Understanding eating distress

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What is normal eating, and what isn't?
What is anorexia nervosa?
What is bulimia nervosa?
What is compulsive eating?
What is binge eating?
Who's affected by eating distress?
What causes eating problems?
What can be done to help?
What can I do to help myself?
What can friends and relatives do?
Useful organisations
Further reading

'At first, it was such a relief not to worry about anything else. The eating disorder started as a coping mechanism to help me avoid my other problems. But, in the end, it became the biggest problem of all.'

'I was horrified by what I was doing to my family. But in a way, that made me feel more unworthy than ever.'

'Anorexia is something I feel I will never be completely free of. At times of stress I feel myself slipping back into denying myself food, and seeing myself as grossly overweight. However, if people had told me ten years ago that I would have the life I have now, I would not have believed them. I would never have believed I could have the control I now have over it.'

Anorexia, bulimia, bingeing and compulsive eating can blight people's lives. This booklet describes the signs of eating distress, explains possible causes and looks at the kinds of treatment available. It aims to help anyone who thinks they themselves, a friend, or a member of their family, may have a problem of this kind.

What is normal eating, and what isn't?

If 'normal eating' is eating when you get hungry, without giving it much thought, the vast majority of people probably don't eat normally. We all have different eating habits. Some of us have one large meal a day, while others have lots of small snacks. At times, we may experiment with food, cutting out things we feel may be bad for us, trying out new foods, or fasting.

Eating is often affected if people are under pressure. They may crave a particular food (such as chocolate), lose their appetite or eat more for comfort. Some people become unable to eat at all, feeling ill if they do. As a rule, they get back into their usual eating habits, once the difficulties have passed.

However, if they go on eating too much or too little over a period of time, they may be in danger of developing eating distress. Food may then become the centre of their lives. They may deny themselves anything to eat, even when they are very hungry, or they may eat constantly, or binge. The subject of food, and how much they weigh, can be on their mind all the time. Food can become a sort of addiction, affecting life in a very negative way. Being 'addicted' to food presents huge problems, because we need to eat to live, so if we have an eating problem, we have no choice but to wrestle with this problem every day.

It's important to understand that eating distress isn't just about food and eating. It's about difficult problems and painful feelings, which people can't express, face or resolve. Focusing on food is a way of disguising this, even from themselves.

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What is anorexia nervosa?

Someone who has anorexia may be torn between not being able to bear putting on weight, and yet not wanting to die of starvation. To them, putting on weight means losing control. What they eat, and if and when they eat it, may feel like the only part of life that they have under control. The act of eating can come to represent everything bad, including the feelings that aren't allowed to come to the surface. Not eating, and losing weight, can therefore become that person's only way of feeling safe.

Although 'anorexia' means loss of appetite, this is quite misleading. Someone with anorexia will deny themselves food, although they may actually feel extremely hungry. It's also very inaccurate to call it the 'slimmer's disease', and dangerous if it means dismissing the problem. It takes no account of what's behind such an extreme response; negative feelings, such as low self-worth, extreme fear of rejection and a distorted self-image.

There are a number of signs that someone with anorexia may show:

• losing a great deal of weight
• denying they feel hungry
• taking drastic measures to avoid putting on weight, such as: avoiding foods high in calories; making themselves sick; exercising excessively; using drugs that quell the appetite or speed up digestion; counting calories meticulously, and wearing baggy clothing to cover up any weight loss, or to keep warm
• weighing much less than they should (at least 15 per cent less than the expected weight for their age and height)
• believing that they look fat, although they are considered underweight
• being physically underdeveloped (this may happen if the problem occurs before puberty)
• missing three, or more, menstrual periods in a row (although this may not occur if they are taking a contraceptive pill)
• losing interest in sex or become impotent
• hiding food, or throwing it away
• changes in their personality.

People can get a 'high' from denying themselves food or exercising too much. But, as they eat less and less, they will feel weaker, perhaps depressed and more and more tired. Anorexia can affect every aspect of life; the way they think, their concentration and their ability to move around. It may be life threatening.

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What is bulimia nervosa?

Bulimia means eating large amounts of food, and then trying to undo the effects by starving themselves, or by vomiting or, less usually, by using laxatives (both known as purging). In  extreme cases, someone can be making themselves sick as often as 30 to 40 times a day.

Bulimia is more common than anorexia, but because people keep their weight roughly the same, it's not so visible.

People are often at great pains to keep the bulimia outwardly hidden. Inwardly, they will be thinking constantly about eating, and having irresistible cravings for particular foods. They dread being fat and believe they should be much thinner than a normal weight.

Contrary to what people believe, taking laxatives doesn't actually help with weight loss, but removes essential minerals, such as potassium and sodium, which keep the muscles working. Being sick gets rid of less than half the calories  consumed, according to one study, and diuretic drugs, which rid the body of fluid, have no effect on the calories absorbed. A flat stomach may be a temporary benefit, but it soon returns to normal when fluid levels rise again.

Media attention has glamorised, and so trivialised, bulimia nervosa. But the effects are not trivial. They include having poor skin, because of being dehydrated, bad teeth caused by stomach acids eroding the tooth enamel, bad breath, a sore throat and mouth ulcers. Periods may also become irregular or stop altogether. Frequent vomiting can cause epileptic fits, muscular weakness and heart problems, while taking a lot of laxatives can also cause permanent damage.

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What is compulsive eating?

Someone who eats compulsively has come to rely on food for emotional support. They may pick at food all day, and feel they can't stop themselves. As a result, they are likely to be heavily overweight, and in danger of developing health problems because of it.

Compulsive eating is a way of masking problems, often connected with close relationships. Underneath it, people may feel very worthless, lonely and empty, and have a deep sense of loss. Compulsive eaters often deal with problems in life by denying there's anything wrong.

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What is binge eating?

When people eat very large quantities of (often) high-calorie food, all in one go, it's known as binge eating. The binges are often triggered by some serious upset, and may take place in secret. During these binges, someone may feel quite out of control. If the person is bulimic, they may follow up these episodes by making themselves sick or purging with laxatives. Others, inevitably, put on a lot of weight. Excessive binge eating may be life threatening.

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Who's affected by eating distress?

Eating disorder charity beat [sic] has estimated that at least one million people in the UK are affected. The numbers involved have increased alarmingly over recent years. It can develop in boys, girls, men and women, regardless of background. As many as one woman in 20 will have some form of eating distress, the overwhelming majority of them aged 14 to 25 years old. One in a hundred women in the UK, between the ages of 15 and 30, experience anorexia. Girls as young as five are reported to be weight-conscious, and thinking about dieting.

It's possible for people to experience both anorexia and bulimia in the course of their lives. Bulimia tends to be more common among older women than anorexia, affecting one or two in every hundred, in the UK. Compulsive eating seems to be a problem for both men and women, equally, at all ages.

According to statistics, men are ten times less likely to develop anorexia than women, and rarely report bulimia. But, there is some feeling that the statistics don't reflect the true picture, because men are less likely to seek help than women. People who experience eating distress may also have other self-harming behaviour. (For more information, see Understanding self-harm.)

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What causes eating problems?

It's vital not to make assumptions about why someone might have an eating problem. There is never one single cause for eating distress, but rather a set of different causes, which may be to do with personality, past experiences, and current events or pressures. (See What can friends and relatives do?)

Stressful experiences
Often, the beginning of eating distress is linked to a stressful event or trauma. This can mean physical, mental or sexual abuse, the death of someone very close, or serious family problems, such as parents getting divorced. Or it could be particular pressures at school or work, such as exams or bullying. (For more information, see Further reading.)

Developing eating problems often coincides with life changes, such as puberty, going to a new school, concerns over being gay or lesbian, or leaving home for the first time. To other family members, looking in from the outside, the eating distress may appear to come out of the blue.

Health problems
Being under constant pressure from ongoing physical or mental health problems can provoke eating distress.

Personality
Some people may be more vulnerable than others to eating distress. It's sometimes called a 'self-esteem disorder', because an abiding lack of self-esteem is one of the few common factors. Other important causes may be a sense of insecurity, stemming from childhood, and a longing to be safe and in control. People with eating distress, especially with anorexia, are often perfectionists, who are extremely self-critical and highly competitive.

They often come from families where there's a strong focus on food and diet. It's been suggested that people might even inherit a gene that makes eating distress more likely.

Conforming to the ideal
It seems to be more and more acceptable for dieting or exercising to dominate people's lives. Images of perfect people are constantly being presented on TV and in magazines. Women are expected to be thin and men muscular. From a very early age, children are bombarded with these images, even in their toys. They may strive to achieve what they think is an ideal shape, believing this is a route to happiness and popularity.

Spiritual quest
Fasting is an important ritual in many religions. Sometimes, people give spiritual reasons for their anorexia. They may feel that their bodily needs and desires are impure. They may want to dissociate themselves, as much as possible, from their physical side, while trying to be more in touch with their spirituality.

Family problems
When someone is experiencing eating distress, there are often family problems in the background. Sometimes it's the case that a child or youngster is being neglected (although not necessarily deliberately). They may have a father or mother who is ill. They may be acting as a go-between between warring parents, or providing one or other of them with emotional support. But living with someone who has an eating problem can be extremely painful and hard to cope with. It puts a great deal of pressure on the family as a whole. Any difficulties within the family could partly result from this, and will certainly be aggravated. It's important not to underestimate this. (See  What can friends and relatives do?)

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What can be done to help?

People need the help and support of friends, family and professionals so they can start coming to terms with the underlying reasons for their behaviour. Otherwise, they may never be free from their problematic relationship with food. Receiving help early on, from people who are experienced in treating eating distress, may be crucial. The first step is usually to contact the GP, who will need to check that symptoms, such as weight loss, are not due to an underlying illness. The problem needs tackling on both the physical front, through changing the eating pattern, and the emotional front, in terms of the feelings behind it. GPs may not have the necessary time or skills to help, but should be able to offer advice and  referrals. There are professionals, clinics and organisations specialising in helping people with eating distress.

Talking treatments
Talking to a counsellor or psychotherapist can help people to face and release painful feelings, in a way that's constructive rather than destructive. These professionals are trained to listen and to help people find their own solutions to problems. Counsellors usually focus on current problems, helping the person to find the best way to tackle them. Psychotherapists usually work more frequently and intensively with their clients, with more emphasis on their general experience of life and past history. Psychologists often practise cognitive behaviour therapy (CBT). This involves helping people identify their negative thought patterns and behaviour (such as those behind low self-esteem) to replace them with more positive ones. It often incorporates homework, such as keeping a record of eating patterns.

Group and family therapy may also be an option, and can be invaluable in providing insight into the problem, supporting the family as a whole, and improving the way people relate to each other and communicate.

Talking treatments are sometimes available on the NHS, and private practitioners are often able to offer a 'sliding scale' of fees. (For more information, talk to your GP, contact the Useful organisations or see Further reading.)

Admission to a clinic
If the situation is serious, it may be necessary to go into hospital or to a clinic. Treatment usually involves a combination of re-feeding and talking treatments. At its best, this will be tailored to the individual and to their circumstances. Local  treatment isn't always available, because there are only a few NHS inpatient centres. There are also private clinics, which vary in their approach, and may have different priorities as far as re-feeding and therapy regimes are concerned. Some centres are strict and impose penalties if patients don't comply with their requirements. Others allow patients to go at their own speed, in their own way. They may include complementary therapy, as well as conventional medicine, using programmes similar to Alcoholics Anonymous, intensive psychotherapy (individually or in groups), drug treatments, New Age therapies, and arts therapies. Ask for information about the treatment on offer.

The most successful units offer a wide range of experts dealing with the multiple problems all at once. The staff could include doctors, psychotherapists, occupational therapists, social workers, family and relationship therapists and specialist nurses. There may be guidance on buying, preparing and serving food, on how to cope with stress and anxiety, how to be more assertive, and how to manage anger and communicate better. Good treatment will reduce the chances of relapse, although someone with severe eating distress may relapse more than once. Before treatment can be really effective, the person has to want to get better. It may take them time.

The Mental Health Act (1983 and 2007) can be used to admit someone to hospital for treatment of an eating disorder. Most court cases have focussed specifically on the diagnosis of anorexia nervosa and whether force feeding is 'medical treatment' as defined by the Act. Contact your local Community Health Council, law centre or solicitor, or MindinfoLine if you need advice about this. (See, also, the series of Mind's rights guides.)

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What can I do to help myself?

Self-help groups
If you experience eating distress, you may feel extremely ashamed. You may feel no-one really understands what you're going through. You may also be very used to hiding your behaviour, and this can be very isolating. There are great  benefits from talking to others with the same problem. (See Useful organisations, for more information.)

Alternative therapies
Alternative therapies can help people who find it hard to express themselves in words to do so through dance, movement, art or music. People with eating distress often have a difficult relationship with their bodies. Dance and movement therapies can help someone feel more connected to, and happier with their body. (see Mind's factsheet Arts therapies) Other therapies, such as massage, reflexology and aromatherapy, may also be very beneficial. (See Useful organisations and Further reading.)

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What can friends and relatives do?

It's a mistake to try to look for a simple explanation for a friend or relative's eating distress. The urge to do so may come from your need to explain, and possibly control, a problem that can seem very hard to understand. Sometimes people assume, automatically, that someone with eating distress has been sexually abused. Or that it's an attempt to stop the body developing during adolescence, or to attain an ideal body image. But if you interpret someone's eating distress in a particular way, without really listening to the person themselves, it could add to their feeling of being out of control. It could make them even less able to share their emotions.

It may also make the situation worse, not better, if you try and persuade your friend or relative to change their behaviour, either to put on weight or to lose it. You may find it very hard to accept that what your friend or relative does is their own decision, and that you can't, magically, make them better.

For your friend or relative, their eating distress is a solution and not a problem. It's a way of expressing terribly painful feelings, which may include anger, rage, guilt and loss. They may not want to recognise that they have an eating problem. They may be secretive and even obstructive. This is one of the obstacles to treatment that needs to be overcome. Without trying to persuade the person to change, you may want to talk about how their eating behaviour makes you feel. It's important to be honest, and to get support for yourself.

But, there are also ways you can be of great support to them. Help them by giving them the opportunity to talk about their feelings. But if they don't want to, make it clear that you still care for them and will be there, if they want to talk to you another time. You could also encourage them to seek professional help. If they are worried about doing this, you could offer to go along with them.

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Useful organisations

British Association of Art Therapists (BAAT)
24-27 White Lion Street, London N1 9PD
tel. 020 7686 4216
web: www.baat.org
Provides a list of therapists

British Association for Behavioural and Cognitive Psychotherapies (BABCP)
The Globe Centre, PO Box 9, Accrington BB5 0XB
tel. 01254 875 277
web: www.babcp.com
Can provide details of accredited therapists

British Association for Counselling and Psychotherapy (BACP)
tel. 0870 443 5252
web: www.bacp.co.uk
Has details of local practitioners

British Society for Music Therapy (BSMT)
61 Church Hill Road, East Barnet, Hertfordshire EN4 8SY
tel. 020 8441 6226
web: www.bsmt.org
Contact for the name of a local practitioner

beat (formerly the Eating Disorders Association)
adult helpline: 0845 634 1414, youthline: 0845 634 7650
web: www.b-eat.co.uk   
Support and understanding around eating disorders

The Institute for Optimum Nutrition
tel. 020 8614 7800
web: www.ion.ac.uk
Nutritional information and list of nutritional therapists

Mental Health Act Commission
web: www.mhac.org.uk
See their guidance note on the treatment of anorexia nervosa under the Mental Health Act

Overeaters Anonymous Great Britain
PO Box 19, Stretford, Manchester M32 9EB
tel. 07000 784 985
web: www.oagb.org.uk
Runs local groups throughout the country

UK Council for Psychotherapy (UKCP)
tel. 020 7014 9955
web: www.psychotherapy.org.uk
Umbrella organisation for psychotherapy in UK. Regional lists of psychotherapists are available free

YoungMinds
Parents information service: 0800 018 2138
web: www.youngminds.org.uk
Information for both parents and young people, including podcasts on the website

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Further reading

About self-harm: a guide for young people (Mind 2007)
The bird and the word: the Mind education pack (Mind 2001)
Confidence works: learn to be your own life coach G. McMahon (Sheldon Press 2001)
Diet of despair: a book about eating disorders for young people and their families A. Patterson (Lucky Duck Publishing 2002)
The food and mood handbook A. Geary (Thorsons 2001)
Heal the hurt: how to forgive and move on A. Macaskill (Sheldon Press 2002)
How to assert yourself (Mind 2006)
How to cope with doubts about your sexual identity (Mind 2006)
How to cope with the stress of student life (Mind 2006)
How to deal with bullying at work (Mind 2004)
How to increase your self-esteem (Mind 2006)
How to survive family life (Mind 2004)
Making sense of cognitive behaviour therapy (Mind 2007)
The Mind guide to food and mood (Mind 2006)
The Mind guide to managing stress (Mind 2006)
The Mind guide to physical activity (Mind 2006)
The Mind guide to relaxation (Mind 2006)
Overcoming childhood trauma: a self-help guide using cognitive behavioural techniques H. Kennerley (Robinson 2000)
Overcoming low self-esteem: a self-help guide using cognitive behavioural techniques M. Fennell (Robinson 1999)
Overcoming social anxiety and shyness: a self-help guide using cognitive behavioural techniques G. Butler (Robinson 1999)
Mind rights guide 1: civil admission to hospital (Mind 2007)
Mind rights guide 3: consent to medical treatment (Mind 2007)
Mind rights guide 4: discharge from hospital (Mind 2005)
Understanding anxiety (Mind 2006)
Understanding bereavement (Mind 2005)
Understanding childhood distress (Mind 2007)
Understanding depression (Mind 2007)
Understanding self-harm (Mind 2007)

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This booklet was written by Louise Flory
First published by Mind 1988. Revised edition © Mind 2007
ISBN 9781874690238
No reproduction without permission