Signs, types, symptoms of an eating disorder; causes, diagnosis and treatment of eating disorders; impact on the family; social work role in multidisciplinary team
This page has three sections:
Background Material that provides the context for the topic
A suggested Practice Approach
A list of Supporting Material / References
Feedback welcome!
Background Material
Key facts
https://www.healthdirect.gov.au/eating-disorders Last reviewed May 2020
An eating disorder is a serious mental health condition that involves an unhealthy relationship with food.
Eating disorders can have a significant physical and emotional impact on the person affected, and their family.
Eating disorders include binge eating disorder, bulimia nervosa, anorexia nervosa and other specified feeding or eating disorder (OSFED).
Anyone can have an eating disorder but it is more common in adolescents and young adults.
It's important to seek help for eating disorders as early as possible.
What is an eating disorder?
An eating disorder is a serious mental health condition that involves an unhealthy preoccupation with eating, exercise or body shape.
Anyone can develop an eating disorder, regardless of cultural background, gender or age. Eating disorders are estimated to affect approximately 4 in every 100 people in Australia (or about 1 million people in Australia). About 1 in 7 people experience disordered eating in their lifetime.
A person with an eating disorder may experience any the following:
A preoccupation and concern about appearance, food and gaining weight.
Extreme dissatisfaction with one's body — seeking to lose weight even though friends or family worry that the person is underweight.
A fear of gaining weight.
The person lets people around him or her think they have eaten when they haven't.
Keeping eating habits secret.
Eating makes the person feel anxious, upset or guilty.
Lack of control around food.
Constant checking by, for example, weighing oneself or pinching one's waist.
Vomiting or using laxatives in order to lose weight.
What are the common types of eating disorder?
There are several types of eating disorder, including:
Binge eating disorder (BED)
BED makes up almost half of all cases of eating disorder in Australia. People suffering from this disorder will frequently consume very large quantities of food, even when they are not hungry (known as 'binging'). They often feel shame and guilt after an eating binge; however, unlike people with bulimia nervosa (see next section), they do not purge their food. It is common for people with binge eating disorder to fast or go on diets in response to the way they feel after a binge.
Bulimia nervosa
People with this disorder have frequent eating binges, often in secret, then get rid of the food through vomiting, laxatives or diet pills (known as 'purging'). People with bulimia often feel out of control. About 1 in 10 people with eating disorders have bulimia nervosa.
Anorexia nervosa
Less than 1 in 100 people in Australia has anorexia nervosa. People with this condition can be severely underweight, are preoccupied with food and fear putting on weight. They often have a distorted body image and see themselves as fat. People living with anorexia nervosa may create extreme rules and restrictions about their diets and exercise schedules.
Other specified feeding or eating disorder (OSFED)
A person with OSFED has many of the symptoms of other eating disorders but their condition doesn't align with any specific disorder. People with OSFED commonly have very disruptive eating habits and can have a distorted body image. Around 1 in 3 people who seeks treatment for an eating disorder have OSFED.
What are the symptoms of eating disorders?
It is not always easy to tell if someone has an eating disorder, since they may try to hide it because of shame or guilt. However, some of the behaviours associated with eating disorders include:
Dieting: this could mean calorie (kilojoule) counting, fasting, skipping meals, avoiding certain food groups or having obsessive rituals related to eating.
Binge eating: including hoarding of food or the disappearance of large amounts of food from the kitchen.
Purging: vomiting or using laxatives to rid the body of food. People who purge often make trips to the bathroom during or after eating.
Excessive exercise: a person may refuse to disrupt their exercise routine for any reason, insist on doing a certain number of repetitive exercises or become distressed if unable to exercise.
Social withdrawal: the person may avoid social events and situations that involve eating, or they prefer to eat alone.
Body image: the person may focus on body shape and weight.
Change in clothing style: the person may start wearing baggy clothes, for example.
There are also physical signs that a person may have an eating disorder, such as:
Weight changes: fluctuations in weight or rapid weight loss.
Disturbed menstrual cycle: loss of or disrupted periods.
Dizziness: feeling light-headed or faint.
Fatigue: constantly feeling tired.
Being cold: sensitivity to cold weather.
Inability to concentrate (or think rationally).
Some of the emotional signs of an eating disorder include:
Obsession with weight: preoccupation with weight, body appearance or food.
Low self-esteem: feelings of low self-worth or a negative body image.
Negative emotions: anxiety, depression and feeling that life is out of control.
Meal-time anxiety: feeling anxious, upset or guilty in relation to food.
Mood changes: depression or anxiety, moodiness or irritability.
What causes eating disorders?
It is unlikely that an eating disorder has one single cause. It's normally due to a combination of many factors, events, feelings or pressures. A person might use food to help them deal with painful situations or feelings without realising it.
These factors may include low self-esteem, problems with friends or family relationships, problems at school, university or work, high academic expectations, lack of confidence, concerns about sexuality, or sexual or emotional abuse.
Traumatic events can trigger an eating disorder, such as the death of someone special (grief), bullying, abuse or divorce. Someone with a long-term illness or disability (such as diabetes, depression, vision impairment or hearing loss) may also have eating problems.
Studies have shown that genetics may also be a contributing factor to eating disorders.
How are eating disorders diagnosed?
Many people who suffer from eating disorders keep their condition a secret or won't admit they have a problem. However, it's important to get help early (see, 'Where to get help').
The first step is to see your GP, who can refer you to the appropriate services. A doctor or mental health professional will make a diagnosis.
There is no single test to determine whether someone has an eating disorder, but there is a range of evaluations that lead to a diagnosis, including:
Physical examinations: Disordered eating can take a toll on the body, so the doctor must first check the person is physically OK. The doctor is likely to check height, weight and vital signs (heart rate, blood pressure, lung function and temperature). They may also check blood and urine.
Psychological evaluations: A doctor or mental health professional may talk to the person about eating and body image. What are their habits, beliefs and behaviours? They may be asked to complete a questionnaire or self-assessment.
Diagnostic instruments that could help include (Bosco-Ruggiero, 2020):
Eating Disorder Inventory (EDI-3) (https://www.parinc.com/Products/Pkey/103)
SCOFF Screening Tool (http://www.cedd.org.au/hne/other/scoff_questionnaire.pdf)
Eating Attitudes Test (EAT-26) (https://insideoutinstitute.org.au/assets/eating%20attitudes%20test%20eat-26.pdf )
Eating Disorder Examination Questionnaire (EDE-Q) (https://insideoutinstitute.org.au/resource-library/eating-disorder-examination-questionnaire-ede-q)
Treatments for eating disorders (Source: Butterfly Foundation https://butterfly.org.au/eating-disorders/eating-disorders-treatment/)
Starting treatment as early as possible is important because there can be long-term health consequences for people with chronic eating disorders.
Person-centred, stepped care is the most effective way to treat someone with an eating disorder. This approach means that treatment is specifically customised to suit that person’s illness, situation and needs and also recognises that people with eating disorders may need to move up and down variously through these levels of care over the duration of their illness.
When considering treatment approaches for an eating disorder, it is important to understand that different people respond to different types of treatment, even if they are experiencing the same eating disorder.
These evidence-based treatments have been found to be effective in the treatment of eating disorders. Typically, these treatments are not stand-alone treatments and a person with an eating disorder will usually receive a combination of treatments as part of their recovery program.
Some treatments are better suited to specific eating disorders than others and a multidisciplinary approach to treatment is often the best way to treat an eating disorder.
Multidisciplinary treatment includes psychology, psychiatry, dietetics, nutrition, general medicine, family therapy as well as self-help and various complementary or allied treatments.
Psychotherapy utilises a variety of techniques to manage and treat someone with an eating disorder. Emphasis during psychotherapy is placed on thoughts, emotions, behaviours, patterns of thinking, motivations and relationships. It can include models such as Cognitive Analytic Therapy, Cognitive Behavioural Therapy and Dialectical Behavioural Therapy.
Psychotherapy will usually be conducted by a psychologist. However, other professionals such as psychiatrists, psychotherapists and counsellors can use certain aspects of psychotherapy to treat someone with eating disorder.
Family approaches are most common when adolescents, young adults and children are suffering from an eating disorder.
Family approaches will involve the whole family or support network of the person with the eating disorder during treatment. The aim of a family approach is to treat the person with the eating disorder, while also supporting and educating the entire family about how to care for the person with the eating disorder. Focus can also be placed on strengthening family relationships and improving the family dynamic.
Self-help approaches are carried out by the person who is suffering from the eating disorder and often involves forms of Cognitive Behavioural Therapy.
Self-help treatments can be useful; however, they are most effective when combined with other treatment approaches that are provided by professionals and clinicians. Patients who only adopt self-help approaches and ignore or reject other forms of medical treatment may not recover from their eating disorder and may also be at high risk of recurrence or relapse.
Nutritional management approaches are provided by a dietician or nutritionist during treatment. They can also sometimes be provided by a GP. This approach has been designed to ensure that the person with the eating disorder is receiving the right level of vitamins and minerals throughout the treatment process and to help the person with the disorder develop normal and beneficial eating habits and behaviours.
Medication-based approaches are often vital when someone with an eating disorder also has another type of disorder or illness, such as depression, anxiety, insomnia or psychosis. This is known as a co-morbid disorder. Medications can be prescribed by psychiatrists or by medical doctors and GPs and should only be used in conjunction with another treatment approach.
With the right professional, social and emotional support, a person with an eating disorder can recover.
Where to get help
It is important to seek professional help as early as possible: visit the doctor. Other sources of help include the Butterfly Foundation Helpline (1800 33 4673) and Eating Disorders Victoria (1300 550 236).
Practice Approach
Treatment of eating disorders requires a multidisciplinary team of professionals to provide the appropriate care for the patient. This team usually consists of a primary medical physician, a psychotherapist and/or psychiatrist and a dietitian. It is the responsibility of every team member to inform each other, as well as appropriate family members, of the patient's state. Together, the team decides what type of treatment is necessary along the continuum of care:
outpatient therapy
partial hospitalization
inpatient care
residential care.
The interventions used in treatment need to be developmentally appropriate. As this is a complex multifactorial group of disorders, caregivers must anticipate long-term care, as treatment may require months or even years.
Therefore, the role of the social worker is to encourage the person to seek professional help.
Wientge (2018) suggests social workers have a role in assisting recovery from eating disorders by facilitating support, encouragement and ongoing motivation for both the person with the disorder and those supporting them. Sources of support for the person can be a loved one, other family members (family therapy is a proven tool for assisting recovery), friends, peers and support groups. Support groups can provide a sense of shared identity for those living with eating disorders, as well as increasing a person’s mental capacity to protect his/her own well-being. Support groups offer a safe space for those in eating disorder recovery to express themselves.
It is important for caregivers to stay connected to their own friends, seek out their own support, and set aside time to replenish themselves emotionally. Guilt, shame, frustration, sadness, fear, and anger are just some of the emotions commonly expressed by people when someone they love is struggling with an eating disorder. Attending support groups for caregivers and educational workshops facilitated by treatment professionals can help (Wientge, 2018).
Wang et al. (2018) and Kendal et al. (2016) examined the effectiveness of online support groups for people with eating disorders. Wang et al., examining Twitter, found two online communities: a large community defending eating disorders (i.e. seeing little problem with them) and a smaller community supporting efforts to recover from the disorders. Kendal et al. conducted research on a youth-orientated, moderated, online, eating disorders discussion forum run by an eating disorders charity. They concluded a moderated online discussion forum can make a positive contribution to support for youth with eating disorders in five ways:
Taking on the role of mentor
Providing a safe space for discussion
Forming online friendships
Providing flexible help—responding to the needs of people at different points on the recovery journey
Providing peer support for recovery and relapse prevention
Kendal et al. concluded that an online discussion forum can facilitate support by allowing more control over the process by a young person. As a result the young person meets fewer barriers to help-seeking, leading to more engagement in personal recovery.
Other ways social workers can assist people with an eating disorder include the following.
Try to use ‘I’ statements that are not accusing, such as “I am worried about you”, rather than ‘you’ statements such as “You are making me worried”. Try not to just focus on weight or food. Instead, allow the person to discuss other concerns that are not about food, weight or exercise. Make sure you give the person plenty of time to discuss their feelings and reassure them that it is safe to be open and honest.
You should suggest to the person that they may benefit from seeking professional help. It is best to encourage the person to seek help from a professional with specific training in eating disorders. A referral from a GP may be necessary.
If the person reacts negatively, don’t try to force change. Instead, encourage the person’s interests that are unrelated to food or physical appearance. Acknowledge their positive attributes, successes and accomplishments, and try to view them as an individual rather than just someone who has an eating disorder. You cannot force the person to change their attitudes or behaviours, or to seek help, but you can support them until they feel safe and secure enough to seek treatment.
Clinical social workers can use a range of evidence-based therapies to treat eating disorders, e.g. interpersonal therapy, dialectical behavioural therapy cognitive remediation therapy, Maudsley model of treatment for a adults with Anorexia Nervosa, integrative cognitive affective therapy, Maudsley family-based treatment (for youth) (Bosco-Ruggiero, 2020).
The Impact on the Family Recently Williams, Wood and Plath (2020) examined parents’ experiences when supporting a child with anorexia nervosa (AN). Their study of nine parents found parents responded well to therapists who expressed empathy, paid attention to building trust, respected the family’s unique circumstances and values, offered support, explained the nature and purpose of the treatment, and provided feedback. Feelings of personal responsibility, guilt, and fear were voiced by parents, who were often exposed to challenging behaviours related to moodiness. Managing mealtimes were often stressful. Parents often found less time to deal with the demands of paid work, with some losing income or job. AN causes disruption to the whole family, their coping mechanisms in particular. This suggests an additional role for social workers, one that provides support to the family, while other professionals focus more on managing the disorder.
Supporting Material
(available on request)
My summary of Anorexia and Bulimia (criteria and treatment)
Health direct website: https://www.healthdirect.gov.au/eating-disorders
Butterfly Foundation website: https://butterfly.org.au/get-support/helpline/
Eating Disorders Victoria website: https://www.eatingdisorders.org.au/
Mental Health First Aid: Eating Disorders (2008)
Kendal, S., Kirk, S., Elvey, R., Catchpole, R., & Pryjmachuk, S. (2016). How a moderated online discussion forum facilitates support for young people with eating disorders. Health Expectations, 20, 98-111. doi: 10.1111/hex.12439
Wang, T., Brede, M., Ianni, A., & Mentzakis, E. (2018). Social interactions in online eating disorder communities: A network perspective. PLoS ONE 13(7): e0200800. https://doi.org/10.1371/journal. pone.0200800
Bosco-Ruggiero, S. (2020). How social workers can help with eating disorders. Retrieved from https://www.socialworkdegreecenter.com/study/social-workers-help-with-eating-disorders/
Wientge, D. (2018). The power of relationships in eating disorder recovery. Retrieved from https://www.socialworktoday.com/archive/exc_0419_2.shtml
Williams, L., Wood, C., & Plath, D. (2020). Parents’ experiences of family therapy for adolescent anorexia nervosa. Australian Social Work, 73(4), 408-419. doi: 10.1080/0312407X.2019.1702707