Introduction to Eating Disorders
‘The mind is its own place, and in itself can make a heaven of hell, a hell of heaven’.
(John Milton 1969, p.67)
Body Image
We are all influenced by our body image, by how we view ourselves and by how we think others perceive us. Thinness is continually advocated and coupled with positive qualities like intelligence, beauty, health and power. Whereas fatness is often associated with laziness, un-attractiveness and greed. Sometimes this image is misshapen and the indication of ones body reflection gets out of control. The reaction to this distortion can precipitate a whole chain of behaviours that can then become unhealthy.
In this article I hope to explore the ‘complicated psychiatric illnesses’ (Michel and Willad, 2003, p.2) that are termed eating disorders; probably the fastest growing neurosis of the western world and an allegory of our era. Although these disorders can include pica, compulsive overeating and eating disorders not otherwise specified (EDNOS), I will concentrate on the two most widely adduced: anorexia nervosa and bulimia nervosa.
In each of these disorders the person often lacks a sense of identity, therefore, as will become obvious, there is a hidden expression of uniqueness, sovereignty and of whom the person is. ‘An eating disorder appears to be a perfect response to a lack of autonomy’ (Hornbacher 1998, p.68), in which the symptoms can be seen as an expression, in an attempt to be perfect.
What Eating Disorders Means
The term eating disorder refers to a broad variety of unbalanced eating rituals and disturbances in eating behaviour, an abnormality between a person and their eating. Each disorder is a deliberated response to ecological occurrences, a coping strategy, with disorders of the mind extant on a progression of functioning. They refer to a set of complex, successive conditions typified by psychological and emotional suffering, acute disorders in eating and physical repercussions.
‘Eating disorders appear ‘to be an enigma’ (Campion 1998, p.83). ‘They cannot be studied simply from the perspective of food and diet’ (Parsons 2005, p.24). What they say more of, is about how the individual copes with overwhelming feelings and an appreciation of the control they exercise around what is usually unbearable to be dealt with in any other way, ‘through the reaction-formation defence mechanism’ (Ledden, 2006). The symptoms are the language and articulation of a story that is trying to be told.
Causes of Eating Disorders
It is the wide ranging combinations of multi-factorial issues that contribute to and is intricately woven in the development of an eating disorder. The predisposing factors can be familial, psychological, biological and socio-cultural. Research has also indicated that these disorders are often linked to precipitating factors of conflict of an internal and external nature such as low self esteem, disturbances around early nurturance, experiences of sexual/physical abuse, bereavement, loneliness and relationship problems.
The factors that perpetuate the disorder are the psychological consequences of malnourishment and the many structures of reinforcement. Of course, the specific constellation of attributing factors will be unique to each individual. These disorders are full of paradoxes because ultimately it is a no win situation and they cannot be explained in a uniform mode. ‘It is, at the most basic level, a bundle of deadly contradictions…’ (Hornbacher 1998, p.6), which have the‘centripetal force of black holes’ (Hornbacher 1998, p.129).
It is also common for there to be co-morbidity with these disorders such as depression, anxiety, phobias and alcoholism, to name but a few.
Similarities between Anorexia and Bulimia
As will be emphasised in the coming pages, the following lines highlight the resemblances that occur for people with either eating disorder.There is a constant search for approval.
- Discomfort when eating with others.
- Problems with interpersonal relationships.
- Preoccupation with weight, size, food and dieting.
- Obvious changes in moods, personality and habits.
- Factors of control, trust, autonomy and low self-esteem.
- Hyperactive behaviour, difficulty with concentration, relaxation and sleeping.
- Complaints about headaches, tiredness, muscle weakness and unexplained gland swelling.
Anorexia
Anorexia Nervosa (loss of appetite of nervous origin) ‘knows no logic’ (Claude-Pierre 1999, p.18). It is ‘a sneaky disease’ (Jackie, 2006) of self imposed starvation that is characterised by a deliberate refusal to eat enough food so as to maintain minimal weight. It is the most life threatening of the eating disorders. While ‘…diagnostic classification tells us nothing about the unique and varied individuals who receive such labels’ (Moorey 1991, Preface), according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) the diagnostic criteria for anorexia nervosa are:
A. Disturbance in the way the person experiences their body weight or shape.
B. The absence of at least three consecutive menstrual cycles in postmenarcheal females.
C. An intense fear of becoming fat or gaining weight, even though under weight. ‘When you’re sick, you’re very irrational’ (John, 2006)
D. Refusal to maintain body weight at or above the minimal normal weight for age and height, with weight loss leading to the maintenance of body weight less that 85% of that expected.
‘Anorexia, however, does not necessarily start with a desire to loose weight. People stop eating for much more complex reasons’ (Haycock 1994, p.9).
There are two specific kinds of anorexics; (1) the restricting type and (2) the binge-eating/purging type, which ‘appears to be more psychopathological’ (Davidson, Neale and Kring 2004, p.247).
‘The anorexic operates under the astounding illusion that she can escape the flesh, and, by association, the realm of emotions’ (Hornbacher 1998, p.93). A symbolic relationship to life through food; anorectics starve themselves of what life can offer.
Its prevalence usually ranges from 12-18 years of age, ‘model children’, 95% of them female, and 40% of them having bulimia too. Athletes, dancers and models are some of the people at greater risk of developing this disorder. It ‘is so disembodied, so imperceptible for such a long time, so socially sanctioned, that you can go a long time clinging to your belief that there’s nothing wrong with it’ (Hornbacher 1998, p.223). Anorexics ‘are often quite hungry but suppress their hunger’ (Ledden, 2006). The result of starving is a physiological releasing of endorphins that produce feelings of euphoria and peace. This in itself becomes a type of reward; therefore to eat becomes harder than not eating.
Signs and Symptoms of Anorexia
| Physical | Behavioural | Psychological |
| Anaemia | Irritability | Isolation |
| Constipation | Mood Swings | Fear of Food |
| Slow Heart Rate | Eating Rituals | Depression |
| Weight Loss | Indecisiveness | Secretiveness |
| Extremeties Cold | High Mortality Rate | Weight Obsession |
| Low Blood Pressure | Denies Food Problems | Hunger Supression |
| Vulnerable to infection | Frantic Exercising | Obsession with Food |
| Abdominal pain, bloating | Obsessive/compulsive | No real sense of self |
| Irregular/ no menstruation, growth of fine downy hair | Minimal weight not obtained, Increased intake of fluids | Distorted body image, Inflexible thinking |
Bulimia
Bulimia Nervosa (or hunger) is characterised by repeated episodes of binge eating followed by behaviours known as purging, to prevent weight gain. It is the cycle of binging and purging that makes a person bulimic. A symbolic relationship to life through food; bulimics are ambivalent in relation to their existence to life. According to the DSM-IV-TR the diagnostic criteria for bulimia nervosa are:
A. Recurrent inappropriate compensatory behaviour in order to prevent weight gain.
B. Self- appraisal that is excessively influenced by body weight and shape.
C. Recurrent incidences of binge eating distinguished by (1) lack of control over eating and (2) eating is discrete and is considerably more than what most others would eat.
D. Occurrences of the above are, on average, twice weekly for three months.
During a binge which is experienced as compulsive, there is an excessive amount of food being eaten, resulting in a possible calorie intake of up to 10,000; an expensive obsession.
The trancelike bulimic episode normally ends when the person has either run out of food, induces vomiting, is physically worn out or is interrupted by somebody.
The purging that normally follows this can take the form of repeated vomiting (which can be assisted with syrup of ipecac) or the overuse of laxatives, diet pills, diuretics or enemas. It can also be symbolised by fasting, excessive exercising and using appetite suppressants. This refers to the non-purging type bulimic. Although, the restricting of the food is more likely to create the appropriate conditions for the next binge to occur.
The binge eating orgies are a way of avoiding stress, of meeting the demand of the accumulative anxiety and of wanting to get enough, to be stuffed up. ‘The physical food transubstantiates in our minds into something more ethereal, of human and emotional nurturance’ (Hornbacher 1998, p.27), while the purging relates to the reward and purification of self from the caloric effects and guilt felt, having binged. The pervasiveness of bulimia is generally between 15-24 years of age, ‘rebellious children’ and largely in females. Often a ‘failed’ anorectic becomes bulimic.
All of these maladaptive behaviours can be understood as being distinctive of what is termed the anorexic attitude, ‘outward signs of something that is seriously wrong inside’ (Moore-Groarke and Thompson, p.23), although the effects of bulimia are less obvious than those of anorexia. ‘Bulimia acknowledges the body explicitly, violently. It attacks the body, but does not deny’ (Hornbacher 1998, p93).
Signs and symptoms of Bulimia
| Physical | Behavioural | Psychological |
| Fatigue | Fasting | Impulsive |
| Fainting | Vomiting | Secretive |
| Dizziness | Shoplifting | Low Self-esteem |
| Constipation | Secret Eating | Hypersensitive |
| Constant thirst | Rigid dieting | Depression |
| Abdominal Pain | Laxative Abuse | Powerlessness |
| Chronic Hoarseness | Suicidal Behaviour | Need for Approval |
| Electrolyte imbalance | Bingeing and Purging | Represses Feelings |
| Muscle crampness/weakness | Obsessive about Self | Feelings of guilt |
| Broken Blood Vessels in the Eye | Secret Hoarding of Food | Tendency to isolate Self |
| Irregular/no menstruation | Sexual abuse/promiscuity | Shame-based existence |
| Cuts/calluses on hands/knuckles | substance/diuretic abuse | Difficulty with intimacy |
Differences between Anorexia and Bulimia
Below is a list of the significant differences between people with anorexia and people with bulimia.
| Anorexics | Bulimics |
|---|---|
| Introverted | Extroverted |
| Asexual | More sexual |
| Rejects food | Steers to food |
| Distorted body image | Dissatisfied with body image |
| Irritable and Listless towards others | Denies feelings to please others |
| Refuses to maintain weight | Difficulties with maintaining weight |
| Denies their Abnormal eating | Recognises their eating is not normal |
Theories
There are many theories and interwoven factors that encompass a person with an eating disorder. For whichever one person, some or all of the following features will emerge to explain the generating starving, stuffing and purging that exist as part of the disorder.
- Addiction; An avoidance of pain that can be seen in behavioural obsession, pre-occupation, lack of self-control, compulsion, craving and eventually, loss of control
- Socio-Cultural; Of aetiological significance, where there is emphasis on weight, thinness, prettiness and a striving for the ideal. Illnesses which have significant connotations for our time.
- Regression; There is an avoidance of the evolving burdens of puberty and adolescence: ‘fear of becoming fat is the symbolic expression of becoming bigger or growing up’ (Ledden, 2006)
- Unconscious motivations and impulses; ‘It was a way for me to destroy myself’ (John, 2006).
- Genetic; Twin and family studies are indicative of an elevated inheritability of anorexia and bulimia. People who have had an anorectic sister or mother are 12 times more susceptible to developing the disorder themselves and 4 times more likely to develop bulimia.
- Neurobiological; Disturbances in the brain affect the endocrine system which then affects eating habits.
- Familial; They provide the backdrop, against which the disorders develop. These families are often referred to as enmeshed, rigid, overprotective or chaotic.
Recovery and Treatment Options
Eating disorders, unless treated appropriately, become a progressively damaging sequence. Generally, it is only when sufferers become medically at risk that professional help is sought. Roughly 70% of anorectics and 80% of bulimics recover.
‘By definition of these illnesses, the affected person is not truly well until the behavioural symptoms are gone’ (Michel and Willard 2003, p.71). The longer they go untreated, the more life threatening they become, therefore the earlier the intervention, the better the prognosis. ‘The crucial aspects of the recovery process include awareness, freedom, independence, learning step by step, and calmness’ (Parsons 2005, p.31). It begins when there is an acknowledgement of the pain in continuing, being worse than the anguish in letting it go, i.e. when it hurts more than it helps.
Treatment Strategies
Due to their intricacy eating disorders necessitate a broad treatment strategy. This usually begins with ones G.P., medical interventions and psychiatric treatment. These often go hand in hand when the disorder becomes life threatening and can be in the form of inpatient or outpatient recovery programmes. The more structured treatment programmes are particularly useful for people who have tried and failed to get well. Nutritional/dietary rehabilitation is also a vital part of that so as to achieve and maintain appropriate weight gain which enables the person to be well enough to work on the psychological factors that underlie and sustain their disorder. Because ‘the battle against an eating disorder is fought in the mind’, (Moore-Groarke and Thompson 19, p.57) psychotherapy becomes the cornerstone of treatment. Also ‘it is of utmost importance that behavioural treatment is used in conjunction with psychotherapy’ (Moore-Groarke and Thompson 19, p.75) because the power base is in the cognitive belief system. In conjunction with the above psychotropic medications like Prozac have also been proven to be useful for helping to resolve anxiety and depressive symptoms connected to eating disorders. Support groups can be beneficial in affirming ones attempt to get well and family therapy, which is geared towards understanding the role the eating disordered person carried out within the system, can assist with recovery.
There is no magical treatment for eating disorders. Treatment is complex and beleaguered by numerous difficulties. Ultimately all valid healing and transformation come from within. The eating disordered person will need to be given plenty of time to assimilate and digest the therapeutic meal that all of the treatment is synonymous of.
Conclusions on Eating Disorders
Clearly ‘eating disorders are “about”: yes control, and history, philosophy, society, personal strangeness, family dysfunction, autoerotics, myths, mirrors, love and death and S&M, magazine and religion, the individual’s blindfolded stumble-walk through an even-stranger world’ (Hornbacher 1998, p.4).Hence an eating disorder must thus be considered a disorder of control, manifesting in disordered eating, with recovery involving the gradual and constant transferral from the sufferer’s pathological sense of control to one of an appropriate and healthy control. What contributes most to the person achieving that is a high level of commitment and the appropriate support from external resources.
References:
Campion, M. (1998) Hope. Understanding Eating Disorders. The O’Brien Press Ltd. Dublin
Claude-Pierre, P. (1999) The Secret Language Of Eating Disorders. How You Can Understand and Work to Cure Anorexia and Bulimia. Vintage Books. USA Davidson, G. C., Kring, A. M. and Neale, J. M. (2004) Abnormal Psychology. 9th Edition. Wiley & Sons, Inc. USA
Ledden, P. (2006) Abnormal Psychology Lecture Notes
Michel, D. M. and Willard, S. G. (2003) When Dieting Becomes Dangerous. A Guide to Understanding And Treating Anorexia And Bulimia. Yale University Press.USA
Parsons, H. (2005) Considering eating disorders within the context of addiction: A
Psychoanalytic Perspective. Inside Out. The Journal for the Irish Association of Humanistic and Integrative Psychotherapy. No.45 Spring 2005
Haycock, K. (1994) Dealing with Eating Disorders. Wayland Publishers Ltd. East Sussex
Hornbacher, M. (1998) Wasted. A memoir of Anorexia and Bulimia. Flamingo. London
Moorey, J. (1991) Living with anorexia and bulimia. Manchester University Press. Manchester
Moore-Groarke, G. and Thompson, S. When Food becomes your Enemy: Anorexia, Bulimia and Compulsive Overeating. Mercier Press. Dublin
Soundings. (1969) Gill and Macmillan. Dublin
The Late Late Show. (2006) Males and Anorexia Nervosa. Friday 24th November
