There are few conditions that attract as much media attention as eating
disorders, and yet there are many misconceptions surrounding the whole
area of food and eating. While there is still a great deal to learn about
the factors regulating normal eating behaviour, we know that the desire
to eat, and the feelings of being hungry and satisfied are affected by
a complex interplay of physiological, psychological, and social factors.
At times of stress and illness it is quite normal for this delicate
mechanism to be disrupted, leading to a short-term loss or gain in
appetite which normalises once the stress has passed. Similarly, it
is quite normal to alter your intake of food voluntarily for a limited
period of time so as to lose or gain weight.
In certain individuals, however, food and eating assume an abnormal significance,
and rather than eat in response to hunger or appetite, such people use
eating or not eating to help block out painful or uncomfortable thoughts
and feelings. While physiological factors may play a part in predisposing
a person to developing and/or maintaining an eating disorder, it should
be stressed that eating disorders are primarily mental illnesses, with
serious physical and psychological consequences, which can continue for
many years if left unchecked. An eating disorder disrupts every aspect
of the sufferer's life (personal, emotional, social, sexual, occupational
etc) and that of close family and friends, and can be fatal.
"An eating disorder is a way of coping with life and yourself.
At the same time it allows you to avoid both"
"It is a way of life - an all embracing obsession with food which
destroys your life and those involved closely with you"
"A constant preoccupation with food and weight. An imaginary
and false escape from loneliness. A denial of one's need for love and
affection. A shrinking of everything - body, mind, horizons, trust, love,
hope"
Eating disorders fall into a number of different categories depending
on the behavioural and physical characteristics:
- Anorexia Nervosa
- Bulimia Nervosa
- Binge-eating Disorder
- Eating Disorder Not Otherwise Specified (ED-NOS)
- Other eating disorders including
- Compulsive (over)eating
- Compulsive Exercising
- Body Dysmorphic Disorder
- Night Eating Syndrome
- Sleep Eating Disorder
- Pica
- Prader-Willi Syndrome
Back to questions
Is Anorexia a 'slimming disease'?
While the development of anorexia or bulimia is sometimes preceded by
dieting behaviour, both illnesses are much more than just being on a
diet. Eating disorders are serious mental illnesses which pervade all
aspects of life of the sufferer and have profound physical and psychological
effects on sufferers and those around them.
The McKnight Foundation has produced a newsletter with information
for parents who may have concerns about weight/shape/appearance issues
and their adolescent daughter. Click here to
view the newsletter.
Is Anorexia just a phase that you can grow out of?
People with anorexia rarely just 'grow out of it'. Once the illness
takes hold, anorexics are often is such a deep state of denial of the
amount of weight loss and its physical and psychological consequences,
and are so afraid of gaining even the smallest amount of weight, that
they are terrified of seeking treatment. However, left untreated, anorexia
can continue to dominate the life of the sufferer indefinitely, and in
around 10-20% of cases is fatal.
Back to questions
Why do people with eating disorders have so much trouble getting help
from GPs?
This is a common question and it was than was raised by people with
anorexia nervosa and their carers in the National
Institute of Clinical Excellence (NICE) guidelines on eating disorders.
Engaging with primary care:
- GPs may think issues and symptoms are trivial, partly because they
often have little experience
of eating disorders
- A GP's inexperience and lack of training in eating disorders can
lead to a delay in diagnosis
- Pathways between primary and secondary care are slow and fraught
with obstacles, including lack of choice
- There are often difficulties in receiving information and effective
communication particularly in relation to the treatment of poorly motivated
adolescents
Within the NICE guidelines there is a section for recognition and assessment
in primary care. One problem that is highlighted is that most often in
primary care the cases do not meet all the classical diagnosistic criteria
and there is also a large amount of "noise" with many of the
population (over 50%) with some sort concern about their weight and on
diets. Thus sorting out signal cases from noise is not easy especially
when classically people with an eating disorder down play their symptoms.
This problem has been recognised within the guidelines and the suggestion
is that it is important to consider the time course. Thus if eating disorders
is a possible diagnosis or if parents are very concerned make a second
appointment in a month (and keep under review).
Here is the good practice point from NICE;
In assessing for anorexia nervosa attention should be paid to the overall
clinical assessment, repeated over time, including rate of weight loss,
objective physical signs and appropriate laboratory tests. (GPP)
Back to questions
"My doctor said he did not consider me to be a 'proper anorexic'
and because of this I cannot get help."
We often find that there are many barriers to getting help. It is of
concern if the problem is dismissed. It is the norm rather than the exception
for people presenting in general practice not to present as the classic
textbook case. Such cases now have a name EDNOS eating disorder not otherwise
specified. It is so important that these cases can be picked up as they
represent the opportunity to administer an early intervention. There is
evidence that treatment early improves outcome and so it is important
to detect people in the early phase of their illness. (We already have
some tools to help such case in the form of books
which can help them and their family manage their illness (Treasure
& Scmidt) and there are projects afoot to be able to get information
that can be more tailored for the individual by using a CD ROM).
If people with anorexia nervosa meet such a response it often makes people
even determined to lose so much weight that they get really ill in the
hope that treatment will be forthcoming.
People with anorexia nervosa
are usually very ambivalent about their need for help and this just
adds to their problems. Often people with anorexia nervosa say they feel
like a frauds and they worry that they are wasting people's time.
We have also had people reporting the opposite problem i.e. that the
person with anorexia nervosa is too ill for treatment! This rather ridiculous
reply comes about because some treatment centres may not be able to provide
high intensity care. It represents a lama table fragmentation of services.
Back to questions
How common are eating disorders?
While anorexia is the illness that tends to receive the most media attention,
bulimia is far more common, affecting around 1%-2% of women aged between
15 and 40 years of age. Anorexia is estimated to affect between 1 and
5 women in every 100,000, normally developing in the teenage years. Around
5% to 10% of all cases of anorexia are boys.Fore more information about
prevalence rates of eating disorder cases in the general population click here.
Back to questions
Who
develops eating disorders?
Eating disorders can affect anyone regardless
of age, race, gender or background. However, young women are most vulnerable,
particularly between the ages of 15-25 years. However, Anorexia Nervosa
can occur in children as young as 7years of age. There is a greater
proportion of males in the younger age group (young Male:Female 1:3 vs
adolescent M:F 1:10). Excessive exercise rather than extreme food restriction
may be the way that Anorexia Nervosa normally presents in adolescent
males. Older women (over 30) can develop a syndrome of extreme weight
loss with pronounced depressive features. They can usually provide no
explanation for their weight reduction, but family members observe that
they eat very little. Sufferers may deny that they want to be thinner
and say they are trying to gain weight. However, the attitude to food
and eating is frequently distorted. Often these women have had to face
severe stress such as the loss of close family members.
Back to questions
What causes eating disorders?
Eating disorders are complex illnesses with no single cause. Psychological,
interpersonal, socio-cultural and biological factors all seem to play
a role in tipping an individual over the precipice.
"I think it is a varietty of things - there is no one single
cause... the individuals basic make-up, the events in their lives, their
copoing abilities and self-esteem..."
"For me it was a lack of self-esteem and self-worth. I did not
believe I was entitled to eat food , enjoy life, or have anything good
happen to me"
"I believe the scene was being set throughout my childhood, starting
before my birth. Anxiety, a tendency towards obsessionality and perfectionism
made me vulnerable. These traits in combination with my dangerously low
self-esteem, a lack of life skills, a tacit knowledge that my parents
could not allow us to separate, and of course, the over-emphasis at home
on food, all worked together to make me feel I had little choice open
to me than to 'shrink to fit'".
Psychological factors:
Low self-esteem seems to represent a significant risk factor for the development
of eating pathology
Tendencies to be perfectionistic and to set rigid standards for oneself
Depression, anxiety, anger, emptiness or loneliness
Feelings of lack of control in life or feelings of inadequacy
"In response to my parents' need for us to do well at school,
I worked tirelessly for my 'O' levels, and was awarded with eight As.
But paradoxically, this further eroded my self-esteem, making me feel
I could not achieve anything unless it half killed me".
Interpersonal factors:
Difficulty expressing one's feelings and emotions
Family disharmony and troubled interpersonal relationships
A history of being ridiculed based on size or weight
A history of sexual and/or physical abuse
Family factors such as obesity in the family, parental preoccupation with
eating and weight, unrealistic expectations for achievement
"A breakdown of communication with others, being unable to express
your traumas, worries and fears"
"The need to starve out all traces of adult femininity had its
roots in the way I saw my mother - desexed, deskilled and devalued. Despite
her high education, she was expected to be the housewife - an all-consuming
role which alienated her from so much of herself".
Socio-cultural factors:
Cultural pressures that place extreme value on 'thinness' and obtaining
the 'perfect body'
Cultural norms that place emphasis on physical appearance rather than
one's inner strengths and qualities
Persistent and pervasive media messages encouraging dieting, likely to
lead to high rates of chronic dieting in at-risk groups of adolescents
"Surrounded by the new stick-thin icons of beauty in the late
sixties, I became painfully aware at around the age of seven, that I did
not conform to the ideal, and developed a fixation about my shape, even
though I was within the normal weight range".
Biological and biochemical factors:
Research is still examining potential biochemical or biological factors.
About half the risk of developing anorexia nervosa or bulimia nervosa
is thought to be genetic. For more information about the genetics of eating
disorders click here.
It has been found that some eating disorder sufferers have imbalances
in certain brain chemicals that control hunger, appetite and digestion.
Investigation into the implications of these imbalances is still underway.
Back to questions
What are the associated health risks of eating
disorders?
Can eating disorders cause permanent damage?
How do you treat eating disorders?
Is it possible to fully recover from an eating disorder?
The simple answer to this question is 'yes'. Many people are able to
make a full recovery from their eating disorder, and all the physical,
psychological and social repercussions. However, it is unusual to see
somebody who is able to shake off all their abnormal attitudes to food,
eating and body size, shape. Perhaps this is not surprising, as anorexic
attitudes to food and eating merge into Western cultural attitudes about
health and attractiveness. Even after a 2-3 year period of recovery, relapse
can occur, particularly after stressful events, or if weight loss has
been triggered for any reason. For example, after childbirth, the increased
stress of looking after a new child, combined with the weight changes
after birth, can lead to a relapse. However, people are often aware of
the danger signs and can stop the illness getting a severe grip on them.
It is perhaps important to consider Anorexia as an Achilles' heel that
may return at times of stress. Other people continue to have rather rigid
eating habits and never eat as much or as freely as others.
"It's a hard question. Recovery starts within YOU. You have to
be ready to change, to give up 'some' of the eating disorder. It's like
chipping away gradually"
"I have discovered that staying grounded and well involves a
continual process of awareness, and can so easily be overturned in times
of stress, allowing former unhealthy patterns to emerge".
"While still plagued from time to time by grief over time and
potential wasted, I have begun to see the illness as a necessary part
of my life, creating an opportunity for much greater growth than might
have otherwise occurred".
For more information on recovery from an eating disorder click here.
Back to questions
How long does it take to get over Anorexia?
Many people have unrealistic expectations and think that they can recover
from the illness after a few months. Unfortunately, once eating disorders
have taken hold, one needs to think in terms of years rather than months.
After five years, approximately half the population with Anorexia will
have recovered; 30% will remain quite severely affected by their illness;
and 20% will still be underweight and without their periods.
People who have recovered from eating disorders, often talk of the experience
as a journey, or a long process of change during which they learn new,
healthy coping mechanisms in place of the dysfunctional ones they had
previously relied on.
"Getting better was a journey. It was not a formula, and it has
taken a lot of time".
"There was no overnight cure or quick fix, but a gradual awakening
through a slow and painstaking process, during which I came to learn the
skills I needed to feed myself in different areas of life".
"Through therapy I have been able to overcome many of my problems
but I believe it will always be part of my life to some degree"
"It's amazing how I am moving forward. So much so that I'm shocking
myself. I am beginning, after so long, to realise that I need to be a
normal healthy weight to move on in life"
Back to questions
What are the factors that affect recovery?
Outcome is affected by two key factors:
1. Severity of the illness
The more weight that has been lost and the more extreme the emaciation,
the worse is the outcome;
The longer the illness has gone on before treatment starts;
If the illness has failed to respond to several attempts at treatment.
2. Background vulnerability
Childhood problems such as school refusal and emotional problems;
Difficulty in making friends, severe shyness and alienation;
Difficulties within the family.
Can eating disorders be prevented?
Very little work has been done on the area of prevention, although studies
have been carried out looking at risk factors which might predispose a
person to developing an eating disorder, and the effects of intervention,
to alter these risks. Other studies have focused on early recognition
of the signs and symptoms of eating disorders in order to 'nip' these
in the bud before the eating disorder becomes entrenched. There is considerable
evidence that the earlier treatment begins after onset of an eating disorder,
the more successful will be the outcome.
There is evidence to suggest that a person is more likely to develop
an eating disorder if he/she
Has poor self-esteem
Has a lack of social skills
Has a tendency to avoid difficult issues/interpersonal situations
Has a tendency towards perfectionism
Has been brought up in an environment where food and eating, weight or
body shape have assumed a disproportionate significance
Has experienced overprotective and/or over-controlling child rearing,
where independence has not been encouraged
Has not been encouraged to think for her/himself
Has a tendency to comply to other people's demands
Has been physically or sexually abused
While eating disorders most commonly make their appearance in adolescence
or early adulthood, the seeds are sown much earlier at the biological,
familial and social levels. While it is impossible (at present) to alter
one's genetic makeup or to tackle single-handedly society's distorted
emphasis on appearance, weight and shape, it might be helpful to encourage
young people to critically appraise the messages given out by advertising
and the media, and to develop their own non-competitive values of personal
achievement in different spheres of life. By helping a child to develop
good self-esteem, good social and coping skills, to have a realistic understanding
of boundaries both personal and external, and to encourage independence,
it is possible that parents, teachers or other carers might go a long
way to prevent her/him from developing an eating disorder later on.
Back to questions
References
- Treasure J. Anorexia nervosa. A survival guide for sufferers and those
caring for someone with an eating disorder. Hove: Psychology Press., 1997.
For more information click here.
-
Schmidt, U. & Treasure J. Getting Better Bit(e) by Bit(e) A Survival
Kit for Sufferers of Bulimia Nervosa and Binge Eating Disorders. For more
information click here.
