Some features of eating disorders

Some of the features of the eating disorders, such as weight loss, are visible and obvious. Others are psychological and impossible to see. As the two conditions are so intertwined, people with either anorexia or bulimia will often exhibit many of the same signs and symptoms. A number of these focus on food and its consumption and on ideas about weight and shape.

CHANGES IN BODY WEIGHT

Loss of weight is a primary symptom of anorexia nervosa. If the weight loss is extreme it can be a real threat to health. Of course, height must be taken into account in assessing weight loss as must the weight before the illness started. There is some evidence that every person has a weight or weight range where their body tends to settle naturally. This weight may not be the so-called ‘ideal’ weight found in weight tables or the weight that the person might prefer to be, given an entirely free choice. As a general rule of thumb, a weight loss of 10 to 15 per cent for someone of average body weight is significant. A loss of 25 to 30 per cent is even more cause for concern because it may of itself threaten health and well-being. Anorexia nervosa occurring in a child who has not finished growing can be especially damaging. The child may end up with stunted growth if the disorder is long lasting.

People with bulimia nervosa may have a weight that is stable. However, the stability is fragile as it reflects a tenuous balance of binge eating, attempted restraint and the person’s attempt to eliminate extra calories, for example, by vomiting or using laxatives, or taking excessive exercise. She may also have wide fluctuations in weight.

EATING RESTRAINT

In the stories of Heather and Susan, both of them were concerned about their body weight and both of them attempted to slim by cutting down on the amount of food eaten or avoiding ‘fattening’ foods. This is what is called eating restraint. In our society the most common reason given for eating restraint is the wish to lose weight. However, it can also be undertaken for other reasons, for instance because of a desire for self-punishment, for self-purification or other reasons connected with ideas of health or religion. Some cases of so-called atypical eating disorders seem to arise through eating restraint motivated in these more unusual ways.

Eating restraint has serious consequences. The young woman who restrains her eating while still retaining a normal appetite will tend to become hungry, pre­occupied with food, impulsive with regard to food, and more emotional and irritable than usual. Someone who has anorexia nervosa, in particular, may feel all of these things, although sometimes it may be difficult to admit them even to herself. They are the predictable consequences of semi-starvation.

The eating patterns of people with eating disorders vary widely. In general, those with anorexia nervosa will eat small amounts of a narrow range of foods that they consider ‘safe’ or less ‘fattening’. Sometimes eating becomes a form of ritual that has to be done in a certain way and at a certain time. Other people, particularly close family members, may become involved in these rituals. They may feel that going along with them is the only way to get the sufferer to eat at all.

Strangely, some people with anorexia like to spend time cooking and preparing food for others. This may be a way of coping with their preoccupation with food and at the same time demonstrating to themselves and others their own self-control.

Apart from bingeing, people with bulimia nervosa may appear to have more normal eating habits. Some may eat very little except during a binge, but most will appear to eat normally or seem to be dieting in a fairly commonplace manner. Their problem and its associated suffering are easier to keep secret than is anorexia nervosa.

BINGE EATING

Binge eating is the central feature of bulimia nervosa. It may also occur in anorexia nervosa. A typical binge involves the consumption of large amounts of food in a short period of time with an accompanying sense of loss of control. At worst, the person feels frantically driven by some inner force to eat, and to eat in a way that is frightening, upsetting or even painful. It is quite different to the pleasurable overindulgence common on occasions like Christ­mas, which may also sometimes be described as a binge.

Binge eating is probably triggered by various factors including emotional turmoil. However, it is likely that the most important is an on-going attempt to restrain eating. If someone is in a semi-starved state, the drive to eat is likely to be increased. It makes sense for human beings to have a built-in mechanism which leads to food preoccupation when food is scarce and an increased drive to eat when food is found. When the deprivation is self-imposed, the sufferers may feel guilty if they give up and eat. It may come to feel like a major defeat or a moral collapse. On the other hand, it may feel like a drug trip or a drunken splurge. The emotions experienced during a binge vary from one person to another, but a sense of being out of control is a crucial part of bingeing. Afterwards the person often feels upset and even disgusted with herself. A frequent reaction is to resolve to control her eating and eat even less in future, ignoring the fact that this very resolve makes further bingeing more likely.

FEAR OF LOSING CONTROL

The fear of being out of control is central to much of the thinking of people with eating disorders.
The person with anorexia nervosa may be frightened of bingeing but fears gaining weight even more. She feels that unless she is vigilant and takes steps to avoid it, her weight will rise uncon­trollably. Even the smallest rise in weight is frightening, whereas losing weight is reassuring. By responding to this fear she continues to control her eating and inevitably the weight goes down.

A person with bulimia nervosa may share something of this fear, although bingeing makes weight loss less predictable. However, for neither sufferer is there much sense of having an ‘automatic pilot’ which will control weight and eating habits. The entire business of weight and eating control feels unstable and unsafe.

Sometimes fears of loss of control can become so extreme that an individual feels that any lapse will lead to everything going wrong. For instance, someone with anorexia nervosa may believe that eating just a small amount of what she considers a ‘fattening’ food will cause her to become obese. Any rational objection to such a view is pushed aside because that is how it feels to the sufferer. People with eating disorders, especially anorexia nervosa, usually experience their bodies subjectively. They see themselves as being quite different from how they appear to those around them.

DISTURBED BODY IMAGE

Most people with eating disorders see their bodies as objects of concern and worry. Many are described as having a disturbance of their body image. This is sometimes illustrated by a picture of an emaciated young woman looking into a mirror and seeing a reflection of someone who is grossly overweight. Such extreme dis­tortion is not always found even in those with the most severe anorexia nervosa, although lesser degrees of disturbance are common in those with eating disorders. Moreover, such a picture oversimplifies a complex issue.

All of us, to some degree, experience our bodies in a way that reflects our beliefs and our wider view of ourselves. Other people who are concerned with their body size, such as genuinely obese people and pregnant women, share with those with eating disorders a tendency to misjudge body size and shape.

The problem for most eating disorder sufferers is not so much that they see themselves as fat. Instead, they cannot easily dismiss the feeling that they are fat or at risk of becoming fat if they fail to keep things in control. Such feelings are usually quite independent of their actual weight. So someone may acknowledge that they feel just as fat at six stones (38 kg) as they did at 10 stones (63 kg). They know that this does not make sense but cannot rid themselves of the feeling.

ABNORMAL METHODS OF WEIGHT CONTROL

Eating restraint is the most commonly adopted method of attempting to control weight. But people with both of the eating disorders may try additional ways to avoid weight gain, especially if they have succumbed to binge eating. The most common methods are self-induced vomiting and the abuse of laxatives and diuretics. Some people chew food and then spit it out without swallowing as an alternative to vomiting.
Vomiting shortly after eating is obviously an effective way of reducing the amount of food absorbed by the body. Vomiting is usually brought on by stimulating the back of the throat with something such as the finger or a toothbrush. However, vomiting is dangerous. Repeated vomiting tends to deplete the body of the salts and ions, especially potassium, which must be kept in balance for the body to work properly. The body works hard to keep things in balance but it can be overwhelmed.

Then the person may be in real danger. For instance, the sufferer may experience seizures or the heart may be affected or even stop, although fortunately this is rare.

However, erosion of tooth enamel and damage to the tissues of the mouth, throat or gullet are much more common complications of repeated vomiting. It can also lead to swelling of the parotid salivary glands, which may give the person a ‘hamster cheek’ appearance.
Another method is the excessive use of laxatives. The abuse of laxatives is based upon the idea that if the passage of food through the gut is speeded up, the amount that is absorbed will be cut down.

This is not true, but still some people take enormous quantities of laxatives to try to achieve this effect. In doing so they are taking the same sort of risks with their health as those who vomit. This is because the main effect of taking laxatives is to stop the reabsorption of fluid and salts from the gut. Excessive use can cause severe depletion of vital fluids and salts. Although the body weight may change markedly after a big dose of laxatives, this reflects only a change in the amount of fluid in the body. There is no change in body substance or fat. And when water or fluids are taken in again, the body weight will increase.
The same is true of the abuse of diuretics, or water tablets. Doctors prescribe powerful diuretics for a variety of reasons including the treatment of heart failure. However, mild diuretics can be bought over the counter and when taken in high doses can have damaging effects. Abusing laxatives or diuretics can lead to the body’s fluid balance becoming so out of kilter that fluid retention, weight gain and swelling (oedema) occur.

EXCESSIVE EXERCISING

People with eating disorders will often take excessive amounts of exercise in an attempt to control weight. Again, the effect of exercise on weight loss is often exaggerated. It is in truth rather small. There is no doubt that, in general, exercise has real advantages in promoting fitness and health. However, people with eating disorders often drive themselves into frantic activity because they believe that it will help them avoid weight gain.

Usually they will exercise alone. They may attend several aerobic classes each week or even every day, go jogging and also exercise at home. The whole process may become so much a part of their emotionally charged routine that any thought of stopping becomes frightening. Only by going on and on and on can the fantasies of loss of control be kept in check. Any positive benefit of exercise is outweighed by the emotional and physical costs of pushing a body weakened by weight loss or metabolic imbalance into a programme that is quite literally punishing.

AMENORRHOEA AND HORMONAL CHANGES

Amenorrhoea is the medical term for an absence of menstrual periods, and it is one of the key features of anorexia nervosa. This is because anorexia nervosa leads to important changes in the hormones, the body’s natural chemical messengers that help to regulate the meta­bolism and the reproductive func­tions of the body.

Similar changes occur in sufferers from bulimia nervosa even when they maintain an average weight, but these changes are less profound and consistent. This is probably because the changes in anorexia nervosa are largely caused by the loss of body weight itself.

In growing children, the normal increase in body weight and body fat seems to play a part in promoting the physical changes of puberty. Hormonal changes are triggered as the body weight passes a certain threshold. These changes eventually result in menstruation in girls and parallel, although less evident, developments in boys. Their bodies could be described as being ‘switched on’ by physical growth.

With weight loss this process seems to go into reverse. The body ‘switches off’ the hormonal systems that sustain menstruation and the periods stop. If the girl has yet to start her periods their onset will be delayed.

This switching off may represent a built-in protection against pregnancy in times of food scarcity and starvation. But when the food deprivation is self-imposed for emotional reasons, the effects of the hormonal changes can take on many meanings. For instance, the girl may feel less sexual or less grown up. If she has been struggling with the emotional upheaval of adolescence, this may come as a relief. For others, the chief experience is of a loss of sexual feeling and libido. For most sufferers, these types of changes just add to the sense that life has become changed, confused, unpredictable and frightening.

Amenorrhoea is the outward sign of hormonal changes which indicate that the whole reproductive system is closed down. Women with amenorrhoea caused by anorexia nervosa are almost always unable to conceive because they are not ovulating.

The thinning of bones, known as osteoporosis, is another important consequence of anorexia nervosa. This can lead to fragility and fractures. It is probably caused by the hormonal changes, although poor nutrition may play a part.

Other hormones, such as thyroid and growth hormone, are also changed by the weight loss of anorexia nervosa but the effects are less evident and probably less important.

OTHER PHYSICAL COMPLICATIONS

There are many other physical complications of eating disorders but most are rare. Furthermore, they tend to occur only in the most severe cases. However, there is a wide range of minor physical symptoms that are not specific but nevertheless are often found in people with eating disorders. These include symptoms such as bloating, constipation, wind, weakness and fainting. Self-starvation and bingeing are just not good for the body and it is likely to complain and answer back.

PSYCHOLOGICAL FEATURES

Many of the features already described, such as body image disturbance and worries about loss of control, are psychological rather than physical. But there are others which are less specific but still important. Most, if not all, people with anorexia nervosa and bulimia nervosa are unhappy and troubled. In particular, they usually have low self-esteem and a deep-seated lack of confidence.

Many people with eating disorders are anxious and depressed. Others have noticeable symptoms of an obsessive disorder, such as checking rituals. Some people with eating disorders use additional, potentially damaging, ways of coping with difficult emotions. For instance, they may abuse alcohol or drugs. Some will go through crises in which they will feel suicidal or experience the impulse to damage themselves. Many will find that their relation­ships with others are changed by the effects of their illness.