A degree of weight loss can make many of us happier and healthier. But for those who take weight loss too far or adopt the wrong approach, eating disorders can lead to very unhealthy outcomes and possibly even death.

This article discusses various types of eating disorders, who is at risk of developing them, their causes, warning signs and effects. It also provides information about where to get help with them should you or a loved one need it.

The information contained in this article has been generously provided by the Eating Disorders Foundation of Victoria.

History of Eating Disorders

Eating disorders are not new illnesses. They have been present in one form or another for centuries, although attempts to understand them have increased in the last 100 years.

The first known medical documentations of anorexia nervosa appeared in 1873 when two physicians, Sir William Gull and Dr E. C Lasegue published separate case histories of patients.

Bulimia nervosa was first recognised as a separate eating disorder in the 1970s, and in 1976 it appeared in psychiatric diagnostic manuals for the first time.

Binge eating disorder has only recently (1990s) been recognised as a separate eating disorder.

Different types of Eating Disorders

There are many forms of eating disorders; anorexia and bulimia nervosa, binge eating disorder and eating disorders not otherwise specified.

Anorexia Nervosa

Anorexia is characterised by:

• severe restriction of food intake.

• loss of body weight to an unhealthy level.

• loss of menstrual periods (female).

• an intense fear of getting fat, and/or losing control of eating.

• often a disturbed body image - still regarding self as fat despite being quite underweight.

Bulimia Nervosa

Bulimia is characterised by:

An over-preoccupation with food and weight resulting in out of control eating patterns such as:

• eating binges which involve the consumption of large amounts of food. These usually occur secretly, and the person may feel a sense of loss of control or shame.

• attempts to compensate for binges and avoid weight gain by one or more of the following unhealthy measures: self induced vomiting, misuse of laxatives, fluid or diet pills, excessive exercise, periods of strict dieting.

Binge Eating Disorder

Binge Eating Disorder is characterised by:

Periods of binge eating without compensatory behaviour such as vomiting or excessive exercise.

Other Eating Disorders

There is a wide range of other disordered eating patterns and not all people with eating disorders have a clear cut diagnosis. For example, anorexia and bulimia may co-exist, or one may develop into the other, or some people may have a very restricted food intake without fulfilling all of the criteria for anorexia nervosa. These conditions are no less serious; intervention and attention are still required.

Who is at risk

Eating disorders are most commonly experienced by adolescent females and young women, but also occur among males, people of all ages and across all socio-economic and cultural backgrounds.

Generalisations are not always useful but some of the common themes among people with eating disorders may include:

• low self esteem.

• need to seek the approval of others.

• difficulties in expressing needs and feelings, including anger and anxiety.

• perfectionism.

• difficulties being assertive with others.

• people who diet.

Causes

There is no single cause of an eating disorder. It is currently agreed that eating disorders are multi-factorial – with social/cultural, psychological, biological, family and precipitating factors all playing a part in varying degrees for different people.

Contributing factors may include:

Social/Cultural Factors

• idealisation of thinness.

• focus on appearance.

• weight loss, fashion, fitness cosmetic and pharmaceutical industries, etc.

• media representations of happy, thin, successful people.

• socialisation of women and men.

Family Factors

There is no typical family 'type', however, some family characteristics may need to be addressed during the recovery process such as:

• communication within the family/how family deals with feelings.

• attitudes around the importance of appearance, achievement, etc.

• parent's own body image/dieting behaviour.

Biological Factors

The importance of biological factors is still being researched. Possible factors include:

• predisposition to imbalances in serotonin (a neuro-transmitter involved in mood and brain function).

• reduced blood flow to the temporal lobe.

• fasting, over-exercise and vomiting may affect chemicals involved in mood control.

Individual Factors

Not everyone exposed to cultural and family factors develops an eating disorder, therefore individual factors play an important role. Again, there is no one single cause, but some common experiences such as:

• people with high personal expectations.

• belief that love is dependent on being 'perfect'.

• self-esteem issues.

• high need for approval from others.

• social anxiety.

• people who find it difficult to express their own needs.

• difficulty being assertive.

• personality factors may be affected by malnutrition.

Precipitating Factors

Often the onset of an eating disorder can be triggered by an external factor such as:

• life crisis - family loss, friendship loss, moving to a new home, school or job, personal disappointment, etc.

• accumulation of minor stressors; the impact of cultural, family or individual factors may intensify during periods of stress.

• dieting.

• history of abuse.

• uncertainty.

Warning Signs

It is not uncommon for an eating disorder to go undetected. The symptoms of the eating disorder may be the first indications that the person is experiencing psychological problems and distress. The signs associated with bulimia can be more difficult to detect as the person may be of normal or fluctuating body weight. Some people exhibit many signs of a disorder, others only a few.

Possible early warning signs of eating disorders

Possible early warning signs of eating disorders may include:

• dieting or overeating.

• weight loss or change, mostly due to dieting, but sometimes from a stressful situation or illness.

• preoccupation with body appearance or weight.

• loss or disturbance of menstrual periods (females).

• sensitivity to the cold.

• faintness, dizziness, fatigue.

• increased mood changes, irritability.

• social withdrawal/isolation.

• anxiety, depression.

• increased interest in preparing food for others.

• mental list of 'good' and 'bad' foods.

• obsessive rituals, for example, only drinking out of a certain cup or eating certain foods on certain days.

• wearing baggy clothes/change in clothing style.

• excessive or fluctuating exercise patterns.

• avoidance of social situations involving food.

• making frequent excuses not to eat.

• slow eating/eating with teaspoons.

• fast eating.

• hoarding food.

• rearranging food on plate.

• disappearance of large amounts of food, food wrappers in bins.

• feelings of being out of control with food.

• trips to the bathroom after meals.

Physical effects of eating disorders

Among the most serious physical effects of eating disorders are:

Food Restriction and Starvation:

• severe sensitivity to the cold.

• reduced bone density and osteoporosis.

• fertility problems/infertility.

• kidney dysfunction.

• reduced metabolic rate leading to slow heart rate, low blood pressure, reduced body temperature and bluish coloured extremities.

• growth of down-like body hair.

• headaches.

• changes in hair, skin and nails (dry, brittle).

• cardiac irregularities.

• muscle wasting or weakness.

• constipation or diarrhea.

• hormonal irregularities.

• oedema (retention of body fluid giving a 'puffy' appearance).

• easy bruising.

• anaemia (iron deficiency).

• fainting.

• heartburn.

• abdominal pain.

• stunting of height/growth.

• hypoglycaemia (low blood glucose levels) which can cause confusion, illogical thinking, coma, shakiness, irritability and fatigue.

• reduced concentration, memory and thinking ability.

Vomiting can cause:

• erosion of tooth enamel.

• sore throat, indigestion and heartburn.

• abdominal pain and bloating.

• enlarged salivary glands.

• electrolyte imbalance resulting in cardiac arrhythmia, muscle fatigue and cramps.

Laxative misuse can cause:

• bowel problems, constipation, diarrhea, cramps.

• dehydration which impairs body functioning.

• weakening of bowel which may to lead difficultly with bowel movements.

• bleeding which can lead to anaemia.

• bowel disease.

• electrolyte imbalance.

Emotional and Psychological Consequences of Eating Disorders

Eating disorders place tremendous emotional strain on people. Left unattended eating disorders can destroy the quality of a person's life and are potentially life threatening. Potential emotional and psychologoical consequences of eating disorders include:

• anxiety, anxiety disorders.

• depression.

• obsessive behaviour.

• social isolation/withdrawal.

• irritability/moodiness.

• difficulty with relationships.

• suicidal thoughts or behaviour.

• drug misuse.

• poor quality of life.

• lack of assertiveness.

• sensitivity to criticism.

• guilt, self-dislike.

• impaired achievement at school, work, etc.

Management of Eating Disorders

Recovery and treatment involves medical, nutritional and psychological therapy in varying degrees of relevance. This multi-disciplinary team approach may involve accessing services provided by psychologists, psychiatrists, counsellors, social workers, family therapists, general practitioners, physicians, dietitians, and others.

A thorough assessment will help to ascertain the type and severity of the disorder. An initial phone call to book a long consultation and to advise the practitioner of your concerns is advisable. Once an assessment is made the appropriate approach can be decided. The Eating Disorder Foundation of Victoria (EDFV) can provide information about general practitioners, and other health professionals with experience and understanding in the area of eating disorders.

Therapy Options

Medical Treatment

There are many physical complications that can result from an eating disorder. Left unattended, they can lead to serious health problems or death. It is important that physical health is monitored, preferably by a medical practitioner with experience in the area of eating disorders. A medical examination may involve several tests, followed by treatment of any medical problems such as anaemia, heartburn, disturbances in heart rhythm, low bone density, etc.

Nutritional Counselling/Advice

Dietitians or nutritionists may be useful in the treatment of eating disorders as education and establishment of a well-balanced diet are essential to recovery. Nutritional counselling and advice may be useful to help the person identify their fears about food and the physical consequences of not eating well. Education about the nutritional values of food can be beneficial particularly when the person has lost track of what 'normal eating' is. Dietitians or nutritionists may work in conjunction with other professionals.

Psychological Therapy

The basis of psychological treatment is in forming a trusting relationship with the therapist and addressing pertinent issues to the person such as the thoughts, feelings and behaviours that lead to the development and maintenance of the eating disorder. This may include issues with anxiety, depression, poor self esteem and self confidence, difficulties with interpersonal relationships and empowering the person to realise their own resources to overcome their difficulties.

Some particular models of psychological therapy that may be used in the treatment of eating disorders include:

Psychotherapy

Psychotherapy aims to identify the psychological stresses that may have contributed to the onset of the eating disorder. Through talking and other techniques (personal development exercises, etc) the aim of this process is to reduce the feelings of inadequacy, low self-esteem, negative body image and guilt, etc, and help people to develop their life skills.

Cognitive Behavioural Therapy

CBT has become a popular form of treatment for people experiencing eating disorders. Based on the premise that thoughts and feelings are inter-dependent, CBT encourages people to re-examine and challenge existing thought and behaviour patterns. Challenging distorted or unhelpful ways of thinking can allow healthier behaviours to emerge.

In relation to eating disorders, CBT aims to change the way the person thinks about food and themselves. It aims to identify the characteristic thoughts that reinforce disordered eating behaviour and encourage more positive ways of thinking. Some thought patterns that CBT may challenge include black and white thinking, magnification (of importance of events, etc) and errors in attribution (misunderstanding of the relationship between cause and effect).

Interpersonal Psychotherapy

IPT has been used successfully in the treatment of eating disorders, particularly bulimia and binge eating problems. IPT focuses on interpersonal difficulties in the person's life which are considered to be the basis of the eating disorder. Generally, therapy involves three phases including the identification of interpersonal difficulties, the development of a contract to work on several specific issues and the assessment of changes. The therapy is usually medium term (16-20 weeks).

In the initial stage, the therapist will generally explore the history of eating problems, interpersonal relationships prior to and after the development of an eating disorder, significant life events and self-esteem and depression issues. Major problem areas are identified and typically fall into four categories; grief, role disputes with other people, role transitions and interpersonal skills. A therapeutic contract is developed between the client and the therapist based on the major problem areas in the person's life.

Group Therapy

The main purpose of group therapy is to provide a supportive network of people who have similar issues to explore issues around their eating disorder. Groups may address many issues from alternative coping strategies, underlying issues, ways to change behaviours, triggers to personal needs and long-term goals. Groups are generally closed in attendance for a specific period of time (eg. 8 weeks).

Family therapy

Family therapy usually involves the people that are living with or are very close to the person with the eating disorder. This may involve parents, siblings and/or spouses. The family, as a unit, is encouraged to develop ways to cope with issues that may be causing concern including the eating disorder. The success of this treatment is dependent on the family being willing to participate and make changes to their behaviours. Family therapy can also offer education to other family members about the eating disorder and how better to support the person they care about. Overall the family is encouraged to develop healthy ways to deal with the eating disorder.

Family therapy also acknowledges that every family has issues that are difficult to deal with. As a part of a person's recovery from an eating disorder, it can be useful to address issues in the family context such as conflict or tension between members, communication problems, difficulty expressing feelings, substance abuse or physical or sexual abuse.

Drug therapy

Drug therapy may be used to treat hormonal or chemical imbalances. In the treatment of eating disorders, anti-depressants belonging to the Serotonin Specific Reuptake Inhibitor group (SSRI) such as zoloft, prozac, aropax and paxil are commonly prescribed.

Research suggests that anti-depressants such as prozac are useful in suppressing the binge/purge cycle, particularly for people with bulimia. For people experiencing anorexia nervosa, they may be useful in stabilising weight recovery. However, like all medications, not all anti-depressants work for everyone as people respond differently. Some people experience side effects in varying degrees of severity such as anxiety, nausea, loss of or increase in appetite, nervousness, insomnia, headaches, rashes, abnormal dreams and blood pressure changes.

The effectiveness of drug therapy increases when combined with other forms of therapy such as Cognitive Behavioural Therapy.

Support Groups

Support groups differ from therapy groups in that they are intended to offer mutual support, increased understanding and information. Where a therapy group is generally closed in attendance and runs for a specified period (eg. eight weeks), support groups are generally open in attendance (people can attend as often as they wish) and meet on a regular basis (eg. fortnightly). Generally, support groups are not run by professionals, but by people who have had experience with the issue, either personally or indirectly.

The EDFV runs two separate support groups, one for people with an eating disorder and one for families and friends. These groups alternate on Monday evenings in Glen Iris. Several times a year the Foundation runs combined groups where people with an eating disorder and relatives and friends meet together.

Hypnosis

Traditional hypnotherapy typically involves a sleep-like state or altered state of consciousness usually induced by a therapist. It is based on the premise that during this altered state of consciousness, a person is more responsive to suggestions and has greater access to influential functions usually outside their conscious control. However, more recent theories of hypnosis may include role playing, story telling and interpersonal influence between the therapist and the client.

Education

Information about eating disorders, their effects, treatments and recovery stories etc, can be a useful resource for people experiencing an eating disorder and their family and friends. The EDFV has a reading list and a library. Books are also obtainable from most book stores.

Alternative Therapies

Alternative therapies can be useful for some people as an adjunct to psychological, nutritional and medical treatments. For instance meditation can help with reducing anxiety levels or massage can help us to reconnect with our bodies. Each approach is different, however alternative therapies are generally concerned with treating the person as a whole, including their mental and physical health and may include:

Naturopathy

Herbal treatment aimed at stimulating the body to heal itself.

Acupuncture

An ancient Chinese therapy using needles and herbs to stimulate the body's energy flow.

Aromatherapy

Use of essential oils for relaxation and stress relief.

Meditation

Mental relaxation intended to create an inner calmness.

Homeopathy

Aims to stimulate the body's natural defences (anti-bodies) to illness, by introducing the problem substance into the body.

Therapists and Health Professionals

Many different professionals can assist individuals in different ways. Below is summary of the different roles of health professionals.

Therapists

When seeking therapy, many people ask what the differences are between therapists such as counsellors, psychologists and psychiatrists. The professional difference is largely in qualifications, but the model or style(s) of therapy they employ depends on many factors such as their interests, personal characteristics, specialist-training etc. Two practitioners may have the same qualifications (ie: two psychologists) but employ different therapeutic techniques.

Because different therapists work in different ways, it is important that people choose someone they feel comfortable working with. Sometimes this can take time, and a person may see several counsellors, psychologists or psychiatrists before they find someone they feel comfortable with.

Psychologists

Psychologists must have completed a general degree in psychology, post graduate studies (usually specialising in a particular area(s) and two years of supervised practice to be accredited as a practicing psychologist by the Australian Psychological Association. In Victoria a psychologist must also be registered with the Victorian Registration Board for their discipline.

Psychiatrists

A psychiatrist is a qualified medical practitioner (General Practitioner) who has completed at least 3-4 years of additional study in psychology or psychiatry. Because they are medically qualified, psychiatrists can prescribe drug treatments such as anti-depressants.

Counsellors

There are many different qualifications a counsellor can obtain. General courses in counselling techniques, or welfare studies etc can range from three months to four years. Although there is a National body of Counsellors, a person can work as a counsellor without being a member of this body or having any specific qualifications.

Medical Practitioners

A qualified medical practitioner holds a medical degree. Medical practitioners are concerned with people's physical health. They may offer a medical examination, medical advice, education and referrals to specialist medical practitioners or therapists. They are also able to prescribe drug treatments such as anti-depressants.

Dietitians

A dietitian can offer information about foods, the way the body uses them, nutritional management and dietetic counselling. A dietitian can be useful for people with eating disorders to re-educate them about the value and necessity of food, and also to develop meal plans. Generally, a dietitian has completed a four year course in nutrition and dietetics.

Social Workers

A social worker's main function is to assist people practically. This may involve helping them with their finances, getting in touch with people or helping them with difficult relationships. In some cases social workers may also provide counselling. 

Males and Eating Disorders

Historically, the majority of people diagnosed with eating disorders are female. However, males also experience eating disorders and body image concerns. Research into eating disorders is fairly new (bulimia nervosa was only diagnosed as a separate illness from anorexia in the 1970s and binge eating disorder was only diagnosed in the 1990s). Our research into males and eating disorders is limited.

Current Research

Research tells us that:

• 10% of people diagnosed with eating disorders such as anorexia and bulimia nervosa are males (Options Magazine, June, 1994).

• 31% of young males want their body to be heavier and 31% want their body to be lighter. (Body Image. Issues in Society, NSW, Vol 105, 1999).

• It is estimated that 17% of males are on some form of diet and that steroid abuse and exercise disorders are increasing in the young male population (Weekend Australian, April 1999).

• Preliminary research into Binge Eating Disorder (a newly recognised eating disorder in the 1990's), indicates similar prevalence rates between males (3.0%) and females (3.4%). (Paxton, S. (1998) Do Men Get Eating Disorders? in Volume 2, August 1998).

• Males are increasingly concerned about their appearance. In 1972, 15% of men reported being dissatisfied with their overall appearance. By 1985, this had risen to 34%, and by 1997, 47% of men were dissatisfied with their overall appearance. (Garner, D. M. (1996) cited in Drummond, M. (1998) Bodies: an emerging issues for boys and young men Everybody, Volume 2, August 1998).

• We live in a culture which encourages women to be small and thin and men to be big and muscular (Drummond, M. (1998) Bodies: an emerging issues for boys and young men Everybody, Volume 2, August 1998).

• 11% of men reported that they would be willing to trade 5 years off their life to be at their ideal weight. (Garner, D. M. (1996) cited in Drummond).

Under-reporting

• In many health matters, males are less likely than females to seek treatment, particularly for psychological issues.

• Males may be less likely to be diagnosed with an eating disorder because of the myth that it is a largely female condition.

• Males may have different forms of eating disorders, for example, a female may focus on losing weight where as a male is more likely to focus on gaining weight. As research into eating disorders is relatively new and our acknowledgment that males also experience eating disorders, it may be some time before we have a clearer picture of this.

This may explain why in cases of childhood anorexia (pre-pubescent), approximately 25% of cases are diagnosed in male children (Paxton, 1998). Children are more likely to be taken to a health professional, and perhaps health professionals are more open to diagnosing eating problems in children than adult males.

Differences for males and females

Eating disorders are different for every person, regardless of gender. The causes, behaviours and successful treatment of eating disorders vary from person to person. Initial research indicates some similarities and differences between males and females with eating disorders:

Similarities:

• Demographics (age, etc).

• Additional conditions (ie: depression).

• Medical complications.

• Self-esteem concerns.

• Shape and weight concerns.

• Treatment.

Differences:

• Males have a greater likelihood of a history of obesity.

• Males have a greater occurrence of dieting in relation to sports participation.

• Males appear to have more psychiatric issues but engage in less emotional eating than females.

• Homosexuality and bi-sexuality seem to be a specific risk factor for males.

• Males are more likely to exercise and females are more likely to diet for weight control.

Treatment Options for eating disorders

Treatment for eating disorders is a personal choice and what works for one person may not work for another. The treatment options are largely the same for males and females, and are more likely to be limited by age restrictions, financial considerations and other factors. There are a few issues that may be useful to consider, however:

• Finding someone who has had experience treating other males with eating disorders may be beneficial.

• Many books written on the topic use she although this is starting to change. However, as there are many similarities between males and females with these conditions, these books still offer some valuable information, hope or insight to people regardless of their gender.

Conclusion

An appropriate amount of weight loss can make many of us healthier and happier. But for others who take weight loss too far, eating disorders can lead to very unhealthy outcomes and can even be life-threatening.

This article discussed various types of eating disorders, who is at risk of developing them, their causes, warning signs and effects. It also provided information about where to get help with them should you or a loved one need it.

For more information or immediate help with eating disorders in your area, please use the following hotlines:

Victoria: (03) 9885 0318 or 1300 550 236.

South Australia: (08) 8332 3466 or (08) 8212 1644.

Queensland: (07) 3891 3660 or (07) 3891 3662.

Northern Territory: (08) 8981 4128.

Western Australia: (08) 9300 1566.

New South Wales: (02) 9412 4499.

ACT: (02) 6290 2166 or (02) 6286 2043.

Tasmania: 1800 675 028.

New Zealand: (09) 818 9561.

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