Would you recognise disordered eating if it walked through the door? (Part 1/2)

Eating disorders and disordered eating

Eating disorders, pervasive disturbances in eating behaviour and body weight, touch individuals across every socio-demographic sector. Not just a silent war battled behind closed doors, these disorders have significant socioeconomic implications. In 2018 alone, eating disorders bore a $3.2 billion cost to the Australian Government, and disturbingly, over a million Australians struggle with an eating disorder in any given year. Amidst the tumult of the COVID-19 pandemic, this number saw a marked rise, reflecting the intricacy and profundity of the issue.

Eating disorders, far from being monolithic, present a myriad of diagnostic challenges. Historically pigeonholed as disorders predominantly affecting those with low body weight, recent research challenges this stereotype and highlights this dangerous presumption. This traditional bias poses significant barriers for individuals with higher weights, leading to misdiagnosis and under-treatment of this harmful condition.

Differentiation is important, but not essential

In the realm of eating disorders, a diverse spectrum of symptoms and behaviours exists, reflecting the intricate interplay between mental health and eating habits. Anorexia Nervosa, for instance, manifests as restrictive eating, body image distortion, and an overwhelming fear of weight gain. Significantly, its diagnosis breaks traditional confines; there’s no fixed BMI threshold. This gives rise to conditions such as “atypical anorexia nervosa”, where individuals may have lost substantial weight but maintain a higher BMI. Bulimia Nervosa, on the other hand, is marked not by weight but by an intense overvaluation of weight and shape, punctuated by cycles of binge eating and compensatory actions like vomiting or excessive exercise. Then there are disorders like Binge Eating Disorder, characterised by binge episodes without compensatory behaviour, and ARFID, a unique condition marked by an aversion to food not rooted in body image concerns.

This intricate landscape is further complicated by the presence of subthreshold disorders, purging disorders, and night eating syndromes. The fluid nature of these conditions and the frequent crossover between them highlight the continuum of eating disorders. As patients navigate this spectrum, they may evolve from one diagnosis to another, emphasising that while differentiation is valuable in understanding and treating these disorders, it isn’t always strictly essential. 

On a global level, establishing precise prevalence rates is intricate. A mix of methodological approaches and changing diagnostic criteria has resulted in wide-ranging statistics. For instance, in 2019, an estimated 55.5 million people globally suffered from eating disorders, of which anorexia nervosa was noted bearing the unfortunate distinction of having the highest mortality rate among psychiatric disorders.

What is disordered eating?

Disordered eating is an umbrella term that encompasses a wide range of abnormal and potentially harmful eating behaviours and attitudes. While you may be familiar with conventional eating disorders (such as anorexia nervosa or bulimia nervosa), the landscape of disordered eating extends far beyond these diagnoses. It’s crucial to recognise that not all unhealthy eating habits fit neatly into traditional diagnostic criteria, yet they can still pose significant health and psychological risks.

Among the less conventional manifestations is “orthorexia,” an obsession with consuming only foods perceived as pure or healthful, which can lead to dangerous nutritional deficiencies. Similarly, “drunkorexia” refers to individuals who limit caloric intake or engage in purging behaviours to compensate for the calories consumed from alcohol, risking both alcohol poisoning and nutritional deficits.

Then there’s “night eating syndrome,” where individuals consume a significant portion of their daily calories after dinner or during the night. This syndrome often coexists with insomnia, leading to a disruptive cycle of irregular eating and sleep patterns. “Purging disorder” is another lesser-known condition where individuals engage in purging behaviours, such as vomiting or excessive use of laxatives, without the associated binge eating found in bulimia.

Additionally, the phenomenon of “exercise bulimia” has emerged, where individuals use excessive exercise as a compensatory behaviour after consuming food, akin to the purging in bulimia nervosa, but through physical activity.

Outside of these lesser known conditions is the notion that disordered eating begins with a poor relationship to food, and a disordered or skewed idea of nourishing our body. Both these relationships are important to consider holistically and check in on various points in our life. 

Should disordered eating be screened alongside anxiety?

There is a well-documented relationship between anxiety and disordered eating habits. Not only do they have similar risk factors, but the psychological relationships they share are uncanny. Both anxiety and disordered eating can stem from risk factors such as genetics, brain chemistry, and personal temperament. For instance, those with a predisposition towards perfectionism, a need for control, or sensitivity to stress may be at risk for both conditions. Similarly, the same individuals may use food or the control of food as a way to manage anxiety or to gain a sense of control in their lives. Restricting food, binge eating, or purging can temporarily relieve anxiety for some, creating a cycle where the disordered behaviour becomes a maladaptive coping mechanism.

Outside ongoing efforts to normalise self-appreciation, body image concerns continue to drive a media-fueled angle of disordered eating behaviours. Anxiety can manifest as a hyper awareness or extreme concern about one’s body image. Constantly worrying about body shape, weight, or appearance can be both a symptom of anxiety and a trigger for disordered eating. In addition, chronic anxiety can lead to physiological responses and symptoms such as nausea, or a lack of appetite. Over time, this can affect eating habits and patterns around nourishment.

It is known that many individuals diagnosed with an eating disorder also have a co-occurring anxiety disorder. Research has found high rates of obsessive-compulsive disorder (OCD) among those with anorexia nervosa, suggesting concurring anxiety disorders may be more prevalent than we realise. In the same light, disordered eating behaviours can exacerbate anxiety. The physical effects of malnutrition or the guilt and shame after a binge episode can heighten feelings of anxiety, which then further fuels the disordered behaviour.

Given the intricate relationship between anxiety and disordered eating, it’s crucial to approach treatment from a comprehensive perspective. Addressing only the eating disorder without tackling underlying or coexisting anxiety may not be as effective in the long run. Similarly, understanding the root causes and triggers of anxiety can be key in preventing or treating disordered eating.

Clinical Summary

Anorexia Nervosa:
Characterised by restrictive eating, body image distortion, and intense weight gain fears, its diagnosis doesn’t necessarily prescribe a BMI limit. This breaks the mould for those who may have lost significant weight but remain at higher BMI – leading to diagnoses like “atypical anorexia nervosa.”

Bulimia Nervosa: 

While individuals with this disorder may not be underweight, their overvaluation of weight and shape is a distinguishing criterion. Characterised by binge eating followed by compensatory behaviours such as vomiting, excessive exercise, or laxative use.

Binge Eating Disorder and ARFID:

Binge eating disorder involves repeated binge episodes without subsequent compensatory behaviours. Unlike other disorders, ARFID (Avoidant/Restrictive Food Intake Disorder) is characterised by an aversion to food and eating, but not due to body image concerns.

Disordered Eating:

There is a strong upward trend of disordered eating habits in correlation with rising prevalence of anxiety and depression. Be conscious of the patient that does not fit into these traditional diagnoses but describes overvaluation of weight and shape, challenging social life and extensive thoughts and motivations around weight loss. Although these key factors may be seen as products of societal norms and damaging beauty standards to some, they provide the basis of a slippery slope towards the more traditional categories of eating disorders in the immediate future. 

Hay, P.J. et al. (2023) ‘Current approaches in the recognition and management of eating disorders’, Medical Journal of Australia, 219(3), pp. 127–134. doi:10.5694/mja2.52008.