In this blog post we’re going to talk about eating difficulties (also known as disorders), what they are, how they occur and how we can heal them.
An eating difficulty is a mental health concern that is characterised by marked distress expressed in relation to eating and/or body image, shape or size. Related behaviours almost always go on to have a negative effect upon the individual’s physical health.
Eating difficulties and disordered eating are currently more prevalent than ever, yet remain stereotyped and misunderstood. Between 50 and 75% of women have disordered eating and 28% of men have disordered eating. A recent survey in the UK said that 40.7% of 16-year-olds had some kind of eating difficulty. The problem can start with a diet and then become disordered eating.
The stereotype that all people with eating difficulties are very skinny is untrue. The reason that slimming programmes don’t work is that 50% of people who use them already have an eating difficulty. Most people with an eating difficulty look exactly like anybody with a body mass index (BMI) that’s healthy. Another way to consider our bodies is that it’s possible to be ‘healthy at every size’ (HAES). Unfortunately, usually the medical profession will not work with people until they have a low BMI. We need to help these people when they have normal body weight sooner to avoid enabling them to become more ill.
An eating difficulty is caused by anxiety and we have to look underneath it to support what is going on. It’s a ‘thief of souls’ with people losing their cognitive ability to function, where the person no longer exists. It promises them the illusion of control, not real control. It seduces them, but then imprisons them, so that they no longer live in their bodies, but work on them. So, they need help to understand that it is an illusion in which they start as the master and then they become the puppet of the eating difficulty.
It often starts with the first diet we do, resulting in side-effects:
– Your innate hunger and fullness cues
– Slowed metabolism
– Overeating and bingeing
– It undermines your own innate ability to recognise hunger and fullness.
– Relying on someone else to tell you what to do, resulting in eating too much or too little.
– Loss of muscle mass
– Rebound weight gain
– Food obsession
– Guilt and anxiety when you inevitably fail
– Deprivation backfires.
These problems do not appear suddenly. Rather, that person’s behavior in relation to food progressively changes. The difficulty shows its face when the following signs appear, for example:
- Weight change, often sudden (either upwards, when gaining weight, or downwards, with significant weight loss).
- Radical changes in food choices: they suddenly reject things they used to eat, or only consume the same type of food…
- They begin to spend a lot of time in the bathroom, where traces of vomiting, etc. are also discovered.
- Sometimes, they associate these behaviours with digestive pain without any specific cause being found. Curiously, it seems that low-calorie foods are good for them and high-calorie foods are bad for them.
- Non-food symptoms are also observed. For example, greater social isolation, they avoid going out to eat or dine out (or ordering food at home), and, in general, they avoid eating in public.
- They appear more irritable, anxious or stressed.
J. Gale says that, ‘Eating disorders, disordered eating and other food, weight and body image concerns are complex and multifaceted; each individual has her own unique story and puzzle of risk factors to do with why her disordered eating started, as well as an assortment of reasons regarding its maintenance; what starts an eating disorder isn’t always what keeps it going.’
She goes on to identify a number of ‘underlying and maintaining issues’ that may need to be worked through in order to enable someone to recover fully:
• body dissatisfaction and dieting
• insecure attachment styles
• history of complex trauma
• family system and relationship dynamics
• family environment of eating difficulties, dieting and food rules
• childhood emotional neglect and lack of attunement
• soma (body) and soul
• internal family systems (with the roles of perfectionist, rebel, pleaser, victim etc.)
• thoughts, feelings, urges and behaviours
• mechanisms to gain soothing and to cope with problems
• identity crisis: asking, ‘Who am I?’
• self-harm and punishing self
• cultural expectations
• setting high standards for self
• seeking approval, status, power and control
• the influence of biology, genetics and the brain
• shame and low self-worth, i.e. feeling ‘not good enough’
• media and the thin ideal (social media has a huge influence. We have so much social media, which shows bodies that people can’t have, with a perfection that is unachievable.)
• history of sexual abuse
• lack of value, meaning and purpose
• underlying anxiety/depression.
Difficulties include:
• anorexia nervosa:
- Not all people with anorexia are very thin.
- Weight ranges from slightly underweight to very thin, normal weight or overweight.
- Clients feel huge and are terrified of weight gain.
- They are very fearful of eating, with very restricted eating habits.
- They hear a voice telling them to keep eating less.
- Some anorexics vomit or take laxatives after normal meals, snacks or a binge (the most sinister form of anorexia).
- Fear of weight gain
- Refusal to maintain a safe weight
- Altered perception of body shape
- Absence of menstrual cycle
- Restricting type does not engage in compensatory behaviours
- Binge-eating /purging type
- Acute anorexia is where weight is being lost
- Stable anorexia or chronic restricting anorexia may be a long-term condition.
• binge eating/compulsive eating:
- Overeat in secret, either all or some of the time
- Feel that their eating isn’t normal
- Feel guilty about what they eat
- Try to lose weight or try to stop themselves from gaining weight
- Think and anguish about food all the time
- Feel out of control around certain kinds of food or any food
- Eat in a discrete period an amount considered more than most people
- A sense of a lack of control
- Absence of compensatory behaviours
• other specified feeding or eating disorder (OSFED):
- Atypical anorexia nervosa (weight is not below normal)
- Bulimia nervosa (with less frequent behaviours)
- Binge-eating disorder (with less frequent occurrences)
- Purging disorder (purging without binge-eating)
• diabulimia: (composed of diabetes and bulimia) an eating difficulty in which people with Type 1 diabetes deliberately give themselves less insulin than they need, for the purpose of weight loss. Insulin-dependent diabetics reduce or omit insulin to allow themselves to eat without digesting the nutrition. It is not currently recognised as a mental illness.
• bulimia:
- Recurrent episodes of binge-eating
- Sense of lack of control
- Irresistible craving for food
- Using compensatory behaviours – vomiting, purging or over-exercising
• orthorexia: a condition that includes symptoms of obsessive behaviour in pursuit of a healthy diet. Sufferers often display signs and symptoms of anxiety disorders that frequently co-occur with anorexia nervosa or other eating difficulties. It’s referred to as a flight out of anorexia nervosa.
• night eating syndrome (NES): it may be comorbid with compulsive eating or bulimia nervosa. Night eaters can become psychotic if they are put on a diet and may suffer from morning anorexia.
• ARFID: avoidant/restrictive food intake disorder was previously known as selective eating disorder (SED).
• pica: persistent ingestion of inedible substances such as dirt, stone, etc.
• rumination disorder: repetitive, habitual bringing-up of food that might be partly digested, rechewed, swallowed or spat out.
• body dysmorphic disorder (BDD) is an anxiety disorder that causes a person to have a distorted view of how they look and to spend a lot of time worrying about their appearance. For example,
- they may be convinced that a barely visible scar is a major flaw that everyone is staring at, or that their nose looks abnormal.
- It frequently occurs with comorbid depression, obsessive compulsive disorder (OCD) and social phobia.
• compulsive physical activity: doing activity to earn the right to eat, a recurrent problem among patients with anorexia nervosa and present in 30–80% of patients
• muscle dysmorphia: also known as ‘bigorexia’, is an anxiety disorder that causes someone to see themselves as small, despite being big and muscular. It can affect men and women, but it is thought that many cases go unreported. It is sometimes described as a kind of ‘reverse anorexia’. Also, exercise is used to build muscle rather than lose weight. Anabolic steroid misuse and cosmetic surgery are associated with it.
• bulimarexia: a combination of anorexia and bulimia nervosa.
The relationship between autism and eating difficulties is often overlooked or misunderstood. Generally 20–30% of women in studies of anorexia nervosa meet the criteria for autism (Elliot and Mandy, 2018). They often go into hospital but it’s not detected and they’re treated without taking their autism into account, so we need to work with and understand that these people need to be treated in a very different way.
Standardised mortality for eating difficulties is as high as 20%. Causes of death in eating difficulties include cardiac arrest, electrolyte disturbances and ‘sudden death’. However, the second leading cause of death in people with eating difficulties is suicide. Udo, Bitley and Grilo, reporting on a 2019 survey of more than 36,000 US adults, noted that US adults with a lifetime history of anorexia nervosa, bulimia nervosa or binge eating disorder are at increased risk of having a suicide-attempt history. The Suicide Prevention Research Center (2020) wrote that Udo, Bitley and Grilo had found that, ‘the prevalence of suicide attempts was 24.9% among those with a history of anorexia. The researchers also found that 31.4% of those with a history of bulimia and 22.9% of those with a history of binge eating disorder had attempted suicide in their lifetime. After adjusting for sociodemographic variables, individuals with any type of eating difficulty history were more likely to have a greater number of suicide attempts compared to those without an eating difficulty history.
Comorbidity, both psychological and physical, is common in people with eating difficulties. For example, the National Comorbidity Survey Replication (Hudson et al., 2006), carried out in the United States, found that a comorbid psychiatric disorder was present in 56.2% of anorexia nervosa patients, 78.9% of binge eating disorder patients, and 94.5% of bulimia nervosa patients. Autism spectrum disorders and eating difficulties are also highly correlated. Anorexia, binge eating and bulimia are all also associated with various physical health risks, such as low weight (in the case of anorexia) and severe obesity (for binge eating).
While services vary greatly, most are overloaded and underfunded. Therapists with a specialism in eating difficulties are currently working more with those affected. However, even the best treatment isn’t always successful. Working with clients with eating difficulties requires complex understanding, complex responses, multidisciplinary working, and action outside of the usual competencies of therapists. If they deny the complexities of eating difficulties and over-simplify their response, they are doing their clients a disservice.
Accessing help is often delayed or rejected. For example, Hudson et al. (2006) write: ‘Although most respondents with 12-month bulimia nervosa and binge eating disorder report some role impairment … only a minority of cases ever sought treatment.’ Relapse is common for people with eating difficulties, and the duration of their illness can be long. Balancing physical and mental health can be challenging, and people are faced with finding a way of managing in a world that is full of toxic diet culture.
When people with eating difficulties don’t understand their own condition, or seek treatment with therapists who aren’t adequately trained and knowledgeable in this client group, they may:
• experience delays in accessing care
• avoid seeking future/additional help
• feel increased shame and worthlessness
• engage in more destructive behaviours
• have a sense of hopelessness.
Sometimes, therapists may have their own bias that leads them to perceive the client as difficult. They may be seen as ‘difficult’ for a number of possible reasons:
• They may be prone to denial, secrecy and lies.
• Eating difficulties tend to be coping mechanisms for other deep-seated issues.
• Cognitive function may be affected.
• Treatment-related trauma can be a factor.
Further training, doing lots of reading on the topic, and getting some experience are vital for therapists working with people with eating difficulties. It’s also important to explore their own processes in therapy.
An eating difficulty has a purpose and it shouldn’t be taken away, but rather replaced with strategies because it’s about control, it’s safety, it’s a friend and is their identity. We should work slowly and methodically with positive attention in a gradual process of recovery to give people other strategies that aren’t going to damage them.
In therapy there is the person, the therapist and the voice. The voice relentlessly argues, fights and screams. The therapist needs to separate the person from the voice and to give it a name to distinguish who they’re working with because, the person or the voice.
We can ask someone four questions to find out if they need support with their eating:
– Does eating rule your life?
– Do you think about food, weight and shape a great deal?
– Are you unhappy and distressed about your eating behaviour or does it give worry to others?
– Is some of your behaviour with food a secret?
We also need to have the three Ps in mind when first encountering a person who we believe may have an eating difficulty. First there’s ‘predisposing’ or what makes you liable to develop an eating difficulty. Next there’s ‘precipitating’ or what life events start it. Finally, there’s ‘perpetuating’ or life events and what then keeps it going.
Predisposing factors are:
- childhood obesity (linked to bulimia)
- traumatic events
- having a relative with an eating difficulty
- cultural factors
- perfectionism
- personality
- anxiety disorders
- family
- an avoidant style of coping
- obstetric complications, being born between April and June
- body issues
- the environment
- maternal stress
- OCD
- development
Precipitating factors are:
- Bullying
- Maturation (puberty, sexual …)
- Glandular fever
- Divorce/separation
- Stress or loss (family members/friends …)
- Abuse
Perpetuating factors are:
- Trauma (abuse and neglect especially)
- Low self-esteem or low self-worth
- Stress (puberty, exams …)
- The media
- Guilt
- Fear
- Shame
- A way of exerting control
- Loss
- Denial
- Poor diagnosis
- An avoidance mechanism
- Delayed treatment
- Rapid change in the environment
- Peer pressure
- Emotional numbness
- A lack of assertion
- A need to regulate emotions
All eating difficulties are self-traumatising conditions and can become more like post-traumatic stress as time goes on. Therefore, it’s really important that we have a good understanding of them as these people need and deserve to be treated properly.
Sources:
O’Neill, K. (2022). Exploring Eating Disorders: A Complex Field Requiring Specialist Training [lecture]. Counsellor CPD. Counselling Tutor. [Viewed: 01/07/2024].
Wright B (2021) Working with Eating Disorders, Counsellor CPD. Counselling Tutor. [Viewed: 01/07/2024].
https://www.ocu.org/salud/salud-mental/consejos/trastornos-alimenticios 05/02/024