Eating disorders

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About this leaflet

We hope that this leaflet will be helpful if:

• you feel that your eating or dieting may be a problem
• 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.

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

• the symptoms of anorexia and bulimia are often mixed - some people say that they have "bulimarexia"
• the pattern of symptoms can change over time - 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 height
• 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.

When does it start?

Usually in the teenage years. It affects around:

• 1 fifteen-year-old girl in every 150
• 1 fifteen-year-old boy in every 1000.
• It can also start in childhood or in later life.

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 can't stop thinking about food.
• You become more afraid of putting on weight, and more determined to keep your weight well below 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 develop some of the symptoms of bulimia. Unlike someone with Bulimia Nervosa, your weight may continue to be very low.

Bulimia Nervosa

What are the signs?

You find that you:

• worry more and more about your weight
• binge eat (see page 6)
• make yourself vomit and/or use laxatives 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.
• Not grow to your full height.
• 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
• damage your kidneys
• have epileptic fits
• be unable to get pregnant.

If you use laxatives regularly, 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 slip into 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 can express your feelings, or have any say in family affairs.

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.

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 body building, wrestling, dancing, swimming, and athletics.
• 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?

A 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 a 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 a problem with your eating.

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.
• 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.
• 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.
• 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).

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 can be a lifeline.
• Avoid websites 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.

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.

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, school, 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 to feel better, you will need to get back to a healthy weight. You will need to know:
  • what is your healthy weight?
  • how many calories are needed 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 sense of self-esteem.
• 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. They 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 supplements.
• 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.

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 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 five to six 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.

NHS Direct

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

Bodywhys – The Eating Disorders Association of Ireland
Tel: 01 2834963
Helpline: 1890 200 444
Email: info@bodywhys.ie

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

Online CBT resources

Overcoming Bulimia

http://www.overcomingbulimiaonline.co.uk

Overcoming Anorexia

http://www.overcominganorexiaonline.co.uk

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).

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.
www.update-software.com/abstracts/
ab003385.htm

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.

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