Eating disorders

What is an eating disorder?

Eating disorders are psychological conditions that compel sufferers to make abnormal choices involving food, in a way that is damaging to their physical health. They commonly involve denying your body the calories it needs to properly function or eating excessively, on a regular basis.

Anorexia nervosa and bulimia nervosa were previously the only eating disorders recognised by major health boards. However, binge eating – where an individual feels the urge to overeat regularly – is now recognised as its own disorder.

In the UK, the National Institute for Health and Care Excellence (NICE) also uses the term ‘atypical eating disorders’ to recognise harmful eating patterns that do not fit within a diagnosis of those mentioned above. The mortality rate for individuals with eating disorders is higher than those with other mental illnesses. 1 in 5 die from physical complications of an eating disorder or from suicide related to an eating disorder. If you suspect you have an eating disorder, it is vital you seek help. Eating disorders can vary in severity and may present different symptoms in different individuals. It is therefore important you don’t overlook symptoms just because they differ from someone you know.

Are there different types of eating disorders and what are their signs?

Categories of eating disorder officially used by healthcare professionals in the UK include anorexia nervosa, bulimia nervosa, and binge eating disorder. A fourth category, used for individuals who have a mix of symptoms that don’t exactly match one of the above disorders, is atypical eating disorders. It is possible for an individual to experience different eating disorders that arise at different times. For instance, bulimia can develop from an anorexia diagnosis, or atypical eating disorder can evolve from anorexia.

Modern ideas around food and eating have also prompted a surge in what seem like new eating disorders. These include terms such as othorexia nervosa (an obsession with healthy or ‘pure’ foods), compulsive overeating (over bingeing on far more food than needed), anorexia athletica (an addiction to burning off calories through exercise), and night eating disorder (consuming food mostly at night.) If you are wondering 'do I have an eating disorder?', below are some general signs.

General signs of an eating disorder

There are some consistent symptoms across almost all eating disorders.

Behavioural signs that indicate an eating disorder include:

▪ Obsessive thoughts about food, body weight, or body shape

▪ Viewing food or the body as something that can be ‘controlled’

▪ Distorted body image (e.g. believing you are overweight when your weight is normal or underweight)

▪ Repetitive weighing of self in fear of weight gain

▪ Obsession with image (e.g. looking in the mirror often)

▪ Discomfort when eating in public

▪ Hiding food

▪ A tendency to lie about what you have eaten or your eating habits

▪ Enjoying making food for others but not for yourself

▪ Social withdrawal from family and friends

▪ Punishing yourself for not losing weight

▪ Constant self criticism

▪ Underestimating your problem, even after diagnosis

▪ Habits of self-harming

Physical signs of an eating disorder include:

▪ Sudden changes in weight

▪ Depression and low self-esteem

▪ Moodiness and irritability

▪ Tiredness, with a lack of concentration or focus

▪ Lack of libido

▪ Sleeping issues, e.g. insomnia

▪ Dizziness

▪ Stomach pain

▪ Weakness or loss of strength

▪ Amenorrhea (menstruation halts or becomes very irregular)

▪ Oedema (swelling of hands, feet, and/or face)

Anorexia Nervosa is when someone keeps their weight low by obsessively restricting the amount of food they eat, keeping their weight low through dieting.

Additional symptoms to those above include:

▪ Only eating low calorie food or drinks, counting calories obsessively

▪ Fearing fattening foods

▪ Use of diet pills, appetite suppressants, and/or laxatives

▪ Pretending you have eaten when you haven’t

▪ Believing you are overweight when you are underweight

▪ Often skipping entire meals

▪ Cutting up food into small pieces and pushing it around your plate instead of eating it

▪ Obsessive behaviour (possible OCD)

▪ Punishing yourself for not losing weight

▪ Coldness, low body temperature

▪ Hair falls out on head but fine downy hair grows all over body

Bulimia Nervosa (Bulimia)

Bulimia is when someone is trapped in a cycle of eating large amounts of food before purging in an attempt to not gain weight. This can be done via induced vomiting, laxative or diuretic use, over-exercising, or performing enemas.

Additional symptoms to those above include:

▪ Bingeing (consuming large amounts of food)

▪ Purging after eating (e.g. vomiting, over-exercising, using laxatives)

▪ Being secretive about food habits

▪ Fluctuating weight

▪ Organising your life around buying food, eating food, purging food

▪ Feeling guilty, ashamed, or out of control

▪ Continual anxiety and tension

▪ Lethargy

▪ Gastric problems (e.g. constipation, bloating)

▪ Callouses on your hand from using it to vomit

Binge Eating Disorder

There are similarities between Binge Eating Disorder and Bulimia, with both involving an individual overeating a large amount of food. However, it doesn’t then involve purging to keep your weight under control. You are likely to receive a diagnosis if you bing eat at least once per week for three months or more.

Symptoms of Bing Eating Disorder can include:

▪ Ritualistic eating where a binge is planned and certain foods are purchased

▪ Eating far more quickly than usual

▪ Bingeing secretly or in private

▪ Eating when not hungry

▪ Feeling of ‘zoning out’ when bingeing and ‘coming to’ afterward

▪ Extreme guilt over binge episodes

▪ Often involves issues with being overweight

Atypical Eating Disorders

Atypical disorders - also known as ‘eating disorder not otherwise specified’ (EDNOS) - is a diagnosis given in the following situations:

▪ You don’t quite meet a diagnosis for Bulimia or Anorexia

▪ You don’t have symptoms of both disorders

▪ You have disordered eating habits that don’t officially match recognised disorders

Sometimes a diagnosis of an atypical eating disorder can be based on something very small, such as your body weight sitting just above the threshold of anorexia, or that your purging habits are not quite frequent enough to warrant a bulimia diagnosis. Remember, diagnostic terms are created as shorthand for doctors to use, and being diagnosed with an atypical eating disorder is just as serious as any other eating disorder diagnosis. What matters most is not your exact diagnosis, but recognising you have a serious problem with eating that is threatening your life and requires treatment.

The term ‘eating disorder not otherwise specified’ (EDNOS) is more commonly used in America and is no longer an official medical diagnosis. A feeding or eating disorder that causes great distress but doesn’t meet the criteria for diagnosis of a recognised eating disorder is now termed as ‘other specified feeding or eating disorder’ (OSFED). This term includes purging disorder (attempting to reduce caloric intake via vomiting, medications, or over-exercising, but not bingeing beforehand) and night eating syndrome (consuming 25% or more of your daily calories in the evening).

How common are eating disorders?

It is estimated 725,000 people in the UK suffer from an eating disorder of some kind.

While eating disorders have been popularised as a form of psychological illness affecting teenage girls, NICE statistics estimate males contribute to 11% of those living with eating disorders in the UK. This trend is particularly present in adults. Of the 7% of adults who develop an eating disorder in the UK, 25% of these adults are male. Eating disorders can also develop at any age. Anorexia nervosa has been recognised in children as young as seven years-old, as well as senior citizens.

The most common types of eating disorders are atypical eating disorders, accounting for 50% of all reported eating disorders. By comparison, bulimia nervosa accounts for 40% and anorexia nervosa for 10%. Bulimia nervosa typically develops at a slightly older age than anorexia, and adults are more prone to binge eating than other groups.

What causes eating disorders?

The development of an eating disorder is usually complex and can involve a number of different factors. Some of these factors can include negative life experiences, learned behaviour, genetics, negative relationships, society and culture. A number of possible casual factors can be seen to lead to the development of anorexia and bulimia. A combination of these factors commonly occur.

Our Experiences

Studies have uncovered that, like many other mental health conditions, the development of eating disorders can be linked to past experiences. Negative experiences in childhood and adolescence can have a particularly negative lasting effect on us.

Stressful life events and trauma can also be linked to eating disorders. Links have been found between difficulties in family relationships and the developments of eating disorders, placing much importance on creating positive and healthy family relationships while young to aid our emotional and mental health development.

Someone who has experienced negative relationships or stressful life events can feel a lack of control in their life. When someone feels that something in their life is out of control, this can become difficult to deal with emotionally. One way of seemingly gaining some control back is through the control of our own weight and body. This is something that other people don’t have power over; therefore controlling our weight can be used as a way of feeling in control more generally.

Negative Feelings

Many individuals will use food as a way of dealing with their negative emotions. For example, an individual experiencing Binge Eating Disorder can often have thoughts such as, “I will feel better if I eat something.” However, this can be a short term fix and sufferers can be left with more negative feelings after their binge and further negative consequences from overeating.

Common emotions that can trigger binge eating include; depression, anxiety, stress, boredom, loneliness, and low self-esteem/self-worth. Sufferers of binge eating may fall into patterns and habits of eating that can be difficult to break, with some likening their disorder to an addiction.

Genetics/Learned Behaviour

Research has uncovered that eating disorders can be found to run in families, and it is not known whether or not genetics or learned behaviour is the reasoning for this. Results of studies support both suggestions.

If a child observes a parent using food to cope with emotions, they may be more inclined to copy this behaviour. Many parents also reward children with food, which can enforce unhelpful ideas around food from a young age.

Abnormalities in certain regions within the brain (e.g. the hypothalamus) may also affect our appetite and have some impact.

Societal and Cultural Influences

The pressures of society and the media can influence us. Many young people (particularly females) may experience pressure to be slim from sources such as peers, friends, siblings, cultural background, websites, magazines, film, and music. Certain professions may also lead to pressure to be slim, with eating disorders found in high prevalence in professions such as dancers, models, or athletes.

Misunderstandings and stigma

It can be difficult to understand eating disorders, with many of their symptoms going against our natural instincts. The friends and family of a person suffering from an eating disorder can often become frustrated and worried due to misunderstanding such conditions. Many people assume that those with anorexia or bulimia are ‘attention seeking’ or ungrateful for food. Those suffering from binge eating disorder may be seen as being ‘greedy.’

Eating disorders are complex and overcoming one can be extremely difficult, thus falsified beliefs are unhelpful for an individual’s recovery. Many individuals will require specialist psychological support to change their behaviours and overcome underlying issues. An empathetic, considerate approach can help us better understand the problems faced by individual sufferers.

What are the diagnostic criteria?

Anorexia Nervosa

Within the DSM-5 criteria, a diagnosis of Anorexia can only be made when an individual displays:

▪ Persistent restriction of energy intake leading to significant low body weight (in context of what is Persistent restriction of energy intake leading to significantly low body weight dependent on sex, age, physical health, and development.)

▪ Either an intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain (even though significantly low weight)

▪ Disturbance in the way one’s body weight or shape is experienced, undue influence of body shape and weight on self-evaluation, or persistent lack of recognition of the serious of the current low body weight.

There are two subtypes of Anorexia Nervosa:

Restricting – When an individual restricts their food intake.

Binge eating/purging – When an individual restricts their food intake but also regularly engages in binge eating and purging behaviours.

Bulimia Nervosa

Within the DSM-5 criteria, a diagnosis of Bulimia can only be made when an individual displays:

▪ Recurrent episodes of binge eating

▪ A sense of a lack of control over eating during the episode

▪ Recurrent inappropriate compensatory behaviour in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics or other medications, fasting or excessive exercise

▪ Binge eating and inappropriate compensatory behaviours occurring on average at least once a week for three months

▪ Self-evaluation which is unduly influenced by body shape and weight

▪ Disturbance which does not occur exclusively during episodes of Anorexia Nervosa

Binge Eating Disorder

Within the DSM-5 criteria, a diagnosis of Binge Eating Disorder can only be made when an individual displays:
▪ Recurrent episodes of binge eating (at least once a week for three months)

▪ Binge eating not associated during the course of Anorexia Nervosa, Bulimia Nervosa, or with the recurrent use of inappropriate compensatory behaviours such as self-induced vomiting

▪ A sense of lack of control about eating during the episode

▪ Marked distress about binge eating

Episodes of binge eating are commonly associated with three or more of the following:

▪ Eating far more rapidly than usual

▪ Eating until feeling uncomfortably full

▪ Eating large amounts of food despite a lack of physical hunger

▪ Eating alone because of feelings of embarrassment

▪ Feelings of disgust, depression or guilt after bingeing

What could happen if an eating disorder is left untreated?

It is beneficial to see a therapist if you have an eating disorder. Eating disorders can lead to significant consequences for our health, relationships, occupation, and everyday functioning. If you are suffering from an eating disorder, you should seek professional help and begin treatment immediately. If an eating disorder is left untreated, the worsening of symptoms and the development of further mental health problems, such as depression, become a key risk. An individual’s relationship with food is also likely to become more complex and thus difficult to change. Underlying issues surrounding the eating disorder will also likely remain unresolved without treatment.

Anorexia and Bulimia often affect the body negatively. Those suffering from Anorexia are likely to experience the adverse effects of malnutrition without treatment. If the body lacks the energy it requires for survival, energy will then be sought from the muscles and eventually the organs.

Other health consequences include reduced muscle and tissue mass, decreased mobility, chemical imbalance, higher risk of heart failure, chest infections, breathing difficulties, acute kidney failure, liver damage, fertility problems, osteoporosis (bone weakness), risk of hyperthermia, and a lower recovery rate from wounds and infections.

Anorexia sufferers can also develop Lanugo, a layer of soft fine hair that may begin to grown all over the face and body. This occurs as a consequence of malnutrition, with the body attempting to keep warm when lacking the fat needed to accomplish this. Dryness of the skin can also occur, and individuals may feel dizzy or faint due to malnutrition and dehydration. Individuals may be taken into hospital for treatment of malnutrition depending on its severity.

Anorexia can sometimes prove fatal and has the highest mortality rate of any psychiatric disorder in adolescence.

Bulimia sufferers are likely to develop significant problems with their oral health, including halitosis (bad breath) caused by frequent vomiting. Excessive vomiting may also lead to swelling in the cheeks. Misuse of laxatives can also damage muscles and nerve endings within the bowel, which can result in chronic abdominal pains and constipation.

The effects of obesity (a body mass index of 30 or above) can be serious and sometimes fatal for those suffering with Binge Eating Disorder. Other consequences include sleep apnoea, breathing difficulties, gallstones, high blood pressure, heart disease, high cholesterol, type-2 diabetes, joint and muscle pain, osteoarthritis, gastrointestinal issues, and certain types of cancer.

What should I expect from treatment?

Like with most mental illnesses, treatment and recovery for eating disorders takes time. Receiving the right treatment can bring positive results and allow individuals to lead a happier and healthy life without the anxieties and problems of an eating disorder. These improvements can stretch across various life areas.

You may undergo an initial assessment to explore the eating disorder and its development. During therapy, you will work together with a therapist to overcome any underlying issues and establish better coping mechanisms.

Further advice

When aiming for recovery, it is recommended that individuals make small steps. It may be that you slowly begin to change your behaviour; for example, trying new foods, weighing yourself slightly less, eating slightly more, and speaking to someone when you feel low. Eating disorders can involve dishonesty, so it is therefore important to be open and honest not only to those people trying to help you but also to yourself.

After treatment, many can experience some of the symptoms of their eating disorder but to a lesser extent. Many symptoms will go away over time, but issues such as Orthorexia (a fixation with food content to lesser degree than someone with Anorexia or Bulimia) and a continually complicated relationship with food may still persist.

If you notice that some symptoms and signs of an eating disorder still persist or re-emerge at any point then consider seeking further support.

The following are some suggested first steps for those looking to begin recovery:
▪ Keep a food diary and record your food consumption. Looking back on this can help you identify existing patterns and may motivate you to change your behaviour.

▪ Try to do something else when you are feeling depressed, anxious, or stressed. Speak to someone, call a helpline, read a self-help book, or practice self care.

▪ Exercise. This can help with weight loss (if needed) and can boost your mood. Exercise releases endorphins within the brain, helping us to feel happier.

▪ Try sticking to three meals per day and avoid snacking.

▪ Choose healthy food and drink options rather than make unhealthy choices.

▪ Try stress management techniques such as meditation, breathing exercises, having a bath, or listening to music.

▪ Listen to your body. This will you to better understand when you are hungry or not and you will only eat when you are genuinely hungry.

▪ Keep yourself occupied to deal with feelings of boredom.

▪ Seek help from others.

Recommended treatments for Anorexia and Bulimia

Research has show that psychology-based treatments are often the most successful in treating eating disorders. While some medications can reduce associated symptoms, such as depression, some suggest that they often do not alleviate the problem and are thus not effective treatment exclusively. Therapy aims to improve an individual’s understanding of their eating disorder, its development, and how to manage it effectively. A better understanding of ourselves can help us move towards recovery.

Cognitive Behavioural Therapy (CBT) is a talking therapy that can assist in the treatment of Anorexia and Bulimia. Cognitive Behavioural Therapy helps you to learn to recognise negative thoughts associated with your eating disorder before challenging them and replacing them with more helpful thoughts. As our thoughts affect the way we feel and behave, positively changing the way we think can then lead to positive changes in our feelings and behaviour.

Psychotherapy and counselling can address the underlying casual factors of the eating disorder. Exploring how and why the eating disorder has developed can be a useful tool to help individuals overcome it. Psychotherapy can help individuals to cope with their past experiences and any negative emotions they may be experiencing.

As eating disorders can often be influenced by and have an impact on families/carers, interventions may be more effective when we include those around us. Educating both the individual with an eating disorder and other people in their life can lead to a collective understanding of the condition, improving the likelihood of working together towards recovery. Family/systemic therapy may also benefit individuals with an eat disorder, helping to explore relationships and dynamics within their family and work on improving them to positively aid recovery. The unique circumstances of each individual will ultimately influence which treatment method is most suitable.

What support is available? Where can you start to get help?

It is important to acknowledge that recovery from an eating disorder can be a long process that often requires support from others.

Some helpful websites include:
▪ ‘B-eat’

▪ NHS Online

▪ MIND: The mental health charity

Some helpful telephone numbers and email addresses include:
▪ The B-eat Adult Helpline – 0845 634 1414, or email: help@b-eat.co.uk.

▪ The B-eat Helpline for Under-25s (Youthline): 0845 634 7650, or email: fyp@b-eat.co.uk.

▪ Eating Disorders Support: 01494 793 223

There are many counselling and therapeutic services and organisations available. There are also many trained professional who will be able to support you, including counsellors, psychotherapists, psychologists, and psychiatrists. Here are details of some available services:

▪ The NHS – see your General Practitioner and ask for a referral to see a specialist.

▪ Charities (B-eat, MIND, Rethink, Young Minds, The Mental Health Foundation) – some charities may provide support groups, therapy, and advice in your local area. See their websites for further details.

▪ Private Counselling and Psychotherapy Clinics and Services.

There are many therapists and counsellors with experience treating anorexia, bulimia and other eating disorders. At Prohealth Therapy, we vet our therapists to ensure that they are registered and insured to practice as a therapist in the UK. We check that they are registered members of UK professional bodies, to ensure that all of our therapists have completed the professional training necessary to work as a licensed practitioner.