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In my early days as a therapist, I was something of an anomaly; now in view of the publicity given to Princess Diana following the revelation of her bulimia, and other celebrity sufferers, the press appears to have rediscovered eating disorders as an issue of national interest. My colleagues and I are pleased but not entirely surprised to find the subject we have dealt with for may years hot news. We hope that this surge of interest can be directed toward a better understanding of these distressing problems by sufferers and bystanders alike rather than concentrating on their more sensational aspects.
Firstly, I would like to address the origin of all eating difficulties, which partly relates to the culture in which they arise. Although there are reports of anorexia nervosa dating back to the 1800s, eating disorders are largely a cultural phenomenon. They do not exist in third world countries where there is generally insufficient food. Bulimia nervosa became a diagnostic entity only 10 years ago, and the more common Binge Eating Disorder (which you may know of as compulsive overeating) was so named only recently. We do not have any real data about the growth of eating disorders in the community but this is what we think is happening.
Several very important things have affected our eating behaviour in the last half century. The first is the availability of food. In a physical sense (and this arises from many millennia of uncertainly over the availability of food) we are biologically determined to gain weight in times of plenty (in other words people who do not tend to gain weight have been regarded as genetically unsuitable) for survival and we are, therefore, gaining weight, and maturing earlier.
We are also being urged to eat far more than we need by the incessant messages in society. These messages urge us to eat for all sorts of secondary reasons like relaxation or recreation. Watching the television for only two hours each day exposes us to over 20,000 messages each year encouraging us to eat.
At the same time we are being asked to deny ourselves. A recipe for chocolate cake in any magazine is likely to be side by side with an article on how to lose body fat, and if you take no notice of these pressures and you are not jogging every night you would be considered at least unwise, and at worse lazy, inadequate, and a sloth.
Women have always been expected to change their shape to suit the fashion of the day. We have seen this in an extreme form among Chinese women in olden days whose feet were bound: we saw gross malformations resulting from the use of stays in the 18th century. But never at any time in our history have women been expected to be so thin. This does not just apply to women - I think it is true to say that leanness becomes more valued generally as we move towards cultural development and towards higher social strata. Twenty years ago a womans role model would be Marilyn Monroe - who would undoubtedly be advised to go away and lose some weight if she tried for a job today. A study of centrefolds in Playboy magazine shows that the ideal size has come relentlessly down over the years and is now 25 per cent smaller than it was. Role models such as Farrah Fawcett, Princess Diana and Jane Fonda have less than 10 per cent body fat. The normal range for a women is between 15 and 18 per cent body fat, and one has to speculate what many models and personalities have to do to themselves, and for how long, to keep that way. Most of them have eating disorders - they are not lucky as people think they are - so one has to ask why are we trying to look like that?
This pressure to be thin, especially on women, has resulted in a pursuit of the ideal body that experts compare to a feeding frenzy in which there is an insatiable desire for new information, devices, books and medicines that will make us slimmer, fitter and more aesthetically appealing.
This behaviour is fuelled by two hidden assumptions:
1. that weight and shape can be changed as desired with the right diet, and
2. that many rewards are associated with achieving the ideal body.
Recent research suggests that body weight and size however are not totally under environmental control, for example genetic predisposition, resting metabolic rate, and fat cell number can all influence the degree to which body weight and shape can be altered. Dieting is in fact remarkably unsuccessful as a weight control strategy. Only between 3 and 5 per cent of losers maintain weight loss. Certain kinds of diet have even lower success rates, for example where diet pills are used, or liquid meal replacements, or diets eliminating important nutritional elements like the Hip and Thigh Diet. This has more to do with the built in disadvantages of dieting rather than moral deficiencies of dieters themselves, and I think it would be useful at this point to define the side effects of dieting among other things so that you will better understand the usual origin of eating disorders.
In brief, dieting has profound physiological and emotional side effects. Dieting depresses the resting metabolic rate and brings about chemical changes in the body which seek to protect fat at the expense of body tissue which is metabolically more active. Although the mechanisms of set weight are not well defined, dieting is thought to move the thermostat in an upward direction which is why people usually regain just a bit more than they have lost. There is strong evidence that repeated cycles of dieting and regaining (yo-yo dieting) are associated with increasing difficulty in weight loss together with an increased tendency to gain, as well as increased morbidity and mortality.
Dieting is associated with depression, preoccupation with food, and social withdrawal. Finally and significantly dieting also leads directly to lack of control with food. Studies show that fat or thin people on a diet find it hard to stop eating when full and show marked preferences for foods rich in sugar and fat. In subjects not over concerned with weight gain these symptoms may take up to 5 months to subside. We will note the importance of this in due course.
One consequence of pursuing the ideal and falling short is body dissatisfaction, and this is what is at the root of most eating disorders. Since most of us wish to be a bit thinner, it is hard to define normal eating any more. Most of have a ticker tape running through our heads....for example "I ate too much last night so I will skip breakfast today" or "I am going out tonight so Id better have fruit for lunch today" However most people are not aware of the point at which they accept that food has become a struggle. One exception to this of course is anorexia where a feature of the illness is denial that anything is wrong.
I am sure that you are all familiar with anorexia. Nothing is more fascinating than someone who seems to be deliberately and relentlessly starving herself to death. Nothing is more terrifying for friends and family who stand helplessly by. Nothing is more frustrating for the professional counsellor who discovers that reason, persuasion and brute force all equally meet an impenetrable wall of denial, lies, evasions and manipulation.
There is a vast literature about anorexia and its aetiology. The syndrome is now better understood. It would appear that physiological changes associated with starving are responsible for many of the emotional changes which perpetuate the illness. For example bloatedness, which leads the anorectic to experience herself as fat, is a real physical effect of eating after a period of starvation. Similarly, the cognitive shifts, (which cause the anorexic to see a fat mirror image) arise as a neurotic defence against giving up control and thereby experiencing a loss of self.
Only 3 per cent of women are anorexic - only 5 in 100 reporting for treatment are men, and the average age for anorexia is 16 years. Additionally, some anorexics also binge eat sporadically and then purge, but this is not the same as normal weight bulimia. Recovery rates are associated with length of time before the illness is addressed, which emphasises the importance of bringing the condition to focus should you suspect that it is happening.
Much more common is compulsive overeating, recently named Binge Eating Disorder, which represents a major obsessional preoccupation with food. Estimates of presence in the population vary. In one study, 40 percent of women interviewed outside a family planning clinic confessed to having had at least one binge in the last month but when stricter definitions of a binge were applied (high calories etc) the figure dropped to around 12 per cent. This disorder affects men and women of all ages but it is mostly women who seek help for it. It is tempting to think of this as purely an emotional problem. My clients will say to me "I want you to get to the root of it".
There is always dieting in the history and most experts now agree that compulsive eating is a direct outcome of dieting due to the effects described before. The cravings for food and the emotional highs and lows associated with this disorder can be in part attributed to swings in blood glucose (or blood insulin) levels associated with eating foods rich in refined carbohydrate.
Compulsive eating can include picking, continuous eating (grazing) or full blown bingeing of large amounts of food. To satisfy the conditions of being a disorder, the behaviour usually happens in secret, is accompanied by guilt and remorse, extreme sensitivity to rule breaking - the binger will typically say " Ive blown it I might as well carry on until tomorrow or next week or next month or whatever" - and there will be patterns of making unrealistic promises: " I will never eat chocolate again or I will always be good if I can lose some weight". There will also be strenuous efforts to lose weight, including starving, exercising, spending fortunes on diet books, taking pills etc. While compulsive overeating has physical antecedents it rapidly becomes an addiction - a way of dealing with feelings, and coping with the stresses and strains of everyday life.
It has similar features to chemical addiction. In each case the sufferer has preoccupation with a substance together with loss of control over it. Each has a need to use that substance to cope with stress, and each protects the addiction by keeping it secret. It has similar features to obsessive compulsive disorders (ritualisation) but not all bingers register high on obsessionality. It is not a moral weakness based on lack of willpower - many binge eaters are competent people leading highly successful lives.
An ominous variant of binge eating disorder, suggested above, is where people deal with the effects of binge eating by making themselves sick or taking laxatives. We call this bulimia nervosa and it afflicts between 4 and 10 per cent of women, higher up the social and educational scale. Five in one hundred of people seeking treatment for bulimia are men. The average age of people seeking treatment is 18 but bulimia, like Binge Eating Disorder, affects people of all ages. Bulimia also exerts a fascination on the minds of people who are repelled by the quantities taken in which are subsequently expelled
There are some glamorous members of the Bulimia club but it is not a glamorous illness. The most common complication is a disturbance of the electrolyte balance in the body. Abnormalities of potassium levels are of particular concern since these are most affected by purging, causing dehydration and giving rise to irreversible damage to heart, kidney and brain.
Fatigue, depression, sore muscles, faintness, sensitivity to cold and a tendency to gain weight easily are also common symptoms attributed to large fluctuations in blood sugar levels as a result of bingeing on high sugar foods. It is also believed that vomiting destroys the complex message or satiety system which enables people to stop eating at the right time. The brain, never knowing whether food will be retained encourages continual overeating in the hope that some of this will eventually be absorbed.
The behaviour causes a great deal of irritation of the gastrointestinal tract. Swelling of the salivary glands and dental erosion are common. There may be ruptures of the oesophagus and functional disorders of the stomach. In rare cases the stomach may swell and the individual may be unable to vomit necessitating emergency medical help. Finally, laxatives are ineffective in reducing calorie absorption and yet few bulimics are aware that this is so. Abuse can permanently damage the bowel. Laxative abusers have long term problems with bloating, constipation and diarrhoea long after stopping their use.
These effects can be life threatening and little is known about the long term effects of purging on reproductivity and mortality.
It would be incorrect to consider bulimia simply as a psychological illness based on the fear of fat. Since vomiting has stress relieving properties bulimic individuals become hooked on the bingeing and purging behaviour and use it as a way of coping with life. And they make adjustments in their lives to accommodate it. Then, gradually, healthy coping skills are given up and replaced with bulimic ones. This behaviour is maintained despite negative social and legal consequences - many steal or shoplift to support their habit.
Overcoming an eating problem is a lengthy and often complex process, and may involve behavioural changes found threatening to a patient, such as the giving up of a dream to be the ideal shape. The patient will often reveal details of her or his behaviour which she will consider shameful - and at no time must the therapist be judgmental. It is always necessary in the beginning to explore the beliefs and expectations of clients - how would they like to be eating, how much weight do they want to lose, what kind of relationship do they wish to have with food, and, are these expectations realistic. Anorexics are notably poor compliers, but among a group successfully treated, none of them wanted to be helped at the outset, but within one year almost 90% of them admitted that they had been in desperate need of treatment. This presents a case for coercing anorexics into treatment programmes.
Most specialists in the field believe that behavioural therapy has much to offer for all eating disorders, from anorexia to weight reduction for obesity. Behaviour therapy was pioneered by Stirt in the 60s and, broadly speaking, it attempts to replace dysfunctional habits with new appropriate ones, and aims to help people become environment planners rather than victims of forces they feel to be out of their control. Indeed most people who overcome their eating problem make permanent changes in the way they shop for food, cook it and store it, use it in family rituals, and indulge in activities which are incompatible with eating.
The elements of behaviour therapy appropriate for the treatment of eating disorders are firstly, the keeping of a diary to monitor food intake, daily activities and reporting of emotional states. The aim is to help the patient become his or her own therapist, to observe their behaviour rather than just experience it, and to search for the patterns contained in their behaviour.
Secondly, but of equal importance, we aim to have our patients give up dieting for the duration of treatment, and we advise a programme of regular frequent feedings, high in complex carbohydrates and low in sugar and stimulants such as caffeine and alcohol. This is to help with the stabilisation of blood sugar levels which can be significantly disrupted as a result of feasting and fasting. It is necessary to motivate people by a combination of judicious counselling and re education, and since clients often remember little of what is said in a session I give them handouts of essential information to take home with them or lend them appropriate books. It is important for a bulimic to know, for example, that weight loss through purging is invariably temporary. And it is important for an on-off dieter to realise that a long period of learning to cut down gradually is more slimming than bursts of starving followed by rebound binge eating, which often makes the problem worse.
Behaviour therapy also teaches stimulus control techniques, (avoiding or managing trigger situations) - helping people to accept their vulnerability and reduce their exposure to threatening food situations.
Lastly, we explore and adjust where necessary all of the factors in a patients lifestyle which maintain the eating problem. This could involve a change of job, reducing stress, building general levels of health, and so on.
As the behavioural methods start to take effect, underlying emotional issues may come to light. For example the eating diaries may reveal the existence of certain mood states prior to eating and it may be useful to investigate with dynamic psychotherapy. Alternatively the charts may reveal a patients eating to be largely dictated by the influences of other people, which points to a need for assertion training. Research has indicated that eating disordered patients are markedly low in self esteem - where this expresses itself in poor body image, it of course makes them vulnerable to pressures to diet.
Teaching the skills of personal growth is therefore an important part of our treatment programme. Developing an inner sense of self esteem is perhaps the single most important emotional predictor of a cure.
A recent adjunct to behavioural programmes is the addition of teaching problem solving methods otherwise known as Relapse Prevention. These techniques focus largely on the cognitive aspects of each persons problem, in that they help people to identify their negative thoughts about food and eating and about their own personal attributes. Anyone trying to overcome a long standing eating habit, and doing daily battle with cravings or impulses to starve, will have times when things go wrong, and a lapse might be the start of a slippery slope " Ive blown it, I may as well finish the packet and start again tomorrow / next Monday etc". "Im so weak / Im just greedy etc." They call themselves names and feel worse so they end up eating more and try afterwards to starve, or they vomit. Therapy consists of teaching them about the process of relapse and the self defeating self talk and behaviour which accompanies relapse, and the techniques to use to minimise the damage. We can teach them how to avoid dangerous situations or find more constructive ways of coping.
The cognitive approach pioneered by a man called Aaron Beck helps them to identify and challenge their negative thoughts - to be kinder to themselves and examine their assumptions about the kind of people they have to be; the things that are important in their lives. This of course will involve examination of the social pressures of dieting and their own weight goals.
Research into the eating disorders is now continuing apace and we are learning much about the role of the body in maintaining eating dysfunction. There is a hormone - CCK- which is implicated in satiety, and we are beginning to explore the relationship between several brain chemicals, including Serotonin and Melatonin, and the craving for carbohydrates. There is interest in the relationship between hyper-insulinism and cravings, and there are drugs which switch off some forms of compulsive behaviour, including bulimia, although at present the behaviour returns when the person stops taking the drug. Both bulimia and grazing-driven obesity respond, in certain cases, to Imipramine based antidepressants; but the control is only maintained while the drug is being taken.
Despite feverish attempts to find cure-all drug therapies for problems of eating and weight control, it is the psychological procedures I have just described which have the best long terms outcomes for eating control. Such treatments take time and patience, but the control achieved is likely to be more resistant to relapse, and is currently the best defence against a culture which is food toxic and ever more geared to the pursuit of eating.
Information provided by Deanne Jade
Founder of the National Centre For Eating Disorders
Deanne is acknowledged as one of the UKs leading experts on Eating Disorders. She is a Psychologist, Master Practitioner of NLP and a Member of the European Council on Eating Disorders and the DCP Special Interest Group for Eating Disorders.
The National Centre for Eating Disorders
Tel: 01372 469 493 Fax: 01372 469 550