eating disorders

eating disorders The modern term that covers all forms of the conditions known as anorexia nervosa and bulimia nervosa. It also sometimes includes obesity. The recorded prevalence of all three has increased during the past 40 years.

Anorexia nervosa, a form of food refusal, is mostly found in young girls, though 1 in 20 cases is a boy. Sometimes it improves spontaneously and sometimes it continues throughout life. The sufferers are usually intelligent high achievers and are often ambitious, and come from families who have ample food. Some have markedly ‘hysterical’ personalities, tending to be dramatic, to overreact, and to manipulate those in their environment. Others are more obsessional, ruminate constantly about food, and develop rituals connected with it. Anorexia means a lack of appetite, but the condition is misnamed because sufferers control rather than lose their appetite. It has been called ‘the relentless pursuit of thinness’. Sufferers rigorously suppress their desire for food in order to be thinner, avoiding all food that they think contains more than the minimum of calories. They often tell lies about the food they do or do not eat, perhaps hiding it or disposing of it secretly to give the impression that it has been eaten. They think about food constantly, weigh themselves several times a day, and have distorted ideas about their bodies, believing that they look fat when they are actually dangerously thin. They tend to wear many layers of loose clothes, partly to hide their condition and partly because they suffer from the cold. Many exercise obsessively and constantly in an attempt to lose further weight. Some, like sufferers from bulimia, have episodes of binge-eating, after which they make themselves vomit to get rid of the food. The most severe cases are medical emergencies and require the most skilled care of a physician in hospital to avoid death. The underlying condition, and the full care of less severe cases, is usually managed by psychiatrists.

Bulimics, who are usually of normal weight, gorge food, but then induce vomiting, sometimes several times a day. They deliberately vomit, at least initially, in order to become thinner. However, it frequently becomes a habit that is hard to break and their whole lives may be concentrated on bingeing and vomiting. Frequent vomiting leads to unpleasant mouth odour and can promote tooth decay, so sufferers tend to be secretive, to avoid close contact with other people, and to clean their teeth several times during the day. Famous bulimics have included Princess Diana and Audrey Hepburn.

Anorexia nervosa and bulimia nervosa are sometimes regarded clinically as different forms of the same illness.

A number of ‘causes’ are believed to underlie these conditions. Those most discussed are disturbed family relationships and social pressures to be thin. Some sufferers also use their obsession with food as a means of controlling their families, perhaps by creating parental anxiety or by insisting that they do all the family cooking and preventing their parents going away because they are doing this. Some have very dominant mothers and feel that the only way in which they can gain power themselves is by controlling their intake of food.

A theory has arisen that anorexia and bulimia are ‘caused’ by sexual abuse in childhood. Sometimes there is an association between the two. However, therapists of doubtful training and repute have suggested that those with eating disorders have invariably been abused in childhood. In pursuit of this belief they may have used persuasive techniques to elicit many apparent ‘memories’ of sexual abuse of which the patient was previously unaware. This has given rise to what has been labelled ‘false memory syndrome’, which has disrupted many otherwise intact families. The current view among most psychiatrists is that true memories of sexual abuse in childhood are seldom if ever repressed and that ‘memories’ which emerge for the first time during treatment, especially with a therapist who believes that they must be there, should be treated with great caution.

Anorexia nervosa was identified by William Gull in the nineteenth century. It has certainly existed for much longer, perhaps throughout the history of civilization, wherever there was ample food. It used to be regarded as a rare condition, partly because doctors tended to believe what their patients told them, and to look for physical disease. Many cases in the past were probably misdiagnosed as tuberculosis, endocrine disease (such as Simmond's disease, a failure of the pituitary gland), or loss of weight from unknown cause. The secretiveness and deceptiveness of the patients made the diagnosis difficult for those who were unaware of this tendency. Since then doctors have realized that anorexia nervosa is usually not difficult to identify and that bulimia is much more common than was supposed.

The recorded incidence of anorexia nervosa increased greatly during the 1950s and 1960s, and it became a worrisome epidemic, especially in girls' boarding schools. This rise was undoubtedly partly due to the increasing recognition of the condition by doctors, but partly because of the fashion for thinness, which became popular and was accompanied by hostility to plumpness and fear of gaining weight. Those responsible for the care of young girls have shown hostility towards the fashion trade's flaunting of skeletal models to display and advertise clothes, but the custom persists, as does the epidemic of anorexia, which is found at ever younger ages, even as young as 6 or 7. Some of the youngest sufferers are the children of anorexics and bulimics, many of whom raise their families with bizarre attitudes towards food. Doctors have expressed anxiety about the threat to health in children who are fed on skimmed milk and high fibre food, virtually free of sugar and fat. Such a diet is unsuitable for growing bodies and can cause long-term damage. The fact that eating disorders tend to run in families may not be entirely due to parental feeding practices: it seems likely that there is a genuine genetic factor in their causation.

The ‘epidemic’ of anorexia may now have peaked as the incidence seems no longer to be rising. According to figures from the Eating Disorders Unit in the University of London, during 1988–93 the incidence of anorexia remained stable at about 20 cases per 100 000 of the population, whereas the incidence of bulimia rose from 15 to 50 cases per 100 000. This apparent dramatic rise in bulimia can be at least partly explained by the fact that the disease was first described in 1979: doctors and the public have only gradually become aware of it. Probably it was common before it was identified. Since the sufferer usually looks normal, the condition is unlikely to be diagnosed unless the sufferer admits to having the problem or their behaviour is noticed by others.

Some people with these conditions recover spontaneously but many need help, which they are often reluctant to seek. Various treatments have been tried, including incarceration with ‘rewards’ (such as having visitors) for weight gain, sedatives (to suppress activity), and various forms of psychotherapy. Antidepressant drugs are often quite effective and many clinicians believe that there is considerable overlap between eating disorders and depression.

Obesity represents the other end of the eating disorders spectrum. Classically, it is a problem of middle age, but its incidence has been rising, even among young children, especially in the developed world. It affects women more than men and lower social classes more than upper. It is associated with higher than average morbidity and mortality. Heart disease, high blood pressure, diabetes, and even accidents are much more common in overweight people than in those of normal weight. Obesity is commonest where food is ample but protein is expensive and it is particularly likely to develop in people whose diet is high in processed foods, since these often contain many ‘hidden’ calories in the form of fat and sugar. The recent increase in obesity is thought to be related to the sedentary and labour-saving characteristics of modern life in the developed world. People drive cars rather than walk, guide the vacuum cleaner rather than scrub the floor, and spend much time watching television. A sedentary lifestyle makes it difficult to lose weight. Many people control any tendency to gain weight by deliberately taking exercise, perhaps joining a gym or playing an energetic game regularly, but others dislike taking exercise. It is often harder to persuade a patient to take exercise than to keep to a slimming diet.

Ann Dally

See also dieting; development and growth; obesity.