Eating Disorder Awareness Week – Anorexia, Bulimia & Binge Eating

Eating Disorders – Anorexia Nervosa, Bulimia Nervosa & Binge Eating Disorder

What are they? What are the signs? How are they treated? This week marks Eating Disorder Awareness Week so we have compiled information from the CPsychI Eating Disorder Special Interest Group and BodyWhys to answer these questions and provide helpful resources.

If you or someone you know is affected by eating disorders please visit the BodyWhys website for support and information.

What is Anorexia Nervosa?

Anorexia Nervosa is one particular type of Eating Disorder which negatively affects the person’s relationship with food and body image. It causes the young person to become preoccupied with weight and body shape to the point that weight loss becomes a central feature of life. Thoughts about body shape and about food become distorted by illness and consequently the person has difficulty making any realistic appraisals about food intake or the individual’s own body shape. Behaviour becomes almost solely directed towards the goal of weight loss with previous interests becoming secondary and relationships with friends and family frequently becoming strained as others struggle to comprehend the behaviour.

Distinguishing ‘normal dieting’ from Eating Disorder Symptoms

• Denial of being “on a diet” despite obvious restriction and weight loss; Denial of hunger or craving;
• Claims of needing less food than others;
• Change in food ‘rules’, e.g. vegetarianism, not eating after 6pm; Attempts to hide weight loss, e.g. wearing baggy clothes; Increased interest in food/cooking for others;
• Unusual eating behaviours: eating very slowly, chopping food up into tiny amounts, segregating foods;
• Eating alone;
• Bathroom trips after eating; Ritualised behaviours;
• Social isolation, low mood; Increased exercise.

What signs should I look out for?

• Noticeable weight loss;
• Avoidance of eating with others;
• Meals left unfinished or thrown away;
• When eating, moving food around the plate repetitively or cutting food into very small pieces;
• Using bathroom immediately after eating;
• Excessive exercise, fidgeting, running;
• Frequent excuses to explain not eating;
• Minimisation of weight loss.

What are the effects of Anorexia?

• Low mood; Low energy; Decreased concentration;
• Decreased ability to perform to potential in work environment;
• Loss of confidence;
• Loss of enjoyment of activities;
• Increasing social isolation and avoidance of friends.

Physical Complications:

Cardiovascular: Low blood pressure and heart rate. Changes and abnormalities in heart rhythm. The person may complain of feeling weak, dizzy or faint. Gastrointestinal: Slow stomach emptying, bloating, decreased motility in the gastrointestinal system. These may all lead to a feeling of fullness even after eating only a very small amount. There may also be high cholesterol, and abnormal liver function tests.

Renal: Dehydration, kidney stones, abnormal kidney function tests, passing urine more frequently and ankle swelling.

Haematological: Anaemia. Iron deficiency.

Endocrine: Abnormal thyroid functioning, growth failure, osteopenia, swollen salivary glands and amenorrhoea.

Reproductive: Menstrual cycle disturbance and potential infertility.

Central Nervous System: thinning of the brain, seizures.

Other: Dry scaly skin, Muscle wasting and “lanugo” hair (fine downy type hair) on the face; Increased risk of osteoporosis; Cold extremities; Weakness and fainting.

Is it a serious condition?

Anorexia is a potentially life-threatening condition, particularly if it is left for a long time without being treated. There is a high mortality rate (approximately 5% per decade) both from medical complications and from suicide. Progress in treatment is frequently slow. Approximately 50% recover and one third have chronic symptoms. The earlier treatment is initiated the better.

Can anyone develop Anorexia Nervosa?

Approximately one in a hundred people have Anorexia Nervosa. Anorexia nervosa can affect both males and females of all ages. It is most common amongst girls and young women. Around 10% of people with anorexia are male. Many factors can contribute to making someone more vulnerable to anorexia than another and these factors vary from person to person. Anorexia is not primarily about food and weight issues or about ‘slimming’. As with all eating disorders, the psychological issues and emotional distress underlying the physical symptoms must be addressed for long-term recovery to be possible.

What Causes Anorexia Nervosa?

There is no single cause of Anorexia Nervosa and it is described as ‘multifactorial’ in origin. The person may be predisposed to developing the illness for a number of reasons including individual factors, family factors and cultural factors. Anorexia Nervosa may develop following a ‘normal’ diet which goes out of control. The ‘trigger’ for Anorexia could be one or more of a multiplicity of factors. For example, in a person who is vulnerable to developing an Eating Disorder, the trigger could be a stressful life-event such as work or bereavement or critical comment by a peer about shape and size. The person may experience the control of food intake as helping to minimise the effects of other stresses.

Genetic Factors

Researchers have proven that Anorexia Nervosa has a genetic component. This has been explored by research with identical twins. It has been shown that when one identical twin has Anorexia Nervosa, the other twin is more likely to develop the illness when compared to non-identical twins. This provides proof of the genetic contribution to the development of Anorexia Nervosa, as the greater the genetic similarity the higher the likelihood of developing the illness. There is also an increased rate of Eating Disorder in siblings. Furthermore, parents who themselves have eating concerns may pass this on to children.

Psychological Factors

There are a number of psychological theories that have been proposed to explain the development of Anorexia Nervosa. People who develop Anorexia Nervosa are commonly noted to have perfectionistic traits. A person with Anorexia Nervosa typically bases self-worth on thinness. In the case of children and young adults some theorists have suggested that Anorexia Nervosa develops as a result of the young person’s fear of growing up. This theory proposes that the young person with Anorexia Nervosa prevents sexual development by not eating and consequently maintaining the body in a prepubertal state.

Cultural Factors

As mentioned above, there has been much recent debate in the popular media about the role of the ‘fitness culture’ on social media in precipitating Anorexia Nervosa. St John of God Hospital in Dublin’s Stillorgan has warned of a real increase in young women presenting at the clinic with a real aversion to certain food groups, encouraged by the “healthy, Instagram lifestyle”. In 2016 a review of all studies on social media and its impact on body dissatisfaction and eating disorder behaviours revealed that higher rates of social media use is associated with body image dissatisfaction and disordered eating behaviour. Focus groups conducted with young people by Bodywhys identified social media as the main pressure on body image and self-esteem.

When is Professional Help required?

Because of the nature of the disorder, a person with anorexia may have difficulty admitting to the seriousness of the risks to their physical and their mental health. The prospect of recovery can be very frightening and resistance to treatment is normal. This may have the effect of delaying appropriate treatment and can cause severe distress for carers and family members. Carers should seek information and support for themselves to increase their understanding of the disorder and their ability to help. Attending a support group for family and friends can be helpful.

Treatment

The overall aim of treatment is to:

1) restore a healthy Body Mass Index.

2) change the faulty, maladaptive thinking that is integral to Anorexia Nervosa, for example, morbid fear of fatness, belief that one is fat despite evidence to the contrary.

3) address other non-food/ weight issues such as perfectionism and interpersonal relationship problems.

Some people may require hospitalisation. The time needed for recovery from anorexia nervosa varies according to each individual.The general clinical approach is to encourage a stepwise return to a balanced diet using ‘behavioural’ principles. The person’s target Body Mass Index is calculated as is target daily calorific intake (which increases as treatment progresses). A ‘contract’ is agreed with the person that details rewards which are contingent on successfully reaching an agreed target and consequences for the person if calorific intake is not maintained.

Psychoeducation is a fundamental aspect of treatment. This involves increasing the person’s awareness of the need for regular meals and regular exercise. Providing their family/partner/carer with information on Eating Disorders and the physical, behavioural and psychological effects of starvation is essential.

Cognitive Behavioural Therapy: is also used in the treatment of Anorexia Nervosa. This form of therapy focuses on helping the person challenge beliefs about thinness, body-shape, food and exercise. The person is helped to make links between thinking about food and weight and behaviour, such as restricting food intake. The person is encouraged to see the link between thoughts such as ‘I am fat’ and feeling states such as sadness and to develop alternative strategies to deal with these thoughts.

What is Bulimia Nervosa?

This is characterised by recurrent episodes of binge eating and subsequent inappropriate compensatory behaviour in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, enemas, or other medications; fasting, or excessive exercise.

What signs should I look out for?

• Weight loss or unusual fluctuations in weight;
• Alternating restricted and binge pattern of eating; Large amounts of food disappearing from cupboards;
• Use of bathroom immediately after meals;
• Preoccupation with food.

What are the effects of Bulimia?

• Largely similar to Anorexia Nervosa
• Low mood; Low energy;
• Decreased concentration;
• Decreased ability to perform to potential in work and life environment;
• Loss of confidence;
• Loss of enjoyment of activities;
• Menstrual cycle disturbance and potential infertility; Increasing social isolation and avoidance of friends.

The physical effects include:

Increased risk of osteoporosis; Repeated vomiting can lead to a number of complications. Oesophagitis which is an inflammation of the oesophagus may occur and causes symptoms of heartburn and chest pains. If the vomiting is severe, persistent tears can develop in the wall of the oesophagus leading to bleeding which may be life threatening. Severe vomiting can also result in electrolyte imbalances such as low potassium levels. Electrolyte imbalances can lead to cardiac problems such as abnormal heart rhythms; Calluses may occur on the back of the hands from rubbing on the teeth to induce vomiting; Inflammation of the pancreas leading to abdominal pain may occur The salivary glands can become enlarged and painful; Acid from the stomach may wear away the enamel of the teeth leading to tooth decay and gum disease;

Is it a serious condition?

The overall prognosis for someone with Bulimia is better than for Anorexia Nervosa. Approximately one third of people with Bulimia will remain continuously ill. Relapses are extremely common and occur in approximately 60% of people with Bulimia.  Depression very frequently co-occurs.

Can anyone develop Bulimia Nervosa?

Bulimia Nervosa is more common than Anorexia Nervosa. About 30% of people with Bulimia will have had Anorexia Nervosa. Frequently, people with Bulimia describe a long history of dietary problems. The peak age of onset tends to be later than for Anorexia Nervosa, occurring in late adolescence and early twenties.

What causes Bulimia Nervosa?

As with Anorexia Nervosa, the causes of Bulimia are multi-factorial and similar to those mentioned above.

Biological

Genetic studies have revealed that there is a genetic contribution to Bulimia Nervosa. Chemical transmitters in the brain such as serotonin and dopamine have also been studied and have been found to be lower than the levels found in people without Bulimia.

Psychological

People with Bulimia have been found to show high rates of Depression and alcohol misuse. They also commonly describe feelings of impulsivity and low self-esteem. Occasionally, there is a history of sexual abuse.

Familial

Families of people with Bulimia have been noticed to demonstrate high levels of other mental health difficulties, particularly Depression.

When is Professional Help required?

The effects of bulimia are less apparent than the effects of anorexia. A person with bulimia can maintain a normal weight for their height and they may outwardly give the impression of coping well with life’s challenges. They may put off seeking help and support because they are frightened of the reaction they might get if they disclose what they are doing. Shame and the fear of rejection become powerful barriers to change. Being able to come out of isolation may take time. Recovery can only begin when a person is ready to change. Change can be made easier for a person if those around them inform themselves about bulimia and about how they can offer support and show understanding.

Treatment

As with Anorexia Nervosa, the treatment of Bulimia involves many different therapeutic approaches. Most people with Bulimia can be treated as outpatients. Helping the person to understand the importance of healthy eating with a regular diet is a cornerstone of treatment.

Cognitive Behavioural Therapy can be very helpful in enabling the person to challenge distorted beliefs about food and diet. Overvalued ideas about body shape and weight can be replaced with more realistic and helpful thinking. The person can be helped to understand more about the emotional cues that trigger bingeing and restricting patterns of eating. This awareness can facilitate changes in the person’s relationship to food by generating alternative, healthier responses to situations that would previously have triggered a binge or purge.

Interpersonal Therapy (IPT) may be very helpful in older adolescents where there are often difficulties with relationships.

Medication: Antidepressants such as Fluoxetine can be helpful in the short term both for comorbid depression and reducing binges.

What is Binge Eating Disorder?

Binge eating disorder (BED) is characterised by periods of binge eating or overeating. The person affected by BED may diet frequently, however they will not engage in purging behaviour after a binge. Over time this can, but may not always, result in significant weight gain.

Binges almost always occur in secret, and an appearance of ‘normal’ eating is often maintained in front of others. The food that is eaten is usually filling and high in calories. It tends to be food that people regard as fattening, and which they are attempting to exclude from their diet. The food is usually consumed very quickly, and is seldom tasted or enjoyed.

While in binge eating disorder there is no purging, there may be sporadic fasts or repetitive diets, and often feelings of shame or self-hatred surface after a binge.

A person affected by binge eating disorder may find themselves trapped in a cycle of dieting, binging, self-recrimination and self-loathing. They can feel particularly isolated which can contribute to the prolonging of their experience.
What signs should I look out for?

• Out-of-control eating
• Eating more than the body needs at any one time
• Eating much more quickly than usual during bingeing episodes
• Eating until uncomfortably full
• Eating large amounts of food, even when not hungry
• Eating alone (often due to embarrassment at amount of food being eaten)

What are the emotional and psychological effects of Binge Eating?

• Feelings of inadequacy and worthlessness
• Feelings of guilt and shame
• Depression and related symptoms
• Low self esteem
• Dissatisfaction with body image
• Feeling out of control
• Anxiety

What are the physical effects of Binge Eating?

• Significant weight gain
• Digestive problems
• Joint and muscular pain
• Breathlessness
• Poor skin condition

Is it a serious condition?

Binge Eating disorder is a serious mental health condition. Obesity is a weight classification – a symptom – which may occur as a result of binge eating disorder. While many of the health consequences associated with binge eating disorder are directly related to obesity, it is important to maintain a distinction between this symptom and the disorder itself.

Binge eating disorder has a significant impact on the physical, as well as the emotional, health of the person affected.

Health consequences may include:

• Digestive problems such as bloating, stomach cramps, constipation or diarrhea;
• Malnutrition because of the quality of foods consumed (high in fats and sugars, but lacking in vitamins in minerals)

Where significant weight gain occurs, related health consequences may include:

• High blood pressure;
• High cholesterol levels;
• Heart disease;
• Diabetes;
• Gallbladder disease.

Most physical symptoms can be reversed with weight loss and normalisation of a balanced diet and eating habits.

Can anyone develop Binge Eating Disorder?

Binge eating disorder is almost as common among men as it is among women, and is thought to be more common than other eating disorders such as Anorexia Nervosa and Bulimia Nervosa.

What causes Binge Eating Disorder?

Psychological factors:

• Low self-esteem, poor body image
• Depression, anxiety, anger, loneliness
• Feelings of ineffectiveness and/or a lack of control over life
• Perfectionist tendencies and thought patterns
• Difficulty expressing emotions and feelings in daily life

Socio-cultural factors:

• Narrow definitions of beauty that include only women and men of specific body weights and shapes
• Cultural norms that value people on the basis of physical appearance, and not inner qualities

Familial factors:

• Genetic factors
• Familial disharmony, which can cause insecurity and emotional distress
• Familial problems around conflict management and negotiation of needs
• Traumatic experiences such as sexual, physical and/or emotional abuse
• Loss of a significant family member through death, separation, illness or alcoholism

Dieting

The single most important precipitating factor in binge eating is a period of dieting. Here, a combination of physical and psychological factors might be involved. When your body is in starvation, it will give you strong cravings for food because it is not getting enough nutrition. Psychologically, dieting and preoccupations with food may raise the risk of loss of control. This happens when a minor slip from a person’s stringent diet causes them to abandon the diet completely and to overeat instead.

People with BED are often stuck in a vicious cycle of dieting and bingeing. Underlying this is a profound lack of self-esteem. This leads vulnerable people to be extremely concerned about their shape and weight, about how they are viewed by others, and can drive them to go on strict diets. The dieting then encourages overeating through both physiological and psychological mechanisms. The bingeing causes guilt and to compensate, people diet again. The only way to break this cycle is to stop dieting.

When is Professional Help required?

People often try to control Binge Eating Disorder on their own, and if they fail they may feel demoralised and depressed. This may lead to further episodes, and consequent feelings of social isolation, missing work, school, etc.

More often than not, people who experience BED will need the help and support of a health care professional.

Treatment

• Consultation with a General Practitioner is an important first step towards self-care.  The GP will look at the physical effects of binge eating and, if necessary, can make a referral to a dietician or to a psychologist or a therapist.
• Individual psychotherapy and family therapy can be useful in addressing the psychological and emotional issues that may be underlying the disorder.
• Cognitive behavioural therapy (CBT) teaches people to look at their unhealthy patterns of behaviour and how to change them.

For change to occur and to be lasting, a recovery approach which tackles both the physical and psychological aspects of the disorder will be required.

Resources

Bodywhys

PO Box 105, Blackrock, Co.Dublin

Local Helpline: 1890 200 444

Email: info@bodywhys.ie

Website: www.bodywhys.ie

Eating Disorders Association

103 Prince of Wales Road

Norwich NR1 1DW UK

Email: info@edauk.com

Website: www.edauk.com. This is the leading UK website for people with eating disorders and their families. Postal address: Beat, 103 Prince of Wales Road, Norwich, NR1 1DW, United Kingdom.

YoungMinds

102-108 Clerkenwell Road, London EC1M 5SA

UK

Patient’s Information Service: (UK) 0800 018 2138

Website: www.youngminds.org.uk

National Institute for Clinical Excellence

Midcity Place,

71 High Holborn

London

WC1V 6NA

Email: nice@nice.hns.ie

Website: www.nice.org.uk

Books

• Eating disorders: a parents’ guide. Rachel Bryant-Waugh and Bryan Lask (2004). Brunner Routledge.
• Breaking free from anorexia nervosa: a survival guide for families, friends and sufferers Janet Treasure (1987). Psychology Press.
• Getting better bit(e) by bit(e): survival kit for sufferers of bulimia nervosa and binge eating disorders. Ulrike Schmidt and Janet Treasure (1993). Lawrence Erlbaum
• Anorexia nervosa: the wish to change. A.H. Crisp et al (1996). Psychology Press.
• Overcoming Binge Eating. Christopher G. Fairburn (1995).Guilford Press.
• Bulimia Nervosa: a guide to recovery. Peter J. Cooper (1993). Robinson Publishing.
• Anorexia nervosa and related eating disorders in childhood and adolescence 3rd edition. Bryan Lask and Rachel Bryant-Waugh (2007). Routledge.
• Treatment manual for anorexia nervosa: a family-based approach. James E. Lock (2002). Guilford Press
• Just take a bite. Lori Ernsperger and Tania Stegen-Hanson (2004). Future Horizons

The following two publications are available from:

Royal College of Psychiatrists Research Unit

4th Floor Standon House

21 Mansell Street, London E1 8AA

Tel: 020 7977 6655

Web: www.focusproject.org.uk/publications

Eating problems in children: Information for parent(s). Claudine Fox and Carol

Joughin (2002).

Childhood-onset eating problems: findings from research. Claudine Fox and Carol

Joughin (2002)

References

McNicholas F, Lydon A, Lennon R, Dooley B (2009) Eating concerns and media influences in an Irish adolescent context Eur Eat Disord Rev 17(3):203-13