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The term ‘eating disorder’ is usually applied to two conditions. These are anorexia nervosa and bulimia nervosa. They are closely related and indeed there is even some debate as to whether they are best thought of as different manifestations of one basic disorder.

Anorexia nervosa

Anorexia nervosa literally means ‘loss of appetite for nervous reasons’. It is characterised by weight loss. However, a woman with anorexia nervosa has not lost her appetite. She has lost weight because she is suppressing her urge to eat.

This eating restraint is often due to her ideas about body weight and fears about getting fat. She will often experience herself as being fat even when she is very thin. This is referred to as having a distorted body image.

The majority of people who develop anorexia nervosa do so in their teens or early twenties.

DIAGNOSTIC CRITERIA FOR ANOREXIA
  • There is weight loss leading to a body weight of at least 15 per cent below the normal or expected weight for height or age. In children, this could be due to lack of weight gain rather than weight loss.
  • The weight loss is self-induced by avoiding fattening foods.
  • There is a self-perception of being too fat, with an overwhelming dread of fatness. This leads to a self-imposed low weight threshold.
  • There is a widespread hormonal disorder which may lead to amenorrhoea (lack of menstruation) in women and a loss of sexual interest and potency in men.

Bulimia nervosa

Bulimia nervosa is diagnosed chiefly by the presence of binge eating. However, bingeing in bulimia nervosa is not simply an occasional splurge or indulgence. It involves eating an unusually large quantity of food, often in a rather frantic manner, and is accompanied by a sense that the eating is out of control.

People with bulimia nervosa also have an exaggerated fear of being fat. But unlike sufferers of anorexia, their body weight may be high, low or average. They often try to restrain their eating but the balance between restraint and bingeing may produce a kind of stability of body weight albeit a precarious one. Furthermore, binge eating is often followed by self-induced vomiting or laxative abuse, again because the sufferer hopes to avoid gaining weight.

Bulimia nervosa tends to begin at a slightly higher age than anorexia nervosa, typically in women in their late teens and twenties. It is thought to be more common than anorexia nervosa.

It is possible to have a mixture of the features of anorexia nervosa and bulimia nervosa. The person may then be said to have bulimic anorexia nervosa. It is also possible to have some, but not all, of the features of one of the conditions. The usual terms then are ‘atypical anorexia’ or ‘atypical bulimia’, although sometimes the term ‘partial syndrome’ is used. Such atypical and partial states may actually be more common than the full disorders.

DIAGNOSTIC CRITERIA FOR BULIMIA
  • There are recurrent episodes of overeating at least twice a week over a period of three months. Large amounts of food are consumed in short periods of time.
  • There is a persistent preoccupation with eating, and a strong desire or sense of compulsion to eat.
  • The person attempts to counteract the fattening effects of food by one or more of the following: self-induced vomiting, self-induced purging, alternating periods of starvation, drugs such as appetite suppressants or diuretics.
  • There is a self-perception of being too fat, with an excessive fear of fatness.

Are there other eating disorders?

Two other conditions are sometimes described as eating disorders but are not usually included as such in medical classifications.

Obesity

One is obesity, which can be a serious problem but is not always associated with disordered or unusual eating. So although some obese people may have an eating disorder and have some of the characteristics of bulimia, obesity itself is not considered an eating disorder.

Compulsive eating

The other condition, often referred to as compulsive eating, is a vague term that has not been clearly defined. It often seems to apply to some eating patterns within bulimia nervosa or a partial syndrome.

Case history

Heather: a story of anorexia

Heather was the younger daughter of two schoolteachers. Her early childhood was settled and happy, but things started to go wrong when she was about 14 and her sister Fiona was 16. Their father, who was then 46, had a heart attack. He had to stop working and abandon his chance of becoming a headmaster, which had been his ambition. He came to be prone to bouts of depression. He was touchy and irritable, especially with Fiona. Over the next two years, rows between the two of them dominated the household.

Much to her parents’ disapproval, Fiona left school and got a job in a local record shop. At 18 she became pregnant and left home to live with her boyfriend. Her father was devastated, and said that he would have nothing more to do with Fiona. Her mother and Heather continued to visit her secretly.

When Fiona’s baby was born there was some reconciliation, but her father continued to be low. He often complained of chest pain and sometimes said that Fiona had ruined his life. Heather’s mother struggled to hold things together, working hard at her job, acting as a go between and looking after her sick and troubled husband.

Heather, on the other hand, was doing well in school. Her parents were delighted when her teachers suggested she try for a place at Oxford or Cambridge. She was studying modern languages, her father’s subject, and he coached her in the evenings. He described himself as her ‘trainer’ and talked of Oxbridge entrance as ‘the Olympics’. He also encouraged her to go jogging, making pronouncements about a healthy mind in a healthy body. As his disappointment with Fiona developed so did his involvement with his younger daughter. Heather valued his interest but she was increasingly aware of the extent of his expectation. She began to fear letting him down.

Heather started going out with a boy named Andrew. She soon became aware of a sense of conflict between her wish to spend time with Andrew and her wish to devote herself to her studies. She also felt that her father disapproved of her boyfriend and that he feared that she would ‘end up like Fiona’.

One weekend she stayed out late, worrying her parents. Her father had an angina attack and her mother reminded Heather how important it was for her father not to be upset. She began to make excuses to Andrew and before long he left her for another girl. Heather felt heartbroken and secretly angry that her father seemed so pleased at the end of the relationship.

She felt confused and uncertain, but vowed to pull herself together. She decided to try for Oxford and dreamed about being a success there. She could wait for her reward. In the meantime she would work hard, save money, get fit and even lose some weight as she had been promising herself she would do for months.

At first, everything went well. Heather worked hard. Her father was pleased. Her mother seemed more relaxed. Even Fiona began to visit more often. Heather produced a timetable for her studies and her father helped to plan it all out. She lost a few pounds by taking up running and following what her mother called a ‘sensible diet’.

Heather felt good much of the time, but sometimes when studying her mind would wander. She would then chide herself for wasting time daydreaming. She worried about what would happen if she didn’t do well. She felt bad when one evening she realised she had eaten an entire packet of biscuits. She weighed herself and discovered she had put back on three pounds. She felt that things were slipping. Somehow she must get things back on track.

She produced a new timetable which covered all of her activities, including running, eating and studying. She rationed the times when she would allow herself to get a cup of coffee and just one biscuit. Soon she stopped the biscuits altogether.

As the weeks went by, Heather lost more weight. At 16 she had weighed about nine stones (58 kg). A year later, she weighed just six and a half stones (42 kg) and her periods had stopped. She was now preoccupied with just two things – succeeding at her studies and controlling her weight. She feared that she would fail at both.

She was studying so much that even her father advised her to ease off. Her mother was worried about her eating but Heather would lie, telling her she had eaten earlier in the day. She wore baggy clothes and avoided letting her mother see her undressed. She often felt fat but knew she looked thin. She thought about food a lot but distracted herself with still more studying. Once she got up in the middle of the night and ate two packets of biscuits and a large tub of ice cream. She then tried to make herself vomit but could not manage it. This reinforced her feeling that if she allowed herself to eat freely, everything would get out of control.

That autumn, Heather was rejected by Oxford. By now it was evident that she was very thin. At Christmas, her behaviour led to major upsets and rows in the family. Finally, early in the New Year, her parents persuaded her to see the family doctor. When weighed at the surgery, she was just under six stones (37 kg). It was clear now that she was suffering from anorexia nervosa.

Case history

Susan: a story of bulimia

Susan was the elder child and only daughter of a policeman and a nurse. When she was eleven her father left home and went to live with another woman. Susan was very angry, and had almost no contact with her father for the next eight years. She tried to be supportive to her mother. They became very close. Her mother tended to confide in her to an unusual degree and together they looked after Susan’s brother, Sean, who had been only six when his father left.

Susan had no major regrets when her parents were finally divorced two years later. However, she was not sure how she felt when her mother started going out with John, a colleague from work, and within six months announced that they were to marry. Susan was just 14 when her mother married John and he moved in. She told herself that she was pleased for her mother, but she missed their closeness.

She felt uncomfortable with John. He tried hard to be friendly but tended to tease her about her going out on dates, her taste in clothes and about her worry about her appearance. He also teased her about the way in which she was always going on diets which lasted just a day or two.

Over the next year Susan felt more and more isolated and unhappy at home. She tried to spend as little time there as possible. She went out almost every evening, often ending up drinking a lot. This added to her difficulties. She greatly resented it when John started to behave like a strict father. There were lots of rows between them. Later that year, she took her GCSE exams but the results were disappointing. She was unsure what to do but signed up for a course at the local college.

When Susan was 17 she met a professional footballer called Mark, who was seven years her senior. It was a difficult relationship, because although Mark was lively and glamorous he also seemed to be rather unreliable. Just before Christmas, as she was wondering whether to finish with him, she found that she was pregnant. To her surprise Mark seemed pleased at the prospect of being a father, and they decided to live together. Her mother and stepfather protested but Susan suspected that they were relieved that she was leaving home.

She dropped out of her course at Easter and gave birth to a baby boy, Rory, in July. She had put on a lot of weight during her pregnancy and afterwards felt fat and unattractive. She wanted to lose weight but found it difficult. Sometimes she was uninterested in food, while at other times she ate far more than she intended. She became mildly depressed and miserable.

She loved Rory but found motherhood overwhelming. With the start of the football season, Mark was often away and seemed less interested in the baby now. As the months went by the couple fought more and more. Susan worried that Mark would meet other women on his trips away from home. And he became possessive, hating her to go out even with her old girlfriends. She felt increasingly unhappy and isolated, much as she had done a year or so before.

This time, however, she felt that there was no obvious escape route. She certainly did not want to go back to her mother’s house. She also regretted giving up her education, but when she talked to Mark about going back to college he accused her of wanting to meet other men. In the midst of a row, he called her fat, ugly and boring. He said that she had ‘let herself go’. Susan was angry and upset, but secretly these were the very things she had been thinking about herself.

She made another resolution to lose weight. She started by going on a crash diet. She was pleased to lose some weight quickly but felt unhappy, hungry, preoccupied with food and irritable. One evening Mark telephoned yet again to say that he would not be home. She felt angry, upset and out of control. She stuffed herself with food until she could physically eat no more. Then she felt panicky and guilty. She made herself vomit. The next day she resolved to eat even less, but a week later she binged again. Much as she tried to stop, she felt caught in a pattern and soon was bingeing several times a week. Although her eating was now wildly erratic her weight stayed much the same.

Susan left Mark shortly after Rory’s first birthday. The final straw came when Mark hit her in an outburst of jealousy. She had recently re-established contact with her father and he threatened to ‘sort out’ Mark if she stayed. At first she went home to her mother. After a few weeks she moved to a flat on her own and started to build a new life.

In some ways, things began to look up. However, she still felt lonely and unsure of herself. At times she would feel quite desperate and even thought of trying to kill herself. She resumed some contact with Mark but just as friends. She went out occasionally with her old friends and attended a regular aerobics class. She started a course at the local college and talked of eventually going on to university. To other people it looked as if all was well, but secretly her life revolved around a battle with bingeing and vomiting. She had become stuck within bulimia nervosa.

 
KEY POINTS
  • The two recognised eating disorders are anorexia and bulimia nervosa
  • Anorexia nervosa is characterised by excessive weight loss due to restricting eating
  • The main feature of bulimia nervosa is binge eating – eating large quantities of food often in a frantic way with a feeling of loss of control
  • Both eating disorders seem to arise through self-imposed eating restraint often motivated by concern about body weight and shape
  • It is possible to have some but not all of the features of the disorders or a mixture of the two