Understanding Eating Disorders - Which one of these people has an eating disorder?
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Understanding
Eating Disorders
The Eating Disorders Association Inc. (Queensland)
Which one of these
people has an
eating disorder?
...they all do.
Front cover by: Beth Mitchell Photography,
Beth Mitchell photographer, Tim Orange
assistant photographer, Begitta Stolk This booklet was generously funded by the
fashion stylist, Madison Colless assistant English Family Foundation. We thank members
stylist, Fiona Claire makeup artist, Vanessa
of the Foundation for making the update of this
Mulkearns hair stylist.
booklet possible and for giving us an opportunity
Image talent: Broghan Campbell, Tracey to engage creatively with the community.
Walker, Ayden Melhop, Taymin Marks,
Mel Marks, Andi Coleman, Ben Matheson. Understanding the nature of eating disorders is
key to recovery. We hope this booklet is helpful
Copyright 2014
Eating Disorders Association Inc.
for all people and families affected by eating
disorders, for the health professionals who
ISBN 978-0-646-90889-2
support them and for the broader community.
This booklet was first printed in 1992 and The artwork and slogans used in the booklet were the result of
has since had four revisions. The booklet months of consultations with the community and the Eating
has been in constant demand by people
throughout Queensland (and other states) Disorders Association.
who are seeking information relating to The theme of being underwater was used as a metaphor for
eating disorders.
living with an eating disorder; swimming to the surface and
We thank the EDA staff and board who breaking through, a metaphor for recovery. We thank all the
have contributed to the development of
Understanding Eating Disorders, 2014.
people involved in creating the concepts, slogans and wording
The Eating Disorders Association Board for this booklet. The booklet is a collaborative community effort
Members: Broghan Campbell, Keryn (Keri) involving people with a lived experience of an eating disorder,
Campbell, Leanne Chapman, Lexi Crouch, their carers, health professionals and community supporters.
Catherine Doyle and Holly Kirkham.
Thanks also to the Eating Disorder
Association Service Workers Melissa
Photographic acknowledgements
Marks, Mary Anne Kissane, Jasmine Beth Mitchell Photography: Beth Mitchell photographer, Tim
Melhop and Amy Tidbold. Special thanks
to Coordinator Desi Achilleos for her
Orange assistant photographer, Begitta Stolk fashion stylist,
leadership with community development, Madison Colless assistant stylist, Fiona Claire makeup artist,
grant writing, project management and Vanessa Mulkearns hair stylist.
for revising and updating this booklet.
Additional photography by Mark Broadbent.
Appreciation for feedback on this edition:
Dr Leanne Barron, Carmel Flemming, The people photographed are community supporters wanting to
Kim Hurst, Shane Jeffrey, Andrea Muller, contribute to raising awareness about positive body image and
Loretta Ryan. With special thanks to Tania
eating disorders. They are: Lil Crump, Sophia McGregor, Mollie
Rotili and Dr Suellen Thomsen.
McGregor, Lexi Crouch, Tennille Carrier, Angel, Luke Melhop,
Acknowledgement to previous Ayden Melhop, Jasmine Melhop, Desi Achilleos, Taymin Marks,
contributors: Lynda Melville, Dr Suellen
Thomsen, Mary Barram, Margaret Mel Marks, Broghan Campbell, Keryn (Keri) Campbell, Keiran
McAllister, Pin Ying Lim, Joanne Blair, Garland, Tracey Walker, Ben Matheson, Nicole Gibson of The
Karen Hollands, Kirsten Braun, Carmel Rogue and Rouge Foundation, Sarah Dakhili (Social Worker),
Fleming, Julia Arnold. Dominique O’Leary, Andi Coleman, Toni Woods and Hillary
First Edit: Susan Prior of Write-now! Green.
Second Edit: Darryl Rosin.
Thanks also to the people who collaborated with us to create
Booklet Design: Emily Jarvis at Liveworm,
the slogans used in the booklet including Mary Lawson,
Queensland College of Art, Griffith
University. Charlotte Durand, Madeleine Henderson, Amy Bannatyne, Karla
Cameron, Kim Hurst, Shelly Read, Amanda Dearden, Cathy Dart,
The publication of this booklet would
not be possible without the support of Dr Leanne Barron, Dr Suellen Thomsen, Carmel Flemming, Sarah
Queensland Health for funding of the EDA. Walker, Eating Disorders Victoria, the Eating Disorders Network
Further copies of this booklet can
of Queensland, the Eating Disorders Outreach Service, ISIS - The
be obtained from the EDA. Eating Issues Centre and the Child Youth and Mental Health
Services (CHYMS) at South Brisbane and the Gold Coast. Special
thanks to Tania Rotili.
b Understanding Eating Disorders
Contents
SECTION ONE SECTION THREE Therapy and Support ��������������������� 56
Description of Eating Disorders��� 5 Seeking Help, Recovery ÊÊ Psychiatrist��������������������������������� 56
What Are Eating Disorders? ������������� 5 and Recovery Strategies������������� 31 ÊÊ Psychologist������������������������������� 56
The Effects of Starvation and Telling Someone ������������������������������31 ÊÊ Social worker����������������������������� 56
Refeeding����������������������������������������� 8 How to Approach Someone ÊÊ Counsellor��������������������������������� 57
Why Do People Develop with an Eating Disorder ����������������� 32
ÊÊ Mental health services��������������� 57
Eating Disorders? ��������������������������� 10 ÊÊ Get information about
eating disorders������������������������� 32 Family-based Treatment (FBT) for
ÊÊ Risk factors ������������������������������� 10 Children and Adolescents with
ÊÊ Triggers for the onset of ÊÊ Make a time to discuss Eating Disorders����������������������������� 58
eating disorders������������������������� 12 the eating disorder ������������������� 32
ÊÊ The treatment model����������������� 58
ÊÊ Factors that maintain an ÊÊ Going to a doctor, when
to call an ambulance and ÊÊ Does the treatment
eating disorder ������������������������� 13 program work?������������������������� 58
hospitalisation��������������������������� 33
ÊÊ Who will be involved
SECTION TWO Recovery����������������������������������������� 34
with the treatment ������������������� 59
Clinical Diagnosis of Recovery Strategies������������������������� 35
Adult Recovery Therapies ��������������� 60
Eating Disorders��������������������������� 17 Understanding the Stages of
Change in the Recovery Process����� 40 ÊÊ Psychological therapy����������������� 60
What is Anorexia Nervosa?������������� 17
Eating Disorder Diagnosis, ATAPS
BMI vs Body Mass Composition ����� 18
SECTION FOUR and Better Access Schemes������������� 64
ÊÊ Warning signs of
anorexia nervosa����������������������� 18 Treatment Options����������������������� 45
SECTION FIVE
ÊÊ What are the risks associated Getting Help and Choosing
the Right Health Practitioner����������� 45 How Are Family and
with anorexia nervosa��������������� 19 Friends Affected?������������������������� 66
ÊÊ Involuntary treatment orders ����� 20 Your Rights when Seeking Help������ 46
What is Bulimia Nervosa?����������������21 ÊÊ Guiding Principles ��������������������� 46 SECTION SIX
What is Binge Eating Disorder?������� 23 ÊÊ Questions or complaints?����������� 47 What Can Family and
Different Types of Treatment Friends Do?����������������������������������� 69
Other Specified Feeding
or Eating Disorder��������������������������� 24 and Therapy����������������������������������� 48 Advice for Carers ��������������������������� 70
Unspecified Feeding ÊÊ Hospital system������������������������� 48 Carer Allowance������������������������������71
or Eating Disorder��������������������������� 25 Medical Issues��������������������������������� 50
SECTION SEVEN
ÊÊ Pica������������������������������������������� 25 ÊÊ Medical practitioners����������������� 50
Recovery Stories ������������������������� 73
ÊÊ Rumination Disorder ����������������� 25 ÊÊ Medical check-ups��������������������� 50
ÊÊ I choose to reclaim my life... ����� 73
ÊÊ Avoidant or Restrictive Medical Complications
Food Intake Disorder����������������� 25 of Laxative Misuse ������������������������� 52 ÊÊ Anorexia Recovery:
Finding My Way������������������������� 73
What is the Overlap of the Different ÊÊ How to stop misusing laxatives � 52
Types of Eating Disorders?��������������� 26 ÊÊ Where I Came From: My Journey
ÊÊ What to expect from laxative
of Recovery From Bulimia����������� 75
ÊÊ Sub-clinical conditions��������������� 26 withdrawl ��������������������������������� 52
ÊÊ A Parent’s Perspective ��������������� 77
ÊÊ Warning signs of Dental Health and Eating Disorders� 53
an eating disorder��������������������� 26 ÊÊ A Mother’s Story ����������������������� 78
ÊÊ Finding a dentist ����������������������� 53
ÊÊ Complications of ÊÊ A voice from someone who has
ÊÊ Some other helpful hints����������� 53
eating disorders ����������������������� 27 lived with many eating disorders79
Nutritional Rehabilitation
How Common Are and Normalising Eating������������������� 54 Eating Disorder Community
Eating Disorders?��������������������������� 29
ÊÊ The role of a dietitian����������������� 54 Services in Queensland��������������� 82
ÊÊ Guidelines for normal eating����� 54 References ����������������������������������� 84
ÊÊ Out-patient nutritional
management����������������������������� 55
EDA Mission Statement EDA Philosophy
The mission of the EDA is to improve The EDA is a non-profit organisation
the intervention, education and dedicated to providing a service to
support for all people affected by people of all ages, gender and cultures.
eating disorders, and to work towards
The EDA recognises that eating
the prevention and elimination of
disorders are serious and complex
these disorders in society.
issues that require multi-dimensional
approaches to care and support.
We believe that all people experiencing
eating disorders, and their friends,
family and carers, should be treated
with dignity and compassion, and
should be included in all levels of
service.
The Association promotes the
acceptance of all body types and sizes,
and is committed to valuing people as
whole beings.
Everybody, no matter what shape or
size, can take steps towards improving
their health.
Recovery is possible, help is available.
2 Understanding Eating Disorders
The Eating Disorders Association Inc. [EDA]
The Eating Disorders Association Inc (EDA) have recovered, and from carers. Included in the
is a state-wide, not-for-profit organisation newsletter are personal experiences, recovery
started by a group of people with a lived strategies, art work, book and media reviews,
experience of eating disorders and carers. The health professional contacts, eating disorder
EDA opened its centre in 1996 to all people sector research, events and support group
affected by eating disorders and maintains a advertisements, and opportunities for people to
peer-orientated model of service delivery. The get involved at the EDA and other organisations.
EDA welcomes the input of people affected ÊÊ specialist eating disorder library.
by eating disorders in all aspects of the
ÊÊ community education about eating disorders, as
Association’s initiatives and the services it
a to improve the understanding and treatment
provides to the community.
of eating disorders, and to contribute to the
The EDA provides Queensland-wide recovery prevention of these disorders in society.
orientated support, information and referral,
including:
ÊÊ recovery orientated support, information and
EDA Contact details
referral sessions — by telephone, email, face-
to-face or using video conferencing — for ÊÊ Opening hours: 9 am to 4 pm,
individuals with eating disorders and for people Monday to Thursday
who care about them. Face-to-face sessions are ÊÊ 12 Chatsworth Road,
by appointment only. Greenslopes Q 4120
ÊÊ support groups, workshops and peer-support ÊÊ PO Box 346, Stones Corner Q 4120
groups, for people with eating disorders and for ÊÊ Telephone: 07 3394 3661
those who care about them.
ÊÊ Fax: 07 3394 3663
ÊÊ after-hours support by volunteers who have
ÊÊ Email: admin@eda.org.au
recovered from an eating disorder, or carers
who have supported someone to recover. ÊÊ Web: www.eda.org.au
ÊÊ information packs about eating disorders.
Other EDA publications:
ÊÊ referrals to health professionals with a special
interest in treating and supporting people with Consume Magazine
eating disorders throughout Queensland. www.consumemagazine.com
ÊÊ A peer- and carer-driven monthly newsletter
Find us on Facebook:
called Through the Looking Glass, with
contributions from people with a lived www.facebook.com/edaqld
experienced of an eating disorder, people who or on friend’s page
www.facebook.com/eatingdisordersassociation
The Eating Disorders Association 3
Your reflection may be
distorted by socially
constructed ideas of
beauty and worth
4 Understanding Eating Disorders
1
Description Of Eating Disorders
What Are Eating Disorders?
Eating disorders are serious and complex becoming an adolescent, an individual’s personality,
issues, with strong medical and psychological menopause, or going on a diet to be ‘healthy’. As
components, relating to negative body image, a consequence, it is only when someone becomes
weight and shape concerns, problematic quite obviously unwell that treatment is sought.
eating and compensatory behaviours,
Eating disorders often coexist with other mental
including starvation, binging, vomiting,
health issues, such as depression, anxiety, body
compulsive exercise and the abuse of diuretics.
dysmorphia, mood disorders and obsessive-
A person with an eating disorder will often assess compulsive disorders.
themselves negatively in terms of their weight and
Most people recover from an eating disorder
shape, and what they have eaten or not eaten. It is
and recovery is always possible regardless of
important to understand that even though eating
age and length of illness. However, people with
disorders encompass harmful eating practices
eating disorders are at a high risk of developing
and related compensatory behaviours, they are
serious medical complications and dying from
often the outward sign of deeper psychological
their illness. In fact, eating disorders have a
issues and ways that people have coped with life
higher death rate than any other mental illness.
stressors. Recovery from an eating disorder is not
The earlier treatment is sought the greater the
as simple as the person recognising the need to
opportunity for recovery, therefore treatment
‘just eat normally’. Eating disorders are complex
is encouraged as soon as possible. A multi-
mental health problems and are potentially life-
disciplinary treatment team including a doctor,
threatening illnesses.
dietitian and therapist is recommended.
Eating disorders can have serious effects on all
When someone with an eating disorder is
aspects of a person’s life — physical, emotional
approached about their concerning behaviours,
and social. They are often very private and hidden
they will often deny the existence or the
problems, which can exist for a long time before
seriousness of their behaviours and refuse to
they are recognised, particularly when the early
acknowledge any problem. Alternatively, they may
warning signs are similar to the restrictive fad
recognise they have a problem, but choose to do
dieting that is so commonplace in western culture.
nothing about it. Sometimes the shame around
People close to an individual may notice significant
certain behaviours is so great that the individual
behavioural changes — such as heightened
feels they cannot be honest with anyone about
moodiness, anxiety, stress, depression, secrecy,
what they are doing. This denial, ambivalence,
obsessiveness or anger — without necessarily
or shame can be a source of real confusion and
understanding the causes of the behaviours.
frustration for families and friends who want to
Sometimes these behaviours are mistaken for
support their loved one to get well.
The Eating Disorders Association 5
I’m a hairdresser and have been getting help
to recover from anorexia nervosa. I now
Men get eating know that recovery is possible and support is
disorders too. available. I no longer suffer in silence and no
one else needs to either.
Recovery is possible and support is available.
ÊÊ How do you get someone to a doctor if Eating disorders are not lifestyle choices. No one
they refuse to go? chooses a mental illness, however one can choose
ÊÊ How do you encourage someone to eat to recover. Understanding the nature of eating
when they don’t want to? disorders is vital to recovery. The more eating
disorder information a person, their family, friends
ÊÊ How do you support someone to stop
and health practitioners have, the better their
vomiting or binge eating, when they have
understanding of how to recover and how best
been doing it for many years?
to support someone to recover. Reading recovery
Answers to these questions can be the cornerstone stories and connecting to other people who have
of supporting people to get well. Refusal or been through similar experiences can give hope
ambivalence about getting well, despite the threat and be a great support. Gaining information
to one’s life, highlights eating disorders as serious about eating disorders, trying strategies that have
mental health problems. The terms ‘mental health’, helped others recover, understanding the pitfalls to
‘mental illness’, ‘eating disorder’, ‘eating issues’, avoid, finding the best evidenced based therapies,
‘eating problems’ and ‘psychiatric conditions’ will discovering useful ways to support someone and
be used interchangeably in this booklet as an getting on-going support is encouraged.
acknowledgement of the variety of ways people
describe their problematic eating experiences.
6 Understanding Eating Disorders
A multi-disciplinary approach to recovery is Although some eating disorders present most
recommended including seeing a doctor for commonly among young adolescent women in
a medical assessment and on-going physical cultures influenced by western health and beauty
monitoring, a dietitian for nutrtional advice and ideals, women and men of any age, from any
a therapist for psychological recovery. In the first social and cultural background can develop eating
instance, a doctor is recommended to make an disorders. Over the last decade, there has been an
assessment. If you suspect a child is developing increase in young men, children and middle-aged
an eating disorder, trust your instincts and take people diagnosed with eating disorders.
them to the doctor as soon as possible. If you are
Before a diagnosis, an individual, friends or family
supporting an adult, keep encouraging them to
may sense that something is not quite right. We
go to the doctor. Their life may depend on your
encourage people to trust their instincts and seek
support.
support as soon as possible. Unfortunately, many
The medical profession defines the three most carers have had the experience of being turned
common eating disorders as anorexia nervosa, away from health services because their children
bulimia nervosa, and binge eating disorder, have been assessed as not being ‘ill enough’. We
each with specific diagnostic criteria. People who encourage people to seek health professionals
suffer from complex eating issues and do not meet who understand how to treat eating disorders and
the diagnostic criteria are categorised as having an what is needed to prevent mild cases developing
other specified feeding or eating disorder. into clinical disorders. The time and effort put
into finding the right treatment team will be
worth it. We also encourage doctors and health
professionals to carefully consider the concerns of
People with eating disorders can
individuals and carers.
be any weight and do not have to
be underweight to be suffering the Although most people who develop eating
effects of starvation. Most people disorders will recover, eating disorders can have
with eating disorders are in the serious consequences and often irreversible
healthy weight range or above. medical implications if left untreated. The
‘Obesity’ or being above your healthy sooner professional help is sought and treatment
weight range, is not classified as an commenced, the greater the chance of recovery
eating disorder, however, eating and a happier, more fulfilling life for the individual
disorder services internationally are and their family.
starting to respond to people who A good start is to support adequate, regular and
are above their healthy weight range. nutritious eating, and to take care with our words
and actions. Be conscious of the body image and
health messages we send and the way we talk
There is an increase in the number of people about our own body and eating, and that of others.
with eating disorders, an increase in people who
are overweight or obese, and an increase in the
amount of people who have a negative body
image. With such a diversity of people with eating
issues and body, weight and health concerns, we
need to understand social and cultural factors that
contribute to these problems.
The Eating Disorders Association 7
The Effects of Starvation and Refeeding
Before explaining the nature of eating self-criticism and vomiting. One man left the
disorders, it is very useful for everyone to experiment after developing a dangerous a
understand the effects of starvation on starve–binge–purge cycle.
physical, social and mental health. A well- ÊÊ Stress, anxiety, depression, mood swings,
known starvation study carried out at the irritability, disorganisation, hysteria,
University of Minnesota (Keys et al, 1950) hypochondria, outbursts of anger and severe
highlights that many symptoms of eating emotional distress increased.
disorders are actually symptoms of starvation,
ÊÊ Some men became neurotic and psychotic. One
and that anyone who engages in prolonged
man mutilated himself by amputating three of
and severe dietary restriction can suffer
his fingers with an axe.
serious physical, social and psychological
complications. ÊÊ The men became more withdrawn and isolated,
with growing feelings of social inadequacy.
The study included a six-month period of food
Humour and mateship diminished. Social
restriction for 36 young, healthy, psychologically
contacts became strained and declined, and
normal men. The men ate about half of their
sexual interests drastically reduced.
normal food intake (approximately 1560 calories,
or 6552 kilojoules, a day) and lost about 25 per ÊÊ Concentration, comprehension, alertness and
cent of their former weight. The men were then judgement became increasingly impaired;
gradually renourished during the following three however, there seemed to be no signs of
months. diminished intellectual abilities.
ÊÊ Physical changes included hair loss; dizziness;
Changes in the men after six months of
headaches; hypersensitivity to noise and light;
semi-starvation
increased sensitivity to cold temperatures; cold
ÊÊ Despite little interest in food or food hands and feet; reduced strength; poor motor
preparation prior to the experiment, there was control; gastrointestinal problems; decreased
a dramatic increase in food preoccupation, need for sleep; oedema (excessive fluid causing
including incessant and intrusive thoughts swelling); visual disturbances, such as an
about food, menus, food preparation and inability to focus; aching eyes or seeing ‘spots’;
eating, including dreaming about food. auditory disturbances, such as ringing in the
ÊÊ Abnormal and ritualistic behaviours around ears; and tingling or prickling sensations.
food increased, including making strange food ÊÊ An overall slowing of the body’s physiological
combinations and concoctions. processes occurred, such as decreases in body
ÊÊ There were often conflicting desires between temperature, heart rate, and respiration, as well
wanting to gulp food down ravenously as in basal metabolic rate, which is the amount
and prolonging the time taken to eat food, of energy burned at rest.
sometimes for hours. ÊÊ Most of the men eventually became tired,
ÊÊ A significant increase in the use of salt, spices weak, listless, and apathetic, and complained
and gum chewing. Drinking of coffee and tea of lack of energy. Some maintained exercise
increased so dramatically they had to be limited regimes and some attempted to lose weight by
to nine cups a day! excessive exercise in order to obtain more food,
ÊÊ Some had a complete breakdown in control, or to stop a reduction in their food rations.
unable to stick to their restrictive diets and ÊÊ Apathy also became common, and some men
reported episodes of binge eating followed neglected various aspects of personal hygiene
by emotional upset, self-reproach, disgust, when previously they had taken great care.
8 Understanding Eating DisordersI will feed myself and fight Your body hears
this illness, not feed this everything your
mind says.
illness and fight myself.
During the three months of the renourishment, the study did not identify why. The fact that serious
most of the emotional disturbances, abnormal binge eating developed in a small subgroup of
attitudes and behaviours in regard to food men supports research indicating that people who
continued to be quite severe. Particularly in regularly diet by restricting food, develop binge
the first six weeks, some men actually became eating behaviours.
more depressed, irritable, argumentative and
Although the effects of starvation are very clear
negative than they had been during the semi-
from this study, the men were voluntary research
starvation. After between five and nine months
subjects. If we are to understand why eating
of renourishment, most men had returned to
disorders develop, we also need to understand why
normal body weight, normal eating patterns and
individuals engage in self-imposed starvation.
physical, psychological and social functioning was
restored. A few were still binge eating; although,
The Eating Disorders Association 9Why do People Develop Eating Disorders?
Eating disorders develop from a complex to meet this ideal. Society tells us that to be happy,
interplay of many factors. There is ‘no one’ successful and desirable, we need to meet this single
cause for developing an eating disorder, or beauty ideal, which often is so digitally altered it does
for self-induced starvation and its consequent not reflect anybody’s reality.
effects on the individual. No individual or
Trends in the fashion and media industries have
parent is to blame.
created the ideal as being underweight, despite the
We will highlight some issues that people who health risks of malnutrition. Digital modification of
have recovered identified as contributing factors images has also created an unrealistical over-muscular
to the development of an eating disorder and beauty ideal for men. People have a diversity of
some strategies that have been shared with us backgrounds and come in all shapes and sizes, and
regarding recovery. It is important to note that not most do not physically meet these narrow undrealistic
all conditions are experienced by everyone who has definitions of beauty. Beauty ideals used as a standard
a lived experience of an eating disorder. They are of comparison, can cause dissatisfaction, low self-
meant to give an insight into some commonalities esteem and a lack of self worth when not achieved.
and to offer some understanding about the
The fad diet industry sells the ‘thin as ideal’ concept,
complexities of why a person may develop an
and promotes diet products, artificial sweeteners,
eating disorder, in the context of having no clinical
diet pills, diet shakes, food group restriction, fad
evidence to that end.
super foods, protein shakes, processed food, and the
like, as a way to make money from people’s feelings
Risk factors
of inadequacy. Not everyone who diets goes on to
Societal and cultural factors develop an eating disorder, but most people who have
Eating disorders are most prevalent in western developed an eating disorder have dieted. Weight is
cultures and in those becoming westernised. The seen as ‘the’ measure of health, instead of being one
way our society adversely affects our health is too measure among various health measures.
broad to detail in this booklet, so we have made Other complex factors that influence our body image,
a list of things that culturally contribute to low how we eat and what we think include the following
self-esteem, negative body image, problematic topics, too broad to cover thoroughly in this booklet.
eating behaviours and poor mental health. This
ÊÊ Our culture shames people into improving their
list is not exhaustive. It comes from the common
health at the same time as having a vast array of
stories individuals have shared with us about being
conflicting nutritional information.
affected by eating disorders.
ÊÊ“Fat phobia” promotes the myth that all
We are all influenced by social institutions. Social overweight people are unhealthy, unhappy, eat
institutions include human languages; governments, junk food, and are lazy, which is not the case.
the family, education, health, the law, and business
ÊÊ The advertising industry promotes the idea that we
including advertising, food and media corporations.
are incomplete and need to purchase a product to
Our society affects the way we speak, think and
be happy. This idea of being flawed, or incomplete,
relate to each other.
has seen the demand for cosmetic surgery grow
Societal influences that may affect the development and a proliferation of cosmetic surgery procedures.
of eating disorders include the importance that
ÊÊ Hand-held computers with cameras, the arrival
is placed on our appearance, what is considered
of the digital age, and the general acceptance of
beautiful and what defines healthy eating. The
social media has increased the amount of ‘selfies’
ideals of beauty change over time. The present
being published. How you look and what you are
beauty ideal is considered young, white, tall, thin
doing is documented online.
and/or well-muscled, with flawless skin. Images we
see in popular media have been digitally altered ÊÊ Patriarchy, sexism, racism, homophobia, ageism
10 Understanding Eating Disorders and seeing abled bodies as ideal.Society perpetuates one unrealistic, often digitally
Beauty and Worth altered, beauty ideal that most people don’t measure
Cannot Be Measured up to. Many industries make money from people feeling
inadequate or not good enough. Don’t be bound by
Break free. Start a revolution. society’s beauty ideals. Every body is unique, beautiful
Love your body. and valuable regardless of weight, shape and size.
ÊÊ The sexual objectification of women and children, the age of 15, or joining no-eating clubs at the age
and the increasing sexual objectification of men of eight.
ÊÊ The ‘pornification’ of human relations and sexual According to the annual Mission Australia Youth
relationships. Survey, the largest youth survey in Australia, young
ÊÊ Access to an abundance of food, including people consistently rank body image as being
convenient, unhealthy processed food, which is one of their top three concerns, along with family
high in salt, sugar and trans fats. These are often violence, and drug & alcohol issues.
marketed to children. ÊÊ Body dissatisfaction in Australian adolescents is
ÊÊ Plate and portion sizes have increased in a super- at least 75% for girls and 50% for boys.
size-me fast-food culture. ÊÊ Approximately 50% of girls and 33% of boys
ÊÊ Industrial farming and agriculture produces food in Australia, believe they are overweight, when
with fewer nutirents and encourages an over- they are at a healthy weight and
consumption of animal products. ÊÊ One in five girls try to lose weight through
ÊÊ We moralise about our food, declaring it is ‘good’ dangerous behaviours like not eating for two
or ‘bad’, which manifests in judging ourselves on days, taking laxatives, vomiting and smoking.
what we eat. (Wade and Wilksch, 2009)
ÊÊ Many people judge themselves and others largely Research shows that teaching young people media
on their physical appearance. ‘Body bullying’ literacy about body image helps prevent risk factors
is increasing and has become more harmful, that lead to the development of eating disorders.
particularly in the new realm of cyber bullying. (Wade and Wilksch, 2009). There is also much evidence
ÊÊ The increase in steroid abuse for body image to suggest that health changes motivated by self-
instead of athletic performance enhancement. love and self-compassion are more successful than
those motivated by self-hatred.
ÊÊ 95% of people who engage in restrictive dieting
fail to maintain their weight loss, over time Sociologists have said that people who develop
putting their lost weight back on and more. eating disorders are like the ‘canary in the coal
mine’, in that they indicate how society’s messages
Our social messages are wrong if young men are
are affecting us all. Children are not born hating
turning to protein shakes and steroids for a ‘healthy’
their bodies, they learn that from society. What can
body image ideal, or if young women are saving for
you do to help reverse this process?
cosmetic surgery, having botox birthday parties at
The Eating Disorders Association 11Genetics and personality traits An individual’s temperament or personality may
also indicate a predisposition to developing an
There may be a genetic predisposition to
eating disorder, including the following traits:
eating disorders and research is being gathered
internationally to identify possible links with certain ÊÊ a perfectionist
genes. The Anorexia Nervosa Genetics Initiative ÊÊ high achiever
(ANGI) is a global effort to identify the genes that
ÊÊ disciplined
may contribute to eating disorders. The goal of
the study is to transform our knowledge about the ÊÊ obsessive compulsive
causes of eating disorders and to work towards ÊÊ rigid thinker
greater understanding and ultimately a cure for ÊÊ sensitive
eating disorders. Researchers in the United States,
ÊÊ unassertive or passive
Sweden, Australia, and Denmark will collect clinical
information and blood samples from more than ÊÊ avoidant or detached
8000 individuals, both with and without eating ÊÊ eager to please
disorders. If you have suffered from anorexia ÊÊ anxious
nervosa at any point in your life, you can help
ÊÊ depressive
achieve this goal.
ÊÊ stubborn or strong willed
To become part of this important research go to
www.angi.qimr.edu.au for the online survey. Some of these traits can be seen as assets, however,
when coupled with restrictive dieting they may
Genetics may help explain why eating disorders hasten the adverse effects of starvation and
can develop when there are certain factors contribute to an increase in problematic eating
present like a family history of eating disorders, disorder behaviours.
anxiety, depression, obsessive compulsive disorder,
substance abuse, or other mental health conditions. Triggers for the onset of eating disorders
A predisposition to these issues may explain why
Common factors indicated as contributing to the
one person develops an eating disorder and
onset of eating disorders often involve a change,
another doesn’t. It may explain why some men
loss or trauma of some description, along with
in the starvation study made a full recovery, while
related stress, anxiety, depression and difficult
others developed binge eating. Genetics may
emotions. Despite having genetic or personality
explain if comorbidities develop or are exacerbated
predispositions to developing eating disorders, not
by the effects of starvation. For example, some
everyone with these predispositions will go on
people may have depression before developing an
to develop an eating disorder. Sometimes trigger
eating disorder, while others develop depression as
events are described as contributing to self-
a consequence of their eating disorder. Either way,
starvation and the development of eating disorders,
starvation exacerbates depression and other eating
and eating disorder behaviours are often described
disorders issues, such as binging and purging.
as ways to cope with life stressors.
Brain imaging research indicates that people
who develop anorexia have major differences in Some of the stressors that can trigger eating
their brain functioning compared with control disorders include the following:
populations. Perhaps genetic research can help ÊÊ Major life changes or life stressors:
unlock information about genetic predispositions adolescence, becoming an adult, menopause,
and the effects of starvation on the brain. ageing, changing schools, entering high school
or university, marriage, divorce, changing jobs,
moving house, and so on.
ÊÊ Trauma: death of family member, grief, loss,
bullying, being a victim of crime, sexual
violence, etc.
12 Understanding Eating DisordersÊÊ Occupational stress on body image: acting, emotional, social and behavioural issues. These
performance, dance, modelling, gymnastics, problems are not likely to be the experiences of
athletics, sport and fitness, or careers with an families who actively seek to support their children,
emphasis on your physical appearance. however, some family and peer problems identified
ÊÊ Physical illness that impedes appetite: by people in recovery include:
cystic fibrosis, diabetes, celiac disease, viruses, ÊÊ having to deal with difficult decisions, or
glandular fever or tonsillitis, etc. difficult emotions within the peer group or
family
Triggers can result in food restriction and weight
loss because people do not feel well enough to eat. ÊÊ domestic violence, verbal abuse, sexual abuse,
Losing weight from grief, loss or illness may push relationship difficulties
the individual into a state of malnutrition along ÊÊ family or peer group drug and alcohol issues
with its detrimental effects on the mind and body.
ÊÊ bullying, including body bullying and cyber
Low self-worth, low self-esteem and the inability bullying
to cope with difficult emotions and life stressors, ÊÊ peer pressure to starve, vomit, use harmful
are very common for people with eating disorders. diuretics or steroids
Food can be used as a means to cope emotionally.
ÊÊ pressures around physical appearance, body
Some may feel their eating patterns are the only weight and shape or an over-emphasis on
thing that they can control when other aspects fitness in the family home, at school or in peer
of their life seem out of control. As we receive groups
cultural validation for food restriction and weight
ÊÊ high expectations to succeed in sport, creatively,
loss, people may continue to restrict or control food
academically or with a body image ideal
intake to try and increase positive worth and self
esteem. ÊÊ authoritarian parenting
ÊÊ dynamics that foster a fear of growing up, a
Others may use food to reflect on how they feel, so
desire to disappear or a desire to be noticed
low self-esteem and feeling out of control can be
mirrored in their relationship with food. Starvation, ÊÊ identity confusion driving behaviours to fulfil
binging and purging can reflect a low self-worth a sense of belonging or driving behaviours to
and feelings of guilt, shame or disgust in oneself. express a sense of not belonging
Therefore strict control and loss of control over food ÊÊ role models who do not have a positive body
and compensatory behaviours, can be seen ways to image
cope with upheavals in one’s life, difficult emotions ÊÊ family or peer conflict, confrontation or poor
and a low self-esteem. communication.
Family problems and peer pressure People have described the above issues as
impacting on the development of their eating
Most people with eating disorders come from
disorder, but no one issue or person is
loving, nurturing and functional families with
responsible for an eating disorder. An inability
supportive peer groups. When someone develops
to develop one’s own identity as separate from
an eating disorder the whole family and friendship
parents, other family members or peers, can leave
circle can be affected, because eating disorders
a person unsure of who they are and what they are
often pose a serious threat to life. It is important
capable of. These issues and other complex factors
to understand that no one chooses to develop
underlying the reasons for developing an eating
an eating disorder and neither parents or carers
disorder are best addressed through therapy. Most
are responsible for the development of an eating
families want the best for their loved one and there
disorder. However, there can be a range of peer
is no doubt that supportive friends and family can
and family problems that contribute to complex
be vital to recovery.
The Eating Disorders Association 13Factors that maintain an eating disorder develop around gaining weight. In fact the fear of
gaining weight can be a much stronger motivator
Reinforcing aspects of weight loss creates an
than the reality of being physically compromised or
ambivalence to get well
dying from starvation. Hours can be spent looking
Weight loss can change your relationship to mind, into mirrors with self-disgust. To avoid gaining
body and food in negative ways. For much of weight, compensatory behaviours like purging or
human history food has been scarce and our minds compulsive exercising can develop, despite being
focused on food for our survival. Today, despite an malnourished and medically compromised from
abundance of food in Australia, cultural messages starvation. Although adequate, regular nutrition is
say only a thin body is healthy. Being praised vital for eating disorder recovery, adequate support
for weight loss can give a sense of achievement, is not as simple as saying ‘just eat’ any more than
success, strong will power and feelings of being it is to tell someone with a spider phobia that
special and happy. It is easy to want more validation they step into a room full of spiders to get well.
and continue with restrictive eating, dieting rituals Sometimes fat phobias can be so strong that the
of calorie counting, weighing food, excessive idea of gaining weight in order to get well increases
exercising and engagement with harmful practices anxiety levels, which can be disabling and counter
like vomiting or diuretic abuse. to recovery. Consequently, when starvation has
Developing a mental illness and phobias been the self imposed goal for such a long time the
brain changes in ways that are unhealthy, including
There comes a point when one’s physical and
an ambivalence to get well despite serious risks to
mental health becomes severely compromised by
health.
starvation and related compensatory behaviours.
The effects of starvation on healthy bodies and Starvation–binge–purge cycle
healthy minded people has been well documented, Most people who struggle with eating issues
and demonstrates that levels of anxiety, depression, engage in ‘black-and-white’ thinking. This means
moodiness, obsessiveness, compulsivity, rigidity, moralising food as being ‘good’ or ‘bad’. Food
binging, purging and over-exercising can become morals then affect our behaviour and the way we
exacerbated after severe food restriction. The think about ourselves. We are good when we eat
effects of starvation can develop even if the good food, and we are bad, or failures, when we
individual is not underweight. It is easy to deduct don’t. We alternate between seeing ourselves as
that people who are predisposed with certain either good or bad, perfect or a failure, on or off our
genes or to the personality traits of perfectionism, diet. The dieting industry tries to convince us that
obsessiveness, rigid thinking or anxiety for example, eating one piece of anything ‘bad’ will make us fat,
may experience the effects of starvation more and if we are fat we are bad. In reality, one piece of
readily or intensely. Understandably, the intellect is anything doesn’t make anybody fat. And fat doesn’t
one of the last qualities to be affected as we have mean bad. Absolutely everybody is valuable.
evolved from people who needed their intellect in
It is a fairly common story that when a person
time of food scarcity. It is common for a person to
feels pressured to lose weight or to get healthy
be very unwell from starvation but continue to be a
they immediately think of restricting food or only
high academic achiever.
eating ‘good’ food. What constitutes good or bad
For some individuals who develop eating disorders, food can depend on the fad diet being promoted
their mental health can be so compromised at the time and sometimes staple food such as
that they develop an increasingly negative body bread and essential fats are considered ‘bad’. Most
image or a distorted body image, for example the people cannot maintain severe food restriction and
thinner they get, the larger they feel. Delusions extreme hunger. It is very common for people to
can manifest, like the belief you will absorb eat too quickly and eat too much when extremely
calories by holding food, or that water or the hungry. When starvation leads to binging it can
air you breathe contains calories. Phobias can evoke feelings of guilt and self-loathing. ‘Breaking’
14 Understanding Eating Disordersour diet and eating something ‘bad’ means we have of the cancer. Similarly, it can be useful to see the
‘blown it’ leading to feelings of being out of control. eating disorder as the reason for the individual’s ill
Of course, binging makes one feel ‘bad’ and so health, not the individual or the family being the
the cycle to be ‘good’, get healthy and lose weight reason for it. For example, when someone is in a
begins again, usually on a Monday. Binging can state of high anxiety at a weigh in, thinking they
also lead to purging behaviours like compensatory have gained weight when in reality they have lost
exercise, vomiting or laxative abuse with an ethos weight, it offers an opportunity to highlight how the
of redemption to ‘rid’ the amount of food eaten in illness or the eating disorder affects their perception.
the binge. When someone throws a tantrum about eating a
meal, it often means the illness is having a powerful
People can spend decades being on and off diets
affect at that moment. With meal support it can be
and, as a consequence, feeling inadequate. The
useful to think we need to support our child to eat
diet–binge–purge cycle is maintained because
more than the illness allows them to eat. It is the
this way of life can become habitual and can help
illness that can make someone with anorexia upset
deal with underlying uncomfortable feelings. For
about the weight restoration that is needed for their
example, purging can bring with it a feeling of self-
survival. This separation can help carers understand
disgust, but also a sense of relief. It can be easy to
the illness and also help the individual separate
fall into familiar coping patterns and can mean an
the illness from their identity. Glimpses of recovery
inability to see yourself changing or getting better.
are apparent when the individual’s true personality
Strong identity with the eating disorder returns as a result of regular, adequate nutrition.
Someone with an eating disorder is often spending Malnutrition
a lot of time obsessing about their weight and
Eating disorders are extremely complex medical
shape, and about food. Eating disorders may
conditions, exacerbated by the profound effects
be masking underlying issues, including why
of malnutrition within the brain. Only recently
self-starvation was imposed. Starvation can shift
have scientists had brain-imaging tools to examine
the focus of one’s life to incessant and intrusive
the neurobiology of eating disorders. Starvation
thoughts about food and eating disordered
or malnutrition, binging and purging and other
behaviour. These incessant thoughts are often
harmful behaviours can be maintained because of
interpreted as the ‘self’ rather than seeing the
the physiological responses compounding mental
thoughts and behaviours as being the result of the
illness and problematic behaviours. For example,
effects of starvation. The eating disordered thoughts
the starving brain loses volume and regresses, and
or behaviours can become a means of coping with
vitamin and mineral deficiencies can create hormone
other issues, and can create a false sense of security
loss, electrolyte imbalances, altered serotonin and
and perceived control over life.
dopamine metabolism, and sleep disruption, which
Separating or externalising the eating disordered can affect our fear and stress response to food,
thoughts and related behaviours can be very useful anxiety, mood, body image distortion and further
in recovery. We all have negative thoughts but mental health problems. More research is being
often they are balanced with positive thoughts. conducted to ascertain the causes of differences in
Sometimes when someone develops an eating brain imaging for people with eating disorders in
disorder, the healthy self, true self, or the positive hope for new treatments. Many people with eating
thoughts are overpowered by incessant critical disorders are relieved to know that their brains are
thoughts that rule one’s behaviour. When these working differently to control groups. The discovery
negative thoughts become fused with one’s identity, of neuroplasticity, that our thoughts can change the
there can be a denial that there is a problem and an structure and function of our brains, is an important
ambivalence to change. breakthrough in our understanding of the brain and
If a child is affected by a cancerous tumour, it is easy means that despite the effects of eating disorders on
to see that the child’s ill health is a consequence the brain, most people can and do recover.
The Eating Disorders Association 15Eating disorders
run deep
The deeper you sink under the
weight of an eating disorder
the darker it gets. It’s like being
tied to an anchor, it happens so
fast that it blindsides you. The
impact of the negative rigid
thinking of an eating disorder,
interprets things as all or
nothing, black or white, perfect
or a failure, rather than a sea of
possibility.
Recovery can mean finding
your worth and realising that
no one is perfect.
16 Understanding Eating Disorders2
Clinical Diagnosis Of Eating Disorders
What Is Anorexia Nervosa?
The most obvious characteristic of someone There are two subtypes of anorexia nervosa:
who has developed anorexia nervosa is 1. Restricting type
significant, deliberate, self-starvation and During the last three months, the individual
consequent weight loss, together with an has not engaged in recurrent episodes of
intense fear of being fat irrespective of their binge eating or purging behaviour (specifically,
current weight and shape. Initially, behaviour self-induced vomiting, or the misuse of
around developing anorexia may be difficult laxatives, diuretics, or enemas). This subtype
to distinguish from normal dieting, but it describes presentations in which weight loss is
soon becomes obvious that the behaviour has accomplished primarily through dieting, fasting,
an abnormal drive and resolve to it, and it is and/or excessive exercise.
relentlessness. Anorexia nervosa is a serious
2. Binge eating or purging type
and complex mental health condition and
During the last three months, the individual has
people may die if it is left untreated.
engaged in recurrent episodes of binge eating
To be diagnosed with anorexia nervosa using the or purging behaviour (specifically self-induced
DSM-5 Diagnostic tool, a person will meet the vomiting, or the misuse of laxatives, diuretics, or
following criteria: enemas).
ÊÊ Restriction of energy intake relative to The minimum level of severity is based, for adults,
requirements, leading to a significantly on current body mass index (BMI) or, for children
low body weight in the context of age, and adolescents, on BMI percentile. The ranges
sex, developmental trajectory, and physical below are derived from World Health Organization
health. Significantly low weight is defined as categories for thinness in adults. For children and
a weight that is less than minimally normal adolescents, corresponding BMI percentiles should
or, for children and adolescents, less than that be used. The level of severity may be increased to
minimally expected. reflect clinical symptoms, the degree of functional
ÊÊ Intense fear of gaining weight or becoming disability, and the need for supervision.
fat, or persistent behaviour that interferes with
Mild Anorexia: ≥ 17 BMI
weight gain, even though the person is a at
significantly low weight. Moderate Anorexia: 16–16.99 BMI
ÊÊ Disturbance in the way in which one’s body Severe Anorexia: 15–15.99 BMI
weight or shape is experienced, undue Extreme Anorexia: < 15 BMI
influence of body weight or shape on self-
(American Psychiatric Association, 2013)
evaluation, or persistent lack of recognition of
the seriousness of the current low body weight.
The Eating Disorders Association 17BMI vs Body Mass Composition
Body Mass Index ( BMI ) is a measurement of a ÊÊ fine hair appearing on face and body (bodies
person’s weight in relation to their height. response to stay warm)
The world Health Organisation BMI scale indicates; ÊÊ loss or disturbance of menstrual periods in
females
Underweight: < 18.5 BMI
ÊÊ decreased libido.
Health weight range: 18.5–25 BMI
Psychological signs
Overweight: 25–30 BMI
ÊÊ preoccupation with eating, food, body shape
Obese: 30 + BMI and weight
The problem with BMI is that it does not reflect ÊÊ feeling anxious and/or irritable around meal
the changes in body composition when weight times
changes. Body mass composition indicates what ÊÊ an intense fear of gaining weight
percentage of the body is fat, water, protein,
ÊÊ refusal to maintain a normal body weight for
mineral, bones, organs, etc. Malnutrition can be
the person’s age and height
defined as a loss of body cell mass which includes
non-fat cellular components of tissues, skeletal ÊÊ depression and anxiety
muscle, internal organs, blood and brain. The BMI ÊÊ slowing down of thinking and an increased
measure does not give you this figure. For example, difficulty concentrating
two people with a BMI of 20 may have different
ÊÊ ‘black-and-white’ thinking or rigid thoughts
body compositions, one may be suffering from
about food being good or bad, which extends
malnutrition and the other may not.
to feelings of being perfect or a failure
Warning signs of anorexia nervosa ÊÊ having a distorted body image (for example,
seeing themselves as fat when in reality they are
Contrary to popular myths, most people with
underweight)
anorexia nervosa do eat, just not enough to sustain
themselves. Although the term ‘anorexia nervosa’ ÊÊ low self esteem
is derived from the Greek word meaning loss of ÊÊ increased sensitivity to comments relating to
appetite, a person can retain an intense appetite food, weight, body shape, exercise
and interest in food. ÊÊ extreme body image dissatisfaction.
The warning signs of anorexia nervosa can be Behavioural signs
physical, psychological and behavioural and include:
ÊÊ dieting behaviour, for example, fasting, skipping
Physical signs meals, counting calories/kilojoules, and avoiding
ÊÊ rapid weight loss or frequent changes in weight food groups such as fats and carbohydrates.
Becoming a vegetarian is common, but is often
ÊÊ fainting or dizziness
more aligned with restricting food groups than
ÊÊ feeling cold most of the time, even in warm for animal liberation reasons. Other radical
weather (caused by poor circulation) changes can include suddenly disliking food
ÊÊ feeling bloated, constipated, or developing they have always enjoyed, and reporting of
intolerances to certain foods food allergies and intolerances
ÊÊ feeling tired, lethargic and not sleeping well ÊÊ laxatives, appetite suppressants, enemas and
ÊÊ facial changes to pale looking, sunken eyes, diuretics misuse
brittle hair
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