Editor’s note: in part 2 of her series on eating disorders, our psychologist covers conditions classified as distinct from Anorexia Nervosa, the best known eating disorder. Some of the description is graphic, and may upset more sensitive readers, or those triggered by mention of eating disorders, in which case, we advise you to read no further.
“Finally, Ashley said, so casual, “I guess we should eat those sandwiches, huh ? Before they get cold?”
Yes, I suppose we’d better.
And the corn chips, and the cookies, and the peppermint patties, and the Cap’n Crunch, and the tuna salad, and the cold leftover spaghetti, and an entire bag of frozen cocktail meatballs dipped in BBQ sauce, and the rest of the Diet Coke. […]
I was making noises that no human being should make.It was pure torture. If Ashley Barnum thinks I’m ever trying Ex-Lax again, she is insane. […]
“Listen, Isabelle,” said Ashley.”You have to give your body time to adjust. To flush itself out. Plus, you really should alternate between throwing up and Ex-Lax, otherwise you could really mess up your system.”
“How come you know so much ?” I asked
“I read a lot.” […]
Here we were, just two girls with lovely manners, sharing a meal.
“Could you please pass me a napkin ?” I said.
“More salt ?” asked Ashley. “Ketchup for your eggs ?”
Before you knew it, we were both using our hands. Mopping, shoveling, stuffing. We must have finished everything in about sixty seconds. A record. In the back of the diner, we stood on crates and threw up next to each other in a dumpster. […] When Ashley finished, she wiped her mouth on the back of her hand. It came back smeared with red.
“Ashley,” I said. “You know what ? I think you’re bleeding.”
“ Am I ?” said Ashley, and spat into her palm. Blood. “Huh”, she said.
“Are you okay ?”
She looked at me and smiled. “Yeah, it doesn’t hurt or anything […] It’s no big deal, Isabelle, it just happens sometimes.”
“I feel so much better,”Ashley said, “don’t you, Isabelle?”
My head nodded yes, but other parts of me were saying No! ! Like my throat, which hurt. And my eyes, which wouldn’t stop watering.
“I feel great !” Said Ashley. […]
I took a quick look at Ashley’s face to see what I could see. Her mouth was smiling, all right.
The thing is, if you just look at a person’s mouth, you can be fooled. What you have to do is look at their eyes. That’s where the truth is. And with Ashley, the eyes weren’t saying Great!, I can tell you that.
Natasha Friend, Perfect, Milkweed Editions, 2004.
Anorexia is probably the oldest and most studied eating disorder. It is also the most dangerous, and often the most visible. However, other eating disorders are just as serious as anorexia, especially bulimia.
Bulimia has a lot of similarities with anorexia: they are two sides of the same coin. Two criteria are necessary to diagnose it :
- Large compulsive intakes of food, at least twice a week, for a minimum of three months;
- One or several behaviours to counteract those intakes: in 90% of cases, intentional vomiting, but also fasting, skipping meals, hyperactivity, or laxative abuse.
Bulimia nervosa is more recent than anorexia nervosa; it started to be recognised at the end of the 19th century. One explanation probably lies in the fact that food in the previous centuries was usually a rare and expensive commodity, and binging would have been difficult, except in the upper classes. Another explanation is that it has long been considered as just another aspect of anorexia.
Bulimia, like anorexia, usually starts during adolescence, although usually later than anorexia – bulimia in children is extremely rare, to the point of being non-existent. Women more than men suffer from it, and it also has a genetic component, as in other family members usually suffer from an eating disorder, depression or anxiety.
Four important points:
- People suffering from bulimia have the same mindset as anorexia sufferers: they fear weight gain just as much, and except during the binges, they also limit their food intake and exercise excessively.
- They also need to control everything – especially their food intake – and this is why the binges are so hard to endure for them, because they represent a complete loss of control. This loss of control will usually lead to intense self-hatred, sometimes even suicidal thoughts.
- This need to be “full” also fills the bulimia sufferer with self-disgust – there is no pleasure in ingesting the food. The food chosen for the binge isn’t chosen because it tastes good, but because a) it’s available and b) it’s easy to ingest and vomit.
- A binge is huge. It’s not just overeating a little at mealtimes, or even eating a pack of biscuits : it’s eating enough food for one extra meal, or two, or three, and purging, sometimes several times during the binge. There can also be several binges a day.
The dangers of bulimia are the same as those of anorexia nervosa. Since vomiting is more frequent, the dangers associated with it are even more acute, as frequent vomiting causes a loss of electrolytes ( especially potassium), and can lead to cardiac arrest, and/or oesophageal rupture.
The person suffering from bulimia usually keeps his/her bingeing and purging a secret. They need a huge amount of courage to see a professional, because this disorder is associated with ideas like “what I do is disgusting”, and “who in their right mind would waste food like that”. It is, however, the only way to recover, via therapy, and sometimes medication like antidepressants or anti-anxiety drugs.
The main differences with bulimia are :
- There are no countermeasures to the binges
- People suffering from binge-eating disorder are usually overweight (40 to 50% of cases) or obese (20 to 30% of cases). Thus, the risks associated with obesity, like cardio-vascular issues, are increased.
- It is more rarely associated with anxiety and depression, and very rarely with suicidal thoughts.
- The binges tend to be stable in time – neither increasing nor decreasing in terms of frequency and quantity of food ingested, whereas in bulimia nervosa, the binges increase over time.
Like for bulimia, people need to go and see a professional to get help. It is extremely difficult to stop on one’s own.
An even “newer” disease, since orthorexia was first coined by Dr Bratman, an American physician, in 1997. Between obsession and phobia, it shares several characteristics with anorexia and bulimia.
Orthorexia is usually defined (although it is not yet in most psychiatric classifications) as:
- Excessive amount of time spent thinking about food and meals: more than three hours per day, and meal planning for the next day.
- Food is chosen not for its palatability, but for its supposed virtues; “healthy eating” comes before one’s desires or even appetite. Food is separated between “clean/pure” and “unclean/impure”.
- This behaviour has a clear impact on everyday life, leading to self-satisfaction when the objectives are reached and intense culpability if they are not. It also has an impact on social life.
- Obsessive following of food and ‘healthy lifestyle’ blogs on Twitter and Instagram, and extreme interest in other people’s diets.
People suffering from orthorexia have no desire to get thinner: they just want to eat healthily, but their conception of healthy is not itself healthy, as it can lead to strict avoidance and restrictions, and therefore exclusion of whole food groups and essential nutrients.
It is usually treated like anorexia and/or obsessive compulsive disorder.
Other Specified Feeding or Eating Disorders (OSFED)
These include atypical forms of anorexia (a person develops all of the criteria for anorexia, except that, despite significant weight loss, a person may be within or above the normal weight range), bulimia (a person may meet the criteria for bulimia, though binge eating or compensatory behaviours may occur, on average, less than once a week and/or for less than 3 months), and binge eating disorder, but also other eating disorders, such as :
- Purging Disorder: recurrent purging behaviour to influence weight or shape in the absence of binge eating.
- Night Eating Syndrome: recurrent episodes of night eating. Eating after awakening from sleep, or excessive food consumption after the evening meal. The behaviour is not better explained by environmental influences or social norms, and causes significant distress/impairment.
- Pica : the person eats non-food items over a period of at least one month. Typical substances ingested tend to vary with age and availability. They may include paper, soap, cloth, hair, string, wool, soil, chalk, talcum powder, paint, gum, metal, pebbles, charcoal, ash, clay, starch, or ice. Pica often occurs with other mental health disorders associated with impaired functioning (e.g.intellectual disability, autism spectrum disorder, schizophrenia). Iron-deficiency anaemia and malnutrition are two of the most common causes of pica, followed by pregnancy. Pica can affect children, adolescents, and adults of any genders.
- Rumination disorder involves the regular regurgitation of food that occurs for at least one month. Regurgitated food may be re-chewed, re-swallowed, or spit out. Typically, when someone regurgitates their food, they do not appear to be making an effort, nor do they appear to be stressed, upset, or disgusted.
- ARFID (Avoidant Restrictive Food Intake Disorder), previously SED (Selective Eating Disorder)
Basically, “picky eating” sufficiently developed to be harmful for health, as in leading to significant weight loss and nutritional deficiency, and interfering with social life.
People with autism spectrum conditions are much more likely to develop ARFID, as are those with ADHD and intellectual disabilities. Children who don’t outgrow normal picky eating, or in whom picky eating is severe, appear to be more likely to develop ARFID. Many children with ARFID also have a co-occurring anxiety disorder, and they are also at high risk for other psychiatric disorders.
Eating disorders are among the most serious and also the most complicated psychological disorders, because no one can live without food. People can live without alcohol or cigarettes, but not without nutrition. This is why it is extremely important to get help and support as soon as possible : it is possible to get better, but the earlier the start of the treatment, the better the outcome.