We have a problem with eating when we are too restrictive of certain foods, only eat fat-free or no carbohydrates, eat while we are standing and don’t realise that we are eating, cut out meals, eat on the run, over-eat consistently or start to resent any food because it makes us fat. This can develop into an Eating Disorder. Eating Disorders are difficult to treat and have the highest death rate of all the psychological disorders.
There are different types of Eating Disorders. The most commonly known are Anorexia Nervosa and Bulimia Nervosa.
A study conducted by Gowers and Bryant-Waugh showed that Eating Disorders were disorders of first-world countries (Gowers & Bryant-Waugh, 2004). However, a study by Thomson (1992) revealed that if rural African people moved into urban settings, their children would become Westernized and may also develop eating disorders. They would be exposed to new factors such as television and fashion magazines (Monro & Huon, 2005) as well as the different values of their peers and a different school set-up, all of which might lead to the development of an eating disorder (Barlow & Durand, 2005). As countries become more Westernized, their rates of Eating Disorders increase. In the USA and in South Africa there is a lower rate of eating disorders among African women, possibly because a more rounded female figure is valued, but this appears to be changing (American Psychiatric Association, 2007).
The mentioned studies suggested that Eating Disorders have moved beyond the stereotype. They used to be considered primarily a health issue for affluent white, teenage girls. Now, the problem has crossed socio-economic, ethnic and gender boundaries (Neuman & Halvorsen, 1999).
Eating Disorders affect a small percentage of the population in the USA. Bulimia Nervosa affects about 1.1 percent of females and 0.1 percent of males. Anorexia affects about 1.62 percent of the population (Barlow & Durand, 2005). However, these figures might be inaccurate as the disorders are often well hidden. Bulimia Nervosa is a lot harder to detect because sufferers are often of normal weight. Ninety percent of females with an Eating Disorder are young and white. They come from upper-middle and upper socio-economic groups living in socially competitive environments (Barlow & Durand, 2005). Hsu (1995) points out that Eating Disorders are culture specific – that is, they are white, Westernized illnesses. An abundance of food and fewer infectious illnesses have led to an increasing average body size in the middle-upper socio-economic class in the Western world. However, the Western ideal was to be thin, and this is reflected in the media. The number of diet-related articles has risen in the past couple of decades and the cover pages of magazines frequently feature thin models. The self-esteem of young females is correlated with thinness and physical attractiveness. Thinness is equated with being successful, intelligent, and attractive and in control. It is therefore common in the West to be preoccupied with one’s body and with being thin.
To understand Bulimia Nervosa and Anorexia Nervosa, it is necessary to look at the clinical picture and the DSM IV-TR explanation. (To diagnose a psychological disorder we use the DSM-VI-TR, our handbook for psychological disorders).
1. Anorexia nervosa
The person suffering from Anorexia Nervosa has an extreme fear of becoming fat or gaining weight. They will starve themselves because they want to lose weight. They generally lose more than 15 percent of their body weight. They cannot judge their body size accurately and have a disturbed body image (Barlow & Durand, 2005). People suffering from Anorexia Nervosa are preoccupied with food, and will often collect it or prepare big meals without eating the food. Research has found an imbalance in the Neuro-peptide Y at the level of the hypothalamus, which enhances the onset of the disorder (Lieberman, 1995). The person suffering from Anorexia Nervosa might severe physical damage: cardiac arrhythmias, hypotension, amenorrhoea (the DSM IV-TR requires the absence of the menstrual cycle for three consecutive cycles), dry skin, brittle hair, sensitivity to cold temperatures, and hair growth on the side of the face. The onset of the disease is from 8 to 13 years of age.
According to the DSM-IV-TR the criteria are: refusal to maintain normal body weight and losing more than 15 percent of it, fear of gaining weight, disturbance in body perception, denial of serious low body weight, and amenorrhoea. There are two types of anorexics, namely: 1. the bingeing and purging type, and 2. the restricting type (American Psychiatric Association, DSM-IV-TR, (2005), pp. 583-89).
Once Anorexia Nervosa develops, it tends to reinforce itself. Positive feedback on weight loss from peers or family members in the initial stages of the disorder may reinforce the desire to continue losing weight. The eating disorder may give the anorexic a feeling of power, self-control or virtue.
The main sign of this disorder is binge eating together with purging techniques such as vomiting, using laxatives or diuretics, or non-purging techniques such as dieting, exercising and fasting. This leads to a sense of self-disgust and loss of control. People who suffer from Bulimia Nervosa are over-concerned with their weight and shape, and often overestimate their body size (Barlow & Durand, 2005). However, most of them are within 10 percent of their normal body weight range.
The DSM IV-TR criteria are: recurrent binge eating, and recurrent compensatory behaviour to prevent weight gain. The compensatory behaviour has to occur at least twice a week for three months, sufferers evaluate themselves by their body shape and weight, and anorexia nervosa needs to be ruled out as a diagnosis. There are two types of Bulimia Nervosa: the purging type (regular purging) and the non-purging type (fasting and exercise) (American Psychiatric Association, DSM-IV-TR, (2005), pp. 589-94).
3. Comparing Anorexia and Bulimia Nervosa
Researchers have compared Anorexia with Bulimia Nervosa to get a better understanding of the two disorders. There are similarities. Many people with Bulimia Nervosa have a history of being anorexic. Many anorexic and bulimic patients used to be obese, or live in a family that is obese. The biggest difference between the two disorders is the degree of success in losing weight. Anorexics are much more successful at losing weight than bulimics. Binge-eating, purging anorexics purge more regularly than bulimics (Rome & Ammerman, 2003). There is a greater incidence of bulimia than anorexia, and the average age of onset with bulimia is 16 to 19 years as compared with 8 to 13 years for anorexics.
Another study by Gowers and Bryant-Waugh (2004) shows that an alarming 0.5 percent to 3.7 percent of females suffer from Anorexia Nervosa, while 1.1 percent to 4.2 percent suffer from Bulimia Nervosa. Furthermore, the onset age of both eating disorders has dropped steadily over the years. Primary school children are reported to be dieting at an early age, with Anorexia Nervosa reported among nine-year-olds. Recent studies in America show that 42 percent of first, second and third grade girls want to be thinner. In a survey of 500 fourth grade girls by the Harvard Eating Disorders Centre in Boston, 40 percent were found to be on a diet, binge eating or afraid of getting fat (Gowers & Bryant-Waugh, 2004).
According to the American Psychiatric Association (2007), eating behaviour is related to thoughts and emotions. People with Anorexia and Bulimia Nervosa tend to be perfectionists who suffer from low self-esteem and are extremely critical of themselves and their bodies. They usually feel fat and consider themselves overweight, sometimes despite life-threatening semi-starvation.
4. Prevalence of Eating Disorders
Eating disorders seem more prevalent in individuals who have been overweight. The individual begins dieting, but at some point normal dieting develops into an Eating Disorder (Markey & Markey, 2005). Taylor’s research (1991) showed that dieting efforts among teenage girls are more likely to lead to weight gain than weight loss, and females who had dieted had a 300 percent greater risk of obesity than those who had not (Taylor, Agras, Losch & Plante, 1991). A 1990 study found that adolescent girls who dieted were eight times more likely to develop an Eating Disorder a year later (Barlow & Durand, 2005). According to the mentioned findings it seems that girls who have a weight problem in their teenage years already are more likely to develop an Eating Disorder compared to girls who do not have a weight problem in at that age.
Apart from those mentioned Eating Disorders we see more and more females and males with Eating Disorders Not Otherwise Specified which means that a diagnosis of an Eating Disorder can be made without that the person has the above mentioned symptoms of Anorexia Nervosa or Bulimia Nervosa. Those individuals will:
? have their normal period,
? have the typical behaviours like females with Anorexia Nervosa but do not lose weight (e.g. restricting themselves of all or certain foods but do not lose an excessive amount of weight),
? binge eat (but less than twice a week or for less than 3 three months) and/or
? chew repeatedly but not swallow their of food.
You can see that as soon as food becomes an obsession it causes problematic eating. Any form of restrictive behaviour is seen as being a problem. Many people think of food already when they wake up and don’t stop thinking about it until they go to sleep. Only allowing themselves “very healthy foods” is a problem as they become fixated with the thought of not being allowed to eat anything else. If they do eat unhealthy foods (or food they THINK is unhealthy), they tend to feel upset, angry and guilty. Often they feel that they have to convert to behaviours such as over-exercising or restricting themselves to compensate again.
If we look at OCD we can clearly see why being obsessed with healthy foods is a disorder.
Obsessions are defined as:
- Re-current and persistent thoughts that are inappropriate and cause marked distress and anxieties.
- Thoughts, impulses and images that are not just worries about real-life problems
- A person having to suppress such thoughts and images
- The person realises that these are images and thoughts are a product of his/her mind.
Compulsions on the other hand are defined by:
- Repetitive behaviour that the person feels driven to perform or a rule that needs to be applied
- Behaviours or mental acts that need to be performed to prevent or reduce the distress. These acts are often mental acts that are not connected to a realist way with what they are designed to neutralize or prevent.
The person with OCD has to realise that the behaviour or thoughts are obsessive (sometimes we get OCD with poor insight which means that the person does not realise that the behaviours and thoughts are obsessive/compulsive). Those obsessions or compulsions cause anxieties and distress in the person’s life and interfere significantly with routine, work, studies etc. (e.g. taking up more than an hour).
OCD goes hand in hand with Eating Disorders, anxiety and/or depression. Those disorders are the most common co-morbid disorders we see.
As you can see, if people obsess with their healthy foods, become too rigid, restrict themselves of certain foods, take up a lot of time thinking about food or preparing food, feeling anxious and guilty if they have not eaten healthily then they could be diagnosed with either OCD or/and an Eating Disorder. Eating Disorders need to be taken seriously because they are potentially life-threatening conditions that affect the individual’s physical, emotional and behavioural development, and may lead to premature death. Among all mental disorders, Eating Disorders have the highest rate of deaths. They can be seen as a slow form of suicide because self-starvation is an attempt to destroy the body. Seemingly innocent dieting might develop into life-threatening Eating Disorder.
I always say, as soon as a behaviour interferes with our daily living it becomes a problem.