I hear the faint sounds of machines beeping and people whispering in the background. My mother is crying and my father looks scared. My sisters and brothers are watching in horror as I lay in bed covered with a blanket because I am cold, with a tube in my nose as it's the only way to get anything of substance into my body. I am Dina. I am 22 years old and I can barely speak as my mouth is dry and my body aches with every move.  I try to smile as I want to believe I am happy secretly. I know that I am not. The thought of eating and allowing myself any pleasure from food is wrong. I don't deserve to eat and if I did I would keep gaining weight and be fatter. I no longer get my menstrual period. I know that means there is something wrong but I can't seem to grasp the severity of the situation. The pain I feel is both physical and emotional. I'd like to call out to someone to  make it stop however I  can't as when I open my mouth no words come out as the voice inside my head is threatening me to keep quiet, reminding me that I will  regret it  later. I lie in bed and watch the world go on around me.  I still don't want to admit that I  have an eating  disorder, but secretly I  know that I do, I  have Anorexia Nervosa.

I think to myself  that I can't get home fast enough. I had to  go out with  my friends for a classmate's birthday and  I wasn't hungry but I ate, and I ate too  much, and now I must  find a way to  throw  up. I run into the house, scream hello to family, thankfully no one is home so I run upstairs and turn on the bathroom sink and watch the food I just ate come up. I sit down on the floor, tears in my eyes. Although the tears are the really  from the  effort it took, I believe they are tears of satisfaction as I can relax knowing that I was able to get rid of the food I just ate. However,  I am still worried so I exercise for  hours and  hours enjoying the  rush I  feel as I increase the intensity of my workout. Lastly, I will take laxatives to help ease my fears.  I am Leah. I am 16 years old and I will deny to anyone what I do. I believe that what I do is normal as I need to believe it is, but sadly I have Bulimia Nervosa.

I am Sarah. I am 11 years old and I was told I still have some baby fat. It upset me and I started cutting back on all the junk I used to eat. First I skip snack and then I tell myself that isn't enough. I pretend to eat at meal time by cutting my food up in small pieces and pushing it around on my plate. At first, no one noticed and I was relieved. No one would make me eat and I no longer had an appetite. Then I felt angry. Here I was, working hard and receiving no satisfaction. I wonder, am I not perfect yet? At my doctor's visit, the scale shows I have lost ten pounds. I see the fruits of my labor and realize I cannot stop. My mother is concerned and I promise I will eat better. I know that's not true and that's when I realize  that "I" am in control over my life. I hear someone say I have Eating Disorder Not Otherwise Specified. I pretend not to listen as I know that I want to believe that I am just on a "healthy diet."

Anorexia Nervosa, Bulimia Nervosa and Eating Disorder Not Otherwise Specified are the three most common forms of an Eating Disorder according to the DSM-IV. The three people above are an example of the many who suffer with eating disorders. Eating disorders are a problem not only in the world at large, but within the Jewish community as well.  No matter how hard we try to protect our children, we still live in a world where being thin is glamorized. Whether or not you have a television or get a newspaper, our children see and hear things that we can't control. Our children hear us on the phone talking about our diets, our weight and dress sizes, and of course there are dating issues related to weight. However, it's important to note that although society's notions and ideas are not helpful, they are not the reason one develops an eating disorder. It just feed into one's already negative perception of herself and her vulnerabilities.  In general, there is usually a combination of social, environmental and biological factors that contribute to eating disorders.

It is challenging to address the psychological component of an eating disorder as no two cases are quite the same. Each situation has multiple factors.  There is no one answer to the questions so often asked: Why did this happen to my child; how could I not have noticed this; and what should I do? All are very real and important questions.  I can only echo some of the concerns of my patients and their families.

They report that they are struggling with the desire to be thin, perfect and in control when they feel their lives are chaotic, pressure-filled and unhappy.  Their eating disorders are fueled by negative perceptions, fears of growing up, feeling lost among siblings, and the need for attention (negative being better than none at all). It is also perceived as a more "socially acceptable" form of an addiction. Physical, emotional or sexual abuse or other underlying mental illnesses also contribute to eating disorders. Parents will often say I don't understand what's going on.  My child is an A student with lots of friends, was never fat and I love him or her" why all of sudden is she not eating or is she vomiting? It seems as if this appeared out of nowhere. The truth is that it usually does not come about all of a sudden. Many times there are initial signs that tend to be overlooked. If you notice a change in your child's normal behaviors or routines, that should send up a warning flag.  For example:  mood changes;child appears more annoyed, angry, depressed or withdrawn; does not socialize as before with friends and family; secretive and isolates themselves; tends to enjoy cooking but does not eat what she makes; vegetarianism; often reading food labels and counting calories; lots of time spent in the bathroom; compulsive exercising; unexplained weight loss; lying and manipulative behaviors. However there are some cases where a person may not display any obvious signs of trouble.

If you have concerns about someone who you think might have an eating disorder, it's important to try and get them to go for help. Since an eating disorder manifests in both a physical and psychological ways, it's imperative that treatment be conducted through a team approach. Evidence supports that there isn't one method or one form of medication that treats eating disorders, but rather through medical and nutritional support, together with proper therapy, and in the most extreme cases medication, there is the greatest chance of a complete recovery.  Medical and nutritional support helps the patient to gain the proper nutrition in their body in order for the patient to be able to allow the therapeutic process to assist in recovery. One of the goals in therapy is for the patient to learn to be more confident in oneself, to make her voice heard through communication, to validate her own emotions, to learn to love herself, and to learn better ways of coping with anger, sadness and stress (and not rely on the eating disorder).  Aside from the individual suffering from an eating disorder, the family members need therapy to help them cope and manage their own feelings.

Dina, Leah, and Sarah are each suffering in their own ways. Although all three cases are different, they each have an eating disorder that they are not able to manage on their own.  Dina is too weak to be at home, and in the hospital she needs tubes to help get the nutrients into her body. Leah's vomiting is being monitored by her doctor with weekly blood tests to make sure her potassium levels are normal. And Sarah is starting Mausdly therapy (Family Based Therapy) as she needs the assistance of her parents to help re-feed and rehabilitate her through their natural parental instincts. At the same time, each girl is addressing her fears, concerns and issues with a therapist. Their families too are being guided as to how to manage their own emotions and how to relate to their loved one who is ill. While each girl's story sounds intense, they are not alone and continue to get the support and encouragement to help fight their eating disorder battle. Not all eating disorder stories are a struggle.  The earlier one goes for help, the greater the chances are for a successful recovery.

Elisheva Wollner, LCSW, specializes in treating eating disorders.  She received training from the Institute of Contemporary Psychotherapy; Center for the Study of Anorexia and Bulimia.  Elisheva maintains a private practice in Brooklyn and Cedarhurst treating children, adolescents and adults with eating disorders and other mental health issues.  Recently, Elisheva has served as the coordinator of clinical care at the Eating Disorder program in the Adolescent Department of Steven and Alexandra Cohen Children's Medical Center of New York ;North Shore-Long Island Jewish Health System. She can be reached at 917 864- 9642.