EATING DISORDERS

Eating disorders are the outward expression of deep psychological and emotional turmoil. Sufferers turn to food and eating as a means of expressing their difficulties. While on the surface the issue appears to be about food, at a deeper level eating disorders express a fundamental unhappiness which may originate from a number of different sources.

An eating disorder can therefore be seen as:

• an avoidance mechanism, in that the sufferer, by concentrating all his/her energies round food and eating, can avoid facing other more painful issues in his/her life
• a way of coping with a life which otherwise appears to be fraught with insoluble problems
• a way of exerting a control over his/her own body, and life in general, in a situation where the sufferer feels other people are controlling them
• a reaction to unresolved stress which my go back many years

Thus eating disorders are fundamentally not disorders of eating; they indicate and express a disturbed perception of self. The precise causes are probably different for each individual.

The term "eating disorders" covers a wide spectrum of disturbed eating behaviour, and the exact relationship between these categories is unclear. This article is about two specific eating disorders, i.e. anorexia nervosa and bulimia nervosa. Many of the underlying issues are also relevant to other eating disorders. Taken together people with eating disorders share many features including:

• a fear of becoming fat and a drive to become thin
• an obsession with food, weight, calories, etc.
• the reliance on eating and/or refusal to eat, in order to cope with emotional discomfort, stressful life events, and developmental challenges
• the fact that female sufferers outnumber males at least 9 to 1
• an increased incidence of depression, obesity, substance abuse, and eating disorders, in the families of sufferers
• a world view that values external appearances over personal integrity

Therefore, anorexia nervosa and bulimia nervosa are both emotional disorders which focus on food and its consumption.

Anorexics practice self-starvation, and say that they are looking and feeling better as a result. Bulimics binge and then purge themselves as a means of weight control. They see this as a means of enjoying food without suffering any ill effect (i.e. weight gain) from it. Like the heroin addict (who at first seizes the drug as a means of pleasure or escape from troubles, and is then seized by the drug as it takes control), the individual with an eating disorder thinks he/she has a solution to their problems, but then the solution then becomes a problem, which the sufferer cannot recognise nor change.

Though these brief descriptions sound very different, doctors are not yet sure whether anorexia and bulimia are separate illnesses or variations of the same one. It is known that many bulimics have been anorexic at an earlier time in their lives, and that some anorexics also suffer from bulimic symptoms. One thing that is common to both illnesses is that the majority of its victims are female; more than nine out of ten reported cases are women.

Although these illnesses will be described separately, it should be remembered that both are only different solutions to the same problems of living with oneself and living with others. Although sufferers are referred to as women, the same information applies to male sufferers.

Individuals with an eating disorder blame most of their problems on their appearance. If they weighed just a few pounds less, then everything would be perfect. They have confused who they are, with what they look like. Even more serious, they often lose sight of what they actually look like, and can no longer see themselves as others see them.

Anorexia nervosa

Anorexia nervosa literally means "loss of appetite for nervous reasons". The name itself is misleading because sufferers from anorexia nervosa have not lost their appetite at all. What they have lost is the ability to allow themselves to satisfy their appetite.

It is important to understand that anorexics are not trying to starve themselves to death. On the contrary, anorexia is an attempt to cope with living. It is a solution which is adopted for difficulties which seem impossible to resolve. Anorexia is an expression of conflicts about dependence, autonomy, and control, and sufferers are particularly terrified of being out of control. It is because of this fear that food and weight loss assume such importance. This seems to be one area of life which sufferers feel able to control. The anorexic conceals her deep rooted fear of failure with her success at losing weight. The anorexic attitude towards life combines a very low self-esteem with high expectations and perfectionism. Anorexia is not merely a silly obsession with slimming, or a misguided wish to be slim and beautiful. Rather it is a desperate bid for psychological survival.

Incidence

People of all ages may show symptoms of anorexia, and cases of sufferers aged from six to sixty have been reported. Although both males and females suffer from anorexia nervosa, it is very much more common amongst women than men. Statistics show that the condition is most commonly found amongst girls, adolescent or slightly older. Sufferers tend to be high achievers who are emotionally dependent on their parents. Although families do not seem to be especially different from average, anorexia nervosa seems to be more common in families where academic and social achievement tends to be highly valued, but it does occur in all social and ethnic groups.

Studies of schoolgirls have shown that between the ages of 16 and 18, about one in every 200 girls suffer from the condition. The incidence is at its highest in the independent sector of education although it is by no means confined to it.

Symptoms

The central symptoms of anorexia are weight loss and a great preoccupation with weight. Anorexics are terrified of being or becoming fat. Life for them becomes so dominated by calories, food, and avoiding food, that sufferers quickly become secretive and socially isolated. They may become hyperactive and restless, and in women menstruation ceases. Many anorexics suffer the symptoms of starvation: severe constipation; abdominal pain; dizzy spells; swelling, especially of the stomach, face and ankles. A growth of downy hair on the body and loss of hair on the head are not uncommon. The consequences of poor peripheral circulation are often obvious. These include extreme sensitivity to cold and dry, and rough, discoloured skin.

A distorted perception of both self and life can make it difficult for sufferers of anorexia nervosa to accept help. As the underlying emotional difficulties are resolved, however, and a more settled pattern of eating returns, these side-effects usually disappear with time. The human body has remarkable tolerance, and can usually return to normal with few or no scars to reflect the past.

Perception

From a distance, anorexics appear to be efficient, decisive, and confident. Closer scrutiny reveals that they are fearful that no matter what they do, it will not be good enough. Anorexics are very concerned with success; they want to be good at everything they do. Unfortunately, no matter how much they succeed, from their point of view it is never enough. In their eyes, other people are always more talented, more intelligent, more attractive. They believe that other people, including their families and friends share this view. Because they are measuring themselves against a standard which is far beyond what is realistic, they are never happy, and see themselves as failures.

The typical picture of someone who might develop anorexia is of an introverted, conscientious, and well behaved child who has seldom presented problems either at home or school. Many surveys note high intelligence and superior scholastic performance, but the two overwhelmingly consistent personality traits are those of perfectionism and obsession. It is when these characteristics are placed within the context of dissatisfaction with life, or when life presents an individual with events for which their existing skills are inadequate, that anorexia becomes a viable alternative.

By concentrating on her fatness (or rather thinness) the anorexic avoids concentrating on her self, her relationships with others, her emotions, and her limitations. Anorexia is only one solution troubled people use as a means of coping with their problems. Some people drink too much, others take drugs, others become more overtly distressed or suicidal. These can all be seen as solutions to issues and difficulties connected with accepting who one actually is, and working out one's own strengths and limitations.

Families

While certain patterns can be found amongst the families who produce an anorexic member, it is important to remember that all families are different and that every family, however fortunate, has its own internal problems and times of difficulty. While it would be quite mistaken to assume that families are to blame for anorexia, certain trends have been noticed by researchers which may contribute to the development of anorexia.

People who develop anorexia have often been unusually easy children. They do not answer back and tend to make less fuss and get less angry than their siblings. Looking back on their childhoods, anorexics often say they tried to do what they thought others wanted them to do. They were supposed to be "good" and "happy" children, so that these were the characteristics they tried to display, whether or not this corresponded to their real feelings.

Most anorexics as teenagers are good students and high achievers. They are anxious to please their parents and teachers. The key word here is "anxious". The young anorexic is not just obedient. She worries about her ability to live up to other peoples expectations and wishes, and fears that if she fails they will not love, respect, or want to know her. Every adolescent and adult shares these fears to some extent, but the anorexic is overwhelmed by them and finds them hard to talk about. She feels that the fears themselves will be ridiculed, and will be the cause of her rejection.

Some experts have found the parents of anorexics to be highly demanding. Parents want and expect their children to be successful, but the children may not feel that these expectations are accompanied by enough love or support for themselves as people. The anorexic child often does not know and cannot hear that she is loved as a person. She feels that she is valued for her achievements, but does not feel that her parents really care about her. At some point it all becomes too much and the anorexic feels the need to demonstrate the kind of self-discipline of which she is capable; her own body becomes her greatest achievement.

Other researchers see anorexia as a compromise between equally strong desires for dependence and independence. Many anorexics come from tight-knit families that encourage their children to stay close. The potential anorexic may want to go her own way and prove that she has value outside the family, but at the same time she feels incapable of doing so and wants to be protected and cared for. Unconsciously, she chooses the symptom of anorexia to resolve this dilemma. By her rigid control of her body she is making a clear statement about who is in charge of her life, while at the same time, by becoming ill, she vividly demonstrates how needy and dependent she feels.

Treatment

In order to recover, anorexics must first of all come to accept and begin to like themselves. They must learn gradually to accept their failures and weaknesses and perceive them, together with their strengths, as being the necessary balance for a happy life. This can be a slow process but gradual small changes can be successfully built upon in working towards recovery.

If weight has been allowed to fall to a very low level and the sufferer feels unable to nourish herself at home, a period in hospital may be necessary. Due to a combination of factors (of which inadequate nutrition, environmental stress, and emotional confusion, make the major contributions) anorexics sometimes become very depressed. In such instances, hospitalisation can be useful because it enables nutrition to be monitored while the home environment is remote, and psychotherapy and counselling services are more readily available.

Weight gain alone is not an appropriate goal for treatment. Many anorexics have the experience of gaining weight in hospital only to lose it again when they are discharged. Forcing an anorexic to eat and gain weight may temporarily meet the person's physical needs, but will not form the basis of a long term recovery. Only by treating the underlying problems can the anorexic be helped. Emphasis on weight alone will only result in a relapse.

Hospitals vary in the amount of psychological support given. Some offer individual psychotherapy, while others use a family therapy approach which aims to involve all family members and see anorexia nervosa as a symptom of family distress. Few hospitals have either the time or the resources to offer psychological help for long, if at all. This can be absolutely vital for the recovering anorexic who may find her needs best met by a counselling agency which is not hospital-based.

Not all anorexics either need or wish to enter hospital for treatment. The Eating Disorders Association has been established as a mutual self-help support organisation which co-ordinates a network of local groups to help both those who suffer alone and those discharged from hospital. The association is also happy to offer support to the families and friends of those who suffer from anorexia.

Bulimia nervosa

Bulimia is a condition in which the sufferer binges (eats exceptionally large amounts of food) and then purges herself by use of starvation, vomiting, laxatives, or diuretics. It is a lifestyle which completely controls the sufferer's every waking hour, an existence in which almost every day, to some extent, is spent thinking about shopping, cooking, bingeing, and finally getting rid of food.

Bulimia usually begins between the ages 15 and 20, although before this time many bulimics will have had problems with eating habits or weight, anorexia nervosa, childhood obesity, adolescent weight in the high-normal range, or lifelong fluctuations in weight. In many cases bulimia begins with the institution of a diet following a distressing event (e.g. the break-up of a romance), a challenge (e.g. making the gymnastics team), or any situation that encourages the person to think about body shape and its links with control, popularity, and achievement.

It is probably not coincidental that the peak age of the onset for bulimia, 16 to 18, is a time of transition from high school to college, from the family to independent living. Sufferers of bulimia nervosa become trapped in a cycle which reinforces their already highly developed feelings of guilt, shame, disgust, and self-hatred. They feel great guilt about their bulimia and, while they are often social people to begin with, they are forced into increasingly private lives to avoid the possibility of being found out. This shame and isolation only increase their feelings of inadequacy and unattractiveness.

Because sufferers tend generally to present a public image of self assurance, happiness, and success, bulimia nervosa is a condition which may go undetected for years. The sad fact is that sufferers are desperately unhappy, have an appallingly low self-esteem, and may be exceedingly depressed. Sufferers of bulimia nervosa are usually normal weight, unless the condition has been preceded by anorexia nervosa, and they seem to eat normally when they are with other people.

Causes

Much of what has been said about the anorexic and her family is also true of the bulimic. The bulimic is likely to be a good student or employee and desire a high level of achievement, but at the same time has many self-doubts and feels insecure about her ability to handle life's demands and difficulties. She fears she is inadequate and does not have the tools to reach the goals she has set for herself. She believes she does not measure up in looks or accomplishment to other people, and may experience problems interacting with them because of this sense of inferiority. She wants to be part of the crowd but fears she will not be accepted.

Stress, anxiety, loneliness, and depression, may cause her to eat large quantities of food as a way of releasing the tension. She cannot control her desire for food, but she can control whether it remains in her body. Some people turn to alcohol or drugs when they are under stress, upset, or depressed - bulimics turn to food.

Many bulimics fear that once they start eating, they will not be able to stop. They binge and then purge as a means of giving in to their desire for food and then controlling it.

A binge

A binge is what happens when eating becomes wholly out of control. Enormous quantities of food are consumed in a frenzy, so much so that food may be eaten uncooked or even straight from the freezer. A binge almost exclusively consists of high calorie foods. These are usually carbohydrates and fats in the form of sweets, chocolate, biscuits, bread, pastry, butter, and cheese. There are, of course, many other variations, and food may have been previously selected on a shopping expedition with the binge in mind.

Bulimics loathe the cycle of bingeing and then ridding themselves of food. The purgation, or "cleansing procedure", is frequently perceived by sufferers as a self-inflicted punishment for the gap which separates their public image from their private selves. The latter, already desolate and stricken by feelings of guilt, comes to be regarded with even greater revulsion. Many sufferers have reported that their behaviour, when bingeing, is to them like a hidden side of their personality, a demonic voice which will not release them. They are totally out of control because the "voice" controls them wholly. So powerful can be the compulsion to binge that there are times when quite literally nothing will prevent sufferers from so doing. As a result, regardless of resolution on the part of sufferers to change, the vicious circle can seem to them to be impossible to break.

If sufferers rely heavily on vomiting to rid themselves of food, then teeth are rapidly affected. The constant acidic action erodes the enamel on the teeth and extensive tooth decay soon follows. Other dangers associated with bulimia include: ulcers; stomach and bowel disorders; mouth and throat irritations; and gum disease. Loss of hair is common to bulimics, as is a general feeling of total apathy after a binge. For those using laxatives or diuretics, there may be serious, even fatal, results.

Constant purging and/or vomiting creates severe mineral imbalances in the body, as the delicate balance of many mineral salts (absolutely vital for the body to function) becomes deranged. Fatigue or complete exhaustion follow, and in the most severe cases stupor, coma, and eventually death. This is because the correct balance of mineral salts is vital for the proper functioning of organs such as the heart and kidneys.

Symptoms

The central features are:

• recurrent episodes of uncontrollable overeating
• efforts to undo the effects of binge-eating by self-induced vomiting, severe caloric restriction, excessive exercising, use of legal or illegal appetite suppressants, and/or use of laxatives or diuretics
• chronic anxiety, guilt, depression, and tension

Commonly associated characteristics are:

• drastic weight fluctuation
• impulsivity and emotional instability
• acting-out via substance abuse, theft, self-mutilation and/or promiscuity
• problems with social adjustment
• depression
• a high need to achieve in order to obtain the approval of others
• shop-lifting

Bulimics have periods of over-eating which become out of control. These may follow excessively long periods of starvation. The process of starvation leads to cravings for food, which become so strong the sufferer loses control and "binges". After a binge a bulimic may resort to laxatives or diuretics, as well as vomiting, to get rid of the effects of bingeing. Many bulimics have a previous history of anorexia nervosa and either "discover" bulimia nervosa, or turn to bulimia nervosa, believing it will solve their dilemma of wanting to eat whilst remaining thin. Initially, bulimia nervosa may seem to hold the answer for people who are dissatisfied with their lives and dislike what they are. However, the answer is superficial, and sufferers rapidly find themselves trapped in a dangerous cycle which reinforces self degradation, guilt, and shame. Although some bulimics never experience a real anorexic episode, they nevertheless share the anorexic's abnormal concern about weight and shape, control and lack of control, and fundamental need to accept their imperfections as possible strengths.

Occasionally there are bulimics whose weight swings from high to low over a period of years, a reminder that anorexia nervosa and bulimia nervosa are not mutually exclusive.

Treatment

As with anorexia nervosa, there is no one way of offering help to bulimics. What suits one woman might not suit another, and anyway not everyone has access to all forms of treatment. One of the greatest difficulties facing women wanting help at present is the sheer lack of resources available.

Bulimic women generally experience extreme ambivalence about giving up the symptom, and this is a profound problem for those offering help. In some situations when the sufferer is in a life-threatening condition, or there are other problems involved as well as bulimia, she is admitted to an in-patient hospital programme. But this is not the case for most bulimics.

Unlike anorexics, most bulimics recognise their eating disorder and desperately want help. In another sense however, the bulimic woman's ambivalence about allowing herself to take in anything good can make it difficult to receive help.

Self-help programmes or self-help groups, combined with back up counselling support or therapy, and the motivation of the bulimic herself, can prove a successful way of tackling this very difficult problem.

Neither anorexia nor bulimia can be cured overnight. Recovery is a long hard process, which often requires the bulimic to face those painful issues she has been avoiding by being bulimic. She will experience all sorts of difficult feelings (depression, anger, frustration, rage). She may also need help in re-learning about "normal" eating. The recovered bulimic should also be aware that she needs to develop ways, other than bulimia, of coping with stress.

The impact of society

Our society emphasises thinness. To be thin is thought to be healthy, attractive, and self-disciplined. To be overweight is thought to be lazy, dull, unattractive, and probably incompetent. Thinness is admired, and interpreted by many to mean the person has value for others and values herself. Fatness is frowned on, and interpreted to mean the person has little respect for herself and is not really worthy of respect from others.

Some experts see a connection between our society's ever-increasing emphasis on thinness over the last 20 or 30 years and the dramatic increase in the number of anorexics in that same period. People who are normal weight want to be thin, like the models they see daily in print and on television. People who are thin want to be thinner, like the 14 year old "sex symbol" in the films and on the magazine cover.

To some extent it is true that a person's physical fitness can be an indication of their personality, values, and interests, but when simply being thin is a determining factor in self-analysis or social success, something has gone wrong. When what a person looks like is confused with who that person is, then the values and ideals of a society are being misplaced.

Women sufferers

Some experts on eating disorders think there are social causes for a disproportionate number of sufferers being women. Anorexics tend to be overly concerned with the opinions other people have about them, such as whether they think she is attractive, well dressed, informed, intelligent, and successful. Our society teaches us that we are not "good" people unless someone else says we are; women, in particular, feel this way. All of us are taught that we are not the best judge of our own value, it is other people who determine our worth.

Unfortunately, if your self-worth is based solely on the opinions of others, then you are always seeking their praise, and never getting enough. You are forced into doing things you do not like to do, or that do not make you happy, as that is the only way you can win or maintain their favour and commendation (or, you ignore or mistreat those around you out of the fear of being judged and the desire to maintain distance so that judgement cannot take place).

Women are told that they must be emotionally sensitive and supportive of others. Men are told that they must be the providers of material benefits. Women are brought up believing they will be accepted by men on the basis of their looks and their personalities. Men are brought up believing they will be accepted by women on the basis of their achievements and personalities. Men often become workaholics, women have eating disorders. They are both extremes of very normal desires, desires our society values highly.

Conflicting messages about food and eating put an additional strain on women who, because of their nurturing role in society, have to think about food a great deal. On the one hand they are told they have a right to derive pleasure for themselves and to meet their needs through food, and on the other they are being warned continually to guard against food' s potential for making them unhappy, unfit, and unwanted.

Exciting, new, and miraculous diets, promising weight loss with minimum effort or discomfort are featured every week in various women's magazines, followed by pictures and recipes for delightful, easy to bake treats. As a result, many women worry continually about what they can and cannot eat, and it is not surprising that so many turn to dieting.

Eating disorders are more likely to occur during periods in a person's life that require adjustments or acknowledgement of significant changes. The beginning of menstruation signals the beginning of the transformation from childhood to womanhood. The prospect of leaving home or school at 17 or 18 signals the change from dependence to independence. These are the two most likely times that the illness might develop, though other pressures (including a divorce, the death of a loved one, or any destabilising event) may incline a person to this illness at any age.

Anorexia usually occurs in women after the beginning of menstruation. Since menstruation requires an emotional as well as physical adjustment, it is not surprising that its onset can be a difficult stage in a woman's life. She may feel she is not in control of her body, or that her body is imposing its will on her. This seeming loss of self-control and self-direction can be very disconcerting. Some anorexics fear their femininity and doubt their ability to be adult women.

Anorexia not only removes menstruation, it removes the other physical symbols of womanhood (hips, buttocks, breasts). Some anorexics do not like being female. They believe that our society gives males more opportunities to feel worthwhile and valuable. Being female is looked on as an unfair burden, which is only complicated by a body that menstruates and seems unmanageable. To overcome these "disadvantages", anorexics may attempt to excel in academic work or athletics as a way of covering up the fact (from themselves and others) that they do not feel very good about themselves. When these successes are not enough, the decision not to eat becomes, in the anorexic's mind, the decision to live a life that is totally self-directed and self-sufficient.

In modem society women often find themselves in a dilemma. On the one hand they may feel committed to traditional feminine values, and on the other to desire vocational career success and achievement. Trying to reconcile these opposing ideologies places great strain on women, leading to the sort of inner turmoil and confusion often expressed by bulimic women.

Pre-menstrual tension can also be a trigger for bulimic binges. Hormonal changes during the pre-menstrual phase cause the amount of sugar in the blood to fall to abnormally low levels. Women who are particularly sensitive to these changes may experience cravings for sweet, high-calorie foods a few days before a period. In addition, the body's own protective mechanism for correcting the blood sugar levels may predispose individuals to binge-eating.

Adrenalin is the hormone which is rapidly secreted to release sugar from the body's stores of glucose in order to restore the blood sugar to its normal levels. As it is also responsible for the "fight and flight" reaction in humans, it may trigger off feelings of panic, tension, and irritability. If this happens, eating may be a way of providing physiological as well as psychological relief, by helping to temporarily blot out these distressing mental symptoms. Pre-menstrual physical discomfort in the form of headaches and a general feeling of bloatedness may also make some people seek solace by eating sweet carbohydrate-rich foods.

Male sufferers

The misconception that anorexia and bulimia nervosa are disorders affecting exclusively young women must be almost as widespread as the view of anorexia as a "slimming disease". Despite greater media interest in recent years and public awareness of eating disorders as a serious health problem, a considerable number of male sufferers of the estimated 5 to 10 per cent of all cases remain unknown to the medical profession, self-help groups, and other support structures. A reluctance on the sufferers' part to seek help, together with a strong denial that anything might be wrong, could excuse some professionals who show a hint of surprise when it is suggested that male anorexics do actually exist.

Even boys as young as eleven or twelve can get it, though it is an illness to which women are very much more vulnerable.

Marilyn Lawrence of the Women's Therapy Centre puts it well when she says: "Anorexia is a problem crucially related to women's psychology, which in turn is related to women's way of being in the world. The fact that it sometimes affects men only indicates that the psychology of women and men is not wholly distinct. Issues problematic for most women can also be so for some men".

Recent research has shown that male and female sufferers have similar personalities and symptoms except that men seem more achievement-oriented and show more sexual anxiety. In general, they appear also to be excessively athletic and over-value physical fitness, body appearance, and muscle strength.

As with female sufferers, the first step toward recovery is to recognise the problem and realise one has to start where one is. During the course of therapy (used in the general sense), there has to be a genuine desire to experience perhaps profound change in lifestyle and circumstance, of which attitude to food and weight is but one, and the need to have realistic expectations of the pace ground can be covered. The work of rebuilding can be lengthy as well as an emotionally-charged process.