Behaviours

 

Eating disorders may include individual or multiple combinations of behaviours, which may change over time, but the thought processes often remain the same for people who struggle over a number of years. Behaviours may include restriction (limiting variety and/or quantity of food eaten), bingeing (eating a significantly larger portion of food than would be considered reasonable for a non-eating disordered person, purging (using behaviours to compensate for calories consumed, including self-induced vomiting, misuse of laxatives, restriction, or compulsive exercise).

While some may find it useful to put a label to what they are struggling with, it is perfectly normal for individuals to go through changes in behaviours over the course of their illness and recovery. For example, someone who has struggled with restriction may begin to struggle with bingeing and/or purging or vice versa. This can be extremely distressing to the individua,l but highlights the point that in the end, eating disorder behaviours (whatever form they may take) are coping mechanisms. The emphasis needs to be placed on how the behaviour impacts the person’s life rather than what the individual behaviour is and how that might be used to categorize a patient into an overall diagnosis (which is only useful in so far that it directs the course and type of treatment).

Bingeing

Bingeing is generally defined as consuming, or engaging in some activity, in a large quantity over a relatively short period of time. In terms of eating disorders, this amounts to eating a lot in a short period of time. It is categorized as either objective (something most people would agree, is a large quantity of food as compared to "normal") or subjective (the individual feels they are eating a large quantity of food, but is not in fact consuming any more than is "normal.")

It is important to note that "normal" is a relative term which makes definitions more difficult.

Bingeing can occur as a coping mechanism in itself, but it can also occur in response to deprivation. Deprivation does not strictly mean starving, it also applies to something as simple as labelling a food item “bad” and treating it and our relationship with it and other foods as such.

Bingeing can occur with any eating disorder or disordered eating. There is often much more shame associated with this behaviour, but whatever your struggle looks like know you are not alone and you deserve recover. Sufferers of binge eating disorder often face a great deal of stigma in our diet-and-weight-loss-centric culture. However, dieting is not a successful solution to bingeing as it does not address the underlying issues and cycles of restrictive eating will only perpetuate the behaviour.

Purging

To purge something is to get rid of it, in the case of eating disorders, to get rid of food that has been ingested either by self-induced vomiting, laxative abuse, enemas, and/or exercise. Restriction can also perform the same functions as purging for some people.

Purging can result in serious, sometimes fatal, physical complications including: electrolyte imbalance (which can lead to sudden cardiac arrest), dental erosion, esophageal tears, and/or Barrett's esophagus (a condition in which the lining of the esophagus is damaged by repeated exposure to stomach acid, which changes the nature of the cells, and can potentially lead to adenocarcinoma.) Laxative abuse can also severely alter the bowel's ability to function. Chronic use of diuretics can also lead to hypotension and kidney failure as well electrolyte disturbances (Psych Central, Binging & Purging.)

Bingeing and purging often go hand-in-hand, as is seen bulimia nervosa, but that is not always the case. Purging can occur with any eating disorder diagnosis.

Restriction

Restriction involves limiting the variety of foods eaten and/or nutritional intake. It can occur in any eating disorder and can lead to health consequences such as depression, insomnia, anxiety, bradycardia, electrolyte deficiencies, vitamin and mineral deficiencies, osteopenia and osteoporosis, diminished concentration and cognitive abilities, hypotension, and hypoglycemia.

Long-term restriction can lead to (though not necessarily) weight loss; however, serious and potentially fatal consequences from restriction can occur at any weight. The body slows metabolism to compensate as best it can, but eventually it will consume its own tissues in order to come up with needed nutrients to keep the vital organs functioning as long as possible. Lab values (blood work) may appear normal in many cases even when severe deficiencies are present in the body's cells, critical nutrients and electrolytes are "stolen" from the intra-cellular spaces in order to keep the blood levels as stable as possible. Even in cases of severe malnutrition, lab values can remain within normal limits over 50% of the time, this can be misleading, invalidating, and even delay care and necessary treatment (NCBI article on the usefulness and limitations of lab values in the assessment of eating disorders.) It is quite common for restriction to lead into bingeing, becoming a cycle of behaviours that can be quite distressing to the individual.

Restriction is often viewed favourably or as a manifestation of self-control and this is a dangerous idea that stems from a very diet-focused. Restriction is not synonymous with control, there is no hierarchy of eating disordered behaviours, nor does restriction serve as way to calm oneself effectively. Restricting actually increases general anxiety in individuals (though they may find they feel more detached and "calm" due to physical exhaustion); their body is on alert for food and is in a threatened state so long as the deprivation continues.

Other forms of restricting

CHEWING & SPITTING

Chewing and spitting is a less discussed eating disorder behaviour, but does occur with eating disorders. Chewing is the first step in the digestive process and sets into motion a whole cascade of hormonal and chemical signals in the body.

People who chew and spit out food can end up with dental problems, including cavities and gum disease. Chewing food also signals stomach acids to kick in, ready to do their job of digesting food. But without the actual food to digest, this may cause stomach problems.

Though studies are limited, there are questions around insulin release and potential insulin resistance in patients who chew and spit.

ANOREXIA ATHLETICA & COMPULSIVE OVER-EXERCISE

Anorexia athletica is not formally recognized in the current DSM (V), but is often discussed in relation to eating disorders. It is similar to, though distinct from, other eating disorders and the use of exercise as a disordered behaviour. Anorexia athletica is more common in those who participate in sports, exercise and physical fitness where leanness is the primary focus, though calorie restriction and a dietary focus can come into play as well.

Compulsive exercise can occur with any eating disorder and is challenging in that it is viewed favourably by the general culture which can normalize the behaviour for individuals struggling.

Exercise and dietary restriction have a number of health complications; a common occurrence in cis-gendered women with anorexia athletica is "female athlete triad syndrome" (FATS). The triad consists of low energy availability (especially in relation to high levels of activity) leading to amenorrhea or oligomenorrhea (period loss or disruption to the normal menstrual cycle) and osteopenia/osteoporosis.

The following article is written by Gwyneth Olwyn. It outlines some ways in which to assess one’s relationship with exercise and the purpose it is serving in one’s life.

"Here are the six facets that are used to determine whether anything has become an addiction (including exercise):

  1. Salience: does the activity become the most important one in a person’s life? Do they think about it more than anything else? Do they crave it or feel they are suffering without it? As soon as they are not doing the activity are they planning when they can next do the activity? Do they forego other previously pleasant activities in their lives so they can do the activity in question?

  2. Mood modification: That’s the subjective feeling of the “high”. The feeling of “in the zone” or “meditative” or “calming”, “neutralizing other stresses”.

  3. Tolerance: Needing to increase the amount and time dedicated to the activity to get the same levels of mood modification.

  4. Withdrawal Symptoms: Irritability, short-tempered, jumpiness, anxiety when unable to do the activity in question.

  5. Conflict: Interpersonal issues arising with loved ones and friends as a result of the activity. Family and friends expressing their anxiety, concern or irritation with the person’s focus on the activity. Intrapersonal conflict where the person experiences guilt or anxiety that she is harming herself and others with her focus on the activity.

  6. Relapse: Attempts to avoid or moderate the involvement in the activity are punctuated with repeated returns to the activity at a quickly restored or even heightened level than before.”

ORTHOREXIA - “CLEAN EATING”

While not in the current DSM (V), the psychiatric Bible of diagnoses, orthorexia is a commonly referred to issue in the context of eating disorders. The term "orthorexia nervosa" literally means "a fixation on righteous eating" (NEDA, orthorexia nervosa.) The obsession in this situation is related to eating what is deemed "healthy" (good) food versus food's that are generally considered indulgent or "unhealthy" (bad.)

Of course there is no inherent morality in food, there are just strong cultural attitudes that influence our thinking about healthy eating and villainize certain foods and/or food groups. The increasing attention on obesity, diabetes, heart disease, and cancer contributes to an increasingly diet-focused culture. Research is ongoing, but headlines are often created from incomplete and/or biased studies which are taken up in the media and spread widely without complete understanding or all the facts.

Following a healthy diet in itself, does not mean you are suffering from orthorexia, and there is nothing wrong with eating healthily. Unless, however, 1) it is taking up an inordinate amount of time and attention in your life; 2) deviating from that diet is met with guilt and self-loathing; and/or 3) it is used to avoid life issues and leaves you isolated and unhappy.