Eating Disorder FAQs
Eating disorders are significant and intricate mental health conditions that come with both physical and psychological health issues, some of which can be severe and even life-threatening.
These disorders are defined by disruptions in behaviors, thoughts, and emotions related to body weight and shape, as well as food and eating.
They affect individuals across all demographics and can manifest at any point in a person’s life.
Approximately one million Australians are living with an eating disorder (4% of the population). Of Australians with an eating disorder:
- 3% have anorexia nervosa;
- 12% bulimia nervosa;
- 47% binge eating disorder; and
- 38% other eating disorders.
Eating disorder symptoms in Australia are on the rise with at least weekly binge eating increasing ~six-fold since the late 1990s and strict dieting
increasing almost four-fold.
Anorexia nervosa is a psychological illness that has serious physical, emotional and social consequences. It is characterised by body image distortion with an obsessive fear of gaining weight, which manifests itself through depriving the body of food. It often coincides with increased levels of exercise.
There are two main sub-types of anorexia:
- Restricting type — this is the most commonly known type of anorexia nervosa, whereby a person severely restricts their food intake. Restriction may take many forms (e.g. maintaining very low calorie count, restricting types of food eaten, eating only one meal a day) and may follow obsessive and rigid rules (e.g. only eating food of one colour).
- Binge-eating or purging type — this type of anorexia nervosa forms when a person restricts their intake as above, but also has regularly engaged in binge-eating or purging behaviour (e.g. self-induced vomiting, over-exercise, misuse of laxatives, diuretics or enemas).
Anorexia nervosa usually develops during adolescence and generally has an earlier age of onset than bulimia nervosa and binge eating disorder (the latter are often developed during late adolescence or early adulthood). However, like all eating disorders, anorexia can develop at any age or stage of life for people of any gender, including males.
Evidence tells us that anorexia nervosa has a moderate-high genetic heritability. Ongoing research into this field is analysing hundreds of genes that may influence the chance of developing an eating disorder with the hope of improving treatment and even preventing illness.
Other research also shows that women with autism may have a higher chance of developing anorexia nervosa. It appears that up to 20-35% of women with anorexia meet the diagnostic criteria for autism. Symptoms and treatment for people with autism and anorexia nervosa may differ from other populations, with research into this field still ongoing.
Bulimia nervosa is a serious psychiatric illness characterised by recurrent binge-eating episodes (the consumption of abnormally large amounts of food in a short period of time), followed by self-induced vomiting, fasting, over-exercising and/or the misuse of laxatives, enemas or diuretics.
Bulimia nervosa differs from binge eating disorder (BED). While binge episodes in both illnesses are associated with a sense of loss of control and are followed by feelings of guilt and shame, a person experiencing bulimia nervosa will immediately engage in compensatory behaviours such a vomiting or exercise.
A person with bulimia nervosa can be of any body shape, size or weight.
Bulimia nervosa often starts with weight-loss dieting. The resulting food deprivation and inadequate nutrition can trigger what is, in effect, a starvation reaction — an overriding urge to eat. For some, the desire to eat is uncontrollable, leading to a substantial binge on whatever food is available, followed by compensatory behaviours. A repeat of this behaviour often follows, leading to a binge/purge/exercise cycle, which can become more compulsive over time.
Binge eating disorder (BED) is a mental illness characterised by regular episodes of binge eating. Binge eating involves eating an excessive amount of food, which may take place in a rapid space of time, or may be more of an extended grazing. These episodes can feel chaotic, uncontrollable and highly distressing.
During a binge eating episode, a person may not be hungry, but may continue to eat past the point of feeling comfortably full. It is common for people to binge eat alone or in secret, and experience intense feelings of guilt, shame, disgust and low mood after a binge.
BED is a serious mental illness which affects more people than any other eating disorder. In fact, research suggests equal percentages of males and females experience binge eating disorder.
A binge is different from overeating and is far more pervasive. It is the intense drive to overeat which is experienced again and again over time, accompanied by feelings of shame, guilt and feeling out of control. Binge eating is highly distressing and can affect a person’s ability to engage fully in aspects of life (e.g., work or school, recreational activities, socialising and relationships).
Binge eating disorder is similar to — but not the same — as bulimia nervosa. Where people experiencing bulimia nervosa will engage in compensatory activities after a binge eating episode (such as self-induced vomiting, fasting, over-exercising and/or the misuse of laxatives, enemas or diuretics), Binge Eating Disorder is characterised by an absence of compensatory activities, despite experiencing similar feelings of intense guilt, shame and self-hatred after a binge episode.
Avoidant/restrictive food intake disorder (ARFID) is defined by the DSM-5 as an eating or feeding disorder characterised by a persistent and disturbed pattern of feeding or eating that leads to a failure to meet nutritional/energy needs.
Diagnosis is associated with at least one of the following:
- Significant weight loss (or failure to achieve weight gain/physical growth in children);
- Significant nutritional deficiency;
- Dependence on tube feeding (supplying nutrients directly to the gastrointestinal tract) or oral nutritional supplements;
- Marked interference on an individual’s psychosocial functioning (e.g., impacts on daily activities).
Diagnosis is made if symptoms are not better explained by a concurrent medical condition (e.g., allergies, intolerances, other medical conditions), other mental illness (including other eating disorders, such as Anorexia Nervosa), a lack of available food or a cultural practice (e.g., Ramadan). ARFID differs from picky or fussy eating, which is common in childhood and generally resolves over time (e.g., food neophobia).
The food avoidance and restriction that define ARFID can lead to medical or mental health consequences that further exacerbate food avoidance and restriction and serve to maintain the illness. ARFID is persistent, more severe, can involve the restriction of both familiar and new foods, and has significant physical and mental health consequences.
A person may restrict the amount or type of a particular food or avoid a particular food based on factors such as the appearance of the food (e.g., colour, size, shape), texture, smell, temperature, or food group (e.g., all vegetables after a bad experience choking on a vegetable). They may also restrict food intake due to early satiety (i.e., prematurely feels full) or due to past experiences, such as trauma associated with a food experience (e.g., choking).
Defined by a pattern of eating that is limited in variety (e.g., avoidance of specific foods) and/or volume (e.g., restriction of amount), ARFID can cause a person to become seriously ill because their bodies aren’t getting all the nutrients they need. For example, individuals may experience medical or mental health consequences such as poor growth, diabetes, cardiovascular disease, fatigue, poor self-esteem, family mealtime conflict, peer social isolation, and difficulties with school, relationships and work.
While ARFID is similar to anorexia nervosa in that a person restricts their food intake, the intent or reason for restricting food intake differs between the two eating disorders. People with ARFID do not restrict food to avoid weight gain/control weight or to change their body size/shape. ARFID is not associated with weight or shape concerns – weight loss or change in shape may occur as a result of poor nutritional intake, not because a person is intentionally engaging in weight control behaviours.
According to the DSM-5 criteria, to be diagnosed as having OSFED, a person must present with symptoms similar to other eating disorders but not meet the full criteria of, for example, anorexia or bulimia. This does not mean that their illness should be taken any less seriously. People with OSFED still present with disturbed eating patterns and need to seek help from a health professionals, such as a GP or psychologist, as soon as possible.
A diagnosis might then be allocated that specifies a specific reason why the presentation does not meet the specifics of another disorder. These could be any of the following:
- Atypical anorexia nervosa — This is where all criteria is met for anorexia, except significant weight loss. The individual’s weight might be within or above the normal range.
- Binge eating disorder (of low frequency and/or limited duration) — When all of the criteria for BED are met, but binges happen less frequently than expected or have been occurring for less than three months.
- Bulimia nervosa (of low frequency and/or limited duration) — When a person has all the symptoms of bulimia but the binge eating and subsequent purging occurs at a lower frequency and/or for less than three months.
- Purging disorder — This is when a person eats what is considered a ‘normal’ amount of food (i.e. does not engage in binges or food restrictions) but still uses laxatives or self-induced vomiting to influence their weight or shape.
- Night eating syndrome — When someone either wakes up during the night to eat or consumes a lot of food just before going to bed, after their evening meal. Night eating syndrome is diagnosed when the behaviour cannot be better explained by environmental influences or social norms or by another mental health disorder (such as BED).
According to the DSM-5 criteria this category applies to where behaviours cause clinically significant distress or impairment of functioning, but do not meet the full criteria of any of the feeding or eating disorder criteria.
This category may be used by clinicians when they are unable to, or choose not to, specify why criteria are not met, including presentations where there may be insufficient information to make a more specific diagnosis (e.g. in emergency room settings).
According to the DSM-5 criteria, pica is the diagnosis given to someone who regularly and persistently eats non-food substances such as chalk, soap or paper for more than one month. It also extends to any edible items that hold no nutritional value, such as ice.
In order to be diagnosed with pica, GPs or psychologists will consider whether the eating behaviour is part of a culturally supported or socially normative practice, and if occurring in the presence of another mental disorder (e.g. autistic spectrum disorder), or during a medical condition (e.g. pregnancy), whether it is severe enough to warrant independent clinical attention.
The developmental level of the individual is also considered. For example, it is common for babies and toddlers to put non-food items into their mouths out of curiosity. Therefore, normally only children older than two will be diagnosed with pica. It is most common in children and some scientists have linked it to the nervous system, and have understood it as a learned behaviour or coping mechanism.
It can be difficult to identify people with pica, as they usually don’t avoid regular food and don’t typically have a desire for weight loss or to affect their shape. Often pica is only diagnosed when the items they have been eating cause other medical issues, such as cracked teeth, toxicity or infection.
According to the DSM-5 criteria, a person with rumination disorder will repeatedly regurgitate their food effortlessly and painlessly for more than a month. The regurgitated food may be re-chewed, re-swallowed, or spat out and it is not caused by a medical condition such as a gastrointestinal condition.
The key difference between rumination disorder and conditions like bulimia nervosa is that typically a person with rumination disorder won’t appear to make an effort to bring up their food and it can happen spontaneously or without intent. However, people with anorexia nervosa, bulimia nervosa, binge eating disorder or avoidant/restrictive food intake disorder may also have rumination disease.
Rumination disorder can lead to malnutrition, weight loss, damage to teeth and gums, and electrolyte disturbances if left untreated.
Chewing and spitting (CHSP) is a form of disordered eating where someone chews food, but spits it out, rather than consuming it. Often the food is high in salt, sugar or fat, or regarded by the person as ‘bad’ or ‘junk’ food. Chewing the food for some time and then spitting it out is seen as a way of enjoying the taste without gaining weight or consuming calories. CHSP can exist as a symptom of a diagnosed eating disorder, or as a separate form of disordered eating. CHSP is not widely recognised or researched, and people who engage in this behaviour can be reluctant to seek help due to guilt or shame.
- The effects of chewing and spitting are just as significant as other eating disorders, including:
Damage to digestive system – The sight, smell, thought and taste of food triggers the cephalic phase of gastric secretion, which prepares the body for digesting food. Even though the food is not swallowed, CHSP triggers this response increasing stomach acids, digestive enzymes and insulin. When the food is not digested, the stomach acid can damage the stomach lining, causing ulcers. Insulin levels are also affected, which may potentially lead to weight gain and an altered metabolism.
- Damage to teeth and mouth – Like bulimia, CHSP can also lead to dental problems, such as tooth decay and cavities. Excessive chewing can also cause swollen salivary glands.
- Malnourishment – CHSP can lead to malnutrition if insufficient calories or nutrients are consumed. Many people who engage in chewing and spitting actually gain weight. This can be as a result of increased likelihood of binging on the “forbidden” foods, or unintentionally consuming extra calories. It may also be caused by the increase in insulin released into the body.
Disordered eating refers to a wide range of abnormal eating behaviours, many of which are shared with diagnosed eating disorders. The main thing differentiating “disordered eating” from an “eating disorder” is the level of severity and frequency of behaviours.
Disordered eating can have a negative impact on a person’s emotional, social and physical wellbeing. It may lead to fatigue, malnutrition or poor concentration. It can affect someone’s social life (when socialising is restricted due to anxiety around food and eating), and can lead to anxiety and depression.
Disordered eating behaviours and attitudes include:
- Binge eating
- Skipping meals regularly
- Self-induced vomiting
- Obsessive calorie counting
- Self-worth based on body shape and weight
- Misusing laxatives or diuretics
- Fasting or chronic restrained eating
What is considered ‘normal’ in terms of quantities and types of food consumed varies considerably from person to person. ‘Normal eating’ refers to the attitude a person holds in their relationship with food, rather than the type or amount of food they eat.
It is normal to:
- Eat more on some days, less on others
- Eat some foods just because they taste good
- Have a positive attitude towards food
- Not label foods with judgement words such as ‘good’, ‘bad’, ‘clean’ etc
- Occasionally over-eating and occasionally under-eating
- Crave certain foods at times
- Treat food and eating as one small part of a balanced life
Dieting is the number one behavioural risk factor in the development of an eating disorder.
The strict, restrictive and often unsustainable nature of many diets can leave dieters feeling constantly hungry and deprived. Dieters often ignore this hunger for a short time but such deprivation can eventually lead to powerful food cravings and over-compensatory behaviour such as bingeing. This can, in turn, lead to feelings of shame and failure, which contribute to negative emotional associations with food and eating.
Fluctuating weight is common for people who diet frequently (‘yo-yo’ dieting), as most people regain all the weight they have lost after a diet within a few years. Diets disconnect people from their natural bodily responses through imposed food related rules and restrictions, which may overlook hunger, physical activity and a person’s individual nutritional requirements.
- slow the body’s metabolism (the rate it burns calories)
- cause food cravings and an increased appetite, leading to over-eating
- reduce the total amount of muscle tissue and bone density
- cause constipation and/or diarrhoea
- lower the body’s temperature in order to use less energy
- cause headaches
- cause insomnia and fatigue
- reduce the ability to feel hungry and full, making it easier to confuse hunger with emotional needs.
Dieting can lead to feelings of guilt over ‘lack of self-control’, low self-esteem, a poor body image and obsessive thoughts and behaviours surrounding food. In addition, people who diet frequently are more likely to experience depression.
Please note that any combination of these symptoms can be present in an eating disorder, because no eating disorder is exactly the same as another. It is also possible for a person to demonstrate several of these signs and yet not have an eating disorder. It is always best to seek a professional opinion.
Behavioural warning signs
- Constant or repetitive dieting (e.g. counting calories/kilojoules, skipping meals, fasting, avoidance of certain food groups or types such as meat or dairy, replacing meals with fluids)
- Evidence of binge eating (e.g. disappearance of large amounts of food from the cupboard or fridge, lolly wrappers appearing in bin, hoarding of food in preparation for bingeing)
- Evidence of vomiting or laxative abuse (e.g. frequent trips to the bathroom during or shortly after meals)
- Excessive or compulsive exercise patterns (e.g. exercising when injured or in bad weather, refusal to interrupt exercise for any reason, insistence on performing a certain number of repetitions of exercises, exhibiting distress if unable to exercise)
- Making lists of ‘good’ and ‘bad’ foods
- Changes in food preferences (e.g. refusing to eat certain foods, claiming to dislike foods previously enjoyed, sudden interest in ‘healthy eating’)
- Development of patterns or obsessive rituals around food preparation and eating (e.g. insisting meals must always be at a certain time, only using a certain knife, only drinking out of a certain cup)
- Avoidance of all social situations involving food
- Frequent avoidance of eating meals by giving excuses (e.g. claiming they have already eaten or have an intolerance/allergy to particular foods)
- Behaviours focused around food preparation and planning (e.g. shopping for food, planning, preparing and cooking meals for others but not consuming meals themselves, taking control of the family meals, reading cookbooks, recipes, nutritional guides)
- Strong focus on body shape and weight (e.g. interest in weight-loss and fitness websites and social media)
- Development of repetitive or obsessive body checking behaviours (e.g. pinching waist or wrists, repeated weighing of self, excessive time spent looking in mirrors)
- Social withdrawal or isolation from friends, including avoidance of previously enjoyed activities
- Change in clothing style, such as wearing baggy clothes
- Deceptive behaviour around food (e.g. secretly throwing food out, eating in secret (often only noticed due to many wrappers or food containers found in the bin) or lying about amount or type of food consumed)
- Eating very slowly (e.g. eating with teaspoons, cutting food into small pieces and eating one at a time, rearranging food on plate)
- Continual denial of hunger
Physical warning signs
- Frequent changes in weight
- Sensitivity to the cold (feeling cold most of the time, even in warm environments)
- Loss or disturbance of menstrual period (for those born female)
- Signs of frequent vomiting — swollen cheeks or jawline, calluses on knuckles, damage to teeth
- Fainting, dizziness
- Sudden or rapid weight loss
- Fatigue — always feeling tired, unable to perform normal activities
- Psychological warning signs
- Increased preoccupation with body shape, weight and appearance
- Intense fear of gaining weight
- Constant preoccupation with food or with activities relating to food
- Extreme body dissatisfaction/ negative body image
- Distorted body image (e.g. complaining of being, feeling or looking fat when actually a healthy weight or underweight)
- Heightened sensitivity to comments or criticism about body shape or weight, eating or exercise habits
- Heightened anxiety around meal times
- Depression or anxiety
- Moodiness or irritability
- Low self-esteem (e.g. feeling worthless, feelings of shame, guilt or self-loathing)
- Rigid ‘black and white’ thinking (viewing everything as either ‘good’ or ‘bad’)
- Feelings of life being ‘out of control’
- Feelings of being unable to control behaviours around food
Emerging evidence shows that the development of an eating disorder may have a biological link relating to a person’s genetics. Studies show that eating disorders such as anorexia nervosa, bulimia nervosa and binge eating disorder have moderate-high heritability. Ongoing research into this field is analyzing hundreds of genes that may influence the chance of developing an eating disorder with the hope of improving treatment and even preventing illness.
While genetics are beyond a person’s control, there are steps that can be taken to modify risk, such as addressing psychological, social risk factors and other risk factors.
- Feelings of inadequacy
- A belief that love from family & friends is dependent on high achievement
- Difficulty expressing emotions and feelings, particularly negative emotions such as anger, sadness, anxiety or fear
- Fear or avoidance of conflict
- Low self-esteem
- Impulsive or obsessive behaviours
- High concern with the opinions of others, often with a need to please
- Prone to extremes, such as ‘black and white’ thinking
- Difficulty coping with stress
- Depression or anxiety
It is important to note that psychological symptoms can also be present as the result of an eating disorder and the impact of starvation syndrome. Psychological symptoms may resolve with adequate re-nourishing and subsequent recovery.
- Cultural value placed on ‘thinness’ or small bodies as a moral and health imperative
- Normalisation of intentional dieting and weight loss in pursuit of the ‘thin ideal’
- Valuing of people according to outward appearance
- Media and popular culture’s portrayal of ‘ideal’ shapes and bodies
- Professions with an emphasis on body shape and size (eg. dancers, models, athletes)
- Significant life stages, such as puberty, pregnancy and post-partum and menopause
- Life events, particularly those involving major changes or trauma (e.g. loss of a family member or friend, the divorce or separation of parents, moving schools or jobs)
- Autism, particularly in women
- Engaging in dieting
- Poor body image
- Peer pressure
- Difficulties with personal or family relationships
- Sexual or physical abuse
- Food insecurity
- Unmet needs (emotional, psychological, social, professional, spiritual, physical or pleasure)
- Experiencing bullying, particularly when based on weight or shape
- NEDC fact sheets www.nedc.com.au/fact-sheets
- Centre for Clinical Interventions (CCI) www.cci.health.wa.gov.au/resources/consumers.cfm
- Recovery Record self-monitoring app www.recoveryrecord.com/
- King’s College London Eating Disorder Research Group www.kcl.ac.uk/ioppn/depts/pm/research/eatingdisorders/index.aspx
- Suicide prevention information www.beyondblue.org.au/the-facts/suicide-prevention
Books *Available to buy at the clinic subject to availability.
- Overcoming Binge Eating (2nd Edition) by Chris Fairburn
- Unpack Your Eating Disorder by Ganci & Atkins
- Embrace by Taryn Brumfitt
- The Picky Eater’s Recovery Book: Overcoming Avoidant/Restrictive Food Intake Disorder by Jenny Thomas, Kendra Becker, & Kamryn Eddy.
- Maudsley Parents http://www.maudsleyparents.org/
- NEDC for parents and carers https://www.nedc.com.au/support-and-services/families-carers-lived-experience/
- Eva Musby https://anorexiafamily.com/?v=6cc98ba2045f
- Butterfly Foundation
Books *Available to buy at the clinic subject to availability.
- Survive FBT by Maria Ganci
- My Kid is Back by June Alexander & Daniel Le Grange
- Eating with your Anorexic by Laura Collins
- Help Your Teenager Beat an Eating Disorder by James Lock & Daniel Le Grange
- ARFID/Avoidant Restrictive Eating: Broccoli Boot Camp by Keith Williams & Laura Seiverling
- The Royal Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines https://www.ranzcp.org/practice-education/guidelines-and-resources-for-practice/eating-disorders-cpg-and-associated-resources
- National Eating Disorder Collaboration (NEDC) https://nedc.com.au/
- WA Eating Disorder Outreach and Consultancy Service (WAEDOCS) https://www.nmhs.health.wa.gov.au/Hospitals-and-Services/Mental-Health/Specialties/Eating
- Centre for Clinical Interventions (CCI) https://www.cci.health.wa.gov.au/Resources/For-Clinicians
- Online CBT-E training: https://www.cbte.co/for-professionals/training-in-cbt-e/
- Cognitive Behavioural Therapy and Eating Disorders. Author: C. Fairburn
- Treatment manual for anorexia nervosa: A family-based approach (2nd ed) Authors: Lock and Le Grange
- National Eating Disorder Collaboration (NEDC) https://nedc.com.au/professional-development/educational-professionals/
- Media Smart https://www.flinders.edu.au/engage/community/clinics/mediasmart
- Confident Body Confident Child https://www.confidentbody.net/