Unbenannt-2To many, mental health issues are still a taboo subject. As it is Mental Health Awareness Month in the USA, we want to contribute to de-stigmatization and raise awareness about the topic of mental health. For this reason and in accordance with the motto of this year’s awareness month – “Life with a Mental Illness” – , EXPOSING THE TRUTH is publishing a series of interviews throughout April and May, to let people affected by mental illness speak for themselves.

In 2014, an estimated 43.5 million adults in just the United States of America were suffering from a mental illness such as depression, bipolar affective disorder, or schizophrenia. Eating disorders are among the most common of mental illnesses: The National Eating Disorders Association (NEDA) estimates that in the United States, 20 million women and 10 million men suffer from a clinically significant eating disorder at some time in their life.

This week Anne, a 24-year-old female who suffers from anorexia since she was 15, shared her story with me. We talked about the pro-ana community, her body image as well as the struggle to maintain a healthy eating behavior.

Eating disorders feature serious disturbances in eating behavior and weight regulation. They are associated with a wide range of psychological, physical, and social consequences. Although they affect both genders, rates among women and girls are 2½ times greater than among men and boys. Eating disorders frequently appear during the teen years or young adulthood, but also may develop during childhood or later in life. The International Classification of Diseases (ICD-10) – a standard diagnostic tool published by the World Health Organization – distinguishes between the following types of eating disorders:

Anorexia Nervosa (AN): Characterized by self-restricted intake of food and fear of gaining weight as well as a strong desire to be thin.

Bulimia Nervosa (BN): Marked by periods of overeating followed by purging, sometimes through self-induced vomiting or the use of laxatives.

Overeating Associated with Other Psychological Disturbances (BED): Is also called “binge eating disorder”, which is out-of-control eating.

Other Eating Disorders: Pica – appetite for substances that are largely non-nutritive such as ice, paper or clay –, or Rumination Disorder which is characterized by effortless regurgitation of most meals following consumption, due to the involuntary contraction of the muscles around the abdomen.

Hello Anne, thank you for letting me ask you some personal questions about anorexia – I understand that some of this might be hard to talk about, so let’s start with a more general topic. What do you think about online communities encouraging or advocating eating disorders? Pro-ana still seems to be quite popular…

I think they are absolutely awful. I’m glad I only visited a pro-ana site once, and at a point in my recovery at which I was feeling like something had to change. I was never proud of being anorectic and I wouldn’t wish anyone to experience it. I don’t understand how people can really think that it is a good idea to encourage others to continue this behavior. Me and my friends try to do it the other way around: we support each other when we are feeling low and try to get through difficult times as healthy as possible. I can only advise anyone who suffers from an eating disorder to never visit those sites and not to get involved with pro-ana.

Unfortunately, it’s easy to argue that an unhealthy eating behavior is normal for a majority of people living in Western societies – especially women. How is your eating different from those of others who haven’t been diagnosed with an eating disorder?

I think the biggest difference lies in the obsessive need to control what you are taking in, which manifests itself in some strange rituals when it comes to eating. Because it terrified me to lose control over the food I was consuming, I always needed to know exactly what was in there or else I couldn’t eat it. During my worst phases, it even had to be very specific times during which I allowed myself to eat. If I had to eat earlier or later than those times – even if it was only a minute – it was absolute hell for me. I also started eating with a little spoon and ate very slowly to trick myself and others into thinking that I was eating more than I actually did.

Another big difference between the eating behavior of a “normal” person and that of one who struggles with an eating disorder is that eating is connected to a sense of fear, I would say. Fear of gaining weight, even if you only eat a little bit. My food looked – and still looks – very much the same every day, because I am too afraid to change anything as changing my diet might lead to weight gain.

Wow, that sounds exhausting. What happens if you feel like you don’t have absolute control over the food you are taking in, for example when you are travelling or eat at a restaurant?

That is really difficult for me. When I go out for dinner, I usually check the menu on the internet beforehand to see if there is something on there that would be “allowed” for me to eat. Most of the time I end up ordering a salad without dressing. When I am invited to eat somewhere else, for example at a friend’s house, I will have to ask in advance what we will be having. When there is nothing there for me, I will find an excuse to show up late and eat food that is “safe” for me at home.

I noticed that you use words like “safe” and “allowed” when talking about food. I heard that many people with eating disorders tend to do this. How is that with you? Which foods do you allow yourself and according to which criteria do you categorize your food?

That depends on the relation between taste, repletion, calories, fat, and sugar. Vegetables and skim milk products are generally allowed. Fruit are a special case, because I only allow myself to eat sweet fruit like bananas or pears when I am having a “good” day. Fast food or anything that contains a lot of fat, sweets, oil or cream is forbidden. When I treat myself to those things, it has to be a special occasion and I have to earn it. I have no idea how I came up with those categories. They are in my head.

How did you come to finally realize that you might be suffering from an eating disorder?

I didn’t realize that myself. When it all started, I was 15 and still living with my parents. One evening when we were sitting at the dinner table, they handed me a list which contained the symptoms of anorexia, and asked me what the difference between my eating behavior and that of an anorectic person was. I had no answer to that question. It was after that talk that it slowly started to dawn on me that something was wrong.

Another situation that showed me that not only my parents, but also my friends, were worried about me, was when I received a text message from my best friend at the time – initially intended for someone else and accidentally sent to me. This message made me realize that my eating behavior might actually be a lot more disturbed than I wanted to admit to myself…

How old were you when you finally received your diagnosis?

That was also at the age of 15. Because there were – and still are – long waiting lists for therapy programs, and I needed help quickly, I ended up going to a counseling center where I was diagnosed with anorexia. At a later point, my physician gave me the same diagnosis.

Did you manage to receive therapeutic treatment afterwards?

Yes, apart from a one-year pause I have been in therapy ever since, both outpatient and inpatient. I first spend seven weeks in a clinic in 2009 and received outpatient care since then. Unfortunately, I relapsed in 2012 and became dramatically underweight, so I had to return to the clinic for another twelve weeks. I was stable and feeling well afterwards, satisfied with going to see my therapist once a week until summer 2015, when I relapsed and got caught up in anorectic behaviors and attitudes again. My condition worsened due to an additional metabolic disorder that I am still struggling with at the moment and I will return to the clinic in June.

I am really sorry to hear that! How do the things you learned in therapy help you in difficult times like these?

I definitely learned to become more realistic and reasonable in assessing my condition. The degree of suffering is high, and I know that I wouldn’t be able to recover on my own this time.

Do you talk about all of this with your friends and family? Do you feel supported by your social environment?

I am dealing very openly with my disorder. Of course, I don’t write “ I have anorexia” on my forehead, but if someone confronts me then I don’t deny that I have an eating disorder. The feedback so far has always been positive – be it in school or at work. I tell my family about it when I feel low or go through a difficult phase. The only thing I find kind of hard is to talk about the thoughts which are directly connected to my eating disorder with people who are not affected by it. I try to keep specific fears and thoughts about this topic to myself, and only talk about those things to friends I have made in the clinic.

Can you tell me a bit more about your treatment? Did it help you for the time being?

I am a bit conflicted when it comes to outpatient treatment. It rather dealt in depth with the possible causes for my eating disorder and how I deal with those things, rather than trying to change something in the present. Nonetheless, I felt supported and I guess I would have relapsed much quicker if it hadn’t been for outpatient care.

Concerning my inpatient treatment, I definitely have to say that both stays in the clinic helped me a lot – especially the second one. I don’t regret going there at all because it not only helped to regain weight but also with normalizing my relationship towards food. When my weight became more stable, I was allowed to participate in therapy sessions. In those I learned that, instead of starving myself in stressful situations, I have the ability to handle my emotions much more productively. It also helped me to understand how my perception of myself was – and at times still is – distorted by my eating disorder.

Yes, I have heard from many people suffering from eating disorders that they struggle with maintaining a stable and undistorted image of their own bodies. A person who suffers from an eating disorder might look at themselves in the mirror and see themselves as overweight, even if others tell them that they look absolutely normal, or even underweight. How to you perceive your own body? Does your body image change, depending on your mood and daily form?

Retrospectively, and looking at old images of myself, this is definitely applicable to me. Even with a BMI of 13, I felt like there were still parts of my body which were “too fat”. I didn’t notice at that time that this image of myself was totally skewed. Still today, the acceptance and perception of my body still very much depends on my daily form. There are days on which I can much more accept some parts of my body than on others.

Anorexia and other mental illnesses such as depression are often intertwined. Did you also receive medical support to help you ease other symptoms connected to your disorder at that time?

I would say that I definitely have depressive tendencies, and in the clinic my therapists and I also discussed the possibility of supporting my treatment with antidepressants. In the end, I dismissed this option as I wanted to try to recover without the use of medication first.

Would you recommend therapeutic treatment to others who have been diagnosed with an eating disorder?

Yes, definitely, and best as soon as possible because the sooner you deal with your difficulties the easier it will be to overcome them. I have met different people in the clinic who went there at a young age or at an early point of their illness, and it was much easier for them to overcome their fears and destructive behaviors – I guess that’s because the destructive behavior hasn’t asserted itself so much yet.

Another thing I would like to advise others who struggle with their eating behavior is to open up about it as much as possible. I did the same and it was one of the best things I could do in my situation. When you speak openly about how you feel and what is happening to you it will be much easier for friends and family to deal with your situation. Also, it will help you as a person because people will be more empathetic and understanding if you let them know what you are going through.