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    Eating Disorders: A Help Guide
    This guide provides information and resources for those who are suffering from an eating disorder, those who are concerned about a loved one who may be affected, and anyone who would just like to understand more about the issue.


    What is an Eating Disorder?

    An eating disorder is a psychological condition that compels you to make abnormal choices around food in a way that is damaging to your physical health. Usually it involves either depriving your body of the calories it needs to properly function or eating excessively.

    The most well-known eating disorders, and for a long time the only ones officially recognised by major health boards, were anorexia nervosa and bulimia nervosa. But recently, binge eating was recognised as its own disorder.

    In Australia, the National Health and Medical Research Council (NHMRC) also uses the term 'atypical eating disorders' for psychologically distressful eating patterns that do not quite fit a diagnosis for any of the above. In America, these were called eating disorders not otherwise specified (EDNOS), but since the official recognition of binge eating disorder, which many cases of EDNOS were, this is no longer an official diagnoses.

    Eating disorders are serious. Of all mental illnesses, eating disorders actually claim the most lives, with 1 in 5 dying from the physical complications they create or from related suicide. If you suspect you have one, it is important you seek help.

    And don't overlook your symptoms just because they differ from someone you know. Eating disorders vary in degrees of severity and can present different symptoms in different individuals. 


    How common are Eating Disorders?

    It's estimated that nearly 1,000,000 people in Australia suffer from some kind of eating disorder.

    Eating disorders have been popularised a form of psychological illness that strikes teenage girls, but this also affects teenage boys, men and women. Of the almost 7% of adults having some form of eating disorder, 25% are men. Eating disorders can also develop at any age, with anorexia being reported in children as young as 7, as well as in senior citizens.

    As for which eating disorder is most common, it varies. Bulimia tends to develop at a slightly older age than anorexia, and binge eating is far more common in adults. But in general, the most common sort of eating disorder tends to be atypical eating disorders. If this term includes binge eating disorder, it accounts for 50% of all reported eating disorders, with bulimia accounting for 40% and anorexia for 10%. These statistics shows how important it is that other types of eating disorders are finally officially recognised. 


    What are the different Eating Disorders and their signs?

    Modern ideas around food and eating can lead to what seem new eating disorders, with terms being used like orthorexia nervosa (an obsession with only healthy and 'pure' foods), night eating disorder (eating most of your food at night) compulsive overeating (grazing, over bingeing, on far more food than they need), and anorexia athletica (addicted to burning off calories through exercise).

    But the eating disorder categories officially used by health care professionals in Australia include anorexia nervosa, bulimia nervosa, and binge eating disorder. The fourth category used for those who have a blend of symptoms that do not quite match one of the above disorders is simply atypical eating disorders.

    It's possible to have different eating disorders at different times. For example, bulimia can develop from anorexia, or what starts as anorexia can become an atypical eating disorder.

    General signs of an eating disorder

    There are some symptoms that show up in almost all eating disorders. 

    Behavioural signs that indicate an eating disorder include:

    • obsessive thoughts about food, body weight, or body shape
    • see food and their body as something that must be 'controlled'
    • distorted body image (believing self to be overweight when weight is normal or underweight)
    • a fear of gaining weight involving repetitive weighing of self
    • obsession with image (eg looking in the mirror often)
    • discomfort when eating in public
    • a tendency to lie about what they have eaten or their eating habits
    • hiding food
    • enjoying making food for others but not for self
    • possible social withdrawal from family and friends
    • punishing self if weight is not lost
    • constantly criticising oneself
    • a tendency to underestimate their problem even after diagnosis
    • a habit of self-harming

    Physical signs of an eating disorder are:

    • sudden changes in weight
    • depression and low self-esteem
    • moody and irritable
    • tired, unable to concentrate or focus
    • lack of libido
    • sleeping issues such as insomnia
    • dizziness
    • stomach pains
    • weakness, loss of strength
    • amenorrhea (menstruation halts or is very irregular)
    • oedema (swelling of hands, feet, and/or face)
     
    Anorexia Nervosa (Anorexia)

    Anorexia Nervosa is when someone keeps their weight low by obsessively restricting amount of food they eat, keeping their weight low by dieting.

    Additional symptoms to those above can include:

    • only eating low calorie food or drinks, counting calories obsessively
    • fear of fattening foods
    • possible use of diet pills, appetite suppressants, and/or laxatives
    • excessive exercising to burn calories
    • pretend they have eaten when they haven't
    • think they are overweight when they are underweight
    • often skipping meals entirel
    • cutting food up as small as possible and pushing it around plate over eating it
    • obsessive behaviour or even OCD
    • punishing self if weight is not lost
    • coldness, low body temperature
    • hair falls out on head but fine downy hair grows all over body
     
    Bulimia Nervosa (Bulimia) 

    Bulimia is when someone is caught in a pattern of eating large amounts of foodthen purging afterwards in an attempt to not gain weight. This can be viainduced vomiting, laxative or diruetic use, overexercising, or performing enemas.

    Additional signs and symptoms to the ones mentioned above may include:

    • bingeing- consuming large amounts of food
    • purging after eating – vomiting, overexercising, fasting, using laxatives
    • very secretive about food habits
    • fluctuating weight
    • organising life around buying food, eating food, and purging food
    • feeling out of control, guilty, and ashamed
    • ongoing anxiety and tension
    • lethargy
    • gastric troubles, bloating, constipation
    • callouses on hand from using it to be sick
     
    Binge eating disorder

    Binge eating disorder is similar to bulimia in that it involves overeating large amounts of food quickly. But it does not then involve purging to keep your weight under control. It is diagnosed when you binge at least once a week for three months or more.

    Symptoms of binge eating disorder can include:

    • ritualistic eating where a binge is planned and certain foods purchased
    • eating much more quickly than usual
    • usually bingeing secretly in private
    • eating when not hungry
    • a feeling of 'zoning out' when bingeing and 'coming to' afterwards
    • extreme guilt over binge episodes
    • often involves issues with being overweight
     
    Atypical eating disorders

    Atypical eating disorders, also known as eating disorder not otherwise specified (EDNOS),  is a diagnosis given in the following situations:

    • you don't quite meet a diagnosis for bulimia or anorexia
    • you have symptoms of both disorders
    • you have disordered and distressful eating habits that don't officially match recognised disorders

    Sometimes the reason you end up with a diagnosis of atypical can be based on something very small, such as having a body weight that is just above the threshold of anorexia, or that your purging habits are not quite frequent enough to gain a diagnosis of bulimia.

    Remember, diagnostic terms are created as a short hand for doctors to use, and being told you have an atypical eating disorders is just as serious as any other diagnosis. What matters is not your exact diagnosis, but recognising you have a serious problem with eating that is life threatening and requires treatment.

    Eating disorder not otherwise specified is actually no longer an official diagnosis in America. Since their main diagnostic guide, the DSM, officially recognised binge eating disorder, this has been dropped. There is now instead other specified feeding or eating disorder (OSFED) which applies to a feeding or eating disorder that causes you great distress but does nto meet the criteria for a diagnosis of recognised eating disorders. This includes purging disorder (regularly attempting to reduce caloric intake by vomiting, overexercising, or using medications, but not bingeing beforehand) and night eating syndrome (consuing 25% or more of your calories in the evening). 


    Why do people develop an Eating Disorder?

    The development of an eating disorder is usually complex with a number of different causal factors. Some of these factors may include negative life experiences, negative relationships, learned behaviour, genetics, society and culture.

    Our experiences

    Much research has shown that, along with many other mental health issues, eating disorders are often linked with our experiences. In particular, negative experiences in childhood and adolescence can have significant lasting effects on us.

    Stressful life events and trauma are also linked to eating disorders. In addition, there have been links found between difficulties in family relationships and the development of an eating disorder. Having positive and healthy family relationships, particularly whilst young, is very important for our emotional and mental health development.

    When someone experiences negative relationships or stressful life events they can feel a lack of control in their life. When someone feels that something in their life is out of their control, this can become difficult to deal with emotionally. One way of seemingly regaining some control back is by controlling ones’ own weight and body. This is something that other people do not have any power over; therefore controlling ones own weight can be used as a way of feeling in control.

    Negative feelings

    Many individuals will use food as a way of coping with negative emotions. An individual suffering from Binge Eating Disorder can often have thoughts such as ‘I will feel better if I eat something’. However, this is generally a short term fix and sufferers can be left with even more negative feelings after their binge, along with further negative consequences of over-eating. The common emotions that can trigger eating binges include depression, anxiety, stress and feelings of low self-esteem/ self-worth. Boredom and loneliness are also triggers for binging. Sufferers may fall into patterns and habits of binge-eating which can be difficult to break. Some describe their disorder as being similar to an addiction. 

    Genetics/learned behaviour

    Eating disorders have been found to run in families. Whether or not genetics or learned behaviour is the reasoning for this is not entirely known. Research has found results that support both suggestions.

    Binge eating disorder has been found to ‘run in families’. This could be due to genetics, a theory which is supported by some research. Equally it could be a learned behaviour. If a child observes a parent using food to cope with emotions then they may be more likely to imitate this behaviour. In addition, many parents reward children with food. This can enforce unhelpful ideas about food from a young age.

    Biological implications have also been linked to binge eating disorder. Low levels of serotonin in the brain have been linked to this. Also, the brain controls our appetite and when someone suffers with brain abnormalities in specific regions (e.g. the hypothalamus), this may have some impact.

    Societal/cultural influences

    People are often influenced by the pressures of society and the media. Many young people (females in particular) may experience pressure from other sources to be slim e.g.  peers, friends, cultural background, siblings, websites, magazines, music & film.

    Certain professions may also hold the pressure to be slim e.g. dancers, models or athletes. Eating disorders have been found as higher in prevalence in such professions.

    It can be seen that there are a number of possible causal factors to developing Anorexia and Bulimia. Often the reason will be an amalgamation of such factors.


    Misunderstandings and stigma

    Often the friends and family of a person suffering from an eating disorder can become frustrated and worried due to misunderstanding the conditions. Many people assume that those with Anorexia or Bulimia are ‘attention seeking’, or ungrateful for their food. Those suffering from Binge Eating Disorder may be judged as 'greedy'. It can be difficult to understand, particularly as many of the symptoms of an eating disorder go against our natural instincts.

    However, falsified beliefs are unhelpful for recovery. Eating disorders are complex and overcoming one can be extremely difficult. An empathetic and considerate approach can be a better way to understand the problems that face individual sufferers. It is important to remember that there are always underlying causes to the development of an eating disorder. Many individuals will require specialised psychological support to change their behaviour and overcome the underlying issues.


    What are the diagnostic criteria

    Anorexia Nervosa

    According to the DSM-5 criteria, a diagnosis of Anorexia can only be made when an individual displays:

    • Persistent restriction of energy intake leading to significantly low body weight (in context of what is mininmally expected for age, sex, developmental trajectory and physical health)
    • Either an intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain (even though significantly low weight)
    • Disturbance in the way one's body weight or shape is experienced, undue influence of body shape and weight on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight 

    There are two subtypes of Anorexia Nervosa:

    Restricting - This is when an individual restricts their food intake.
    Binge-eating/purging - This is when an individual restricts their food intake but also regularly engages in binge eating and purging behaviours.

    Bulimia Nervosa

    According to the DSM-5 criteria, a diagnosis of Bulimia can only be made when an individual displays:

    • Recurrent episodes of binge eating
    • A sense of a lack of control over eating during the episode
    • Recurrent inappropriate compensatory behaviour in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics or other medications, fasting or excessive exercise
    • Binge eating and inappropriate compensatory behaviours occurring on average at least once a week for three months
    • Self-evaluation which is unduly influenced by body shape and weight
    • Disturbance which does not occur exclusively during episodes of Anorexia Nervosa 

    Binge Eating Disorder

    According to the DSM-5 criteria, a diagnosis of Binge Eating Disorder can only be made when an individual displays:

    • Recurrent episodes of binge eating (at least once a week for three months)
    • Binge eating not associated during the course of Anorexia Nervosa, Bulimia Nervosa or with the recurrent use of inappropriate compensatory behaviours such as self-induced vomiting
    • A sense of lack of control about eating during the episode
    • Marked distress about binge eating

    The episodes of binge eating are generally associated with three or more of the following:

    • eating much more rapidly than normal
    • eating until feeling uncomfortably full
    • eating large amounts of food when not feeling physically hungry
    • eating alone because of feelings of embarrassment 
    • feelings of disgust, depression or guilt after bingeing


    What could happen if left untreated?

    One risk if an eating disorder is left untreated is the worsening of symptoms and the development of further mental health problems such as depression. If left untreated, a person’s relationship with food is likely to become more complex and more difficult to change. The underlying issues are also unlikely to be unresolved if untreated.

    The body is often negatively affected by Anorexia and Bulimia. Anorexia sufferers are likely to experience adverse effects of malnutrition if left untreated. The body requires energy to survive and when someone is malnourished the body can seek energy from muscles and eventually the organs.

    Other health consequences include reduced muscle and tissue mass, chemical imbalance, decreased mobility, difficulties in breathing, higher risk of heart failure and chest infection, Osteoporosis (bone weakness), lower recovery rate from infections and wounds, risk of hyperthermia, acute kidney failure, liver damage and poor libido (sex drive). Many untreated sufferers will also experience fertility problems.

    Anorexia sufferers can also develop Lanugo, which is a layer of soft, fine hair growing all over the face and body. This is due to malnutrition and is the bodies’ attempt to keep warm when lacking fat to accomplish this. Skin can also become dry and rough. Individuals may experience dizziness and can faint due to malnutrition and dehydration. Over time, individuals may be placed in a hospital setting for treatment of malnutrition.

    Anorexia can sometimes prove fatal and has the highest mortality rate of any psychiatric disorder during adolescence.

    Bulimia sufferers are likely to develop significant teeth problems and halitosis (bad breath) caused by frequent vomiting. It is also common for those to develop swollen cheeks caused by excessive vomiting (from enlargement of the salivary glands). The ongoing use of laxatives can also be very damaging; bowel muscles and nerve endings can be damaged. This can result in permanent constipation and abdominal pains.

    For those suffering with Binge Eating Disorder, the effects of obesity (body mass index of 30 or above) can be serious and sometimes fatal. Some of these include breathing difficulties, sleep apnea, type 2 diabetes, high blood pressure, Gallbladder disease, high cholesterol, Heart disease, certain types of cancer, Osteoarthritis, joint and muscle pain and gastrointestinal problems. In addition longevity can be much affected by obesity.

    Eating disorders can lead to significant impairment in health, occupation, relationships and everyday functioning. Individuals suffering with symptoms should seek help and should not delay treatment.


    What should I expect from treatment?

    Like most mental illnesses, treatment and recovery take time. Many individuals see positive results from the right treatment and then can begin to lead a happier and healthier life without the anxieties and problems of an eating disorder. Many individuals will experience improvement in various life areas.

    Initially you may undergo an assessment to explore the eating disorder and its development. During therapy, you will gradually build up a rapport with a therapist and work together to develop better coping mechanisms and overcome underlying issues.

    Further advice

    It is recommended that individuals make small steps when aiming for recovery. It could be that you slowly begin to change your behavior, for example eating slightly more, trying new foods, weigh yourself slightly less, purging less than usual and speaking to someone when you feel down, along with accessing treatment.

    It is important to be open and honest to the people trying to help you as well as being honest to yourself. Eating disorders can involve dishonesty however this is something that will not help with your recovery.

    After treatment, many can experience some of the symptoms but to a lesser extent for example some people can still have some issues with food but this will not be life threatening. Over time many symptoms will go away yet some suffer with ‘Orthorexia’. This is a fixation with food content yet to a lesser degree of someone with Anorexia or Bulimia.

    If you notice that some symptoms and signs still exist or re-emerge at any point then consider seeking further support.

    Here are some steps which individuals can take towards recovery:

    • Keep a food diary and record your consumption. When looking back on this, it can help you to establish existing patterns. This tool can also increase your motivation to change your behaviour
    • Try to do something else when you are depressed, stressed or anxious. Try speaking to someone, call a helpline, read a self-help book or do something which relaxes you.
    • Exercise - This will help with weight loss (if needed) and can help to improve your mood. When we exercise, our brain releases endorphins which help us to feel happier.
    • Try sticking to three meals per day and avoid snacks
    • Eat healthy foods instead of unhealthy foods and do the same with drinks.
    • Try stress management techniques such as meditation, having a bath, breathing exercises or listening to music
    • Listen to your body - This will help you to distinguish when you are hungry or not and you will only eat when you are genuinely hungry
    • Keep yourself occupied to deal with feelings of boredom
    • Seek help from others  


    Guidelines for help: Royal Australian and New Zealand College of Psychiatrists

    The Royal Australian and New Zealand College of Psychiatrists quality standards are a set of specific, concise statements that act as markers of high quality, cost effective patient care, covering the treatment and prevention of different diseases and conditions.

    Click here  to read a publication relating to core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders.


    Recommended intervention for Anorexia and Bulimia

    Much research suggests that the best approach to treatment is almost always psychology based. Some medication can reduce symptoms such as depression, however some suggest they often do not alleviate the problem, therefore are not an effective treatment exclusively. 

    Cognitive Behavioural Therapy (CBT) can be highly effective in treating Anorexia and Bulimia. This works by individuals learning to recognise negative thoughts or ‘eating disorder thoughts’ and challenging and replacing them with more helpful thoughts. Our thoughts affect the way we feel and the way we behave. If we positively change the way we think then our feelings and behaviour are also likely to positively change. Therapy aims to improve the understandings of one’s own eating disorder, its development and how to manage it effectively. By understanding ourselves it can be more likely that we can help ourselves towards recovery. 

    Psychotherapy and counselling can address the underlying causal factors of the eating disorder. Exploration as to why and how the eating disorder has developed can be a useful tool to go on and overcome it. Psychotherapy can help the individual to cope with their past and the negative emotions they experience. 

    Because eating disorders can often be influenced by and have an impact on families/carers, interventions may be more effective when including those around us. Educating both the individual with an eating disorder and other people in their life can lead to a collaborative understanding and improve the likelihood of working together towards recovery. In addition, family/systemic therapy can be highly effective for many individuals who have an eating disorder. This can help to explore relationships and dynamics within a family and work on improving them. This can then have a positive impact on recovery. The most suitable treatment method will depend on the individual.


    What support is available? Where can you start to get help?

    It is important to acknowledge that recovery from an eating disorder can be a long process which often involves support from others. It may be worthwhile reading a self-help book.

    Some helpful books include:

    • Overcoming Anorexia Nervosa: A self-help guide using cognitive behavioural techniques. Dr Christopher Freeman (2009)
    • 8 Keys to Recovery from an Eating Disorder: Effective Strategies from Therapeutic Practices and Personal Experience. Carolyn Costin, Gwen Schubert Grabb and Babette Rothschild (2011)
    • The eating disorder sourcebook: A comprehensive guide to the causes, treatments and prevention of eating disorders. Carolyn Costin (2006)
    • Eat, drink and be mindful: How to end your struggle with eating and start savoring food with intention and joy. By Susan Albers, 2009.
    • Feeding the hungry heart: The experience of compulsive eating. By Geneen Roth.
    • Overcoming binge eating. By Christopher Fairburn, 1995.

    Some helpful websites include:

    Some helpful telephone numbers and email addresses include:


    There are now many counselling and therapeutic services and organisations available. There are many trained professionals who will be able to support you such as Counsellors, Psychotherapists, Psychologists and Psychiatrists. Here are details of available services:

    Medicare: The Australian Department of Human Services - seeing your GP and asking for a referral to see a specialist.

    Charities- (such as ReachOut, The Butterfly Foundation, The National Eating Disorders Collaboration and many more.) Some may provide support groups, therapy and advice in your local or near-by area. See their websites for further details.

    Counselling and psychotherapy clinics and services- Search through online directories or contact your council for organisations that offer can therapeutic help. (One to One Counselling is one such clinic)

    When seeing a healthcare professional you may be involved in an initial assessment. This will include being asked some questions to identify the issues, causes and problems. Try to be honest and open in your answers. The person asking the questions just wants to understand and help.


    References

    Beat (Beat eating disorders) www.b-eat.co.uk

    Diagnostic and statistical manual of mental disorders (DSMV). (2014) Washington, DC: American Psychiatric Association.

    Fairburn, C.G. (2008). Cognitive Behavior Therapy and Eating Disorders. New York, NY: Guilford Press.

    The Royal Australian and New Zealand College of Psychiatrists Guideline - https://www.ranzcp.org/Files/Resources/Publications/CPG/Clinician/Eating-Disorders-CPG.aspx

    Wilson, G.T., Grilo, C., & Vitousek, K.M. (2007). Psychological treatment of eating disorders. American Psychologist, 62(3). 199- 216.
    World Health Organisation. (1992). ICD-10 Classifications of Mental and Behavioural Disorder: Clinical Descriptions and Diagnostic Guidelines. Geneva. World Health Organisation.

    http://www.harleytherapy.co.uk/eating-disorders-help-guide.htm