Questions and Answers

Anorexia is an abbreviation of anorexia nervosa or self-starvation. Anorexia means lack of appetite. The condition is often associated with an exaggerated fear of becoming fat. Those suffering from anorexia nervosa eat very little food or exclusively eat food with low fat and calorie contents.

Early warning signs for anorexia nervosa include:

• A vegetarian diet
• Avoidance of sweets
• Eating slowly or postponing meals
• Eating alone
• Excessive interest in food and weight
• Constantly thinking about dieting
• Increased physical activity
• Weight loss
• Mood swings
• Avoidance of social situations

Symptoms of anorexia nervosa:

• Excessive weight loss
• Feeling fat, regardless of actual body weight
• Excessive physical activity
• Sleeping problems
• Constipation
• Isolation from family and friends
• Anxiety
• Depression
• Suicidal thoughts
• Obsession with food and food preparation
• Irregular or loss of menstruation
• Low body temperature and feeling cold
• Thinning of hair
• Low blood pressure that can result in fainting and exhaustion
• Weakened reflexes
• Irregular heart rhythm that can result in cardiac arrest

Bulimia is an abbreviation of bulimia nervosa, derived from Latin, the word bulimia that means insatiable appetite. Those who suffer from bulimia, show a more or less uncontrollable need to binge; eating large quantities of food in a short period time. A person suffering from bulimia cannot stop eating even though she/he would like to.  Binge eating is followed by self-induced vomiting, increased physical activity, and often, the use of laxatives. A bulimic individual has the same complicated relationship with food and weight as an anorexic individual does; both are afraid of gaining weight and both are constant dieters.

Early warning signs for bulimia nervosa:

• Irregular meals (often skipping breakfast)
• Eating “healthy” foods in social situations but large amounts of “unhealthy” food when alone.
• Large amounts of food “disappear” at home
• Mood swings
• Fixation on food and weight
• Constant dieting
• Increased physical activity/self induced vomiting

Symptoms of bulimia nervosa:

• Eating large amounts of food in a short period of time (binge eating)
• Binge eating is usually followed by self-induced vomiting
• Eats socially between episode of binge eating
• Excessive physical activity
• Strong mood swings
• Anxiety and depression
• Suicidal thoughts
• Sleeping disorders
• Isolation from friends and family
• Cancels meetings and other activities
• Money may disappear at home, and petty theft to finance binge eating is common
• Irregularity or absence of menses
• Constipation, digestive problems and/or acid reflux
• Swollen salivary glands
• Bloodshot eyes
• Recurring throat pains
• Weakness/exhaustion
• Dehydration
• Dental problems
• Seizures
• Irregular heart rhythm that can lead to cardiac arrest

Your fear of becoming fat stems from having abnormal eating behaviour, which has disrupted your body’s natural signals for hunger and satiety. This means you have to guess when you are hungry and when you are full. In addition, when you have lost weight due to short-term or long-term starvation, this exacerbates your fear of becoming fat. The more weight you lose, the more you become anxious about regaining weight.

The reason that it is difficult to restrict your activity is because exercising gives you temporary relief from your anxiety. When you move, do sit-ups or a similar activity anxiety goes away for a while. The problem is that this does not offer a long term solution; your anxiety will soon return, leading you to exercise again and again in attempt to get some relief, keeping you trapped in a cycle that maintains the illness. The only way to get out of this situation is to resist the urge to exercise and sit with your anxiety when it emerges. If you fight the urge to exercise, it will soon become easier to sit still and to limit your physical activity. In addition, if you remain satiated throughout the day, this will decrease your anxiety. You should not view feeling satiated as a personal failure.  Feeling satiated is a positive sign and an indication that your body’s signals for hunger and satiety are functioning normally. However, you cannot normalise your eating behaviour while being highly active; the high activity will always “win”. You need to accept that in order to recover you must restrict your physical activity. As you recover, you can gradually increase your activity levels, but you must normalise your eating behaviour first.

You ask this question repeatedly because your mother’s answer works just like a scale for you. What she says and her tone of voice tell you what and how much to eat. Asking these questions is an indication that you don’t know what or how much to eat; instead you have to guess. It is also a sign that you are focusing far too much on yourself and not enough on other things in your life. These thoughts need to be interrupted. Rather than thinking, “this is the last time’’ or “only one more time” decide that the last time has already happened. When you find you are about to ask a question about your weight, ask something completely different. For example, “Do you think I should have a haircut?” or “Do you know what a prime number is?” or “I would like to be able to speak Spanish” or ask a question about something you have just read or seen on TV.

Compulsive behaviours are behaviours that you feel forced to do in order to keep your anxiety under control. Examples may include repeatedly checking things, excessive cleaning in order to avoid bacteria, or extreme dieting in order to avoid calories. It is common for people with eating disorders to develop rituals around food, such as cutting food into a certain number of pieces or spinning a glass seven times before taking a sip. Even though a person with compulsive behaviour may recognise that their behaviour is illogical, it can feel impossible to stop. A similar problem is obsessive thinking; where certain thoughts feel so overwhelming that you try to avoid them by focusing on other, harmless thoughts. Compulsive behaviour is a common consequence of starvation. The less you eat, the more limited your repertoire of behaviour becomes, leaving you with only a few behaviours to choose from. As behaviours reduce, the remaining behaviours become exaggerated and repeated over and over again. These constraints on behaviour dissipate as hunger is resolved and you learn to eat regularly and adequately.

Feeling as if you are not understood is common in patients with eating disorders. Social isolation and the inability to find words for your feelings can lead to the feeling that no one understands you. At the Mandometer Clinic we have well-trained staff who understand eating disorders, and can explain the different emotional states that patients tend to experience in different stages of treatment. We also provide the opportunity for you to meet with a former patient who attends the follow-up program. You can ask them any questions you may have, and they can explain how they felt when they were in your situation.

No, eating behaviour does not become normal just by having a normal weight. Normal eating behaviour implies that; you can feel both hunger and satiety, you eat when you are hungry, you don’t avoid any particular foods, you can eat at a normal speed, you can eat spontaneously, and you can eat without feeling guilty or anxious. These are things that you learn during treatment. When you have normal eating behaviour, it also means that you have learned to recognise your biological signals correctly, and that you dare to trust your hunger and satiety signals. When this happens you will no longer be afraid of getting fat, because you will be in control of your food intake. You will know when to eat and when to stop eating. It takes about 3-4 months to normalise eating behaviour using a Mandometer®.

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The conflict between eating and not eating is ongoing 24/7 for individuals with anorexia or bulimia. The same complicated conditions exist between food and the patient’s own body. When eating is disordered, that is, when satiety signals do prompt you to stop eating, you have to guess when to eat, how much to eat and whether you are or not satisfied. You do not experience degrees of satiation, such as feeling a little satisfied, quite hungry or extremely full. Instead you think: either I eat or I don’t eat. Not eating feels like you are in control, while eating feels like you have lost control because you risk becoming fat when you eat. When you learn to eat normally again, you can trust your biological signals to tell you when you are full, and you will not be afraid of eating too much.

Mood swings are part of the eating disorder and are usually a consequence of not being able to cope with situations you are exposed to, or expected to be able to cope with. As long as eating remains disordered, you will not be able cope with things that you would normally be able to cope with. You can tolerate more when you eat normally; thinking becomes less rigid, and you do not take offence at the same things, nor with the same intensity.  When you eat normally, it is easier to shake off problems and unwanted comments, and continue as normal.

Anxiety is unpleasant, but it is not harmful or dangerous. However, it is common to be afraid of the anxiety itself, because it can be excruciatingly painful. Some people believe that anxiety may damage the body, but this is incorrect. Anxiety just feels uncomfortable. Anxiety associated with eating disorders decreases as eating behaviour normalises, because it is the disordered eating that is causing the anxiety. When food, eating and body weight become normal anxiety levels also normalise.

The psychiatric problems associated with eating disorder do not disappear solely based on weight gain. This is why a patient who is tube fed to a normal weight still has remaining psychiatric symptoms. Eating behaviour also needs to be normal. When eating behaviour is normal, an underweight patient will gain weight, while normal weight patient will maintain their weight. Your psychiatric symptoms may temporarily increase when you start to gain weight, but this is only temporary and your symptoms will subside once you realise that you are not gaining excessive amounts of weight; only as much as you and your case manager have agreed. In addition to having a normal weight, it is important that you learn to eat normally in order to feel better mentally. This is why it can take a little longer than the time it takes for you to reach a normal weight for your mood to improve.

Anorexia nervosa starts with some form of food restriction or increased physical activity. For most people it’s a combination of both; they start to eat less and they increase their physical activity. For example, the risk of developing anorexia nervosa is greater for people who participate in regular fitness activities. The condition tends to develop slowly through the gradual reduction of food intake. The more weight you lose the more difficult it becomes to eat. Hunger sensations disappear and you start to feel full all the time. Initially losing weight feels great, and is often further rewarded by comments from friends saying you look slimmer. Eventually, the negative aspects of weight loss appear; you think about food and dieting all the time, and you don’t know how much to eat or at what pace you should eat. You have lost your ability to recognise the satiety signals that would normally prompt you to stop eating. At the same time, your pulse slows and you feel cold all the time. Anxiety, depression and dark thoughts start dominating your thinking.

Anyone who feels that they fail all the time loses confidence. When everyone else seems to be able to control their food intake, every episode of binge eating feels like a personal failure. For this reason, it is imperative to put strategies in place to enable you to change your way of living. The first thing to understand is that you need to feel satiated throughout the day in order to eliminate food cravings. This means eating 4-6 regular meals per day without vomiting afterwards. Your food intake also needs to be varied in order to prevent cravings for foods that you think that you shouldn’t eat, but cannot stop eating, even though you want too. These feeling are difficult to control and it can be hard to keep food down due to the fear of becoming fat because you have binged. However, you must ignore these thoughts. You will be able to eat what you want and stay slim once your normal signals for hunger and satiety have been restored. To help yourself, you must start directing your attention towards activities other than food, eating and your body. Any activity you do to distract yourself from these thoughts will help you refrain from binge eating. Instead of saying to yourself “today is my last binge” you must also decide that, “from this day forward I will keep down all food that I eat, even if I binge eat”. Every evening when you go to bed, you must try to rid yourself of all of your thoughts about food and self criticism.

Approximately 1% of all girls and women between 14-19 years of age have anorexia nervosa, and approximately 1.5% of all girls and women between 17-25 years of age have bulimia nervosa. In Sweden there are about 4,000 individuals with anorexia nervosa and somewhat more with bulimia nervosa. More than 95% of those affected are women and about 5% are men. The proportion of the population with these diagnoses has not changed over the years, but the eating disorder that has increased dramatically in recent years is EDNOS (Eating Disorders Not Otherwise Specified). Individuals with EDNOS meet some of the diagnostic criteria for anorexia or bulimia, but not all. Today, every third woman in Sweden meets the diagnostic criteria for EDNOS.

It is likely that eating disorders are much more common in girls than in boys due to different behavioural responses to food restriction between girls and boys. Experiments have shown that when healthy volunteers of both sexes were subjected to a period of food restriction, boys compensated for the lack of food by eating much more food when food became available, and by eating faster than they usually do. However, when girls were given access to food after a period of food restriction, they ate less food than they normally would, and they ate it more slowly than usual. This experiment suggests that boys eat more when needed, but girls do not. The results also suggest girls can develop an anorexic pattern of eating by going on a food-restriction diet, and that they have the capacity to withstand starvation better than boys. This biological constraint combined with the strong social pressure on young women to be slim, means it is likely that they will restrict their food intake at some point, making them vulnerable to developing an eating disorder.

About half those who suffer from anorexia nervosa develop bulimia nervosa. This is because patients are rarely healthy when they leave most treatment facilities, and they continue to have problems with food, body image and psychiatric issues. Less than 3% of patients with anorexia nervosa treated at the Mandometer Clinics have developed bulimic behaviour. This number is so low because our patients remain in treatment until they are in complete remission: normal eating behaviour, normal feelings of hunger and satiety, normal weight, no psychiatric problems, food and weight are no longer a considered a problem, normal blood values, returned to school or work, and no binge eating or vomiting in the last three months. These comprehensive remission criteria make it more likely that a patient with anorexia nervosa will not develop bulimia nervosa, or relapse into disordered eating patterns again.

Eating disorder patients develop:

Psychiatric problems

• Anxiety
• Depression
• Obsessive thoughts and behaviours, such as repeated hand washing, showering, clothes washing, and washing of food and household utensils
• Repeated dressing and undressing
• Repeated jumping exercises
• Going of long runs
• Suicidal thoughts—approximately 25% have attempted to commit suicide, usually by overdose of medication or by cutting themselves.
• Extreme mood swings

Heart and circulatory problems

• Low blood pressure (<90/60 mm Hg) and low pulse (<60 beats/min), leading to exhaustion and dizziness.
• Cold hands and feet due to decreased blood circulation
• In cold weather, circulation can become even worse, and in extreme cases fingers and toes swell up (Raynaud’s phenomenon).
• Patients with anorexia nervosa are usually dehydrated.
• Patients with low potassium are at risk of heart arrhythmia.

Problems of the oral cavity

• Disturbed salivary production and tooth decay
• Degraded tooth enamel, particularly on the inside of the front teeth due to frequent contact with stomach acid during vomiting.
• Enlarged salivary glands and decreased salivary flow.
• Sores in the corners of the mouth.
  Throat injuries from vomiting and the use fingers to induce vomiting.

Digestive problems

• Eating disorder patients frequently experience stomach pains.  Patients with anorexia nervosa have a reduced stomach size, and reduced rate of gastric emptying.  This situation leaves the patient feeling extremely full after eating, and gives the sensation that food is “stuck in your throat”.
• It is common for individuals with both anorexia and bulimia nervosa to suffer from constipation due there only being a small volume of food passing through the gut.  Dehydration and low potassium further impairs digestive processes.
• Bleeding in the oesophagus can occur, and ulcers may develop because of stress and poor eating habits.
• Constipation and the use of laxatives can lead to tearing and bleeding of the rectum.

Hepatic function

• The skin may get a yellowish tinge due to impaired liver function, where the liver is unable to remove a yellow pigment called bilirubin from the blood.
• Patients are also at increased risk of developing kidney stones due to dehydration from insufficient fluid intake and vomiting, which reduces the amount of urine production.

Problems with blood

• Anaemia is common, but is often masked by dehydration.
• Patients with anorexia nervosa may have normal or even high haemoglobin levels, but a more detailed analysis often shows deficiencies of iron, folic acid and vitamin B12.
• Low concentrations of sodium and potassium can be seen in patients who vomit repeatedly.

Problems with the nervous system

• General muscle weakness, and in some cases muscle injuries with longterm damage can occur during extended periods of starvation.
• Fatigue, concentration difficulties, and learning difficulties are common due to low blood sugar level.
• Disturbances in brain function may occur, but these appear to be reversible.
• Patients with bulimia nervosa who are treated with antidepressants may develop epileptic seizures.

Skeletal Problems

• Osteoporosis is regularly seen in severely underweight patients due to nutritional and oestrogen deficiency.  The skeleton is not only a support system for the body; it is also the body’s calcium reserve. The amount of calcium in the bones is maximal at approximately age 22.  Since calcium and phosphate are required to create normal, strong bone; lack of these minerals leads to softer bones, and a more brittle skeleton.  The risk of osteoporosis and fractures increases with the length of time an individual remains underweight and there is suppression of gonadal hormones.  Absence of menses is an indication of suppressed hypo-gonadal axis.
• Those who develop anorexia nervosa prior to puberty risk being short in stature, and not achieving their full height potential. The levels of important minerals and vitamins, as well as oestrogen, need to be measured carefully and supplements must be given to these patients.

Skin and hair problems

• The skin becomes dry and thinning of head hair occurs
• Soft, downy hair begins to grow on the face, arms, legs and back

Hypothermia (low body temperature)

• Hypothermia is a sign of anorexia nervosa, however people with bulimia nervosa can also suffer from low body temperature in between binges.
• Individuals with anorexia nervosa often try to compensate for feeling cold by increasing their physical activity.
• Women have a lower peripheral body temperature than men, and this low temperature in the outermost parts of the body often affects their ability to sleep.
• People with anorexia nervosa often only sleep only a few hours per night, and those with bulimia nervosa normally sleep badly and wake up early.

Menstruation

• Loss of menstruation is a criterion for the diagnosis of anorexia nervosa. It can take a long time before menstruation returns, even after a patient has regained a normal weight.
• In both anorexia and bulimia nervosa, the body down-regulates gonadal hormone production; from the hypothalamic-pituitary axis down to the ovaries. The ovaries stop producing normal amounts of oestrogen, testosterone, and do not release a monthly egg.
• When the gonadal axis is suppressed, eating disorder sufferers may develop ovarian cysts. These cysts disappear when eating behaviour is normalised.

Vitamin deficiencies

• Starvation can lead to severe vitamin deficiencies.
• Vitamin A can be stored in the liver for up to a year, but beyond that deficiency may occur.
• Vitamin C deficiency develops after three months of eating foods lacking in vitamin C content.
• Vitamin B12 and folic acid deficiency can also develop with prolonged periods of food restriction.
• Vitamin D deficiency also interferes with bone mineralisation and calcium absorption, leading soft bones that are poor in calcium.
• Zinc deficiency is also common.
  Vitamin deficiencies can also lead to cramps, seizures paralyses, and memory disorders.

Mortality rate

The mortality rate for anorexia nervosa is 5.5% to 15% within a 10-20 year period of becoming ill.