Dear Internets; please stop diagnosing people with eating disorders.

Dear Internets; please stop diagnosing people with eating disorders.

Why am I talking about eating disorders?

Once upon a time, far far away and a long time ago, or more accurately, about an hour on the train from London and a few years back, I worked in an Eating Disorder Unit.

I worked in a psychiatric hospital that had an adolescent eating disorder unit (ages scarily young to 17) and a young adults (ages 18-25 unless you managed to get admitted at age 24.5), starting doing nursing assistant stuff (I am a fricking demon with a spillage pack and some vomit to clean up) and moving on towards a job that was more based around group activities and group therapy. I have certificates and everything.

During this time I started to regularly answer the question “what do you do?” in social situations with ever more bizarre made up jobs. I think I once said proctologist. Why? Because 95% of people who hear you say you work with people with eating disorders say one of two things:

1) “really? wow. My aunts friends sisters dog walkers girlfriend had that! oooh, it were terrible”.

2) “Is it the fault of them skinny models then?”

And actually no-one was paying me to do psycho-education outside of normal work hours, and I was getting to the stage of headdesking any time 2 came up, which was most of the time.

So fast forward several years and one seriously strange career jump, and it appears I am STILL headdesking because of comments similar to 2. And also when people tell other people to eat a cheeseburger. And also when people make allusions to the BMI criteria for eating disorders. And also when people basically imply that they can make judgements about health from pictures on the internet. And also when people imply that saying negative things about pictures of other people is motivated by concern about their health or in some way will help their health. So here’s for why.

I’m going to try to keep this simple, but eating disorders are really complicated and also I’ve forgotten most of the things I ever knew (I now know lots of random facts about taxing structures across the globe instead), so it might be slightly wibbly in parts.

What are eating disorders?

Lets start with a fact about prevalence. The number of people in the UK diagnosed with an eating disorder is about 1%.

That’s not very many at all. Even less end up in hospital. The reason people get so het up about eating disorders is that they are confusing and scary and arguably have the highest mortality rate of any mental health problem – not to mention being occasionally very, very visible, which most psychological issues aren’t. But in spite of the focus on them in women’s magazines, full blown eating disorders are rare. Disordered eating and having poor body image, practically normal in terms of prevalence, but I need to explain the difference before I say anymore about that, which will take some time.

Anorexia Nervosa:

Refusing to keep your body weight at a minimally acceptable level – which is pegged as 85% for adolescents (your healthy weight changes week by week at that age), or 18.5 BMI.

This is the much vaunted physical criteria for eating disorders but note the first 5 words – refusing being the key one. Lots of people end up under this weight because of other illnesses or problems. Sometimes people get so depressed they don’t eat. Sometimes people with chronic fatigue stop eating because they’re so tired. People with drug or alcohol problems lose weight because they don’t care about food, and people with dementia sometimes can’t remember whether they’ve eaten or not. But if you have an eating disorder, its a decision not to eat, based on ideas in your head about you and your weight and your life.

Intense fear of gaining weight or becoming fat, even though actually underweight.

This is the bit that baffles people, but if you think of it like a phobia it makes way more sense – people with eating disorders are genuinely terrified, there’s some evidence of disturbances in their visual cortex, and, as with phobias, they build ideas from minimal evidence about their bodies , food and weight. I once had to point out to someone that if they could absorb calories through their skin, she believed at the time, then we wouldn’t bother fighting to get food into them, we’d just put them in a vat of food substitute every night. I’m not sure they were entirely convinced!

Disturbance in the way you see your weight or shape, using body weight and shape as a huge factor in self evaluation, an/or denial of the seriousness of your own low body weight.

We’re talking here about people who have lost so much weight that their appearance in public worries people immensely but who firmly insist that they are fine. This actually often only applies to certain stages of the illness – often people who are recovering, while still immensely bothered and struggling with this sort of idea, do have increasing insight and know that there’s a problem.

Amenorrhea – your periods stopping, or in the case of adolescents, never starting.

If you’re a genetic woman, your cycle is linked to how healthy you are and your weight; its actually such a good indicator of minimally healthy weight that if your cycle starts normally at a BMI level below 18.5, eating disorder units will sometimes let you stop there. But as with the weight itself, on its own it means nothing, there are a thousand reasons your periods can stop, so it has to be the psychological symptoms that distinguish this from other health problems.

Sub types – restrictive eating, that is, reducing your calorie intake, or binge purge, that is, eating lots and then getting rid of it through vomiting, laxatives, diuretics etc.

Bulimia nervosa

Recurrent episodes of binge eating, where binge eating is characterised by the amount and a sense of losing control.

Recurrent behaviours to stop subsequent weight gain. That can be vomiting, diuretics, laxatives, all sorts of things. Its also says it must be at least twice a week for 3 months.

Then again we have:

Disturbance in the way you see your weight or shape, using body weight and shape as a huge factor in self evaluation.

I know most people think if it involves vomiting its bulimia and starving is anorexia, but most people are wrong – it’s more complicated than that.

You don’t need to have all of the symptoms to get diagnosed, nor even all of them to get put into a hospital without your consent ( a process we call sectioning in the UK).

If your weight is falling very fast, that's actually very dangerous even if its not yet gone below the diagnostic criteria. If you are binge purging to a huge extent, that's also very dangerous – both for the same reason, which is that your body can’t maintain a sensible electrolyte balance, which causes heart problems. You know, and death. So the under 18.5 BMI thing in and of itself thing really isn’t the key diagnostic or risk assessment thing.

Do not get me started on the problems with the stats used here.

There’s also a bunch of other disorders that sit in the same group that are rarer and I won’t cover here, but its worth mentioning a subtype most professionals would recognise but doesn’t seem to have made it into the books, which is people who do restrict their calories but also over exercise. When you wear a hole in the flesh over the base of your spine because you’ve done so many sit-ups, you have a problem. If you did it because you thought you were fat, it’s probably an eating disorder problem.

Dull, lifeless hair and flaking nails, skin problems, teeth problems, and all the rest of that stuff that gets touted as signs of an eating disorder? Not so much – again, they can be a sign of any number of things, so unless you have an accurate picture of what's happening inside a persons head, its impossible to say based on how they look.

Like most things mental health wise, the difference between a disorder and “normal” is extent. Full blown eating disorders are like addictions – the person with them loves them and things they’re a great solution and can’t see what the problem is, and everyone else slowly realises that the food and weight issues have taken over their life, their personality, and that the person is self destructing.

Why do people develop eating disorders?

So why would someone end up believing that they are fat, that being fat makes them a terrible person, and that the solution is to starve, purge or exercise themselves away?

As with most things mental health wise – we’re not exactly sure. But clearly, its not just exposure to skinny models, or every woman in the UK with reasonable eyesight would be in hospital by now. The reason most eating disorder teams are multi-disciplinary is because there seem to be dozens of things that go into the mix.

Firstly, as well as being like addictions, they are actually addictive and do seem to be linked to some physiological tricks. The binge purge cycle tends to repeat, for example, for both physical and psychological reasons. Starving yourself will initially give you a bit of a high. Meanwhile, people inadvertently reinforce the “good” behaviour of at the start of anorexia, often complimenting weight loss and perceived self restraint or “healthy” eating! On some now-considered highly unethical experiments in the 1950′s, Keyes managed to recreate eating disorder symptoms in originally perfectly health people by restricting their intake. So it does seem to be one of those things where the way we are wired can be a tad maladaptive!

Like many psychological problems, eating disorders often seem like a fantastic solution to a problem someone faces – initially. If you value control and don’t feel you have any, if you want to avoid being sexualised or having to deal with having periods, if you have been abused in any way, if you have been bullied (especially about weight or shape), if you have horribly low self esteem, if you have family, academic or social difficulties, dealing with this by changing your eating habits can seem like a good option sometimes.

However, most of these things are also linked to other mental health issues, so why would someone be more likely to develop an eating disorder than, say, depression, a drug addiction, or something else? Its a mixture of not well understood factors including genetics, quirks of brain chemistry, what happens to get reinforced, family attitudes towards food and eating, and yes, finally – societal focus on thinness and perfect bodies!

Wait, so it is all about the skinny models?

Lets unpick that last bit a little. There is cross cultural research that shows a correlation between increases in the incidence of eating disorders and increased focus on thinness. I can’t recall the reference but someone did a neat piece of research that correlated references to low weight in lonely heart adverts in India and rates of eating disorders. There’s also a tonne of feminist analysis of why women in particular might react to the focus on their bodies and how they enact this, and you should totally read it. But that doesn’t make it The Cause, or even The Main Cause, and it doesn’t make it as simple as “skinny models make people hate themselves enough to starve themselves to death”.

Some young women with eating disorders regard them as a trigger, others as a maintenance factor, and some think the entire thing is hilarious – I will forever remember the day I wandered into the dayroom to find two of the girls stalking up and down, hips bizarrely forward, backs and heads at an unnatural angle backwards; they were pretending to be on a catwalk, and they thought it was absolutely ridiculous! They were right too . . . I saw that exact same walk a few years ago at Harrogate, there was one model I was seriously concerned would fall over!

So as far as eating disorders go, here’s my plea; stop talking about the skinny models so simplistically. Because its not as simple as “skinny” vs “normal” vs “plus sized”

Its the fact that we obsess over looks. Its the fact that you put a picture on the net and instead of talking about the clothes or the makeup or the styling or the art concept or the thing they are doing, we talk about the peoples weight and supposed health. Lets stop talking rubbish about peoples health based on pictures. You cannot diagnose a psychological problem from a picture. Hell, you can’t even diagnose a physical health problem from a picture. And its not your job to anyway, so why do it? Who does it help? No-one. Its our obsession with looks and weight and shape that is the problem, not the lauding of one particular size or shape.

Here’s the other plea, and the other reason to stop doing it. Eating disorders are relatively rare. Very few people have such traumatised lives in such a toxic environment that they go all the way down to starving themselves to death – even I only saw it happen once and I worked with at the most severe end of the spectrum for 4 years.

But disordered eating? Eating when you’re not hungry, not eating when you are, crazy dieting, yoyo dieting, hating on your body, thinking that bits of it are “wrong” or “bad”, stressing out about what you look like and whether people like it and all the rest? A national obsession, and not just for women. And you know what? It won’t kill you, and it won’t be half as horrific as the things I’ve seen and others have been through at that serious end of the mental health spectrum, but it is not doing doing any of us any good. It’s wasting your time and your energy, stopping you from enjoying yourself and doing fun stuff and productive stuff, its holding you back, and more than that, its holding you down. So yes, lets change how the fashion industry works, and post your pictures up and celebrate you and have fun and absolutely not body snark ever – but lets do it for all of us.

If you want more information on these issues, try:

Many, many books by Susie Orbach

One of the books I very much enjoyed which may or may not make any sense to anyone else!