change their body out of dissatisfaction rather than self-care or a desire to improve their wellbeing. Some exercise-related warning signs to watch for can include:
Often at the core of an eating disorder can be a client’s dissatisfaction with their body. This can originate from a number of aspects within a client’s life, including family history, observing modeled behavior, weight stigma, and frequent messaging in media outlets that encourages people to strive for a thin, white, beauty ideal.
Clients who are unhappy with their body may make self-disparaging statements about their appearance. They may say things like, “I hate the way I look,” or “I’m so fat and ugly,” or “I need to lose weight because I look horrible.”
Culturally responsive care means that as a clinician, you understand the societal and cultural influences your clients are exposed to on a daily basis. While this can refer to issues of race and gender, in the case of eating disorders, it also takes the form of constant pressure to conform to a standard of beauty that is based in white supremacist patriarchy.
These impossible standards of beauty can be used as a tool for oppression, and as such it is essential to recognize the need for culturally responsive care in treating clients with eating disorders. In the context of EDs, this can mean understanding your client’s perspective and experience in their body and in society. This can be especially important for transgender clients, for whom there is additional stigma and pressure to meet imposed expectations of attractiveness.
As a mental health care provider, recognizing these symptoms in a client is a cue for you to do further assessment and seek consultation. Eating disorders are extremely complex, often requiring teams of care professionals that include physicians, psychiatrists, dieticians, and therapists to guide patients through recovery. But while eating disorders can be difficult to recognize and separate from health concerns, early intervention–including from mental health providers–is key in preventing the long-term harm that can result from undiagnosed EDs.
Suggested training resources:
Suggested assessment resources:
If you or someone you know is struggling with disordered eating, contact the NEDA helpline at (800) 931-2237.
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The content of this blog is not intended to be a substitute for professional medical advice, diagnosis, or treatment.