The A to Z of Eating Disorders
Emma Woolf is a writer, broadcaster, former columnist for The Times and Newsweek, and co-presenter on Channel 4’s Supersize vs Superskinny. Having studied English at Oxford University, she worked in psychology publishing before going freelance and now writes for a range of newspapers and magazines both in the UK and internationally. She speaks at schools and universities on issues relating to eating disorders and body image, and at literary festivals from Cheltenham to Mumbai. Emma is a regular reviewer on Radio 4’s Saturday Review and BBC London, and other media appearances include Newsnight, Woman’s Hour and the Daily Politics show.
Her first book, An Apple a Day: A memoir of love and recovery from anorexia, was translated into many languages. Her other non-fiction titles include The Ministry of Thin, Letting Go, and Positively Primal, and she has also written several novels.
Emma is the great-niece of Virginia Woolf. You can find her on Twitter @EJWoolf.
Overcoming Common Problems Series
A full list of titles is available from Sheldon Press,
36 Causton Street, London SW1P 4ST and on our website at
Beating Insomnia: Without really trying
Dr Tim Cantopher
Chronic Fatigue Syndrome: What you need to know about CFS/ME
Dr Megan A. Arroll
Coeliac Disease: What you need to know
Coping Successfully with Hiatus Hernia
Dr Tom Smith
Coping with a Mental Health Crisis: Seven steps to healing
Catherine G. Lucas
Coping with Difficult Families
Dr Jane McGregor and Tim McGregor
Coping with Endometriosis
Jill Eckersley and Dr Zara Aziz
Coping with Memory Problems
Dr Sallie Baxendale
Coping with Schizophrenia
Professor Kevin Gournay and Debbie Robson
Coping with the Psychological Effects of Illness
Dr Fran Smith, Dr Carina Eriksen and Professor Robert Bor
Coping with Thyroid Disease
Depression and Anxiety the Drug-Free Way
Depressive Illness: The curse of the strong
Dr Tim Cantopher
Dr Dawn’s Guide to Brain Health
Dr Dawn Harper
Dr Dawn’s Guide to Digestive Health
Dr Dawn Harper
Dr Dawn’s Guide to Healthy Eating for Diabetes
Dr Dawn Harper
Dr Dawn’s Guide to Healthy Eating for IBS
Dr Dawn Harper
Dr Dawn’s Guide to Heart Health
Dr Dawn Harper
Dr Dawn’s Guide to Sexual Health
Dr Dawn Harper
Dr Dawn’s Guide to Weight and Diabetes
Dr Dawn Harper
Dr Dawn’s Guide to Women’s Health
Dr Dawn Harper
The Fibromyalgia Healing Diet
Helping Elderly Relatives
How to Stop Worrying
Dr Frank Tallis
Invisible Illness: Coping with misunderstood conditions
Dr Megan A. Arroll and Professor Christine P. Dancey
Living with Fibromyalgia
Living with Hearing Loss
Dr Don McFerran, Lucy Handscomb and Dr Cherilee Rutherford
Living with the Challenges of Dementia: A guide for family and friends
Overcoming Emotional Abuse: Survive and heal
Overcoming Low Self-esteem with Mindfulness
Overcoming Worry and Anxiety
Dr Jerry Kennard
Post-Traumatic Stress Disorder: Recovery after accident and disaster
Professor Kevin Gournay
The Stroke Survival Guide
Ten Steps to Positive Living
Dr Windy Dryden
Treating Arthritis: The drug-free way
Margaret Hills and Christine Horner
Understanding High Blood Pressure
Dr Shahid Aziz and Dr Zara Aziz
Understanding Yourself and Others: Practical ideas from the world of coaching
When Someone You Love Has Dementia
The Whole Person Recovery Handbook
Overcoming Common Problems
The A to Z of Eating Disorders
To Cecil and Jean Woolf
Note to the reader
This is not a medical book and is not intended to replace advice from your doctor. Consult your pharmacist or doctor if you believe you have any of the symptoms described, and if you think you might need medical help.
Since I started writing a weekly column in The Times, and then my first book An Apple a Day: A memoir of love and recovery from anorexia (Summersdale, 2012), I’ve been contacted by readers around the world who have similar thoughts and feelings – women and men, of all ages and all walks of life, who experience shame about their appetite, guilt with every mouthful, anxiety when eating in public, dislike of their own bodies or just a sense of being out of control around food. An eating disorder can be life-threatening, but everyday disordered eating is also surprisingly common.
Eating disorders are more complex than just diets. The fact remains, however, that the single biggest predictor of developing disordered eating is going on a diet. If the current Western obsession with losing weight – with forever slimming down and toning up, with getting the perfect bikini body or the sculpted six-pack – is to continue, we need to understand the risks, reasons and potential damage that dieting can do. The A to Z of Eating Disorders is a practical, comprehensive, no-nonsense, myth-busting guide to all the parts of eating disorders that are hard to understand and hard to explain.
The A to Z is written for those who are struggling with any kind of disordered eating or body-image anxiety, and acknowledges both ends of the spectrum. Whatever your attitude, whatever your weight, modern life has made the simple daily act of eating more complicated than ever before. We are tempted to treat ourselves but told to show restraint, we are urged to indulge while being warned of looming obesity epidemics. Given the contradictions between consumption and deprivation and the nonsense terminology around good and bad foods, clean and dirty eating, virtue or sinfulness, it’s no wonder that many of us avoid food, crave it or overdo it. How can we enjoy something that makes us feel so guilty, greedy or fearful?
The A to Z is also a personal project. Although not referring directly to my own illness, clearly my ten years’ experience of anorexia and recovery informs everything I write on the subject. I hope my first-hand knowledge will help others to understand how it feels from the inside and reassure those still going through it. I believe that we need to banish many of the inaccurate assumptions about eating disorders. They are not just female problems, they are not just young people’s problems – and they are not narcissistic! I am intimately familiar with the shame and secrecy of an eating disorder; they are ugly conditions, they are physically and emotionally self-destructive, and they cause immense pain to others. They are also forms of self-harm. I have not shied away from these more unattractive aspects, because there is a deep need for honesty in this area, as a foundation for recovery.
Science can give us the facts, but it still cannot explain why a starving person will not, cannot, eat. If my experience does anything, I hope it will shine some light on what that feels like from the inside and how to start to break that cycle.
Eating disorders are increasing at an alarming rate. The statistics speak for themselves: a 34 per cent increase in admissions for inpatient care since 2006; an annual increase of 12 per cent in children being treated in hospital for eating disorders; exponential increases among boys and young men, with up to 25 per cent of those affected now thought to be male; girls as young as six years old saying they feel ‘fat’ or dislike their bodies, and girls under ten starting on the lifelong cycle of dieting.
Nor is it only the young who are affected: a 2017 study from University College London made headlines with its findings that a ‘significant’ number of women in their forties and fifties had an active eating disorder, and 15 per cent of them had experienced an eating disorder at some point in their lifetime. National Health Service (NHS) research estimates that up to 6.4 per cent of UK adults display signs of an eating disorder. With the cost of illness and treatment potentially as high as £15 billion a year, eating disorders are now acknowledged to be a major concern within the medical, psychiatric and public health community.
Along with anorexia nervosa and bulimia nervosa, less well-known conditions are proliferating, including orthorexia, binge-eating disorder (BED) and other ED-NOS (eating disorders not otherwise specified). In the mainstream media, the debate over clean eating and extreme restrictive dieting continues – as it does at the other end of the spectrum in relation to the so-called ‘epidemic’ of obesity and its medical and financial implications.
There is no doubt that mental illness has risen up the agenda in recent years, with more awareness on the part of medical professionals, more attention from politicians and public health officials and more coverage in the media. For too long, people with mental illnesses have struggled alone, experiencing shame, guilt and confusion about their private problems. With this increased exposure and discussion, however, comes a need for accurate information and authentic real-life testimony.
Mental illnesses, especially eating disorders, cannot necessarily be diagnosed from a medical encyclopaedia or treated with a simple pill. Psychiatric conditions such as anorexia, bulimia and BED are still widely misunderstood. Research is at a relatively early stage and the complex interplay between the physical and the mental aspects remain a mystery to many (including those affected). The roots of any eating disorder are complex and specific to each case, and what works for one person in recovery may not work for another. Anorexia, bulimia and other behavioural disorders are a minefield from the inside and a mystery from the outside. This A to Z aims to bridge the gap between psychology and everyday life, demystifying the key issues and terminology and giving everyone the confidence to deal with these complex conditions.
One thing is clear: eating disorders are about much more than just food or body weight. This A to Z explores the subject from a wide range of angles – physiological and psychological, body and mind, head and heart, emotional, social, medical and nutritional. Whatever the disorder, the impact on an individual’s life is considerable. It affects not only physical health but also education or career, friendships, professional interactions and intimate relationships. Food is ever-present in our society, and eating with others is an everyday social bonding experience. To find oneself trapped in the cycle of disordered eating can be intensely isolating. Eating disorders are a heavy burden to carry.
I have balanced the coverage between anorexia nervosa, bulimia nervosa, BED and other ED-NOS. Of course these conditions do not fit under neat labels and people commonly present with a range of different behaviours, sometimes restricting and at other times bingeing and purging. I’ve explored the issues around body image – from simple confidence and self-esteem, to the more serious body dysmorphic disorder (BDD). I’ve also looked at less common conditions, such as childhood eating disorders and night-eating syndrome. In addition, I have touched on the recent findings of neurobiological research into eating disorders, which is promising but still at an early stage.
Eating disorders affect not only the person but also the entire family. This A to Z is written with an awareness of parents and siblings, friends and partners. Few conditions are as disruptive to family life as eating disorders: as well as creating tension at mealtimes, there are the deceit, secrecy and subterfuge that surround a disordered relationship with food. Many parents of young people with eating disorders blame themselves for the illness and wonder what they did wrong. While the stress on families is considerable, they are also an invaluable source of support and love during the recovery process.
One of the most important findings to come out of research in this area is that eating disorders are emphatically not confined to teenage girls. They can affect anyone, of any age, gender, sex or social class. From the young man fighting anorexia to the middle-aged mother struggling with BED to the elderly man hiding bulimia, disordered eating can be a way of coping with loneliness, depression or even boredom. It may be a reaction to serious trauma or abuse or it may simply develop from the cycle of deprivation and excess of constant dieting. There are no rules respecting who gets ill and, sadly, as yet, no cure.
Greater awareness around eating disorders has coincided with the explosion of social media and all that goes along with it, notably the sheer visibility of bodies – especially women’s bodies – everywhere every day. We are bombarded with thousands of images on celebrity gossip sites, of digitally retouched bodies in advertising and endless selfies on Instagram, Twitter and Facebook. Although the online world has given many lonely people a voice, enabling them to write about their personal experiences and struggles through blogs and internet forums, it has also fuelled the compare-and-despair cycle that makes many young people feel inadequate, scrolling through other people’s apparently perfect lives. The internet has also enabled the proliferation of dangerous ‘pro-ana’ and ‘pro-mia’ websites which glamorize and even promote conditions such as anorexia and bulimia nervosa.
As incidence and awareness have grown, so has the need for accurate information. Eating disorders may be on the public agenda, but they remain widely misunderstood. Let’s be honest, eating disorders are almost impossible to understand from the outside. In severe anorexia, for example, it seems incomprehensible that these people could truly believe they are overweight or not accept how desperately they need to eat. Because the consequences are often shockingly visible – emaciation or obesity – eating disorders are seen as physical illnesses. It is assumed that these individuals are obsessed with being thin and attaining the perfect body or they’re inordinately greedy and have no self-control. In most cases, however, restricting, bingeing and purging and compulsive overeating have their roots in difficult emotions or other painful problems. In this A to Z, I have emphasized the psychological – as much as the physical – aspects of eating disorders.
It must also be noted that eating disorders are not always visible. Conditions such as bulimia nervosa do not necessarily lead to marked weight gain or loss; many people remain a normal weight despite disrupted and dangerous purging behaviours. Sadly, this means that the problems remain hidden and untreated.
This element of secrecy is common to almost all disordered eating. Although every individual and every illness is different, they share this overwhelming sense of shame, guilt and secrecy. Whether they are anorexic, bulimic or binge-eating, people feel embarrassed about their struggles and ashamed to ask for help. They pretend they’re OK because it seems silly to admit they can’t cope. Also, whether undereating or overeating, there is a sense of being out of control around food, of trying to regain control or impose order on a situation that feels unmanageable (in anorexia, say) or of giving up and burying one’s emotions in food (as in BED).
As well as providing factual information and the latest research, I hope the A to Z will reassure anyone with any eating disorder that it is not a life sentence. Although it must be acknowledged that these are life-threatening conditions, they can be overcome. Whether you’re at your lowest point of the illness or well on your way to full recovery, I want you to believe that it can be beaten. From overweight to underweight, overeating to undereating, bingeing, purging, constantly dieting or just privately hating your body, you are not alone. The experience of disordered eating is bewildering and lonely, but there is nothing to be ashamed of, and there is great strength in asking for help.
A word on terminology. In the interests of brevity, I have mostly used the term ‘individual,’ ‘person’ or ‘people’ to describe the person with the eating disorder. This seems preferable to the terms ‘anorexic’, ‘bulimic’ or ‘binge-eater’ – although I sometimes use them – but I’m aware how reductive these labels can feel. You are a person, not an eating disorder, a mental illness or a collection of symptoms. Please be assured, in every case I simply mean ‘the individual with the eating disorder’ and do not wish to define or stigmatize anyone.
I hope that this A to Z will carry you from illness to recovery with determination and optimism, and I wish you well on your journey back to health.
The term ‘addiction’ usually refers to some kind of illegal or damaging behaviour. Food is a completely legal substance and eating is a normal social activity. Food, however, is also a deeply personal issue and disordered eating encompasses a wide range of complicated and individual behaviours. Just like oxygen, food is a fundamental physiological requirement, but we have made eating far more complicated than breathing. We all need food in order to stay alive, but what, when and how much we eat can easily get out of control.
For someone with an eating disorder, food is often both a best friend and a worst enemy. Eating can be a reward and a punishment, consoling and confusing, comforting and guilt-inducing, all at the same time. Starving, purging or bingeing to the point of sickness are painful and pointless behaviours, yet they are self-inflicted (at least at the start). The question is: why would anyone choose such behaviour and how does it become addictive?
Conditions such as anorexia nervosa, bulimia nervosa and BED are highly complex mental illnesses and stubbornly resistant to treatment. Unlike a drug or alcohol addiction, beating an eating disorder is not a simple case of avoiding the substance altogether: you have to learn to eat in order to live.
Eating disorders also bring other problems with them. Alcohol and drug abuse, overspending and even shoplifting (see KLEPTOMANIA) are common co-addictions, or dual disorders, in those with disordered eating. It appears that many of the emotional factors fuelling these problematic behavioural patterns are similar. These factors may include guilt, hunger, boredom or a need to find an escape route from difficult feelings. Drugs or alcohol may be used initially to numb depression or anxiety or help with sleeping problems.
Exercise addiction is also extremely common in those with eating disorders. In recent years, exercise has become more intense than ever before and it has become fashionable to work out really hard, for women as well as for men. A swim or aerobics session no longer cuts it: instead gyms offer a wide choice of ‘bootcamp’ workouts, circuit training and spin classes. Kick-boxing and military-style fitness classes are full of very toned, fit, thin individuals burning hundreds of calories early in the morning or late at night, often on little fuel. Participation in marathons, triathlons and Iron Man competitions has soared as ‘normal’ non-athletes push themselves further and further.
It is difficult for outsiders – friends, family, even medical professionals – to accept that an eating disorder and compulsive exercise can be such powerful addictions, but there is growing evidence to suggest that they really are. While exercising regularly and eating healthily are beneficial for most people, in vulnerable individuals they can easily become dangerous, compulsive and sometimes life-threatening addictions.
As we have seen, eating disorders often go hand in hand with other forms of addiction and substance abuse, including alcohol.
Individuals with restrictive eating habits such as anorexia are wary of calories in all forms and many of them avoid drinking alcohol for the ‘empty calories’ it contains. Still, it’s estimated that around 15 to 20 per cent of those with anorexia drink excessive amounts of alcohol. In other eating disorders, however, such as bulimia and BED, alcohol abuse is more common, affecting between 30 and 50 per cent of those with binge–purge behaviours. Just as with food, these individuals commonly drink large quantities of alcohol in sporadic binge sessions.
Occasional overindulgence is part of Western culture – getting tipsy at large social events is considered normal, for example – but repeated binge-drinking is far more serious. Many who have BED and bulimia are also affected by substance abuse disorders. A combination of chemical, psychological and sociocultural factors makes them even more vulnerable to addiction. Just as high levels of sugar and fat in binge-eating cause an initial dopamine surge in the brain, so the first few alcoholic drinks create a feeling of euphoria and confidence. People may find themselves bingeing more and more frequently on food and alcohol because they crave that intense rush of chemicals. If they have low dopamine levels – common in those with slight to moderate depression – the dopamine rush seems to lift their depressed mood.
In situations of stress or anxiety, common in everyday life, individuals predisposed to BED or alcoholism may find themselves turning to alcohol or other drugs as a coping mechanism. As with many aspects of an eating disorder, the initial behaviour sets up a cycle of deprivation, craving, excess and guilt. Low self-esteem and low impulse control contribute to problems with alcohol and other substance abuse.
Alcohol abuse is always a cause for concern, but it’s particularly dangerous in those who are malnourished, underweight, vomiting frequently or drinking on an empty stomach. It can cause alcohol poisoning, memory loss, blackouts, injuries, brain damage and even death. (See also DRUNKOREXIA.)
This describes the generalized difficulties of putting feelings into words seen in some individuals with anorexia. Although often highly intelligent and otherwise articulate, they may struggle to express their emotions and distinguish between facts and feelings. This may be due to specific cognitive deficits associated with anorexia (see COGNITIVE IMPAIRMENT) or it may be due to the many conflicting emotions they experience around food, eating and their own bodies.
See COGNITIVE IMPAIRMENT.
ALTERNATIVE AND COMPLEMENTARY THERAPIES
Many people find alternative or complementary therapies effective for dealing with a range of physical and emotional issues. From acupuncture, aromatherapy, homeopathy and naturopathy to massage, reflexology, meditation and mindfulness, complementary therapies are based on a belief in the body’s ability to heal itself. In general, they adopt an holistic approach to the workings of the body, taking into account the mind–body balance. They are thought to be less invasive than conventional medicine and cause fewer unpleasant side effects.
In theory, eating disorders should respond well to complementary therapies. Anorexia, bulimia and other forms of disordered eating have a significant psychological component, which should make them ideally suited to this more holistic, person-centred approach. Clinical research into complementary therapies in relation to eating disorders is limited, however, and therefore evidence-based data are lacking. As alternative or complementary therapies fall outside mainstream health care, they are generally offered by private practitioners.
Evidence suggests that individuals with severely disordered eating respond best to psychotherapy and other talking therapies, as well as nutritional counselling. Anecdotally, however, many people find complementary, holistic mind–body treatments effective for coping with depression and anxiety, which lie at the root of many eating disorders, or find them beneficial during times of emotional stress and anxiety. Complementary practitioners tailor their treatments to the individual, listening to address specific physical or psychological concerns, and can offer a genuine boost to individuals struggling with eating disorders, but these approaches are not sufficient as stand-alone treatments. They contribute to general health, both mental and physical, and can help with hormonal or nutritional imbalances. They can promote a sense of mental well-being, relaxation and calm. In conjunction with conventional medicines and talking therapies, therefore, complementary therapies can help during the recovery process.
Some herbal treatments can interact with other medications so you should always consult your doctor or counsellor before embarking on complementary or alternative therapies.
This is a condition in which periods are absent. There are many reasons why periods may be missed, but in the context of eating disorders, we will focus on weight-related causes.
If you are not pregnant, breastfeeding or approaching the menopause, you should be menstruating on a regular ‘monthly’ cycle (cycles shorter or longer than this are normal, however). Missing periods for several months in a row, and certainly for more than six months, is a cause for concern, though, and should be discussed with your GP.
Essential hormones that control the female menstrual cycle are very sensitively balanced and easily upset when body fat, calories, energy or activity levels become imbalanced. Body fat is essential for the female reproductive system to function, and women need adequate stores of body fat in case of pregnancy. Amenorrhoea is common in anorexia, as well as in those who are underweight or have lost a large amount of weight rapidly. This absence of periods may be the first sign that something is wrong.
When calories are being severely restricted, the body’s warning systems go off. The body goes into famine mode, concentrating all its precious resources on keeping it alive. Calories are channelled towards the vital organs and non-essential functions, such as the reproductive system, shut down. To put it simply, with barely enough food for one person, let alone two, the anorexic body cannot risk getting pregnant.
It is generally agreed that body fat needs to be around 17 per cent for menstruation – this explains why female athletes who have a higher than normal muscle-to-fat ratio may miss periods. Even though their calorie intake is high, their energy expenditure is also high and their body fat is low. (See also ATHLETIC TRIAD and EXERCISE.) Some put the figure for body fat lower: the American College of Sports Medicine, for example, gives a range of 8 to 12 per cent essential body fat to maintain menstruation. While low body fat contributes to menstrual dysfunction and amenorrhoea, it’s clear that other factors, such as low calorie intake, inadequate nutrition and excessive exercise, are also highly significant.
In overweight women, there is more than enough body fat, but this can also cause menstrual disturbances, as increased amounts of body fat are related to low levels of sex hormone-binding globulin – a protein that governs the activities of the sex hormones oestrogen and testosterone. Although most oestrogen is produced by the ovaries, some is made in body fat and other sites, and body fat also acts as an oestrogen store. Too much fat therefore causes hormonal imbalance, which disrupts normal egg development and ovulation. Polycystic ovary syndrome is also a common cause of amenorrhoea and can be alleviated by weight loss.
The good news is that, for both overweight and underweight individuals, amenorrhoea is largely reversible. Losing excess weight, or regaining healthy weight, is highly effective at restoring healthy hormone balance. When weight and body fat are at healthy levels – not too high and not too low – hormone levels return to normal, stimulating ovulation and regular periods (see also FERTILITY AND INFERTILITY). However, young girls who have primary amenorrhoea, whose periods never start, may permanently damage their reproductive system and never menstruate as adults.
Anaemia occurs when the body’s red blood cell count is lower than normal. The body needs iron to produce red blood cells, which help store and transport oxygen around the body. When red blood cell levels are low, the body’s organs and tissues do not receive as much oxygen as they need. Symptoms of anaemia include fatigue or lethargy, shortness of breath, dizziness or muscle weakness, skin pallor, repeated infections or illness, depression, confusion and poor memory. (See also IRON.)
The most common form of anaemia – iron deficiency anaemia (caused by insufficient or poor absorption of iron) – is often seen in eating disorders. In anorexic individuals, iron deficiency may be caused by the general nutritional deficiencies of a restrictive diet. Additionally, these individuals are often vegetarian or vegan, thus avoiding animal products, which are a reliable source of iron. In bulimia, bingeing and purging behaviours lead to iron deficiencies due to repeated vomiting and the disrupted digestion and absorption of food.
Iron deficiency anaemia is straightforward to diagnose and treat and, in most cases, simple iron supplementation is sufficient. (See also VITAMIN B GROUP.) In anaemia linked to eating disorders, symptoms will improve as nutritional balance is restored in line with overall physical recovery. Food sources of iron include dark green leafy vegetables, brown rice, pulses, beans, nuts, seeds, iron-fortified cereals and bread, meat, fish, tofu, eggs and dried fruits, such as dried apricots or prunes.
The literal meaning of the original Greek is ‘nervous loss of appetite’. Anorexia nervosa is characterized by distorted body image, excessive dieting, severe restriction of calories, avoidance of food, extreme or rapid weight loss and a pathological fear of gaining weight. Individuals with anorexia may persist in the belief that they are fat even when they have become dangerously thin. Although anorexia is often diagnosed on the basis of this very low body weight, it should be remembered that it is a psychiatric disorder: the characteristic preoccupation with thinness and restriction of food can exist even in those who are not – or not yet – clinically underweight.
Along with avoidance of energy intake, people with anorexia are also dominated by an intense need to expend energy. They are overcome with guilt about anything that breaks their self-imposed rules. They find it very hard to respond to their body’s physical needs, even simple needs such as warmth, rest and food. As anorexia develops, previously enjoyable activities, such as sport, become compulsive and self-destructive; the person is driven to increase the duration and intensity of exercise to damaging levels. Rigid discipline and self-control, especially around food and exercise, come to dominate the person’s life.
The peak average age of onset of anorexia is between 15 and 19 years old. Anorexia has a strong preponderance among female members of the population, with an overall sex ratio of around 10:1 female:male, although in adolescence this ratio varies greatly and there is a growing incidence among young men (see MALES). Anorexia is a varied, complex and multifactorial disorder, with no single cause. Every person will present with his or her own specific life circumstances, but will also share many traits in common with others with anorexia. Biological, psychological, sociocultural and neurological research in recent years has contributed greatly to the understanding and diagnosis of anorexia nervosa. It is also increasingly understood that eating disorders have different aspects. That is, there are predisposing factors that may make an individual vulnerable; precipitating factors that may trigger or encourage disordered eating; and perpetuating factors that help to maintain the disorder once it has started.
As research has developed, the diagnosis of anorexia has developed too. Previous editions of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (see DSM) outlined strict medical criteria for anorexia, such as having amenorrhoea (absence of periods) for at least three months or losing a certain percentage of body weight. In the latest edition of the DSM (5th edition, 2013), however, the criteria for anorexia nervosa were changed and amenorrhoea is no longer a requirement. The individual’s behaviour and emotional state are considered to be more relevant. This change reflects an important shift in understanding among those in the medical community: anorexia is not defined only by what individuals weigh but also how they feel about their own bodies, eating patterns and behaviour.
In most cases of anorexia, the focus is not solely on food, weight and shape. Other preoccupations include control and self-discipline, perfectionism, self-esteem, identity, sexuality, family, cognitive rigidity and many other issues not directly related to food.
This is a feature often seen in anorexia, where individuals display a lack of awareness of their illness or deny that they are ill. This is common when anorexic people are admitted to hospital but still maintain they do not have a problem with eating. They may not understand the true extent of their illness or they may explain their severely restrictive diet as just being healthy eating. Anosognosia is not the same as hiding a problem, such as in bulimia, where a person understands that his or her behaviour is problematic but is keeping it secret.
Some (but not all) anorexic individuals have a distorted view of what they see in the mirror. They may see themselves as normal weight or even overweight, although outsiders can clearly see they are dangerously underweight.
Anosognosia in eating disorders is confusing as individuals often fluctuate between having insight into the situation and other times when they are in denial. This type of shifting insight presents a challenge for clinicians working with people in therapy. It is also difficult for families, friends and partners of individuals who are severely unwell, as it may feel like progress is not being made.
ANTIDEPRESSANTS AND DEPRESSION
Everyone feels sad, hopeless or anxious at times. This is a normal part of life’s ups and downs for all of us, especially when we’re faced with work, exam or relationship stresses, or unforeseen events, such as bereavement or serious illness. Depression, however, sometimes has no specific cause and does not pass with time. Antidepressant medication is prescribed when an individual is struggling with moderate or severe depression that doesn’t lift naturally. As well as extremely low mood, individuals may experience difficulty sleeping, lethargy, poor appetite and decreased libido, as well as a general sense of despair or even suicidal thoughts. Medication, often in conjunction with support or counselling, can be very effective in these cases. Antidepressants may have to be taken for many months and treatment should not be stopped too soon, as symptoms are likely to reappear.
Depression is thought to be caused by a reduction of certain chemicals in the brain called neurotransmitters, which affect mood by stimulating brain cells. Antidepressants increase the level of these excitatory neurotransmitters, usually by blocking their reabsorption. Three main classes of drugs are used to treat depression: tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs) and monoamine oxidase inhibitors (MAOIs).
Depression is very common in individuals with eating disorders. There are many reasons for this (explored in detail throughout this book): depression may be a cause or a consequence. The depressed mood may be something the individual has struggled with for a long time; it may in the end be hard to disentangle it from the eating disorder itself. Conditions such as anorexia, bulimia or binge-eating are also inherently depressing: they create daily anxiety and isolate you from friends and family. Eating disorders make normal situations – such as shopping or eating out – feel stressful or threatening.
Individuals with eating disorders often have low self-esteem and may feel they do not ‘deserve’ to be OK. They may resist the medication that is offered to help alleviate their depression. They may also fear the side effects, such as weight gain. It’s essential to understand that depression makes recovery even harder, and essential to accept that antidepressants are an important part of beating the eating disorder. Depression is not something to be ashamed of – in fact it’s surprisingly common. Taking antidepressants does not make you a failure. Boosting those neurotransmitters in your brain makes a real difference to the feelings of hopelessness and despair. By lifting the depressed mood, you can start to see and think more clearly and take positive steps towards normalizing your eating.
Anxiety is a natural and necessary part of everyday life, with worries or nerves affecting most people at some point. Experiencing anxiety around exams, job interviews or first dates is perfectly normal. ‘Normal’ levels of anxiety sometimes get out of control, however, affecting the individual both physically and mentally and interfering with daily life. Anxiety is the body’s evolutionary response to threatening situations: when it senses a potential threat, the brain triggers the adrenal glands to release adrenaline into the bloodstream. The adrenaline rushes to the heart, lungs and muscles, increasing energy and oxygen levels in preparation for a fight or flight. Tension, a racing heartbeat and sweating are signs that your body is preparing to respond to a perceived threat.
Anxiety is considered abnormal when it is out of proportion to the stressful situation, the anxiety persists after the stressful situation is over or it occurs for no apparent reason. When anxiety feels unmanageable and interferes with daily life, this is considered an anxiety disorder. People with an anxiety disorder may struggle to control their thoughts and feel an overwhelming sense of dread or panic, often alongside distressing physical symptoms. They experience anxiety most days and find it hard to recall a time when they felt relaxed.
The World Health Organization estimates that 1 in 3 people will experience depression or an anxiety disorder at some point in their lives. Research from the University of Cambridge (2016) estimates that more than 60 million people are affected by anxiety disorders every year in the European Union. Anxiety is the primary symptom in a range of related conditions, including obsessive compulsive disorder (OCD), generalized anxiety disorder, post-traumatic stress disorder, social anxiety disorder, phobias and panic disorder.
Physical manifestations of anxiety include sweating, shaking or tremors, shortness of breath, flushing or burning skin, dry mouth, hyperventilating, palpitations or elevated heart rate, chest tightness or stomach pain, nausea, headache and dizziness. Triggers, causes and symptoms of anxiety are wide-ranging and unique to each individual. What may trigger a panic attack in one person may not affect another.
Anxiety disorders have many causes, from brain chemistry to childhood experiences, genetics, habits, diet, medication, major or minor life events and sleep patterns. An individual’s temperament plays a role: some of us are naturally more anxious than others. Often the precise trigger for the anxiety is not clear or is something very minor, and the level of anxiety felt can be out of proportion to the trigger itself. Social media use may exacerbate feelings of anxiety or panic: in surveys, 45 per cent of young people say that social media leaves them feeling ‘worried and uncomfortable’.
In the context of eating disorders, people may experience intense anxiety around food and social eating situations: it could be a restaurant, a supermarket or a hotel buffet, a work dinner or a picnic with friends. Whether food is experienced as a threat, as in anorexia, or as a trigger, as in binge-eating, many of these everyday eating situations induce extreme anxiety. This makes sense: the more you avoid a situation or feel out of control, the more anxiety builds up around it. Unfortunately, avoiding situations only leads to greater fear and social exclusion (see LONELINESS).
COGNITIVE BEHAVIOURAL THERAPY (CBT) is usually the first line of treatment for anxiety disorders and can be very effective. On your own, simple mindfulness techniques and deep breathing can prove very helpful in reducing levels of anxiety and arousal (see also YOGA).
It must also be noted that disordered eating exacerbates anxiety, in a nutritional sense. The brain does not function well without good fuel: in particular, the neurotransmitter serotonin, which regulates mood and checking behaviours, is affected. Insufficient intake of carbohydrates can lead to serotonin depletion, which contributes to feelings of anxiety. Eating good-quality carbohydrates is therefore essential for those with anxiety disorders (see also OBSESSIVE COMPULSIVE DISORDER and SEROTONIN). Noradrenaline is another essential neurotransmitter that is strongly implicated in anxiety disorders (see NORADRENALINE).
The Greek term anorexia nervosa misleadingly suggests a lack or loss of appetite. Although individuals with anorexia do not in fact start out by losing their appetite, over time the repeated disordered behaviours can confuse the body’s natural appetite cues and hunger signals. Similarly, individuals with bulimia or BED may struggle to identify with their appetite or hear when their body is hungry as they are eating large quantities of food in response to emotional, not physical, needs. In all forms of disordered eating, the body’s natural appetite is repeatedly confused, ignored or overridden. Getting back in touch with your appetite is crucial to recovery from any eating disorder. (See also HUNGER.)
The female athletic triad refers to the combination of three conditions seen in female athletes: disordered eating, amenorrhoea and osteoporosis. The triad reflects the dangerous consequences of intense physical training, low calorie intake and low body fat, and can result in cessation of menstrual periods, low bone density, infertility and other health problems. Although these are often seen together, an athlete may have only one of these conditions.
Striking a balance is harder than it sounds. Life can sometimes feel like a constant balancing act between work and play, career and family, duty and pleasure, food and exercise, discipline and indulgence. As we grow up, most of us are trying to maintain a happy medium between what we want to do and what we ought to do: what we need for ourselves and what others need from us, as well as what would be best for our own health and our future prospects. You may look around you and think that everyone else is finding it easy – but balance is hard for all of us.
Modern life, and especially online modern life, promises us instant gratification just one click away. It offers countless flavours, brands, destinations, styles and filters, and countless possible versions of ourselves. Navigating our way through this minefield can be bewildering, and often it all gets too much.
Imbalance is at the heart of most disordered eating behaviours, in many different forms. The imbalance may be the all-or-nothing mindset, where a strict diet or exercise regime is taken to dangerous extremes; it may be binge-eating or bingeing and purging. The person wonders why everyone else is apparently able to eat normally, not too little and not too much, while they swing from one extreme to the other. The emotional toll of eating disorders is driven by this lack of balance, where the dominant emotion is guilt at one’s own extreme behaviour, shame at being selfish or narcissistic, or worry over creating so much anxiety for family and friends. The individual is all too aware of his or her imbalanced emotional, behavioural and eating patterns, yet feels powerless to change.
Balance sounds very simple, and is not simple at all. Striving towards balance, however, is achievable. In the cycle of disordered eating, individuals often finds themselves pulled between extremes. Understanding that a little indulgence is possible can be a revelation for someone with long-term disordered eating. Harmony, indulgence, pleasure and treats are part of a balanced life, even for those who have lost their way.
It’s not only individuals with eating disorders who have a sense of imbalance. The endless possibilities and varieties can make even ‘normal’ individuals feel that there are simply too many potential alternatives, in restaurants, in supermarkets, at college or in the workplace, and of course online. This is known as the paradox of choice: a kind of paralysis in our more more more world. When everything is available, it can be hard to choose. Finding an inner equilibrium is tricky when the world appears to offer so much.
Individuals with eating disorders tend to experience this sensation of being overwhelmed, unable to choose from all the possibilities, frozen in the headlights. In anorexia, the perfectionist tendency makes them terrified of making the wrong choice, eating the wrong thing – hence they reject it all. Bulimics often experience a similar sense of overload, and they respond by overdoing it, and then trying to get rid of it all, literally to purge themselves. Disordered eating takes many forms, but the imbalance is the same.
You may remember an old saying, ‘a little of what you fancy does you good’. It’s simple and true. We live in an obsessively self-controlled society: in food, in exercise, in how we should look and even how we should feel. We’re constantly reminded to avoid wheat, dairy or gluten, to wear this, to drink that, to be calmer, more serene, more mindful. We should be a slave to our Fitbit or personal trainer and have perfectly toned abs. We are surrounded by rules and standards and judgement and guilt. We tell ourselves we are not ‘allowed’ certain things and use food as punishment or reward. It’s not surprising that, with or without an eating disorder, anxiety is on the increase.
There are no easy answers, but there are ways to make the balancing act a little easier. Most importantly, stop seeing things as ‘good’ and ‘bad’; instead aim for somewhere in the middle. This is hard in a society that demonizes everyday substances such as dairy or grains and evangelizes ‘clean eating’. The 80/20 rule is an excellent guideline for being healthy most of the time, but also allowing yourself treats. This goes for eating but also for exercise regimes: regular activity is important, but the body also needs days off to recover.
Whatever you follow, don’t follow it slavishly! Individuals with eating disorders, especially anorexia, have too many rules already. The essence of balance is cutting yourself some slack. No meal, no workout, no body will ever be ‘perfect’; good enough, healthy enough, happy enough is fine. Aim for moderation and see where it takes you.
This is a form of BODY DYSMORPHIC DISORDER (BDD) in individuals, usually men, who spend a lot of time weight training in gyms and seems to be becoming increasingly common. Bigorexia is also referred to as ‘muscle dysmorphia’ or ‘reverse anorexia’. As well as becoming obsessed with bodybuilding, individuals experience distorted perceptions of their body shape and size and may risk their health with steroid abuse. They lift weights compulsively in order to bulk up, but continue to see themselves as weak and skinny, no matter how muscular they become. This kind of excessive training regime exerts a physical strain on the body, especially dangerous in conjunction with steroids, and often causes mental distress, such as depression, anxiety and even suicide.
Research shows that up to 1 in 10 men in gyms could have bigorexia, although the condition is often hidden due to shame. It’s still hard for men to admit to struggling with mental health issues, especially those connected with what might be seen stereotypically as ‘feminine’ problems around body image.
Just as society and the media create pressures on women to be thin and have the perfect body, so they also create pressures on men to display the chiselled torso and perfect six-pack. Typically, a man with bigorexia will work out compulsively, sometimes visiting the gym twice a day, to the exclusion of his social life, study or career, family and relationships. He may become overly concerned with his appearance and have very low self-esteem.
Signs of muscle dysmorphia or bigorexia may include: constantly visiting the gym or lifting weights at home, and becoming panicky or angry if they cannot do this; exercising despite injury or illness; extreme preoccupation with appearance, especially muscle definition in the torso and upper body; consuming large quantities of bodybuilding supplements and protein shakes; and depression, anxiety, irritability or mania. A significant proportion of men will take anabolic steroids to maximize their muscle growth. Side effects of steroid abuse include mood swings, aggression, hair loss, impotence, testicle shrinkage and heart and liver damage.
As with other mental illnesses (see MYTHS AND MISUNDERSTANDINGS), bigorexia is widely misunderstood. It is seen as narcissistic posing, whereas in fact it is a serious form of body-image distortion. It often masks insecurities in other areas of an individual’s life. As with anorexia, bigorexia involves a mismatch between the person’s internal self-perception (as effeminate or weedy) and the external reality of a very muscular man.
This kind of body dysmorphia may develop as a result of childhood abuse, trauma or bullying at school, or it may be a response to the unrealistic expectations created by the modern media. Male models display the ‘perfect body’ and create pressures on men, similar to those on women, to achieve the same physique. While it used to be characterized as a particular issue for gay men, who were thought to be closer to women in their concern over appearance, it is now clear that body dysmorphia can affect all men, gay or straight, young or old.
Intriguingly, male body dysmorphia is almost the exact opposite of female anorexia: where women shrink themselves into nothingness, men are trying to increase their physical presence in the world, creating a larger shape and gaining muscle. Despite these apparent differences, both conditions involve complex interrelated pressures about appearance, the ideal body, individual perception and self-esteem.
BINGE-EATING DISORDER (BED)
BED is characterized by recurrent and persistent ‘binge’ episodes displaying the following features: eating much more rapidly than normal, eating until feeling uncomfortably full, eating large amounts of food when not physically hungry, eating alone because of embarrassment at the amount of food one is eating, and experiencing self-disgust, depression or extreme guilt after bingeing. There is a loss of control (or a sense of being out of control) during these episodes. The person will usually eat very quickly and often in secret. Individuals with BED may also stockpile food to consume secretly at a later time. They often eat normally with others but binge when alone. They experience anxiety that can only be relieved by eating, although they do not actually reach satiation, and they often experience numbness or lack of sensation while bingeing.
BED was included in the latest (5th) edition of the DSM (see DSM). In previous editions, it was relegated to an Appendix and many experts included it under the catch-all term ‘eating disorders not otherwise specified’ (see EATING DISORDERS NOT OTHERWISE SPECIFIED). The recognition since of BED as a distinct eating disorder in its own right is important in terms of diagnosis and treatment, as well as for those individuals who have this highly distressing condition. Like anorexia, BED has long been misunderstood, with the main focus being on the large quantities of food consumed and resulting weight problems. BED’s inclusion as an official mental disorder opens up the way for a deeper understanding of this complex condition.
While obesity is an increasing health problem across Western countries, binge-eating is more complicated than just overeating. Binge-eating is not just having the occasional large meal or an overindulgent weekend. According to the online support group BEDA, BED is now the most common form of disordered eating in the USA, affecting three times as many people as anorexia and bulimia combined. Binge-eating differs from overeating in the quantity of food consumed and the frequency and psychological distress caused by the behaviour. Unlike bulimics, binge-eaters do not usually compensate by vomiting or over-exercising. A typical binge is followed by feelings of intense shame, guilt or self-disgust.
Binge-eating is an expensive and uncomfortable habit to maintain, inducing both physical and psychological distress. The frequency of binges may vary from daily to a few times a month. Whereas an average binge can consist of several thousand calories, a severe binge can involve consuming up to 30,000 calories in a single sitting: this is around two weeks’ worth of food for the average adult. Individuals may visit many different shops to avoid detection or adverse comments.
Binge foods are usually high in sugar, fat and carbohydrates. Biscuits, bread, cake, ice-cream, pizza and crisps are typical. This high-calorie food is often consumed at great speed in a kind of trance or stupor – people report not even tasting the food as it goes down. Binges are also characterized by unusual combinations of food: a jar of lemon curd, fish fingers and chocolate cake, for example. The person focuses more on rapid consumption than on enjoyment or flavour. Some people say they feel that they are trying to make themselves ‘explode’. Like individuals with anorexia, they may hear a ‘voice’ telling them to eat more and more; like anorexics, they are secretive about their behaviour. They conceal empty packets inside other packets or eat in the car, in the middle of the night or plan binges when alone.
Although most people with obesity do not have BED, up to two-thirds of people with BED are obese and experience the medical complications associated with this condition. They also display higher levels of anxiety and depression than control groups of obese people who do not binge, and normal-weight people. Clearly, binge-eating can be extremely dangerous to an individual’s physical health, with risks including cardiovascular disease, type 2 diabetes, hypertension, muscle and joint pain, and gallbladder and gastrointestinal complications.
Binge-eating also affects individuals’ emotional well-being. They may become socially isolated and depressed, even suicidal. Binge-eating can affect anyone, male or female, of any age. The condition is still widely misunderstood and carries social stigma, with people being shouted at in public places, told to ‘just stop eating’ or get some willpower. (See also MYTHS AND MISUNDERSTANDINGS.)
Like anorexia and bulimia, the roots of BED often lie in early experiences of insecurity, rejection or fear. When a child is not able to rely on emotional support, it makes sense that he or she will turn elsewhere for reassurance. Difficult emotions are buried under the routine of ‘comfort’ eating instead, and the behaviour becomes habitual.
Awareness among the medical community is slowly improving, but specific treatment for BED remains limited: most eating disorder services in the UK focus on anorexia and bulimia. Professional support from psychiatrists, nutritionists and therapists is essential for addressing these distressing and destructive eating habits.
CBT has been shown to be highly effective in the treatment of BED. Compared with waiting list patients, people with BED who received CBT showed significant reductions in body mass index (BMI), in the number of days a binge occurred, and in disinhibition, hunger, depression and low self-esteem. Those who had CBT were also more likely to be free from binge-eating at the end of treatment.
Dialectical behaviour therapy, another form of talking treatment that was originally developed to help those with borderline personality disorders, can provide practical strategies to cope with stress, regulate emotions, and minimize and eventually stop binge-eating. Other forms of interpersonal group therapy and support groups can help people to feel less alone by discussing issues and sharing coping strategies, and to dispel the shame and secrecy of BED.
Individuals with BED are also more prone to alcoholism and other substance abuse. Research shows that binge-eating and binge-drinking share many common risk factors. The cycle of secretive and self-destructive behaviour, fuelled by shame and low self-esteem, is common to both bingeing on food and bingeing on alcohol. (See also ALCOHOL.)
Bioavailability describes how readily the body can absorb the nutrients it needs, specifically in relation to essential vitamins and minerals. For example, iron from ‘haem’ or meat sources is said to be more bioavailable than iron from ‘non-haem’ or plant-based sources. This does not mean that non-meat-eaters cannot absorb the iron they need from a vegetarian diet, but they may need to combine it with other nutrients (such as vitamin C) to optimize its absorption by the body. (See also VEGANISM, VITAMIN B GROUP, VITAMIN K, SUPPLEMENTS and IRON.)
The eating disorder most commonly associated with bipolar disorder is bulimia nervosa. However, bipolar disorder is also seen in individuals who have anorexia and BED. Bipolar disorder differs from major depression in that it has two ‘poles’ – hence ‘bipolar’ – and oscillates between extreme highs and lows. Individuals with bipolar disorder may sink into a deep depression lasting several days or weeks. At other times, they develop a euphoric or manic mood elevation, hence the old-fashioned term ‘manic-depressive’ illness.
While the depressive aspects of bipolar disorder can be crippling for the person, the manic side also causes problems – that is, the highs can be as perilous as the lows. When manic, individuals may experience unlimited enthusiasm and optimism, throwing themselves into new projects, spending money, socializing or exercising to dangerous excess, believing they can achieve anything and harming themselves in the process. During manic episodes, people with bipolar disorder often have no insight into their condition; the sense of creativity and invincibility can cause problems in their careers, personal relationships and finances, and may put them physically at risk. The flip side of these euphoric episodes is the periods of extreme lows, when individuals’ self-confidence and positivity evaporate, they despair and may even become suicidally depressed.
Individuals with bipolar disorder often struggle with eating disorders too. The rapid mood fluctuations symptomatic of bipolar disorder can be significantly worsened by erratic eating patterns and cycles of bingeing and purging. It is not clear exactly why bipolar disorder should be linked with eating disorders (especially bulimia), but they share many characteristics, including eating irregularities, weight problems, poor impulse control, self-destructive habits, compulsive behaviours and repeating certain acts or rituals according to certain rules (similar to OCD). Eating disorders and bipolar disorder also share a tendency to ‘cycle’: between bulimia and anorexia, and between depression and mania.
Bipolar disorder sounds alarming to those who do not understand it and still carries an unfortunate social stigma, even though it is not really rare: approximately 0.5–1 per cent of the adult population are thought to have it and many more experience major depressive episodes. There is growing evidence that bipolar disorder may run in families. As research has developed, treatment has improved, with medication such as lithium often proving helpful in stabilizing neurochemical imbalances. Talking therapies, and a good relationship with a counsellor, can significantly improve an individual’s experience.
Managing bipolar disorder and an eating disorder can be challenging. For example, some antidepressants used to treat eating disorders can trigger a manic mood swing in people with bipolar disorder. Conversely, some mood stabilizers or antipsychotics used to treat bipolar disorder have been known to trigger binge-eating episodes. The severity of a person’s bipolar disorder is likely to have an influence on the severity of the eating disorder, and vice versa. Recovery depends on both conditions being properly diagnosed.
Cyclothymia is a milder form of bipolar disorder also common in eating-disordered individuals (see CYCLOTHYMIA).
BODY DYSMORPHIC DISORDER (BDD)
This describes an extreme preoccupation with one or more features of one’s own body that are not particularly noticeable or abnormal to others. Individuals with BDD are usually very self-conscious; they may describe themselves as ‘ugly’ or ‘different’ and experience a feeling of not being ‘right’. They often compulsively check their appearance in the mirror, never satisfied with what they see. In severe cases of BDD, individuals may undergo unnecessary and repeated cosmetic or dermatological procedures, which rarely resolve the psychological problem.
Symptoms of BDD range widely and include compulsive skin-picking, trichotillomania (where a person feels compelled to pull their hair out), anorexia, bulimia, depression, social phobias and anxiety disorders. It is a complex condition; those who look ‘normal’ may be affected, while those with actual physical disfigurements such as burns or scars may not.
Up to 1 per cent of the world’s population are thought to have BDD, and it is more prevalent in cultures where cosmetic surgery is common and in societies where appearance is highly valued. As every person is individual, it is impossible to find a single cause for BDD and body-image issues. There are some obvious triggers, such as being teased or bullied in adolescence, but other factors also make the individual more vulnerable, such as childhood abuse or trauma. Having a family history of mental illness appears to contribute, as does the culture and environment in which you grow up, your own personality and other psychological and neurological traits.
BDD is not solely linked to body size, shape and weight: the most common concern is with the skin, especially problems such as acne or eczema, followed by concerns about facial features such as the nose, chin, lips or eyes. People complain about a lack of symmetry, often feeling that specific features or parts of their body are too large, too small or out of proportion.
Both sexes are equally affected by BDD, although women and men tend to focus on different parts of their body. Women are more likely to be preoccupied with breasts, hips, weight and legs, whereas men tend to be preoccupied with body build (see BIGOREXIA). Men are also more likely to report concerns over their genitals, usually that their penis is too small, or concerns that their chest and torso are not masculine enough.
BDD usually begins in adolescence, a period of significant physical changes, with sexual development, hormonal changes and what can be quite significant growth spurts, affecting height and weight. It’s also the period when people are most sensitive about their appearance, and most concerned about being physically attractive to their peers.
Secrecy and shame are a large part of BDD. Many people hide their problems for many years or never seek help as they feel ashamed of their feelings. Not only do they dislike their appearance, but they also fear being labelled as vain or narcissistic. Just as anorexia is easily confused with wanting to be thin and beautiful, BDD is easily confused with vanity. In fact, the opposite is true: people with BDD want to fit in, not stand out.
The degree of impairment in BDD varies from mild to severe. While some people are able to keep their disorder mostly hidden, others find it affects relationships, work, social interactions and every area of their lives. Even in its mildest form, however, BDD causes emotional or mental distress. You might avoid social activities you have previously enjoyed and become withdrawn. You might spend more time alone, in bed or avoid seeing friends. You might use alcohol or drugs to numb your feelings or ruminate on unpleasant or upsetting things that have happened. You might experience humiliation or rejection, blaming any failures or setbacks in your life on your supposed physical abnormalities.
In the past, BDD has been portrayed as a kind of ‘imagined ugliness’, as if people were wildly delusional. However, people with milder BDD often have a good insight into their condition. They are aware that their feelings about their appearance may be unfounded or irrational – but they are still unable to control them. At the more severe end of the spectrum, people may be convinced of their supposed abnormality. To them, their physical defects are a reality, no matter how many times other people reassure them that they look normal.
Although research into BDD is nowhere near as advanced as research into depression and other mental illnesses, things are changing. As more trials are being carried out into different psychological therapies and medication, doctors and therapists are starting to develop effective guidelines and treatment. The experience of individuals (in books, blogs and articles) also provides valuable evidence of the causes and consequences of mild, moderate and severe forms of BDD, and how they respond to treatment. The evidence indicates that BDD is treatable, and people can get back to a normal life. Whether this involves self-help, CBT, anti-obsessional medication or a combination of all three, BDD is not a life sentence.
People with BDD are often also very depressed, and sadly have a high rate of attempted suicide. BDD is more common than we might think, and nothing to be ashamed of: the most important first step is to speak to someone, and to seek help from mental health professionals.
This describes our internalized sense of what we look like, the picture we hold in our minds of the size, weight and shape of our own body. This mental representation is made up of various factors, including mirror image, photographs we see of ourselves, how we think we look in the eyes of observers, idealized images of how we would like to look, the feedback we receive from others, and our general sense of worth and self-esteem.
The term ‘body image’ is widely used in magazines, on TV, in casual conversations and in everyday life, but it stands for a complex set of self-beliefs, attitudes and perceptions. It involves deeply personal issues of body ownership and identity, how we feel we look and how we judge ourselves. Body image also describes our attitudes towards the constituent parts of our body: which bits do we focus on, what do we criticize or wish we could change? (See also LANGUAGE.)
Body image is multidimensional, formed through a range of interrelated factors: activity in our brain’s somatosensory cortex, but also endless input from the world around us. Body image may or may not be stable: it may change over time, for example from adolescence to middle age, and for women during and after pregnancy, and after the menopause. Social and cultural standards change too, with expectations for body shape constantly shifting with the fashions, from boyish androgyny to hourglass curvy.
Body image can be affected from day to day by mood and by hormones (especially in women) and even by simple factors such as what we’re wearing: tighter or looser clothes affect people’s perception of their own size. Body image can be affected by what we’ve eaten, what others do and say, and how we perceive they act towards us. Stepping on the bathroom scales can have a positive or negative impact on body image (see SCALES), as can looking at images of ourselves and others, online, on social media or in magazines.
Not everyone responds to different parts of their body in the same way. We tend to be good at responding to temperature by, for example, putting on or taking off a jumper, or at responding to thirst by drinking a glass of water. However, hunger is far more complicated, and those with eating disorders display real difficulty in responding to this simple physiological need (see DEPRIVATION).
Nor do we judge all parts of our body in the same way: women often express far more emotional or critical responses to specific aspects of their bodies, usually those associated with sexual attractiveness. They feel that their breasts or bottoms, for example, are too big or too small, whereas they rarely say the same about their hands or feet. Interestingly, the areas of the body most commonly misrepresented among people with eating disorders are their hips, thighs and torso.
Body-image disturbance is a core symptom of eating disorders. We have seen that, due to cultural and social factors, and the Western concept of the ‘perfect body’, almost all women (and many men) express dissatisfaction with their body weight and shape. However, research shows that in eating disorders, disturbed body image is significantly different from that seen in the general population.
Some degree of body-image disturbance is common – in studies, patients with anorexia generally overestimate their body size more than healthy controls – but this varies widely. One of the myths and misunderstandings of anorexia is that all people have wildly distorted body image: the anorexic stereotype shows an emaciated woman looking in the mirror seeing an obese woman looking back. This is not always the case. Some anorexics have considerable insight into their physical condition and can clearly see how underweight they are. Others may genuinely see fat where others see skin and bone.
Body image, therefore, isn’t just about what you see: it’s about how you feel in your own skin. The paradox in severe eating disorders is how persistent the perceptions and beliefs around body image can be, despite the facts. For example, someone with severe anorexia can be confronted with the evidence: their weight is much lower than that of the general population. They have to buy the smallest size of clothing in the shops. They are unable to eat a normal meal like others do. They are causing intense anxiety to their family, friends and doctors; they may even be in hospital.
These individuals are often highly intelligent, and yet in some way their mental image of their body is stronger than the facts. They have a persistent experience of feeling fat even when all the evidence proves that they are extremely underweight. They are often unable to accept that they are dangerously malnourished, because the feeling of being fat or greedy overrides the medical or visual reality. However, research into neuroscience and body-image perception has found that anorexic individuals tended only to overestimate their own body size, not the sizes of other bodies or neutral objects, which suggests that body image and self-perception are complicated issues – for both healthy individuals who are eating, and those who are not.
The influence of cultural factors, especially the thin body ideal of Western society and the growth of social media, has contributed to increasingly unstable or negative body image. An NHS study in 2016 reported that mental illness among young women was soaring, with anxiety, depression, self-harm and eating disorders all on the increase. Young women have become a ‘key high-risk group’, with 1 in 5 women, compared with 1 in 8 men, having a mental illness. It is notable that rates of serious mental illness have remained largely unchanged among men for the years during which they have been rising among women.
Along with individual reasons such as childhood trauma and sexual abuse, social media has been identified as one of the major contributors to increased mental illness. Social media exerts pressure on young people to look a certain way, presenting them with unrealistic expectations and airbrushed images of physical perfection. With or without the physical and psychological impact of eating disorders, many individuals are familiar with the daily body-image struggle: how they feel and how they think they ought to look.
Neuroscientific research has not yet located a specific area in the brain associated with the body-image disturbance seen in eating disorders. Indeed, it is unlikely that there is one single region or pathway that determines an individual’s body image, although the insula is of great interest to scientists (see INSULA). Research has, however, highlighted the complicated and interrelated factors involved in the simple experience of being inside one’s own body.
Mood and hormones play a role, as do outside social and cultural influences, as do a person’s temperament and other random factors. Aggravating aspects of eating disorders such as prolonged restriction, extreme low weight, substance abuse, purging, and neurochemical imbalances associated with bingeing and purging, make the situation even more complicated. Neuroimaging studies have highlighted similar neural patterns in anorexia and bulimia, suggesting that brain processes involved in body-image disturbance in the two conditions are closer than it might appear. As ever in eating disorders research, it is unclear whether neural differences are a cause or a consequence of starvation.
As a first step, however, it is important to remember that feelings are not facts: body image isn’t always reliable. For everyone, it’s a deeply personal interaction between the inner world and external reality, psychological and sociocultural factors. In those with eating disorders, body image tends to become more positive as other symptoms improve: a more stable eating pattern and improved nutrition lifts the mood and bolsters self-esteem.
BODY MASS INDEX (BMI)
BMI is calculated by dividing weight in kilograms (kg) by the square of the height in metres. A BMI above 25 is defined as overweight and above 30 is defined as obese. Although the BMI calculation gives an accurate guide to an individual’s weight to height ratio, it fails to take into account different body shapes or composition.
In recent years, some experts have discredited the standard BMI measurement as a blunt instrument because it takes no account of the fact that abdominal fat, the so-called ‘apple shape’, tends to be more dangerous than fat around the bottom and thighs, the ‘pear shape’. Nor does BMI take into account the fact that healthy muscle weighs more than unhealthy fat. For example, even though many bodybuilders have only 10 per cent body fat, a BMI calculator would give them an ‘overweight’ result. For the same reason, some elite athletes would also be classified as overweight when they are clearly not. Another measurement, known as ABSI (A Body Shape Index) and which combines BMI and waist circumference, has been introduced as a possible alternative to BMI. (See also SCALES.)
It may seem surprising to include boredom in an A to Z of eating disorders, but many people find that boredom is their main trigger for overeating. This is part of the obesogenic society in which we live: opportunities for eating are everywhere, simply to pass the time, such as in airports, shopping centres or cinemas. As a result, we find ourselves buying and consuming food that we are not really hungry for. When constant snacking becomes a habit or a way to fill the time, we can lose the ability to identify what genuine hunger feels like.
The solution to boredom snacking, of course, is to get busy! When you’re studying, working, interested or absorbed, rushing around with no time to spare, you’re unlikely to consume excessive quantities of unhealthy snacks. Although there is nothing wrong with the occasional indulgence or just enjoying cake and coffee with a friend, in general food should be fuel. Food should be consumed mindfully not mindlessly (see MINDFUL EATING). Instead of grazing in front of the TV, at the cinema, when hanging around at the airport, we should try to sit down to a meal three times a day. This is not always possible during a busy working day, but it’s always possible to give a few minutes to focus on the food in front of us, even if it’s just a sandwich at your desk. Finding different ways to respond to boredom is essential: a walk in the fresh air, writing a page or two of a journal, ringing a friend. This will break the association between food and boredom and help to re-establish the link between hunger and eating. (See also EMOTIONAL EATING.)
The brain is a hungry organ, and in order to function properly it needs regular, good-quality fuel. Although the brain makes up only 2 per cent of total body weight, it uses 20 per cent of the body’s energy supplies. Brain cells need high-energy foods because every cell connects and communicates with thousands of other cells. When calories are severely restricted, as in anorexia, the brain struggles to function. This causes cognitive impairment, including impaired memory, concentration, learning, studying and creative thinking. In semi-starvation, all the brain’s normal functions are affected.
The root of the neuroscientific approach to eating disorders is that starving the body also starves the brain. As neuroscience has developed in recent decades, the understanding of anorexia nervosa has progressed rapidly. Most clinicians, psychiatrists and neuroscientists would now agree that there are significant genetic and neurological factors involved in anorexia. Whether the identifiable differences in brain structure – such as the shrunken insula and thalamus – are caused by pre-existing factors or caused or exacerbated by starvation is not known. However, it is clear that anorexia shows many markers of being a brain disease rather than simply a lifestyle choice, food phobia or loss of hunger.
This is a portmanteau word describing the combination of both bulimia and anorexic symptoms. Few individuals with an eating disorder will fit neatly into a single category of only restricting or only binge-purging. Instead most people alternate between episodes of restriction and episodes of binge-purging, although one behaviour is usually more dominant. The cyclical nature of disordered eating means that self-starvation is likely to lead to overeating, which is likely to lead to purging, hence the common syndrome of bulimarexia, where several different characteristics are present.
The original root of this is the Greek word boulimia, meaning ‘hunger like an ox’. As with the literal meaning of anorexia, this definition is misleading (and possibly offensive). Those who have bulimia do not ‘hunger like an ox’: they have simply developed disordered behaviours in relation to food.
Bulimia is characterized by recurrent episodes of binge-eating (see BINGE-EATING DISORDER) but with self-induced vomiting, laxative and diuretic abuse, and other compensatory behaviours to avoid weight gain. In the latest edition of the DSM (5th edition, 2013), requirements for diagnosing bulimia nervosa were changed from ‘at least twice weekly for 6 months’ to ‘at least once weekly over the last 3 months’.
As in anorexia, shape and weight are core preoccupations in bulimia, and people tend to overestimate their own body shape and weight. Bulimia can be more difficult to detect than anorexia because people tend to be of average, or only slightly above/below average, weight. Unlike anorexia, therefore, the physical signs of bulimia are not immediately visible.
Like the hungry ‘high’ that many anorexics experience in prolonged starvation, bulimia can become addictive, behaviourally but also chemically. Both bingeing and vomiting can trigger waves of endorphins, potent ‘feel-good’ brain chemicals. The release of these natural heroin-like chemicals reinforces the powerful compulsion to purge, which bulimics often feel helpless to fight. For outsiders, who associate vomiting with feeling very unwell, this is incomprehensible. Everything about vomiting appears to be unpleasant, so bulimia is deeply misunderstood.
In fact, bulimia is surprisingly common, although exact figures are impossible to come by, because of the hidden nature of the condition. Studies at American high schools and colleges have reported that from 60 to 80 per cent of the female students binge, purge and starve on a regular basis. Girls reported that skipping meals turns into all-day fasting, followed by ‘pig-outs’ when the hunger becomes unbearable, after which vomiting, laxatives or diet pills are used.
Calcium is the most abundant mineral in the human body. Its primary function is to build and maintain healthy bones and teeth. It also regulates muscle contractions, including the heartbeat, and ensures that blood clots normally. Around 90 per cent of the body’s calcium is in our bones.
When there is insufficient calcium for normal biological functioning, stored calcium is used instead. This can seriously deplete bone mass and lead to brittle bones, fractures and breakages. Fragile and porous bones and its precursor osteopenia (see OSTEOPOROSIS/OSTEOPENIA) are serious conditions. As vitamin D is essential for calcium absorption, it’s important to get enough vitamin D through regular exposure of the skin to daylight (at least 15 minutes a day) and through adequate dietary intake.
Bones increase in size and mass up to the age of around 30, so it is crucial to obtain adequate calcium (and vitamin D) in childhood and adolescence, especially for girls and women. Insufficient calcium is extremely common in young women who are restricting calories, avoiding dairy products and fat, and are missing periods. It should be noted here that low-fat dairy options contain the same amount of calcium as the corresponding full-fat products, so they are good sources of calcium.
Adults need around 700 mg of calcium a day. Women who are breastfeeding or postmenopausal need more. Milk, yogurt and cheese are rich natural sources of calcium. Non-dairy sources include green leafy vegetables such as kale, broccoli and cabbage. Soya, tofu, nuts and fish with bones (such as pilchards and sardines) are also good sources of calcium. Other strategies for healthy levels of calcium include not smoking, and taking regular weight-bearing activity (such as walking or running) to keep the bones strong.
As well as being crucial for bone health, calcium plays a central role in neuronal activity: almost every neurochemical signal in our brains involves calcium. When too much calcium is released, as in the bone loss seen in anorexia, this may lead to brain cell loss.
The human body is designed to run on carbohydrates. While protein and fat also provide energy, carbohydrates are the easiest and most immediate source of fuel.
Carbohydrates can be particularly problematic for individuals with eating disorders. In anorexia, the person tends to avoid ‘bulky’ carbohydrate foods, such as bread and pasta, in the mistaken belief that these will make them fat. In reality, they need these carbs for a wide range of body functions, from concentrating to staying warm, moving around and maintaining stable moods and good digestive and bowel functioning. Carbohydrates control our blood sugar, which in turn controls our appetite and weight and metabolism.
Carbohydrates can also be problematic in bulimia and binge-eating. Most ‘binge’ foods are carbohydrate-heavy and of the simple, sugary variety rather than complex, slow-release carbs. As we will see, consuming large quantities of simple carbs only worsens the inevitable blood sugar imbalance. During a binge, the body experiences a rapid increase in blood sugar levels, followed soon after by a crash (and purging only worsens this yo-yo cycle), but cutting out carbohydrates is not the answer: everyone, whatever their weight, benefits from a steady release of energy from ‘good’ carbs. In order to understand which carbohydrates to choose, we need to differentiate between complex and simple carbohydrates.
•Complex carbohydrates include whole grains, pulses, lentils, beans and vegetables. The body takes longer to digest these foods, breaking down the fibres and taking the nutrients it needs. This slower digestion process releases energy slowly, keeps blood sugar levels steady and keeps you feeling fuller for longer. Complex carbs also aid the digestive process.
•Simple carbohydrates are refined, white or overcooked foods, such as white bread, white rice, white pasta, refined sugars such as glucose, honey and syrup, dried fruit and sweets. Refined carbs act like refined sugars: the process of refining or cooking foods starts the process of breaking down complex carbs into simple carbs, effectively pre-digesting them. This means that the sugar is rapidly absorbed, causing a spike in blood sugar and energy levels. Fruit admittedly contains simple sugars, but in many fruits this is fructose rather than glucose. The body has to convert this fructose into glucose, for use in cells, which slows down the energy-release process. Grapes and dates contain glucose (and are therefore simple, fast-release carbs), whereas apples contain fructose (and are therefore much slower-release).
In general, there are a lot of tempting, simple carbohydrates around: cakes, biscuits, chocolate bars, sweets, white bread, pasta, fruit juices, most breakfast cereals and many other artificially sweetened substances. In fact, sugar consumption in Western diets is excessive: we could all benefit from fewer simple carbs and more complex ones. Endurance athletes may need this immediate, abundant energy but most of us don’t, and when sugar is not required as fuel, it is stored as fat. Sugar is also low on nutrients (around 90 per cent of the vitamins and minerals have been removed from white sugar) so sugary simple carbohydrates are empty calories.
Conversely, complex carbohydrates not only provide our bodies with an excellent, steady source of fuel, they are also essential for healthy brain functioning. Restricting carbohydrates leads to depleted levels of the mood regulator serotonin. Individuals on extreme low-carbohydrate regimes often become very depressed. Lack of carbohydrates also risks exacerbating anxiety and OCD (see ANXIETY and OBSESSIVE COMPULSIVE DISORDER).
There has been an explosion of low-carb eating in recent years, such as the Atkins and Dukan diets, with their severely restricted carbohydrate content. While these diets appear to show rapid results, any weight loss is mostly short-lived, and is caused by dehydration and water loss rather than an actual decrease in body weight. Additionally, these low- or no-carb diets often ration fruit and vegetables (which contain essential vitamins and minerals) and substitute carbs with excessive fat: bacon, eggs, cream, butter and so on. Clearly, this kind of unbalanced eating is unwise: it’s just as unhealthy to consume too few carbs as too many. Extreme low-carbohydrate diets also create a sense of deprivation: Atkins dieters often report cravings for bread, pasta, potatoes and other forbidden carbohydrates. Eliminating entire food groups can be a trigger for binge-eating and bulimia, where the craving for ‘bad’ food gets out of control, and the individual just crams it all in. (See also BINGE-EATING DISORDER, DEPRIVATION, SEROTONIN and ANXIETY.)