Binge Eating Disorder in Young Men and Anorexia During Pregnancy

Dr Jane Morris hears a young man discuss his binge eating disorder and reflects on the feelings of powerlessness, guilt and shame surrounding eating disorders. And a mother tells us about her experience of anorexia nervosa during pregnancy, how health services responded, and what life is like now. 

For more resources on eating disorders, please see this page. 

Transcript

Ella Marchant: Hello, and welcome to the Royal College of Psychiatrists podcast with me, Ella Marchant. The first week of March marks National Eating Disorders Awareness Week here in the UK, which serves to bring focus, education, empathy to people living with eating disorders and the people who support them.

Binge eating disorder was the last major eating disorder to enter any official classification systems in mental health. Historically, in 1959, psychiatrist and researcher Dr Albert Stunkard first labelled this as night eating syndrome. More recently, it was referred to as non-purging bulimia. Many people who suffer from binge eating experience shame, loss of assertiveness, irritability and depression.

Talking on the podcast, we have Dr Jane Morris, an author and psychiatrist working in eating disorders in Scotland; and we have Abi Reynolds, she experienced anorexia nervosa for the first time in her 30s and throughout her second pregnancy. Now, we will hear a first-person account from a young man called Barry living in the northeast of England who experienced binge eating disorder in his late teens.

Barry: My relationship with food had always been one of overindulgence. I had never been fat as a child or teenager, but only because I had a very active lifestyle during those years. Once I moved to university, I started to struggle more with my mental health, which led to an even less healthy relationship with food. Throughout my first two years at university, I self- medicated heavily with drugs and alcohol, and gained a significant amount of weight. I took a year out from university to improve my mental health and became interested in fitness and bodybuilding.

It was through this that I discovered a dieting method known as intermittent fasting. The basic premise is that if you're fasting for most of the day, it's harder to over-consume in the hours when you can eat. This seemed to make sense to me as it felt easier to just not eat, rather than make a concerted effort to change my diet.

At first, I fasted for 16 hours and following this was allowed to eat at an eight-hour window. Steadily, I began to increase the length of my fasts and I exercised three to four times a week losing a significant amount of weight. However, as I saw changes in my body, it led to an obsession with the fasting element as I believed this was the key to seeing improvements.

As the length of the fasts increased, I started to look unhealthy due to the amount of weight I'd lost. I was fasting for 20 to 24 hours at a time and when I broke the fast, it was becoming difficult to stop eating. I must admit that although I knew what I was doing was not healthy, I wasn't consuming enough calories in these eating windows to put on weight. This allowed me to convince myself that eating until I felt ill or physically sick was fine because the positives outweigh the negatives. I was also getting more attention due to my weight loss.

I was so invested in the fasting and its effects that I continued a cycle of guilt-induced starvation, followed by shameful binge eating for months. I would feel so bad about my inability to control myself that it would lead me to attempt even longer fasts, over 24 hours, which would only lead to a greater rebound once I broke it.

I believe part of the reason I did not realise how bad it was and didn't seek help was that the habits of exercise and fasting had become intertwined in my head. I knew that exercise was healthy, but I thought it was pointless without the fasting. I refrained from telling my counsellor as I was scared he would suggest I stop, which I interpreted as a route to putting back on all the weight I had lost. I thought eating under control would represent a physical and mental regression.

In terms of how I felt whilst I ate, it was just a relief as I'd starved myself for so long. I would switch from sweet to savory and then back, as this would enhance my appetite and allow for me to indulge the habit for longer; staving off the inevitable guilt that I knew would follow. No one knew how bad the binge eating had become until a friend saw me eating after breaking a 24-hour fast. I was having dinner at his house. We had a full takeaway and then I emptied his cupboards and gorged until I could barely move.

I remember the embarrassment and the shame at the time, which made me start to look from an outside perspective. It also confirmed what I had known for a while - that I didn't want to socialise for the fear I would eat in public and I wouldn't be able to stop. Although this was the starting point of getting my eating under control, I would say that the content I saw online was not helpful.

Fitness influencers who I would see fasting or doing calorie challenges, it would momentarily provide enough of a smokescreen within my own psyche that I could convince myself one more binge wouldn't hurt. However, this would only ever lead to extreme guilt and some depression as well. I was even more ashamed after binging. I decided to make changes to my diet and quit fasting.

However, I still found it difficult to stop eating. It was almost as if my brain had no off-switch. I made a conscious decision to eat high-volume foods and eat them slowly, which allowed my brain to process what I was doing and feel more satisfied. What kept me in the cycle was what other people said. They noticed my body changing. This was a self-esteem boost.

I had never previously received this attention from my peers and other people who had known me a long time. I had struggled with body image and I'd never been very confident. I felt the confidence I had developed was entirely dependent on me maintaining a physical image. Although initially harmless, this led me to believe now people expected me to look a certain way and if I did not live up to that, I would be a failure or no one would believe I'd ever changed.

This undoubtedly caused the cycle to continue, and this mentally remained for some time after the binge eating had been brought under a degree of control.

Ella: Jane, reflecting on that piece we just heard, are these themes of dieting, fasting, self-image, compliments from other people, something that you feel familiar with?

Dr Jane Morris: Oh, yes. We try very hard to see our patients as the individuals they are but by the time people have been taken over by a severe eating disorder, unfortunately, their individuality seems to be wiped out by it. This is just so familiar to me both in terms of everybody I see with eating disorders who's been brainwashed by the disorder to thinking that the way they relate to other people in the world is by their physical appearance. Also, by being absolutely overwhelmed by rules and number-based values and perhaps above all, the most characteristic thing is the guilt and shame.

It's bad enough what Barry is having to put himself through, but he hates himself throughout. Not only does he seem to hate his body size and shape, but he hates what he has to do to try and take control of it and then he even blames himself for not being in control. Sadly, this is the final common picture that you tend to see when people do finally come and see professionals like me for help.

I suppose there is one other thing that is particularly characteristic of binge eating disorder, rather than, for instance, restrictive anorexia, which is that this is a young man. Among patients seeking help for, say, anorexia, there's a much greater predominance of women and often even young women. Whereas in the case of binge eating disorders, we're seeing people of both or all genders and at all ages.

The other thing perhaps that people might have overlooked is that he had already been susceptible to alcohol and drug misuse. That seems to be a much more common linkage. The people who are vulnerable to binge eating disorder and to some extent bulimia nervosa, are more likely also to have experienced that kind of vulnerability. Barry is actually describing a very, very classic presentation.

Ella: Abi, as someone who's experienced an eating disorder, was there anything in this young man's account that felt familiar to you?

Abi: Yes, absolutely. Though in my diagnosis of anorexia nervosa rather than binge eating disorder, there really does seem to be so much overlap, particularly in the mental aspects of eating disorders, between the different diagnoses.

I think firstly, this man's description gave a good sense of how all-consuming these illnesses are and the way the behaviours and thought patterns involved can really very rapidly become extremely entrenched. I developed my eating disorder late. I was in my 30s and already a wife and mother, and it really did come out of the blue.

I'd always enjoyed a pretty relaxed and balanced relationship with food and movement, but a combination of very stressful times at home and feeling low in confidence, having put on quite a lot of weight after my son was born, prompted me to try to get myself into slightly better physical shape ahead of trying for another baby.

Within three months of just starting to dip my toe into dieting and running, I had lost a third of my body weight and quite literally thought about food, calories, weight and exercise 24/7. The need to keep the number on the scale going down and the step counter on a fitness tracker going up was utterly compulsive. Within weeks that compulsion dictated every aspect of my life.

Like the man in the account, Barry, described, there is that initial buzz and confidence boost when people start to notice you've lost weight. I never set out to become thin or for people to be impressed at my willpower or discipline, but when suddenly everyone around you is saying how great you look now you've lost weight, how good you are for saying no to cake or I suppose how healthy you are for running everyday, I think subconsciously you do start to absorb the message that you are somehow more worthy or more acceptable.

The people around me were saying how great I looked now I'd lost weight, and how healthy I looked and how disciplined I was for running every day. I definitely started subconsciously to absorb the message that I was somehow more worthy or more acceptable for having made myself smaller, and that I wasn't good enough as I was before.

That I think for me is when I started to become really trapped by the illness because I felt like my productivity and lovability and value in society were dependant on me sticking to these increasingly inflexible and punishing rituals around food and exercise. The longer you're ill, the less you are able to hold onto the objectivity and insight that you do have, and the louder the disorder thoughts become.

Although I was becoming increasingly aware that the intensity of my cognitions around weight and calories were probably not healthy and were demanding so much of my mental and physical energy that my relationships, my social life, my mood, my spontaneity, my creativity were all seriously suffering, the thought of trying to take a step back or to try and restore some balance was utterly terrifying. Because in my mind that would represent me losing control, or giving up or becoming somehow less again.

I think Barry's account also raised the issue of shame really well, and Jane mentioned this too. I'm yet to speak to anybody with an eating disorder for whom shame hasn't played a huge part in their illness. For me, the secrecy, the deceit and really the loss of what I perceived to be my true values and personality, which maintaining my disorder behaviours brought about, caused so much shame, which in turn really fed into the self-critical thoughts which were driving me to sustain these punishing rituals in the first place, to force myself to tolerate excruciating hunger and flog myself endlessly with exercise.

I've experienced binging as well as part of my illness. The sense of shame that comes from that feeling of having lost control, or having been weak or gluttonous, definitely traps you in the cycle of then responding to those binges with restriction or purging because you feel like you're this anomaly. That you're wired wrong and that your appetite is somehow something which needs to be artificially manipulated or dampened to make it acceptable, or normal or comparable to other people's.

Ella: Thank you so much for sharing that personal account. Jane, binging disorder was the last major eating disorder to be given official classification. Could you explain why this is and a bit more about the disorder? Who's likely to have it? What are the symptoms?

Dr Jane: Yes. I think a lot of us, especially in the specialty of eating disorders, can feel quite frustrated with diagnostic classifications. It's actually a way of specialists wrestling very hard to identify the clusters of symptoms that hang together so that we can investigate treatments that work, but they're by no means laws. It's not as if you could do a lab test and find the virus that's responsible for any particular eating disorder.

In the past, we all knew, I think, about the existence of this picture that we now call binge eating disorder, but perhaps we had different names for it. For instance, non-purging bulimia nervosa. In some countries though, it's been very important to make sure that the disorder is named in a classification. The Americans were the first to do this in 2013 because getting your health insurance to pay for your treatment depends on you having a recognised illness.

Now, in countries outside the US, we tend to use the World Health Organization's classification. We've been slower than the Americans and we've only incorporated a diagnosis of binge eating disorder in the past year or so. It's still coming on stream as it were. I guess the advantage to that is that now that we can officially name and even give numbers and letters to what we're dealing with, it may become more visible.

Interestingly, way back in the '80s and '90s, people were already conducting research trials. Whilst the disorder may not have made it into the headline, happily we knew what we were dealing with. There's probably more high-quality randomised control trials and other good research into treatments for binge eating disorders than for, for instance, anorexia nervosa.

Now, there are many reasons why that might be, but it is one of the few bright spots that we can highlight when we're talking about the condition.

Ella: Is binge eating something that you've seen in both men and women?

Dr Jane: Absolutely, and the research bears that out. Both genders or all genders are equally likely to have binge eating disorders and indeed, quite a lot of men have spoken to us about their need for help. Whereas that seems to be far less common, we know, for instance, that certainly more than 1 in 10 of sufferers from anorexia are male, but there are various reasons why they don't come forward for treatment.

On the other hand, in the case of binge eating disorders, there is a clamour for treatment, possibly because the disorder hasn't already got a name for being a particularly feminine disorder. The other thing about binge eating disorder is that classically, people didn't present to our services. They would go to obesity services instead where of course both genders were catered for.

Even now, quite a lot of people still seek help for the overweight aspects of their eating disorder, rather than being able to recognise that the behavioural and emotional side of things not only is equally important, in fact perhaps even more disabling, but also that without addressing the very, very important psychological underpinnings and consequences of their disorder, then treatments for people who have got a more straightforward overweight condition will not work for them.

Ella: You said something very interesting there. You described anorexia as feminine. Is this something that discourages men from coming forward because they see anorexia as specifically feminine?

Dr Jane: Oh, yes, very much so. I think a lot of people feel embarrassed or ashamed to be diagnosed as having anorexia nervosa, which is something we have to work on, but when it comes to men and boys accepting that it's a condition that they have, it's been very, very badly stigmatised. In fact, there are many treatment centres in England that only accept female patients. Of course, there has been a whole, I think, very appropriate feminist input to the management of eating disorders that has emphasised why people who are female, or for that matter any people who do not identify as male, might be more likely to be vulnerable.

Ella: Carrying on from that, Jane, what do you think health services could do to better support people with binge eating disorder? Why is it under the radar? Is it because it's a more recent classification?

Dr Jane: Yes, I think that's one reason. I think that any recently recognised disorder tends to experience a bit of a lag before service provision catches up, but in the case of binge eating disorder, it's more complex than that. I think anorexia is far more visible because you can see the consequences. In the case of binge eating disorder, it's not necessarily clear that just because somebody may be a little overweight, some not and others may be frankly, obese, it doesn't stand out as necessarily a hallmark of the person having an eating disorder. It's a lot less visible.

Also sadly, when services are strapped for cash, they focus on the conditions that are more likely to bring about death. Anorexia nervosa is famous for having a very high death rate, whereas the physical consequences of binge eating disorder are subtler, so they tend to get seen as a milder disorder because of the lower mortality rate.

Then finally, there's another complexity here, which is that, as I said before, people may attend obesity services- where there are such things- rather than services that are based on the mental aspects of the condition. There's been a very, very unfortunate divide. People have each criticised the other specialty for not taking account of both sides of the picture.

In mental health, we've not had very great success in helping people who are overweight to lose weight. Whereas on the other side of things, the people who focus on weight loss above all have not had very good results in minimising the behavioural and emotional effects. It's only been fairly recently that we've started to work together.

I think that's absolutely crucial because we're now seeing that good psychological treatment can actually contribute to modest weight loss and above all, prevention of further weight gain; and far, far more importantly, an overall improvement in quality of life and relief of suffering. I think we need to work together. Eating disorders' services are still very small and very under-resourced.

On the other hand, the movement for preventing and treating obesity is much better-resourced, although it doesn't always consist of the expertise that we can bring it from eating disorders specialties. I think for me the message is we need to work together.

Ella: Abi, talking about health services a little bit more, could you tell us about your experience with health services and how you feel you could have been better supported?

Abi: I think for me, my experiences of health services form a bit of a tale of two halves. During the first year or two after I developed anorexia and although at the time, I couldn't have labelled it all and I wasn't totally clear in my own mind what was going on, I had a few fairly damaging, I suppose, interactions with healthcare professionals.

Having lost a significant amount of weight in a very short space of time, my body was definitely giving me signs that it wasn't happy. I lost my periods very quickly, and my husband and I were trying to conceive so that was problematic. I was having trouble sleeping. I was feeling extremely irritable. I just felt really detached from my family and friends and what had been my life for the 30 years before I became ill.

Although I think I knew deep down that these symptoms were a result of not eating enough and of exercising excessively, I was so terrified of the idea of having to gain weight- proper being-chased-by-a-lion level of terror- that there was no way I could have told a doctor, or at that stage any other person really, that I had an eating disorder. I did know something needed to change.

I went to my GP and essentially, presented my symptoms from the angle of struggling with infertility. I told her that my BMI had gone from within the overweight area of the chart to bordering on the underweight zone in the space of a few months. I asked if gaining a bit of weight back or cutting down my exercise a bit might help me get my periods back.

I think in hindsight, I was just absolutely desperate to be told that that's what I needed to do; that I needed to eat more. Because I couldn't find it within me to feel deserving of eating more or of giving up the punishing exercise regime, which was quite literally ruining my life. She simply said, "Oh, we never tell anyone with a technically healthy BMI to eat more or move less. That's the opposite of what we're here to encourage." Then she just told me that my body would get used to my new lower weight and everything would get back to normal.

I left that feeling pretty dismissed and I think probably inevitably, my illness continued to escalate. A year later, I went back to the doctor and told her I still wasn't having periods. Again, she didn't ask anything at all about my relationship with food, or my mental state or anything else, really. She just recommended I see a fertility specialist, which I did. I had scans and all sorts of things, but was just told I should start on, of course, a fertility drugs.

I'd conceived my first child very quickly at my much higher weight, so my instinct told me that it wasn't really a fertility issue at heart but an absence of periods because of being it to suppress body weight for me, even if I still happened to fall into the healthy part of the BMI chart. I managed what felt like the most excruciating feat of gaining a few pounds back.

By some miracle, I conceived on my first cycle. I was obviously thrilled but unfortunately, because I had barely begun to tackle any of the disorder behaviours I was trapped in, my illness became much more severe very quickly during my pregnancy. Because in order for me to keep the number on the scale the same or going down despite the growing baby inside me, I had to restrict and exercise even more intensely.

Although my baby was growing fine, I was personally losing significant amounts of weight. I reached out a lot to my midwife about how much of a struggle I was finding it to eat and rest as I knew I needed to for the baby, but my increasingly desperate concerns and pleas were repeatedly dismissed with reassurances of, "Well, your baby is growing fine so you must be managing."

That just made me feel so ashamed and isolated because I continued to have a battle raging in my head every time I thought about eating more or exercising less. It kind of came to a head when I saw my consultant obstetrician when I was six months pregnant. I told her, I said it out loud, I said, "I definitely have an eating disorder," and I told her I was really worried about mine and my baby's health. She quite literally said, "Well, you just need to park your eating disorder until after the baby's born." As if I wouldn't have parked this life-limiting mental illness years earlier if it were that simple.

I think just the idea that you can have a serious mental illness and just be asked to press pause on it at will is pretty ridiculous and just really illustrates the lack of understanding around these disorders. I mean, she wouldn't have said to someone with cancer, "Well, you just need to stop having cancer for the next three months, please."

Then by a month later, so when I was really heavily pregnant, I was so terrified for my baby's safety and I think even more so for my mental health, that I walked into my GP's office sobbing and I just said, "I have an eating disorder and I'm really scared my baby is going to die." I think that's when the second half of my story of services- the much more positive part- kicked in. I was referred urgently to eating disorder services and was diagnosed with anorexia and because I was pregnant, I immediately started to receive intensive community-based treatment.

Although honestly, I've never been more scared in my life than when I started having to challenge the eating disorder, it was at the same time such an immense relief to have someone take my illness seriously, and to be told that it was a real thing that there was treatment available for and that someone was going to help me and my baby. I had amazing support from an MDT of psychiatrists, therapists, dietician, assistant psychologists and nursing.

I'm now two years into treatment and recovery, and apart from one five-week stint in a mother and baby mental health unit when I needed inpatient treatment but there was an endless waiting list for the eating disorder unit and my BMI wasn't low enough to warrant a bed; apart from that, I've been hugely fortunate to have been able to stay at home with my children throughout treatment.

I honestly cannot praise the community team at NHS Lothian highly enough. I think their empathy and knowledge, the respect and flexibility and professionalism that has underpinned my care has saved my life, both literally and I think more importantly I suppose, in terms of allowing me to actually build back a life truly worth living.

Ella: Thank you so much for sharing your personal account, Abi. It's quite distressing to hear that your BMI wasn't low enough to get you the help that you needed.

Abi: It's so dependent on each individual, and now I know for a fact that my body at BMI 20 does not function properly. [chuckles].

Ella: Absolutely, and it kind of builds on what Jane was saying before, when they prioritize people where they can visually see that there is something wrong, rather than looking at the mental health of someone. Jane, in the personal account we heard at the beginning about binge eating, the young man spoke a lot about guilt. Why do you think guilt is such a huge part of eating disorders?

Dr Jane: It's a really difficult question. I spent a lot of time thinking about both guilt and shame, and it seems to figure very strongly in many, many different mental health disorders. Not only eating disorders, but I've never come across disorders- perhaps OCD- but otherwise, this seems to be the field in which guilt and shame are most pronounced. I think it may be because an eating disorder, it's not really a disorder of eating at all. Eating is just one of those things that has to be tackled by people seeking to change their body shape, and the reasons for doing that come down to values and relationship to what society respects.

I completely agree with Abi that we should not be making BMI, or indeed any other number, a kind of binary way of describing whether people do or don't get a diagnosis, and whether they should or not have a particular kind of treatment. Luckily, the Americans have now taken BMI out of the diagnosis of anorexia nervosa.

The important part of deciding whether you have anorexia or not is a combination of the classic eating disorders' state of mind together with having lost a significant amount of your bodyweight or failed- if you're pregnant or if you're a growing child- failed to increase your weight in a healthy way. I think that's the way we all ought to go.

When it comes to binge eating disorder of course, you're looking at a slightly different conundrum, really. In that instead of the person saying to you, "Oh, well, your weight isn't low enough to get treatment," people are saying to you, "Well, if you do have a weight problem, it's that you're overweight and you should deal with that."

I'm horrified by how popular weight loss methods do seem to rely a lot on shaming people. People are encouraged to stick a photograph of themselves at their most unattractive on their fridge door and that sort of thing. There is a whole conspiracy of society shaming people over fatness, and I don't think that helps. When people internalise that shame, it's almost as if they've changed their value system.

We all depend on feeling guilt and shame to guide us to the fact that we're going against our own value system. It's a necessary human emotion. If you do something very unkind, you feel guilty and it tends to stop you from behaving in the same way again. If you carry on doing something unkind over and over, you end up feeling not so much guilt but a kind of persistent shame and hopefully, that would lead you to seek help to change that.

When it comes to this pathological guilt and shame, I think that's because the disorder imposes a different value system. By living a normal life, you're exposing yourself to the guilt that you've betrayed this new pathological system that dictates to you that the rules are all about over-exercising, or checking yourself all the time or starving yourself or making yourself sick. Then on top of that because you're still a human being and you still have your beloved old human value system, when you do obey the eating disorder voices, then you're actually betraying your real value system. You just can't win.

I think- but Abi will be able to say a bit more about this from recent experience, but I think that people are trying to serve two masters or even two gods, and they cannot put a foot right so they're just immersed in constant guilt and shame.

Ella: When you were describing anorexia there and you mentioned OCD a little bit earlier on as well, it made me think about how closely linked anorexia and OCD actually are because they both involve a huge amount of intrusive thoughts and compulsions as well. People with OCD tend to feel quite chronic guilt.

Dr Jane: Yes. There is actually a school of thought, which I must declare I subscribed to, which says that for many people they're the same illness, with obviously the physical consequences of anorexia superimposed and then bringing their own extra psychological consequences. I would say that many, many of my anorexic patients have anorexia as a form of OCD and often, they have suffered from different pictures of OCD in their lives.

Sometimes, when they get better from anorexia, they realise that there are other obsessive compulsive features to their behavior that they want to address as well. Sometimes that isn't the case, but I agree they are very closely linked.

Ella: That's really interesting. Thank you so much. Abi, in the personal account that we just heard at the beginning, the young man was speaking a lot about guilt. Why do you think guilt is such a huge part?

Abi: I can 100% confirm what Jane was saying about how once you have an eating disorder, you do have these two entirely conflicting sets of values. You're in a constant tug of war and you feel like you cannot please either master, really. You can't - You feel like you're failing at everything. You're either failing at being a decent human being, the loving kind of - whatever - partner, mother, friend, colleague that you would want to be and wanted to be before your eating disorder, but you're also - if you're, I suppose, allowing yourself to be that person and by going against the eating disorder, you just get a huge wave of guilt.

In my case, every time I wasn't moving or every time I was eating, it is - That's really how I can describe it; it's being in a constant tug of war. I think for me, there was and still is a huge amount of guilt around how I behaved as a result of my illness. The level of fear of weight gain and therefore, I suppose, of anything which might potentially cause it, whether that be not exercising as much as I felt I had to that day or eating when I wasn't so desperate with hunger that I simply couldn't help it, it consumed me to such a degree that I honestly felt to my very core that weight gain would be a fate worse than death.

For me, I suppose that became a reality and that I became suicidal at the prospect of having to try and challenge the eating disorder. There's just - Yes, you feel every fibre of your being is telling you that weight gain is to be avoided at all costs, and those costs are really high. I lied about what I had or hadn't eaten to the people I loved. I avoided eating with others in case they pressured me to eat more. I turned down social invitations and lied to people about what I was doing so that I could spend every second possible moving in order to compensate for the little food I was eating.

The anorexic thoughts and I suppose, the obsessive-compulsive ruminations that run through my head every second of the day was so loud, I genuinely could barely stand to try and hold a conversation with someone. I was distracted and irritable and cold and hungry, and I couldn't be present with the people I was so close to before I became ill- my husband, my children, the most important people in my life- and so much guilt comes from that.

The feeling that you are so far removed from your real meaningful life and morals, and like you're watching your own life from the other side of an impenetrable sheet of glass, makes you feel like a terrible person. You can't fathom how this force, this sort of evil dictator has taken you over to such an extent that you are totally unrecognizable to yourself and to others, physically and mentally.

I think for me the biggest source of guilt was the fact that I felt so unable to challenge the cognitions even when I was heavily pregnant. I had this ferocious, instinctive, protective love to my unborn child, and yet this illness was making me starve myself and put us both at risk. I felt utterly hopeless because there I was thinking it was impossible for anything to contend with the love a mother feels for her unborn child. Yet, here I was gripped entirely by something so at odds with keeping my baby safe.

I distinctly remember when I was six months pregnant, there was a day when I hadn't felt the baby move and I was really worried something had gone wrong. I was sick with fear. I ended up calling the maternity unit and they said, "Oh, don't worry. Just drink a cold bottle of full-sugar Coke and just wait to feel the baby kick." So simple, [chuckles] and yet I genuinely felt like I was being asked to run into a fire.

I had already consumed my kind of measly self-allotted allowance of calories for that day, and this bottle of Coke would tip me into what I saw as weight-gain territory. I was paralysed with fear. I sat for the best part of two hours staring at this small bottle of Coke, so desperate to make sure my baby was okay, but feeling like there was a physical wall stopping me from doing what I needed to do to just drink a bottle of Coke.

I drank it, in the end, but I was consumed by guilt for days. It was both guilt at having hesitated even for a second about drinking it but honestly, even more guilt at having had more calories than I'd burned off that day. I couldn't shake it off. I felt like I had failed on all counts; failed as a mother, failed as - I suppose the puppet to this eating disorder - puppet master. The guilt just feeds into the self-loathing, which just drives those behaviours.

Ella: That sounds like such a horrible experience, Abi, and it sounds like you were very, very conflicted during that time.

Abi: Yes. I mean, it was so terrifying to feel like there simply isn't enough of the real you left to live in a way that reflects the person that you were before and the person that you know you want to be. I suppose how I view my eating disorder has changed at different periods of the illness. At times when I've been really psychiatrically overwhelmed, it has felt like I was possessed. That something else had taken over my body and mind. Then at less-intense times, I suppose I saw it more as sort of a devil on my shoulder trying to tempt me to do the wrong thing.

I mean, there's the internal conflict which rings around your ears 24/7, and I'm talking day and night. There were months and months where I just didn't sleep because you just start - You cannot switch off the thoughts. I remember just in the middle of the night just saying to my husband, "Look, something really awful is going on in my head and I can't switch it off. If I could just switch it off for 20 minutes, then I could work out what to do about it," but you can't.

I think you've got this certain amount of insight and objectivity, but you're unable to tap into it because it feels like this external force is putting something between you and your right mind, I suppose.

Ella: Thank you to all of our speakers today for sharing their stories of eating disorders and for helping to educate us on what it can feel like to have these experiences. If you would like to know more about eating disorders, working as an eating disorder psychiatrist or how to get support, please head to our website at www.rcpsych.ac.uk.