Eating disorders

Written by Christine Webber, psychotherapist and lifecoach

What are 'eating disorders'?

Many adult women are guilty of passing on mixed messages about food to younger generations.

In 2009, the Royal College of Psychiatrists estimated that eating disorders affect roughly 7 young women in every 1,000, and 1 in every 1,000 young men. So these disorders are clearly a lot commoner in females than in males.

The common eating disorders are:

• anorexia (often called ‘anorexia nervosa’)
• bulimia (often termed ‘bulimia nervosa’)
• binge eating disorder.

As we approach the end of the first decade of the 21st century, they appear to be getting steadily commoner in Britain. But why do they occur? The reasons are complex, and they are connected with our rather curious and ambivalent attitude to food …

Mixed messages about food

At a recent international conference, one of the speakers said that 'the majority of women have a slightly odd relationship with food'. Although this seems a rather sweeping statement, most of the females in the audience promptly nodded.

Certainly, many adult women have a ‘love-hate’ relationship with their food. Furthermore, a lot of them manage (quite unintentionally) to pass on mixed messages about food to their children.

Listen, for example, to two female friends lunching together. If they succumb to the delights of the dessert trolley one will almost certainly say to the other: 'I shouldn't be having this.' In other words, she is indulging her pleasure, her palate and her hunger, but she's punishing herself as she does so. Most probably, her friend will say something like: Oooh yes, I shouldn’t be having this either – but isn’t it lovely!’

Recently, we eavesdropped on a group of three women in a pub.

The first woman - Katherine - was telling her colleagues, Suzie and Caroline, that she'd had a tummy bug the previous weekend.

'It was awful' she said. 'I felt like death. Still...'

'Yes...' encouraged Suzie.

'Well - usual compensations...'

'I bet,' agreed Caroline. 'You look great, how much weight did you lose?

'Four pounds,' said Katrina, not even bothering to conceal the note of pride that crept into her voice.'

'Gosh. Fantastic. Four pounds...' Her two companions looked and sounded envious.

Let's face it, most women understand that conversation because deep down they subscribe to the view of the late Duchess of Windsor when she said: 'You can never be too thin or too rich.'

Even those women who know how dangerous this kind of thinking is, still cling to it. And it is that very type of thought - constantly, if unwittingly, being passed on to children - which has helped to increase the feelings of ambivalence about food among women in today's society.

Skinniness means success

We live in a very 'beautiful people' kind of world where television, magazines and newspapers continually bombard us with images of extremely slim people. This is undoubtedly a bad thing, because it makes women and girls feel deep down, that slimness equates with success. Small wonder then that there is an increasing number of children as young as 11 who are on some sort of diet.

And we in Britain are not alone in our unnatural obsession with food and weight. It's interesting to note - and very sad too - that as our kind of 'civilisation' spreads to the farthest corners of the world, so the desire for the perfect body spreads too. One study found that when television reached the Fiji islands, it wasn't long before the young women there became so concerned about their figures - for the first time ever - that 15 per cent of them began to induce vomiting as a means of controlling their weight.

When does dieting become an eating disorder?

But where does dieting stop and an eating disorder begin?

Well, plenty of people who occasionally go on a diet are psychologically healthy and certainly don't have eating disorders. And there are vast numbers of adults who are carrying a stone or two more than they should, and who have nothing wrong with them except for the fact that they take in more calories than they use up.

What about the countless women who have a funny kind of love/hate relationship with food? Well, their attitudes are certainly unhelpful, but most of them don't actually develop full-blown eating disorders.

So what is an eating disorder? In a nutshell it is an outward sign of inner problems. As BEAT (which has recently changed its name from the Eating Disorders Association says: 'An eating disorder occurs when eating or not eating is used to help block out painful feelings.'

BEAT also says that without appropriate help and treatment, such difficulties may persist throughout life.

How widespread is the problem?

There is no doubt that eating disorders are on the increase. BEAT currently provides rather higher estimates than those of the Royal College of Psychiatrists. BEAT believes that 1.15 million people in this country have a significant problem and that between 60,000 and 90,000 of those are having treatment.

Certainly, the scale of the problem is such that every GP in the land is likely to have one or two anorexics among his or her patients, and no less than 18 bulimics. However, most GPs don't identify all these people as having eating disorders because of the secret nature of these conditions.

One GP told us recently: ‘I have never had anyone come into my surgery and actually complain of bulimia. So it’s hard work making the diagnosis.’

Quite apart from anorexia and bulimia, there is also ‘binge eating'. Compulsive or binge-eating is also classed as an eating disorder but far fewer studies are done about these people. And when compulsive eaters – who are sometimes extremely overweight – do visit their doctors they are likely to be given a diet sheet rather than offered any kind of counselling which might get to the root of the problem.

But does counselling help eating disorders? In fact during the last few years, cognitive behaviour therapy (CBT) has been shown to be very useful – particularly in the treatment of bulimia nervosa and overeating.

In CBT, the person with the eating disorder is helped to address the issue behaviourally – in that he or she is asked to eat regularly and not to ban any foods and so on – but also to look at the thinking behind why they eat. There is much emphasis on addressing the thoughts that persuade us to eat. For example, if someone eats because they’re miserable, she will be encouraged to challenge the idea that eating makes her happy and to find other ways of comforting herself that does not include food.

There are a number of excellent books written by CBT practitioners that are of great help to bulimics and to overeaters and some of them are listed at the end of this article.

Female or male?

When we talk of eating disorders we tend to think 'female'. But it's important to recognise that a significant minority of people who have an eating disorder is male.

And it has recently been claimed that of those men with eating disorders, 25 per cent are gay.

It's also claimed that the vast majority of 'eating disorder men' were bullied at school.

Causes

But why do so many people now have eating problems?

One reason appears to be poor self-esteem. Certainly many eating disorders begin when young people become convinced that if only their bodies were more perfect, they would feel better about themselves.

There are also issues of control. If young people are bullied, or even just living in bossy or super-achieving households, they can easily feel that everyone else controls them. To counter that, they seek out some way in which they can be certain of exerting some real control of their own. And many of them choose to have ultimate control of their own bodies by rigidly governing how much food they'll allow to pass their lips. The sense of power can be very elevating – at least initially – and having had this kind of excited 'fix', most young people are reluctant to relinquish it.

Another cause of eating disorders is undoubtedly media pressure at a time when a young person is feeling vulnerable and awkward. But there is some suggestion that a person's genetic make up may make them more prone to eating disorders than other folk are.

Unfortunately, some young people suffer traumatic events such as bereavement or sexual abuse in their early years and there is substantial evidence that such episodes can trigger problems with food.

Also, households where there are high academic expectations are well-known breeding grounds for eating disorders.

Finally, many young women between the ages of 14 and 25 develop an eating disorder when they are not only under stress at school or college but also uncertain of their sexual orientation or sexual attractiveness.

It’s important to note however that eating disorders are not the sole province of the young and to acknowledge that there may be people well into mid-life who are seeking answers to eating difficulties.

Excessive exercise

In the case of some youngsters – notably young men – the emphasis of the disorder is on excessive exercise rather than on food. Indeed many guys nowadays are 'addicted' to exercise.

At first sight an excessive exerciser will look extremely fit. So much so that his friends, parents or GP will be unlikely to spot the problem until it's got completely out of hand. However some doctors are particularly clued up about this kind of syndrome and they're likely to pick up on it when a patient keeps presenting with sports injuries.

Hot topic

It's now exactly 30 years since the therapist Suzie Orbach published her classic book Fat Is A Feminist Issue in 1979.

But now it's quite clear that fat - or the lack of it - has become an intensely political issue. In fact, eating disorders have never had so much press as they have over the past few years.

In 2003, the UK government held a 'body image' summit where the media were asked to try and stop pressurizing young girls to be thin.

However, it's not just the government who are concerned. The British Medical Association also issued a report about eating disorders at around that time.

The report stated: 'Fashion models are becoming thinner at a time when women are becoming heavier, and the gap between the ideal body shape and the reality is wider than ever.'

It continued: 'It has been estimated that models and actresses [have] 10 per cent to 15 per cent body fat – the average body fat for a healthy woman is 22 to 26 per cent.'

The BMA are concerned that anorexia and bulimia nervosa have one of the highest mortality rates of all psychiatric illness and that even when they're not fatal these conditions can lead to serious medical consequences.

And in 2007, there has been a great deal of discussion in the media and fashion industry – and in medical circles – about the trend for 'Size Zero' models, many of whom are perceived to have eating disorders. Further to this fuore, in early April it was announced that Allegra Versace – the niece and heiress to the Versace empire – has been struggling with anorexia for many years.

Eating disorders – the facts

So now let’s look in detail at the various types of eating disorder.

Anorexia nervosa

• Anorexics restrict the amount they eat and drink - often to dangerous levels.
• The usual age range for the onset for anorexia nervosa has been reported to be from 14 to 25 years.
• Anorexics often come from families where there is not much communication but where there is considerable pressure to perform well or to 'be perfect'.
• In anorexia there's a refusal to maintain weight at a normal level.
• Anorexics have an intense and growing fear of gaining weight or of becoming fat
• As time goes by, an anorexic loses a proper perspective of his or her own weight, frequently believing that he or she is much bigger than reality.
• Anorexic girls can become so seriously undernourished that their periods stop and downy hair appears on their bodies.
• Anorexics frequently have mood swings.
• Anorexics will often have dizzy or fainting spells and will usually feel cold.

Bulimia nervosa

• A bulimic has an uncontrollable urge to eat vast amounts of food.
• Bulimics have an emotional hunger that cannot be satisfied.
• Bulimics binge then vomit, or use laxatives or diuretics, as a means of controlling weight.
• Bulimics are frequently of normal weight.
• Bulimics often suffer from mood swings.
• Bulimics sometimes have abrasions on the back of one hand. This happens because their teeth graze that hand whenever they stick their fingers down their throat to induce vomiting. This tell-tale sign can be useful for friends, parents or doctors in identifying the problem.
• Bulimics frequently have sore throats because of their constant vomiting. This again is a symptom that may help doctors identify the problem of bulimia in their patients.
• Bulimics develop problems with tooth decay - this is because of the acid in their vomit constantly washing over their teeth. Dentists are often the first people to spot this problem and sometimes confront the bulimic with their suspicions and encourage her to seek treatment.
• Bulimics eat to gain emotional satisfaction but as they start to feel full they are overcome by feelings of guilt and shame.
• In severe cases, the bulimic can develop dangerously low levels of essential minerals in the body that can badly affect - sometimes fatally - the vital organs.
• Occasionally, severe bulimia can lead to heart attacks.

Compulsive/binge-eating

• A compulsive eater will indulge in regular episodic overeating of large amounts of food perceived to be fattening.
• A sufferer will think obsessionally about food and weight.
• A compulsive eater will have a sense of being out of control.
• A compulsive eater will indulge secretly.
• A sufferer will eat until she feels uncomfortably full.
• A compulsive eater will suffer guilt and remorse after eating.
• Some sufferers say that they never feel full and that they always have a sense of emptiness.

Treatment

The one thing that all the experts agree on in the treatment of eating disorders - particularly in the case of anorexia nervosa - is that it should begin sooner rather than later. Start by going to your GP.

Treatment is likely to consist of one or more of the following:

• counselling
• family therapy
• group therapy
• support group involvement
• drama or arts therapy
• nutritional advice.

It's vital to accept one important fact however, which is that the person must want to get better if treatment is to advance very far. In a way the situation is much like that of excessive smokers, drinkers or drug takers. Like them, a person with an eating disorder is a kind of addict: he or she becomes locked into an addictive form of behaviour concerning food and exercise. Although this behaviour causes ill-health, the prospect of giving it up is quite terrifying and the sufferer may well feel that everyone is asking her to relinquish the one thing that spells safety and control.

With bulimics, the treatment tends to centre on avoidance techniques: the bulimic is encouraged to delay bingeing or to delay vomiting. But the desire to go back to the usual mode of behaviour can be overwhelming. For that reason, though bulimics often start a treatment programme with verve and enthusiasm, they commonly drop out suddenly. It's as if they view the treatment in the same way as they do food: at first they long for it and consume it - and then they violently reject it.

This response makes it very difficult to treat bulimia and the therapist needs to be a particularly strong person – and one with a great deal of insight - if she is to deal with this roller-coaster of initial acceptance and compliance from the client, followed by rejection.

There are about two dozen NHS eating disorders clinics in the UK. But provision of treatment depends very much upon where the sufferer lives.

There are several private clinics in the country too, but these are very expensive. Some of these clinics do take NHS patients but the cost to the health service is some £300 to £500 per day.

A lot of families and sufferers handle the problem as best they can with a mixture of help from the GP, BEAT (formerly the Eating Disorders Association) and some counselling.

In areas where there is no eating disorders unit, a young patient who is severely anorexic may end up in a general psychiatric ward - which is obviously not ideal.

Most people will begin the quest for treatment by approaching their GP.

BEAT (The Eating Disorders Association)

BEAT ( formerly known as The Eating Disorders Association is the organisation regarded as the undisputed expert in the complex world of eating disorders and we would urge any parent, friend or sufferer to contact BEAT if they haven't already done so.

There are a number of ways of doing this.

• Adult Helpline: 0845 634 1414. This is staffed Monday to Friday from 10.30 am to 8.00 p m, and at certain other times.
• Youthline: 0845 634 7650. This line is for 18 year olds and younger, and is staffed during weekdays during office hours.
• Text service (Youthline): 07786 20 18 20. You should get a text reply within 24 hours, except at weekends.

BEAT also has an excellent website.

If you approach them, you will get advice and support and the chance to obtain a number of relevant leaflets. You will also be told about the network of self-help groups up and down the country.

Useful reading

• Breaking Free From Anorexia Nervosa - A Survival Guide For Families, Friends and Sufferers by Janet Treasure, published by Psychology Press, price £12.99.
• Overcoming Anorexia Nervosa – A Self-Help Guide Using Cognitive Behavioural Techniques by Christopher Freeman and Peter Cooper, published by Robinson, price ££9.99.
• Getting Better Bit(e) by Bit(e) - A Survival Guide for Sufferers of Bulimia Nervosa and Binge Eating Disorders, by Schmidt and Treasure, published by Psychology Press, price £12.95.
• Bulimia Nervosa and Binge-Eating - A Self-help Guide Using Cognitive Behavioural Techniques by Peter J. Cooper, published by Robinson, price £9.99.
• Bulimia Nervosa – A Cognitive Therapy Programme for Clients, by Myra Cooper, Gillian Todd and Adrian Wells, published by Jessica Kingsley publishers, price £19.99.
• Overcoming Binge Eating by Dr Christopher Fairburn, published by The Guilford Press, price £13.50.
• Breaking Free - Help For Survivors Of Child Sexual Abuse by Carolyn Ainscough and Kay Toon, published by Sheldon, price £14.99.