Note from Recovery column editor, Eta Levenson: Eating disorders can be very serious, even fatal. This article is dedicated to the memory of Gavrielle bat Asher Selig, z”l, who succumbed to the disorder and its comorbid depression this past month.

Michelle was first referred to me by the school nurse. Some of Michelle’s friends had come to her, concerned. Apparently, Michelle was counting out her peas at lunch, allowing herself only seven. She would chew each one slowly, carefully monitoring them, declaring herself full after the allotted number.

I had the initial meeting with her parents, who were dismayed and denied any real problem. “She looks great now,” her dad told me. “She had gotten a bit chubby, but she got herself in hand and is eating really well, and has taken it off.”

Her mother nodded in agreement. “She can’t possibly have a problem,” she added. “Her grades haven’t slipped one iota. If she really was in trouble, wouldn’t her grades have gone down?”

I listen to them sympathetically. I gently explain that rather than contradicting the diagnosis, this actually is one of the confirming symptoms. Anorexia is a disease of great discipline and dedication. Grades rarely suffer even in the throes of it.

Michelle reports that she grew up in a functional family, has good relationships with both parents and siblings. When she started high school, she experienced anxiety over being in a brand-new environment “where nobody knew me.” She started snacking and eating more after school, swiftly gaining 15 pounds. She endured “good-natured teasing” from her family, and some classmates. Over the summer between freshman and sophomore year Michelle “began to eat healthy” and the weight dropped off, to the great approval of all who knew her. When she reached her goal weight, Michelle did not want to stop. It felt too good to resist food where others “pigged out.” Besides, she still could lose more weight and look even better, couldn’t she?

It has been four months since Michelle has had a menstrual period, and she is constantly cold, even as the weather warms up. The thought of eating more, and incorporating foods like carbs into her diet, puts her into severe anxiety.

Michelle is conflicted about wanting to stop. On one hand, she is tired of the constant obsessive thoughts about food, and just wants to “be normal and eat like a normal person.” On the other hand, she fears that once she changes her habits she will “blow up like a balloon.” Secretly, though, she is proud of her extreme discipline and dedication.

Ashley comes each Monday at 4 p.m. She calls herself “a failed anorexic.” She is 17 and has begun the college admissions process, and is very absorbed in her SATs, applications and campus visits. She reports that she starts out each day with full intention to restrict food, and is fairly successful until around dinnertime. By then she is so hungry and depleted that she not only “overeats” at the table, but then makes multiple return trips to the kitchen cabinet to snack on various things until she feels so full and disgusted with herself. Ashley usually solves the problem by bending over the toilet and regurgitating what she so recently has consumed.

Sarah is 24 and considered clinically obese. Her mother made the initial call, concerned about her daughter’s inability to control her weight. There is no denying her ever-expanding body. Her mother is worried about her dating and marriage prospects if she doesn’t get this under control.

Sarah herself is embarrassed but admits to feeling powerless. She, too, starts each day with good intentions and usually eats the same sensible breakfast each morning. Very soon afterwards, things change. There are “too many things that call” to her and are impossible to resist. She loves carbs, and large amounts of them. She will indulge in binging behavior, where she will eat an inordinate amount of the things that she craves in a relatively short time span. She reports sometimes being in an almost fugue state, not paying attention to the taste or quantity of food ingested, and only stops once she is feeling so full that she wants to burst.

Sarah has tried every diet she has heard of. She always starts out very motivated and hopeful, and after a week or two starts getting cravings again, and the familiar patterns of behavior quickly resume. She feels hopeless and helpless.

All three young women exhibit feelings of shame and powerlessness over their situations. They try to keep their behaviors secret from those around them, with little success. Each is at risk for dangerous outcomes if she does not stop, or at least lessen her actions.

Let’s say you are Michelle, Ashley or Sarah, or one of their family members. What do you do?

According to NEDA (National Eating Disorders Association) some warning signs to look out for are:

Dramatic weight loss or consistent weight gain

Dresses in layers to hide weight loss or stay warm

Preoccupation with weight, food, calories, fat grams and dieting

Refuses to eat certain foods, progressing to restrictions against whole categories of food (e.g., no carbohydrates)

Makes frequent comments about feeling “fat” or overweight despite weight loss

Denies feeling hungry

Develops food rituals (e.g., eating foods in certain orders, excessive chewing, rearranging food on a plate)

Consistently makes excuses to avoid mealtimes or situations involving food

Expresses a need to “burn off” calories taken in

Withdraws from usual friends and activities and becomes more isolated, withdrawn and secretive

Seems concerned about eating in public

Resists or is unable to maintain a body weight appropriate for their age, height and build

Has intense fear of weight gain or being “fat”

Has disturbed experience of body weight or shape, undue influence of weight or shape on self-evaluation, or denial of the seriousness of low body weight

Menstrual irregularities—amenorrhea, irregular periods or only having a period while on hormonal contraceptives (this is not considered a “true” period)

Difficulties concentrating

Dizziness

Fainting

Feeling cold all the time

Sleep problems

Cuts and calluses across the top of finger joints (a result of inducing vomiting)

Dental problems, such as enamel erosion, cavities and tooth sensitivity

Dry and brittle skin and nails

Swelling around area of salivary glands

Cavities, or discoloration of teeth, from vomiting

For a more complete list go to https://www.nationaleatingdisorders.org/learn/by-eating-disorder/anorexia/warning-signs-symptoms.

I have gone to schools, gyms, summer camps and various other places, speaking to nurses, teachers, trainers and counselors on warning signs to look out for. It is important to be aware of red flags that signal behaviors indicative of disordered eating. It’s a race against time… the sooner diagnosis and treatment are implemented, the better the prognosis.

Here is what I tell them: It is not your job to fix this. That’s not possible. There are professionals and organizations whose job it is to guide you and offer treatment options. Your job is to pay attention and get help.

Some helpful resources are:

Local psychotherapist specifically trained in eating disorders

NEDA—Nationaleatingdisorders.org

The Renfrew Center for Eating Disorders—Renfrewcenter.com

The National Association of Anorexia Nervosa and Associated Disorders—Anad.org

While eating disorders are of concern and potentially can result in serious, dangerous situations, the earlier the diagnosis, the better the prognosis.

Emily Bitton is a licensed clinical social worker in private practice. She specializes in eating disorders, and also focuses on life issues pertaining to women. She has offices in Florham Park and West Orange, New Jersey. She can be reached at [email protected] or 973-669-0093.

Since the passing of her son Eric by suicide in 2016, Eta Levenson and her family founded the Eric Eliezer Levenson Foundation for Hope to fight the stigmatization of mental illness, raise awareness about mental health challenges and help prevent suicide. She can be reached at [email protected].