“Beyond Anorexia, Bulimia and Binge Eating Disorder: Understanding The Spectrum of Disordered Eating Behaviours” 

Last week I had two people ask me questions about Orthorexia. One person asked, ‘if by encouraging healthy/ clean eating, professionals like myself might inadvertently be encouraging orthorexia?’ The other one asked me if orthorexia was even a ‘real thing’ and if it was, ‘how could it be bad, as surely it’s a good thing if people want to eat healthily?’

In the same week I had a new client start, who disclosed to me that though she ‘didn’t have an eating disorder’, she has a history of chewing food and then spitting it out, to satisfy her craving to over eat/ binge, without the risk of weight gain. It turns out, that a very painful and debilitating narrative also held by this woman, was that she was ‘big’ and therefore undesirable.

More than one person I am currently working with, struggle to eat without a distraction such as the tv or their phone. These behaviours often accompany overeating or binging behaviours.

Countless other clients over the years, have faced a fear of eating in public.  The process of supporting them to take tiny steps to taking the risk of tasting foods, eventually leading up to being able to eat whole meals in restaurants, is long and grueling.

The purpose of this blog is to address the issues of misunderstanding, belittling and dismissing of various lesser well-known disordered eating behaviours.

Firstly I’d like to demystify some of these, in particular the above mentioned behaviours, and secondly, I’d like to address the issue of why it is so dangerous to ignore or dismiss them.

I shall start with orthorexia, a condition that is now becoming much more recognised in both mental health circles and also in public spheres.

Orthorexia can be defined as an obsessive and/ or unhealthy preoccupation with eating healthy food.

The term was first used in 1997, by physician Steven Bratman, who identified that some of his patients’ desires to be healthy, had paradoxically become problematic. Their preoccupations led them to ‘social isolation, anxiety, loss of ability to eat in a natural, intuitive manner, reduced interests in the full range of other healthy human activities and in some rare cases even severe malnutrition and death’ (Bratman & Knight, 2000).

Orthorexia Nervosa is not currently recognised as a condition by the American Psychiatric Association, nor as a diagnosable condition in the current Diagnostic and Statistical Manual of Mental Disorders (DSM). I think it should be!

I have now been working with people suffering from eating disorders for ten years. My first ‘proper job’ out of college was as a youth worker in London, at an inner-city facility run by Westminster Children and Family Services. The kids I worked with were mostly first and second generation immigrant and many had learning difficulties as well as behavioural issues. Most of these young people came from such poor families, health food was in no way part of their experience. In fact I remember planning cooking classes for them in which we actively wanted to promote more awareness of non ‘junk’ food. Disordered eating and body image issues presented as either obsessive desire to lose weight by restriction, or binge eating.

My first encounter with orthorexia was about a year later with a young woman I was mentoring through a voluntary project I had gotten involved with. She was in early recovery from binge eating and bulimia. She was not under the guidance of a nutritionist or dietitian and had gotten involved with the project I worked with, who offered peer support and mentoring for vulnerable young people. She attended groups during the week with other young people overcoming emotional difficulties and met with me to talk about how it was all going.

I was by no means an expert in the field. My own experiences as a younger woman and teenager, included poor body image and dis-regulated eating, as so many of us (unfortunately) can relate to. I had gone from that space, to one of a passionate and authentic pursuit to not only love and nurture my body, but to empower others to do the same. But I was, at that stage, not qualified to support people in positions such as hers, in the ways that I am now!

She presented as extremely anxious to eat most foods. She was vegan, gluten free, sugar free, additive free and didn’t like to consume any cooking oil except for virgin olive oil. She believed that this way of eating was the only way she could remain safe and abstinent from bulimia. She was convinced that if she ate anything from these ‘outlawed’ categories, that she would become so overwhelmed by guilt, that she would inevitably want to purge. She described how these foods made her feel ‘unclean’. She didn’t restrict the quantities that she was eating, but was extremely restricted in the sense that she felt unable to eat food prepared by anyone but herself, for fear that the food may be contaminated with these ingredients.

On the one hand it was commendable that she could now go weeks without bingeing and purging, but she had replaced one extreme obsessive behaviour with another. The obsession cost her her social life, an awful lot of money (health foods do!) and caused conflict with her parents.

I now see how this woman was suffering from orthorexia. I have now seen these symptoms exhibited in countless other people over the years.

Today, I work to address, explore and treat these symptoms.

What does that look like?

In short, I support the client to make achievable, measurable behavioural changes; essentially ‘detoxing’ them from the unhealthy patterns they feel trapped by, slowly introducing different foods and working towards a more flexible way of eating. In conjunction with this diet-focused process, I support clients to identify, explore and understand the ‘underneath’ stuff that’s causing them to want to act out with food in the first place.

I believe that all addictive-compulsive behaviours stem from a lack of acceptance/ inability to face certain emotions, narratives and memories. By addressing these things in a therapeutic setting, cognitive changes around them can occur, tools can be introduced to help identify when these emotions and narratives are present and to manage them. Healing these deep wounds so that they no longer feel so unbearable that acting out feels like the only option, is the key.

This is why I feel frustrated when people dismiss these lesser well-known disordered eating behaviours. My experience has led me to very confidently believe that no one ends up in these sort of patterns without there being something else going on, something that feels as if it requires some sort of distraction from, or total obliteration of uncomfortable thoughts or feelings. These things need healing. If they aren’t addressed, they persist and the behaviours (coping mechanisms) developed to deal with them become harder to shift out of, thus limiting a person’s life ever more destructively.

Let’s examine a few other behaviours I mentioned above:

I’ll begin with chewing and spitting food. When mentioned to an audience not ‘in the know’, this behaviour sounds at best ‘strange’ and at worst ‘disgusting’. People have asked me ‘why on earth someone would do that?’ Well, the answer is simple. It’s a way of taking oneself out of feeling difficult feelings, by using food. But the rationale usually given, the first layer of the onion of what it’s all about, is usually either that someone has or does over-eat and the fear and shame of this behaviour ends up in a head-to-head battle with the craving to do it.  A solution to attempting to control it (rather than to assess what’s behind it in the first place and learning how to healthily manage it), is chewing and spitting out the food. Another example of when it may be used, is by those suffering from anorexic nervosa, either as a way of ‘tricking’ caregivers into thinking they are in fact eating, or as a way of ‘tasting’ (there are usually latent desires to eat and with them, incredible shame), whilst simultaneously controlling the consequence of potential weight gain.

Another behaviour aforementioned is the fear of (in some cases inability to) eat with others. This once again, is usually linked to shame and perceived judgments and negative associations assumed by the sufferer, as to what food and eating suggests about them.

There are many more I could unpack, but I will save us both the time by jumping ahead to the point I’d like to emphasize. These behaviours are inevitably symptoms of unprocessed, uncomfortable feelings (fear, shame, guilt, resentment…) Obsessive and compulsive behaviours always are and without proper treatment can not only spiral into much more severe manifestations, but simply deny a person the opportunity to live a truly free, flexible and fulfilling life.

Disordered eating/ food-related behaviours are some of the hardest to shift. Undoing these habits, which translate for the sufferer as an essential safety net, can take a lot of time, patience and gentle but deep therapeutic exploration.

I wrote this blog to help demonstrate why it is so important not to dismiss, belittle or ignore behaviours such as (but not limited to), the ones I have described.

Whether you have a loved one, student, colleague, friend – or it is in fact you who is exhibiting these symptoms; know that seeking help is justified, necessary and can help! I have many clients who have previously seen therapists who told them ‘not to worry’ about these behaviours. Not only can this dismissal lead to the symptoms worsening, but it denies the client an amazing opportunity to delve into and tackle whatever issues lay beneath the behaviours. I encourage my colleagues in the field of mental health, to think of these behaviours as a ‘doorway’ into a whole universe of opportunities to heal!

I’m aware that sometimes it can be confusing to know when a certain behaviour is in fact problematic or not. Please feel free to contact me, another eating disorder expert, or a specialist organisation and describe what you’re witnessing, hearing about or experiencing. There is no shame in asking for clarification and guidance, but there is surely a lot to be lost if you don’t.