- What constitutes disordered eating
- Characteristics of bulimia nervosa and binge eating disorder
- Longer-term therapy and treatment
Despite a great deal of information and interest in eating disorders for many years, many health professionals do not fully understand what an eating disorder is. The question “do I/does my child have an eating disorder?” is often asked by people who come to my practice. Even the label ‘eating disorder’ is contentious because this implies that there is something we call ‘normal eating,’ which is gender and culture specific. In 21st century Britain, myriads of people are dieting, struggling to lose weight, overeating, eating for comfort, avoiding carbs and then binge eating or eating a great deal because they are stressed or depressed. And more importantly, as evidenced by the weight of the nation - if not the world - many people are overeating and becoming fat without having a clinical eating problem.
A broad definition of an eating disorder is given by Fairburn and Walsh, clinicians at the cutting edge of eating disorder research for many years. They propose “a persistent disturbance of eating and related behaviours intended to control weight which significantly impairs physical, emotional health and social functioning.”1 A second condition is that “body image (beliefs about appearance) is poor and dominates self worth.” Thirdly that these problems are “not secondary to other mental conditions.” These criteria cover a wide range of eating difficulties; there are many overlaps between the symptoms of different eating disorders including those that are specific to overeating. It’s also important to remember that an eating disorder is not an illness that you can have in the same way as one has for example, measles or mumps. Many ordinary normal people experience an eating disorder at some point in their life.
Our current shared understanding of over-eating disorders is that there are severe forms which fit very tight criteria, and less severe forms which do not fit comfortably into any particular condition and may be mixed in presentation. Some overeaters for example are so fearful of weight gain that they resemble people with anorexia. This has added to our difficulty in knowing how to label what is really going on for the person who comes to us for help.
The overeating disorders meeting tight criteria in the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSMV) classification2 are bulimia nervosa – recurrent overeating followed by purging, and binge eating disorder where there is overeating without purging.
Be mindful that even these descriptions vary considerably between one person and another. For example some people with bulimia purge by vomiting or laxatives daily after eating large amounts to prevent weight gain, while others purge after eating a normal meal in order to try to lose weight. People who binge eat without purging also vary considerably in their presentation. For this reason, some experts argue for letting-go of definitions in favour of a transdiagnostic (inclusive) explanation of eating disorder.3 With these caveats in mind, I describe our current classifications below.
Bulimia nervosa usually presents with recurring episodes of overeating followed by compensatory behavior, like purging or excessive exercise to offset calories and prevent weight gain. The typical bulimic might for example eat very little when they are not binge eating, for fear of losing control and subsequently binge eat “forbidden food”4 then purge with self-induced vomiting or taking laxatives, although diuretics and exercise are among the alternative means of purging.
Binge eating disorder is recurrent eating of abnormally large amounts of food in a discrete period of time with loss of control and excessive amounts of guilt and remorse. Dieting behaviours are common but there is no attempt to purge and thus many binge eaters struggle with their weight. Binge eating is common among the overweight with, it is thought, up to 50% of the obese “seeking help for their weight problem” having an active eating disorder. Less severe forms of binge eating include quite common behaviours like constant picking, nibbling, for foraging for food considered fattening. In the throes of their desire for forbidden food, bulimics and binge eaters have been known to shoplift, store, hide and hoard food for binge events.
Over 85% bulimia sufferers are female and less is known about males with the disorder.5 The usual age of onset is during late adolescence, although bulimia can start at any time and persist for many years. Binge eating problems without purging are less gender-specific and can emerge at any time post puberty.
Common characteristics of overeating disorders include
secrecy and considerable distress. Eating occurs in the presence of irresistible cravings that feel compelling, while there is also a desire to restrain eating and lose weight. Also typical is body
image disturbance and constant worrying about food or weight. “What did I eat, what should I eat, what will happen to my weight, I’ve blown it again.” Sufferers say that they eat without being hungry and find themselves unable to stop when they have had enough. They interpret this as lack of willpower, compulsive behaviour, emotional eating or an addiction to food, or to certain kinds of food, like chocolate.
One problem we have with diagnosis is what characterises a “binge”, as this is a very personal interpretation of an eating event. We all overeat at times for a variety of reasons and we all are to some extent emotional eaters. True eating disordered behavior is thus a matter of degree and asks us to look at what else is present in the repertoire of behaviours - like dissociated eating, loss of control, plus emotions like overwhelming anxiety and guilt.
Some people have overeating patterns that do not fit the tight descriptions of bulimia nervosa or binge eating disorder in severity or frequency. There are also people who purge without bingeing to encourage weight loss. There is an overeating disorder called Night Eating Syndrome with compulsive night-time eating, sleep difficulties, morning loss of appetite and characteristic endocrine presentation. We now group these less severe or atypical forms of overeating disorder, plus atypical anorexia, within the category Feeding and Eating Disorders Not Elsewhere Classified (FEDNEC). Within this category there are wide differences and it may take a specialist to determine whether they have an eating problem or a different psychiatric presentation, and predict a common outcome or a common appropriate treatment.
Overeating disorders mostly follow a period of strict dieting, and some overeaters may even have had an earlier anorexia. But not all dieters develop eating disorders, so clearly something else is going on. There is no single cause of an eating disorder; there are usually a number of factors in the history of the individual leading to deficits in self worth, body insecurity and coping. There are also - for a variety of reasons - problems expressing or managing emotions in the presentation of such patients, sometimes (but not always) due to early abuse.6
A clinician is more interested in maintaining factors than in remote causes and must build a formulation of all the factors, nutritional, relational and emotional that is keeping a person stuck. Certain eating disorder behaviours, such as purging, begin as attempts to thwart weight gain, but evolve to become ways to manage powerful unwanted feelings. Significant among the maintaining factors is a typical eating disorder mindset; automatic unhelpful beliefs which lead to unhelpful repetitive behaviours. Such beliefs, many which are subconscious, include thoughts which impede motivation to change such as “I am not sure I really wish to stop bingeing because it’s the only way I get to have fun”. Other examples of faulty thinking include the erroneous belief that “purging will keep me thin” or “If I vomit I will get rid of everything I have eaten.” These surface thoughts are usually a reflection of deeper beliefs that a person can never live up to their own exacting and unrealistic standards.
Bulimia nervosa is perhaps the most dangerous of the eating disorders because it is not easily recognised. But binge eating is also dangerous. The ingestion of large amounts of food, usually high in fats and sugars in all these disorders impairs metabolism leading to diabetes, liver complications, high blood pressure over time and cardiovascular complications. Further, self-induced purging compromises the gastrointestinal tract, leads to hormonal changes affecting fertility and damage to heart, kidney and brain arising from electrolyte losses. Sufferers are commonly distressed and anxious; suicide rates are notably high in sufferers of overeating disorders.Treatment is regarded as parallel track; the first phase of therapy is behavioural, which means replacing old unhelpful behaviours with new more adaptive ones. Food monitoring is a useful tool for collaborative analysis of what is going on, supported by psycho-education, and nutritional guidance helps relieve some of the cravings and unhelpful emotions that are simply caused by dietary chaos. It is impressed on patients that they must suspend attempts to lose weight during treatment while their relationship with food is slowly repaired. Skills work, such as appetite sensitivity training and mindful eating skills help reconnect the person to hunger and satiety signals from which they have become disconnected by years of dietary chaos. It is also useful at some point to explore the patient’s early experiences with food in their family of origin.
The second phase of treatment is described as cognitive-emotional and will address the unhelpful thoughts and emotional issues that lie beneath the overeating. Cognitive therapy targets eating disorder thinking and is associated with lowered risk of relapse.7
A variety of strategies are used at the same time and according to need, in order to build emotional resilience. We are less interested in addressing past harms than in building long term
skills for managing the feelings that day-to-day life throws up - including the use of emergency strategies for times when we feel it is hard to cope.
The final phase of treatment ensures that the patient is able to cope and indeed thrive with a more intact sense of self-worth that is less dependent on body shape and size. The eating disorder therapist also builds a relapse prevention plan to ensure that the patient has good strategies for times when they feel vulnerable
Cognitive-behavioural strategies are improved with third wave therapies such as dialectical behaviour therapy, acceptance and commitment therapy, and intuitive eating training; these are improving outcomes for clients who believe that their problems are insurmountable. Therapists thus need to build a large repertoire of knowledge and skills in a number of domains, including even neuroscience and physiology. Our patients, many who recover, deserve no less.
1. Fairburn & Walsh. Atypical Eating Disorders. In Eating Disorders & Obesity. A Comprehensive Handbook. New York Guildford Press (3rd Edn) Eds Fairburn, C.G., & Brownell, K.D. 2002;171-7.
2. DSMV Criteria, 3 Atypical eating disorders, 22-3 Binge Eating Disorder, 19-20, Bulimia Nervosa, 13,17-18.
3. Fairburn CG, Cooper Z. Thinking afresh about the classification of eating disorders. International Journal of Eating Disorders 2007;40:(S3)107-11.
4. Fitzgibbon ML, Blackman LR. Binge eating disorder & Bulimia Nervosa: Differences in the quality and quantity of binge eating episodes. International Journal of Eating Disorders 2004;27:(2)238-43.
5. Carlat DJ, Carmago CA. Review of bulimia nervosa in males. American Journal of Psychiatry 1991;148:831-43.
6. Waller G, Corstophine E, Mountford V. The role of emotional abuse in the eating disorders: Implications for treatment. Eating Disorders 2007;15:317-31.
7. Therapy for Eating Disorders (3rd Edition) 2014 Theory Research and Practice: Sara Gilbert. Sage Publications.
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