ANOREXIA AND BULIMIA

Royal College of Psychiatrists

Introduction

Everybody eats. We do so both because we need to and because we enjoy it. However, as with all human behaviour, there are huge differences between people. Some eat more, some eat less, some put on weight easily, others do not. And some people go to such extremes that they harm themselves, by eating too much or too little. As a result they may harm their health and come to the attention of doctors. This text deals with anorexia nervosa and bulimia nervosa.

Although it is easier to talk about them as different conditions, individual patients often suffer from symptoms of both. Indeed, it often happens that bulimia develops after a period of months or years of anorexic symptoms. Women suffer from these disorders 10 times as often as men, and so this article refers to the sufferer as "she". Although often thought of as adult problems, these disorders most often start in the teenage years while the sufferer is still at home.

Anorexia

The main symptoms of anorexia are:

• fear of fatness
• under-eating
• excessive loss of weight
• vigorous exercise
• monthly periods stop

Anorexia usually starts in the mid-teens and affects one fifteen-year-old girl in every 150. Occasionally it may start earlier, in childhood, or later, in the 30s or 40s. Girls from professional or managerial families are perhaps more likely to develop it than girls from working-class backgrounds. Other members of the family have often had similar symptoms.

Nearly always, anorexia begins with the everyday dieting that is so much a part of teenage life. About a third of anorexia sufferers have been overweight before starting to diet. Unlike normal dieting, which stops when the desired weight is reached, in anorexia the dieting and the loss of weight continue until the sufferer is well below the normal limit for her age and height. The tiny amount of calories that she is taking in may be disguised by the quantities of fruit, vegetables, and salads, that she eats. Also, she will often exercise vigorously or take slimming pills to keep her weight low. Moreover, in spite of her own attitude to eating, she may take an avid interest in buying food and cooking for others.

Although technically the word anorexia means "loss of appetite", sufferers with anorexia actually have a normal appetite, but drastically control their eating. As time wears on, however, the teenage girl with anorexia may also develop some of the symptoms of bulimia. She may then make herself sick or use laxatives as ways of controlling her weight. Unlike sufferers from "pure" bulimia, her weight will continue to be very low.

Bulimia

The main symptoms of bulimia are:

• fear of fatness
• binge-eating
• normal weight
• irregular periods
• vomiting and/or excessive use of laxatives

This condition usually affects a slightly older age group, often women in their early to mid-twenties who also have been overweight as children. It affects three out of every 100 women at some time in their lives. Like anorexics, people with bulimia suffer from an exaggerated fear of becoming fat. Unlike women with anorexia, the bulimic woman usually manages to keep her weight within normal limits. She can do this because, although she tries to lose weight by making herself sick or taking laxatives, she also "binge eats". This involves eating, in a very short time, large quantities of fattening foods that she would not normally allow herself. For example, she might get through numerous packets of biscuits, several boxes of chocolates, and a number of cakes, in two hours or less. Afterwards she will make herself sick, and feel very guilty and depressed. This bingeing and vomiting may raise or lower her weight by up to ten pounds within a very short period of time. It is extremely uncomfortable, but for many it becomes a vicious circle that they cannot break out of. Their chaotic pattern of eating comes to dominate their lives.

Consequences

• The effects of anorexia and bulimia are many, including:
• starvation
• broken sleep
• constipation
• difficulty in concentrating or thinking straight
• depression
• feeling the cold
• brittle bones which break easily
• muscles become weaker; it becomes an effort to do anything
• death

Excessive and repeated vomiting has many effects:

• stomach acid dissolves the enamel on teeth
• puffy face (due to swollen salivary glands)
• irregular heartbeats
• muscle weakness
• kidney damage
• epileptic fits

Excessive usage of laxatives likewise has serious effects:

• persistent stomach pain
• swollen fingers
• damage to bowel muscles which may lead to long-term constipation

There are many different ideas about the causes of these two disorders and it is important to stress that not all will apply to every sufferer. They are discussed below.

Social pressure

In societies which do not value thinness, eating disorders are very rare. In surroundings such as ballet schools, where people value thinness extremely highly, they are very common. Generally in Western culture 'thin is beautiful'. Television, newspapers and magazines are full of pictures of slim, attractive young men and women. They push miracle diets and exercise plans to enable us to mould our bodies to the pattern of these artificial, idealised figures, to conform to the shape the media tell us we should be. As a result, almost everybody diets at some time or other! It is easy to see how this social pressure might cause some young women to diet excessively and eventually to develop anorexia.

Control

It has to be said that dieting can be a very satisfying activity. 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 have managed to control ourselves in a clear, visible way. It can be especially satisfying for girls in their teens who may often feel that weight is the only part of their lives over which they do have any control. So it is easy to see how dieting can become an end in itself, rather than just a way of losing weight.

Puberty

A girl with anorexia may lose or not fully develop some of the physical characteristics of an adult woman, such as pubic hair, breasts and monthly periods. As a result, she may look very young for her age. Dieting can therefore be seen as a way of putting off some of the demands of maturing, particularly the sexual ones. Unfortunately, this condition makes it difficult for her to develop the maturity and self-awareness that come from facing and dealing with the problems of growing up.

Family

Eating is a most important part of our lives with other people. Accepting food gives pleasure to whoever is providing it, refusing it will often cause offence. This is particularly true within families! Some children and teenagers seem to find that saying no to food is the only way they can either express their feelings or have any influence in the family.

Depression

Most of us are familiar with the experience of eating for comfort when we are upset, or even just bored. Many sufferers with bulimia have depressive symptoms and it may be that their binges started off as a way of coping with feeling unhappy. However, feeling stuffed and bloated will make these feelings worse, while vomiting and purging leave a feeling of guilt and wretchedness.

Upsets

We all have different ways of reacting to the bad things that happen to us in life. For some people, anorexia or bulimia seem to be triggered off by an upsetting event, such as the break-up of a relationship. Sometimes it need not even be a bad event but just an important one, like marriage or leaving home.

Seeking help

In anorexia, it is usually family members who realise that something is wrong when they notice their sister or daughter is not only thin but continuing to lose weight. Although to others this weight loss appears alarming and excessive, the sufferer will hardly ever admit that there is a problem. She continues to believe that she is over-weight. In fact, even others may not recognise the problem for some time because of the large amounts of "healthy" (but of course non-fattening) foods that she eats.

In bulimia, the sufferer often feels guilty and ashamed of her behaviour, and may go to great lengths to hide it. This is despite the fact that eating huge amounts of food and then vomiting it back up is extremely time-consuming and exhausting. It may affect her performance at work and will certainly make it difficult to lead an active social life.

So, it can be a huge relief finally to have to admit to the problem. She may often be forced to do this by changing circumstances, such as a new relationship or living with other people.

Recognition

The first step to treating a disorder is recognising it. It is much easier to help somebody with anorexia or bulimia if the problem is spotted and dealt with quickly. The longer that it remains unrecognised, the worse the problem tends to become, and the harder it is to help. Anorexia can be life-threatening, so it is important to see a doctor, the sooner the better.

Referral

Once the problem is recognised, the sufferer should be seen by a psychiatrist or psychologist who has experience with these disorders. Your family doctor will know who to contact. Although until recently there has been a tendency to admit people with anorexia to hospital, most can be treated as out-patients if the weight loss is not too severe.

Assessment

The first step the psychiatrist will take is to have a long talk with the patient to find out when the problem started and how it developed. This will involve discussing many aspects of her feelings and her life. She will need to be weighed. Depending on the loss of weight, a physical examination and blood tests may be necessary. With her permission, the psychiatrist will almost certainly want to talk with her friends and family members, to see what light they may be able to shed on the problem.

Treatment
Anorexia

If someone has become excessively thin and her periods have stopped, it makes sense for her to try to get back to somewhere near an acceptable weight. To help with this, both she and her family will first need information. What is a "normal" weight for her? How many calories are needed each day to get there? For many sufferers, the most important question is, "How can I make sure that I don't shoot past that weight and become fat?".

In anorexia, the patient has excessive control of her eating. How can she ease up? For youngsters still living at home, it is the parents' job to watch over the food that is eaten, at least for a while. This involves both making sure that she has regular meals with the rest of the family, and that she gets enough calories. Mounds of lettuce can be very deceptive. It is also important that the family see the psychiatrist regularly, both to check on weight and for support, since having an anorexic in the family can be extremely stressful. For most sufferers it is important to discuss things that may be upsetting them (e.g. boys, school, self-consciousness, family problems, etc).

Only if these simple steps do not work, or if the weight loss threatens life, is admission to hospital usually considered. In-patient treatment consists of much the same combination of dietary control and talking, only in a much more structured environment.

Bulimia

Here, the priority is to get back to a regular pattern of eating. The aim is to maintain a steady weight on three meals a day at regular times, without either starving or vomiting. Sufferers are usually older than anorexics and not living at home, so the emphasis is more on their keeping diaries of their disordered eating habits and developing self-control. Again, dietary information needs to be given so that the sufferer does not get disheartened by gaining too much weight.

The other important part of treatment is psychotherapy - talking about things in the past or the present that may have a bearing on the eating disorder and other personal difficulties. For those sufferers with depression in addition to their bulimia, antidepressant medication may be necessary.

Self-help

Having seen a doctor or specialist, it may be helpful to join a self-help group in which other people share similar problems. These groups can provide both information and support during the difficult times that everybody with these problems goes through. Your family doctor should be able to recommend a suitable local group.

Reading can help to give the information needed to eat sensibly, and to know what a reasonable weight is.

Useful organisations

The following organisations offer help and advice:
Eating Disorders Association
Sackville Place
44 Magdalen Street
Norwich
Norfolk
NR3 1JE
01603 621414

The Priory Centre
11 Priory Road
High Wycombe
Bucks
HP13 6SL
01494 21431

Society For The Advancement Of Research Into Anorexia
Stanthorpe
New Pound
Wisborough Green
Billingshurst
West Sussex
RH14 OEJ

Books

The following books are recommended:

• "A To Z Of Anorexia Nervosa", from the Eating Disorders Association (see above)
• "Anorexia Nervosa And Bulimia - How To Help", by M Duller and R Slack, published by Open University Press
• "Anorexia Nervosa", by R L Palmer, published by Penguin Books