I’m a psychologist – the subtle red flags someone you love has an eating disorder

Are you worried about someone’s relationship with food – or, indeed, your own?

From an extreme obsession with ‘clean’ eating to point-blank refusing to touch certain foods, there are often obvious signs all is not right.

Not only that, but excessive exercise and gym-going can also be part of the wider picture.

But when is it just healthy living, and when should you be worried that it’s become something more concerning?

Here, DR JOANNA SILVER, lead psychological therapist at Orri, an eating disorder treatment clinic, reveals the signs to look out for, how you can approach a loved one you’re concerned about, and why – contrary to popular belief – eating disorders aren’t just about food…

Eating disorders are on the rise  

Hospital admissions for eating disorders have increased by 84 per cent in the last five years, according to figures released last year by the Royal College of Psychiatrists.

Children and young people are the worst affected and there was a sharp rise in boys and young men being treated,

But there has been an alarming increase in adults, too.

These figures (and hospital admissions are just part of the story) highlight that, despite what many think, eating disorders don’t just affect young, white girls.

In fact, you can be perceived as the pinnacle of health, be a normal weight and still be suffering with a hidden eating disorder.

Most eating disorders aren’t actually about food  

An eating disorder (or exercise addiction) may develop when someone is going through a particularly challenging time in life.

This might include being bullied at school, going to university, being made redundant, menopause, going through a divorce, becoming a new parent or saying goodbye to children going to university.

The feeling of being overwhelmed by the experience, or a series of experiences, can prompt us to feel unsafe and uncertain in our lives – perhaps also triggering feelings such as anxiety or depression.

This, in turn, can trigger us to develop disordered behaviours that provide a false sense of security and safety, such as controlling our food or body weight.

Common signs of eating disorders  

It’s crucial to remember these signs are not prescriptive. 

The person may not have all of them, but that doesn’t mean that they don’t have an eating disorder. 

Signs can also change and evolve over time, for example someone may initially be diagnosed with anorexia then develop bulimia later on in their illness.

OSFED: Other specified feeding/eating disorder

This actually accounts for the highest percentage of eating disorders – it’s an umbrella term for when someone doesn’t fit into any of the categories below but still has a valid eating disorder.

For example, a person may have all the signs of anorexia, but their weight might not be quite within the anorexic range. Or they may have symptoms of bulimia or binge eating, but don’t have episodes often enough to meet the criteria for diagnosis.

This is really important as people can feel invalidated if they don’t meet all the criteria – yet they are still very much suffering, and the implications of their eating disorder can be just as serious and dangerous.

Anorexia nervosa  

Anorexia typically involves restrictive eating due to an irrational fear of gaining weight and/or distorted body image.

It may also be accompanied by excessive exercise and/or cycles of binging and then purging (trying to ‘undo’ the effects of the binge through processes such as vomiting, laxative overuse, fasting or excessive exercise), as a way of compensating for any food eaten.

Common signs:

• Food and/or exercising has started to dictate life decisions
• Preparing meals and eating them has become a challenge. The person may be counting calories, be trying to make the ‘perfect’ meal, or just generally extremely anxious around food
• The person has employed food ‘rituals’ in the preparation or eating of food such as eating at a very slow pace, using a very small knife and fork to eat, cutting food into tiny pieces, eating foods on their plate in a specific order, making sure that foods on a plate do not touch
• Social withdrawal and isolation
• Preoccupation with size and body image
• Insomnia or struggling to sleep/stay asleep
• Low self-esteem and insecurity
• Perfectionism, often at the expense of relationships
• May be accompanied by depression and anxiety

Bulimia nervosa 

With bulimia, people tend to eat large quantities of food – called bingeing – often to provide relief in times of stress, and then purge it from their system.

Purging doesn’t always take the form of self-induced vomiting. 

Sometimes, someone might rid their system of calories by fasting, exercising compulsively, or taking laxatives or diuretics.

People who suffer with bulimia are often high-functioning individuals with a ‘normal’ weight’ and who conceal their symptoms, so the illness goes undetected.

Common signs:

• Eating uncontrollably (binging) and/or fear of eating uncontrollably
• Vomiting, excessive exercise
• Secretive eating and isolation
• The person will often feel disgusted, ashamed and repulsed by themselves after a binge and/or purge
• Perfectionism
• Depression and other conditions such as OCD
• Low self-esteem
• Preoccupation with body image and appearance

Binge eating disorder 

This is where people eat large quantities of food – bingeing – but don’t typically engage in compensatory behaviours such as purging, as with bulimia.

People often talk of entering a trance-like state when bingeing, or becoming preoccupied with planning their binges as they go about their everyday lives.

Sometimes it can be hard to distinguish between binge eating disorder and overeating, as to occasionally overeat, and ‘comfort eat’ is normal behaviour for human beings.

One of the biggest differences between is that the person living with binge eating disorder often feels they do not have control over their urges to eat. For many, the impulse to eat is an emotional response and a self-soothing behaviour.

Common signs:

• Eating uncontrollably (bingeing) and/or fear of eating uncontrollably
• Consuming food in a fast and hurried way
• Secretive eating and isolation in order to prevent feelings of shame or embarrassment
• Perfectionism
• Depression and other conditions such as OCD
• Low self-esteem
• Preoccupation with body image and appearance
• Feeling disgusted with oneself, depressed or very guilty after bingeing

ARFID: Avoidant restrictive food intake disorder

ARFID is a relatively new eating disorder diagnosis. Previously called ‘selective eating’, it involves limitations and/or restrictions around food, particularly around the intake of certain types of food or certain amounts.

Unlike other eating disorder diagnoses such as anorexia or bulimia, it doesn’t typically involve distress around body image or a pursuit of thinness.

Rather, ARFID typically involves avoidance of certain foods often due to a sensitivity in taste, texture, smell, appearance or temperature.

While there’s no single cause, it may be that someone had a distressing experience while eating – such as choking or vomiting – that harmed their relationship to food. 

It is also common for people with autism spectrum disorder to be diagnosed with ARFID, due to sensory sensitivity.

Common signs:

• Avoiding particular types of food
• Displaying a lack of interest in food or lack of appetite – sometimes missing meals altogether when distracted
• Taking a long time over mealtimes
• Only eating certain textures of food and maintaining a limited range of options
• Anxious around mealtimes
• Avoiding eating in social scenarios
• Fears choking or vomiting
• Not eating enough food to be nutritionally healthy and satisfied
• Weight loss
• Stunted growth in children

Orthorexia

This is characterised by symptoms of obsessive behaviour towards food, often in pursuit of ‘health’ or a ‘healthy’ diet.

The person maybe extremely selective and restrictive with their food and food types. They may categorise food as ‘good’ or ‘bad’ and attempt to eat only ‘pure’ or ‘clean’ while following a seemingly ‘perfect’ diet.

But where is the line between healthy eating and an obsession? They key is, is it causing them distress? Is it getting in the way of the person socialising and getting on with life? If so, then it’s become a concern.

Common signs:

• A preoccupation and obsession with eating so-called ‘healthy’ foods – possibly spending hours a day planning meals
• Regimented eating and/or lack of intuitive eating. Feeling unable to eat foods that aren’t deemed ‘healthy’ or ‘pure’
• Guilt and shame associated with eating foods that don’t fall into these categories
• Prioritising ‘healthy’ eating over family time, social lives and/or their career. Possibly not attending social events or meals that don’t have healthy food options
• An unusual interest in what others are eating and an obsessive following of food blogs or social media profiles
• Basing self-worth around their diet and the pursuit of health

Anorexia athletica

This is addiction to exercise which can also be combined with restrictive eating. However, because exercise is seen as a ‘good’ thing, it can go unnoticed.

Common signs:

• Exercise has become the priority above anything else – friends, family, work and socialising
• They exercise despite injuries or feeling exhausted
• They might be hyper-aware of the food they eat and its nutritional content, and use exercise as a means of ‘purging’ what they eat or drink
• They feel an intense guilt for not exercising
• Exercise is the most important thing that makes them feel good about themselves. Often, people who suffer with an addiction to exercise struggle with low self-esteem or self-worth, which is masked by the euphoric (but fleeting) sense of achievement when exercising

Muscle dysmorphia 

This is a type of exercise addiction and is most often seen in men. Here, the person is obsessed with building muscle or ‘bulking up’. 

It displays in a similar way to anorexia athletica, e.g. the person puts going to the gym above everything else, continues to train when they have an injury, etc.

How to approach and support a friend you’re worried about  

Pick the right time – and understand that eating disorders aren’t just about food.

It’s so important you communicate your concerns if you feel someone is struggling. Pick a time when tensions aren’t running high and when the other person appears to be receptive.

Broach the topic gently and with compassion, keeping in mind that despite how they appear, eating disorders are not just about food. 

Rather, the way the person is with food is a symptom of emotional distress. They may also be feeling a lot of shame around what is happening – especially if they bingeing and/or purging – and it’s important to remember whatever they’re experiencing is not a choice, but a way of managing a difficult situation.

If someone is suffering from physical symptoms of food restriction, such as fainting, then of course this must be mentioned. But focusing on food behaviours in isolation may cause someone to become defensive or to deny their experience.

Instead, it’s better to go in with something like ‘you don’t see yourself at the moment, I’ve noticed you seem a little withdrawn. Could we have a chat about what might be going on?’

Get their ‘buy in’

Try and discuss with the person understand how the eating disorder might affect their life in the short and long-term. 

A young person might not care that an eating disorder will affect their bone health or reproductive health in the future, but they may well care about the shorter-term implications, such as becoming unable to do everyday activities they enjoy.

Accept that things probably won’t change overnight

Generally, if someone has an eating disorder, letting go of it can be very difficult, as it’s a coping mechanism.

It’s rarely the case that after the first conversation the person says ‘yes OK, I’ve got a problem, let’s go to the GP’.

Be prepared they might scream and shout and the conversation may need to be parked for a later date. Keep lines of communication open and let them know you are always there if they want to talk.

(In extreme cases, if the person’s health is perilous due to an eating disorder, they may need to be treated against their will.)

Hold onto hope that recovery is possible

We know that recovery is possible because we see it happen every day at Orri. But everyone’s recovery journey is different, and there will be ups and downs along the way.

Avoid diet talk 

While eating disorders are not about food, be mindful of how you talk about food and your choices around someone who is struggling. By labelling foods as ‘good’ or ‘bad’, you’ll risk exacerbating someone’s fixation on the nutritional content.

Find a specialist who may help

First off, try and help them speak with their GP. The eating disorders charity Beat has a brilliant crib sheet you can take along to help the conversation and to help you understand the process.

Offer to go with the person – either into the consultation room or simply sit in the waiting room if they prefer.

Depending on the outcome of the GP appointment, finding specialist help may also be vitally important. An eating disorder psychotherapist, psychologist or specialist clinic, combined with a specialist dietitian, can help people understand more about their eating disorder and take important steps towards recovery.

Orri is a specialist eating disorder treatment clinic based in London that provides intensive day treatment and outpatient services — online and in person — for those aged 16 and over.

All programmes follow a ‘stepped approach’, meaning that treatment evolves with each individual client as they progress in recovery. 

For more information on eating disorders, visit the Beat charity website: https://www.beateatingdisorders.org.uk.