The nature of eating disorders
There are many variants of eating disorders; more common are anorexia nervosa and bulimia nervosa. People who experience an eating disorder may differ from each other in numerous ways, but tend to share one common feature: their lives are dominated by concerns about their perceived need to control their weight and, by implication, their eating.
Although a larger percentage of the population go on diets at some time, for most people this will be a temporary period of abstemiousness that will come to an end without going too far. The person with an eating disorder, however, tends to be engaged in a relentless pursuit, which becomes all-consuming and takes over their life. Neither does the person necessarily stop at a sensible level. It is as if the pursuit of the goal becomes more important than the goal itself. The emphasis on the qualitative difference between eating disorder and dieting does not mean that there is a sharp dividing line between the two. There appears to be a continuum of eating disorders, but clearly there is a time and place for drawing lines, even if those lines appear arbitrary.
The spectrum of eating disorders
Psychological disorders unfortunately do not fall into neat packages that are easily identifiable and separate from anything else. One has to accept that there are many shades of grey. From many of the studies conducted in this area, it is possible to identify a substantial number of young women who possess many of the symptoms of anorexia nervosa without fulfilling the strict criteria. There appears to be “partial syndromes” which apply not only to anorexia nervosa, but also to bulimia nervosa.
The spectrum of eating disorders range from “normal” eating through to persistent dieters and partial syndromes to frank bulimia nervosa and anorexia nervosa. While there may be great differences in the severity of such disorders, there might be much in common across this spectrum. The underlying causes of eating disorders can only be enhanced by studying the entire spectrum as people tend to move along this spectrum.
Causes of eating disorders
Eating disorders are multifactorially determined. Broadly speaking, there appears to be three classes of variables that seem to be possibly implicated: social, biological and psychological:
- Social factors: There is an overwhelming preponderance of eating disorders in females. This is perhaps largely due to the enormous popularity of dieting or slimming in young women in Western society. Most women are concerned about their weight and most will diet at some point. Aside from dieting, body dissatisfaction is also high among females which appears much more likely to be linked to self-esteem. From a historical point of view, there is also evidence that the cultural ideal of slimness for women has increased in recent times (Garner et al, 1980; Rossner, 1984). It seems reasonable to suppose that the more people diet, the more they will succumb to eating disorders. However, social factors alone cannot explain eating disorders. In spite of widespread social influences, it is only very much a minority of women who get into big trouble with eating.
- Biological factors: A number of genetic studies have found a higher concordance rate among relatives with eating disorders. Holland et al (1984) found 56% concordance for anorexia nervosa among identical twins. There is also evidence of increased risk for other psychiatric disorders amongst relatives, with particular emphasis on affective disorder. As well as potentially predisposing some individuals to an increased risk of developing eating disorders, biological factors seem to also play a role in perpetuating the disorder. There is considerable evidence to support the presence of a disturbance in hypothalamic function in anorexia nervosa. The weight of evidence, however, points to this as mainly being a result of malnutrition and possibly also emotional factors, rather than reflecting any primary abnormality. There is also substantial evidence that hunger and satiety mechanisms in bulimia nervosa have become disturbed, possibly mediated by hypothalamic/neurotransmitter dysfunction. Hence, there seems to be the case that biological factors may lay a part both in the initiation and maintenance of eating disorders.
- Psychological factors: The bulk of literature on eating disorders tends to point towards psychological factors as playing the most significant role. The literature points in several directions, one of which is personality factors. Certain kinds of personality characteristics tend to dominate in eating disorders. Anorexics, for example, tend to display emotional over-control, conceptual rigidity and lack of development of self. In addition to personality characteristics, the other psychological ingredient of eating disorders is thought to be a developmental one. The timing of the typical onset of eating disorders around early adulthood tends to point in this direction. There is also considerable evidence that low self-esteem is closely associated with body dissatisfaction in this age group, particularly among females.
Although the precise cause of eating disorders is unknown, there is some support for the view that eating disorders are more likely to develop in females with psychological vulnerabilities affecting cognition, emotion, sense of self and interpersonal relationships. Such vulnerabilities may relate to both biological and familial experience and are likely to be put to considerable challenge during the emergence towards adulthood.
The war of the sexes
About 60,000 people may have anorexia nervosa or bulimia nervosa at any one time in the UK (Royal College of Psychiatrists Report, 1992). Of this figure, approximately 90% are women. Some experts believe there are underlying social causes for the disproportionate ratio.
Women, in general, are brought up believing they will be accepted by men on the basis of their looks and personalities. Men are brought up believing they will be accepted by women on the basis of their achievements and personalities. Conflicting messages about food and eating put an additional strain on women who, because of their nurturing role in society, have to think about food a great deal. Exciting, new and miraculous diets promising weight loss with minimum effort are featured every week in various women’s magazines, followed by pictures and recipes for delightful, easy-to-bake treats.
Anorexia usually occurs in women after the beginning of menstruation. Since menstruation requires an emotional as well as physical adjustment, it is not surprising that its onset can be a difficult stage in a woman’s life. Some anorexics fear their femininity and doubt their ability to be adult women. Anorexia not only removes menstruation, it removes the other physical symbols of womanhood; eg, hips and breasts.
Pre-menstrual tension can also trigger bulimic binges. The changes in hormonal levels can cause the amount of sugar in the blood to fall to abnormally low levels. Hence, those women who are particularly sensitive to these changes may experience cravings for sweet, high-calorific foods a few days prior to the onset of menstruation. The guilt associated with the binge may then set off the binge-purge cycle.
The two most common eating disorders
Anorexia literally means loss of appetite. However, people suffering from anorexia nervosa have a normal appetite, and are often very hungry because of their restrictions. This feeling of hunger is oftentimes frightening for someone who is terrified of gaining weight and there is frequently much anxiety associated with food and mealtimes.
The first medical account of anorexia nervosa was documented in 1689, in a textbook of medicine written by Richard Morton. He referred to the condition as "nervous consumption" caused "by sadness and anxious cares". It is not until the 20th century that in-depth understanding and insight into the true psychopathology of anorexics was established.
Anorexia nervosa is very often an attempt to cope with living. It appears to be a solution which is adopted for difficulties which seem impossible to resolve. It is about autonomy and control. The anorexic tends to have a very low self-esteem, and yet have very high expectations and perfectionism. Anorexia nervosa is not an obsession with slimming, or a misguided wish to be slim. It is a desperate bid for psychological survival.
With this condition, there is the similar desire for thinness but sufferers are usually either constantly dieting, or bingeing. It is a lifestyle whereby the sufferer’s every waking hour is consumed by thoughts of shopping, cooking, bingeing and getting rid of food. During a binge session, the person will eat exceptionally large amounts of food, and then purge it by starvation, vomiting, laxatives or diuretics.
In many cases, bulimia nervosa begins with the institution of a diet following a distressing event (eg, the break-up of a relationship), a challenge (making the gymnastics team), or any situation that encourages the person to think about body shape and its links with control, popularity and achievement. Bulimics generally tend to present a public image of self-assurance, happiness and success, and hence can go undetected for years. However, this picture that they paint often cover up the exact opposite; they can be desperately unhappy, have an appallingly low self-esteem and may be exceedingly depressed.
Further information can be saught from: Eating Disorders Association, Sackville Place, 44 Magdalen Street, Norwich NR3 1JU. Tel: 01603 621 414.
There is a local eating disorders group in most areas/counties.