‘Eating Disorder’ vs ‘Disordered eating’ – though these terms are often used interchangeably, where to draw the line can be a decision that is difficult to make. So when does ‘disordered eating’ become an eating disorder? And how do you distinguish disordered eating from normative dieting behaviours that seem to be so prevalent in todays society?
Statistics from the National Institute of Mental Health suggest that 2.7 percent of adolescents suffer from an eating disorder. This number seems to be on the increase in younger children (age 8 – 11) and in males. However this is a relatively small percentage compared to suggested rates of disordered eating. It is thought that up to 50% of the population demonstrate a problematic or disordered relationship with food, exercise or their body image. In our culture there exists an increasingly prevalent obsession with size and weight, diet and exercise, meaning that many people may see their disordered relationship with food as ‘normal’. There remains a huge number of people with disordered eating who never seek help for their difficulties and the tendency to see these behaviours as ‘common, normal , or ‘healthy’ may contribute to this.
The most recent version of The Diagnostic and Statistical Manual of Mental Disorders (DSM-V) recognizes 4 different categories of eating disorder: Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder, and Eating Disorder Not Otherwise Specified (EDNoS). This last category was designed to describe behaviors that meet some but not all of the criteria for anorexia or bulimia. EDNoS is actually a far more prevalent eating disorder than either anorexia or bulimia and it is likely that a large number of people with ‘disordered eating’ would meet criteria for EDNoS. Falling into this category does not mean that a person has a less significant problem with food, or that their difficulties exist without physical or emotional risk.
So what are the symptoms of disordered eating?
Symptoms of disordered eating may include the kind of behaviours that are commonly associated with the other three categories of eating disorder:
However, disordered eating might also include:
What distinguishes disordered eating from a diagnosable eating disorder is mainly about degree, and the amount of distress that changes to eating, weight or behaviour evokes. If someone engages in ‘disordered eating behaviours’ on a majority of days, or experiences distress and anxiety either when they are unable to use these behaviours or when they have chosen not to, it is likely that they may be diagnosed with an eating disorder. In our experience it seems that many people with ‘disordered eating’ would not view themselves as having an eating disorder, and would rarely even consider themselves to have disordered eating. It is more likely that they will see themselves as ‘getting it right’ or ‘being healthy’. However when food choices are made due to anything other than hunger and appetite, when food preferences are held with more importance than other things like attending social events, and when eating has the ability to evoke strong negative emotions – we would very much argue that this is an eating disorder and should therefore be taken seriously.
Many people see these behaviours as common, normal or healthy. However, whilst the behaviours might be increasinly prevalent in todays culture, they are certainly not healthy. Disorderd eating puts people at high risk of developing other physical and mental health conditions including more severe eating disorders. Other consequences may include:
• Concentration and ability to focus – people describe spending a huge amount of time thinking about or planning food and exercise – time that could (or should) often be spend focusing on other things.
• Social life – socializing is often limited due to anxiety about eating out in restaurants or prioritization of exercise.
• Coping skills – diet and exercise often starts to become a way of ‘coping’ with difficult life events. Whilst this may feel like an effective strategy in the short term, it actually prevents people from using healthy ways of coping with emotions meaning that stress can build up over time.
• Difficult emotions – thoughts about food and weight often start to become anxiety provoking, putting people at risk of depression or chronic anxiety
If your eating is causing you distress, or starting to have a negative impact on any areas of your life it is probably time to seek help. Many people avoid seeking help as they fear that their problem isn’t serious enough, or they feel anxious about what help will involve. If you want to, then it is never too soon to get help with what may become a significant problem the longer you allow it to continue.
There are a multitude of physical, emotional and psychological consequences of eating disorders. One of the issues that we commonly get asked about is what impact eating disorders have on fertility – both short term and long term.
Concern about fertility is one of the most common reasons that women cite for seeking treatment for an eating disorder. Whilst we still don’t feel that there is enough research in this area to be able to give a definite statement about the long term impact of either anorexia or bulimia on fertility, we do know that women with current eating disorders are more likely to experience fertility problems.
It is fairly well known that in restrictive eating disorders, where periods stop due to low weight, fertility issues are very likely. However studies have also identified fertility difficulties in women with eating disorders who are at a healthy weight.
A research study done in 2013 (Int J Eat Disord 2013; 46:826–833) is the most recent study that we are aware of that investigated the impact of a current eating disorder on fertility. The researchers compared 2,257 women with a current diagnosis of an eating disorder with 9,028 women without an eating disorder. An advantage of this study is that it explored fertility issues in women across all eating disorder diagnoses: anorexia nervosa, bulimia nervosa, atypical eating disorder and binge eating disorder.
The researchers found that across all eating disorders, women were more likely to be childless. Whilst this doesn’t necessarily point to fertility problems in itself, it does support previous research in highlighting the presence of increased fertility difficulties in women with eating disorders. This research also found that women with bulimia nervosa or binge eating disorder were at increased risk of miscarriage.
Previous research has also found that in restrictive eating disorders with resulting low weight, up to 1/4 of patient may never regain normal menstruation cycles, suggesting that fertility may be affected even following successful treatment. In women that do become pregnant there is a known increased risk of complications like miscarriage, birth defects and low birth weight babies, Cesarean section, and postpartum depression.
We would reinforce that we don’t feel there is enough research at present to know what the long term fertility implications for people in recovery from an eating disorder are. There is some evidence though that fertility may not always return to normal once a person has fully recovered from an eating disorder. We would suggest that this is more likely if the eating disorder has been severe and long term.
I you are concerned about the impact of an eating disorder on your fertility, we would encourage you both to seek professional help and to be open about your eating disorder history with your GP or any other professional involved in your fertility care.
Thinking traps may also be referred to as ‘thinking errors’ or ‘cognitive distortions’. Most people use thinking traps from time to time, however they tend to be more common in people who experience psychological distress such as anxiety or depression. They are also very common in people with disordered eating. Often people will use these thinking traps so often they they will not be aware that they are using them. However, awareness of these thinking styles can be an important stop in understanding and changing unwanted moods and behaviours.
Here are eleven of the most common thinking traps that you might have experienced:
1. Mental Filter
Mental filtering is when we focus exclusively on the most negative and upsetting features of a situation, filtering out all of the more positive aspects.
Example: You undertake a performance review at work which is ninety-five percent positive and complimentary – but you dwell and focus exclusively on the five percent of the review that mentioned ways in which you could have performed better. This leaves you feeling that you are a failure, that you haven’t done well enough and that your boss sees you in a negative way. The impact of this mental filter may be that you not only don’t recognise the praise that you were given but that you start to feel anxious or low when thinking about your job.
2. Disqualifying the Positive
Disqualifying the positive is when we continually discount and dismiss the positive experiences we encounter, by deciding they are unimportant or ‘don’t count’. Positive information or experiences may be seen as a fluke.
Example 1: A friend compliments you on a dinner you made, but you decide that “they are just saying that to be nice” or “they are trying to get something out of me”.
Example 2: “I know I wear a size 10-12, but my thighs are too big”, “He only asked me out because he was lonely or feels sorry for me, he doesn’t really like me”.
3. ‘Black and White’ or ‘All or Nothing’ Thinking
This involves thinking in extremes, with no middle ground. These types of thoughts are characterised by terms such as or ‘every’, ‘always’, or ‘never’ . Everything is seen as good or bad or a success or failure. It is generally the negative perspective that is endorsed, discounting all the shades of grey that lie in between the two focussed on choices.
Example 1: If you get eighty per cent on a test, you feel like a failure that you didn’t get a perfect score.
Example 2: People with eating disorders often believe that if they can’t be ultra-thin, they will be obese, and that they must be completely in control of their eating or there will be chaos. You may believe that if you begin eating normally you will lose all control and end up extremely overweight. When you think this way you are thinking in extremes; ultra thinness and obesity are not the only alternatives, in fact your body functions best within a natural weight range, which is somewhere between these two extremes.
To avoid black and white thinking it is often helpful to look for the grey area in between. Look for all the possible alternatives. For example “Getting a mix of As, Bs and Cs for my exams is fine and does not mean I am a failure” or “Obesity is not the only alternative to thinness, it is more likely that I will be in a healthy weight range”.
Thinking in an over-generalising way means we will often see a single unpleasant incident or event as evidence of everything being awful and negative, and a sign that now everything will go wrong.
Example 1: If you fail to get a job you interview for, you decide you are never going to get a job.
Example 2: If you go on one unsuccessful date, you decide you are never going to find a partner.
Example 3: Believing that if something turns out badly once, then it will always happen that way. For example, failing your driving test and believing you are totally inadequate in all areas of your life.
For people with eating disorders a common generalisation is thinking that because I have put on some weight, I am just going to continue to put on weight forever. However, the facts show us that initial weight gain following re-introduction of regular eating is your body counteracting effects of past deprivation or starvation.
5. Jumping to Conclusions
This thinking trap involves making a negative interpretation or prediction even though there is no evidence to support this conclusion. This type of thinking is often made when thinking about how others feel towards us. It can show up as either ‘mind reading’ (assuming the thoughts and intentions of others) or ‘fortune-telling’ (anticipating the worse ad taking it as fact).assuming the worst even when there is no reason to.
Example 1: “People are staring at me because I am so fat” (mind reading).
Example 2: “My boss wants to speak to me – I must have made a massive mistake and I’ll get the sack” (fortune telling).
Example 3: “Sarah didn’t call – I must have done something to upset her” (mind reading).
Example 4: You are at a party and you don’t like what you are wearing and you decide ‘everyone is laughing at me’ (mind reading).
Example 5: You are going to take your drivers test and ‘know’ that you are going to fail (fortune-telling).
6. Magnifying or Minimising (Also referred to as “Catastrophisation”)
Thinking in a magnifying or minimising manner is when we exaggerate the importance of negative events and minimize or downplay the importance of positive events. In depressed individuals, it is often the positive characteristics of other people that are exaggerated and the negatives that are understated (and then when thinking of oneself, this is reversed).
Catastrophising is only paying attention to the negative side of things or overestimating the chances of disaster. When we think catastrophically we are unable to see any other outcome other than the worse one, however unlikely this result may turn out to be.
Example 1: “I had one binge – I am back to square 1 – I’m never going to get better”. “Nothing ever works for me – I may as well give up now”.
Example 2: You send out the wrong letter to a client at work, and this turns into “I will now lose my job, and then I won’t be able to pay my bills, and then I will lose my house.”
A person engaging in personalisation will automatically assume responsibility and blame for negative events that are not under their control. This is also called ‘the mother of guilt’ because of the feelings of guilt, shame, and inadequacy it leads to.
Example: You feel it’s all your fault that your dog injured his foot even though you weren’t at home when it happened but were out shopping. Your thoughts might be ‘if only I didn’t go out’ or even ‘maybe when I came home I accidentally stepped on the dog and hurt him’ even though this is entirely unrealistic.
8. Shoulds and Oughts
Individuals thinking in ‘shoulds’, ‘oughts; or ‘musts’ have an ironclad view of how they and others ‘should’ and ‘ought’ to be. These rigid views or rules can generate feels of anger, frustration, resentment, disappointment and guilt if not followed.
Example: You don’t like playing tennis but take lessons as you feel you ‘should’, and that you ‘shouldn’t’ make so many mistakes on the court, and that your coach ‘ought to’ be stricter on you. You also feel that you ‘must’ please him by trying harder.
9. Emotional Reasoning
Emotional reasoning is when we assume feelings reflect fact, regardless of the evidence. The idea here is “I feel it, therefore it must be true”. Such thinking can lead to self-fulfilling prophecies whereby our thoughts can end up eliciting the very behaviour we predicted, just because we changed our behaviour in accordance with that thought.
Example 1: if you think “I feel ugly and stupid, so then I must actually be ugly and stupid” you might then stop buying yourself new clothes and start doing poorly at the course you are taking at university, even though you look fine and were doing very well at school.
Example 2: Taking your emotions as an accurate reflection of what is happening. For example, “I feel fat therefore I am fat”, even when you are actually underweight.
Labelling is an extreme form of ‘all or nothing’ thinking and overgeneralisation. Rather than describing a specific behaviour, an individual instead assigns a negative and highly emotive label to themselves or others that leaves no room for change.
Example: You make a mistake on a form you filled out and it’s sent back to you in the post. So you decide “I’m such a loser” or “I’m so stupid” rather than thinking “I made a mistake as I had a busy day when I was filling this out”.
11. Expecting perfectionism and having double standards
These two often go together. People with eating disorders often expect themselves to be perfect and anything less than excellence equals failure. They judge themselves by what they achieve and expect others to judge them in the same way.
Additionally, they may have double standards, for example, thinking it is OK for other women to be a normal weight, but that they will only look good at X weight. It may be OK for other people to make mistakes but unacceptable for them.
We praise the recognition among schools that encouraging pupils to strive for perfection in all areas can increase the risk of mental health conditions including depression and eating disorders.
Unrelenting standards and a core sense of failure or not being good enough are common difficulties among people who present to us for treatment. Targeting these issues at a younger age and encouraging people to resist the urge to need to be perfect at all times is crucial to good mental health. We hope to see more schools following this example.