Prof. Jim Lucey was a guest on Today with Pat Kenny on RTE Radio 1 on Monday the 13th of February. Listen to the podcast or read Jim's blog below
Eating Disorders are not simply disorders of eating, nor a misguided attempt to be thin nor about vanity. Eating disorders are serious mental health disorders
Does the ultra-slender ideal-body image portrayed in the media contribute to the development of eating disorders?
Who is at risk of developing an eating disorder?
Eating disorders are serious and potentially life threatening mental health disorders. People with eating disorders judge their self worth predominantly or entirely in terms of their shape and weight and their ability to control their shape and weight. In contrast, the majority of people appraise their self-worth on multiple domains of their life (relationships, work, creativity etc.). This core thinking problem in eating disorders results in an intense preoccupation with weight and leads to marked changes in eating, exercise interest and use of other weight compensatory behaviors. These thoughts and behaviours become an unhealthy preoccupation and become severe enough to interfere with the person’s functioning and relationships.
Eating disorders require appropriate assessment and treatment to address the complex physical, nutritional, psychological and mental health needs of those suffering with these disorders. Early detection and treatment has been found to have a better outcome.
All age groups, gender, socio-economic and cultural back-ground can be affected by eating disorders, though adolescents and young woman are at heightened risk.
A person with an eating disorder can be under-weight, normal weight or over-weight.
In Western countries 5-10% of young women have some form of eating problems, although 1-3% has an eating disorder.
Anorexia Nervosa is characterized by significant restriction of food, excessive weight loss, dangerously low body weight, intense fear of weight gain and thinking one is over-weight despite being seriously underweight.
Siobhan is 19 years old college student. She is in second year of college. Things have been difficult at home, her father had recently been diagnosed with terminal cancer, she was finding college really tough and she was not really coping with living away from her family. When she went home on the weekends her family noticed that she was getting thinner. Her mother also noticed that she was not finishing her meals and if encouraged to do so, Siobhan would get up from the table and return to her room. She started to isolate her-self from her family and friends. She was not coming home so frequently. Siobhan had not been home for three weeks. Her mother received an unexpected call from an A&E department. Siobhan collapsed at college. She was admitted to the A&E department for re-hydration and monitoring. Siobhan was only eating apples at this stage. She was having one for breakfast, two for lunch and dinner. Siobhan did not use any other weight loss behavior. A psychiatrist assessed her in the A&E department and diagnosed her with Anorexia nervosa. Siobhan told the psychiatrist that restriction of food and control of her weight was the only thing that she had control of her in life. She felt that everything else around her was too distressing and she could not cope with everything that was going on. Her weight was 32 kgs.
Siobhan was treated initially as an inpatient in a specialized unit where her physical risk could be monitored and where she was able to receive help with initial weight restoration and meal support. Following a 6 week inpatient programme she attended a day programme where she found the group programmes very useful, particularly the self-esteem groups. She currently continues to attend the day programme and also attends college. Siobhan weight is slowly increasing. She is receiving help on alternative ways to cope with stressors and finds the support from the team particularly around meals beneficial. She is learning to cope with her father’s illness and she continues everyday to try and not use restriction of food as a way to cope with her difficulties
Bulimia Nervosa is diagnosed when a large amount of food (more than most people would eat in a meal) is eaten over a short period of time which is then followed by the use of compensatory weight loss behavior: vomiting, use of laxatives over-exercising or frequent dieting or fasting. People with bulimia nervosa may be very secretive and ashamed of their bingeing and compensatory behavior.
Patricia is a 23 year old pharmacist who could no longer tolerate her regular and secretive binges. For the last six months she was eating Chinese take-out for two, a tub of Hagan-Daz, big bag of Doritos, and a family size packet of biscuits and 2L of diet coke nearly every other day. She consumed the food within the hour and shortly following her binge she would make herself sick. The day following a binge, she used to feel disgusted with herself and punished herself by restricting. She regularly used laxatives as she thought this would help her lose weight. She longed to be able to diet as her weight was constantly fluctuating; she could only restrict and adhere to a diet for no more than two days after which she developed a strong urge to binge. She was teased and bullied in secondary school for her looks as she suffered from acne. She became very self-conscious about her looks and avoided being in any relationships.
She thought about food all day and become very depressed. She started drinking to help her cope with her low mood and eating difficulties, eventually resulting in a drink-driving charge. She took time off work and received treatment. She availed of psychological, psychiatric and nutritional treatment. She was put on a meal plan to try and normalise her eating pattern to help her with the vicious cycle of restricting and binging. She required an antidepressant for the treatment of her depression and received individual psychotherapy. Pat has better control of her binging behavior, she no longer diets rather sticks to her meal plan. She continues to attend regular psychotherapy to work on her self-esteem problems, eating disorder behaviours and coping skills.
Binge Eating Disorder is characterized by periods of uncontrolled, impulsive or continuous eating to the point of being uncomfortably full. There is usually no compensatory behavior after bingeing which may result in obesity. Repeated binges often result in feelings of shame and self-hatred. Many people with binge eating disorders may also suffer with depression and alcohol problems.
Eamonn is a 32 year single man who developed NIDDM and hypertension. His diabetic team told him that if he could not get his diabetes under control with his current medications they would have to consider insulin. They advised him to increase exercise and to lose weight. This was the last thing Eamonn wanted to hear. Eamonn currently weighed 120kgs. He was too ashamed to tell his diabetic team that he had a problem with food. He was trying to diet, though dieting seemed to make things worse for him.
He had difficulties with his weight for as long as he could remember. He was never bullied as a child because he was overweight though his friends and family made joking remarks to him about his weight, though as he got older he become much more sensitive about the comments. Girls at school and later at college only saw him as a friend or their ‘big buddy’. They would not consider him as anything more. From his mid-teens Eamon coped with stress and bad days by turning to food. Eamonn would soothe himself with food. His habit of turning to food started to lead to binges, initially occurring 3-4 times per week though gradually occurring anytime he become down or was not coping which could be some days more than once. His binges varied though predominantly consisted of eating 3-4 chocolate bars, within a 10min period. This pattern of eating on a bad day could occur 2-3 times over the course of the day. Eamonn also tried many diets. The more he tried to diet, the worse his binging behavior became. He could only tolerate 2-3 days of dieting after which he lost control and stated to binge. Sometimes these binges could be large and he ate till he felt he was going to burst (his large binges would consist of anything he could find in the fridge/cupboards at the time).
He decided to see his general practitioner as he was feeling desperate at this stage. He wanted help to lose weight, though could not do this on his own. His gp sent him to a specialist team. He received a diagnosis of binge eating. He was put on a meal plan which recommended that he have regular meals and snacks to prevent the restriction related binging behavior. He also started psychological work where he learnt to identify triggers for his binge eating and methods to help prevent binges. By eating regular meals and stopping dieting and having better control of his bingeing, Eamonn has steadly lost weight. He has also incorporated exercise into his daily routine to also help this process. Control of his binging has also led to better glycaemic control. On his last visit his diabetic team were encouraged with his progress. Insulin treatment has been put on hold.
The majority of people who have eating disorders may not be diagnosed with anorexia, bulimia or binge eating disorder and these individuals may be found to have Eating Disorder Not Otherwise Specified (EDNOS). These people may have some features of the various eating disorders. EDNOS are equally serious disorders which also require professional help.
It may appear that each of these disorders is distinct. However, these disorders have much in common and individuals may migrate between the disorders.
Amy is 16 years old. She became self conscious about her weight in 3rd year and was also feeling very stressed about her junior cert. She began to stop eating junk food and stopped eating chocolate and crisps. Then she began to stop eating her school lunch and noticed that she didn’t miss it. She stopped eating all carbohydrates and then started skipping breakfast. At dinner time she complained of feeling bloated and asked for a smaller portion. She became obsessed with counting calories and started measuring out some of her food portions using a scale. She began walking for an hour every day and doing 100 sit ups at home by her bed. She lost 2 stone quickly but still felt she needed to lose weight. She stopped going out with her friends as she didn’t want to eat in front of them as she was afraid they would think she was greedy. She became more tired and started feeling the cold a lot. She began to get dizzy episodes and feel fat. She couldn’t concentrate in school and started becoming overwhelmed about her exams. Previously Amy was an excellent student and always had her work done to a high standard. She found out that the group of girls that she hung out with had a party and didn’t invite her and she felt that she didn’t fit in well with this group as she didn’t have a boyfriend.
While out for her walk Amy collapsed and was brought to A + E. Her bp and pulse were low and she was told by the doctors that she was severely underweight. She was very upset as she felt fat and wanted to lose more weight and she didn’t believe this was true. She went home with her parents but was unable to eat her meals with them and they brought her for an assessment for EDP. Her parents told her that she couldn't go back to school until she gained weight and she agreed to get some help but didn’t agree that she needed to gain weight. She weighed 6 stone at this stage.
She began the eating disorders programme in Willowgrove. She was seen by the dietician, a psychotherapist, nursing and medical team. Amy and her parents were also seen by the family therapist. The team explained to her that the reason she was so tired and weak was because she was severely malnourished and that she needed food for nutrition to help her become well enough to go to school. She agreed that she didn’t have a healthy attitude towards food or her weight and when she understood that she would get a lot of support in coping with the distressing thoughts she had about eating and her weight she felt less scared of trying the programme.
She had a meal plan that included 3 meals supervised and 3 ensure high calorie drinks. At first she was afraid that the staff was trying to make her fat and she thought the portions were too big. However once she started this and saw that her weight gradually went up in a step wise fashion she was less afraid it would go out of control even though she still felt she was fat. By talking to the nurses and having psychotherapy she realised that she had been using food as a way of coping with her low self esteem, difficulties that she had with her peers and exam stress. She started talking about some of the low mood she had experienced and feelings that she wasn't as good as some of the other girls as they had excluded her from nights out and she had never had a boyfriend. Amy started telling her parents about some of the fears that she had and was surprised to hear that they had noticed the days she had come home from school stressed but didn’t want to talk to them.
Amy managed to restore her weight to a healthy body mass index and also managed to learn other coping skills when upset or sad. Her communication at home with her parents improved and she started having the confidence to go out with her friends. She went back to school and did her Junior Cert. After been in hospital she attended the outpatient clinic for a number of months for therapy and she found this helped a lot as she had somewhere to discuss any issues that she had and after 6 months she no longer needed any support and was discharged.
There is no single cause for the development of an eating disorder. Eating disorders are caused by a combination of genetic, biological, psychological, interpersonal and social factors. Those that display a number of these factors may be at heightened risk of developing an eating disorder.
Genetic factors: Studies suggest that anorexia, bulimia and binge eating disorders are complex genetic disease, in which the risk of developing eating disorders in first-degree relatives is increased ten-fold About a third of genetic risk for eating disorders, depression, anxiety and addictive disorders may be shared.
Biological factors: Developmental changes of puberty (hormonal increase, and brain development), stressful events and challenges could trigger eating disorder behavior and the subsequent nutritional deprivation on the developing brain may maintain the illness. Birth-related peri-natal complications and premature delivery increases the risk of developing of an eating disorder.
Psychological factors: Clinical perfectionism, core low self esteem, mood intolerance, difficulties in expressing emotions, fear or avoidance of conflict, competitiveness and interpersonal difficulties
Social factors: Professions with an emphasis on body shape and size may be at increased risk, culture and media emphasis on slimness,
External factors: History of teasing bullying particularly when based on weight and shape, sexual or physical abuse, personal or family history of obesity
It can be sometimes difficult to determine whether a person has an eating disorder: some individuals can be within a healthy weight range, there may be shame and guilt about their behavior and they may go to great lengths to hide it away, many do not realize they have a problem and others do not want to give up their behavior as it may serve some purpose for them. The following are symptoms and signs of a possible eating disorder and any combination can be present. A person may also present with several of these symptoms and yet may not have an eating disorder.
Eating disorders are complex mental health problems with potential physical complications. Individuals affected will benefit from professional assessment and intervention. For most people, earlier the treatment given the easier it may become to overcome the problem. A delay in seeking treatment is associated with poorer physical and mental health outcome.
Admitting to having an eating disorder can be a big step for many people. Following this initial step what to do next can also seem overwhelming for individuals and their families. A medical practitioner should perform an initial assessment, preferably one with some experience in the area of eating disorders, so that the severity of symptoms can be determined and an appropriate treatment plan can be collaborated with the individual and family. Your GP would be an advisable first point of call for many people.
Treatment options for people are based on the severity of physical and psychological symptoms. Due to the complex nature of eating disorders several different professionals may be required in the care and treatment of the individual. Different treatment settings (in-patient at medical or psychiatric hospital, day programme, out-patient, private/public psychological therapies, support groups) and treatment plans may be effective for different people depending on the stage and associated complications of the disorder, age, the type of disorder, underlying causes and support networks available to the individual. There is evidence that some treatment options are more effective at certain age groups or particular type of disorders, though no one treatment modality has been shown to be effective for all cases of eating disorders. An eating disorder may be a long-term illness for some and long-term treatment may be required for these individuals.
The main treatment interventions for eating disorders are nutritional rehabilitation, physical health management, psychological and psychiatric management. In some cases, drug treatments may be required and have shown to be effective. Some individuals with mild symptoms may also do well with self-help programs and support group attendance.
The media’s endorsement of the thin- ideal size zero physique is unobtainable by the average woman and may lend itself to the development of body dissatisfaction and low self esteem. Culture and media may perhaps play a role in the development of eating disorders in vulnerable individuals. Bullying and criticism focused on weight, food and shape may also increase the risk of developing eating disorders.
However, eating disorders are biologically based mental health disorders in which genetic, biological and environmental factors contribute to the development and maintenance of these disorders. Anorexia nervosa was described in the early 19th century, long before our current preoccupation with the thin ideal. If the development of eating disorders was only due to cultural and media influence the incidence of eating disorders in Western nations could be assumed to be much higher. Our cultural and media’s preoccupation with the thin ideal has also caused a misunderstanding of what eating disorders are and has led many to dismiss and stigmatise those that suffer from eating disorders as simply slimming and vanity taken to the extreme.
Prof. Jim Lucey | Medical Director, St Patrick's University Hospital & TCD
Recovery stories prepared with the assistance of Dr. Sarah Prasad, Director of Eating Disorders at St. Patricks University Hospital and Dr. Sarah Buckley, Director of Adolescent Services at Willowgrove Adolescent Centre, St. Patricks University Hospital.
The Support & Information Service is a free & confidential telephone and email service staffed by experienced mental health nurses 9-5 Monday to Friday with an answering and call-back facility outside hours. You can contact the Support & Information service by calling 01 249 3333, or if you would like to email your query to info@stpatsmail.com we will endeavour to get back to you within these hours.
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