Eating Difficulties and Eating Disorders

“I am scared of eating and becoming fat”

Anorexia is an eating disorder causing people to fixate on their weight and how much they eat. An individual with anorexia nervosa may demonstrate a range of symptoms including a restriction of caloric intake, excessive exercising and rigid food rules leading to low body weight.

Anorexia is a serious, potentially fatal, disorder characterised by a compulsion for self-starvation and/or excessive exercise, severe weight loss, distorted body image and impaired thinking, particularly around issues of food, weight and body. The illness can cause severe medical complications such as bone loss and heart dysfunction and is often experienced along with other psychological challenges including depression, obsessive compulsive disorder, self-harm or suicidal ideation. Anorexia nervosa has two forms – restricting subtype and binge eating/purging subtype – and patients may swing from one subtype to the other during the course of the illness.

“I am full but I can’t stop”

Binge-eating disorder is the regular occurrence (at least once per week) of bingeing. Binges are discrete instances where someone eats an amount of food that is definitely larger than average, in a way that feels out of control and causes significant distress. Binge-eating is a serious mental illness characterised by regular episodes of binge eating. A person with Binge eating disorder will not use compensatory behaviours, such as self-induced vomiting or over-exercising after binge eating.

Additional Resources for Binge-eating disorder:

Overcoming Binge Eating

The Stop Binge Eating Podcast

Other symptoms associated with binge-eating include an intense fear of gaining weight, frequently eating until uncomfortably full, eating large amounts of food when not physically hungry and an inaccurate perception of one’s body weight or shape.

“I will eat now and purge later”

Bulimia nervosa is characterised by the regular occurrence of binge-eating followed by unhealthy behaviours to compensate for overeating. A binge is where someone eats an above average quantity of food at one sitting causing a sense of lost control and significant distress. 

Bulimia is a serious, potentially fatal, disorder characterised by frequent binge eating followed by inappropriate compensatory behaviours, and is diagnosed when occurring on average at least twice a week for at least 3 months. Bulimia is classified into two subtypes. The purging subtype is characterised by the use of self-induced vomiting, laxatives, enemas, or diuretics; or the non-purging subtype, where fasting or excessive exercising is used to compensate for binge eating.

Other symptoms associated with bulimia nervosa include an intense fear of gaining weight, feelings of shame and self-disgust and an inaccurate perception of one’s weight and shape.

“The quality and purity of my food is paramount”

Orthorexia refers to an obsession with eating healthy food and avoiding unhealthy food. Although it is not recognised as a clinical eating disorder, left untreated and/or combined with other risk factors, orthorexia can progress into a full clinical eating disorder.

Eating disorders are typically brought on by a combination of factors, feelings and life pressures. The most common risk factors for an eating difficulty or eating disorder include:

• Experiences of trauma
• Low self-esteem
• Lack of confidence
• Trouble at school, university or work
• Long-term illness
• Sexual or emotional abuse
• Academic or social pressures

It is possible to live a life free from the stresses of an eating disorder. Through treatment of an eating disorder, you will acquire new tools for life as you work through the emotions that underlie your symptoms relating directly to food. Given that it is not uncommon for individuals be to be tempted to return to eating disorder behaviors during stressful periods, an important part of treatment will involve establishing a plan to cope with future stressors and triggers that cause distress or urges to engage in eating disorder behaviours. It is suggested to build a support system that can be drawn upon to help you navigate challenging times in life, and identifying the signs that indicate you might need to seek further treatment.

Eating disorders are estimated to affect approximately 4% of Australians, or around 1 million people.

Eating disorders are complex illnesses, impacted by genetic, biological, psychological and socio-cultural factors. Research is yet to identify a single ’cause’ explaining why some people develop an eating disorder. It is much more likely that some people have personal characteristics that make them vulnerable to developing an eating disorder and that the experience of specific life events then trigger the onset of illness. Once the illness is triggered, particular factors come in to play, acting to maintain the disorder.

The period of adolescence is one of intense change which can bring with it a great deal of stress, confusion and anxiety for many. The physical transformation that takes place during this time is enormous and often intertwined with feelings of self-consciousness, low self-esteem and comparison with peers. In addition, there are hormonal and brain changes taking place which affect a person physically, mentally, emotionally and psychologically. There is also the issue of social and environmental change, with the period of early adolescence often being a time when a person will change schools, friendship groups and perhaps develop an interest in the opposite or same sex. All in all, adolescence is a time where many big changes take place in a seemingly short period of time whereby a person may feel tremendous pressure to find their place in the world despite a great deal of confusion, and a sense of feeling ill-equipped or welcome to the plethora of changes around them. In light of the stress and confusion that accompanies the period of adolescence, it is little surprise that an individual may struggle to deal with the whirlwind of change, uncertainty and often low self esteem. Eating disorders are very often a coping mechanism for people to attempt to gain control of their situation when they feel helpless in the face of other aspects of their life. When this quest for control goes too far, the risk of developing an eating disorder dramatically increased. In addition, body image concerns and peer pressure are heightened during the period of adolescence, and are potential risk factors in the development of an eating disorder.

There are two main treatment options that we offer at Wise Institute. The first option is Maudsley Family Based Therapy (FBT) and the second is Enhanced Cognitive Behavioural Therapy (CBT-E).

Maudsley Family Based Therapy (FBT)

The Maudsley Model of family based treatment is an outpatient treatment that involves the family working together to defeat the anorexia their child is experiencing. It is suitable for children and adolescents who have short course of illness (less than 3 years) and are under 19 years of age. The Maudsley model has 3 clearly defined phases.

Phase 1 of treatment focuses on the eating disorder. The parents are charged with re-feeding their young person, with weekly treatment sessions. Therapy focuses on food related issues and behaviours that are preventing the young person putting on weight. Each session the young person is weighed and the direction of weight gain (loss or gain) dictates the direction of the session. Typically the therapist will spend time with the young person by themselves at the weigh time and use this time to enhance engagement. This will span over 10-20 sessions.

As the family enters Phase 2, the mood of sessions should become lighter as the parents are feeling more in charge and the young person is less captured by the anorexia. The young person is still weighted each session and still has some weight to put on. The challenge now is for the young person to take back ‘normal’ adolescent control of food and their life at a pace they can handle without relapse. This will span approximately 9 sessions, and the sessions occur on a fortnightly basis.

Phase 3 is the briefest phase of treatment and aims to ensure that the young person has taken up a taken hold of their adolescent world again. Likewise the parents can now relax and reinvest in their lives and relationship. Adolescent issues that may have been present at the development of the eating disorder may now be explored if still required. If other family or couple issues need to be addressed then referral or recontracting therapy may be required to address these issues. This will span approximately 6 sessions, but this can vary greatly, with the sessions spaced out to monthly or every 6 weeks.

Research

To date there have been 4 randomised controlled trials of Maudsley Family Therapy. The first (Russell et al, 1987) compared the Maudsley Model to individual therapy and found that family-based treatment was more effective for patients under 19 years of age with less than three years duration of illness. Ninety percent of these patients achieved a normal weight or the return of menses at the end of treatment including at 5 year follow-up (Eisler, et al, 1997). Two further randomised trials compared standard Maudsley treatment with a modified version where the patients and parents were seen separately (Le Grange et al 1992, Eisler et al, 2000). In these trials approximately 70% of patients returned to a normal body weight (>90% IBW) or experienced the return of menses at the end of treatment, regardless of which version of the model was employed. Finally, the outcome using family based treatment appears just as positive for children (9-12 years old) as it does for adolescents (Lock et al, 2006).

Enhanced Cognitive Behavioural Therapy (CBT-E)

Enhanced Cognitive Behavioural Therapy (CBT-E) on the other hand is more suited to older adolescents or adults. It is considered one of the leading empirically supported treatments for eating disorders. It is based on a Transdiagnostic perspective of eating disorders and thus provides treatment for Eating Disorder psychopathology rather than a specific Eating Disorder diagnosis; it is thus applicable across a range of Eating Disorder diagnoses. CBT-E is most commonly used in the treatment of bulimia nervosa. It is delivered in 4 defined stages. CBT-E focuses on the links between thoughts, emotions and behaviours. It helps people to identify and change unhelpful thinking styles or beliefs that perpetuate the eating disorder and to learn healthier ways of coping and relating to issues of food, shape and weight.

Research

Currently, research supporting the use of CBT-E is limited. Cognitive behavioural therapy (prior to it being enhanced) was the clear leading treatment for bulimia nervosa in adults. However, research indicated that CBT for bulimia resulted in only fewer than half of the patients who completed treatment making a full and lasting recovery. The new “enhanced” version of the treatment (CBT-E) appears to be more effective; however no clear statistics are available on treatment efficacy. In adolescents the research has focused mainly on family therapy (as this is the first line treatment), with the result that the status of CBT in younger patients is unclear. Preliminary findings have been reported from a 3-site study of the use of the enhanced form of CBT (CBT-E) to treat outpatients with anorexia nervosa. This is the largest study of the treatment of anorexia nervosa to date. In brief, it appears that the treatment can be used to treat about 60% of outpatients with the disorder (BMI 15.0 to 17.5) and that in these patients about 60% have a good outcome. Interestingly and importantly the relapse rate appears low. When comparing the two treatment approaches for adolescents, Maudsley FBT tends to demonstrate better outcomes when compared with individual adolescent focused therapy.