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An eating disorder is a mental illness, which means that an individual will have a very complex relationship with food that is likely to be out of control. Eating disorders can lead to other mental illnesses such as stress, anxiety, depression and phobias. People will commonly experience at least one of these alongside a diagnosis of an eating disorder.
Unlike some mental illnesses, eating disorders can have a serious effect on an individual’s physical health as well as their mental health, and for this reason early identification of the signs of an eating disorder is beneficial in being able to treat it successfully. It is estimated that in the UK, approximately 1.6 million people live with an eating disorder. Of these, it is estimated that up to 75% are female and 25% are male. However, this figure is likely to be higher because many cases of eating disorders will go undetected and therefore undiagnosed.
The Diagnostic and Statistical Manual for Mental Disorders (DSM) defines each individual type of eating disorder separately and, as such, does not provide a general definition for this type of mental illness. However, the Cambridge English Dictionary defines an eating disorder as: “a mental illness in which people eat far too little or too much food and are unhappy with their bodies.”
Types of Eating Disorders
It is a common mistake for people to think that there are only three types of eating disorder because these may be the ones that they have heard of the most in the media:
- Anorexia nervosa
- Bulimia nervosa
- Binge eating disorder (BED)
These are the ones that will be specifically focused on for the content of this unit; however, it is worth knowing that there are other types of eating disorder that are not as well known:
- Pica: Where an individual feels a compulsion to eat unusual substances such as foam or soil
- Rumination disorder: Where the individual will not swallow food and spits it out after chewing it
- Avoidant/restrictive food intake disorder: Where the individual has a general issue with food not caused by a medical condition, which means that they do not have enough nutrients in their diet
Believed to be the most common of eating disorders, anorexia nervosa (literally meaning ‘loss of appetite through nervous origins’) is characterised by an individual trying to keep their body weight as low as possible by dieting, vomiting, exercising excessively or using laxatives. How they see their own body is often in contrast to what it actually looks like; people who have anorexia will commonly complain that they are too fat when, in fact, their weight is dangerously low.
Someone will be diagnosed as anorexic if their body weight is more than 15% lower than it should be for their height, sex and age. They will also have a BMI measurement of 17.5 or less, where the measurement for someone of average weight should be around, but under, 25. Women will mostly be affected but statistics show that the amount of men who are being diagnosed with anorexia is increasing. The age of diagnosis is around 16-18 but this can vary dependent upon the individual.
One of the main features of anorexia is a fear of food, or, more precisely, what food will do to the individual’s body, which ties in with a disturbed perception of what they believe their body actually looks like. Many individuals will report that they feel hungry all the time but they cannot make themselves eat because they fear the consequences of what will happen if they do.
Individuals who have been diagnosed with bulimia (literally meaning ‘ox-like hunger through nervous origins’) will experience frequently recurring episodes where they eat very large quantities of food and feel as though they have no control over themselves whilst they are doing this. Those who have the condition report that they get little pleasure from eating a lot yet cannot stop themselves from doing so. Foods typically eaten during a binge episode will be highly calorific and tend to include:
- Multiple slices of toast with butter
- Packets of biscuits
- Tubs of ice cream
- Bars of chocolate
- Multiple bowls of cereal
After the binge eating, the individual will feel extreme guilt and shame and will be concerned about putting on weight. Therefore, they will try to compensate for the fact that they have overeaten by using laxatives, force vomiting, excessive exercising, fasting or a combination of all of these – this behaviour is known as purging.
Bulimia is different to anorexia because those who experience bulimia usually manage to maintain a normal weight (and are sometimes actually overweight), and because of this, bulimia is easier to hide and therefore may be less diagnosed than statistics suggest.
Binge Eating Disorder (BED)
Binge eating disorder is similar to bulimia nervosa in that there are frequent episodes of binge eating, however, unlike bulimia, there are no episodes of purging, excessive exercising or fasting afterwards. As a result of this, individuals who have this disorder are often overweight or obese (where their BMI is between 25 and 30 and over 30, respectively).
A characteristic of this disorder is that the binges that take place are usually planned and carried out as a form of ritualistic behaviour. The individual may buy specific foods that are ‘special’ for bingeing and then take them to a place where they will not be disturbed and consume them all in one sitting.
Some individuals report that when they are bingeing it is like they are in a ‘dazed’ state, and many will carry out the act in the middle of the night. Many will not remember what they have eaten and this can lead to guilt, shame and disgust at what they have done.
Binge eating disorder affects both men and women equally and is diagnosed more frequently in adulthood than other common eating disorders, which tend to be diagnosed through the teenage years. Binge eating is a difficult habit to break because it causes blood sugar to rise and crash, making the individual feel as though they need to eat again when their body does not actually need more nutrients.
Causes of Eating Disorders
Like many mental illnesses, the cause of eating disorders is largely unknown but is thought to be connected to one or more of several potential factors. These factors are a mixture of physical and social and it is unlikely that one single factor would result in an eating disorder that takes over an individual’s ability to lead a normal life.
It is thought that eating disorders may develop because of specific factors that can be categorised as:
- Biological: Hormone dysfunction and genetics
- Psychological: Poor body image, low self-esteem and confidence, anxiety and stress, striving for perfectionism, a phobia of being overweight
- Environmental: Trauma, lack of control, problems in development transitions, peer pressure, media pressure, bereavement, abuse
Hormone levels are known to play a part in the onset of multiple mental health conditions. Hormones are responsible for all kinds of issues that make up how people think and how they behave. For example, someone who is lacking the hormone serotonin, will display characteristics of depression because serotonin is responsible for lifting a person’s mood. Some hormones may affect part of the brain that is responsible for controlling when someone feels hungry or feels full, which will make it difficult for someone to know when to eat and when to stop.
Alternatively, when someone has already developed an eating disorder, their pleasure hormones may be over stimulated when they miss a meal or exercise excessively, and because this makes them feel good, they are likely to repeat the behaviour that prompted the feeling.
Genetics are also thought to play a part in the development of an eating disorder, although it is not clear why this is. Someone who has a relative who has had an eating disorder is more likely to develop one themselves, although this may be influenced by them modelling the behaviour they have seen rather than a genetic link. However, anxiety is known to have genetic links and has been found to be a large aspect of many individuals’ eating disorders. It is known that some people are much more prone to anxiety than others and so it can be said that genetics do, in fact, play a part in the development of an eating disorder.
When someone has a poor body image this can lead them to developing an eating disorder because how they perceive their body may not be an accurate reflection of what it really looks like. For example, people with anorexia will continually tell others how fat they are when really they are extremely underweight. When they look in the mirror, they may perceive their skin as rolls of fat and it is this type of thinking which contributes to their condition not being treated because they fear that if they seek help, others will force them to eat and put on weight.
Individuals who develop bulimia or binge eating disorder may know that they are overweight and it is this that makes them eat more. Food becomes a comfort mechanism to them, even though they know that this will mean that they put on more weight and are likely to have more problems with their body image.
A poor body image can have a direct effect on someone’s confidence and self-esteem and many people try and make up for this lack in confidence by doing something that they think will be desirable to others; for example, being thin. Not eating or excessively exercising can also temporarily increase someone’s self-esteem because they will experience a rush in knowing that they are contributing to their mission of not becoming overweight.
Alternatively, a lack of confidence and self-esteem can cause individuals to binge eat to seek comfort because of what they feel that they lack. However, this ends up being a negative cycle because once the binge eating (and purging if this is part of the condition) takes place, the individual will feel disgusted with themselves, they will have a lowering of their self-esteem, and the need to eat for comfort begins again.
When someone sets a goal for themselves, this can be very motivating in helping them to achieve what it is that they want. However, with eating disorders, the ambition of achieving that goal can lead to perfectionism, which the individual thinks will be broken if they allow themselves to eat normally. If someone has strict goals for themselves, this may mean that they only allow themselves to drink water for a day or to only eat salad for a week. Not only will this feed into their eating disorder but it can also have extremely detrimental effects on their physical health.
A final, and arguably the most debilitating, psychological factor that might lead to an eating disorder is the fact that someone may actually have a phobia of food or of getting fat. Phobias are extremely serious mental illnesses that can cause people’s lives to be completely disrupted and, often, they may need care in order to be able to fulfil even the simplest of daily activities. A phobia of food may result in individuals avoiding places where it is served, and someone who has a fear of being fat may avoid social situations altogether where they fear they may see someone who is overweight. These examples may sound as though they are exaggerated, but when a phobia takes over someone’s life, it is difficult for them to think normally about what the source of their fear is, and this is why they become subject to withdrawal and isolation, which are further factors in the onset of other mental illnesses.
Some individuals who experience anxiety and stress may develop an eating disorder as part of trying to regain control of their lives. Often stress is caused when someone feels as though things are ‘getting away from them’, and when they cannot control one aspect of their life, they turn to another. This can result in the development of an eating disorder because individuals can be in complete control of what they eat, and this may provide them some relief from the symptoms of stress and anxiety. When someone chooses not to eat, this is also a form of control because the individual feels as though they are in control of their ultimate goal, which is to not put weight on. This also applies if someone experiences some form of trauma either in childhood or later on in life; this may begin the onset of an eating disorder because the individual may feel as though this is the only way they can deal with the ordeal that they have faced. Traumas may include abuse, bereavement, parental divorce or being involved in an accident.
Puberty seems to be a time when eating disorders are thought to begin. Although it is not certain, it is argued that this is because surges and changes in hormones are combined with teenagers being unable to cope with transitions in their life (such as having more responsibilities and dealing with exam pressures). Once again, the eating disorder acts as a form of coping mechanism whereby the individual attempts to regain some kind of control over their life.
Peer pressure to be thin comes from the fact that in Western culture the most desired body shape is argued to be that which is slim and not overweight. Girls especially feel pressured to remain a certain size and may feel pressured by their friends to do so. If the only way that they can stay with their friends is to be like them then this may begin the onset of an eating disorder.
Pressure can also come from the media and from certain job roles such as sports or modelling careers. Every day in Western society, people are bombarded with images of thin and beautiful people who appear to be successful because of the way that they look. Young children can be extremely influenced by these images and they are thought to be a genuine risk factor in the development of an eating disorder; this is because success is equated with being thin and is therefore desirable.
Although all of the above factors are thought to be important in the development of an eating disorder, it is extremely unlikely that just one would be a single cause. This is because all mental illnesses are complex and not easily definable, therefore it is likely to be a combination of factors that ultimately cause the development of an eating disorder.
Signs and symptoms of Eating Disorders
Sometimes the signs and symptoms of an eating disorder are hard to identify because the individual will go to great lengths to keep their condition secret from other people. However, when they are identified, it is important to encourage the individual to seek help for their condition before it takes over their life – if this hasn’t happened already. Signs and symptoms that should be monitored can be classified as either:
Physical symptoms include:
- Sudden weight loss
- Frequent changes in weight
- Disturbed sleep patterns
- Osteoporosis – bones become very brittle
- Extreme sensitivity to cold (even in warm weather)
- Swollen jawlines and teeth damage caused by frequent vomiting
- Excess body hair growth
- Skin problems
- Frequent minor illnesses
- Weakened muscles
- Amenorrhea – periods stopping for women, which can lead to infertility
- Stomach pains
- Low blood pressure (anorexia)
- High blood pressure (bulimia and binge eating)
Psychological symptoms include:
- Increased preoccupation in body shape, weight and food calorie values
- Intense fear of gaining weight
- Negative body image
- Anxiety at meal times
- Sensitivity to comments about appearance
- Low self-esteem
- Impaired cognitive functioning
Behavioural symptoms include:
- Signs of vomiting, using laxatives or binge eating
- Constantly checking body weight
- Wearing baggy clothes to hide weight loss or gain
- Lying about eating habits to cover up behaviour
- Making constant lists of ‘good’ and ‘bad’ foods
- Shopping and cooking alone
- Excessive calories counting for even the smallest food items
- Avoiding eating with other people
- Obsessive and ritualistic behaviours, such as cutting food into tiny pieces
- Eating very slowly to make it appear as though more food has been consumed than it actually has
- Hiding food or feeding it to a pet
- Excessive exercising
- Refusing to admit there is a problem or the seriousness of the problem
Clearly, the extensive list of signs and symptoms indicates how serious the problem of an eating disorder can be. Like with many mental illnesses, the categories of signs and symptoms are extremely unlikely to be experienced individually and there will almost certainly be a crossover between them. For example, someone who has developed anorexia may suffer from depression due to the fact that they feel they cannot control their life. Their depression may lead them to believe that they are not a socially desirable person to be with and so they try to lose more weight to counter these feelings. Eating disorders can be very complex and, as such, they are very difficult to treat in many cases; something which will be discussed in more detail in the next section.
Experiencing Eating Disorders
An eating disorder can be a very isolating condition and this is one of the feelings that the individual is likely to face from the outset of the issue. Individuals who have a genuine fear of food will avoid places where food might be present. Since this is in most places, individuals will avoid seeing people so they can stay where they can control their exposure to food.
Isolation is a big risk factor for depression, and statistics indicate that for individuals who have anorexia the risk of suicide is 57 times greater than for those who do not. Also, it has been found that 1 in 5 people who experience an eating disorder will die as a result of their condition, either directly due to malnutrition or indirectly because of suicide.
Eating disorders can make people feel worthless and this is what may lead them to self-harming behaviours. The feeling of being out of control can have a dramatic impact on their ability to function normally because they can never see an end to their problem and their eating disorder.
Many individuals will report that their condition makes them feel trapped because they have been unable to control their issues around food and those issues now control them. The feeling of being trapped can lead to issues with guilt if the person goes a single calorie over the amount that they have allotted to themselves or if they have not completed the gruelling exercise regime that they have self-administered as well. Guilt then leads to frustration, which may result in the calorie intake being lowered and the exercise minutes being increased so that the individual can punish themselves for what they see as a failure to stick to the perfect schedule that they have drawn up in order to remain thin.
Finally, those people who have eating disorders may feel as though they are selfish because they know the effect that their condition has on the people around them and yet they cannot change their behaviour and so continue to lose weight or believe that they are fat, despite clear evidence to the contrary. Like other mental illnesses, the effect on other people can be devastating and this often serves not as a motivation to get better or to change habits but to continue the negative behaviours. This is because they act as a comfort mechanism at a time when they feel most vulnerable.
How Eating Disorders affect a person’s life
There are many different ways in which the individual will be affected by their eating disorder and these are unlikely to be experienced in isolation from each other, meaning that the individual is ‘attacked’ by their disorder in many different ways. Some examples of the effect that the condition has on their life include:
- Physical illness
- Low confidence and self-esteem
- Completely skewed body image
- Having to plan their day around food
- No interest in socialising
- No hope for the future
Arguably, physical illness is the most serious impact that an eating disorder can have on an individual’s life. For those individuals who have anorexia, they are prone to many minor illnesses because their immune system is not fully functioning due to the lack of nutrients that the body is subject to. Since anorexia can have an impact on all internal organs, the ability to fight off illness is reduced and this can have a very serious effect on overall physical health. For example, someone who gets a minor chest infection can usually fight this off with some antibiotics and their own immune system. For someone who has anorexia, their lung function may be inhibited and so a minor infection may become something much more serious.
Also, anorexia can cause muscle wastage and bones to become brittle and this can lead to an unsteady walk and an inability to perform simple physical tasks, such as walking upstairs or getting up easily from a chair. Poor physical health tends to lead to poor mental health and the two can end up becoming a cycle that is very difficult to break.
Those individuals who have bulimia or binge eating disorder are subject to high cholesterol, high blood pressure and possible Type 2 diabetes, which can all be risk factors in the development of coronary heart disease. These two eating conditions can also cause internal bleeding, and many people are thought to die because of complications, especially of bulimia.
When someone has low self-esteem and confidence this can have a knock-on effect to many aspects of their life. For example, the individual may feel as though they are not important enough to be treated, and because of this they do not seek medical assistance for their condition, even when it is obviously having a detrimental effect on their health. Low self-esteem can lead to individuals feeling as though no one likes them or likes spending time with them, and because of this they are, once again, subject to isolation. Low self-esteem and confidence can also make problems with stress and anxiety worse, and as these are often a cause of eating disorders, the issues can become a vicious circle. For example, someone who is feeling anxious and stressed tries to take control by severely restricting what they eat. Because of this, they feel guilty and worthless and this leads to low self-esteem. This then causes them to feel anxious about everything and so the control over what they eat becomes even more fastidious.
A skewed body image means that someone sees their body in a negative way, which does not reflect how it actually is. This is linked to a serious medical condition known as body dysmorphic disorder, which is often experienced alongside an eating disorder. Someone who has anorexia is especially prone to body dysmorphic disorder because when they look at themselves, no matter how thin or underweight they are, they still believe that they are fat. Since many people with an eating disorder have a phobia of being fat or overweight, this can mean that they restrict their food intake even more and yet the mental image they have of their body does not change.
Those people with eating disorders often find that their condition has taken over their life to the point where their entire day is planned around food. Sometimes, individuals with anorexia will look at pictures of food and count this the same as though they had actually eaten it. Also, they will take great steps in preparing an elaborate tale that ensures that they avoid eating with other people or make it look as though they have already eaten when it comes to mealtimes.
People with bulimia or binge eating disorder may plan their time around when they are going to eat the food that they may have stashed away for that day as their ‘special treat day’. This might involve waiting until others are out of the house or when they know that they will not be disturbed. Any disruption to this plan may cause frustration, meaning that when the binge eating does take place, it may be even more severe to make up for the ‘delay’ in when it was supposed to happen.
Planning a day around food does not necessarily mean that the individual will prepare when they are going to eat and how much, but how they can avoid food at all costs. This is especially prevalent for those individuals who may have an actual phobia about being fat or of eating food. This may mean that they avoid any situations where there may be food or even where there may be someone who is overweight. Considering that there is the possibility that food may be anywhere, such as on advertising hoardings, being eaten by someone walking down the street and in abundance in any place where there are a lot of shops, this may mean that the person restricts themselves to going to places where they know that encountering food is less likely. Eventually though, this may mean that the person doesn’t leave their house much, and certainly does not attend social events where the likelihood of food being present is much higher.
Avoiding social events also increases the possibility that someone’s eating disorder may go undetected. When with family and friends who know them well, signs and symptoms may be impossible to hide, so avoiding all of the people who may know that something is wrong is another way of ensuring that their condition is kept secret.
Finally, there may come a point when the individual becomes so obsessed with food and eating that they see no hope for the future and a way of living their life as they did prior to their condition. Feelings such as this are made worse by social isolation and by the fact that they may also be experiencing physical illnesses which have a negative impact on their overall well-being. When someone has no hope for the future, this becomes a risk factor for self-harm and, sadly in some cases, for someone feeling as though they have no other option but to end their life.
How Eating Disorders affect others
The parents of a child who has an eating disorder may deny that there is anything wrong with them and this can lead to a delay in getting treatment and support for them. If the eating disorder is acknowledged, this may result in the parents feeling powerless, angry and worried about their child, as well as feeling guilty that they have ‘allowed’ this to happen and have not been able to do anything to stop it.
Family members may find that they are continually arguing about what to do in order to help the person who has the eating disorder. They may be unsure whether to confront them about it so that they can get support or whether this will make the situation worse because the individual will realise that everyone knows about the condition that they have been trying to hide. The disorder can have an effect on normal family functioning if the individual will not go to any place where they have to encounter food or where they feel that they cannot partake in rituals. This means that days out, holidays and other family activities will be reduced or cancelled whilst the individual is feeling the effects of their condition.
Siblings of the individual who has an eating disorder may feel as though their needs are not being met, because of the attention that is given to the individual. This can lead to resentment within the family, which may be the foundation of further arguments. Friends of the individual may find that they continually have to defend their friend’s behaviour, and when this becomes too much they may reject the friend because they are overwhelmed by the effect that the friend’s condition is having on them.
Parents or other family members may become unofficial carers to the individual who has the eating disorder and this can lead to further resentment, especially if the individual continues to insist that they do not need help, even though it is clear to all that they do. Caring can be an extremely stressful occupation and those who take on the role are subject to a reduction in their own physical and emotional well-being because of the time they invest on caring for someone else.
It is important for carers that they have support for themselves and are encouraged to take care of their own health as well. A support group for carers can provide an excellent place for carers to discuss any of the issues that they are having in their role and it helps them to talk with others who are in the same position that they are as well. Many support groups offer advice and guidance about caring and this can be very comforting to someone who feels as though they are struggling to cope in their caring role.
Approaches to the treatment of Eating Disorders
Unlike many other mental illnesses where medication is a ‘go-to’ treatment, this is not the case for eating disorders; however, medication may be prescribed if there are issues of stress and anxiety alongside the eating disorder. Instead, there are a number of potential treatments that may help the individual to gain control of their condition and perhaps even overcome it completely:
- Nutrition planning and counselling
An eating disorder may be caused by an event in someone’s life that has caused them to over or under eat as a way of dealing with the pain that it has caused them. If this can be identified as the cause of the eating disorder, then therapy may be an effective way of getting to the root cause of the issue so that the eating disorder that has occurred as a consequence of it can be dealt with.
Psychotherapy is a type of ‘talking therapy’, which may be useful in getting to what the root cause of the trigger of an eating disorder, or any other mental illness, may be. It is useful because it can identify subconscious trauma that the individual cannot bring into their conscious mind because it is too painful. Because they cannot think about it, they cannot identify the cause and therefore they cannot resolve it.
Many individuals will undergo months of psychotherapy before having a ‘breakthrough’ in identifying why they are experiencing mental illness, but once the cause is identified then this will enable the individual and the therapist to work together to resolve any ongoing issues that the initial trauma has caused.
Other types of therapy such as CBT (cognitive behavioural therapy) and person-centred counselling may also be useful when the individual is beginning to make a recovery. They can help because they can reduce the levels of stress and anxiety that might predispose a recurrence of the eating disorder. Person-centred counselling also provides an environment that is non-judgemental and therefore the individual may feel as though they are able to open up to someone for the first time about their eating disorder, its potential causes and its effects on their life. This type of counselling may be especially useful for bulimic individuals who do not need to put on weight but who need to understand what is causing them the need to binge eat and then purge themselves afterwards.
Family therapy might also be a useful possibility for someone who is experiencing an eating disorder, because often families want to help the individual but they do not know how. Families are taught ways in which they can support their loved one, even through the most difficult and distressing times of their illness. It is hoped that family therapy will develop a better understanding of the condition and that family members will look to each other for support rather than arguing about how to deal with the eating disorder.
Nutrition Planning and Counselling
Often someone’s eating disorder has such an impact on their ability to function normally that they genuinely forget to eat because they have become so conditioned to eating less and less and may not recognise the signs of hunger. When issues such as this are under control, educating the individual about proper nutrition may help them to understand that eating three balanced meals per day will not make them put on weight. When they are able to understand the effects that food has on their body, this may make them less afraid to eat. The individual’s eating habits will be closely monitored and they will be advised to try and gain weight slowly, at around 0.5kg per week. However, this can be an exceptionally long and drawn out process, especially for those individuals who have an actual phobia of eating.
In severe cases of anorexia, where the individual’s BMI has fallen below 13.5, then a period of treatment in hospital may be the only solution to stop them from becoming seriously ill or possibly even from dying. Individuals may be hospitalised against their will if they are assessed and decided that it is necessary to ‘section’ them under the Mental Health Act 1983. Many individuals will be very averse to treatment because they know that this will involve having to put weight on. Many cannot see the consequences on their health that their illness is causing, and because of this they have to be treated even when this goes against their wishes.
Treatment in hospital may involve the individual being given an intravenous drip that will help to build up their strength and immunity. They may be fed gastrically, which means that food bypasses normal digestion processes and goes directly into the stomach. Their general health will also be assessed because it is likely that by the time hospitalisation is required, the individual may have other physical ailments that are affecting them, such as low blood pressure and a deficiency of the immune system.
After treatments have been applied, then monitoring will help to lessen the chances of relapse. It is important that the individual and their family know the signs of when this might happen so they can seek treatment at the earliest opportunity if a relapse occurs. When someone is monitored, they feel supported, and when they know that they have had treatment that works to help them manage their condition, they may be more willing to seek help in future.
Interested in a Mental Health qualification?
We offer the TQUK Level 2 Certificate in Mental Health Awareness, which covers a full unit on Understanding Eating Disorders.