Eating Disorders:  If I did have one, so what?

Eating disorders tend to attract lots of emotions. Parents of affected people feel worried, responsible and powerless. A person affected by an eating disorder usually has mixed feelings about it (feeling like it helps them; feeling it's nobody else's business; but also feeling bad about themselves in some way). And the media occasionally like to write emotive stories about them. The following information is designed to give you some facts and to explain the approach that we take here at Basten and Associates.

What is an eating disorder?  

The “eating disorders” are a spectrum of problems that affect a person in three ways: (1) a huge focus is placed on the importance on body weight and shape, (2) eating behaviours that are not usual or healthy in some way, and (3) weight control control behaviours that are extreme or unhealthy.

(1) Most people place some importance on their appearance, especially weight and shape and some people place more emphasis on this than others. There are certain times in our life when our appearance, weight and shape take on extra importance. This often happens when we are in our teens and early adulthood – but can also happen when we feel out of control in our life or unhappy; then we turn to our body to help us feel better about ourselves or our life. It is possible to get too focused on our weight and shape. When this happens, it is almost impossible to feel “attractive enough” or “thin enough” - so it does not really make us happy in a lasting way. Such emphasis also leads to extreme dieting behaviours and weight control behaviours.  

(2) Dieting behaviours in an eating disorder tend to include restricting the amount of food eaten, restricting the type of food eaten, and delaying meals. Some people develop strict rules about when to eat and what to eat and become distressed when they break these 'rules'. Another common eating behaviour in disordered eating is binge eating. A binge is usually defined as an objectively large amount of food, eaten in a short period of time, with a sense of loss of control. Many people feel like they binge even when it has not been a large amount of food – this is because they have broken one of their personal 'rules' or expectations.  

(3) Other weight control behaviours that some people engage in include vomiting after eating, misuse of laxatives, spitting food, or exercising desperately to compensate for calories.

SPECIFIC EATING DISORDERS

Various eating disorders can be distinguished: Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder and a general Eating Disorder (sometimes called Eating Disorder not Otherwise Specified; where someone does not quite meet the criteria exactly for one of the above conditions).  Each of these various problems have more in common than differences.

Anorexia Nervosa is characterised by:

1. Very low weight.  People lose weight but it usually does not feel enough. Or perhaps the feelings of achievement and personal strength is so positive, that it feels the right thing to do is to lose more. Once a person has lost about 20% of their minimum healthy weight, this is considered a cut-off for Anorexia Nervosa. Most people with Anorexia do not agree that they are underweight; or, if they do, they don't agree that it is serious or a problem.

2. Impact on Physical Health.   If anyone diets and loses weight to this point, there will be a number of health issues that follow. One of the main ones for women is that their periods become irregular or stop. This reduction in oestrogen is also bad for bone density and makes a person vulnerable to osteoporosis. There are many other health changes some of which won't be noticeable (like electrolyte imbalances) and others that will be noticeable (poor hair quality, increased body hair, poor temperature regulation and poor concentration).

3. Importance on weight and shape. The person with anorexia nervosa is usually terrified of weight gain or fat. This means that they also usually come to fear foods. Underneath all this are concerns that they are not good enough and need to correct who they are as a person by correcting their body image and having control over what they eat. The importance they place on weight and shape tends to distort things in their life. For instance, they might tolerate health problems because their fear of fat is greater than their fear of health problems. It also distorts how they see themselves.

 Bulimia Nervosa is characterised by:

1. Binge eating.  A binge, here, is a very large amount of food that is eaten in a reasonably short period of time. The person usually feels that they can't stop it once it starts - even though they may have planned to eat a certain food or even planned to binge. The main triggers for a binge include emotions (boredom, stress, worry, overwhelmed, useless) or feeling like you've broken an important eating rule.

2. 'Compensating' for the binges. This means trying to get rid of the calories that you are worried that you consumed in a binge. This could be by fasting for a period, exercising, vomiting or some other means of trying to get rid of the calories.

4. Over-importance on weight and shape. Just as in anorexia, people with bulimia nervosa place a huge importance on their appearance and weight and shape. They usually diet – and it is the strict dieting rules and behaviours that actually set up some binges.

HOW DO PEOPLE GET EATING DISORDERS?

There are many 'pathways' into an eating disorder – too many to list here. The common themes, though, include that the person decided to diet and found that some success at dieting helped them to feel much better, and so they continued it more aggressively, until it became a problem in some way. That raises the question of why do some people find it so important? In other words, why do some people end up placing an extreme importance on weight and shape? The two main factors are (i) low self-worth and (ii) obsessional perfectionism.  

(i)  Low self-worth.  If a person feels unacceptable or just not 'good enough', then that increases the need to find some way (any way, even if unhealthy) to compensate for that and feel a bit better. People do get positive comments from others if they lose weight. They also feel better within themselves if they lose weight (stronger, in control, less ugly, proud of an achievement). So, low self-esteem makes a person more likely to develop an eating disorder.

(ii) Obsessional perfectionism. This is a personality trait that includes valuing certainty, valuing thoroughness, valuing control, setting high standards, wanting to get things 'just right', all-or-nothing thinking, and keeping strict moral standards (e.g. a strong sense of right and wrong). These traits make a person tougher on themselves and mean that the rewards of dieting successfully are stronger for them (e.g., our success with weight is exact and certain, while our success at being a good friend is never exact and never perfect).

HOW EATING DISORDERS AFFECT OUR HEALTH

There are many many ways and, as noted above, some are noticeable but others are not.

Poor nutrition and low weight can affect the following:

A. Moods (more irritable; mood swings; more depressed; edgy or anxious feelings).

B. Thinking (worse concentration; poorer memory; more rigid problem-solving; thinking about food and dieting ALL the time).

C. Health (poor skin, poor hair quality, slowed heart rate, low blood pressure, poor temperature regulation, increased body hair,   disturbed menstrual periods, lowered bone density, feeling weak and faint).  

Vomiting (and laxative misuse) can have all of the same effects as low weight and poor nutrition, noted above. In addition, it can lead to changes in electrolytes (like the levels of potassium, sodium and chloride in your blood). These are essential for the healthy functioning of your heart and brain. Some of these effects are permanent, while others are reversible if you eat better.

SO WHAT IF I HAVE A PROBLEM I DON'T WANT TO CHANGE?

It is normal for people to have strong and mixed feelings about their eating attitudes and behaviours. That is, even if you saw a reason to change, there are probably fears about change that make it confusing and hard to change. Most people have found that their 'eating disorder' has been more helpful to them than harmful.  So what should you do?  We suggest to take some time to acknowledge all your thoughts and feelings. We also suggest that you come for at least one appointment to explore these thoughts and feelings. Our usual approach to treatment is based on an understanding of all these factors; we prefer to help you with what YOU want help with, not make you do things that you don't want to do. The only exception to this is if there are serious medical issues, which then means that a person MAY need to alter some behaviours to get themselves a little healthier.

WHAT TREATMENTS ARE AVAILABLE AND WHICH ONE IS RIGHT FOR ME?

There are quite a few treatment options, including hospital treatments (such as Wesley and Northside in Sydney). Most of what is written below assumes that you are out of hospital.

For children and younger adolescents, it is usually important for the psychological treatment to include the parents and maybe other siblings (family therapy). There are also good hospital-based clinics that specialise in childhood eating disorders (Westmead Children's Hospital and the Sydney Children's Hospital at Randwick).

For adults with low-weight eating disorder, individual therapy can help a lot. It can help to (a) explore what those complex and mixed feelings about change are; (b) understand where your eating disorder came from; (c) find some aspect that you may want to experiment with – then see if your worst fears come true. If they don't, then there may be some other very small change (in thinking or diet or exercise etc...) that you then might experiment with. Therapy also includes finding out about how you feel about yourself and helping you to feel OK – meeting your emotional needs – in a healthy way.

For adults with Bulimia Nervosa, the two main treatments that have the best support from scientific treatment-outcome studies are (a) cognitive behaviour therapy and (b) interpersonal psychotherapy.

Cognitive behaviour therapy (CBT) works by helping you to identify the thoughts and beliefs that drive the eating disorder. These thoughts and beliefs are usually relevant to your core self-worth, as well as your body and rules about diet and weight. This treatment is aimed at reducing your fear of fat, normalising eating and, in doing so, stopping bingeing. Most people find (to their surprise) that dieting less strictly (being just a little more flexible) helps them to binge less and stabilise their weight. We also focus on skills to improve your feelings about your self-worth, self-esteem and body image. Many people also need extra help to learn to manage intense feelings.

Interpersonal Psychotherapy (IPT) does not address your thoughts or actions about dieting directly. Rather, the focus is on your relationships – how to improve each of them one by one, until you feel better about yourself and more in control of your life. A few studies have shown that this seems to help the bingeing and then also other dieting behaviours.  At Basten and Associates, we usually suggest CBT first and then, if that does not work, recommend a phase of IPT.

Seeing a GP all the while is essential to therapy.

We also often recommend that people see a dietician.

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