anorexia recovery essay

What Recovering From an Eating Disorder Is Really Like

By Kimberly Neil

TRIGGER WARNING: This story contains sensitive content regarding eating disorders.

We all get sick – from a minor cold to an infection that requires time in the hospital, the process of our body repairing itself is part of being human. Sometimes our bones break, sometimes our organs lose their ability to function properly. The cause of some illnesses take more energy to decipher, and these cases usually inspire episodes of Grey’s Anatomy or Mystery Diagnosis. The phrase “get well soon” explains how the average person views illness. Finding a cure, regardless of how small or big the problem may be, is what those who aren’t well and the people who love them wish for. In an ideal world, getting better is the best possible outcome.

What do you picture when you think about sickness? There are usually physical symptoms. Sometimes, we have to take time off from school or work. Can you imagine days in bed, chicken noodle soup, or negative side effects from strong prescription medication? Your discomfort is usually visible to those around you; and even if people can’t see your pain they can find a way to empathize once it is described. Mental illness is different.

I want you to imagine a time where you really, truly felt ashamed of who you are. A moment where the people around you didn’t get it, and more than anything, you wished the earth would open up and swallow you whole. My eating disorder has always been the personification of that very feeling. It began around the age of 11, and by the time I was 12, it had turned into something I carried around with me daily. That feeling was constant. It was my biggest, most embarrassing secret.

Though I wouldn’t describe it as a literal voice in my head, my eating disorder started with a feeling that I wasn’t good enough. This problem needed to be fixed, and controlling what I ate seemed like the perfect solution. I had no idea how easily avoiding certain foods would lead to eliminating them entirely. Though I could not put it into words as I became a teenager, I felt dirty from the inside out. Not eating specific foods turned into skipping meals, followed by days without food, replaced by days where the rules I had created for myself didn’t matter and all I could do was eat until I physically could not anymore. One day, I pushed myself past the point I thought I was capable of. It hurt, but I kept going – until my impulse changed entirely and suddenly I knew that I just had to get what I had eaten out of me.

Purging became my way of undoing: every mistake I made in class, at dance, or even with life in general, it was always something that I knew I could use as an outlet for all of the underlying negativity. I felt more in control with each meal or mistake that I tried to erase. I internalized the idea that something about me wasn’t good enough until that framed the way I saw myself. Being a teenager, a pre-professional dancer, and attending a competitive high school with amazing, intelligent, talented friends should have made me feel empowered. Sometimes it did, but because of my eating disorder, it became too easy to see myself as inadequate.

At one point, I realized that I loved certain parts of being a dancer. Ballet classes were always something I enjoyed, and I couldn’t get enough of costumes, makeup, or being on stage. Dancing gave me a way to become someone else. The downside of wanting to dance as a career while having an eating disorder was the way that no one around me said anything until I was deep into my illness. For the longest time, my friends and teachers complimented me whenever I lost weight. I noticed that the audition season for summer intensives magnified all of my insecurities. I inevitably was accepted into more pre-professional ballet programs when I was thinner.

I can remember two summers in particular where, in retrospect, I’m honestly amazed that I did not get “caught” in the chaos of my disorder. I was absolutely not healthy enough to dance 6-7 days per week from morning until as late as midnight, considering how out of control my disordered behaviors were. During one of those intensives, I also attended a summer chemistry class three days per week in between classes and rehearsal. I reached a point where I wound up leaving both. Between passing out a few times, feeling dizzy every single day, and eventually, throwing up blood – it all became too much.

Dance seemed like the root of my disorder at the time, but I had no idea how to let it go. I fought so hard to maintain my ED without losing ballet or modern. At one point, after receiving my first professional diagnosis of bulimia nervosa I withdrew from my selective enrollment high school, because my disorder essentially meant that I had to decide between my education and my dream of being a professional dancer. I eventually became so injured that dancing en pointe was no longer physically possible for me. Looking back, I believe that injury would have happened on some level even if I had been completely healthy. But I have no way of knowing if I would have still wound up in a place where dance was too painful to make the chance of a professional career a possibility, had I never developed an ED.

There also is no way I can know with complete certainty that I wouldn’t have struggled with an eating disorder had I never danced in the first place. After losing dance, it took me a little longer than my friends to finish high school by home schooling myself. Education had always been an important aspect of my identity, and losing both dance and my high school also meant that I became more and more isolated, wrapped up in my ED. I wound up pushing most of my high school friends away out of shame and guilt. To this day, I am not sure if my teachers (both from every studio that I’ve danced at and from school) and friends really knew what was going on with me. Did they avoid reaching out because mental illness is stigmatized, and talking about it is really scary? Did everyone just think I was very driven and committed to dance, making it pointless to intervene? Or did people really not know — did I hide it that well?

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Once the raw heartbreak from losing so much because of my ED began to fade away, I decided that I wanted to attend college. Had I graduated from my selective enrollment high school and been healthy enough to put the hard work into college applications, I think that I would have been accepted to at least one of my dream colleges with financial aid. The process of applying as a home schooled student is a little different, so I decided to attend a local community college for at least a year and apply to some of my dream colleges as a transfer student.

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Healing from an eating disorder is almost as stigmatized in discussion as admitting the problem itself. From books like Wintergirls to movies like Starving in Suburbia , the media presents a consistent message that the process of healing is a continuous, upward journey. I cannot speak for everyone with an eating disorder. I can admit how difficult it has been to tell my story at times, because my illness comes and goes in waves. I’ve yet to experience recovery, full stop.

There was a period of time between the end of high school and attending my first college class where my relationship with food became easier to manage. I took a similar DIY approach to recovery as I did to earning a high school diploma. My body became healthy again, and while I still struggled with depression, I felt my confidence come back slowly. I tried out for my [first] college’s volleyball team and not only made it, but received a scholarship offer as well – and I had never played before. I became involved with student government. Out of the four colleges I decided to apply to as a transfer student, I was accepted and offered aid by all of them, including my dream school. I made new friends. All of these aspects of freshman and sophomore year were wonderful, but I put a lot of pressure on myself to be the perfect student.

All of this resulted in a full relapse. It didn’t happen overnight, but my esophagus was healing from a serious tear by move-in day at the college I decided to transfer to. While my first few weeks at this amazing school on the east coast were everything I’d ever wanted out of my college experience, they were also moments that were painful and terrifying. Every single day I spent on this beautiful campus with new friends from all around the world was a day I felt torn between gratitude and self-hatred, and inadequacy. I eventually asked for help, and that lit a fire under my eating disorder. I went from feeling like recovery was possible to thinking it was something I didn’t deserve. I tore my esophagus for the second time, and simultaneously fell into restricting, abusing diet substances like laxatives and water pills, and exercising too much. I also started dancing again, and didn't feel supported by my college’s dance department at all. Even if I had felt that support, I don’t think it would have made a difference.

During the first week of October 2014, I took two cabs across the state of Massachusetts to an inpatient facility outside of Boston. I was 21 years old. It took 10 years for me to be hospitalized for my eating disorder, with an updated diagnosis of Eating Disorder Non-Otherwise Specified (EDNOS – now referred to as OSFED in the DSM-5), and that month was one of the hardest ones of my life. Inpatient was both the best and worst thing that has ever happened to me. I met people that changed my life. Both staff and other patients made me realize that maybe, the thing I was meant to do with my life all along was help other people who shared my struggle. Inpatient also made me realize how much my college meant to me, and how important education would continue to be in order to achieve my goals.

In November 2014, after leaving inpatient and returning to my college campus, I posted a poem on my personal blog. Because I also helped with a shared blog about EDs (that currently has over 40,000 followers) other people spread that poem around. The poem led to me becoming a contributor for Proud2bme , an online recovery community connected with the National Eating Disorders Association (NEDA). More recently, I even received a scholarship to attend the 2015 NEDA conference this October in San Diego, California.

My ED has given me a voice, and more importantly, it has given me a passion for helping others. It also hasn’t completely gone away. More than anything, I hope that someone out there, reading this, is able to look at their personal journey and hopefully feel less alone. I hope that someone that knows and loves someone with an eating disorder will read this, and feel inspired to really support that person through the ups and downs of recovery. Having an eating disorder is never a choice. When you’re sick, people expect you to get better. This is why compassion is essential. Healing takes nonstop effort and requires so much support, but it is possible. No one should feel ashamed of talking about the process, or receiving help along the way.

If you or someone you know is struggling with an eating disorder, the NEDA helpline is here to help at 1-800-931-2237.

Related: The Hidden Eating Disorder Side Effect That’s Both Extremely Dangerous and Far Too Common

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Tess Holliday on Her Anorexia Recovery: 'People Said I Was Lying'

By Macaela Mackenzie

Content note: This story discusses details of disordered eating.

Nearly a year after being diagnosed with anorexia nervosa, Tess Holliday is sharing the challenges of recovery—a process that is often nonlinear—in a new essay for TODAY . “I feel grateful that I’m tough enough to talk about this, but I’ve since taken a lot of steps backwards in my recovery. I’ve regressed. I haven’t eaten today,” the model wrote. “It’s 11 o’clock and I’ve had two sips of coffee, and I feel sick. This has been extremely hard on my mental and physical health.”

Holliday first shared her eating disorder diagnosis in May 2021. “People said I was lying," Holliday wrote in her essay . “There are people who believe I was saying this to get attention. I’ve had some people say, ‘You’re doing this to stay relevant.’ I laugh because I know it’s untrue, but it’s so indicative of what a large problem this is.”

Eating disorders in people with larger bodies are likely severely underdiagnosed . A culture of fat bias and harmful stereotypes about the connection between body weight and health tells us (wrongly) that all larger bodies are unhealthy, that all people struggling with eating disorders are thin. But harmful restrictive eating isn't exclusively a problem for thin people—eating disorders can't be generalized to a certain body type. 

Medical practitioners, even those with good intentions, aren't immune to anti-fat bias. In a 2018 study published in the journal Frontiers in Psychology , researchers found that mental health trainees were more likely to diagnose a client presenting with symptoms of an eating disorder with anorexia when the client was described as “underweight” or “normal weight” vs “overweight.” They also recommended fewer therapy sessions for the clients described as overweight and normal weight than for the underweight group. 

It's that exact bias that makes it so hard for people in larger bodies to get the help they need. “So many people who are in larger bodies have messaged me and said, ‘I never thought I restricted until you started talking about this,’” Holliday wrote. “It’s been very empowering, but it’s also made me incredibly sad… It’s tough when you hear the word anorexia and it’s only equated with one kind of image. It’s detrimental to so many people, including myself.”

Holliday shared that it was her dietitian who first broached the idea that she might have an eating disorder. “When she said anorexia, I laughed. I thought, ‘Do you see how fat I am? There’s no way that word could ever be attached to someone my size,’" Holliday said. Her dietitian referred her to a psychologist who confirmed the diagnosis. “I still struggle with wrapping my head around, ‘How can I be in a fat body and be starving?’ Then I realized that bodies of all sizes and shapes starve,” Holliday wrote. 

When someone in a larger body restricts their eating in a harmful way, it may be diagnosed as atypical anorexia . “Despite official clinical recognition, atypical anorexia nervosa is under-recognized and widely perceived to be less severe than anorexia nervosa,” according to the Acute Center for Eating Disorders and Severe Malnutrition. The symptoms are the same as with typical anorexia patients, except “the individual’s presentation weight is within or above the normal range,” according to Acute. “Patients with atypical anorexia nervosa experience the same incidence of binge eating, purging, psychiatric comorbidity, use of psychotropic medications, self-harm, suicidal ideation, severe depressive symptoms, and obsessive/compulsiveness as classic anorexia nervosa.”

By Sarah Klein, CPT

By Katie Camero

Even with a diagnosis, the journey to recovery isn't straightforward. “Recovery for me is messy. It’s lonely. It’s hard to deal with something for which there isn’t enough support,” Holliday wrote. “Having a diagnosis has been liberating and it has made me feel less alone, but the confused look on people’s faces when I say anorexia or the stares I get if it comes up in conversation—that’s hard.”

This time of year is particularly challenging, Holliday pointed out, as “new year, new you” messages take over your feeds and your IRL conversations. Diet culture is relentless . So are the ads for fitness programs promising to make you your best (read: thinnest) self. “Fat people are more aware of this messaging than anyone because it is shouted at us from the moment we present as fat in the world,” Holliday wrote. 

Support starts with awareness. “The way you can help us is by supporting our mental health,” Holliday wrote, “and by understanding that there are so many people struggling with what I’m struggling with, but they don’t know it, and they can’t name it, and they can’t get a diagnosis, because our system has never been set up to support folks in larger bodies.” 

If you're struggling with an eating disorder, you can find support and resources from the National Eating Disorder Association (NEDA). If you are in a crisis, you can text “NEDA” to 741741 to be connected with a trained volunteer at Crisis Text Line for immediate support.  

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A Personal Narrative: My Eating Disorder Found Hope in Recovery

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Eating Disorders are a distorted perception of your body, one often caused by the unreasonable expectations women feel by society. Each image of a slender tall model seen on an advertisement impacts you. Social media influencers of beautiful women and the comments made by their followers impact you. In the back of your brain these cultural beauty standards make you question your self-worth. Am I good enough? Why don’t I look like that? These can slowly root and distort your concept of a perfect body, till it’s firmly a belief accepted and unquestioned, by you. Most women at some point feel like their body isn’t good enough. 

The contemporary disorder that I am focusing is Anorexia Nervosa. Anorexia Nervosa is starving yourself. It is a weight loss goal that when surpassed still continues. It is a need for control that slowly feeds on any part of who you were before it. These disorders become your identity, your desire, your passion. As it grows stronger you begin to hide behind it, isolating you from anyone who might ask if you need help. Ultimately leading the disorder as your only companion. 

Anorexia became mine. 

Although I had never been jealous of my best friends’ looks, I had secretly wished I was as small as her. When we ate junk food I felt resentment in the back of my mind, that I would gain weight, while she would remain the same. None the less, I was a 14-year-old girl, and my confidence wore thick. I was more than comfortable with my body, and how I looked, and yet before I knew it, in what felt like a single moment, I had forgotten was it was like to love myself.

I began to slowly walk down the staircase towards the living room where my mom was sitting watching tv on the couch with our golden retriever. She could tell I wanted something, which only made my tone less confident. Just say it, just say it, repeated in my head as I looked at her with blank stares.

I was able to mumble a few words, explaining that volleyball season made me want to eat more, and since it was over it had been hard for me to stop, I felt hungry all the time. My mother continued to look at me waiting to see what my drawn-out reasoning’s were about. I looked at the ground as I asked for diet pills shamefully. She reacted calmly, only wanting to know why diet and exercise wasn’t the best option. Inside I felt the confidence seep back into my bones and looked up at her explaining that it was only for me to get my cravings under control, and after a week or two I probably wouldn’t even need them. We went back and forth for a while until she agreed to at least go to the store and see what was available.

That night my mom came to my room and pulled out a bottle from a grocery bag and told to me they were only to help suppress my appetite. She told me to take them twice a day, for a couple weeks until I had it under control. I remained calm, but inside I felt powerful, like the world hadn’t truly seen what I was capable of yet.

So much so, I couldn’t sleep. I felt this intense urge to begin my diet immediately. I grabbed my computer and googled weight loss exercises, and quietly slipped out of my bed and started to do abs on my floor. I looked in the mirror. I wanted to remember exactly how I looked in this moment. I pictured myself five pounds lighter and started to smile.

The next morning, I woke up, rushed downstairs, grabbed my first diet pill and took it. I waited anxiously for 30 minutes, then grabbed my cereal. I couldn’t believe it; I had barely touched my bowl. After a few bites and I felt like throwing up. Usually, I was on my second helping. I grabbed the barely eaten bowl of special k chocolate delight and poured it down the sink. As I walked away an incredible rush of confidence flooded my body. I knew that I looked the same. I knew that I hadn’t lost any weight, yet it felt as if everything had already changed. It was like nothing I had ever experienced.

After a few weeks, I had shed off at least five pounds. I stood in my room, looking at myself in jeans that once struggled to get up to my waist and button now slip on, with a slightly loose waistline. Adrenaline swooped over my body with gratification filling every inch. I grabbed all my jeans from my closest. Each pair fit better than the last. I couldn’t get enough. I Imagined what the jeans would look like after another five pounds gone.

It was my little cousin’s birthday, and we were going out to eat for pizza. I begged my mom the night before to let me skip, but she said I had to go. It wasn’t that I didn’t want to see my family, because I did, but going to a pizza place felt like I was asking myself to gain weight.

I asked my mom to back me up if anyone asked if I wanted more than a salad, because I was still on my diet. It was the first time I hid my true feelings. It wasn’t just the desire to not eat pizza I was worried about; I was terrified to. I knew this was not a diet, because I had no intention of stopping at my goal weight, in fact it wasn’t just about the weight anymore. I was hooked on the control it gave me.

I began to feel anxious, praying nobody would say I looked good or skinny. I couldn’t have anyone asking questions that might lead to suspicion. Plus, it wasn’t their business, my eating disorder was personal, they weren’t allowed to have any part of it. Honestly, I had only lost seven pounds, which wasn’t much anyways. I felt ridiculous even worrying.

The salad bar had tones of options, I grabbed a bowl and filled it with lettuce to fill me up. I added a pinch of cheese and a few croutons. I decided to add a couple peanuts on top so the protein would help curb my appetite. I was barely taking my pills. My body got used to me eating so little it didn’t need them anymore. Which was great, because I could tell my mom I stopped using them.

As we ate, I looked around and felt sorry for them. If only they knew the intoxicating pleasure of refusing food. I was the lucky one, because I was able to see the gift of control while other people stuffed their faces with pizza. I knew they would never be as happy as me. How could they when they had no ability to stop eating whatever they wanted knowing the consequences.

I always spent a weekend during Christmas season at my grandma’s house with the rest of my family. The fear of family dinner had worsened since the birthday party, it now outweighed my desire to socialize. It was almost as if I felt a tattoo saying, I have an eating disorder but don’t want anyone to ask me about it, would somehow appear on my face the moment I arrived.

I instantly could feel the sensation of anxiety creep at every cell in my body as I entered the door. I was on constant look out to remain aware of everyone’s consumption and whether mine would stand out.

The night of Christmas dinner was the final stretch. After three long days of avoiding my family shoving Christmas cookies down my throat and asking me if I had enough to eat every 20 minutes, I was exhausted. As I helped myself to a dinner proportion of my acceptance, I felt every eyeball on me, I repeated in my head, it’s the last roadblock, then no more uncomfortable social interaction and back to focusing on my weight loss.

I felt like a criminal by not overindulging myself while everyone else did. I never realized how much food is around, it was like I couldn’t do anything without people wanting to gather around and stuff their faces in the highest calorie food they can find.

I had worked pretty hard to lose more weight before this cotillion dance, where all the 9th graders in school got together to learn dances. I bought a black dress with one strap, and dangle earrings to match. I wasn’t much for high heels but after seeing my legs look slimmer, I was more than convinced it was the right choice. My Mom helped me curl my hair, and for once in my life it actually stayed curled. I looked great and I felt even better. After my weekly self-weigh in I discovered I was down to 105. It wasn’t exactly my goal weight, but I had to give myself credit, I was two pounds away from losing 25 total since September. I can’t believe I ever let myself weigh that much; it was disgusting.

My mom took me to my friend’s where we started to take pictures, a lot of pictures. I was getting tired. I was happy my mom was there; I honestly didn’t want her to leave. Apart of me didn’t want to stay the night anymore, I liked being at home, playing games with my mom. It was the best way to make sure I never ate my food earlier then the set time. Plus, now that I was counting calories, it was harder to spend the night places.

Later at our sleepover I was lying in bed with my friend trying to sleep when my stomach started to growl. Luckily, she had already fallen asleep. I looked through my bag on the floor next to me and grabbed some peppermint gum to suppress my appetite. I felt homesick, why did I stay, I couldn’t wait for this nightmare to end. I never slept over at friends after that.

I was 101 pounds now and didn’t see myself ever stopping.

I was completely alone. Isolated by my own self destruction, I started to feel myself missing my old life. I wanted out, but if I leave who will be? A world where I wake up and eat whatever I want for breakfast? One where I no longer say no to sleepovers with my friends, not that we talk much anymore. Was it worth it? Losing every sense of who I once was, I had forgotten that guys even liked me yet my desire for flirting was depleted. My days were filled with fake surfaced level conversations with people that I wasn’t close with, because I didn’t have the energy to fake a smile for the friends, I used to have deep conversations and eat frozen blueberries out of giant container with. They just wouldn’t get it, and they never even asked. It felt like it was easier for everyone to pretend nothing had changed even as we continued to grow further apart. Each day I waited till I could go home and see my mom. The only one who did listen for hours about the same calories and the same dieting thoughts that continued to circle in my head 24/7. She did so with no complaint or judgement, her patience and ability to show complete strength amazed me, but she cried in the garage behind the closed doors of her car, because she knew I was lost, and felt no desire to change. I was okay with sacrificing friendships because losing weight gave me a high better than any closeness with a person. Except my mom.

My mom told me it was time to get help. I was fragile, the bones on my ribs felt like they would crumble with one touch. My mind was checked out, and I was a shell of a human. I had not cried in months, and conversations with anyone felt like a task, I just wanted to be alone. I really missed myself, the one who didn’t eat grapes at 11pm and look at Instagram judging girls who I once thought were skinny because I had passed their body weight long ago.

Even after rehab, I was not recovered, but I knew I could no longer go back to the girl who ate 400 calories a day. It took year for me to fully let it go. Years went by till I was able to embrace myself for who I am. It took that long to no longer look in a mirror only to see what needed to be fixed. It took that many years for me to not feel shame eating in front of people. Yet the part most don’t get is this disease is yours to carry for life. If you are stressed you want to fall back, if you get your heart broken, it screams at you to reunite itself and it would be so easy.

Present Day

I no longer feel afraid of the part my anorexia had in my life.

I no longer want to go back to a place of loneliness and isolated.

It gives me the strength to listen and be involved with organizations that allow me to be a beacon of hope for someone who might be feeling alone, just like I was. It's essential I use my experience to empower young individuals to be mindful of their self-care and to speak up when they begin to struggle.

It is nothing to be ashamed of and I want those who are struggling right this moment to know that you are not alone, and we are here to help you get the information and help you deserve.

It’s essential that we as individuals choose to let go of comparing ourselves to unrealistic body images that have been distorted and falsely claimed as real.

Not allowing yourself to see the beauty that is internal is depriving yourself of living the life that is your own.

Our bodies hold the beauty inside of us, not the other way around.

I was lucky to have someone on my team.

My mother was my small dim light that kept me alive when I no longer had the strength to feel what happiness was, and because of that I have felt unconditional love, and it gave me the power to love myself unconditionally. There is not a single thing that I could do to repay the humble role she kindly took on during that time, but what I can do is make an impact to change our perception on eating disorders.

Thanks to my anorexia hidden and dim inside me is now my powerful drive for prevention of this disease.

The more we stand in this power to stop this corrupted, deceitful lie from industries and corporations who see eating disorders as their price to pay for all the money, entertainment and jobs they provide.

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Insights from Relapse to Recovery: What I’ve Learned from Falling and Getting Back up Again

My recovery from anorexia has not been linear, and I know I am not alone in this experience. Research indicates 31% of patients with anorexia relapse after treatment, with the risk for relapse being highest within the first two years after discharge. The likelihood that I am not alone in my many relapses doesn’t console me though. Anorexia is the most lethal mental illness. Because of its physiological and psychological toll, each relapse has the potential to be a dangerous dance with death. I don’t wish this long, difficult journey to recovery for anyone struggling with an eating disorder. But I know that while my recovery has been marked by many falls, it has also been marked by getting back up and moving forward again. I would like to offer three insights I have gained through my experiences of relapse that have helped me to build the stronger recovery that I am now living: 

• Reaching and maintaining a weight that is right for my unique body is necessary for  full recovery. 

When I was first diagnosed with anorexia at age 16, I was given a target weight that landed me  in the lowest end of the “healthy” BMI range. I put healthy in quotes because at that weight my mind was still very sick. Sure, I was warmer, my periods returned, and my vitals were much improved, but my mind was consumed by thoughts of food, exercise, and weight. I was constantly trying to get away with eating less and moving more, and with the scale out of the house, weigh-ins with my therapist each week became a way for me to make sure I did not gain any more weight. Unsurprisingly, within a year of starting treatment, I experienced a relapse and needed a higher level of care. At the treatment center I ended up at, I was given a new target weight. To the utter terror of my eating disorder, it was significantly higher than my original target weight. However, with the consistent, caring, but very firm support of my mom  and treatment team, I made it to that terrifying weight and was surprised to find that as my weight went up, the voice of anorexia quieted down. I still needed the uncompromising full meal support of my mom for many months after discharge, but with full nutrition day after day,  the urge to restrict lessened; and, though it was hard to admit, with time, the desire to eat returned.  

About a year later, the COVID-19 pandemic hit, and weight checks stopped. At the same time, I started increasing the amount of exercise I was doing. Unintentionally, I slipped into energy deficit as the amount of energy I was taking in did not meet the amount I was expending. When I started at a new college a few months later, the weight loss, coupled with the stress of the transition, put me in a vulnerable place. It wasn’t long before restriction became more severe, and my entire focus of attention was consumed by the rules of the eating disorder. Not wanting  to put the semester on hold, I was able to transition to remote learning, which allowed me to do classes from home and have my mom’s support for meals, rest, and weight restoration. It  was during my recovery from this relapse that I learned about the biology of anorexia and began to understand the dangers of energy deficit (intentional or unintentional) for someone  genetically predisposed to anorexia.  

I was able to see that for me, and for other people predisposed to restrictive eating disorders, negative energy balance is a trap . At first it feels good. When I started exercising more and eating less, my anxious mind became more focused, my emotions less turbulent. I felt calm and  in control. Negative thoughts about my body were quieter. But the longer I stayed in the energy deficit that was originally triggered by the change in my exercise routine, the harder it was to  get out and the more vulnerable I became to full blown relapse. Rules became more rigid, and the guilt unbearable if those rules were broken. During weight restoration after this relapse, I  gradually began to see the difference between my mind in energy deficit and my mind in energy balance. I recognized that with consistent, full nutrition day after day, the compulsion towards restriction lessened. I realized that in energy balance, I was freer to think about much more meaningful and interesting things in life than food, weight, and exercise. Negative body image thoughts were still incredibly loud and difficult, but I started to consider that maybe having a mind freed from constant preoccupation with food, exercise, and weight was worth more than my appearance. 

“Food is medicine” is a mantra I repeatedly heard from my mom and FBT therapist during the weight restoration stage of recovery, but I realize now that for someone with a history of anorexia, it should be a mantra for life. Even after weight restoration, food is still medicine.  Thanks to my experiences of relapse, I now know that eating consistently (every 2-4 hours) and adequately (3 meals and 2-3 snacks minimum) daily is not optional. It is essential to keep me from slipping back into energy deficit and back into the grips of anorexia. When I feel guilty  about eating more than other people, I tell myself that this seemingly large quantity of food  and often annoyingly structured way of eating is essential for safeguarding my freedom from an  illness that will steal my attention, ability to be present with others, physical health, and joy. As  I have progressed in my recovery, food has become more than just medicine. Sometimes it is a  source of fuel for weightlifting, a way to connect with other people, and even a source of  comfort and joy. However, I now know that because I have a history of anorexia, food will always first and foremost be medicine. 

I wish I could say that my recovery has been strong since learning about the danger of energy deficit, but it took experiencing two more partial relapses or “lapses” to recognize that not only  energy balance, but more weight, was needed to move away from the edge of illness into a stronger recovery. Both lapses happened at the start of new semesters in college when negative emotions were strong and the slip into energy deficit all too easy. After the second lapse, I reconnected with an eating disorders dietician I had worked with previously. She shared research on set point theory and brain healing to help me to see that my weight needed to be  higher. I was still experiencing a lot of preoccupation with food and exercise, devoting a lot of mental and physical energy to keeping myself at a weight that maybe my body didn’t want to  be at. My dietitian stressed that I needed to take into account that I was four years older than when I was first given my target range. I also needed to consider the number of relapses/lapses  I had experienced since starting treatment and give my brain the best chance at full healing from the damage caused by anorexia. Research suggests that with short term weight restoration, deficits in brain gray matter volume begin to improve, but that full brain healing takes much longer. I began to consider that maybe what my body needed wasn’t just an adequate amount of food, but (scary!) more weight to heal and move further away from that edge of illness and more securely into a place of freedom. Around this time, I also read Emily Boring’s exceptional article on higher target weights on the F.E.A.S.T blog. Her lived experience gave me the courage and hope I needed to gain more weight.  

So, I did. And I can say that paradoxically, I became freer from preoccupation with weight and  food when I allowed my weight to climb higher. I am still struggling to accept how my body looks here, but I know that my brain is much healthier at this weight. I can eat and move on with my life much more easily than even just a handful of pounds lower, and I don’t constantly have thoughts of food and weight and exercise on my mind. I still tend towards rigidity in food and exercise, but I know I have moved further from the edge of illness than I ever have before, which is both scary and wonderful at the same time. Reaching and maintaining a higher weight  and staying in consistent energy balance have helped me get to this point, but I know weight and nutrition are not the only factors implicated in my relapses and recovery. This leads to my  second insight: the importance of addressing comorbidities.  

• Addressing comorbidities is essential for the prevention of the recovery-relapse cycle. 

I can remember the first day of gym class in fourth grade. It is time to change from our school shoes into gym shoes and I’m at my cubby. I pull out the pearly white gym shoes I had gotten the day before at Target. I put them on and tie up the laces. But the shoes are too big. They make my feet stand out. They aren’t right. I’m not right . I feel a tightening in my chest and  stomach. Leaving my spot in line, I go to my teacher. “I think my shoes are too big,” I say. She  tells me they will work fine for today and to get back in line. The lump in my throat gets harder to swallow as we walk to the gym. In class, I sit in my spot and stare at my shoes, unable to  focus on anything else. Finally, when it is time to run laps around the gym to warmup, I go to my gym teacher and burst into tears. But as I try to explain that my shoes are too big, my nose  starts gushing blood. I spent the rest of gym class that day in the nurse’s office, trying to hide  my gym shoes under my chair as I held a tissue to my nose. Since then, I’ve learned nosebleeds can be triggered by high levels of stress. 

Anxiety has been a companion of mine from a very young age. In childhood, it often manifested in ways similar to the case of my size-too-big gym shoes—when I felt that I had done something wrong and needed it fixed right away. It would also manifest in fears about something terrible happening to me, like being kidnapped, or feeling unsafe in situations where there was an element of uncertainty (even if there was no real danger involved), such as when I was around adults who were drinking alcohol. Like many young girls, during middle school my anxious thoughts centered around my appearance. I can remember feeling that the puberty weight added to my stomach and thighs the summer before seventh grade was “wrong.” I started  running cross country and track in middle school, and when I compared myself to the runners I sa w in Runner’s World magazines, I also felt wrong. I scrutinized images of female distance  runners. Unlike these women, my legs were stubby, my breasts too big. My body wasn’t right. 

Research indicates that the comorbidity rate of eating disorders with other psychiatric disorders is very high. Anxiety disorders in particular have been identified as vulnerability factors for the development of eating disorders, commonly presenting prior to the onset of an  eating disorder. For me, anxiety and depression have been two sides of the same coin. Looking back, I can see that both contributed to the development and maintenance of my eating disorder and played a central role in my relapses. Addressing anxiety and depression with the help of medication has been a very important part of my recovery and relapse prevention. In eating disorder recovery, food is medicine first and foremost. Psychiatric medication is little to no help to a malnourished brain. In addition to full nutrition, though, for me, addressing comorbidities with medication has helped to lessen the pull towards restriction and exercise compulsion by lessening the intensity of anxiety and intrusive thoughts that I experience each  day.  

With a well-nourished brain and body, therapy has also helped me grow stronger in my recovery by helping me to gain insight. I am now aware that when I feel vulnerable, anxious, criticized, lonely, stupid, ugly, and uncertain, the pull towards eating disorder behaviors is stronger. At the start of each of my relapses, restriction soothed my anxiety. The rules of the eating disorder provided a detailed oriented focus to my day-to-day existence, helping me to cope with uncertainty and feelings of inadequacy. The world simplified to eating less, losing more weight, following a regimented schedule, and becoming frailer exteriorly to match the inner fragility I was experiencing. I think it’s important not to over-psychologize eating disorders, but while still taking into account the biological nature of anorexia, it has also been helpful for me to consider how the illness has helped me to get needs met that were not being met in healthy ways during different times in my life, such as the need to be seen, attended to, cared for, the need to be unique and confident that I was good at something, the need to set and reach goals. Now I am at a place where I can ask myself how I can get those needs met in healthy ways. I tell myself that restriction is not an option anymore, no matter how bad I feel  about myself or my situation, and that I do not need anorexia to be seen and valued.  

This brings me to my third insight. Along with full nutrition and weight restoration, medication,  and therapy, I needed what I call “life tethers” to build a strong and lasting recovery. These tethers have expanded my world beyond the bubbles of illness and eating disorder recovery. They have helped me to get needs met in healthy ways and to hold fast to life, in all its beauty and complexity, when I feel the pull towards anorexia and despair.  

• “Life tethers” sustain lasting recovery by making my world much bigger than the narrow confines of anorexia.  

Throughout my recovery, there have been periods of time when I have lived in what my therapist and I call “the recovery bubble.” When I am ill with anorexia, my focus is hijacked by eating disorder rules and fears. In the recovery bubble, on the other hand, my focus is narrowed down to challenging those rules and fears, to “fighting the eating disorder.” Being in the recovery bubble is a far better place than being ill, and it has been essential at different points in my recovery journey. When I missed months of school for treatment during my senior  year of high school, the message repeated to me was that my education could wait. Nothing was more important than recovery from this illness. During this critical time, it was helpful to frame recovery as a fight for my life, a battle for freedom from the dark, destructive voice of anorexia. When I graduated from high school, I stayed home for a year, attended community college, and essentially lived in a recovery bubble. My mom supported me through almost every meal, and we had weekly sessions with my therapist. I watched Tabitha Farrar YouTube videos and read eating disorder recovery blogs. In the recovery bubble, my focus expanded beyond the confines of anorexia, but most of my thoughts still revolved around the world of  eating disorder recovery. I held onto the eating disorder world, not wanting to let go of what made me “special.” 

The recovery bubble provided me with a sense of safety. The world outside was uncertain and I felt inadequate in the face of it. In the recovery bubble, however, the most important thing in the world was eating and challenging the voice of anorexia, and I had my mom, therapist, and dietician supporting me in that fight. I think recovery bubbles can be valuable, especially in the  beginning stages of recovery. Eating disorders are very serious illnesses and should be treated  as such. When someone is in the grips of an eating disorder, the most important thing in the  world is recovery. Ultimately, though, I am grateful to say that through lots of perseverance, I am now at a place where I can see that life is so much bigger than the worlds of both eating disorder illness and recovery. This doesn’t mean I deny my history. I know that I need to be on top of my nutrition and cautious of my tendency to slip into rigid routines with food and exercise. But I now have values outside the eating disorder. I have “life tethers” that keep me grounded, helping me to ride the wave of emotions that in the past would have sent me spiraling back to anorexia.  

The first of these tethers is relationships. For a long time, I could not recover for myself. So, I chose recovery for my family. I can remember my mom, with tears in her eyes, telling me that  she needs me to get well. This has been a steadying mantra of mine in recovery— My family needs me to be well . I would not be where I am today without the support of my family. A strong support system, including my family, therapist, dietician, and psychiatrist/physician, has  been essential for my recovery. For years before starting treatment, I lived alone in my mind with the mean voice of anorexia. Looking back on the ways the eating disorder severed relationships and pulled me away from my family and friends, it can be hard to be compassionate with myself. But I am so grateful recovery has given me the freedom to  reconnect and form new relationships. This has required immense perseverance, as I still struggle with social anxiety and inflexibility, but I am now committed to valuing relationships  above the eating disorder. Often this looks like eating the ice cream my sister made for dessert or skipping a planned workout because a friend is visiting. Relationships keep me tethered to  life when it is difficult to choose recovery for myself. 

Another life tether has been exploring and setting goals in areas of life outside of food and exercise. The goals of anorexia are often concrete and involve a regimented daily schedule. In recovery, it can be very difficult and disorienting to let go of the order anorexia provides,  destructive as it may be. I have found that setting goals in hobbies, academics, and work has helped me to feel a sense of control and order in my life, without relying on the eating disorder.  At different points in my recovery, when my self-esteem was very low, I needed encouragement and support to explore life outside the recovery bubble. But with courage and  perseverance, I am now at a place where I want to act in accord with what I value rather than what the eating disorder values. I can choose to read a good novel in my free time rather than feel I should do some sort of movement. I try to write every day, because writing helps me to order the chaos I feel within and without. Even small things, like making my bed each morning  can help me to feel I have some semblance of control when life is chaotic. And when I enter uncertain and new situations, like the start of a new semester or summer job, I try to apply a growth mindset , aiming not at flawless perfection, but growth through effort and perseverance.  This gives me the freedom to make mistakes and view criticism as an opportunity to learn and mature in what I value, not as evidence of my inadequacy in the face of life.  

Lastly, faith in God has been my strongest tether to life in my recovery. Faith frees me to be by speaking to me of my inestimable worth, of the value of my life regardless of what I look like or what I accomplish.  But it also invites me to become , to participate in something much larger than myself, to seek to do good in the world, and to hope and trust that hard as it is, life is good and worth living to the fullest, without anorexia.  

I feel there is much more to say, as I know there are many more factors involved in relapse and recovery. But speaking from my own experience, these three factors—reaching and maintaining a higher weight, addressing comorbidities, and identifying and pursuing values outside of the eating disorder—have helped me to build the stronger recovery that I am now living. I know that this would not have been possible without the support of my family, so I want to encourage parents not to give up, no matter how bumpy the road to recovery may be.  Relapses can be learned from, and insights gained. But it is my deepest hope that while relapse may be common, through sharing our stories and learning from research in the field, it does not have to be inevitable.

10 Comments

Such an important message. I hope the author has been evaluated for “just so” or “just right” OCD. What she describes in #2 sounds very much like it.

This is just unbelievably similar to my daughters experience and words. Thank you so much for sharing them

This article came at the exact time I needed it and I will share it with my daughter who is struggling with gaining back sone weight.

A beautiful story. Congratulations on your bravery and strength.

You are extraordinary in every way. I am amazed at your introspection and courage. Thank you for your authenticity and sharing your story!

Wow, Hannah, what a really fantastic lot of insights.

I am going to send parents to this page whenever they are scared of things getting worse as weight rises, when they are hesitant to experiment with more weight, when they wonder how their child’s body image will evolve, and when they hesitate to continue supporting meals with their struggling but weight-recovered child.

The anxiety you describe in your second point is so common, and I love how you describe finding other ways of getting your needs met.

I’m also moved by how you describe your third point, creating a life worth living.

Thank you for taking the time to write.

This is the MOST helpful, insightful and hope-giving essay I’ve ever read regarding eating disorders. GOD BLESS YOU, HANNAH, for going through what you did and recovering and passing on the wisdom and lessons you’ve learned. I will pass this essay along to my husband and to my daughter who’s struggling with anorexia and depression and to her older sister. With enormous gratitude, Myra

A beautiful brave essay . I am going to use as teaching tool !

Thank you for an insightful, hopeful and raw article. My daughter, 14 is on a slippery backslide right now. She is not well enough or mature enough to understand the importance of keeping weight up and consistent nutrition for life – but we can hold that vision and knowledge for her as she grows. We saw her come back to life with nutrition. I know we can help her get back on track. So wonderful to know that recovery and insights can come to her later in this long journey, as they have to you. We need to keep hearing from voices ahead on this path like yours!

Thank you for this. I have never heard of being re-triggered by an energy deficit, but I think I am experiencing this due to increasing my running training. So glad I read this so I can take the right steps to prevent a relapse <3

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Anorexia Nervosa

The things no one tells you about anorexia and recovery, the big picture of anorexia is easily painted, but the little details matter too.

Posted May 16, 2019

The little things as guiding lights from illness to recovery

Anorexia is a lot about eating not enough, not having body enough, not resting enough, not heeding one’s own needs and desires enough. And so a lot of it is bleakly predictable : having anorexia typically involves being thin, isolated, depressed, cold, judgemental, narrowly obsessive, and much other fun stuff. In a simple sense, recovery is a reversal of all that: growing, connecting, laughing , warming up, accepting, relaxing. All this undoing of the strictures of self-starvation is as profound as anything in life gets, but the idea of it can often feel too abstract and distant and ungraspable to help motivate change.

Changes as all-encompassing as stopping wanting, or being able, to live alone and secretively, or stopping wanting or being able to spend 90% of one’s waking life working, can be hard to believe in the possibility of. And partly because they’re so hard to conceive of, they can also be hard even to want. When so much of my mental world is populated with thoughts of eating and not eating, bodyweight and the shapes of my flesh and bones, can I really make myself care enough about being capable of, say, a fulfilling romantic and sexual relationship, to want to get myself to the state where it is possible? When it feels beyond you not just to change, but to change enough to want to change, the distance to be covered between here and there can feel so vast it’s not even worth trying.

Just as importantly, those enveloping traits and habits of reclusiveness or impatience or indeed thinness can seem too integral a part of yourself to really believe in as separable, as optional, as anorexia-entailed. And so we end up paralysed by the necessity of this and the impossibility of that , with over-generalisation at least part of the problem at both ends.

So, what could help make that distant there of post-recovery feel within reach? What, just as importantly, could help it seem truly, concretely, desirable? What could help you find the reason to do something rather than nothing, to start putting one foot in front of the other, and to keep doing so even as all anorexia’s worst fears start to come true? Well, I’ve suggested answers to these questions in posts like ' Escaping from anorexia ', ' How to make the decision to get better ', ' Recovering from anorexia: How and why to start ', and ' How and why not to stop halfway '. But given the number and strength of the reasons to never change anything that always seem to crowd in on us as soon as we've almost decided to add in that extra afternoon snack or whatever , we can never have too many answers to the question, why is change worth it? So this post offers another. The answer is also a reminder that far more of your current habits and preferences than you may be inclined to acknowledge are determined by your illness, and that you therefore need to be open to them all changing, temporarily or forever, as anorexia becomes part of your past.

You may well read that and think it doesn't apply to you. If so, I invite you to engage in a little personal inquiry – with plenty of attention to detail. Sometimes it helps to bring things down to specifics. Sometimes the tiny detail in the corner of the painting speaks more poignantly than the figures who take up most of the canvas. Sometimes the realism that speaks to us with potency needs to be constructed out of details that may have symbolic value, standing for more than themselves, but also exist, self-sufficiently, as fragments of raw reality. Sometimes (probably always) neither the actual nor the possible can be seen clearly in its entirety. And so synecdoche – the part standing for the whole – may be as close as our minds can come to grasping what reality is and what it could be.

If you find you all too easily switch off when someone asks you how on earth you can bear the cold and the hunger and the depression and the life narrowing down to nothing, maybe the realisation that you’ve never ordered anything but black coffee at Starbuck’s can be a more meaningful reminder of just how constrained your life is. Conversely, if all the sweeping promises about how much happier and full of life you’ll be when you’re better are easy to dismiss as vacuous or implausible or both, maybe the idea of being able to enjoy a lazy weekend morning of sex and brunch when you want feels more worth aiming for. The point about these specifics is they are inherently personal, so these two may not speak at all to you – but you’ll be able to find your own if you try.

Here, then, are some of the strange little ways anorexia made me be who I was, more and more narrowly over ten years. They start with food but stretch far beyond it. How many of them remind you of you, or the ill person you know? How many such things do you deny are anything to do with your eating disorder ?

List 1: The anorexic little things

• Put a large amount of salt on everything savoury.
• Eat raw garlic as a treat.
• Pile up 99% of the margarine in one corner of one of my pieces of bread.
• Eat a large amount of sweet food.
• Crave sweet food insatiably.
• Eat no meat (officially for animal-welfare reasons), and no animal products except milk and yoghurt (because I didn’t want and/or dare to eat any others).
• Eat Go Ahead bars, always bringing them to my mouth with the yoghurt coating face down.
• Fill mugs to the brim so only the surface tension keeps the liquid from spilling out.
• ‘Pre-read’ magazines and newspaper supplements to prepare the good, i.e. the most mindless, bits for reading while I eat.
• Cut out clippings from magazines and newspaper supplements to give to other people.
• Get up to empty my bladder repeatedly during the course of an extended meal.
• Write in my diary every evening, and repeatedly during the course of an extended meal (mostly about eating).
• Change into nightclothes, dressing gown, and slippers on returning home.
• Carry two panniers around on my bike, both always somehow full of books and/or food.
• Turn the minimum possible heating on until it’s time to eat.
• Turn the maximum possible heating on once it’s nearly time to eat.
• Turn on the minimum possible number of lights.
• Sleep with an electric blanket or hot water bottle.
• Sleep in pyjamas.
• Keep a plastic bag full of torn-off nutritional information from food packaging and a calorie-count book.
• Count the calories of one section of my daily diet (a varying set of very sweet things eaten just before sleep).
• Have trousers tailor-made.
• Wear mostly trousers, rarely skirts.
• Go shopping for clothes often.
• Retrieve food from dustbins.
• Never throw food away, or leave food uneaten. (Often scrape mould off things to avoid wasting them.)
• Retrieve magazines and newspaper supplements from recycling bins.
• Care about tidying kitchens.
• Keep food and drink wrapped in plastic bags at the back of shared fridges.
• Use special mugs, bowls, and teaspoons.
• Wear my hair short.
• Have awful spots.
• Wear no glasses or lenses despite being short-sighted.
• Shower once a week.
• Drink no water.
• Eat no fruit.
• Despise gyms.
• Cycle every day to a particular sapling (in Oxford) or round a particular circular city route (in Bristol).
• Travel by train and bus and bicycle, except when other people drive me.
• Have one of my parents collect me and lots of belongings at the end of term, to return to one of their houses for the vacation.
• Work mostly at home.
• Live (by the end) mostly nocturnally.
• Hate setting an alarm to wake up to.
• Read only for work, nearly never for pleasure .
• Never listen to music.
• Listen to Radio 4 (serious talk radio), including The Archers (‘a contemporary drama in a rural setting’), every day.
• Sweat in my sleep.
• Dream rarely .
• Keep a list of everything I spend .
• Shop in the cheapest supermarkets when spending my own money; shop in Waitrose when spending my stepfather’s money.
• Write my daily diary in blank notebooks.
• Dislike blue cheese.
• Have very few friends.
• Live alone.
• Fear the cold and the tiringness and the increased eating involved in skiing.
• Empty my bowels before eating late at night.
• Speak in a rather flat, relatively high-pitched voice.
• Wear a plastic ‘granny hat’ with strings tied under my chin for cycling in the rain.
• Want an academic career .
• Save a teabag used for my first cup to make my second.

And here, (very) roughly in the order in which they changed during or after recovery, are some things that make me who I am now. With some of them, I indicate a series of steps from recovery to now (in these cases the last step may be fairly recent).

List 2: The recovered little things

• Want to eat meat → Eat lots of meat, especially the fat on meat → Eat less meat, for animal-welfare and environmental reasons.
• Use normally small amounts of salt.
• Eat garlic usually cooked.
• Eat butter not margarine.
• Like blue cheese → Dislike blue cheese.
• Have fewer spots.
• Not look in dustbins.
• Not look in recycling bins.
• Not leave food or throw food away other than in exceptional circumstances. (Have a slightly lower threshold for where scraping mould off cedes to throwing away.) Sometimes finish food from other people’s plates (if I know them well!) and scrape out saucepans etc. after cooking.
• Eat unfamiliar foods and check their calories → Eat unfamiliar foods without looking up the calories → Forget many of the calories I used to know → Know the calorific values of very few foods I eat.
• Empty my bowels first thing in the morning.
• Cycle often with just my shoulder bag, or with one pannier for food, gym stuff, or other things.
• Like being warm enough → Often feel warmer than other people. (A former yoga teacher used to warm her hands on me!)
• Fill mugs slightly fuller than most people do.
• Use whichever crockery and cutlery is to hand, though with stronger aesthetic preferences than many other people’s → Have a special mug and teapot kept for me at my mother’s house.
• Get ready for bed at bedtime – but still love slippers.
• Have something sweet before or in bed → Decide to stop that for a while → Not need something sweet before sleep.
• Eat with book, magazine, radio, other people, or none of the above, as I feel like.
• Stop writing a diary altogether → Write once a day, first thing in the morning with tea in bed.
• Live with a partner → Live partly alone, partly with a partner.
• Shower most days, and wash my hair twice a week → Shower about twice a week, and wash my hair once a week.
• Love fatty foods as much as sugary ones.
• Buy trousers in normal shops.
• Often watch a TV episode before sleep.
• Read barely any magazines or supplements → Read some magazines → Read some magazines and sometimes photographing snippets for people.
• Not mind eating even if I need the loo.
• Dislike most overhead lights, and like lower lighting than many people.
• Not feel colder while eating.
• Feel hot in bed.
• Sleep naked.
• Stop treating my parents’ homes as my home.
• Make my tea in teapots.
• Develop a healthy obsession with Waitrose .
• Wear mostly skirts, rarely trousers.
• Go shopping for clothes often → Go shopping for clothes rarely.
• Have little interest in the tidiness of kitchens.
• Have little interest in the visibility of my items in shared fridges.
• Dye my hair → Let my hair grow → Have long undyed hair → Have long dyed hair.
• Wear my glasses for driving and watching TV → Wear contacts.
• Drink fizzy water with meals → Drink next to no water.
• Eat some fruit → Eat next to no fruit.
• Love powerlifting.
• Cycle when I need to get somewhere.
• For long journeys, love driving fast, ideally with roof down.
• Wake up in the morning.
• Hate setting an alarm to wake up to, and almost never do so.
• Read for pleasure a little → Read for pleasure almost every day.
• Listen to Radio 4 almost never → Listen to pop/dance music most days → Listen to football (soccer) chat on Talksport quite often.
• Support a football team (Swansea City, if you care).
• Not sweat in my sleep.
• Dream a lot → Dream now and then.
• Not list money spent → List everything I spend while income is a problem → Not list money spent.
• Write in a page-a-day diary.
• Speaking in a richer deeper though still quiet voice.
• Avoid cycling in the rain, or get wet hair → Wear a raincoat when cycling in the rain.
• Pursue an academic career → Get some job and grant rejections , realise I like other things more → Spend several years writing an academic textbook without a paying job → Create a primarily non-academic primarily freelance career .
• Work mostly at the office or in cafés.
• Love skiing as much as anything in the world.

Using the lists yourself

In themselves these kinds of list might seem silly and/or obscurely over-specific, but make one for yourself and I suspect it won’t feel that way. Indeed, writing your own list before you’re in a position to fill in any of the second section yet may be poignant in a way that feels a new kind of galvanising. Or doing it halfway through recovery might be a little inspiration to carry on – to create a partial ‘after’ list as a snapshot of now, and maybe some predictions about what else will change and keep changing. And wait to gradually find out what things you couldn’t yet see as accessories to the illness but which at some point in recovery are revealed as such.

I’d love to hear some of your items, on either list at any stage, if you’d like to share them!

Recovering versus growing up?

This kind of exercise actually gets rather effectively to the heart of what identity is, and how illness changes it. The broad brushstrokes of the classic anorexic personality traits ( anxious , depressed) and habits or life circumstances (having few friends, never taking vacations) are part of the picture, of course, and they all derive systematically from the damage that systematic undereating does to a mind and body. But the tendrils of anorexia creep far further into the minutiae of life and personality and physicality than can automatically be grasped as consequences or correlates of self-starvation. If you’d told me before I started recovery that recovery would mean my voice changing pitch, my radio being tuned to a football station, and my hair getting long and brightly coloured, I’d have laughed unamusedly at you. And of course, life being the uncontrolled experiment that it is, I can’t say that anorexia was the only reason I spoke, listened, or styled my hair in those ways, nor that recovery is the only reason I do them differently now. Maybe some of these changes were just me growing up. But then, you don’t grow up while you have anorexia, you just get old without growing up, so recovery is still the prerequisite. I know that had recovery not happened, most of the things on List 1 would still stand. And I find it hard to think of anything that induces such a sharp simultaneous reaction of bleakness and gratitude .

Anorexic or not?

I don’t know how representative my list is; maybe lots of people who get better go on to have a hair-colour trajectory from dark blue back to normal and then to turquoise and then pink-and-blue and then blue with blonde overlay and then turquoise with blonde. I suspect that quite a few of the things that seem rather arbitrarily unconnected to anorexia may actually be fairly common manifestations of it. With hair colour, the obvious connection is the discomfort, in anorexia, with being looked at and with expressing one’s personality through any physical qualities but thinness (because the personality is itself reduced largely to what the thinness dictates ) – and the willingness that recovery brings to both see and be seen. I could tell an easy ‘this is why this was actually anorexic’ tale about anything on List 1, and all of them would have had truth to them, and many would also be over-simplifications.

One reason why also writing List 2 is important is that some of the items are the same as or very similar to items on List 1. And that allows some aspects of the life that was anorexic to stand as valid parts of a life that is no longer anorexic – for me, say, not eating fruit (unless there’s a strong social reason to, or it’s nicely disguised in a crumble or a pie), or liking having my own pretty bone china and silver mug for tea and coffee at my mother and stepfather’s house (the mug, as it happens, given to me by one of the two friends who helped initiate my final recovery effort). Those things are harmless, now, and actually more than harmless: for me they feel, respectively, part of a rejection of stupid dietary dogma (e.g. the UK’s nonsensical ‘5 a day’ public health mantra ) and an expression of an aesthetic sense for fine china. I used to not eat fruit because I wanted to save all possible calories for ultra-sweet things; now I don’t eat it because I don’t especially like it, because it’s nutritionally pointless, because I don’t need the ‘I’ll eat fruit cos it’s healthy’ excuse to have something sweet, and also I suppose because I quite like the oddity of not liking it, as of not drinking water. Similarly, with the crockery, I used to have special mugs because I needed the biggest ones possible, and I needed them to be consistent. Now I only use that lovely one a few times a year, and I have other preferred mugs in some other places, and having flexible preferences is fine. So context is everything. It’s the difference between something being part of a pathology and being a little life enhancement, or something that helps make me not a cookie-cutter non-person: something a friend might tease me about or a parent remember about me.

In almost all cases, as in these two examples, the things that have reverted to how they used to be haven’t done so with total symmetry. In most cases, they’ve returned to something similar not identical: eating not very much meat instead of none, for example, and for the professed not concealed reasons; or writing a daily diary but with completely different book, timing, and spirit; or remembering why when I was a teenager I liked watching football, and now actually supporting a team as well (beyond England at Euro ’96). And this is part of the broader fact that nothing is all-or-nothing: rediscoveries are no less valuable than new discoveries, new preferences evolve out of old likes and dislikes, and the things you are and do keep interacting in new ways to create new patterns of change and learning.

It is counterproductive to demonise everything about one’s life with anorexia, forever. I think there’s often value in thrusting all that rubbish away from you with the zeal and the anger of the newly converted – this is the logic of the pendulum that has to swing to the other extreme before it can settle in a stable middle, which I’ve discussed elsewhere in the context of both eating and sex . But anger and distrust have a habit of poisoning the person who feels them if allowed to persist too long. Having anorexia was mostly miserable, but having recovered from it gives you wisdom and a capacity for profound appreciation that you would otherwise never have known; learning to appreciate precisely that is crucial if you’re not to be left with a sterile resentment of all the ‘lost years’. And of course not everything from the whole of your time with anorexia was irredeemably awful.

The flipside of the need to embrace the potential for change is the fact that not everything may need to. You aren’t throwing the last x years away and starting again ; of course you’re not. There is continuity in everything, just as there is permanence in nothing. Just because you happened to love hiking or Cadbury’s creme eggs or postmodernist prose poetry while you were ill doesn’t make those preferences inherently suspect, even though some time away from them will probably be needed to test whether the love is love or dependency (or snobbery!) – and that time out often happens automatically, as you realise the sheer scope of things the world offers that you haven’t even begun to explore yet. (With anything exercise-related, a proper break will be important to insist on, regardless of whether you feel like it or not; see the pair of posts on 'Should you exercise during recovery from anorexia', starting here .)

Radical openness to change

Ultimately, recovering is about letting things big and small change if they need to. Recovery cannot happen if change is resisted – on any dimension at all . If you approach recovery with the view that, well, you’ll sort the eating and exercise but you expect everything else to stay the same, you’ll end up making decisions that in subtle ways ensure it does, and then recovery will probably not happen for you, because while still ill we are incapable of separating anorexic from non-anorexic, and also because change is itself inherently anti-anorexic.

This relates to the fact that some of the things on my list can be classified as ‘voluntary’ changes (I didn’t just wake up one morning to find my hair had been bleached) and some as ‘involuntary’ (I didn’t decide to modulate the pitch of my voice). But this easy distinction doesn’t stand up to much scrutiny: I made the appointment at the hairdresser’s only because I found myself wanting to, and recovery changes everything about what we are able to ‘voluntarily’ choose. This is part of why it’s so scary choosing recovery: I’m not choosing a definable set of things that my life will be, I’m choosing a life that will involve wanting and needing to choose an unpredictable, uncontrollable set of things, including some I currently both fail to understand and despise.

The necessity of openness to change applies to the big things: if you assume you will stay in the same romantic relationship , or stay in the same career, after recovery as before, and refuse to contemplate or allow change, you will probably not get fully better, because you are setting arbitrary limits on what you are willing for recovery to mean for you. It also applies to the little things: if you assume that your hairstyle, reading habits, clothing choices, or bedtime will stay the same, and refuse to contemplate or allow change, you will probably not get fully better, because you are setting arbitrary limits on what you are willing for recovery to mean for you.

At both levels, you are pretending to know who you will be when you are no longer who you are now. You are pretending to want to be free of anorexia while allowing anorexia to dictate what that freedom from it will mean. You may feel different degrees of fear, nervousness, curiosity, cynicism , or excitement on the macro and the micro scales, but change will happen on both, if you let it, and your eating disorder will survive in both, if you don’t. This urgent need for a radical degree of openness is not something many people ever have thrust upon them – and it’s one of those times where being forced into something is actually a privilege. It can be the beginning of an important lifelong habit of liking seeing where life takes you next.

Emily T. Troscianko, Ph.D., is a researcher and writer with a particular interest in the links between fiction-reading and mental health.

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Unlocking a healthy mindset: the road to recovery from anorexia nervosa.

A Q&A with Johns Hopkins psychiatrists Angela Guarda and Colleen Schreyer

Interview and text by Benedicta Kim and Karen Blum

For decades, experts with the Johns Hopkins Eating Disorders Program have challenged the nutritional prescriptions of traditional treatment programs for eating disorders “to start low and go slow.” This has decreased the time needed to restore weight, normalize eating and weight control behaviors, and master relapse prevention skills needed for successful long-term recovery from anorexia nervosa. The Johns Hopkins team has helped hundreds of patients resume schooling, work and relationships interrupted by illness.

Angela Guarda , director of the program and the Stephen and Jean Robinson Professor of Eating Disorders, has called for universal reporting of clinical outcomes by eating disorders treatment programs to increase transparency and help patients, families, providers and payors compare treatment approaches. Headed by Colleen Schreyer, director of clinical research for Johns Hopkins’ longitudinal eating disorders outcome project, the clinical research team has focused on assessing and publishing the program’s treatment outcomes in a series of peer-reviewed articles published in the International Journal of Eating Disorders . The research team’s work reports on treatment outcome variables, including the average rate of weight gain, percent of patients who achieved a minimally healthy weight, safety of the meal-based rapid nutritional rehabilitation prescription, relative cost of treatment, and relapse risk. They also examined patients’ perceptions of treatment, and whether patients felt they benefitted from the program’s rapid weight gain, meal-based, behavioral approach.

In this Q&A, Drs. Guarda and Schreyer explain the rationale for the program’s approach to treating anorexia nervosa and discuss its treatment outcomes and research findings.

Dr. Guarda, before we delve into The Johns Hopkins Eating Disorders Program’s outcomes research findings, could you provide us some background on how patients feel when facing treatment? What is the “anorexic mindset”?

Anorexia nervosa increases anxiety about gaining weight and eating high-calorie foods — and yet this is necessary for thoughts, mood, and body dissatisfaction to improve in patients with the disorder. Key goals of treatment are weight restoration and eating a variety of foods of differing calorie densities at regular meals. We know the starved state and a restricted food repertoire perpetuate eating disorder thoughts and feelings, and alter brain function, so achieving these goals are crucial first steps in recovery — but ones that often feel overwhelming for patients. The Johns Hopkins Program helps patients overcome anxiety about eating and employs a behavioral, meal-based, rapid-weight restoration approach to (1) minimize time spent in intensive treatment; (2) help patients normalize their eating and weight control behaviors and overcome anxiety about eating; and (3) master skills needed to prevent relapse once back at home. The approach is team-based, collaborative, and it includes group, family, nutritional, and occupational therapies.

Dr. Guarda, could we say weight restoration and being able to eat a variety of foods is central to having a “non-eating disordered or healthy mindset”?

In a sense, yes—anorexia nervosa hijacks the healthy brain. Our brains consume 20% of our daily caloric needs; a starved brain simply does not think clearly – and talk therapy is less effective when someone is in a starved state. Furthermore, searching for explanations or a “root cause” — as to why a person developed anorexia — is not enough to get someone well. It’s not so much an “aha moment” of insight that leads to change: We need to help patients change their behavior and restore nutritional health for anorectic thoughts and feelings to gradually fade. That’s what makes weight restoration and normalized eating crucial treatment priorities. In the absence of headway with those, no amount of therapy alone is likely to help someone get well.

Dr. Guarda, the Johns Hopkins program’s average weight restoration rate is four pounds a week — double that of most programs. Is it safe?

Yes, back in 2015, we published a study that included 461 consecutive underweight patients and found that the program’s meal-based, rapid weight-gain behavioral approach coupled with close medical monitoring was safe and effective and did not result in higher risk of a dangerous complication known as refeeding syndrome. Additionally, over 70% of patients left treatment weight restored and at a healthy weight, following a shorter admission and without the need for nasogastric tube feeding. At the time, this approach went against the general belief that restoring weight at a rate greater than 2–3 lbs per week was dangerous and could lead to serious risk. Indeed, partly as a result of this study, the recently updated American Psychiatric Association’s Practice Guidelines for the Treatment of Eating Disorders now recommends that residential and inpatient programs should achieve average rates of weight gain of 2–4 lbs per week for anorexia nervosa. Thanks to a faster rate of weight restoration, most patients reach a minimally healthy weight over weeks rather than months. Faster weight gain means less time away from home, work, or school and, in the long run, less costly care .

Dr. Schreyer, in the longitudinal study — when you followed up with patients after hospitalization — what were the key predictors of good outcomes?

Consistent with the importance of restoring weight, we found that weight at program discharge was more important to avoiding relapse six months later than was age, number of past hospitalizations, or how long a patient had been ill with anorexia. Additionally, patients who reported higher confidence in their ability to eat in a healthy balanced pattern at hospital discharge were less likely to have relapsed six months later. And, despite the rapid weight gain and behavioral focus of the program, patients reported being highly satisfied with the treatment they received. About 83% said they would recommend the program to others . As one patient put it: “With anorexia, any rate of weight gain feels too fast — I’ve lost enough time already because of this illness.”

Dr. Guarda, 83% patient satisfaction with this approach is impressive, given that patients are anxious about weight gain. How is this possible?

Focusing on rapid nutritional rehabilitation and normalizing eating and weight control behaviors may feel anxiety-provoking at first, but when addressed in the context of a specialized behavioral treatment program that incorporates close medical management, family support, group therapies and a collaborative team-based approach to care, patients support one another, learn to lean into their anxiety, disengage from eating-disordered thinking, and achieve mastery over the disorder. In a sense, recovery from anorexia requires unlocking the healthy brain through nutrition, behavior change and psychotherapy — and mastering the tools and skills needed to maintain healthy function and avoid relapse.

Dr. Schreyer, how did the pandemic affect patients in the program?

The COVID pandemic has taken a toll on everyone especially on adolescents — we are seeing a worldwide increase in eating disorders in youth. At Johns Hopkins, we found that adolescents admitted to the program from March 2020 to March 2022 were arriving with more severe eating disorder, depression and anxiety symptoms. Despite this heightened clinical severity, outcomes including weight regain were similar to those of patients admitted before the start of the pandemic. That means we were equally effective in treating these patients, even though they presented as more severely ill.

Dr. Schreyer, we’ve been focusing on anorexia, could you walk us through avoidant/restrictive food intake disorder (ARFID)?

Avoidant/restrictive food intake disorder, or ARFID, is a recently defined eating disorder in which patients restrict their intake due to low interest in food, sensitivity to food odors, tastes or textures, or fear of consequences of eating (e.g., choking, vomiting, or stomach pain). Importantly, patients with ARFID do not endorse marked body image concerns, however their restricted food intake results in a malnourished state and impaired function. The Johns Hopkins weight restoration protocol is effective in treating underweight patients with ARFID . Although weight gain rates were slightly lower for patients with ARFID compared to those with anorexia nervosa, a similar majority of those with ARFID clinically improved and achieved a minimally healthy weight by discharge.

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Header menu - drawer | united kingdom, james' story: my experience with anorexia and eating disorders.

This content mentions eating disorders, body image or generally discusses weight, which some people may find triggering.

It’s ‘Eating Disorder Awareness Week (EDAW)’ from 27 February 2023, and this year’s focus is on eating disorder awareness in men . Yes, that’s us strong, tough men who hide our feelings. Oh, hang on a minute, that’s not actually true, is it?

It’s a myth that it’s only women and girls who suffer with ‘eating disorders’.

The National Association for Males with Eating Disorders estimates that 25% to 40% of people with eating disorders are men and boys.

The big blocker to getting help is stigma , together with a lack of understanding about the size and presentation of eating disorders in the male population can mean that eating disorders are not identified or treated early enough.

Of course, it is possible that men and boys are particularly resistant to early intervention. One of the main reasons for this could be a reduced likelihood of family, friends or medical professionals suspecting an eating disorder as early as they would in a female with the same symptoms.

So, this is my story about how I fell victim to the deadly disease ‘ Anorexia Nervosa ’. Thankfully and luckily, I live to tell the tale and turn my wounds into wisdom. I hope that this will help people who are affected to understand the importance of getting help, no matter what type of eating disorder they may have.

Malnourished to Manpower!

For two years in my early twenties I lived with anorexia but convinced myself that I was fine. Only when my weight dropped, did I finally agree to get the help that I needed. I now raise awareness of the illness to help others.

I was a relatively chubby child, and, as I’m sure you know, kids can be mean. I was bullied at school for the way I looked and, at one point, was even given the nickname ‘Bacon Boy.’

But looking back, it didn’t make me desperately unhappy. Not at the time. It wasn’t like those unkind words made me want to change myself or fit in or triggered an eating disorder. Although, I suppose, in some way, that’s what did happen. It just crept up, surprising me years later when I was 22.

After leaving school, I was happy. I was living at home in Milton Keynes, I studied horticulture and then ended up working for a local company. Everything felt pretty stable. As I got older, I did want to look good and feel better in my skin, so I signed up to the local gym and found that I actually really enjoyed it.

I fell into a good routine; making my own lunch in the morning, going to work and then the gym after that. I lost weight, felt good, and my life as an 18-year-old seemed very normal. Until I got offered a secondment in London which meant being away from home and the familiarity of that entire routine. That’s when things began to change and over those few months away from home, I got used to the feeling of being empty and hungry, and what’s more, I liked it.

What also happened, as I began eating all of my meals alone and doing nothing but work and going to the gym, I began to isolate myself from other people.

I didn’t feel comfortable being around anyone else, having people watch what I was (or wasn’t) eating, so I cut myself off. My work colleagues didn’t really know me, so they didn’t notice much difference, but when I went home after my secondment ended, my family saw that my behaviour had changed.

I kept telling them I was fine. I thought I was. I just wanted to be left alone, and the more they told me to eat, the less I wanted to. But I guess that deep, deep down, I knew things weren’t fine. I remember at the same time thinking that I just wanted to fade away, to not exist, to be gone by the time my sister had her baby, six months later.

However, I pushed those thoughts and feelings down and carried on. There were moments during those months, before my diagnosis, where I was feeling a lot of tension. When you’re malnourished, it plays havoc with your emotions.

I was angry, snappy and volatile. My parents didn’t understand what was happening to me or how to help, how could they when I didn’t know what was happening myself?

When I finally spoke to a GP , they told me that I was severely underweight. You might think that at this point, things would start to look up. But for me, this is where my mental health actually hit rock bottom.

The first thing that happened was that I was signed off work for eight weeks and had to declare my licence to the DVLA as I was considered a risk on the roads. It felt like I was being punished. In fact, worse, it felt like people had taken away my control and were trying to control me.

I was told that I was entitled to 30 weeks of Cognitive Behavioural Therapy . Something that I really didn’t want. It’s hard to explain, but with anorexia you can only start to accept help and get better when you hold your hands up and say, “I need help”. But I still couldn’t do that. I was in complete denial.

My aim then was just to be healthy and for it all to be over - to be left alone. So, I went from being extremely anorexic to binge eating .

I now show myself compassion, and I can give myself a ‘talking to’ when I have thoughts that might not be healthy. Of course, I’ve had setbacks, but over the last eight years I’ve really managed to get myself back on track.

I’m still very aware of what I eat. There’s no doubt about that, but I don’t restrict myself anymore. And on the days that I do indulge, it doesn’t hurt as much as it used to. They helped me see things differently, admit that I ‘did’ need help and recognise that I never want to be back in that painful place again.

People started saying that I looked good and how much ‘healthier’ I must be now that I was gaining weight. What they couldn’t see was the way I was crumbling inside. Even though it’s hard to explain or pinpoint when, why or how the therapy started to help. It just did.

I think when you start to feed yourself physically with food, and mentally with therapy, you get a better perspective and understanding. I learned to recognise the voice in my head - the one telling me that my weight needed to be as low as possible for me to be happy - and change it.

When the therapy ended, the hard work on myself really began, but the treatment had given me the tools to do that, and what’s more, I wanted to.

It’s why I’m now extremely passionate about raising awareness of male eating disorders and talking about how to recognise it in friends and colleagues - and in yourself. Luckily, Cognitive Behavioural Therapy (CBT) helped me, and I’ve turned things around. But I’m very aware that so many people are convincing their friends, family - and themselves - that they’re fine. I hope that by talking about my experience, it will help them.

Things are changing for the better!

Eating disorders continue to have the highest mortality rates of ALL mental illnesses. Yes, all mental illnesses - shocking, I know. There has been much improved training for healthcare professionals over the past year. But we need to see more accurate awareness of the early signs, symptoms and risks of eating disorders, and we need to see more prioritisation of early detection and treatment, especially in men and boys and before medical treatment become necessary.

As someone with lived experience, I strongly believe any related deaths are preventable if people get the right care early enough. Recovery from eating disorders is possible, but getting the right treatment early is key for the sufferer and the increasing strain on our health care system. Eating disorders are a severe mental illness and shouldn’t be underestimated.

And if you could take anything away from my story, it would be the following: “All the advice in the world won’t help, until you are willing to help yourself”. You can and will get better!

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How to Share Your Eating Disorder Recovery Story

Author: Cara Spagnola, MSW, LISW, LCSW

Gone are the days where mental health and medical professionals have the only say in what recovery may be like. And for good reason. 

Hearing stories directly from those in eating disorder recovery  — those experiencing the actual symptoms and navigating treatment, barriers and resources — has brought a wealth of understanding, knowledge and compassion to the field and discussions around mental health . Stories of people’s lived experience in eating disorder recovery provides hope to others that living a meaningful, values-driven life is possible and that recovery is achievable.

If the thought of sharing your story -- or even writing your story -- has been on your mind, you may have a lot of questions. We are here to help guide the way and make the process a little less intimidating.

Getting started

How do you decide if sharing your eating disorder recovery story is right for you? You may want to ask yourself: Will sharing my story add value to my healing journey? If you answered, “yes,” is this decision supported by your therapist or support people?  As you’re contemplating this next step, two of our ERC alumni and Recovery Ambassador Council members offer how their own experiences of sharing their stories have benefited them.

“Sharing my eating disorder recovery story has helped me process what my life was like growing up, in my eating disorder, and as I’ve progressed in my recovery. Sharing has helped me accept what my story is, has helped me see the difference in my life before recovery and now as I live in solid recovery. It has been a way to see and focus on the things I’ve learned in recovery and want to pass on to others that may need to see that recovery is truly possible. Sharing my story has lessened the shame I have often felt with my story. It has helped me find my voice that I was so scared to use. Sharing my story has been a way to see meaningful and good things come from the little girl I was that cried herself to sleep. I live every day with gratitude and want to share hope with those who need it so much.” -  Kelli Evans

“It was near the end of my program with ERC that I knew that I wanted to open New Beginnings Motivation (NBM). The pain that I felt from the loss of my brother was intense. I took that pain and turned it into a positive power source because I didn’t want anyone to feel alone, and that was when I decided to begin my healing journey. For me, sharing my story created the confidence and allowed healing after the death of my brother. Even though I think of him every single day, I can feel that he’s with me as I’m sharing my story. Taking that negative power source that hurt when I lost him and flipping it to a positive power source by making a difference allows me to leave a legacy for my nephews and nieces and godchild.” – Dave Vrablik

Creating your eating disorder recovery story

Writing your story will take brainstorming and preparation. Here are some prompts to get you started.

• Where did your illness start, what happened in the illness, and how did it make you feel?
• What happened to help you surrender to treatment and recovery? Why was treatment important?
• What benefits of recovery have you experienced?
• Which supports helped you the most as you transitioned in and out of treatment or levels of care?
• What is the take-away that you want to give your audience? Infuse your story with what makes it uniquely yours: your interests, your passions, your experiences.

ERC alum Kelli provides these tips and encouragement for anyone looking to share their story:

“Have someone help you write out your story and talk about what parts of your story you want to share and what parts you don’t want to. It is then helpful to organize your story into an outline. Start with small audiences and have someone there with you that you trust, and you can feel support from while you are sharing. One way to begin in a safe way of sharing your story is to write blogs that include parts of your story before you are comfortable sharing verbally and face to face. Don’t try to memorize your story that you want to speak about. Focus on three or four points you want to make sure you include. This can really help decrease your anxiety of trying to remember what you want to say. Also, it’s more than fine to have a card you reference to remember your most important points.” 

What you may not want to share

While aiming to be authentic to show how you were truly suffering at your worst and how well you are doing now, you may feel tempted to share details that are a testament to your journey and all that you have overcome. However, some details could be unhelpful or triggering to others. If you have experienced an eating disorder, avoid giving specific numbers, such as amounts of food, duration of exercise, calories or body weight. Avoid labeling foods as good, bad, healthy, unhealthy or junk. If you experienced eating disorder behaviors, forms of self-harm or suicidality, avoid giving specific details around these experiences or incidents.

Your story is unique and valuable, and everyone’s treatment and recovery journey looks a little different. When sharing your experiences, use “I” statements, such as “what I found helpful was ___” or “for me, I needed to ____. ” Feel empowered to share what helped and worked for you, but do not give clinical recommendations or advice. Instead, refer people back to their own therapist or treatment team to navigate their treatment plan or next steps. If someone wants to know what path they take, direct them to their own treatment team for recommendations and guidance. If they need referrals for outpatient treatment, please direct them to [email protected] .

Additional tips

• Boundaries are important. Think about which topics or details are off-limits and you don’t want to discuss. If you are speaking at an event and someone asks you a question that makes you uncomfortable, you don’t need answer it. You can say “I don’t think answering that will be helpful” or “I think I’ve shared enough on that topic.” Your privacy and safety is important, so do not provide your personal contact information.
• Find meaningful ways and rituals to take care of yourself. While sharing your story can be incredibly rewarding and empowering, it can also bring about a tangle of other emotions: anxiety, lingering shame, discomfort and “vulnerability hangover,” to name a few. You can include grounding techniques or spiritual practices, and prioritize sleep before and after. ERC alum Dave takes care of himself this way: “I have my support team on speed dial or with me so that if it gets rough, we create an environment where I can go and check in with myself. But also after a speaking engagement is done I go home or to the hotel and take a hot shower to decompress and begin breathing techniques.”
• You can always say no. ERC alum Kelli encourages you to “always keep in mind that you are allowed to say yes or no to speaking opportunities. I often thought I needed to speak at every opportunity that was offered to me. It’s important to know how much speaking is healthy for you. I needed help from people around me to learn to say no and not feel guilty about saying no. Remember why it is you want to share your story, and it is more than okay to take an extended break from sharing your story with others.”
• Remember your main message: Recovery is possible -- and worth it!

If you are an ERC Pathlight alumnus and are interested in sharing your story, we’d be happy to chat with you. Please send an email to [email protected] and your Alumni & Community Outreach Liaison will be in touch.

National Alliance on Mental Illness, Seven Steps to Telling Your Story and Story Practice Sheet

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Eating Disorder Recovery: How to Find Healing and Hope

Find support here on your journey to eating disorder recovery. Get tips on how to get over an eating disorder to find healing, hope and lasting…

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Model Tess Holliday Opens Up About Her Anorexia: 'I’ve Since Taken A Lot Of Steps Backwards In My Recovery'

"Recovery for me is messy. It’s lonely."

• Model Tess Holliday says she "regressed" in her anorexia recovery.
• The mom and body positivity activist first opened up about it last year and has been trying to heal from her eating disorder with Pilates and feeding her body regularly.
• But, Tess says "Recovery for me is messy. It’s hard to deal with something for which there isn’t enough support."

She also opened up about how societal expectations for what anorexia “should” look like has been harmful to her recovery process. “Recovery for me is messy. It’s lonely. It’s hard to deal with something for which there isn’t enough support. Having a diagnosis has been liberating and it has made me feel less alone, but the confused look on people’s faces when I say anorexia or the stares I get if it comes up in conversation—that’s hard,” she said. Even now, Tess says she still struggles with accepting her diagnosis but knows that bodies of all shapes and sizes can deal with the same thing.

When some people hear the word anorexia, they often associate the word with thinness. This idea is far from reality and not uncommon. According to the National Eating Disorders Association , “Eating disorders are serious but treatable mental and physical illnesses that can affect people of all genders, ages, races, religions, ethnicities, sexual orientations, body shapes, and weights.”

Tess also didn’t consider herself as someone who could be diagnosed with anorexia due to her weight. “My dietician, Anna Sweeney , first brought it to my attention. She told me, “I’m not licensed to diagnose you, but if I could, I would diagnose you with anorexia nervosa .” She continued, “When she said anorexia, I laughed. I thought, “Do you see how fat I am? There’s no way that word could ever be attached to someone my size.” She referred me to a psychologist, who confirmed the diagnosis.”

Tess first revealed her anorexia diagnosis in May 2021 as she shared a series of selfies in a bright red sports bra and got real in the caption: "To everyone that keeps saying “you’re looking healthy lately” or “You are losing weight, keep it up!” Stop." Then, Tess explained her weight fluctuation: "Yes, I’ve lost weight — I’m healing from an eating disorder & feeding my body regularly for the first time in my entire life. When you equate weight loss with “health” & place value & worth on someone’s size, you are basically saying that we are more valuable now because we are smaller & perpetuating diet culture… & that’s corny as hell. NOT here for it. For folks like me that are trying to reframe our relationships with our bodies & heal, hearing comments about weight is triggering as hell. It sets us back in our progress—and when people working on themselves see you commenting to me that way, it hurts THEM, not just me. I can take it (I shouldn’t have to, but I can) but they didn’t ask for that trauma, ok? If you can’t tell someone they look nice without making it about their size, then baby, please don’t say nuthin at all."

Tess chose to reveal a bit more about her journey on Twitter : "I’m anorexic & in recovery. I’m not ashamed to say it out loud anymore. I’m the result of a culture that celebrates thinness & equates that to worth, but I get to write my own narrative now. I’m finally able to care for a body that I’ve punished my entire life & I am finally free."

Tess previously shared that Pilates has been key in her recovery.

Reflecting on why she initially chose to open up about her eating disorder, Tess explained that it didn’t come from a place of wanting to be thin but rather acknowledging the unhealthy habits that have been a part of her life for so long that she almost didn’t realize it.

For more context, Tess added that her family has always been critical of what she ate which led to unhealthy habits like hiding food. She said, “As I got older, I struggled with anorexia . I didn’t know that’s what it was until last year—but for over 10 years, I have restricted food. That means I don’t eat—or when I do eat, it’s very little. Or sometimes it’s one large meal a day.”

As part of her recovery, Tess says she now surrounds herself with people who hold her accountable for maintaining healthy habits. She said, “I remind myself that my feelings are valid. I go to therapy . Talking about it has helped. I surround myself with people who can gently say, “Have you eaten today?” or, “Let’s have a protein shake." I make sure I have things in my house that are easy to grab and eat. Moving my body makes it easier for me to feed myself because it makes it harder to ignore the feelings of hunger.”

If you or someone you know is struggling with an eating disorder, please reach out to the National Eating Disorders Association or for crisis support, text 'NEDA' to 741741.

Jennifer Nied is the fitness editor at Women’s Health and has more than 10 years of experience in health and wellness journalism. She’s always out exploring—sweat-testing workouts and gear, hiking, snowboarding, running, and more—with her husband, daughter, and dog. 

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Category: Stories of Hope

“do not go where the path may lead. go instead where there is no path, and leave a trail.” ~ ralph waldo emerson.

Watch and read about outstanding women and men and their stories of hope, who exemplify substance, character, and are shining examples of using their unique gifts and talents to lead fulfilling lives and contribute to a better world. All have battled eating disorders and are doing well in their recovery.

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Recovery for Tee Kaa: How I Let Go of My Scale and Found Freedom

Be your best advocate, the promise of hope for greta, destroying my demon, an ongoing process., author sara somers on writing her story of food addiction and healing, taylor engle and her story: how to take your life back – recovering from anorexia, sarah’s story of recovery and fighting the demon of eating disorders, hannah’s recovery story, jordan’s struggle and recovery from anorexia, anorexia, treatment and recovery: one woman’s story, are you a treatment professional or just want to stay informed on eating disorder recovery, our newsletter offers current resources and information. join today.

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Do You Have An Eating Disorder?

Do you have an eating disorder take this online quiz.

Take this quiz to help you decide whether or not you need to seek professional advice or treatment for an eating disorder.

Answer some general questions about how you feel about food, your current eating habits, how you feel after you eat, and other indicators of an eating disorder.

NOTE : This quiz is for general informational purposes only and does not, and is not intended to, constitute medical advice. The quiz is not an attempt to practice medicine and is not a substitute for professional medical advice, diagnosis, or treatment. If you have or suspect you may have a health problem, talk to your healthcare provider and follow their advice regardless of any result you have obtained on this quiz. The quiz does not establish a doctor-patient relationship.

Eating Disorder Hope makes no warranty, guarantee, or representation as to the accuracy or sufficiency of the quiz and expressly disclaims any liability in connection therewith.

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ANAD defines recovery as the following:

Recovery is the process of taking back control of one’s life and working towards a satisfactory and meaningful life no longer dominated by one’s eating disorder.

Recovered people have control of eating disorder thoughts and behaviors, maintain a nutritionally balanced lifestyle, can identify situations of personal risk, and maintain a meaningful self care practice to manage their well-being.

ANAD believes in recovery. We see it every day and know it’s real and achievable. In our recovery-oriented approach, we recognize that recovery from an eating disorder can be both clinical and personal: two separate but interwoven strands (Cook and Morgan, 2016). Clinical recovery focuses on the illness. Personal recovery focuses on the person.

Clinical Recovery

Focus on the illness.

Clinical recovery means that an individual is improving based on measurable outcomes. Often, clinical recovery is achieved when healthcare professionals can say some of the following:

No longer meets the criteria required to be considered to have a clinical eating disorder.

No longer engages in eating disorder behaviors.

Behaviors are no longer a risk factor to basic well-being.

Can recognize positive attributes of one’s self, food, & body. Can share emotions and interact socially.

Personal Recovery

Focus on the person.

At ANAD, we believe that recovery should focus on the person, not just the illness. Most people who have recovered from an eating disorder believe that recovery is about more than just the diagnostic criteria.

See me as a person not simply as a diagnosis of an eating disorder .

If recovery is a choice to pursue then it is a choice to be made repeatedly throughout the recovery process.  It is an on-going process that requires sustained effort.  ANAD encourages  realistic expectations  and understanding that  recovery is not a  “quick fix”  but rather a long journey  with lots of challenges. Part of the recovery process is understanding that  set-backs and relapses are considered to be part of the recovery process and not major obstacles to recovery (Reynen, 2012).

The ANAD Approach

ANAD’s recovery-oriented approach values connection . ANAD recovery mentors and peer support group leaders are all individuals who have experienced both an eating disorder and their own recovery. They share their stories and their personal knowledge of recovery to help those currently struggling with an eating disorder. They provide empathy, understanding, and a level of connection not found from most health care professionals or even well-meaning loved ones. They have traveled the same road, and can support others on just starting their journey.

ANAD volunteers are role models, and serve as living proof that recovery is possible. Peer work is about relationships. It provides a safe, nonjudgmental environment and a sense of connected-ness when individuals are feeling isolated and alone.

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Eating disorders: How psychotherapy can help people recover

Psychologists can play a vital role in the treatment of eating disorders and are integral members of the multidisciplinary team that may be required to provide patient care.

• Eating Disorders

It’s estimated that 20 million women and 10 million men will experience an eating disorder at some point in their lives. 1 People with eating disorders take such concerns to extremes, developing abnormal eating habits that threaten their well-being and even their lives. This fact sheet explains how psychotherapy can help people recover from these dangerous disorders.

What are the major kinds of eating disorders?

People with anorexia nervosa have a distorted body image that causes them to see themselves as overweight even when they’re dangerously thin. Often refusing to eat, exercising compulsively, and developing unusual habits such as refusing to eat in front of others, they lose large amounts of weight and may even starve to death.

Individuals with bulimia nervosa eat excessive quantities, then purge their bodies of the food and calories they fear by using laxatives, enemas, or diuretics; vomiting; or exercising. Often acting in secrecy, or feeling a lack of control as they binge, yet relieved of tension and negative emotions once their stomachs are empty again.

Like people with bulimia, those with binge eating disorder experience frequent episodes of out-of-control eating. The difference is that binge eaters don’t purge their bodies of excess calories.

Another category of eating disorders is “other specified feed or eating disorders,” in which individuals have eating-related problems, but don’t meet the official criteria for anorexia, bulimia or binge eating. 2

It’s important to prevent problematic behaviors from evolving into full-fledged eating disorders. Anorexia and bulimia, for example, usually are preceded by very strict dieting and weight loss. Binge eating disorder can begin with occasional bingeing. Whenever eating behaviors start having a destructive impact on someone’s functioning or self-image, it’s time to see a highly trained mental health professional, such as a licensed psychologist experienced in treating people with eating disorders. 3

Who suffers from eating disorders?

According to the National Institute of Mental Health, eating disorders are most common in teenagers or young adults, but can also affect almost anyone. 3 People of all ages, backgrounds, body weights, and ethnicities can be affected by eating disorders. Although common in teenage women, men and boys can also be vulnerable. People sometimes have eating disorders without their families or friends ever suspecting that they have a problem. Aware that their behavior is abnormal, people with eating disorders may withdraw from social contact, hide their behavior, and deny that their eating patterns are problematic. Making an accurate diagnosis requires the involvement of a licensed psychologist or other appropriate mental health expert.

What causes eating disorders?

Certain psychological factors and personality traits may predispose people to developing eating disorders. Many people with eating disorders may suffer from low self-esteem, feelings of helplessness, and intense dissatisfaction with the way they look.

Specific traits are linked to each of the disorders. People with anorexia tend to be perfectionistic, for instance, while people with bulimia are often impulsive. Physical factors such as genetics may also play a role in putting people at risk.

A wide range of situations can precipitate eating disorders in susceptible individuals. Family members or friends may repeatedly tease people about their bodies. Individuals may be participating in gymnastics or other sports that emphasize low weight or a certain body image. Negative emotions or traumas such as rape, abuse, or the death of a loved one can also trigger disorders. Even a happy event, such as giving birth, can lead to disorders because of the stressful impact of the event on an individual’s new role and body image.

Once people start engaging in abnormal eating behaviors, the problem can perpetuate itself. Bingeing can set a vicious cycle in motion, for instance, as individuals purge to rid themselves of excess calories and psychic pain, then binge again to escape problems in their day-to-day lives.

Why is it important to seek treatment for these disorders?

Research indicates that eating disorders very often go untreated. In one study, for example, less than 13% of adolescents with eating disorders received treatment.

But leaving eating disorders untreated can have serious consequences. Research has found that individuals with anorexia have a mortality rate 18 times higher than peers who don’t have eating disorders, for example. 5

Eating disorders can devastate the body. Physical problems associated with anorexia, for instance, include anemia, constipation, osteoporosis, even damage to the heart and brain. Bulimia can result in a sore throat, worn-away tooth enamel, acid reflux, severe dehydration, and intestinal distress. People with binge eating disorder may develop high blood pressure, cardiovascular disease, diabetes, and other problems associated with obesity.

Eating disorders are also associated with other mental disorders like depression. Researchers don’t yet know whether eating disorders are symptoms of such problems or whether the problems develop because of the isolation, stigma, and physiological changes wrought by the eating disorders themselves. What is clear from the research is that people with eating disorders suffer higher rates of other mental disorders —including depression, anxiety disorders, and substance abuse—than other people. 6

How can a psychologist help someone recover?

It’s important to remember that there is not a one-size-fits-all approach to the treatment of eating disorders. Psychologists can play a vital role in the treatment of eating disorders and are integral members of the multidisciplinary team that may be required to provide patient care. As part of this treatment, a physician may be called on to rule out medical illnesses and determine that the patient is not in immediate physical danger. A nutritionist may be asked to help assess and improve nutritional intake.

A psychologist can help to identify the underlying issues and develop a treatment plan to help a patient work through some of the destructive thoughts and behaviors and replace them with more positive ones. For example, the focus may be on overall health and well-being, rather than weight. Or a patient might be asked to keep a food diary as a way of becoming more aware of the types of situations that trigger bingeing.

Simply changing one’s thoughts and behaviors may not be enough, however. A psychologist may recommend evidence-based treatments such as psychotherapy to help address the underlying psychological issues of the eating disorder, or it may be used to focus on improving one’s personal relationships. It may involve helping one get beyond an event or situation that triggered the disorder in the first place. Group therapy may also be helpful in the treatment of an eating disorder.

Some patients may be prescribed medications as part of their treatment plan, but it’s important to follow the instructions of your health care or mental health professional about taking medications and the possible side effects.

Does treatment really work?

In most cases, eating disorders can be treated successfully by appropriately trained health and mental health care professionals. But treatments do not work instantly and for many, treatment may be long-term.

Incorporating family or marital therapy into one’s care may help to prevent relapses by resolving interpersonal issues related to the eating disorder. Therapists can guide family members in understanding the disorder and learning new techniques for coping with problems. Support groups can also help in overcoming an eating disorder.

The sooner treatment starts, the better. The longer abnormal eating patterns continue, the more deeply ingrained they become and the more difficult they are to treat.

Eating disorders can severely impair one’s functioning and health. But the prospects for long-term recovery are good for those who seek help from appropriate professionals. Qualified therapists, such as licensed psychologists with experience in this area, can help those who suffer from eating disorders regain control of their eating behaviors and their lives.

1, 2 National Eating Disorders Association. (2018). Other Specified Feeding or Eating Disorder .

3 National Institute of Mental Health. (2018). Eating disorders .

4 Merikangas, K. R., He, J.-p., Burstein, M., Swendsen, J., Avenevoli, S., Case, B., Georgiades, K., Heaton, L., Swanson, S., & Olfson, M. (2011). Service utilization for lifetime mental disorders in U.S. Adolescents: Results of the National Comorbidity Survey-Adolescent Supplement (NCSA). Journal of the American Academy of Child & Adolescent Psychiatry, 50 (1), 32–45. https://doi.org/10.1016/j.jaac.2010.10.006

5 Steinhausen, H.-C. (2009). Outcome of eating disorders. Child and Adolescent Psychiatric Clinics of North America, 18 (1), 225–242. https://doi.org/10.1016/j.chc.2008.07.013

6 Hudson, J. I., Hiripi, E., Pope, H. G., Jr., & Kessler, R. C. (2007). The Prevalence and Correlates of Eating Disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 61 (3), 348–358. https://doi.org/10.1016/j.biopsych.2006.03.040

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• Patient Care & Health Information
• Diseases & Conditions
• Anorexia nervosa

If your doctor suspects that you have anorexia nervosa, he or she will typically do several tests and exams to help pinpoint a diagnosis, rule out medical causes for the weight loss, and check for any related complications.

These exams and tests generally include:

• Physical exam. This may include measuring your height and weight; checking your vital signs, such as heart rate, blood pressure and temperature; checking your skin and nails for problems; listening to your heart and lungs; and examining your abdomen.
• Lab tests. These may include a complete blood count (CBC) and more-specialized blood tests to check electrolytes and protein as well as functioning of your liver, kidney and thyroid. A urinalysis also may be done.
• Psychological evaluation. A doctor or mental health professional will likely ask about your thoughts, feelings and eating habits. You may also be asked to complete psychological self-assessment questionnaires.
• Other studies. X-rays may be taken to check your bone density, check for stress fractures or broken bones, or check for pneumonia or heart problems. Electrocardiograms may be done to look for heart irregularities.

Your mental health professional also may use the diagnostic criteria for anorexia in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.

More Information

• Bone density test
• Complete blood count (CBC)
• Electrocardiogram (ECG or EKG)
• Liver function tests

Treatment for anorexia is generally done using a team approach, which includes doctors, mental health professionals and dietitians, all with experience in eating disorders. Ongoing therapy and nutrition education are highly important to continued recovery.

Here's a look at what's commonly involved in treating people with anorexia.

Hospitalization and other programs

If your life is in immediate danger, you may need treatment in a hospital emergency room for such issues as a heart rhythm disturbance, dehydration, electrolyte imbalances or a psychiatric emergency. Hospitalization may be required for medical complications, severe psychiatric problems, severe malnutrition or continued refusal to eat.

Some clinics specialize in treating people with eating disorders. They may offer day programs or residential programs rather than full hospitalization. Specialized eating disorder programs may offer more-intensive treatment over longer periods of time.

Medical care

Because of the host of complications anorexia causes, you may need frequent monitoring of vital signs, hydration level and electrolytes, as well as related physical conditions. In severe cases, people with anorexia may initially require feeding through a tube that's placed in their nose and goes to the stomach (nasogastric tube).

Care is usually coordinated by a primary care doctor or a mental health professional, with other professionals involved.

Restoring a healthy weight

The first goal of treatment is getting back to a healthy weight. You can't recover from anorexia without returning to a healthy weight and learning proper nutrition. Those involved in this process may include:

• Your primary care doctor, who can provide medical care and supervise your calorie needs and weight gain
• A psychologist or other mental health professional, who can work with you to develop behavioral strategies to help you return to a healthy weight
• A dietitian, who can offer guidance getting back to regular patterns of eating, including providing specific meal plans and calorie requirements that help you meet your weight goals
• Your family, who will likely be involved in helping you maintain normal eating habits
• Psychotherapy

These types of therapy may be beneficial for anorexia:

• Family-based therapy. This is the only evidence-based treatment for teenagers with anorexia. Because the teenager with anorexia is unable to make good choices about eating and health while in the grips of this serious condition, this therapy mobilizes parents to help their child with re-feeding and weight restoration until the child can make good choices about health.
• Individual therapy. For adults, cognitive behavioral therapy — specifically enhanced cognitive behavioral therapy — has been shown to help. The main goal is to normalize eating patterns and behaviors to support weight gain. The second goal is to help change distorted beliefs and thoughts that maintain restrictive eating.

Medications

No medications are approved to treat anorexia because none has been found to work very well. However, antidepressants or other psychiatric medications can help treat other mental health disorders you may also have, such as depression or anxiety.

Treatment challenges in anorexia

One of the biggest challenges in treating anorexia is that people may not want treatment. Barriers to treatment may include:

• Thinking you don't need treatment
• Fearing weight gain
• Not seeing anorexia as an illness but rather a lifestyle choice

People with anorexia can recover. However, they're at increased risk of relapse during periods of high stress or during triggering situations. Ongoing therapy or periodic appointments during times of stress may help you stay healthy.

• Acupuncture

Clinical trials

Explore Mayo Clinic studies testing new treatments, interventions and tests as a means to prevent, detect, treat or manage this condition.

Lifestyle and home remedies

When you have anorexia, it can be difficult to take care of yourself properly. In addition to professional treatment, follow these steps:

• Stick to your treatment plan. Don't skip therapy sessions and try not to stray from meal plans, even if they make you uncomfortable.
• Talk to your doctor about appropriate vitamin and mineral supplements. If you're not eating well, chances are your body isn't getting all of the nutrients it needs, such as Vitamin D or iron. However, getting most of your vitamins and minerals from food is typically recommended.
• Don't isolate yourself from caring family members and friends who want to see you get healthy. Understand that they have your best interests at heart.
• Resist urges to weigh yourself or check yourself in the mirror frequently. These may do nothing but fuel your drive to maintain unhealthy habits.

Alternative medicine

Dietary supplements and herbal products designed to suppress the appetite or aid in weight loss may be abused by people with anorexia. Weight-loss supplements or herbs can have serious side effects and dangerously interact with other medications. These products do not go through a rigorous review process and may have ingredients that are not posted on the bottle.

Keep in mind that natural doesn't always mean safe. If you use dietary supplements or herbs, discuss the potential risks with your doctor.

Anxiety-reducing approaches that complement anorexia treatment may increase the sense of well-being and promote relaxation. Examples of these approaches include massage, yoga and meditation.

Coping and support

You may find it difficult to cope with anorexia when you're hit with mixed messages by the media, culture, and perhaps your own family or friends. You may even have heard people joke that they wish they could have anorexia for a while so that they could lose weight.

Whether you have anorexia or your loved one has anorexia, ask your doctor or mental health professional for advice on coping strategies and emotional support. Learning effective coping strategies and getting the support you need from family and friends are vital to successful treatment.

Preparing for your appointment

Here's some information to help you get ready for your appointment and know what to expect from your doctor or mental health professional.

You may want to ask a family member or friend to go with you. Someone who accompanies you may remember something that you missed or forgot. A family member may also be able to give your doctor a fuller picture of your home life.

What you can do

Before your appointment, make a list of:

• Any symptoms you're experiencing, including any that may seem unrelated to the reason for the appointment. Try to recall when your symptoms began.
• Key personal information, including any major stresses or recent life changes.
• All medications, vitamins, herbal products, over-the-counter medications and other supplements that you're taking, and their dosages.
• Questions to ask your doctor so that you'll remember to cover everything you wanted to.

Some questions you might want to ask your doctor or mental health professional include:

• What kinds of tests do I need? Do these tests require any special preparation?
• Is this condition temporary or long lasting?
• What treatments are available, and which do you recommend?
• Is there a generic alternative to the medicine you're prescribing?
• Are there any brochures or other printed material that I can have? What websites do you recommend?

Don't hesitate to ask other questions during your appointment.

What to expect from your doctor

Your doctor or mental health professional is likely to ask you a number of questions, including:

• How long have you been worried about your weight?
• Do you exercise? How often?
• What ways have you used to lose weight?
• Are you having any physical symptoms?
• Have you ever vomited because you were uncomfortably full?
• Have others expressed concern that you're too thin?
• Do you think about food often?
• Do you ever eat in secret?
• Have any of your family members ever had symptoms of an eating disorder or been diagnosed with an eating disorder?

Be ready to answer these questions to reserve time to go over any points you want to focus on.

• Sim LA (expert opinion). Mayo Clinic, Rochester, Minn. Jan. 31, 2018.
• Anorexia nervosa. In: Diagnostic and Statistical Manual of Mental Disorders DSM-5. 5th ed. Arlington, Va.: American Psychiatric Association; 2013. http://dsm.psychiatryonline.org. Accessed Nov. 13, 2017.
• Hales RE, et al. Anorexia nervosa. In: The American Psychiatric Publishing Textbook of Psychiatry. 6th ed. Washington, D.C.: American Psychiatric Publishing; 2014. http://psychiatryonline.org. Accessed Nov. 13, 2017.
• Klein D, et al. Anorexia nervosa in adults: Clinical features, course of illness, assessment, and diagnosis. https://www.uptodate.com/contents/search. Accessed Nov. 13, 2017.
• Mehler P. Anorexia nervosa in adults and adolescents: Medical complications and their management. https://www.uptodate.com/contents/search. Accessed Nov. 13, 2017.
• Mehler P. Anorexia nervosa in adults: Evaluation for medical complications and criteria for hospitalization to manage these complications. https://www.uptodate.com/contents/search. Accessed Nov. 13, 2017.
• Pike K. Anorexia nervosa in adults: Cognitive behavioral therapy (CBT). https://www.uptodate.com/contents/search. Accessed Nov. 13, 2017.
• Walsh BT. Anorexia nervosa in adults: Pharmacotherapy. https://www.uptodate.com/contents/search. Accessed Nov. 13, 2017.
• Anorexia nervosa. Merck Manual Professional Version. http://www.merckmanuals.com/professional/psychiatric-disorders/eating-disorders/anorexia-nervosa. Accessed Nov. 13, 2017.
• Harrington BC, et al. Initial evaluation, diagnosis, and treatment of anorexia nervosa and bulimia nervosa. American Family Physician. 2015;91:46.
• Brockmeyer T, et al. Advances in the treatment of anorexia nervosa: A review of established and emerging interventions. Psychological Medicine. In press. Accessed Nov. 13, 2017.
• Davis H, et al. Pharmacotherapy of eating disorders. Current Opinion in Psychiatry. 2017;30:452.
• Herpertz-Dahlmann B. Treatment of eating disorders in child and adolescent psychiatry. Current Opinion in Psychiatry. 2017;30:438.
• Fogarty S, et al. The role of complementary and alternative medicine in the treatment of eating disorders: A systematic review. Eating Behaviors. 2016;21:179.
• Eating disorders. National Alliance on Mental Illness. https://www.nami.org/Learn-More/Mental-Health-Conditions/Eating-Disorders/Overview. Accessed Nov. 13, 2017.
• Lebow J, et al. Is there clinical consensus in defining weight restoration for adolescents with anorexia nervosa? Eating Disorders. In press. Accessed Dec. 4, 2017.
• Lebow J, et al. The effect of atypical antipsychotic medications in individuals with anorexia nervosa: A systematic review and meta-analysis. International Journal of Eating Disorders. 2013;46:332.
• Five things to know about safety of dietary supplements for children and teens. National Center for Complementary and Integrative Health. https://nccih.nih.gov/health/tips/child-supplements. Accessed Feb. 9, 2018.

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Welcome to "Breaking Bread: Unpacking Everything We Think We Know About ED Recovery," the podcast where we delve deep into the journey of eating disorder recovery. In each episode, your host Stance invites courageous guests to share their personal experiences and insights, shedding light on the often misunderstood world of ED recovery. Join us as we challenge the misconceptions surrounding eating disorders and peel back the layers to uncover what it truly means to heal while living in a diet-obsessed society. From the highs and lows to the triumphs and setbacks, our guests share their stories with vulnerability and authenticity, offering listeners a profound understanding of the complexities that accompany ED recovery. Through heartfelt conversations, we explore the the intersectionality of recovery. Our guests discuss their unique paths to healing, the strategies they've employed, and the support systems that have played a pivotal role in their recovery journeys."Breaking Bread" aims to dismantle societal stereotypes and provide a safe space for open dialogue. We address the impact of diet culture, body image, and societal pressures on individuals navigating their recovery. Together, we challenge the status quo, spark insightful discussions, and encourage listeners to question the narratives surrounding eating disorders.Whether you're on your own recovery journey, a professional hoping to grow, or simply interested in gaining a deeper perspective on the topic, "Breaking Bread" offers a compassionate and illuminating exploration of ED recovery. Get ready to break down barriers, challenge assumptions, and come together to redefine what it means to heal. Welcome to Breaking Bread.

Let's Break Bread Podcast‪!‬ Stance Dexheimer

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Home — Essay Samples — Nursing & Health — Anorexia — Anorexia: A Persuasive Examination

Anorexia: a Persuasive Examination

• Categories: Anorexia Media Influence

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The prevalence and consequences, early intervention and awareness, comprehensive treatment strategies, the role of policy and research.

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Recent advances in understanding anorexia nervosa

Guido k.w. frank.

1 Department of Psychiatry, University of Colorado, Anschutz Medical Campus, Aurora, CO, 80045, USA

2 Neuroscience Program, University of Colorado, Anschutz Medical Campus, Aurora, CO, 80045, USA

Megan E. Shott

Marisa c. deguzman.

Anorexia nervosa is a complex psychiatric illness associated with food restriction and high mortality. Recent brain research in adolescents and adults with anorexia nervosa has used larger sample sizes compared with earlier studies and tasks that test specific brain circuits. Those studies have produced more robust results and advanced our knowledge of underlying biological mechanisms that may contribute to the development and maintenance of anorexia nervosa. It is now recognized that malnutrition and dehydration lead to dynamic changes in brain structure across the brain, which normalize with weight restoration. Some structural alterations could be trait factors but require replication. Functional brain imaging and behavioral studies have implicated learning-related brain circuits that may contribute to food restriction in anorexia nervosa. Most notably, those circuits involve striatal, insular, and frontal cortical regions that drive learning from reward and punishment, as well as habit learning. Disturbances in those circuits may lead to a vicious cycle that hampers recovery. Other studies have started to explore the neurobiology of interoception or social interaction and whether the connectivity between brain regions is altered in anorexia nervosa. All together, these studies build upon earlier research that indicated neurotransmitter abnormalities in anorexia nervosa and help us develop models of a distinct neurobiology that underlies anorexia nervosa.

Anorexia nervosa (AN) is characterized by a persistent restriction of energy intake and leads to a body weight that is significantly lower than what is expected for height and age 1 . There is either an intense fear of gaining weight or becoming fat or persistent behavior that interferes with weight gain (even though at significantly low weight). Individuals with AN experience a disturbance in the way one’s body weight or shape is experienced, undue influence of body shape and weight on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight. A restricting type has been distinguished from a binge eating/purging type; individuals in the latter group may intermittently have binge eating episodes or may use self-induced vomiting to avoid weight gain. AN shows a complex interplay between neurobiological, psychological, and environmental factors 2 and is a chronic disorder with frequent relapse, high treatment costs, and severe disease burden 3 , 4 . AN has a mortality rate 12 times higher than the death rate for all causes of death for females 15 to 24 years old 5 – 7 . Treatment success is modest, and no medication has been approved for AN treatment 8 .

Various psychological or psychodynamic theories have been developed in the past to explain the causes of AN but their underlying theories have been difficult to test 9 . On the contrary, neurobiological research using techniques such as human brain imaging leads to more directly testable hypotheses and holds promise to help us tease apart mechanisms that contribute to the onset of the illness, maintenance of AN behavior, and recovery from AN. This article will review recent advances in our understanding of the neurobiology of AN. Neurobiology is a branch of the life sciences, which deals with the anatomy, physiology, and pathology of the nervous system 10 . Neurobiology is closely associated with the field of neuroscience, a branch of biology, which tries to understand brain function, from gross anatomy to neural circuits and cells that comprise them 11 . The goal of neurobiological research in AN is to develop a medical model perspective to reduce stigma and help develop better treatments 12 . At the earlier stages of brain research in AN, study samples tended to be quite small, which made replication difficult 13 . Most frequently, altered serotonin function was associated with AN and anxiety in the disorder 14 . More recent brain research has built upon those studies and increased sample sizes in structural studies and introduced studying brain function in relation to specific tasks that are thought be related to food restriction, anxiety, and body image distortion. Most studies have been carried out in adults, although there is a growing body of literature that investigated youth with AN.

The most frequently applied brain imaging study design in the past studied brain volume in AN, and more recent research now allows cortical thickness of the brain to be investigated. For a long time, there was the notion that gray matter volume and cortical thickness are lower in patients with AN (when ill and after recovery) than in controls. This research was pioneered by Katzman et al . in adolescents with AN 15 , 16 . However, recent research by Bernardoni et al . 17 and King et al . 18 in adolescents and young adults indicated that such abnormalities are rather short-lived and that both lower volume and cortical thickness normalize with weight recovery. Animal studies suggest that those changes may be due to the effects of malnutrition and dehydration on astrocytes within the brain connective tissue 19 . Two studies from our group have found larger orbitofrontal cortex and insula volume in adults and adolescents with AN after 1 to 2 weeks of normalization of food intake or in individuals after recovery, and orbitofrontal cortex volume was related to taste pleasantness 20 , 21 . Those results were intriguing as they implicated taste perception in relation to brain volume but they need replication. New data from our group in healthy first-degree relatives of patients with AN also show larger orbitofrontal cortex volume, supporting a trait abnormality (unpublished data). Studies by Bernardoni et al . in young adults have found abnormalities in gray matter gyrification in AN, and nutritional rehabilitation seems to normalize altered cortical folding 22 . A valuable lesson from those studies is that food intake can have dramatic effects on brain structure. Whether lower or higher brain volume in AN has implications on illness behavior or is instead an effect of malnutrition without effects on behavior is still unclear and needs further research 23 , 24 .

Functional brain imaging provides the opportunity to tie behavior to brain activation and thus to distinct brain neurobiology, which could become a treatment target. Several aspects of behavior in AN stand out. One is the ability to restrict food intake to the point of emaciation while the typical mechanisms to maintain a healthy body weight are inefficient. Another is how the body can maintain this behavior even when AN patients in therapy are trying to break that behavior pattern.

Relevant to food avoidance behavior is the brain reward system, which processes the motivation to eat and hedonic experience after food intake, and also calculates and updates how valuable a specific food is to us 25 . This circuitry includes the insula, which contains the primary taste cortex, the ventral striatum that comprises dopamine terminals to drive food approach, and the orbitofrontal cortex that calculates a value, while the hypothalamus integrates body signals on hunger and satiety for higher-order decision making and food approach. Many studies have used visual food cues but it has been difficult to draw conclusions on the pathophysiology of AN from those studies 26 .

Several studies from our group using sugar taste stimuli have found that brain activation in adolescent and adult AN was elevated compared with controls in response to unexpected receipt or omission of sweet taste in the insula and striatum 27 , 28 . This so-called “prediction error” response has been associated with brain dopamine circuitry and serves as a learning signal to drive approach or avoidance of salient stimuli in the environment in the future. In addition, orbitofrontal cortex prediction error response correlated positively with anxiety measures in AN 28 , 29 . We found a similar pattern of elevated brain activation in AN to unexpected receipt or omission of monetary stimuli, suggesting a food-independent alteration of brain dopamine circuitry. Importantly, those studies have also shown that brain response was predictive of weight gain during treatment and that brain dopamine function could have an important role in weight recovery in AN. This was supported by a retrospective chart review in adolescents with AN that suggested that the dopamine D 2 receptor partial agonist aripiprazole was associated with higher weight gain in a structured treatment program in comparison with patients not on that medication 30 . Mechanistically, it was hypothesized that dopamine D 2 receptor stimulation might be desensitizing those receptors and normalize behavior response. This, however, is speculative and controlled studies are lacking.

Other lines of research on the pathophysiology of AN are directed toward feedback learning, and several studies have found that AN is associated with alterations, behaviorally or in brain response. A study by Foerde and Steinglass, who investigated learning using a picture association task in patients with AN before and after weight restoration, indicated deficits in feedback learning and generalization of learned information in comparison with controls 31 . Such alterations could translate directly into difficulties in behavior modification toward recovery. Studies from Ehrlich’s group found normal feedback learning in ill, but reduced performance on reversal learning in recovered AN, which made the impact of learning in ill AN less clear 32 , 33 . Furthermore, Bernardoni et al ., using a different study design, found that individuals with AN had an increased learning rate and elevated medial frontal cortex response following punishment 34 . That result supports previous findings of elevated sensitivity to punishment in AN as a possible biological trait 35 . Another very interesting study by Foerde et al . tested brain response to food choice presenting images of food and that research implicated the dorsal striatum in this process in AN 36 . The authors also found that the strength of connectivity between striatum and frontal cortex activation correlated inversely with actual caloric food intake in a test meal after the brain scan. The authors interpreted the findings to mean that this frontostriatal involvement in AN could contribute to habit formation of food restriction behavior. Behavioral research has provided evidence that habit formation or habit strength could be necessary for the perpetuation of AN behaviors and this concept is important to study further 37 – 39 .

The self-perception of being fat despite being underweight is another aspect of AN that the field continues to struggle with in finding its underlying pathophysiology. Some studies have found a specific brain response related to altered processing of visual information or tasks that tested interoception. For instance, Kerr et al . 40 found elevated insula activation during an abdomen perception task, and Xu et al . 41 found that a frontal and cingulate cortex response during a social evaluation task correlated with body shape concerns. A study by Hagman et al ., however, indicated a strong cognitive and emotional influence on body image distortion, and the intersection between altered perception and fear-driven self-perception needs further study 42 . Social interaction and its brain biology constitute another area that was hypothesized to be related to AN behaviors and some research is emerging on this topic. For instance, a study by McAdams et al . showed that the quality of the social relationship or social reciprocity tested in a trust game showed lower occipito-parietal brain response in patients with AN in comparison with a control group 43 . This research suggests altered reward experience from interpersonal contact in AN, which could impact emotional well-being and interfere with recovery. Oxytocin, a peptide hormone related to social behavior, could play a role but this requires more detailed research 44 .

Studies on brain connectivity can test either what brain regions work in concert during a specific task (functional connectivity) or what the hierarchical organization is between areas in the brain (that is, what region drives another) (effective connectivity). Several studies in the past have shown that resting-state functional connectivity is altered in patients with AN compared with control groups. Those studies repeatedly found altered connectivity that involved the insula, a region associated with taste perception, prediction error processing, and integration of body perception, as reviewed by Gaudio et al . 45 . More recent studies found higher or lower resting-state activation in AN across various networks and during rest or task conditions 39 , 46 – 49 . Longitudinal studies will need to test what might be the best resting-state network to focus on to predict, for instance, illness outcome or whether functional connectivity during specific tasks such as taste processing could be more informative. One study by Boehm et al . found normalization of functional connectivity in the default mode but continued abnormal frontoparietal network connectivity in recovered AN 50 . It remains to be seen whether functional connectivity will normalize with recovery or can identify long-lasting or maybe trait alterations.

Effective connectivity studies indicated that while viewing fearful faces, a group with AN had deficits of brain connectivity between prefrontal cortex and the amygdala, which correlated with measures for anxiety and eating behaviors in a study by Rangaprakash et al . 51 . Studies from our group that assessed effective connectivity during the tasting of sucrose solution found that, whereas in controls the hypothalamus drove ventral striatum response, in patients with AN, effective connectivity was directed from the ventral striatum to the hypothalamus 28 , 52 . Previously, a dopamine-dependent pathway from the ventral striatum to the hypothalamus that mediates fear was described and we hypothesized that this circuitry might be activated in AN to override appetitive hypothalamic signals 53 .

In summary, brain research has started to make inroads into the pathophysiology of AN. We have learned that malnutrition has significant effects on brain structure, changes that can recover with weight restoration, but whether those alterations have an impact on illness behavior remains unclear 23 . Research into the function of brain circuits has implicated reward pathways and malnutrition-driven alterations of dopamine responsiveness together with neuroendocrine changes, and high anxiety may interfere with normal mechanisms that drive eating behavior 54 . Habit learning and associated striatal-frontal brain connectivity could provide another mechanism of how brain function and interaction of cortical and sub-cortical regions may perpetuate illness behavior that is difficult to overcome. Those advances are promising to establish that AN is associated with a distinct brain pathophysiology. This will help researchers develop effective biological treatments that improve recovery and help prevent relapse. A significant challenge to overcome will be to integrate the differing brain research studies and develop a unified model 13 . Critical in this effort will be well-powered and comparable study designs across research groups, which take into account confounding factors such as comorbidity and medication use and which use rigorous standards for data analysis.

[version 1; peer review: 2 approved]

Funding Statement

This work was supported by National Institute of Mental Health grants MH096777 and MH103436 (both to GKWF) and by T32HD041697 (University of Colorado Neuroscience Program) and National Institutes of Health/National Center for Advancing Translational Sciences Colorado Clinical and Translational Science Awards grant TL1 TR001081 (both to MCD).

The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Editorial Note on the Review Process

F1000 Faculty Reviews are commissioned from members of the prestigious F1000 Faculty and are edited as a service to readers. In order to make these reviews as comprehensive and accessible as possible, the referees provide input before publication and only the final, revised version is published. The referees who approved the final version are listed with their names and affiliations but without their reports on earlier versions (any comments will already have been addressed in the published version).

The referees who approved this article are:

• Carrie J McAdams , Department of Psychiatry, University of Texas at Southwestern Medical Center, Dallas, TX, USA No competing interests were disclosed.
• Janet Treasure , Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK No competing interests were disclosed.

Aqua fitness helped her overcome eating disorder. Now she teaches it in Singapore

• After childhood trauma led her to have anorexia nervosa, aqua fitness brought Malissa Sander ‘back to life’. She now teaches her brand of it

Malissa Sander was born in Sri Lanka but is of Indian descent.

Aqua fitness is not just exercise for Malissa Sander. Being in the water practically saved her during some of the lowest emotional points in her life.

She also felt unsafe at home – her alcoholic father had a bad temper, Sander says, and her mother was in denial about the family’s problems.

After moving to the United States for university, she tore her ankle tendon while running and could no longer exercise, so she limited her food intake even more.

“That’s when I hit rock bottom. My body totally fell apart,” she says.

“I loved the feeling of being in the water and I wasn’t scared that I’d hurt some part of my body or damage my body further,” she says.

I’ve seen many lives transformed through aqua fitness. Moving in the water can have a unique therapeutic effect

There, aqua fitness, combined with strength training, brought her “back to life”.

The underwater movements were simple and gentle – side walking, leg lifts, dynamic stretching and upper body movements with dumbbells – and Sander liked how they made her feel.

“They helped me regain my strength, slowly and steadily,” she says.

“Being in the water helped me feel confident about moving my body again. I felt safe in the water, a feeling that was foreign to me out of the water.”

Her four years in Sydney were life-changing, and, determined to recover, she put everything she had into beating her illness. With help from a physical therapist, she relearned how to walk and move her body without fear of fracturing bones or falling. She eventually reversed her osteopenia.

Without any family support the recovery process was “painstakingly slow” and “lonely”, but she knew that she had to get through it to survive.

Sander spent the next decade living in various cities in Asia, including Bangkok and Hong Kong. During this time, she met her husband and got married.

In Asia, Sander worked briefly in real estate and at an art gallery but felt that her true calling was in fitness.

She obtained several certifications in fitness and wellness, including an Aqua Instructor International Certification from the Federation of International Sports, Aerobics and Fitness (FISAF).

She continued working out in the pool, making the choice to be “strong over skinny” every day.

“I couldn’t exercise for six weeks after having my son, but I knew that, once I was able to exercise again, I would feel better,” she says.

She had relocated to Singapore the year before and noticed that, with the exception of aqua spinning (also known as aqua cycling), there was a lack of water fitness awareness in the city state.

Fitness, particularly aqua fitness, has saved my life countless times

In 2019, Sander started teaching the Aqua Tula method formally and, over time, calibrated the exercises and sequences to suit people with different needs, fitness levels and abilities.

“Aqua Tula incorporates both shallow- and deep-water workouts,” Sander says.

She uses pool noodles, boxing mitts, aquatic foam dumbbells and space shoes – designed to emulate a step class in the water and good for knee rehab – in different combinations.

“My dance background helps with the choreography element. This and all the fitness knowledge I’ve amassed over the years have helped me create and build a repertoire of exercises not previously seen in aqua fitness.”

“I’ve seen many lives transformed through aqua fitness. Moving in the water can have a unique therapeutic effect,” she says.

With her method, Sander hopes to change how people view aqua fitness. She says that rather than a slow and easy workout, Aqua Tula is the opposite and much more.

“I wake up most mornings with varying degrees of these three things. I’m usually in the pool within the first three hours of my day, and from the second I start moving in the water, I can feel the fear, pain and anxiety dissipate. My mind becomes clearer, I feel stronger, and I’m ready to face another day.

“Aqua fitness has also taught me that healing comes from within. By exercising in a way that is safe and pain-free, and by moving for my mind, I’ve reclaimed my sense of self and my power.”