An Introduction to Eating Disorders

Eating disorders are complex, multifaceted physical and mental health problems. Their development usually involves a number of different contributing and perpetuating factors. The exact processes are unclear and it is uncertain how they interact to develop or maintain an eating disorder (Fairburn & Harrison, 2003).

Contributing factors could include one or a combination of physical, emotional or sexual trauma; cultural emphasis on body image ideals; peer influences; loss and grief; brain chemistry; physiological effects of dieting, starvation or purging behaviours; relationship issues; stress; and maladaptive coping skills. The complexity of eating disorders means there are no simple solutions.

Development of an Eating Disorder

There are many environmental, cultural, psychological and biological factors which combine in different ways in the development of an eating disorder. These factors can be divided into 3 factors – click here to view the Model of Development and Maintenance of an Eating Disorder, by Garner & Garfinkel).

Important factors which predispose a person to developing an eating disorder include being female, living in Western society, being an adolescent, having low self-esteem, perfectionism, and/or depression, and having a family history of any type of eating disorder, obesity, depression, or substance abuse.

Significant precipitating factors which may trigger the disorder include dieting to lose weight, occupational or recreational pressures to be slim, critical comments about weight and shape, and sexual abuse. Key factors which maintain the disorder once it has developed primarily involve the psychological, emotional, and physical effects of starvation.

Stages of an Eating Disorder

Lemberg (1992) also proposes a model of development whereby a person moves from voluntary dieting through a number of stages to reach a fully entrenched eating disorder.

Stage 1: Normal, voluntary dieting behaviour. Unfortunately dieting behaviours have become the “norm”, with 47% of people in Australia having tried to lose weight in the past twelve months.  68% of fifteen year old girls are dieting at any one time, 8% of these are on a severe diet (Lemberg, 1992).

While these diets are severe enough to be considered an eating disorder, they are unhealthy and result in rapid weight changes, disrupted metabolism, dehydration, low energy and lack of essential vitamins, minerals and nutrients.

Stage 1B: (in Bulimia Nervosa only). The hunger associated with dieting and restriction leads to severe and constant cravings, which result in loss of control and overcompensation by bingeing on large amounts of food.

Stage 2: A Diagnosable Disorder. At this stage the dieting behaviour has become a diagnosable mental illness according to the Diagnostic & Statistical Manual IV-TR (APA, 2000).  At this stage there are serious consequences and a morbid fear of fatness, and the dieting is no longer under the person’s control.

However the person is unable to see the negative consequences and is in denial of the eating disorder.  In bulimia nervosa the bingeing behaviours, rather than being due to dietary restriction, occur more generally as a result of stress or negative emotional states.

Stage 3A: Autonomous Behaviour. At this stage the person is generally able to see there is a problem, but as the behaviours are no longer under the person’s control, the disorder does not resolve even if precipitating conditions have been resolved.

Stage 3B: Illness becomes the identity. At this stage, rather than the eating disorder behaviours being a solution to a problem, the person now identifies him or herself only with the eating disorder and has difficulty separating themselves from the illness.

The eating disorder behaviours are now constant rather than used as coping strategies, and the person feels they are nothing without their illness. They identify with being the illness, i.e. I am anorexic, rather than I have anorexia.

The prospect of giving up the disorder can lead to existential fears of nothingness. Recovery requires not only finding alternative coping strategies, but helping the person identify themselves without the eating disorder.

The Starvation Syndrome

One of the most important advancements in the understanding of eating disorders is the recognition that many of the symptoms once thought to be primary features of anorexia nervosa are actually symptoms of starvation.

An experimental study, conducted and published 50 years ago by Ancel Keys and his colleagues at the University of Minnesota (Keys, Brozek, Henschel, Mickelsen & Taylor, 1950) is the best example of the wide-ranging physical, cognitive, social and behavioural effects of starvation, initially thought to be the symptoms of anorexia nervosa.  The subjects of the study were 36 healthy young men who volunteered as an alternative to military service.

During the first three months of the study, the volunteers ate normally while their personality, behaviour and eating patterns were studied. Over the next six months, the men decreased their food intake by about half, losing on average about a quarter of their former weight.  This was followed by three months of rehabilitation where gradual refeeding occurred.

Each volunteer responded differently but there were dramatic physical, psychological and social changes, many of which persisted even during the refeeding stage. The significance of this study (commonly known as the “Starvation Study”) is that the experiences displayed by the volunteers due to starvation are the same symptoms experienced by people with an eating disorder.

The volunteers became overwhelmingly preoccupied with food, plagued by incessant thoughts of food and eating, resulting in poor concentration in other areas. Food became the topic of conversation, reading and daydreams. They played with their food, and there was an over consumption of salt, spices, coffee, tea, and gum.

As starvation progressed, the volunteers increasingly hoarded food and food-related items, such as cookbooks and menus. This tendency to hoard is often observed in persons with anorexia nervosa. During refeeding, most of the abnormal attitudes and behaviours persisted.  40% of volunteers mentioned cooking as an interest post-experiment and some even changed occupations, three becoming chefs and one went into agriculture.

All volunteers reported increased hunger in the semi-starvation phase. Some were able to tolerate this while others were could not control themselves, partaking in episodes of binge eating followed by self-deprecation and disgust, and in some cases vomiting. No factors could be identified to distinguish reasons for these differences. After five months of refeeding, overcompensation of eating persisted, but by eight months of refeeding most had returned to normal eating habits.

The previously psychologically healthy volunteers suffered significant emotional deterioration as a result of semi-starvation. These symptoms included severe depression and extreme mood swings, anxiety symptoms such as biting nails and smoking, apathy, and significant neglect of personal hygiene tasks. Two men were disturbed enough to be admitted to a psychiatric ward.

The emotional disturbances of the volunteers persisted during the refeeding period, with some men becoming more depressed, irritable, argumentative and negative than during semi-starvation.  Previously outgoing and friendly, the men became withdrawn and isolated, unwilling to be involved in planning, decision-making or participating in group activities.

The men’s social interaction with women significantly declined, with those relationships that did continue becoming strained. Libido was also reported to have decreased and was slow to return.  Similar to people with eating disorders during weight gain, the subjects reported that they were “feeling fat” despite body weight and body fat percentages being at pre-experimental levels after nine months of rehabilitation.

Many of the symptoms outlined above are similar to those displayed by individuals with anorexia or bulimia nervosa. Therefore, it is recognised that these symptoms are due to starvation rather than being specific to these disorders. Furthermore, symptoms are not limited to food and weight but affect nearly all areas of psychological and social functioning.  The study challenges the popular idea that body weight is altered with a bit of “willpower” and demonstrates that the body does not simply adjust to a lower weight during severe dieting.

Anorexia Nervosa

MacLeod (1981) states people with anorexia are notoriously difficult persons who are determined to hang on to their symptoms at all costs. This is a common view throughout the medical profession and related fields, possibly due to the ego-syntonic nature of eating disorders—the person is comfortable with the disorder and views it as consistent with their goals and wishes.

It is therefore important for counsellors to develop an understanding of these disorders in order to develop empathy and the ability to validate the client’s experience. This involves realising that letting go of the eating disorder may represent a significant loss for the person, and that there may be a fear that recovery will come at too high a price. Therefore the initial goal of treatment is simply for people to begin thinking about change. At this point, the enhancement of motivation is crucial.

The two categories which will be looked at here are Anorexia Nervosa and Bulimia Nervosa due to the ego-syntonic nature of these disorders. This post will focus on Anorexia Nervosa.

Diagnostic Features

There are a number of essential features associated with a clinical diagnosis of Anorexia Nervosa. These include a refusal to maintain a minimal body weight considered normal for the person’s age and height, an intense fear of gaining weight, and a significant disturbance in the person’s perception of their body shape and size.

In addition, females with this disorder have a condition known as amenorrhea, resulting from abnormally low levels of estrogen, where they have either ceased menstruation or, in younger females, it has been delayed. Also when the disorder occurs in a young person during childhood or early adolescence, rather than a significant drop in weight, there may instead be a failure to make expected weight gains consistent with a continued growth in height.

For a clinical diagnosis of Anorexia Nervosa to be made according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, the person must weigh less than 85% of the weight considered normal for his or her age and height.

An alternative guideline used by the ICD-10 Diagnostic Criteria for Research (World Health Organisation, 1993) suggests a body mass index (BMI) equal to or less than 17.5 for a diagnosis. The BMI is calculated by dividing weight in kilograms by height in squared metres. These are regarded as guidelines only as a person’s individual body build and weight history also need to be taken into account.

Usually weight loss associated with Anorexia Nervosa is maintained primarily through restricted food intake. Sufferers may begin by excluding foods believed to be high in calories or specific food groups such as meat. This often leads to continued restriction resulting in a very narrow choice of foods. Further weight loss is often attempted via purging, such as self-induced vomiting or the misuse of laxatives or diuretics and excessive exercise.

An intense fear of gaining weight and becoming ‘fat’ is usually not alleviated by weight loss; in fact weight concerns often increase as body weight decreases. This leads to a distorted body image wherein the experience and significance of body weight and shape are distorted, either overall or in one or two specific areas of the body, such as the abdomen, buttocks or thighs.

A person with a distorted body image will often engage in a variety of ‘checking’ techniques, including excessive weighing, obsessive measuring of body parts, and persistently using a mirror to check for perceived areas of ‘fat’.

Not all Anorexia sufferers experience a distortion of body image, however even those who can acknowledge being underweight may still deny the serious medical implications arising from this. Individuals with Anorexia Nervosa frequently lack insight into the problem and may even deny the presence of the problem.

As a result, it is often necessary to obtain information from parents or other outside sources to evaluate the degree of weight loss and other aspects of the illness. Anorexia is often brought to professional attention by family members after marked weight loss has occurred.

It is rare for an individual with Anorexia Nervosa to seek help themselves, although they may do so due to the distressing nature of other features associated with the disorder, such as depression and self-loathing.


The following subtypes are used to specify clinical features of the current episode of Anorexia Nervosa:

Restricting Type: This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, or excessive exercise. During the current episode, these individuals have not regularly engaged in binge eating or purging.

Binge-Eating / Purging Type: This subtype is specified when the individual has regularly engaged in binge eating or purging (or both) during the current episode. Most individuals with Anorexia Nervosa who binge eat also purge through self-induced vomiting or the misuse of laxatives, diuretics, or enemas.

Some individuals included in this subtype do not binge eat, but do regularly purge after the consumption of small amounts of food. It appears that most individuals in the Binge-Eating/Purging Type engage in these behaviours at least weekly, but sufficient information is not available to specify a minimum frequency.
Associated Features
Not surprisingly the self-esteem of a person with Anorexia Nervosa is highly linked to their body shape and weight. Weight loss is generally viewed as a positive step and an indication of self-discipline, whereas weight gain is perceived as failure and a complete lack of self-control.

When seriously underweight, many individuals with Anorexia Nervosa manifest depressive symptoms such as depressed mood, social withdrawal, irritability, insomnia, and diminished interest in sex. Such individuals may have symptomatic presentations that meet criteria for Major Depressive Disorder.

Obsessive-compulsive features are often prominent. Most individuals with Anorexia Nervosa are preoccupied with thoughts of food. Some collect recipes or hoard food. Observations of behaviours associated with other forms of starvation suggest that obsessions and compulsions related to food may be caused or exacerbated by undernutrition.

Other features sometimes associated with Anorexia Nervosa include concerns about eating in public, feelings of being inept, a strong need to control the surrounding environment, inflexible thinking, limited social spontaneity, and overly restrained emotional expression (Garner and Garfinkel, 1997; APA, 2000).

Bulimia Nervosa

The essential features of Bulimia Nervosa are binge eating and inappropriate compensatory methods to prevent weight gain at least twice a week for at least three months. The self-evaluation of people with Bulimia Nervosa is excessively influenced by body shape and weight.

A binge is defined as eating in a discrete period of time (usually less than two hours) an amount of food that is significantly larger than most people would eat under similar circumstances. Although the type of food consumed during binges varies, it typically includes sweet, high-calorie foods such as ice cream or cake. However, binge eating is characterised more by the abnormality in the amount of food consumed than by a craving for a specific food.

Individuals with Bulimia Nervosa are typically ashamed of their eating problems and try to conceal their symptoms, hence behaviours usually occur in secrecy. The binge often continues until the person is uncomfortably, even painfully, full. Binge eating is typically triggered by negative mood states, interpersonal stressors, intense hunger following dietary restraint, or negative feelings related to body weight, body shape, and food.

Binge eating may reduce negative mood states temporarily, but self-loathing and depressed mood usually follow soon after. An episode of binge eating is also accompanied by a sense of lack of control. Some sufferers describe a dissociative quality during binge episodes and/or difficulty stopping a binge once it has begun.

Another essential feature of Bulimia Nervosa is the recurrent use of inappropriate behaviours to compensate for binge eating. The most common compensatory technique is the use of vomiting after a binge, the immediate effects of this includes relief from physical discomfort and reduction of fear of weight gain. Other purging behaviours utilised include the misuse of laxatives or diuretics, while another compensatory behaviour involves the use of excessive exercise to neutralise the calories consumed during an episode of bingeing.

Individuals with Bulimia Nervosa place an excessive emphasis on body shape and weight, and these factors are typically the most important ones in determining self-esteem. People with this disorder may closely resemble those with Anorexia Nervosa in their fear of gaining weight, in their desire to lose weight, and in the level of dissatisfaction with their bodies.


The following subtypes are used to specify clinical features of the current episode of Bulimia Nervosa:

Purging Type: The person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas during the current episode.

Nonpurging Type: The person has used other inappropriate compensatory behaviours, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas during the current episode.

Associated Features and Disorders

Individuals with Bulimia Nervosa typically are within the normal weight range. There is an increased frequency of depressive symptoms and low self-esteem in people with Bulimia Nervosa. In most sufferers, the mood disturbance begins at the same time as or following the development of Bulimia Nervosa, and individuals often attribute their mood disturbances to Bulimia Nervosa.

However in some sufferers, the mood disturbance clearly precedes the development of Bulimia Nervosa. There may also be an increased frequency of anxiety symptoms (eg. fear of social situations) which often abate following effective treatment of Bulimia Nervosa. Substance abuse or dependence, particularly involving alcohol and stimulants, occurs in about one-third of sufferers.

Stimulant use often begins in an attempt to control appetite and weight. Preliminary evidence suggests that individuals with Bulimia Nervosa, Purging Type, show more symptoms of depression and greater concern with shape and weight than those with Bulimia Nervosa, Nonpurging Type (Garner and Garfinkel, 1997; APA, 2000).


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