Question: Is it weird to feel very guilty about bulimia. When my mom gives me dieting advice I feel so horrible and guilty I want to scream but I don’t say anything.

Rob Danzman Says...:

Dear Anonymous,

Thanks so much for reaching out. I'll answer your question with some other questions first. 

When you say you feel guilty about bulimia, I'd like to understand more. More specifically, what do you mean by 'about?' This is not a challenge to you but a path I would take to better comprehend how you are experiencing bulimia and the underlying causes (or, more accurately, stressors). I'd like to define what the stressor is and how specifically you feel about it and how it impacts your choices and behaviors. Seems simple but pretty complex when you break it down. It's not uncommon for folks to say they feel 'upset' about something but what does that really mean? Are you angry, sad, sick? I want you to have a safe place where you can define for yourself what you mean by feeling guilty. 

Next, I'd really like to dig into the relationship with your mother (and family in general). When I hear a parent is providing dieting advice, a few concerns start to pop up. Like, why is mom giving dieting advice? Is this in conjunction with other wellness advice like exercise, respect for yourself, yoga, healthy relationships, etc? Does mom have her own eating disorder or psychological issues? Asking and answering some of these questions could help figure out the best way to make some healthy changes in the family system. 

Finally, it sounds like you are not happy with how or what your mom is communicating to you about eating, food or healthfulness. This obviously is tied to the relationship with your mother but also a separate question - How do you respond to anyone that seemingly pushes you in a direction you don't like? I wonder if this is isolated with your mother or a larger pattern manifesting in other relationships. Not a pattern that's your fault but a pattern that if you can recognize, you might be able to change. Here is a really great resource focused on Dialectical Behavioral Therapy or DBT we use often in our practice. This is just one example of some skills you might find useful. 

You have a fantastic opportunity here if you seek help from a professional. If nothing else, reaching out to a therapist that will provide a safe space for you to share your thoughts, feelings and choices will be vital in transcending how stuck you feel. You may not be able to change those around you but you can certainly personally evolve and grow through this tough period. 

Please do reach out to someone whether just a friend, religious leader or therapist for help. You do not need to carry this burden alone. Contact us for help or simply to find some resources. 

Hope this helps. 

Question: If my friend always thinks she is fat and needs to lose weight when she is very skinny already does this mean that she had anorexia? How long does it take to get anorexia after you start dieting? This is my best friend and she has been dieting since she was about 13 and now she is 15.

Rob Danzman Says...:

Dear Good Friend,

Let me start by saying that just the fact that you are reaching out says so much about what a great friend you are. You clearly are concerned and want to help. Next, I'm going to give you some basic information about anorexia and then the warning with some specifics on what you really want to know - What can you do to help. 

First - To be diagnosed by a mental or medical professional, someone needs to have one or more of the following: 

• Refusal to maintain a body weight that is at or above the minimum normal weight for their age and height
• Intense fear of gaining weight or becoming fat, even though they are underweight
• Denying the seriousness of having a low body weight, or having a distorted image of your appearance or shape
• In women who've started having periods, the absence of a period for at least three consecutive menstrual cycles

• Death
• Anemia (low number of red blood cells which move oxygen throughout body)
• Heart problems, such as mitral valve prolapse, abnormal heart rhythms and heart failure
• Bone loss, increasing risk of fractures later in life
• In females, absence of a period
• In males, decreased testosterone
• Gastrointestinal problems, such as constipation, bloating or nausea
• Electrolyte abnormalities, such as low blood potassium, sodium and chloride
• Kidney problems

• Remind your friend what a healthy weight is for your body, especially at times when you or she sees images that may trigger her desire to restrict calories.
• Don't visit pro-anorexia websites. These sites can encourage your friend to maintain dangerous habits and trigger relapses. Anorexia isn't a lifestyle choice. It's a disease.
• Acknowledge that your friend may not always be the best judge of whether she is eating enough or are at a healthy weight. If you (or your parents) are worried enough, talk to your friend's parents. Your friendship may suffer but you may help her avoid a much larger issue later on. 
• Identify problem situations that are likely to trigger thoughts or behavior that may contribute to your friends anorexia so that she can develop a plan of action to deal with them. 
• Look for positive role models. Remind your friend that ultrathin athletes, models or actors showcased in women's magazines may not represent healthy bodies.

Question: What effect will getting pregnant have for a bulimic? Do you think that this person is more likely going to be able to control themselves now? Is purging dangerous to the unborn baby? Is it any worse than having morning sickness if a person is not currently having morning sickness? Is it necessary that a obstetrician know about the eating disorder or is this not something she needs to be made aware of?

Rob Danzman Says...:

Dear Anonymous,

Yikes. An eating disorder during pregnancy can be very serious for the mother, the baby as well as the partner (psychologically and emotionally). Eating disorders affect approximately 7 million American women each year and tend to peak during childbearing years. Pregnancy is obviously a time when body image concerns are more prevalent, and for those who are struggling with an eating disorder, the nine months of pregnancy can cause disorders to become more serious. Anorexia and bulimia are most common. Both types of eating disorders may negatively affect the reproductive process and pregnancy.

Eating disorders affect pregnancy in a number of ways. The following complications are associated with eating disorders during pregnancy: Premature labor, Low birth weight, Stillbirth, Risk c-section, Delayed Fetal growth, Respiratory Problems, Gestational Diabetes, Complications Labor, Depression, Miscarriage, and Preeclampsia.

Women who are struggling with bulimia will often gain extra weight, which places them at risk for hypertension. Women with eating disorders have higher rates of postpartum depression and are more likely to have problems with breastfeeding.

The laxatives, diuretics, and other medications taken by many women with bulimia may be harmful to the developing baby. These substances take away nutrients and fluids before they are able to nourish the baby. It is possible they may lead to fetal abnormalities as well, particularly if they are used on a regular basis.

Do you think that this person is more likely going to be able to control themselves now? 

RD: Not likely. An eating disorder is a coping mechanism for something else that's broken or dysfunctional in a person. They may make sincere attempts at restraining themselves from disordered eating but eventually, without professional support, will slide back into their old patterns and end up feeling worse for failing to 'control' their behavior. In addition, remember that hormones are getting wacky during pregnancy. This individual is actually at their most vulnerable while pregnant. 

Is purging dangerous to the unborn baby? 

RD: As you can see above, it's extremely dangerous for the baby. 

Is it any worse than having morning sickness if a person is not currently having morning sickness? 

RD: Morning sickness is a biological reaction to changes in multiple hormones. It lasts for the first trimester for most women. Bulimia is a behavior and a choice - not a biological reaction. It does not go away like morning sickness. It starves the body of nutrients and is destructive. 

Is it necessary that a obstetrician know about the eating disorder or is this not something she needs to be made aware of? 

RD: It's absolutely necessary that medical professionals are consulted. The implications of bulimia are significant. 

Question: My sister has anorexia. She is pretty skinny but she is not a walking skeleton. If you did not know her you would just think she was a really thin person. She has seen many therapists over the years. I am 10 years older than her so we are not all that close. My parents say she won’t listen to them and they don’t know what to do. They offered her a deal where she could live with me and they would pay her rent so long as I got to control her meals and she went for it. They didn’t ask me first but now they are asking me to try and help. She says she really wants to try and a change of environment is what she needs. From what I know about anorexia this is not a sensible plan. Do you think I have any chance of being able to control what she eats? She can be pretty manipulative to get what she wants. I want to help her but I do not see this working. On the other hand, I guess we don’t have too much to lose by at least trying. She has never lived with anyone but our parents. She is 24 and unemployed. Do you have any thoughts, one way or the other?

Rob Danzman Says...:

Dear Anonymous,

You clearly are a good brother and thoughtful person. Many have been where you are and ignored their loved one so cheers to you for getting curious about your options. I've responded to each of your questions below. Unfortunately, your experience is not unique and the path is not easy. 

A: My sister has anorexia. She is pretty skinny but she is not a walking skeleton. If you did not know her you would just think she was a really thin person. She has seen many therapists over the years. I am 10 years older than her so we are not all that close. My parents say she won’t listen to them and they don’t know what to do. They offered her a deal where she could live with me and they would pay her rent so long as I got to control her meals and she went for it. They didn’t ask me first but now they are asking me to try and help. She says she really wants to try and a change of environment is what she needs. From what I know about anorexia this is not a sensible plan. Do you think I have any chance of being able to control what she eats? 

RD: No - you have zero control over what she eats. Establishing that boundary with yourself is essential. There is something bigger going on here, bigger than just the food issue. Previous therapists were clearly inexperienced and in way over their head. Here's what you can do - 1) Ask her how best to support her, 2) Invite her to participate in family and social events, 3) Let her know you care about her and are worried because of the changes you have noticed. If you see an opportunity, you can delicately ask if you can participate in a therapy session with her since you are confused on how best to support her. 

A: She can be pretty manipulative to get what she wants. I want to help her but I do not see this working. On the other hand, I guess we don’t have too much to lose by at least trying. 

RD: You actually may have more to lose than you realize. Many, many families push their loved one to get better by subtly trying to get them to eat. Eating and food are not the real problems here. There are clearly identity and self-esteem issues co-mingled with control issues. This is not something for a family member to take on alone. Best intention with a bad outcome. 

A: She has never lived with anyone but our parents. She is 24 and unemployed. Do you have any thoughts, one way or the other? 

RD: Ok, let's break this down. There are clearly clinical, legal, ethical and financial issues intersecting here. First - As a competent (arguably) 24 y/o your sis is legally in control of her life until/unless you can convince a magistrate or judge to have her mandated to treatment or give someone power of attorney. I can tell you that's unlikely to happen in this case. Next - the clinical issue of how to treat the eating disorder is best handled by professionals with deep experience and training, especially those with DBT/CBT training (dialectical behavioral therapy/cognitive behavioral therapy). The hardest part is getting her to buy-in to treatment which is intense and long. It can also be expensive if her insurance refuses to pay. 

This is something common but complicated. I highly encourage you to seek outside support from a therapist and case manager. I trained and experienced professional will know how to speak with your sister to get the most positive change and ensure her safety and happiness. 

Good luck. 

Question: Would a 45 year old man ever get something like anorexia? My brother was overweight his whole life. Last year he had a health scare and he turned his life around. He quit smoking stopped drinking, gave up red meat etc etc etc. I do not know the numbers but I would say he has lost 70 or more pounds. He used to be very overweight but not obscenely fat. Now he is a very thin person. Not quite ghoulishly thin but barely recognizable as the person he was 2 years ago. Now he is hyper focused on healthy eating. He won’t eat processed foods, non whole grain foods, farmed meat or fish and the list goes on. He seems to subsist mostly on organic yogurt, nuts and fruits and salads. I am worried because he has these rigid food rules that he won’t break, ever and because he is getting so thin that you would think there was something wrong with him, like he has AIDS or something. He went from fat guy to losing weight guy to really healthy looking guy to guy that really looks like he needs a cheeseburger. I have talked to him about my concerns but he has brushed them off. My other siblings are also concerned but no one knows what to do. J.B. in Tenn

Rob Danzman Says...:

J.B.

We often see clients make big changes and then the family members and friends are caught off-guard. Sometimes those behavioral changes (like starting to use drugs regularly) dramatically change the person in very negative ways. Sometimes, the changes are positive for the person but the family and friends are either not prepared or flat-out disagree with the lifestyle change. Ultimately, the best you and your siblings can do is let him know that you support is healthy lifestyle but also are concerned that it may be too much. It's very appropriate to share your concern. It's also very appropriate for him to have the 'thanks, but no thanks' response. If he FEELS content, if he FEELS good, support him. Make it clear, though, that if he ever starts having concerns about his eating or dietary habits, you will be there for him. There may also be other stuff going on that he has not shared with you. If you push too much, he may not share. If you provide that nurturing, non-judgmental support, he will open-up when he's ready. 

In the meantime, don't secretly add extra butter to meals you're making during family events and encourage others to be positive rather than judgmental. Any back-handed ways of trying to control him will likely backfire. 

Good luck with this. 

Question: My wife has had a history of anorexia. She is stable now but 5 years ago she was hospitalized for it. We had our first child 18 months ago. My daughter is having a lot of feeding problems and our pediatrician is concerned that she is falling behind on her growth curve. She is too small. She wouldn’t go to solid foods and she is really picky about what she will eat. I am at work and my wife is a stay at home mom. I am worried that my wife’s history of anorexia is causing her to underfeed. I don’t think she does it consciously but she sort of sabotages feeding time because she is basically against weight gain, even by an infant. Like one thing she does is she wipes her mouth after every bite and asks her ‘are you done yet’ starting after like the second or third bite. I have to stress I do not think she is doing this on purpose! My wife doesn’t see the problem. She doesn’t think the lack of weight gain is a big deal and she does not see how she contributes to the problem, and when I suggested getting my mom to come in and help with feeding she got really angry and upset, accusing me of accusing her of being a bad mom. So now I do not know what to do? Can you give me any advice?

Rob Danzman Says...:

Dear Anonymous, 

This definitely is a complicated situation. You have your wife's history and dignity to respect yet, at the same time, you are concerned her current behavior is impacting your daughter's development. Bare with me as I dissect this to answer your questions. Obviously, all I have to go on is what you have shared with me but, I'll try and give you some things to consider that may or may not be helpful. Let's jump right in to some things to try:

1. Pediatrician: Get regular appointments set up (more than you would typically have for an 18 month old). I'm sure you pediatrician already recommends healthy eating habits for your daughter but it might be a good idea for you to have them get more specific (meal plans, calories, etc.) so you have concrete numbers. I would also ask the pediatrician at what BMI or weight does it become a safety issue. You may also want to, if possible, be home for at least either breakfast or dinner so you can help feed your daughter. I'm concerned that the pediatrician may not really understand what's going on. Lastly - Pediatricians like many other healthcare providers are what are called mandated reporters. If they suspect neglect or abuse of a child, they are required to contact the local department of health and human service to file a report. They do not have to tell you they are doing it. The more contact you have with them, the less likely they will surprise you with reporting. I'm certainly not saying that they will definitely report you and your wife - I just want to make you aware of a possibility if your daughter's weight does not pick up and they suspect your wife is restricting her food. 

2. Couples Counseling: Addressing this with her is important but you may want to use a neutral third party to help facilitate this. Your wife may be defensive but she may also need help hearing you are not attacking her but concerned for your daughter. A really good counselor that specializes in couples work would be able to help tremendously with this. This is a good space for you to ask what she likes and dislikes about being a new mother. What are some things she wishes she could do if she had more time or support. Questions like these help disarm someone who is prone to being defensive. 

3. Additional Stuff Going On: From the little you described, I wonder if there is more going on with her. She may have some dormant obsessive compulsive-like symptoms that popped up during her pregnancy or during the first few months of your daughter's life. She may also be secretly concerned about her mommy-figure. She may be experiencing some post-partum. If she does not like the idea that she may have regressed, she may deny and bury how she's actually feeling and what she's actually thinking. Depending on what your relationship is like with her, you may want to address your concerns in therapy. It may take awhile for her to feel comfortable enough to bring it up. We often have this fantasy that once an issue in counseling is dealt with, it's fixed forever. More than likely she has psychological programming for diet and behavior restriction that may pop up now and again. Stress can definitely trigger new episodes and catch her off-guard.

4. Your Mother: If she is hypersensitive to judgement right now (which it sounds like she is) having your mother or anyone come in to 'help out' while you're at work will only entrench her position. It has to come from her and be her idea. I also find it interesting that you did not mention her family at all.

5. You: Get involved with the child-rearing as much as possible right now. I suspect there is alot going on with your wife and your involvement will provide oversight as well as support. It might also be a good thing to talk about her going back to work or looking for work (ie. or finding time for herself since she may feel consumed by care for your daughter). It might cost you more money on the front end to find day care or babysitters but malnutrition and an unhappy wife/mother is WAY more expensive in the long run. 

Best of luck. The professionals will be the most helpful support for this issue. If you do not know how to find competent therapists or pediatricians, contact our office and we'll help you out. www.fonthillcounseling.com/contact

Question: I think I have compulsive eating disorder. I binge hard 3 or 4 times a week and I am trying to stop. I have not talked to a doctor or anything like this yet. I would like to know if there are any medications that will help me to deal with the urges I feel.

Rob Danzman Says...:

Here is what almost all therapists and doctors will tell you are the most effective means of controlling the issue you described. It's what our agency suggests as well:

Counseling: More specifically - Cognitive Behavioral Therapy. This is a type of individual counseling that focuses on changing the thinking (cognitive therapy) and behavior (behavioral therapy) of a person with an eating disorder. Treatment includes practical techniques for developing healthy attitudes toward food and weight, as well as approaches for changing the way the person responds to difficult situations.

Medication: Some antidepressant medications, called selective serotonin reuptake inhibitors (SSRIs such as Prozac and Paxil), might be used to help control anxiety and depression associated with an eating disorder. The anti-seizure drug Topamax may reduce binge eating episodes, but side effects can be serious. You really need to talk with a psychiatrist rather than a general practice or family doctor. 

Nutrition Counseling: This strategy is designed to help restore normal eating patterns, and to teach facts and strategies for a nutritious and balanced diet.

Group and/or Family Counseling: Family support is very important to treatment success. It is important that family members understand the eating disorder and recognize its signs and symptoms. People with eating disorders might benefit from group therapy, where they can find support and openly discuss their feelings and concerns with others who share common experiences and problems. I would not recommend starting this counseling before the other strategies above since families can often be either the trigger or, at least a stressor.