Chapter 2

Understanding
Eating Disorders
Eating Disorder Recovery Handbook

2.1 Hidden Meanings of an Eating Disorder

Objective
An eating disorder can develop as a coping mechanism for life, offering a
distorted sense of control and predictability. Eating-disordered behaviours can
also be a way of communicating emotions that are otherwise difficult to express.
The aim of this worksheet is to help you identify thoughts and feelings that may
be influencing your emotions and who might benefit from understanding this.

Task
Read through each statement, placing a tick in the corresponding column if you
feel the statement rings true in relation to your circumstances. Then consider
who, if anyone, you wish would understand this information, placing a name in
the third column, if relevant.

Communicating emotions Tick, if Who I wish

relevant understood
this

I desperately want to be accepted.

Just now I am figuring out who I am.

I have a hard time with the concept of forgiving.

I smile all the time because I don’t know what else to do.

Sometimes the weight of my sadness is bone-crushing.

I hurt myself because pain is the only feeling that I can stand
to feel.

I am terrified of not being good enough.

I cry when no one is around.

I’m deathly afraid of growing up and having adult

responsibilities.

There are so many things I wish I could say.

Words and actions hurt me even though they weren’t meant to.

I am so incredibly mean to myself.

I sometimes need help, but I’m not sure how to ask for it.

I am an emotional and sexual abuse survivor.

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Understanding Eating Disorders

I hold back from full recovery because the eating disorder

gives me an excuse to not chase after my real goals.

I don’t like the eating disorder, but I’m having a hard time
disliking it.

I feel ashamed and dirty.

I have a very difficult time seeing myself as an attractive

person.

I want to make a difference in the world.

I’m afraid to know myself and understand my feelings and

wishes.

As I’m smiling and laughing, I have voices degrading me in

my head.

I blame myself.

My family is more dysfunctional than I like to admit.

I believe that everyone’s flaws should be accepted and

forgiven except for mine.

I would give anything to get out of my head and into my body

when I am being intimate with someone.

I’m always in a state of obsession and never have a moment

of silence in my head.

I’d love to escape to somewhere by the beach, eat, drink,

dance, without a care in the world.

I lied my way through treatment and I’m now paying the

consequences.

I’m scared to leave the student world and enter the real world
alone.

I miss my parents like mad.

I feel there’s an empty hole in me.

More than anything, I long for my mother/father to love and

listen to me.

I feel guilty about all the pain I feel.

I hate, absolutely hate, feeling vulnerable and I will do almost

anything to avoid it.

I feel nothing most of the time and I wait to see your reactions
before I know how to respond/reply/react myself.

I am really sensitive, although I appear unfeeling.

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Eating Disorder Recovery Handbook

Communicating emotions Tick, if Who I wish

relevant understood
this

I’ll lie to everybody to keep them from being hurt or from

hurting them.

I feel like a complete failure.

What I want most is to just hear that I am OK just the way

I am.

I compare myself to others.

Sometimes I feel like I don’t belong anywhere.

I hate being needy and yet I long to be taken care of.

I am frightened and want someone to love me.

Without this mask, I don’t really know who I am.

I’m not trusting of anyone.

I simultaneously crave both fitting in and standing out.

The eating disorder is the only constant in my life, the only

thing that felt unchanging regardless of what external events
happened.

I am so afraid of being in an intimate relationship and fear

being alone for the rest of my life.

I wear my weight like armour.

The bigger my smile, the larger my pain.

I use my body to convey what my words cannot.

I always feel like a burden.

I don’t want to be given up on.

I have big dreams and wish that I believed enough to make

them become a reality.

I want to love my mother/father, but I cannot figure out how.

I have no confidence in myself.

I will not show that I am mad at you.

I want to find something that will make my parents proud

of me.

I am scared because I don’t know what to do with my life and

I cannot cope without direction.

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Understanding Eating Disorders

I only pretend to be immature: I’m scared to show you just

how serious and deep I can be.

I don’t know who I am.

I don’t feel that I deserve unconditional love.

I’m afraid of being successful.

Other:

Other:

Source: Adapted from Something Fishy Website on Eating Disorders1

Reflection time!
Consider sharing this chart or elements of it with the people you have named
in the third column. Reflect on what it would feel like to have this person
understand your thoughts, feelings and needs. What difference would it
make to your recovery?

Until completing this exercise, I had never even considered telling

my partner how I feel. Now that he knows, he can better support me.

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Eating Disorder Recovery Handbook

2.2 Motivations for an Eating Disorder

Objective
Eating disorders can be motivated by a variety of factors, including the need for
security, as a method of avoiding painful emotions, a way to communicate or
even a way to gain a sense of strength. The aim of this worksheet is to help you
identify what motivates your eating disorder.

Task
Read through each motivation in the table below, placing a tick in the
corresponding column if you feel the statement reflects your own circumstances.
Quotes have been provided by other people with eating disorders who can
relate to these motivating factors.

Motivating factors Tick, if Real-life examples

relevant

Security: A way of ‘I feel that if I were to recover, life would have no

obtaining a sense of structure and purpose; the security blanket is hard to
stability and security, shake off.’
helping to structure
‘The rules I have set myself make me feel safe. When
everyday life by
I am sticking to them, I feel good. When I fail to meet
organising days by
my targets, I feel bad and the rules change. They get
means of strict rules
stricter but the stricter they are, the safer I feel.’
and time schedules.

Avoidance: A way ‘Comfort eating and the high from carbs helps me
of avoiding negative avoid my feelings and fear of failure.’
emotions and
‘It’s terrible, but I use anorexia as an excuse if I don’t
experiences, including
do well, but I use the pressure I am put under as an
high expectations,
excuse not to recover, as I say I don’t have time. I’m
producing a feeling a
just avoiding everything.’
being ‘safe’.

Mental strength: ‘When I stick to my rules, I feel strong. My rules

A way of getting an enable me to go to work and function and feel in
inner sense of mastery control.’
and strength, resulting
‘I felt stronger and more in control when I restricted.
in a sense of power
But in recovery, I realised that I was truly strong when I
and invulnerability.
allowed myself to be vulnerable.’

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Understanding Eating Disorders

Self-confidence: A ‘I don’t like me, therefore no one else will. I’ve got
way of feeling worthy to pretend to be someone so people will like me. If I
of compliments and was slimmer, they’d like me more and I would like me
acknowledgment. more and have more confidence.’
‘I thought I’d feel more confident if I lost half a stone,
but when I did, I still didn’t like myself and changed my
target – always chasing more confidence.’

Identity: A way of ‘I got thinner because I thought it would make me a

creating a different better person.’
identity or personality.
‘It’s almost as if anorexia has taken over to the extent
that if I recover, it would take my sense of identity
away, and I will never be who I was before.’

Care: A way ‘Being vulnerable as a person gave me a reason for

of eliciting care being treated with care. People approached me in a
from other people softer way.’
– encouraging
‘I felt that I would only deserve help and attention if it
concern, attention,
was physically necessary.’
attentiveness,
thoughtfulness and
consideration.

Communication: A ‘Words didn’t communicate how bad I felt about

way of communicating myself. Everyone thought I was confident and happy
difficulties to other and I felt like my exterior miscommunicated my true
people, especially personality.’
when feeling
‘My eating disorder has helped me to communicate
misunderstood.
the problems that I couldn’t and didn’t know how to
express.’

Death: A way of ‘It’s less of an explicit want to die and more just a
starving yourself to wish to disappear. I feel as if everyone else around
death – usually related me would be less stressed and worried if I simply
to earlier issues with disappear. It feels as if it is inevitable and that I will
depression or suicide never be able to recover. I didn’t start wanting to die,
attempts prior to the it crept up on me.’
onset of the eating
‘At my worst, death seemed like my only option.’
disorder.

Source: Adapted from Nordbø et al. 20062

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Eating Disorder Recovery Handbook

Reflection time!
What have you learned about yourself and what motivates your eating
disorder? How could you use this new knowledge to strengthen your resolve
towards recovery, or to allow others insight into what drives you so that they
can better support you?

Everyone thinks I’m really smart and always able to succeed. But
having an eating disorder clouds the feelings I have to deal with when
I fail. It’s terrible, but I use my eating disorder as an excuse if I don’t do
well, but I use the pressure I am put under as an excuse not to recover.
I’m just avoiding everything.

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Understanding Eating Disorders

2.3 Eating Disorder Assessment

and Evaluation Forms
Objective
There are a variety of assessment and evaluation forms available for eating
disorders, some of which are used by health professionals as part of diagnosis
and others that are used by those with eating disorders to help them identify areas
of concern or where extra support might be needed. It can be particularly useful
to complete such forms when you are experiencing your best and worst days as
a reminder of changes in behaviour and to gain strength from the better days. If
you do choose to complete such assessments yourself, make sure you have the
relevant support in place.

Task
Take a look at the table of assessments below. Do you feel you could benefit
from completing any of these forms? Perhaps they might help you gain further
insight into your condition? Place a tick next to those you feel you might be able
to benefit from.

Assessment Tick, if Example questions

relevant
SCOFF Do you make yourself sick because you feel
Questionnaire:3 uncomfortably full?
A screening tool Do you worry you have lost control over how much you
for detecting key eat?
characteristics Have you recently lost more than one stone in a three-
of anorexia and month period?
bulimia
Eating Attitudes Am I terrified of being overweight?
Test (EAT-26):4 Do I avoid eating when I am hungry?
A screening Am I preoccupied with food?
questionnaire to help
determine if eating
behaviours and
attitudes should be
further evaluated
Becks Anxiety During the past month, including today, how much have
Inventory (BAI)5 you been bothered by the following symptoms (mildly;
moderately; severely; not at all):
• Numbness or tingling
• Feeling hot
• Heart pounding/racing
• Unable to relax?

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Eating Disorder Recovery Handbook

Assessment Tick, if Example questions

relevant
Bulimic Do you have a regular day-to-day eating pattern?
Investigator Test, Are you a strict dieter?
Edinburgh (BITE)6 Do you feel a failure if you break your diet once?
PHQ-9:7 A tool to Over the last two weeks, how often have you been
screen for symptoms bothered by:
of depression • Little interest or pleasure in doing things
• Feeling down, depressed or hopeless
• Trouble falling or staying asleep, or sleeping too
much?
GAD-7:8 A tool to Over the last two weeks, how often have you been
screen for symptoms bothered by:
of anxiety • Feeling nervous, anxious or on edge
• Not being able to stop worrying
• Worrying too much about different things?

Reflection time!
What did you learn about yourself and your eating disorder and its associated
symptoms from completing these assessments? Did anything surprise you?
Have any areas of need been identified, where more support might help
you? Consider sourcing the above assessment forms for a more thorough
evaluation of your situation. You may also find Section 11.4 helpful (see
page 221).

I didn’t realise how much my eating behaviour was influenced by

anxiety. I told my counsellor about this and we are now working on ways
to deal with anxiety, which is also helping my eating.

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