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.
In the past it was believed that people with bulimia nervosa had a binge-eating disorder and that they dieted in order to counteract the effects of a binge. Although it is true that people sometimes restrict their eating after binging, we now know that dieting in fact precedes, and is the major cause of binge-eating.
Dieting causes binge-eating primarily because it results in a state of deprivation in the body. The body can only tolerate being deprived of essential nutrients for so long and then it rebels and overeats to compensate for what it hasn’t been getting. In the same way that people who become extremely thirsty tend to drink more than usual, people who’s bodies are extremely hungry, will tend to binge. How long it takes to develop binge-eating varies. Some people manage to maintain extreme restriction for a long time without bingeing, however for the vast majority of people, and for 50% of people with anorexia, restriction will at some point result in binge-eating. This is often taken as a sign of failure or weakness, however it is actually near impossible to override a physiological urge to binge
The body makes significant adaptations in response to both restriction and bingeing, meaning that the effect of bingeing on the body can change over time. Firstly, if the body learns that it has to exist on a small amount of energy (as it does in those who chronically diet), it slows its metabolic rate down in order to use food more efficiently. Dieting actually reduces the metabolic rate by around 15-30% and reduces the amount of energy expended during activity. This compensation is found irrespective of the body size of the individual. The longer a person diets for the more the metabolic rate is slowed, and the longer it takes for the metabolic rate to recover.
This has important implications for understanding the effects of binge-eating cycles. It is likely that weight loss becomes increasingly difficult each time a person tries to restrict their food intake, and that the calories taken in during binges are less likely to be burned as fuel and are stored more readily by the body as fat. This is one of the reasons why people with bulimia nervosa tend to gain weight over time, even if their eating doesn’t seem to have changed. This weight gain (or increased difficulty in losing weight) makes it more likely that people will try and diet. However this only serves to increase the frequency and intensity of being eating. Thus a vicious cycle begins.
Vomiting and using laxatives often begin as ways of regaining control after “over-eating.” These practices soon result in even greater breakdown in control since they “legitimize” binging (“It’s all right to binge, because I can get rid of it all afterwards”). They may also contribute to a physical relief after the fullness of binging or eating, and the person may eventually feel she must vomit or use laxatives after every meal or at the end of every day to try to get back the sense of relief. Although the individual may initially lose weight through purging, this is most often temporary as the effectiveness of vomiting becomes limited over time (see blog post: the ineffectiveness of purging). Although vomiting “solves” the short-term problem of getting rid of unwanted food that may lead to weight gain, in fact it only gets rise of around 30% of calories consumed during a binge, and actually makes it more likely that a person will binge as it increases hunger and urges to binge. Thus over time, people who purge after bingeing are also more likely to see an increase in bingeing and resulting weight gain.
Taking laxatives can also be part of this cycle. Regular laxative use can result in a physiological reliance on the laxatives. This may be because the bowel’s normal muscle contracting ability is impaired by repeated laxative use due to damage to intestinal nerves. Severe constipation or water retention can result when laxatives are not used, so that it seems that continuing to take the laxatives is the only way to continue “regular” bowel movements. Besides being extremely dangerous, laxatives are a completely ineffective method of trying to prevent the absorption of calories. In fact all laxatives get rid of is water, thus removing essential hydration from the body.
Occasionally bingeing eating occurs solely because of these physiological effects, however in bulimia nervosa there can often be emotional triggers to bingeing as well. In these circumstances bingeing tends to be triggered by intense emotions or as a desire to escape from strong emotions. This means that when bingeing stops, strong emotions may start to reveal themselves. For these people, it can be very important to seek support from a professional to help them to identify, understand and cope with these strong emotions.
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.
Binge eating disorder, or BED, is a serious condition characterized by uncontrollable eating, usually with resulting weight gain. It is estimated that 3.5% of women, @% of men and 30 – 40% of people seeking weight loss treatments can be diagnosed as having binge eating disorder. People with binge eating disorder frequently eat large amounts of food (beyond the point of feeling full) while feeling a loss of control over their eating. Often, these habits develop as a way of coping with depression, stress or anxiety. Although the bingeing behavior is similar to what occurs in bulimia nervosa, people with binge eating disorder do not engage in compensatory behaviours such as vomiting or exercise in order to get rid of the calories consumed during a binge.
Many people who have binge eating disorder use food as a way to cope with uncomfortable feelings and emotions. These are people who may have never learned how to deal effectively with stress, and find it comforting and soothing to eat food. Unfortunately, they often end up feeling sad and guilty about not being able to control their eating, which increases the stress and fuels the cycle.
Most people overeat from time to time, and many people say they frequently eat more than they should. Eating large amounts of food, however, does not mean that a person has binge eating disorder. People with binge eating disorder have several of the following symptoms weekly for at least 3 months:
People who have binge eating disorder also tend to have:
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.