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EATING DISORDERS


INTRODUCTION


Eating disorders are frequently misunderstood, trivialised or ignored. The view that a sufferer with anorexia nervosa, bulimia nervosa, or binge eating disorder has a serious, chronic, life-threatening and devastating mental illness is often overlooked. Early treatment is a crucial step to making a full recovery. For early treatment to occur an eating disorder needs to be recognised by the sufferer (or in situations whereby the sufferer cannot recognise their illness, the the eating disorder must be recognised by a doctor, parent or friend).


The last people to acknowledge they have a problem will often be the sufferers. Their illness swears them to secrecy and silence. In the case of people with binge eating disorder that has only recently recognised as an illness, many people suffering will not know that their illness can be treated. Therefore, it is the job of friends, family, colleagues, and health professionals to take in many cases the first step – to know What eating disorders are and their symptoms, Why we should care, Who they affect, Why they occur and How they are treated.


WHAT ARE EATING DISORDERS?


In anorexia nervosa, an individual lives at a low body weight, beyond the point of slimness and in an endless pursuit of thinness. Sufferers control their weight by limiting food intake and commonly avoiding “fattening foods”. Some individuals also exercise excessively or vomit after eating to control their weight further.


As in anorexia, individuals with bulimia nervosa are also highly critical of their body weight and shape. In contrast to anorexics, bulimics have intense cravings for food with secretive overeating. These “binges” are then followed by compensatory behaviours called “purges”, including vomiting, fasting, excessive exercise or laxative abuse. So terrifying is the idea of weight gain and so overwhelming is the immediate urge to get rid of food, that sufferers engage in these purging activities in an effort to compensate and prevent weight gain. Many bulimics use a combination of the above-mentioned purging behaviours to control their weight. The cycle of overeating followed by restriction, means that sufferers of bulimia, in contrast to anorexia, often remain at a “normal” weight. In some individuals, bulimia develops from a previous stage of anorexia.


However the most common form of eating disorder is binge eating disorder. Individuals with this condition have lost control over eating and therefore consistently overeat, but they do not use purging behaviours to compensate. Similar to people who experience anorexia and bulimia, individuals with this problem often have symptoms of depression and anxiety with difficulties in relationships or mood and activity regulation from early life. People with binge eating disorder often also have associated problems with obesity and diabetes. Men and women alike can have this disorder, although men are more likely to have this form of eating disorder than anorexia nervosa or bulimia nervosa.


WHAT ARE THE SYMPTOMS?


Anorexia generally starts with mild dieting behaviour, causing little to no concern to the sufferer or those around them. Often, individuals are given compliments about their slimmer figure or their “will-power”. Weight loss is then seen as a positive achievement. Soon, an intense fear of gaining weight and sometimes an obsessive interest in what others are eating develops. A person experiencing anorexia may engage in the following behaviours: obsessively counting calories, spending hours watching cookery television programmes, trawling through recipe books, cooking elaborate meals for others, obsessively examining packages in supermarkets, studying menus, and/or continuously directing the topic of conversation towards food, weight, restaurants, flavours, and diets. Family and friends may initially not realise that the sufferer eats very little – excuses for “having eaten earlier”, not being hungry, plates piled high with vegetables, salads and other low calorie foods to the exclusion of most other foods, and/or the organisation of a hectic schedule in order to skip or “be busy” at meal-times are all symptoms of anorexia. Subtle clues - deadly consequences.


A person with anorexia may have a rigid and excessive exercise routine – burning calories far in excess of consumption. Frighteningly, when challenged about recent weight loss, sufferers will deny they have a problem – believing that they are not “too thin”, that they are in fact fat, or that parts of their body are huge. Their appearance provokes in them excessive personal criticism (whether verbally expressed or not) and sideways glances in the mirror can easily trigger expressions of disgust and revulsion.


In contrast to the overt weight loss and physical decline seen in anorexia, an individual’s bulimia can remain hidden from others for years. Eating behaviors are often associated with secrecy and shame. Bulimics are mortified and worried about their behaviour but are too ashamed to reveal it. Friends and relatives may notice that although the sufferer eats small to normal portions of food at mealtimes, and/or possibly skips meals entirely, large quantities of food frequently disappear from cupboards or empty food packages appear in the rubbish bins. People with bulimia are likely to organise their life around food and weight control – shopping for food, eating and then engaging in purging behaviours. The lingering smell of vomit in bathrooms or the need for the sufferer to use the loo immediately after having eaten are all signs.


Individuals with binge eating disorder may be constantly eating or starting a new form of diet. They may hide food, surround themselves with food, and dedicate much of their time and money to buying food. It is not uncommon for a binge eater to eat multiple meals in one sitting or say that they are still hungry when they are in fact full. It is also not common for a binge eater to sneak away in order to eat, afraid of judgment from others.


As in anorexia and bulimia, binge eaters are often preoccupied with their weight and body shape and are highly dissatisfied with their appearance.


WHY SHOULD WE CARE ABOUT EATING DISORDERS – THE CONSEQUENCES


If left untreated, eating disorders begin to dominate a sufferer’s life. Education and work goals will be lost, individuals will isolate themselves from friends, family and social engagements and enjoyable and leisure activities will be dismissed. It can become all consuming and as a result their eating disorder can become their one and only priority and a full-time occupation. Individuals may be difficult to live with - experiencing low mood, anxiety or frequent, unpredictable fluctuations in temperament. Low self-esteem and self-hatred can lead to scratching or cutting arms or other body parts in disgust. Eating disorders can ultimately stifle and threaten the person’s emotional, mental, physical, Economic and social well-being.


It is important to remember that sufferers can die from their illness. Physical complications and suicide in anorexia make for higher death rates when compared to other psychiatric conditions. In anorexia, a quarter of sufferers go on to develop a chronic illness, disrupting their life profoundly. The same is true for bulimia.


In anorexia, the physical consequences of great weight loss will fail to alarm an individual. Constipation, dizzy spells and faintness, muscle weakness making stairs or lifting things an effort, feeling constantly cold, pale and dry skin, the development of long, fine, downy facial hair and the loss of periods in females may be noticed by others but be insignificant to the sufferer. The reminder of long-term damage to bones with resultant osteoporosis, and possible future fertility problems, will equally cause no anxiety or motivation to gain weight.


Life-endangering risks also exist with other methods of weight control. Frequent vomiting dissolves teeth away and the body becomes depleted of vital salts, disrupting muscle, heart and kidney function. Blood tests will show these abnormalities and the results of a heart trace may prompt urgent treatment. Salivary glands will swell, leaving a puffy and rounded face. Laxatives destroy bowel muscles and drain away salts and water leaving an individual dehydrated.


Binge eating is associated with a variety of medical problems associated with metabolic issues, diabetes and obesity. Large amounts of weight gain over a short period of time can place immense strain on the heart and make the person susceptible to heart failure.


WHO IS AFFECTED BY EATING DISORDERS?


It is estimated that there are over 1 million people in UK living with an eating disorder. Anyone can develop an eating disorder, regardless of age, sex, cultural or racial background, although the people most likely to be affected tend to be young women, particularly between the ages of 15-25. About 1 in 250 females and 1 in 2000 males will develop anorexia; five times this number will suffer from bulimia and ten times this number binge eating disorder.


An eating disorder should never be dismissed as a “teenage girl fad”. Women, other than teenagers live with eating disorders, as do men. In males, a presenting feature is often an obsessional and fanatical interest in sport and exercise.


WHY DO EATING DISORDERS OCCUR?


It is unlikely that an eating disorder will have a single cause. Over recent years, researchers have looked at possible triggers among sufferers. Family studies have revealed that occasionally anorexia or bulimia occurs in more than one relative, linking eating disorders to a genetic predisposition. It is not unusual, for example, to see two teenage sisters in treatment for separate eating disorders or for a sufferer to have a mother, aunt or grandmother who is ill. But this is not always the case.


Eating disorders may be a way of coping with problems in life – a way of avoiding or dealing with issues or emotions that are too painful or uncomfortable to face. An eating disorder may feel like a safety net, a familiar place, a constant protector, a barrier, comforter and/or a welcomed distraction. The sufferer may feel powerful, in control and enjoy the predictability of their eating disorder. In a life that may feel messy, inconsistent, frightening and erratic they know they can always turn to their eating disorder – it’s dependable, it never leaves them, it’s ordered, structured and, it makes them feel good. Unfortunately, it is destructive beyond words.


Sufferers of eating disorders are likely to deal with one or many of the following issues at the beginning or during their eating disorder: low self-esteem, problematic family relationships, the death of someone special, academic pressure, challenging relationships with friends or partners, difficulties at work, school or university, a lack of self-confidence, social insecurities and/or sexual or emotional abuse. Some individuals may have had a harrowing, disruptive and traumatic period in their life that “triggered” the disorder, whereas others can think of no specific cause for the development of their illness; this may add to their self-hatred and sense of worthlessness – “Other people cope with life, why can’t I?”


Many sufferers will never identify ALL of the causes for their illness. No matter what the cause of an eating disorder, treatment is the same - to give individuals the necessary skills and tools to cope with life and its resulting emotions without depending on their eating disorder.


HOW ARE EATING DISORDERS TREATED?


By the time a person is diagnosed as having an eating disorder, the illness is often quite ingrained. As a result, the strength and mental will power that individuals need to break free from their illness can be quite immense. Sufferers cannot recover alone - they need support and they need guidance. They need time, patience and encouragement. For some, breaking free from their eating disorder may be their toughest challenge in life. They will feel lost, alone and vulnerable. And yet as a result of breaking free from their disorder, they will receive their greatest reward – their life!


Recovery is complex. Not only do sufferers have to rebuild their body physically, but also psychologically. A regular, balanced and healthy eating pattern needs to be established and underlying emotional problems and issues need to be explored, addressed and resolved. Weight gain in anorexia, or breaking the binge-purge cycle in bulimia, can both be very long processes. Setbacks are common and, at times, progress seems invisible, but, steps towards recovery can be made and recovery is achievable.


The first and perhaps the most difficult step in treatment is for sufferers to acknowledge that they have an eating disorder. They have to want to change their life and let go of their illness. Ambivalence will lead to an incomplete recovery or relapse.


Many sufferers are initially taken, or more rarely take themselves, to their GP. A GP will be able to confirm the diagnosis of an eating disorder, assess its severity and evaluate the next best course of action. (If for any reason you believe you have one or believe someone you know does and the GP disagrees it is ideal to get a second opinion). From this point, most individuals are referred to a Psychiatrist or a Psychiatrist specialising in eating disorders. Depending on the urgency for treatment, many routes are taken from here.


In outpatient treatment, a sufferer may see a therapist who may be a nurse, doctor or psychologist. Helping to devise a comfortable and safe weight-increasing diet is the aim in anorexia, while supporting the sufferer to relearn how to feed and take care of themselves. With those who suffer from bulimia, the conviction that eating “normally” 3 times a without the use of weight controlling measures will lead to weight gain, needs to be dispelled. For binge eating disordered patients, a regular pattern of eating with a minimum of processed foods and a balanced diet composition is encouraged. Also it is helpful to include regular exercise into their lifestyle.


Weekly sessions with a psychotherapist will aim to help sufferers express themselves, and re-learn how to deal with their emotions and uncomfortable feelings and situations in life without using food. Sufferers will be supported to love themselves, helped to come to terms with any problems they may be avoiding, and shown how to cope with stress, anxiety, guilt or negativity in a less destructive way.


New forms of treatment are being developed. For instance web-based cognitive behavioural therapy with on-line support forums is being tested in the treatment of bulimia nervosa. A variety of approaches involving carers/families - such as workshops or multifamily groups - have been found to be useful. Mobile technology so that interventions and support are available at times of risk are under development as is the use of virtual reality to guide treatment.


If outpatient treatment is proving unsuccessful, or, if the Psychiatrist feels that a greater level of support is needed, “day-care” or “in-patient” beds are available in specialist Eating Disorder Units. Eating Disorder Units usually consist of a ward in a hospital or a separate building or house offering highly structured care, dedicated and designed solely for the treatment of patients with eating disorders.


Patients may just attend the programme for a few days per week and spend nights at home (“day care”) or may remain in hospital full-time (“in-patient” care). Days consist of regular and supervised meals and snacks, with trained nursing staff who offer encouragement, support and reassurance. The regime has to be strict, an eating disorder makes an individual devious; restricted exercise for those on weight-increasing diets, supervision with nursing staff after meals to prevent vomiting and restricted access to kitchens and food supplies to stop bingeing are all necessary measures. Food is interspersed with an intense therapy programme – group therapy with other patients from the unit, individual therapy and family therapy involving parents, brothers, sisters and partners.


Sometimes, the strength and power of an individual’s eating disorder is extreme. The eating disorder impairs individuals’ ability to make rational decisions about their treatment. It is occasionally necessary, when life or health is “at risk”, to admit a patient to hospital to be treated and fed under a “section” of the Mental Health Act.


After intensive treatment, a sufferer may find it helpful to join a self-help group in the community. The Eating Disorders Association has a register of self-help groups throughout the country. The organization runs a telephone support line, gives support and advice to carers and runs an informative website. Overeaters Anonymous run self-help groups for sufferers with all manner of eating disorders nationwide.


HOW DOES THE PSYCHIATRY RESEARCH TRUST HELP?


Eating disorders can affect ANYONE. No one is exempt; even the most unlikely and strongest of people. The initial euphoria, secrecy and captivation are electric and feel like the sufferer’s only way to cope with life. But, the destruction, the pain and the loss are only too quick, too great and too devastating. The gaining of weight or relinquishing of unhealthy behaviours and the return to life is a slow, long, arduous struggle full of emotional turmoil.

The profound distress caused, not only to eating disorder sufferers but also to their friends and family, has led The Eating Disorders Research Unit at the Institute of Psychiatry to dedicate its studies solely to investigating all aspects of disordered eating. The aim of the Unit is to build a causal model for eating disorders, taking into account family, psychological, behavioural and personality factors. Ultimately, the Unit intends to use this knowledge to influence and improve the treatment and recovery outcome of eating disorder victims.

In pursuit of this goal the Eating Disorders Unit is greatly helped by the financial support provided by the Psychiatry Research Trust.


Dr Anna Crane BSc (Hons) London, King’s College London
Mckenzie Cerri, London
Professor Janet Treasure PhD FRCP FRCPsych, Director Eating Disorder Unit


See also “Could this be an Eating Disorder? Information for Carers”
April 2012

Charity No 284286



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