What is Anorexia and Bulimia?

Eating disorders include any difficult relationship with food. Anyone can experience problems with food, regardless of their age, gender, weight or background. In the UK between 1.25 and 3.4 million people are affected by an eating disorder.

According to NICE in the UK, there are:

• 266,300 people aged 16 and over with anorexia nervosa.
• 443,800 people with bulimia nervosa.
• 1,398,000 people with binge-eating disorder.
• 1,309,000 people with other specified feeding and eating disorders.

This accounts for, respectively:

• 0.6% of the population who have anorexia nervosa.
• 1% who have bulimia nervosa.
• 3.2% who have binge-eating disorder.
• 3% who have another specified feeding and eating disorder.

In 2018/19, there were 19,040 admissions to hospital due to eating disorders; this was up from 13,885 in 2016/17. In 2018/2019, 25% of admissions to UK hospitals for eating disorders were for children under the age of 18, according to NHS statistics.

The NICE data suggests that 90% of those with eating disorders are female. Eating disorders affect up to 15% of young women and 5.5% of young men in high-income countries.

What is Anorexia and Anorexia Nervosa?

The terms anorexia and anorexia nervosa have often been used interchangeably; however, they are not the same. When Anorexia is used by itself it simply describes a loss of appetite or inability to eat. It may not always be due to a person’s pathological obsession with losing weight; it often occurs secondary to other conditions such as depression, cancers, infections or as a side effect of medications.

Anorexia Nervosa, which is also known more generally as anorexia, is an eating disorder and serious mental health condition. People who have anorexia nervosa often have a distorted image of their bodies, believing that they are overweight even when they are underweight. Usually it starts in the early teens and most commonly affects young women, although young men are also affected.

The effects of anorexia nervosa are both short and long term. There are the immediate physical effects as the body struggles to function without the nutrients and fuel that it needs. The sufferer is also at risk of developing long-term and potentially life-threatening health problems, particularly if the condition is untreated for many years.

Anorexia nervosa sufferers can experience some or all of the following:

• Abdominal pains.
• Bloating.
• Constipation.
• Disrupted menstrual cycles or no periods at all.
• Dizzy spells and fainting.
• Dry, yellow coloured skin.
• Early morning waking.
• Muscle weakness.
• People with anorexia often develop long, fine downy hair on face and body.
• Poor circulation resulting in feeling constantly cold.

In the longer term, people with eating disorders are at risk of developing osteoporosis, a disease which results in the density of the bones reducing. This is because their bodies are deprived of the vital nutrients such as calcium, which is the most important nutrient that bones need in order to grow and remain strong.

This is particularly serious in young people because dangerous eating patterns commonly develop from the age of 13 and throughout the teens, when the bones are still growing and reaching peak strength. People suffering from anorexia nervosa may be prone to painful fractures, particularly in the spine and hip, persistent and disabling pain and loss of height.

Infertility is another serious and common complication of anorexia nervosa. If a woman’s body fat falls dramatically, she will no longer produce the hormone oestrogen, which is necessary to stimulate ovulation. Anorexia nervosa affects the menstrual cycle and if the menstrual cycle and ovulation is disrupted or suppressed for a long time, this can affect fertility.

Anorexia nervosa has the highest mortality rate of all forms of mental illness, with rates of between 10% and 15%. A significant proportion of these deaths are due to heart failure as a result of long-term, severe anorexia nervosa.

The heart is often damaged when anorexia nervosa has become severe; it results in the loss of muscle mass, including heart muscle. Consequently, the muscles of the heart can physically weaken, there can be an overall drop in blood pressure and pulse and this can contribute to slower breathing rates.

There is also not enough body fat to protect the heart, anaemia, which weakens the blood, can develop and there is commonly poor circulation. This means that the heart is not able to pump and circulate blood effectively. Anaemia is a common result of anorexia nervosa and starvation. A particularly serious blood problem is pernicious anaemia, which can be caused by severely low levels of vitamin B12.

If anorexia nervosa becomes extreme, the bone marrow dramatically reduces its production of blood cells, resulting in a life-threatening condition called pancytopenia.

People with severe anorexia nervosa may suffer nerve damage that affects the brain and other parts of the body. This can lead to nerve affected conditions including the development of seizures, confused thinking and extreme irritability and numbness or odd nerve sensations in the hands or feet, known as peripheral neuropathy.

Brain scans show that parts of the brain can undergo structural changes and abnormal activity during anorexic states. Some of these changes return to normal after weight gain, but there is evidence that some damage may be permanent.

What is Bulimia and Bulimia Nervosa?

Bulimia nervosa, also known simply as bulimia, is an eating disorder characterised by binge eating followed by purging. Binge eating refers to eating a large amount of food in a short period of time. Purging refers to the attempts to get rid of the food consumed. This may be done by vomiting or taking laxatives.

The physical effects bulimia nervosa has on the body are serious, harmful and, if left untreated, can result in long-term problems. Bulimia effects can, for some, become life-threatening and certainly for many, bulimia can have a long-term health impact. There are multiple effects from the cycle of bingeing and purging that are characteristic of bulimia.

These include:

• One of the most well-known bulimia effects is “Russell’s sign” calluses on the knuckles and hands caused when inducing vomiting, as this part of the hand scrapes against the teeth. Russell’s sign, however, is not present in all people with bulimia; many will purge without causing this bulimia effect and may depend on other types of purging such as laxatives or over-exercising.
• Tooth decay is closely linked to the binge-vomit cycle because the contents of the stomach are highly acidic and repeated cycles of vomiting cause tooth enamel to break down through this acidic content. Tooth decay caused by bulimia may be permanent and difficult to treat. Bad breath is another bulimia effect.
• Face swelling is one of the bulimia effects sufferers find most distressing: sometimes described as “bulimia face”, the swelling can make people feel their face looks fat. What is taking place is the body’s reaction to self-induced vomiting and the dehydration it causes. The body reacts by trying to hold on to as much water as possible and this is most evident in the parotid glands around the jawline and side of the face.
• Sore throat and stomach complaints caused through purging.

Bulimia has a devastating impact upon the whole body in the long term, causing multiple serious effects, such as:

• Electrolyte imbalance, particularly potassium. Electrolytes are electrically charged salts or ions used by the body to regulate hydration; that is, how much water is present in the body, nerve and muscle function is determined by hydration. A long-term pattern of purging leaves the body’s electrolytes in a persistent imbalance, and this also affects the heart and kidney function. Potassium is an electrolyte which is also classified as a mineral and this is often depleted by the binge-purge cycle; potassium is particularly important for heart function. People with bulimia should have a potassium level test and receive a supplement, if required, because very low potassium levels can cause irregular heart rhythms and the breakdown of heart tissue fibres.
• Other long-term physical effects of bulimia nervosa and potential risks include menstrual cycle disruption and associated fertility problems. Chronic fatigue caused by the constant depletion of nutrients during purges is also a risk, together with future problems with bone health, due to loss of calcium.

What is the difference between Anorexia and Bulimia?

Anorexia nervosa and bulimia are both eating disorders. They can have some similar symptoms, such as distorted body image. Both anorexia nervosa and bulimia are characterised by an overvalued drive for thinness and a disturbance in eating behaviour.

The main difference between diagnoses is that anorexia nervosa is a syndrome of self-starvation involving significant weight loss of 15% or more of ideal body weight, whereas patients with bulimia nervosa are, by definition, at normal weight or above.

Some anorexia nervosa sufferers also engage in bingeing and purging behaviour; however, the diagnosis of anorexia nervosa supersedes that of bingeing/purging. Excessive exercise aimed at weight loss or at preventing weight gain is common in both anorexia nervosa and in bulimia.

What is Binge eating?

Binge-eating disorder (BED) resembles bulimia but without compensatory behaviours to avoid weight gain, for example vomiting, excessive exercise, laxative abuse. It involves regularly eating a lot of food over a short period of time until you are uncomfortably full.

Binges are often planned in advance, usually done alone, and may include special binge foods. The main symptom of binge-eating disorder is eating a lot of food in a short time and not being able to stop when full.

Other symptoms include:

• Eating when not hungry.
• Eating very fast during a binge.
• Eating alone or secretly.
• Feeling depressed, guilty, ashamed or disgusted after binge eating.

The causes of binge-eating disorder are unknown, but genetics, biological factors, long-term dieting and psychological issues increase the risk. The severity of binge-eating disorder is determined by how often episodes of bingeing occur during a week.

Men and women of any age can develop binge-eating disorder, but it usually starts in the late teens or early 20s. If you have any symptoms of binge-eating disorder, seek medical help as soon as possible. Binge-eating problems can vary in their course from short-lived to recurrent or they may persist for years if left untreated.

What is the cause of Anorexia and Bulimia?

As we have seen above, anorexia is a symptom characterised by a lack of desire or inability to eat.

It may be caused by many reasons such as:

• Depression
• Fever or infections.
• Heart diseases.
• Lung conditions.
• Kidney diseases.
• Bowel conditions such as ulcers, hyperacidity or gastritis.
• Cancer treatment or other medications.

However, the cause of anorexia nervosa is not well understood. Studies suggest that genes may play a role as the condition sometimes runs in families. While anorexia nervosa typically begins to manifest itself during early adolescence, it is also seen in young children and adults.

Based on research, the factors causing anorexia nervosa include:

• Genetics.
• Environmental and emotional factors such as harassment, abuse, failed relationships, loneliness.
• Social factors such as peer pressure to lose weight.
• Psychological factors such as lack of self-esteem, anxiety, feeling of inadequacy.
• Hormone changes regulating how the body and mind influence thoughts, mood, appetite and memory.

It is not possible to pinpoint a single cause for why someone may have developed bulimia nervosa because there are many influences in each individual’s life that may have been contributing factors. As with anorexia nervosa, family history, home life and genetic background can all play a role in whether someone is at risk of developing bulimia.

These are just some examples of common causes and risk factors that can lead to the onset of bulimia:

• Having a family member who has bulimia.
• Being overweight as a child.
• Suffering from sexual or physical abuse.
• Struggling with another mental health condition.
• Having low self-esteem.

Signs and symptoms of Anorexia and Bulimia

Anorexia nervosa can be a difficult disorder to diagnose, since individuals with anorexia nervosa often attempt to hide the disorder.

Denial and secrecy frequently accompany other symptoms such as:

• The individual can become seriously underweight, which can lead to or worsen depression and social withdrawal.
• The individual can become irritable and easily upset and have difficulty interacting with others.
• Sleep can become disrupted and lead to fatigue during the day.
• Attention and concentration can decrease.
• Most individuals with anorexia nervosa become obsessed with food and thoughts of food. They think about it constantly and become compulsive about their food choices or eating rituals.
• Individuals may collect recipes, cut their food into tiny pieces, prepare elaborate calorie-laden meals for other people, or hoard food.
• Individuals may exhibit other obsessions and/or compulsions related to food, weight or body shape that meet the diagnostic criteria for an obsessive-compulsive disorder (OCD).
• Other psychiatric problems are also common in people with anorexia nervosa, including affective (mood) disorders, anxiety disorders and personality disorders.
• Physical appearances are important to the anorexia nervosa sufferer. Performance in other areas is stressed as well, and they are often high achievers in many areas.
• Individuals may have had at some point in their lives, addictions to alcohol, drugs or gambling, and other compulsions involving sex, exercising, housework and shopping are not uncommon. In particular, people with anorexia nervosa often exercise compulsively to speed the weight-loss process.
• Symptoms of anorexia nervosa in men tend to co-occur with other psychological problems and more commonly follow a period of being overweight than in women. Men with anorexia nervosa also tend to be more likely to have a distorted body image.

Everyone experiences bulimia nervosa differently, but there are some behaviours that might be a sign that someone is struggling with bulimia.

These include:

• Frequently weighing themselves.
• Often judging their appearance in the mirror, fear of putting on weight, being very critical about weight and body shape.
• They won’t eat at restaurants.
• They are always on a new diet.
• They don’t eat at regular mealtimes.
• Keeping large amounts of food around the house and large amounts of food suddenly disappear.
• Eating very large amounts of food in a short time, often in an out-of-control way – this is called binge eating.
• Making frequent trips to the bathroom after meals or often take laxatives or diuretics.
• Wearing baggy clothes.
• Exercising excessively.
• They stop spending time with friends and family.
• They become increasingly moody.

The way bulimia affects each individual can vary depending on their genetics, medical history, and how long they’ve struggled with this illness. These symptoms may not be easy to spot in someone else because bulimia can make people behave very secretively.

What are the types of treatment available for Anorexia and Bulimia?

Anorexia caused by secondary conditions is easier to manage by treating the underlying cause of the person’s loss of appetite. For example, if the person has anorexia due to acidity or gastritis their appetite will be restored by managing the gastritis. Sometimes chemotherapy in cancer patients compromises their ability or desire to eat, in which case appetite stimulants may be prescribed to treat this cause of anorexia.

The treatment for anorexia nervosa is more complex and involves three main principles:

• Stabilising the weight loss.
• Starting nutrition rehabilitation to restore healthy weight.
• Treating emotional issues such as low self-esteem, distorted thinking patterns and developing long-term, healthy behavioural changes.

Recovery will be different for everyone; treatment plans will be tailored to the individual’s needs.

Talking therapies that are commonly used to treat anorexia nervosa in adults include:

• Cognitive behavioural therapy (CBT).
• Maudsley Anorexia Nervosa Treatment for Adults (MANTRA).
• Specialist supportive clinical management (SSCM).

Under 18s, can be offered family therapy or adolescent-focused psychotherapy.

According to the Royal College of Psychiatrists up to 60% of adolescents with anorexia nervosa make a full recovery when they receive early expert treatment.

Guided self-help programmes are often a first step in treating bulimia. This often involves working through a self-help book combined with sessions with a healthcare professional, such as a therapist.

These self-help books may take you through a programme that helps you to:

• Monitor what you are eating – This can help you notice and try to change patterns in your behaviour.
• Make realistic meal plans, planning what and when you intend to eat throughout the day – This can help you to regulate your eating, prevent hunger and reduce binge eating.
• Learn about your triggers – This can help you to recognise the signs, intervene and prevent a binge-purge cycle.
• Identify the underlying causes of your disorder – This means you can work on those issues in a healthier way.
• Find other ways of coping with your feelings.

Bulimia sufferers may also be offered cognitive behavioural therapy (CBT); children and young people will usually be offered family therapy.

Help and support available

If you have anorexia or anorexia nervosa you might feel and or do some or all of the following:

• Have an obsession with food.
• Feel like it’s an achievement to deny yourself food and exercise.
• Feel like you need to be perfect or are never enough.
• Have a need for control.
• Hide secrets from friends and family.
• Feel that you are fat and that losing weight is never enough.
• Feel depressed or suicidal.
• Reduce your food intake or stop eating entirely.
• Hide food or throw it away.
• Count calories.
• Cook meals for others without eating the food yourself.
• Use drugs to reduce your appetite.
• Exercise a lot.
• Create rules around eating, for example having good or bad foods.
• Eat at structured times throughout the day.

If you suffer from bulimia you might feel and or do some or all of the following:

• Feel shame or guilt.
• Feel that you are fat.
• Have hatred towards your body.
• Feel lonely and fearful of being found out.
• Experience low moods.
• Think you are stuck in a cycle feeling out of control.
• Go through daily binge and purge cycles.
• Binge on foods that you consider unhealthy.
• Starve yourself between binges.
• Eat in secret.
• Get rid of food using laxatives or by making yourself sick.
• Crave only certain types of food.

If you are feeling and or doing any of the issues above, it may seem daunting to talk to your GP about your eating problem, but they should be able to refer you to a specialist service which should be really helpful for your recovery.

You can also get help and support for yourself or for a friend or family member who may be suffering eating problems from:

• Mind Infoline 0300 123 3393
• Anorexia and Bulimia Care 03000 111213
• Youth Access Search for local services
• Eating Disorders Support 01494 793223
• National Centre for Eating Disorder Help – NCFED 0845 838 2040
• Young Minds 0808 802 5544

People suffering with eating disorders may be referred to a clinic or hospital if they are very underweight or unwell; in most cases patients will have agreed or volunteered to be there.

However, there are some extreme life-threatening situations in which a person can be sectioned under the Mental Health Act (1983) and treated without their agreement.