My name is Natalie; I am an intelligent and educated woman, and I have been anorexic for twenty-five years. I now live with a range of serious and disabling complications from the disorder, and am not expected to live a great deal longer. My own life experiences illustrate just how damaging Eating Disorders can be if they are not treated promptly and effectively.
This article was written to give a brief background on Eating Disorders (Anorexia and Bulimia Nervosa, Compulsive Overeating and related disorders) and as a personal plea from a sufferer for the medical profession to treat these conditions with the seriousness that they warrant.
The article does not attempt to provide clinical descriptions or diagnostic criteria for the the disorders, as these can readily be found in the literature. Instead it seeks to set the disorders in a much wider social, psychological and experiential context in order to address common misconceptions about the disorders.
When referring to sufferers, the female pronoun is used throughout the article, reflecting the fact that around 90% of sufferers are female. However, this must not be seen as precluding the existence of the disorders in males.
In all of the Eating Disorders, the common theme is the (mis)use of food and eating behaviours in response to psychological stressors of one sort or another. This misuse takes on different forms in the different disorders:
In Anorexia Nervosa , the sufferer exhibits a pathological fear of weight gain and a desire to be abnormally thin, and indulges in unduly extreme restriction of her diet in an attempt to achieve this. Excessive exercise and sometimes self-induced vomiting may also be used as a means of weight control. This behaviour leads to a wide variety of harmful physical and psychological consequences and can be life-threatening; in fact anorexia nervosa has the highest mortality rate of any psychological illness.
In Bulimia Nervosa , which may coexist with anorexia nervosa, the sufferer indulges in bursts of massive overeating followed by 'purging' behaviours aimed at limiting the weight gained (self-induced vomiting is the most common mechanism). Risks are similar to those of anorexia nervosa, with additional risks from frequent vomiting.
Compulsive Overeating shows similar overeating behaviour to bulimia nervosa, but without the purging episodes. Risks are generally those associated with obesity.
In all these disorders, the sufferer's quality of life suffers a major impact and the disorders can impinge significantly on social and occupational functioning.
There is a widespread misconception that the Eating Disorders, and especially anorexia nervosa, are essentially a matter of vanity, of wanting to conform to a culturally-imposed ideal of unnatural thinness. Although the cultural ideals may encourage disordered behaviour by providing a positive emotional reinforcement for weight loss in the early stages of the illness, it is not reasonable to conclude that vanity and appearance underlie Eating Disorders.
It is also a myth that anorexia nervosa strikes only adolescent females. It is reported in patients of both sexes, from childhood to old age. When the illness follows a chronic course it can persist for an enormously extended period, and in such cases carries additional risks. If treatment is not initiated promptly, a chronic course becomes very likely and the illness may become intractable. In such cases the mortality rate is especially high.
Contributory factors are many and varied, and no single theory of the aetiology of Eating Disorders can hope to cover all cases. Certain personality traits are often discerned among sufferers, especially of anorexia nervosa: typically over-sensitive, perfectionistic, rigid 'black and white thinkers', usually above-average intelligence. These traits appear to predispose to the deveopment of an Eating Disorder under the influence of an appropriate experiential trigger.
Typical triggers are traumatic experiences of various sorts. These may range from being a victim of child abuse to the loss of a job or a loved person. Adolescents are often affected since that time is particularly full of emotional upheaval and changes in family dynamics; additionally adolescents are perhaps less likely to have learned more appropriate coping strategies than older patients. The only common feature among trigger factors seems to be that they have little to do directly with food or appearance.
Other life changes of a less traumatic nature may also precipitate an anorexic episode, particularly when the patient has already experienced one or more previous episodes. Moving house, or even a new relationship or marriage may constitute a sufficient upheaval to trigger a relapse in a sufficiently over-sensitive person, even if the life change is not negative in its nature.
New evidence is emerging that anorectics may be 'self-medicating' intolerable emotional states by starving and overexercising; definite neurochemical effects have been identified, which are associated with the numbing-out of emotional response and hyperarousal states, to which anorectics seem particularly prone.
In many cases, control may also be an issue: patients who have had their sense of control violated, for example by abuse, may come to feel that their eating and weight are the only features in their life over which they have control, and practice that control pathologically as a substitute for control over other aspects of their lives. It is vitally important to be aware of this element when patients are treated, as any treatment that is perceived as coercive or controlling is likely to be detrimental to the patient's well-being. For this reason the author feels that any use of compulsory admissions (Mental Health Act), aversion therapy, force-feeding and coercive behaviour-modification techniques are to be avoided.
To summarise: the Eating Disorder patient is not an attention-seeker, a time-waster or a superficial and vain person, but a person with serious underlying psychological or emotional issues which deserve to be taken seriously.
Although there can be no doubt that the basic trigger factors in Eating Disorders are of a psychological nature, the disorders do carry significant physical consequences. Unfortunately there is a tendency among practitioners who are not well-versed in these disorders to assume that all symptoms are psychogenic. This attitude is counterproductive and may lead to potentially life-threatening physical sequelae of eating-disordered behaviour being overlooked.
This is particularly true of gastrointestinal effects of Eating Disorders. To be sure, "I feel nauseous" can be an obvious excuse offered by someone who simply objects to eating, but in many cases real problems are apparent. Long-term Eating Disorder sufferers especially may develop multiple food intolerances, malabsorption syndromes, delayed gastric emptying and other motility disorders, and in extreme cases gastroparesis. Such symptoms should not be dismissed as psychogenic without careful elimination of possible physical causes. Patients who induce vomiting, or who vomit spontaneously from acquired motility disorders, frequently develop oesophageal damage, gastro-oesophageal reflux disease (GORD), and damage to the lower oesophageal sphincter. Those who misuse laxatives may develop problems of the large intestine, including colonic atony.
In my own lengthy history of anorexia, I have experienced many cases of insufficient understanding of the disorder, inappropriate treatment, dismissive attitudes, and lack of funding and treatment resources. I have been told to "just snap out of it", told that I am simply vain, or that I am too old to have anorexia, and physical symptoms have sometimes been dismissed as psychogenic or even factitious.
Coercive treatment of any sort, especially threats, are counterproductive and their use on me in the past has exacerbated some of my severely-anorexic episodes. A supportive approach is far more productive, involving the patient in her own care and treatment.
Weight restoration should not be the sole objective of treatment. If the underlying emotional factors are not addressed, relapse is almost inevitable. Supportive psychotherapy is often valuable.
Symptoms which may have a physical cause, especially gastrointestinal problems, should be properly investigated and treated before their existence is assumed to be merely psychogenic.
All too often, Eating Disorders seem to be treated as a forgotten class of illness, with a profound lack of specialist treatment centres in many areas. Provision of NHS funding for treatment, especially when treatment has to be out-of-area due to a lack of local resources, is often problematical: I myself have been subjected to a three-month delay in the funding of vital inpatient treatment, which directly contributed to irreversible physical consequences of my illness.
I hope that this short article has helped to place Eating Disorders in a clearer perspective and to make a case for them to be taken more seriously than they often are at present.
Of course, an article such as this can barely begin to scratch the surface of the subject, and those who may become involved in the care of any Eating Disorder patient are urged to learn more about the conditions and to address them with an open mind and with the seriousness and diligence that potentially fatal diseases must warrant.