Anorexia and Bulimia
	Readable and well-researched information for the public For anyone who is worried about themselves, a friend or a relative.

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About this leaflet

We hope that this leaflet will be helpful if:

• you are constantly thinking with your weight and body image
• you feel that your eating or dieting may be a problem
• you find yourself obsessively using other ways to lose weight, such as over-exercising or making yourself sick
• you think you might have anorexia or bulimia
• other people worry that you have lost too much weight
• you have a friend or relative, son or daughter, who is having a problem of this sort.

It does not deal with the problems of being overweight.

Introduction

• eating too much
• eating too little
• using harmful ways to get rid of calories.

In fact, the 'eating disorders' usually involve a lot more than eating behaviour, so that people affected by them are constantly worrying about how to avoid taking in calories or how to 'burn off' or how to get rid of them. They also find themselves checking their weight and appearance all the time to reassure themselves that their weight has not increased.

This leaflet deals with two eating disorders - Anorexia Nervosa and Bulimia Nervosa. It describes the two disorders separately, however

• the symptoms of anorexia and bulimia are often mixed
• people may also move from bulimia to anorexic, or you may start with anorexic symptoms, but later develop the symptoms of bulimia.

Who gets eating disorders?

Anorexia Nervosa

What are the signs?

You find that you:

• worry more and more about your weight
• eat less and less
• exercise more and more, to burn off calories
• can't stop losing weight, even when you are well below a safe weight for your age and height
• smoke more or chew gum to keep your weight down
• obsessively check your weight, shape or reflection in mirrors
• withdraw from social situations which may involve eating
• lose interest in sex
  • In girls or women - monthly menstrual periods become irregular or stop.
  • In men or boys - erections and wet dreams stop, testicles shrink.

Some people notice that they have developed other obsessive difficulties, such as having to stick to rigid routines and times, or perhaps fears of 'contamination', a need to study or work all the time, or difficulty in spending money appropriately.

When does it start?

We now know that people of any age can have anorexia, but it commonly starts in the teenage years. It affects around:

• 1 fifteen-year-old girl in every 150
• 1 fifteen-year-old boy in every 1000.

What happens?

• You take in very few calories every day. You eat "healthily" - fruit, vegetables and salads - but they don't give your body enough energy.
• You may also exercise, use slimming pills, or smoke more to keep your weight down.
• You don't want to eat yourself, but you buy food and cook for other people.
• You still get as hungry as ever, in fact you find you can't stop thinking about food.
• You become more afraid of putting on weight, and more determined to keep your weight well below what is normal.
• Your family may be the first to notice your thinness and weight loss.
• You may find yourself lying to other people about the amount you are eating and how much weight you are losing.
• You may also make your self sick if you eat anything you did not plan to allow yourself, particularly if you lose control of your eating and find yourself bingeing. However, this is known as 'anorexia, binge-purge subtype' rather than bulimia nervosa. Bulimia nervosa sufferers are by definition in the normal weight range.

Bulimia Nervosa

What are the signs?

You find that you:

• worry more and more about your weight
• binge eat (see below)
• make yourself vomit and/or use laxatives or other ways to get rid of calories
• have irregular menstrual periods
• feel tired
• feel guilty
• stay a normal weight, in spite of your efforts to diet.

When does it start?

Bulimia Nervosa often starts in the mid-teens. However, people don't usually seek help for it until their early to mid-twenties because they are able to hide it, even though it affects their work and social life. People most often seek help when their life changes - the start of a new relationship or having to live with other people for the first time.

About 4 out of every 100 women suffers from bulimia at some time in their lives, rather fewer men.

How can anorexia and bulimia affect you?

If you aren't getting enough calories, you may:

Psychological symptoms

• Sleep badly.
• Find it difficult to concentrate or think clearly about anything other than food or calories.
• Feel depressed.
• Lose interest in other people.
• Become obsessive about food and eating (and sometimes other things such as washing, cleaning or tidiness).

Physical symptoms

• Find it harder to eat because your stomach has shrunk.
• Feel tired, weak and cold as your body's metabolism slows down.
• Become constipated.
• Notice changes in your hair and skin. Some people's head hair falls out, but they grow downy hair on other parts of the body. Skin becomes dry and you can have pressure sores.
• Not grow to your full height, or lose height with a 'bowed over' appearance.
• Get brittle bones which break easily.
• Be unable to get pregnant.
• Damage your liver, particularly if you drink alcohol.
• In extreme cases, you may die. Anorexia Nervosa has the highest death rate of any psychological disorder.

If you vomit, you may:

• lose the enamel on your teeth (it is dissolved by the stomach acid in your vomit)
• get a puffy face (the salivary glands in your cheeks swell up)
• notice your heart beating irregularly - palpitations (vomiting disturbs the balance of salts in your blood)
• feel weak
• feel tired all the time
• experience huge weight swings (see below)
• damage your kidneys
• have epileptic fits
• be unable to get pregnant.

If you use a lot of laxatives, you may:

• have persistent stomach pain
• get swollen fingers
• find that you can't go to the toilet any more without using laxatives (using laxatives all the time can damage the muscles in your bowel)
• have huge weight swings. You lose lots of fluid when you purge, but take it all in again when you drink water afterwards (no calories are lost using laxatives).

What causes eating disorders?

There is no simple answer, but these ideas have all been suggested as explanations:

• Social pressure: Our social surroundings powerfully influence our behaviour. Societies which don’t value thinness have fewer eating disorders. Places where thinness is valued, such as ballet schools, have more eating disorders. ‘Thin is beautiful’ in Western culture. Television, newspapers and magazines show pictures of idealised, artificially slim people. So, at some time or other, most of us try to diet. Some of us diet too much, and may develop anorexia.
• Lack of an “off” switch: Most of us can only diet so much before our
  body tells us that it is time to start eating again. Some people with anorexia may not have this same body "switch" and can keep their body weight dangerously low for a long time.
• Control: It can be very satisfying to diet. Most of us know the feeling of achievement when the scales tell us that we have lost a couple of pounds. It is good to feel that we can control ourselves in a clear, visible way. It may be that your weight is the only part of your life over which you feel you do have any control.
• Puberty: Anorexia can reverse some of the physical changes of becoming an adult – pubic and facial hair in men, breasts and menstrual periods in women. This may help to put off the demands of getting older, particularly sexual ones.
• Family: Eating is an important part of our lives with other people. Accepting food gives pleasure and refusing it will often upset someone. This is particularly true within families. Saying “no” to food may be the only way you feel you can express your feelings, or have any say in family affairs. On the other hand, loving families often try to protect you from the consequences of an eating disorder, and this can mean that the eating disorder can go on longer.
• Genetics: There is a lot of evidence that eating disorders run in families even where the sufferers don't necessarily live together, and that certain genes make people more vulnerable, not only to eating disorders, but to related conditions.
• Depression: Most of us have eaten for comfort when we have been upset, or even just bored. People with bulimia are often depressed, and it may be that binges start off as a way of coping with feelings of unhappiness. Unfortunately, vomiting and using laxatives can leave you feeling just as bad.
• Low self-esteem: People with anorexia and bulimia often don’t think much of themselves, and compare themselves unfavourably to other people. Losing weight can be a way of trying to get a sense of respect and self-worth.
• Emotional distress: We all react differently when bad things happen, or when our lives change. Anorexia and bulimia have been related to:
  • life difficulties
  • sexual abuse
  • physical illness
  • upsetting events - a death or the break-up of a relationship
  • important events - marriage or leaving home.
• The vicious circle : An eating disorder can continue even when the original stress or reason for it has passed. Once your stomach has shrunk, it can feel uncomfortable and frightening to eat.
• Physical causes: Some doctors think that there may be a physical cause that we don't yet understand.
• Certain illnesses and treatments: There is a relatively high incidence of anorexia in people who suffer from diabetes, Cystic Fibrosis or other illness where diet has to be monitored and without adequate treatment, weight is lost. It can be tempting to neglect your health in order to lose some weight, and this is particularly dangerous.

Is it different for men?

• Eating disorders do seem to have become more common in boys and men.
• Eating disorders are more common in occupations which demand a low body weight (or low body fat). These include horse riding, body building, wrestling, dancing, swimming, and athletics.
• It seems that gay men and boys are more likely to suffer from eating disorders.
• It may be that men are now seeking help for eating disorders rather than keeping quiet about them.

People with special needs and younger children

A learning difficulty, autism or some other developmental problems can disrupt eating. For example, some people with autism may take a dislike to the colour or texture of foods, and refuse to eat them. The eating problems of pre-teen children are more to do with food texture, “picky eating” or being angry rather than with wanting to be very thin. The ways of helping these problems are rather different from those for anorexia and bulimia.

Do I have a problem?

The 'SCOFF' questionnaire used by doctors asks:

• do you make yourself Sick because you're uncomfortably full?
• do you worry that you’ve lost Control over how much you eat?
• have you recently lost more than 6 kilograms (about One stone) in three months?
• do you believe you’re Fat when others say you’re thin?
• would you say that Food dominates your life?

If you answer “yes” to two or more of these questions, you may have an eating disorder.

Helping yourself

• Bulimia can sometimes be tackled using a self-help manual with some guidance from a therapist.
• Anorexia usually needs more organised help from a clinic or therapist. It is still worth getting as much information as you can about the options, so that you can make the best choices for yourself.

Do:

• Stick to regular mealtimes – breakfast, lunch and dinner. If your weight is very low, have morning, afternoon and night time snacks too.
• Try to think of one small step you could take towards a healthier way of eating. If you can’t face eating breakfast, try sitting at the table for a few minutes at breakfast time and just drinking a glass of water. When you have got used to doing this, have just a little to eat, even half a slice of toast – but do it every day.
• Keep a diary of what you eat, when you eat it and what your thoughts and feelings have been every day. You can use this to see if there are connections between how you feel, what you are thinking about, and how you eat.
• Try to be honest about what you are or are not eating, both with yourself and with other people. Secrecy is one of the most isolating aspects of an eating disorder.
• Remind yourself that you don’t always have to be achieving things – let yourself off the hook sometimes.
• Remind yourself that, if you lose more weight, you will feel more anxious and depressed in the medium-term, even though you may feel better short-term.
• Make two lists – one of what your eating disorder has given you, one of what you have lost through it. A self-help book can help you with this.
• Try to be kind to your body, don’t punish it.
• Make sure you know what a reasonable weight is for you, and that you understand why.
• Read stories of other people’s experiences of recovery. You can find these in self-help books or on the internet.
• Think about joining a self-help group. Your GP may be able to recommend one, or you can contact the Eating Disorders Association (see page 22).
• Avoid websites or social networks that encourage you to lose weight and stay at a very low body weight. They encourage you to damage your health, but won’t do anything to help when you fall ill.

Don't:

• Don’t weigh yourself more than once a week.
• Don’t spend time checking your body and looking at yourself in the mirror. Nobody is perfect. The longer you look at yourself, the more likely you are to find something you don’t like. Constant checking can make the most attractive person unhappy with the way they look.
• Don’t cut yourself off from family and friends. You may want to because they think you are too thin, but they could be a lifeline.

What if I don’t have any help or don’t change my eating habits?

Most people with a serious eating disorder will end up having some sort of treatment, so it is not clear what will happen if nothing is done. However, it looks as though most serious eating disorders don’t get better on their own. Some sufferers from anorexia will die – this is less likely to happen if you do not vomit, do not use laxatives and do not drink alcohol. Exercise at low weight is dangerous, particularly if you exercise outdoors in cold weather.

Professional help

• Your GP can refer you to a specialist counsellor, psychiatrist or psychologist.
• You may choose a private therapist, self-help group or clinic, but it is still safer to let your GP know what is happening.
• It's wise to have a good physical health check. Your eating disorder may have caused physical problems. Less commonly, you may have an unrecognised medical condition.
• The most helpful treatments for you will probably depend on your particular symptoms, your age and situation.

For anorexia:

• A psychiatrist or psychologist will first want to talk with you, to find out when the problem started and how it developed. You will be weighed and, depending on how much weight you've lost, may need a physical examination and blood tests. With your permission, the psychiatrist will probably want to talk with your family (and perhaps a friend) to see what light they can shed on the problem. If you do not want your family involved, even very young patients have a right to confidentiality. This can sometimes be appropriate because of abuse or stress in the family.
• If you are still living at home, your parents may get the job of checking what food you are eating, at least at first. This involves making sure that you have regular meals with the rest of the family, and that you get enough calories. You will see a therapist regularly, both to check your weight and for support.
• Dealing with this can be stressful for everyone concerned, so your family may need support. This doesn't necessarily mean that the whole family has to come to therapy sessions together (although this can be helpful for younger people). It does mean that your family can get help to understand and cope with the problem.
• You will have the chance to discuss anything that may be upsetting you - how to get on with the opposite sex,studying, work, self-consciousness, or any family problems.
• At first, you probably won't want to think about getting back to a normal weight, but you will want to feel better - and in order to feel better, you will need to get back to a healthy weight. You will need to know:
  • what is your healthy weight?
  • how much food you need each day to get there?
  • how can you make sure that you don't become fat?
  • how can you be sure that you can control your eating?

Psychotherapy or counselling

• This involves talking with a therapist, perhaps for 1 hour every week, about your thoughts and feelings. It can help you to understand how the problem started, and how you can change some of the ways you think and feel about things. It can be upsetting to talk about some things, but a good therapist will help you to do this in a way which helps you to cope better with your difficulties. They will also help you value yourself more, and rebuild your self-esteem.
• Specially focussed versions of Cognitive Behavioural Therapy and Interpersonal Therapy are often offered, once you are well enough to benefit from the challenges of therapy rather than be more stressed by them. If you have therapy while your weight is low or falling, it appears that stress can make things worse rather than better.
• Sometimes it can be done in a small group of people with similar problems.
• Other members of your family can be included with your permission.  The best researched form of family therapy for anorexia is known as the 'Maudsley Model'. Adults who have a partner may be treated as a couple. Relatives and carers may also be seen separately for sessions to help them understand what has happened to you, how they can work together with you, and how they can cope with the situation.
• Treatment of this sort can last for months or years.
• The doctor will only suggest admission to hospital if these steps do not work, or if you are dangerously underweight.

Hospital treatment

• Blood tests will be done to check whether you are anaemic or at risk of infection.
• Regular weight checks - to make sure that you are slowly gaining weight.
• Other physical investigations may be needed to monitor any damage to your heart, lungs and bones.

Advice and help with eating

• A dietician may meet with you to discuss healthy eating - how much you eat and how to make sure you get all the nutrients you need to stay healthy.
• You may need vitamin and mineral supplements for a while as your body may lack essential nutrients.
• You can only get back to a healthy weight by eating more and this may be very difficult at first. Staff will help you to:
• set reasonable targets for gaining weight
• eat regularly
• cope with the anxiety you feel.

Medication

Doctors sometimes prescribe medication to help reduce the anxiety you experience while tackling the illness and, in particular, to reduce the 'ruminations' that sufferers describe. Most experience has been with the drug Olanzapine, as this is safest in young people and in people who are at a low weight. It may be more effective than diazepam and similar drugs and is less likely to be habit-forming.

Gaining weight is not the same thing as recovery - but you can't recover without gaining weight. People who are severely starved usually find it difficult to concentrate or think clearly, particularly about their feelings.

Compulsory treatment

This is unusual. It is only done if someone has become so unwell that he or she:

• cannot make proper decisions for themselves
• needs to be protected from serious harm.

In anorexia, this may happen if your weight is so low that your health (or life) is in danger and your thinking has been severely affected by the weight loss.

How effective is the treatment?

• More than half of sufferers make a recovery, although they will on average, be ill for  6-7 years.
• Full recovery can happen even after 20 years of severe anorexia.
• Past studies of the most severely-ill people admitted to hospital have suggested that 1 in 5 of these may die. With up-to-date care, the death rate is much lower, if the person stays in touch with medical care.
• As long as the heart and other organs have not been damaged, most of the complications of starvation seem to improve slowly once a person is eating enough.

For bulimia:

Psychotherapy
Two kinds of psychotherapy have been shown to be effective in Bulimia Nervosa. They are both given in weekly sessions over about 20 weeks.

Cognitive Behavioural Therapy (CBT)
This is usually done with an individual therapist, with a self-help book, in group sessions, or with a CD Rom. CBT helps you to look at your thoughts and feelings in detail. You may need to keep a diary of your eating habits to help find out what triggers your binges. You can then work out better ways of thinking about, and dealing with, these situations or feelings. As with the treatment for anorexia, the therapist will help you to regain your sense of your own value as a person.

Interpersonal Therapy (IPT)

This is also usually done with an individual therapist, but concentrates more on your relationships with other people. You may have lost a friend, a loved one may have died or you may have been through a big change in your life, like moving. It will help you to rebuild supportive relationships that can meet your emotional needs better than eating.

Eating advice
This helps you to get back to regular eating, so you can maintain a steady weight without starving or vomiting. A dietician can advise you on healthy eating. A guide such as
“Getting Better BITE by BITE” (see references) can be helpful.

Medication
Even if you are not depressed, high doses of antidepressants such as Fluoxetine (Prozac) can reduce the urge to binge eat. This can reduce your symptoms in 2-3 weeks, and provide a “kick start” to psychotherapy. Unfortunately, without the other forms of help, the benefits wear off after a while.

How effective is the treatment?

• About half of sufferers recover, cutting their bingeing and purging by at least half. This is not a complete cure, but will let you get back some control of your life, with less interference from the eating problem.
• The outcome is worse if you also have problems with drugs, alcohol or harming yourself.
• CBT and IPT work just as effectively over a year, although CBT seems to start to work a bit sooner.
• There is some evidence that a combination of medication and psychotherapy is more effective than either treatment on its own.
• Recovery usually takes place slowly over a few months or many years.

Advice

beat (formerly the Eating Disorders Association)
Helpline: 0845 634 1414 (Mon- Fri, 10:30-8.30pm, and Saturday 1.00- 4:30pm.
beat youth helpline: 0845 634 7650 (Mon- Fri, 4.00-6.30pm and Saturday: 1.00-4:30 pm.)
beat is an organisation that campaigns, that challenges the stigma faced by people with eating disorders and that gives people the help and support they need.

Bodywhys – The Eating Disorders Association of Ireland: Helpline: 1890 200 444. Email: info@bodywhys.ie

DWED (Diabetics with eating disorders website)

Eating Disorder Hope: American website offering information, eating disorder treatment options, recovery tools and resources to those suffering from eating disorders, their treatment providers and loved ones.

Mental Health Ireland
Email: information@mentalhealthireland.ie. Provides help to those who are mentally ill and promotes positive mental health.

MGEDT (Men get eating disorders too): A national charity dedicated to representing and supporting the needs of men with eating disorders.

NHS Direct: Tel: 0845 4647 (24hr)
Advice from a nurse on all health topics.

Youth health talk: has a section focussing on young people with Eating Disorders.

Online CBT resources

• Overcoming Bulimia
• Overcoming Anorexia

 Further Reading

Breaking free from anorexia nervosa: a survival guide for families, friends and sufferers by Janet Treasure (Psychology Press).

Anorexia nervosa and bulimia: how to help by M. Duker & R. Slade (Open University Press).

Eating Disorders: A parents' guide by Rachel Bryant-Waugh and Brian Lask (Penguin Books).

Skills-based learning for caring for a loved one with an Eating Disorder: The New Maudsley Method. Janet Treasure, Grainne Smith and Anna Crane.

Bulimia Nervosa and Binge eating: A guide to recovery by P. J. Cooper and Christopher Fairbairn (Constable and Robinson).

Overcoming binge eating by Christopher Fairburn (Guildford Press).

Getting better BITE by BITE: A survival kit for sufferers of bulimia nervosa and binge eating disorders by Janet Treasure and Ulrike Schmidt (Hove Psychology Press).

Anorexia Nervosa and Related Eating Disorders (ANRED).

Self-help tips: http://www.anred.com/slf_hlp.html

References

• Agras, W. S.,Walsh, B.T., Fairburn, C. G., et al (2000) A multicentre comparison of cognitive-behavioural therapy and interpersonal psychotherapy for bulimia nervosa. Archives of General Psychiatry, 57, 459-466.
• Bacaltchuk J., Hay P., Trefiglio R. Antidepressants versus psychological treatments and their combination for bulimia nervosa (Cochrane Review). In: The Cochrane Library, Issue 2 2003. Oxford: Update Software.
• Bissada H. et al. Olanzapine in the treatment of low body weight and obsessive thinking in women with anorexia nervosa: a randomized, double-blind, placebo-controlled trial. Am J Psychiatry 2008 Jun 16.
• Eisler, I., Dare, C., Russell, G. F. M., et al (1997) Family and individual therapy in anorexia nervosa. Archives of General Psychiatry, 54, 1025-1030.
• Eisler, I., Dare, C., Hodes, M., et al (2000) Family therapy for anorexia nervosa in adolescents: the results of a controlled comparison of two family interventions.
  Journal of Child Psychology and Psychiatry, 41,727-736.
• Fairburn, C. G., Norman, P.A., Welch, S. L., et al (1995) A prospective study of outcome in bulimia nervosa and the long-term effects of three psychological treatments. Archives of General Psychiatry, 52, 304-312.
• Hay, P. J., & Bacaltchuk, J. (2001) Psychotherapy for bulimia nervosa and bingeing (Cochrane Review) In: The Cochrane Library, Issue 1.
• Lowe, B., Zipfel, S., Buchholz, C., Dupont, Y., Reas, D.L. & Herzog, W. (2001). Long-term outcome of anorexia nervosa in a prospective 21-year follow-up study. Psychological Medicine, 31, 881-890.
• Luck A.J., Morgan J.F., Reid F. et al. (2002) The SCOFF questionnaire and clinical interview for eating disorders in general practice: comparative study. BMJ, 325, 755-756.
• Milos, G., Spindler A., Schnyder, U. & Fairburn, C.G. Instability of eating disorder diagnoses: prospective study. British Journal of Psychiatry, 187, 573-578.
• Theander, S. (1985) Outcome and prognosis in anorexia nervosa and bulimia. Some results of previous investigations compared with those of a Swedish long-term study. Journal of Psychiatric Research, 19, 493-508.
• Senior R; Barnes J; Emberson J.R. and Golding J. on behalf of the ALSPAC Study Team (2005) Early experiences and their relationship to maternal eating disorder symptoms, both lifetime and during pregnancy. British Journal of Psychiatry, 187, 268-273.

Produced by the Royal College of Psychiatrists' Public Education Editorial Sub-Committee.

Series Editor: Dr Philip Timms
Expert review: Dr Jane Morris
User & Carer input: Royal College of Psychiatrists' Service User Recovery Forum

© Illustration by Lo Cole: www.locole.co.uk

This leaflet reflects the best available evidence available at the time of writing.

© February 2013. Due for review: February 2015. Royal College of Psychiatrists.This Leaflet may be downloaded, printed out, photocopied and distributed free of charge as long as the Royal College of Psychiatrists is properly credited and no profit is gained from its use. Permission to reproduce it in any other way must be obtained from the Head of Publications. The College does not allow reposting of its Leaflets on other sites, but allows them to be linked to directly.

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