Anorexia and Bulimia

Anorexia and Bulimia

Everybody eats. We do so both because we need to and
because we enjoy it. However, as with all human
behaviour, there are huge differences between people.
Some eat more, some eat less, some put on weight easily,
and some do not.

And some people go to such extremes that they harm
themselves, by eating too much or too little. As a result
they may harm their health and come to the attention of
doctors. This fact sheet deals with anorexia nervosa and
bulimia nervosa.

Although it is easier to talk about them as different
conditions, individual patients often suffer from symptoms
of both. Indeed, it often happens that bulimia develops
after a period of months or years of anorexic symptoms.

Women suffer from these disorders 10 times as often as
men, and so this fact sheet refers to the sufferer as 'she'.
Although often thought of as adult problems, these
disorders most often start in the teenage years while the
sufferer is still at home.

Features of anorexia

Fear of fatness

Under-eating

Excessive loss of weight

Vigorous exercise

Monthly periods stop
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Anorexia usually starts in the mid-teens and affects one
15 year old girl in every 150. Occasionally it may start
earlier, in childhood, or later, in the 30s and 40s. Girls
from professional or managerial families are perhaps more
likely to develop it than girls from working-class
backgrounds. Other members of the family have often had
similar symptoms.

Nearly always, anorexia begins with the everyday dieting
that is so much a part of teenage life. About a third of
anorexia sufferers have been overweight before starting to
diet. Unlike normal dieting, which stops when the desired
weight is reached, in anorexia the dieting and the loss of
weight continue until the sufferer is well below the normal
limit for her age and height.

The tiny amount of calories that she is eating may be
disguised by the quantities of fruit, vegetables and salads
that she eats. Also, she will often exercise vigorously or
take slimming pills to keep her weight low. Moreover, in
spite of her own attitude to eating, she may take an avid
interest in buying food and cooking for others. Although
technically the word anorexia means 'loss of appetite',
sufferers with anorexia actually often have a normal
appetite, but drastically control their eating.

As time wears on, however, the teenage girl with anorexia
may also develop some of the symptoms of bulimia. She
may then make herself sick or use laxatives as ways of
controlling her weight. Unlike sufferers with 'pure' bulimia,
her weight will continue to be very low.

Features of bulimia

Fear of becoming fat
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Binge-eating

Often Normal weight

Irregular periods

Vomiting and/or excessive use of laxatives

This condition usually affects a slightly older age group,
often women in their early to mid-twenties who also have
been overweight as children. It will affect three out of
every 100 women at some time in their lives. Like
anorexics, people with bulimia suffer from an exaggerated
fear of becoming fat.

Unlike women with anorexia, the bulimic woman usually
manages to keep her weight within normal limits. She can
do this because, although she tries to lose weight by
making herself sick or taking laxatives, she also binge
eats.

This involves eating, in a very short time, large quantities
of fattening foods that she would not normally allow
herself. For example, she might get through numerous
packets of biscuits, several boxes of chocolates and a
number of cakes in two hours or less.

Afterwards she will make herself sick, and may feel very
guilty and depressed. This bingeing and vomiting may
raise or lower her weight by up to 10lb within a very short
period of time. It is extremely uncomfortable, but for many
it becomes a vicious circle that they cannot break out of.
Their chaotic pattern of eating comes to dominate their
lives.
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Physical problems

Starvation
Vomiting
Laxatives
Broken sleep
Stomach acid
Persistent tummy-
dissolves the
pain
enamel on teeth

Constipation
Puffy face (due to Swollen fingers
swollen salivary
glands)



Difficulty in
Irregular
Damage to bowel
concentrating or
heartbeats
muscles which
thinking straight
may lead to long-
term constipation
Depression Muscle
weakness

Feeling the cold
Kidney damage

Brittle bones
Epileptic fits

which break easily
Muscles become


weaker, it
becomes an effort
to do anything
And finally, death




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There are many different ideas about the causes of these
two disorders and it is important to stress that not all will
apply to every sufferer.

Social pressure

In societies which do not value thinness, eating disorders
are very rare. In surroundings such as ballet schools,
where people value thinness extremely highly, they are
very common. Generally in Western cultures, we believe
'thin is beautiful'. Television, newspapers and magazines
are full of pictures of slim, attractive young men and
women. They push miracle diets and exercise plans to
enable us to mould our bodies to the pattern of these
artificial, idealised figures, to conform to the shape the
media tell us we should be. As a result, almost everybody
diets at some time or other!

It is easy to see how this social pressure might cause
some young women to diet excessively and eventually to
develop anorexia.

Control

It has to be said that dieting can be a very satisfying
activity. Most of us know the feeling of achievement when
the scales tell us that we have lost a couple of pounds. It
is good to feel that we have managed to control ourselves
in a clear, visible way. It can be especially satisfying for
girls in their teenage years.

Teenagers who may often feel that weight is the only part
of their lives over which they have any control. So it is
easy to see how dieting can become an end in itself,
rather than just a way of losing weight.

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Puberty

A girl with anorexia may lose, or may not fully develop
some of the physical characteristics of an adult woman,
such as pubic hair, breasts and monthly periods. As a
result, she may look very young for her age. Dieting can
therefore be seen as a way of putting off some of the
demands of maturing, particularly the sexual ones.
Unfortunately, this condition makes it difficult for her to
develop the maturity and self-awareness that come from
facing up to, and dealing with, the problems of growing up.

Family issues

Eating is a most important part of our lives with other
people. Accepting food gives pleasure to whoever is
providing it, refusing it will often cause offence. This is
particularly true within families! Some children and
teenagers seem to find that saying no to food is the only
way they can either express their feelings or have any
influence in the family.

Depression

Most of us are familiar with the experience of eating for
comfort when we are upset, or even just bored. Many
sufferers with bulimia have depressive symptoms and it
may be that their binges started as a way of coping with
feeling unhappy. However, feeling stuffed and bloated will
make these feelings worse; while vomiting and purging
leave a feeling of guilt and wretchedness.

Emotional upsets

We all have different ways of reacting to the bad things
that happen to us in life. For some people, anorexia or
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bulimia seems to be triggered by an upsetting event, such
as the break-up of a relationship. Sometimes it need not
even be a bad event but just an important one, like
marriage or leaving home.

In anorexia, it is usually family members who realise that
something is wrong when they notice their sister or
daughter is not only thin, but also continuing to lose
weight. Although to others this weight loss appears
alarming and excessive, the sufferer will hardly ever admit
that there is a problem. She continues to believe that she
is over-weight.

In fact, even others may not recognise the problem for
some time because of the large amounts of 'healthy' (but
non-fattening) foods that she eats.

In bulimia, the sufferer often feels guilty and ashamed of
her behaviour and may go to great lengths to hide it. This
is despite the fact that eating huge amounts of food and
then vomiting it back up is extremely time-consuming and
exhausting. It may affect her performance at work and will
certainly make it difficult to lead an active social life. So, it
can be a huge relief finally to have to admit to the
problem. She may often be forced to do this by changing
circumstances, such as a new relationship, job, or living
with other people.

Recognition

The first step to treating a disorder is recognising it. It is
much easier to help somebody with anorexia or bulimia if
the problem is spotted and dealt with quickly. The longer
that it remains unrecognised, the worse the problem tends
to become, and the harder it is to help. Anorexia can be
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life-threatening, so it is important to see a doctor, the
sooner the better.

Referral

Once the problem is recognised, the sufferer should be
seen by a psychiatrist or psychologist who has experience
with these disorders. Your family doctor will know who to
contact.
Although until recently there has been a tendency to admit
people with anorexia to hospital, most can be treated as
out-patients if the weight loss is not too severe.

Assessment

The first step the psychiatrist will take is to have a long talk
with the patient to find out when the problem started and
how it developed. This will involve discussing many
aspects of her feelings and her life. She will need to be
weighed. Depending on the loss of weight, a physical
examination and blood tests may be necessary. With her
permission, the psychiatrist will almost certainly want to
talk with her friends and family members, to see what light
they may be able to shed on the problem.

Anorexia

If someone has become excessively thin and her periods
have stopped, it makes sense for her to try to get back to
somewhere near an acceptable weight. To help with this,
both she and her family will first need information.

What is a normal weight for her? How many calories are
needed each day to get there?

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For many sufferers, the most important question is, "How
can I make sure that I don't shoot past that weight and
become fat?" In anorexia, the patient has excessive
control of her eating. How can she ease up?

For youngsters still living at home, it is the parent's job to
watch over the food that is eaten, at least for a while. This
involves both making sure that she has regular meals with
the rest of the family, and that she gets enough calories.
Mounds of lettuce can be very deceptive. It is also
important that the family see the psychiatrist regularly both
to check on weight and for support, as having a person
with anorexia in the family can be extremely stressful.

For most sufferers it will be important to discuss things
that may be upsetting them - relationships, school, self-
consciousness, family problems, etc.

Only if these simple steps do not work, or if the weight loss
threatens life, is admission to hospital usually considered.
In-patient treatment consists of much the same
combination of dietary control and talking; only in a much
more structured environment.

Bulimia

Here, the priority is to get back to a regular pattern of
eating. The aim is to maintain a steady weight on three
meals a day at regular times; without either starving or
vomiting.

Sufferers are usually older than anorexics and not living at
home; so the emphasis is more on their keeping diaries of
their eating habits, and increasing self-control. Again,
dietary information needs to be given so the sufferer
doesn't get disheartened by gaining too much weight.
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The other important part of treatment is psychotherapy -
talking about things in the past or the present that may
have a bearing on the eating disorder and other personal
difficulties.

For those sufferers with depression in addition to their
bulimia, anti-depressant medication may be necessary.

Having seen your doctor or specialist, you may find it
helpful to join a self-help group in which other people
share similar problems. These groups can provide both
information and support during the difficult times that
everybody with these problems goes through.

Your family doctor should be able to recommend a
suitable local group.



Original work copyright Royal College of Psychiatrists
(RCP) 1998, adapted with permission from RCP, in
collaboration with the Service User Steering Group.
Flesch-Kincaid level 8.3. Date written: October 2006 Date
for review: October 2009.
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