tag:theconversation.com,2011:/us/topics/anorexia-nervosa-19701/articlesAnorexia nervosa – The Conversation2023-11-27T16:39:57Ztag:theconversation.com,2011:article/2168002023-11-27T16:39:57Z2023-11-27T16:39:57ZPsilocybin shows promise for treating eating disorders, but more controlled research is needed<figure><img src="https://images.theconversation.com/files/560977/original/file-20231122-15-kimes4.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5760%2C3837&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Psilocybin is showing promise for treating mental disorders, but cautious optimism is required while researching safe doses.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/psilocybin-shows-promise-for-treating-eating-disorders-but-more-controlled-research-is-needed" width="100%" height="400"></iframe>
<p>Psychedelic research has surged in recent years, sparking enthusiasm among clinicians, investors and the general public. Clinical trials are indicating transformative outcomes for people struggling with <a href="https://doi.org/10.3389/fpsyt.2021.800072">mental illnesses</a> like depression, post-traumatic stress disorder and end-of-life anxiety. </p>
<p>Recently, the spotlight is turning to eating disorders (ED), a group of severe and difficult-to-treat conditions. A survey revealed that <a href="https://doi.org/10.31083/j.jin2003059">70 per cent of people view psychedelic medicine as a promising avenue for EDs</a>, and numerous reports depict positive results. </p>
<p>Media platforms abound with compelling personal stories, from online articles to Netflix documentaries, Reddit threads, TikTok videos and YouTube clips. But the critical question remains: does the scientific evidence align with the hype?</p>
<p>As a doctoral student in the field of neuropsychiatry with a personal interest in EDs, I delved into the literature to assess the evidence for <a href="https://doi.org/10.47626/2237-6089-2022-0597">psilocybin-assisted therapy in ED treatment</a>.</p>
<h2>Long-term management of EDs</h2>
<p>EDs have the highest mortality rate among psychiatric disorders and their <a href="https://doi.org/10.1016/j.jadohealth.2021.07.014">prevalence</a> is on the rise. Treatment usually involves a combination of medication and therapy, but avoidance, drop-out and <a href="https://doi.org/10.1186/1471-244X-13-282">resistance</a> are all too frequent. Many patients go untreated or endure symptoms for life. Overall, we lack treatment options that yield long-term improvements.</p>
<p>While the causes of EDs are diverse, patients often exhibit alterations in brain connectivity and serotonin signalling. <a href="https://doi.org/10.3389/fnins.2020.00043">These changes</a> affect regions involved in body image, mood, appetite and reward, resulting in “<a href="https://doi.org/10.1007/s40519-016-0331-3">cognitive inflexibility</a>.” </p>
<p>This manifests as rigid thought patterns like religious calorie counting, restrained emotions and punishing exercise regimens, among other ED behaviours. Cognitive inflexibility may also be the culprit for treatment resistance itself. </p>
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<a href="https://images.theconversation.com/files/560978/original/file-20231122-27-kw6xzp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="a woman in a red bathing suit with a black bob haircut seen through a distorted lens" src="https://images.theconversation.com/files/560978/original/file-20231122-27-kw6xzp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/560978/original/file-20231122-27-kw6xzp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/560978/original/file-20231122-27-kw6xzp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/560978/original/file-20231122-27-kw6xzp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/560978/original/file-20231122-27-kw6xzp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/560978/original/file-20231122-27-kw6xzp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/560978/original/file-20231122-27-kw6xzp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Body dysmorphia and eating disorders can require long-term treatment and care.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<h2>Underlying mechanisms</h2>
<p>It seems that standard treatments do not address the full range of mechanisms underlying EDs. Unlike conventional talk therapy led by therapists, psilocybin therapy uses the psychedelic experience to alter brain activity and foster cognitive flexibility.</p>
<p>Psilocybin, a naturally occurring plant alkaloid found in the Psilocybe genus of mushrooms, was first introduced to western medicine by <a href="https://doi.org/10.1038/s41429-020-0311-8">Indigenous communities</a> in the 1950s. It increases serotonin signalling while reducing the activity of brain networks linked to rigid thinking patterns. These changes are thought to enhance body image, reward processing and relax beliefs, ultimately <a href="https://doi.org/10.1111/acps.13249">catalyzing the therapeutic process</a>. But does clinical evidence support this? Well, somewhat. </p>
<p>A <a href="https://doi.org/10.1016/j.amp.2021.08.004">case study</a> described a woman with treatment-resistant anorexia nervosa who, after two doses of psilocybin, experienced immediate mood enhancement, increased insight into the root of her symptoms and long-term weight resolution. </p>
<p>Another study found that a single dose of psilocybin was <a href="https://doi.org/10.1038/s41591-023-02455-9">safe and tolerable in women with anorexia nervosa</a>, reducing their body image concerns.</p>
<p>In <a href="https://doi.org/10.1097/00004714-199604000-00011">another report</a>, an individual with body dysmorphia responded well to both fluoxetine and psilocybin treatment, but was treatment-resistant to other medications. </p>
<p>Theoretical evidence suggests a role for psilocybin in treating <a href="https://doi.org/10.1016/j.clinthera.2020.10.014">binge eating</a>, <a href="https://doi.org/10.1007/7854_2021_279">compulsive overeating</a> and <a href="https://doi.org/10.3390/bs11060080">food addiction</a>, while also improving symptoms of depression and trauma. However, despite these exciting prospects, numerous limitations temper the results.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-potential-of-psychedelics-to-heal-our-racial-traumas-218233">The potential of psychedelics to heal our racial traumas</a>
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<h2>Challenges with conducting research</h2>
<p>The gold standard of evidence for any intervention is the <a href="https://www.unicef-irc.org/KM/IE/impact_7.php">randomized controlled trial (RCT)</a>, where participants are randomly assigned to an intervention or control group, ideally without knowing which they were assigned. The idea is to reduce the impact of individual differences and expectancy bias to truly see if an intervention is effective or not. </p>
<p>However, for psychedelic RCTs, it can be difficult to properly blind participants — hallucinations are a bit of a dead giveaway. </p>
<p>Many studies feature small sample sizes lacking diversity, which limits real-world applicability. While psilocybin has a good safety profile, participants are highly vulnerable during psychedelic experiences. The experience is often ineffable and different for everyone, making the process of informed consent ethically challenging.</p>
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<a href="https://images.theconversation.com/files/560979/original/file-20231122-27-u5geo5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="someone wearing a labcoat and surgical gloves weighs dried mushrooms" src="https://images.theconversation.com/files/560979/original/file-20231122-27-u5geo5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/560979/original/file-20231122-27-u5geo5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/560979/original/file-20231122-27-u5geo5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/560979/original/file-20231122-27-u5geo5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/560979/original/file-20231122-27-u5geo5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/560979/original/file-20231122-27-u5geo5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/560979/original/file-20231122-27-u5geo5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Researching psilocybin contains challenges because of the unique difficulties in conducting randomized control trials.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>It is also crucial to acknowledge “<a href="https://doi.org/10.1177/02698811221133461">excessive enthusiasm</a>” in the field, where researchers’ and participants’ personal use of psychedelics may introduce bias. Among other limitations, we need to be aware of how this impacts the results portrayed in the media. </p>
<h2>Patient safety</h2>
<p>Over-emphasizing the therapeutic actions of psilocybin or selectively presenting positive results may cause more harm than good. Due to legal restrictions, some patients source psilocybin illegally, without proper safety protocols or medical supervision. While this may reflect a health-care system failure, a proper mindset and environment are vital for a safe and productive session. </p>
<p>The therapeutic actions of psilocybin extend beyond the psychedelic experience; integration with a therapist is key to applying the benefits. Narratives suggesting a single psilocybin experience as a cure-all are dangerous. </p>
<p>Lastly, we need to consider how the financial hype surrounding psilocybin could inflate costs, limiting access to the individuals who need it most. </p>
<p>While excitement about psilocybin-assisted therapy is justified, cautious optimism is essential. We still need to determine the optimal therapeutic framework for EDs and how this can be effectively and ethically provided at large.</p><img src="https://counter.theconversation.com/content/216800/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Elena Koning receives funding from the Ontario Graduate Scholarship (OGS) Program. </span></em></p>Can psychedelics assist in recovery from eating disorders? The findings are promising, but patients and doctors need to proceed with caution until there is additional and extensive research.Elena Koning, PhD Student, Centre for Neuroscience Studies, Queen's University, OntarioLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2119122023-08-22T20:07:29Z2023-08-22T20:07:29ZA male character on Heartstopper has an eating disorder. That’s more common than you might think<figure><img src="https://images.theconversation.com/files/543857/original/file-20230822-38016-v420lw.jpg?ixlib=rb-1.1.0&rect=20%2C30%2C3355%2C1650&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://media.netflix.com/en/only-on-netflix/81059939/assets/eyJpZCI6IjM3MGU2Y2MwLTA5MmItMTFlZS1hYjdhLTBlYzdkMTlhM2U3ZCIsIm5hbWUiOiJIZWFydHN0b3BwZXJfUzAyX1RlYXNlcjIuanBnIn0=">Netflix</a></span></figcaption></figure><p>Season two of the series <a href="https://www.imdb.com/title/tt10638036/">Heartstopper</a> on Netflix brings out an issue that is often hidden – male eating disorders. Centred on two teenage boys in love, the show helps bust the common perception that eating disorders are only seen in girls and women. </p>
<p>In one episode of the series, based on a series of graphic novels, Nick asks Charlie about his eating because he is becoming worried about him. Charlie responds, saying</p>
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<p>Some days I’m fine and other days I control it. I used to do it a lot last year when everything at school was really bad. Sometimes it feels like the only thing I can control in my life.</p>
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<p>Although under represented in research, <a href="https://nedc.com.au/eating-disorders/eating-disorders-explained/eating-disorders-in-males/">statistics</a> indicate one third of people with an eating disorder are male and <a href="https://www.missionaustralia.com.au/publications/youth-survey/2618-youth-survey-2022-report/file">body image in boys</a> is a major concern. Eating disorders affect mental and physical health. Shame and stigma are among the reasons people who identify as male <a href="https://jeatdisord.biomedcentral.com/articles/10.1186/s40337-022-00543-8">don’t seek help</a>. </p>
<h2>A range of disorders</h2>
<p><a href="https://www.frontiersin.org/articles/10.3389/fpsyt.2019.00864/full">Body dissatisfaction</a> comes from not liking one’s size, shape and weight and leads some boys and men down the dangerous path to <a href="https://nedc.com.au/eating-disorders/eating-disorders-explained/body-image/">an eating disorder</a>. </p>
<p>An <a href="https://www.eatingdisorders.org.au/eating-disorders-a-z/eating-disorders-explained/">eating disorder</a> is an unhealthy relationship with one’s body and eating and includes such disorders as anorexia nervosa (fear of weight gain and deprivation of food), bulimia nervosa (which typically involves eating large amounts and then purging) and binge-eating disorder. </p>
<p>Binge-eating disorder is the most common of these for both males and females. It <a href="https://www.webmd.com/mental-health/eating-disorders/binge-eating-disorder/binge-eating-disorder-men">involves</a> a preoccupation with eating, often rapidly, an amount of food much greater than someone would eat in a short amount of time, to the point of feeling uncomfortable. Disgust with oneself often follows in the aftermath.</p>
<h2>What drives it</h2>
<p>This obsession with one’s body and its <a href="https://nedc.com.au/eating-disorders/eating-disorders-explained/body-image/">perceived faults</a> comes from our society’s obsession with appearance particularly around a person’s weight, size and shape.</p>
<p>Male media images promote an idealised body that is often <a href="https://www.sciencedirect.com/science/article/abs/pii/S174014452030437X?casa_token=ePw-Tcht4hoAAAAA:ICTulL_wHHWg6aWGzTMe3d_yFyAZgHPeSptJ3wEKoAdoAW-4tB-v276f6lueG3cCYHfd2qpn">unattainable</a>. Seeing one’s own body as inferior in comparison can lead to attempts to <a href="https://www.mayoclinic.org/diseases-conditions/eating-disorders/symptoms-causes/syc-20353603">change it</a>. </p>
<p>Over <a href="https://nedc.com.au/eating-disorders/types/co-occurring-conditions/">half those diagnosed</a> with an eating disorder also receive a diagnosis for at least one psychiatric disorder such as depression, anxiety disorders (including obsessive-compulsive disorder), post-traumatic stress disorder and personality disorders. This makes treatment even more complex.</p>
<p>Other factors involved in the development of an eating disorder can be parental or peer teasing about appearance, especially about weight. Poor self esteem, a need for control (as articulated by Heartstopper character Charlie), experiencing sexual trauma and identity disturbance are also <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8355094/">drivers</a>. Eating disorders are more common for <a href="https://jeatdisord.biomedcentral.com/articles/10.1186/s40337-020-00327-y">LGBTIQ+ people</a>. </p>
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<iframe width="100%" height="577" src="https://www.youtube.com/embed/ScNbNi2BTs0" title="Joe Locke:"Eating disorders on TV are scary, #heartstopper shows it's going to be okay & gives hope"" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen=""></iframe>
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Read more:
<a href="https://theconversation.com/when-i-work-with-people-with-eating-disorders-i-see-many-rules-around-good-and-bad-foods-but-eating-is-never-that-simple-188803">When I work with people with eating disorders, I see many rules around 'good' and 'bad' foods – but eating is never that simple</a>
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<h2>Dangerous methods</h2>
<p>Boys and men may engage in dieting and other weight-loss methods to try and <a href="https://theconversation.com/body-image-issues-affect-close-to-40-of-men-but-many-dont-get-the-support-they-need-179046">change or control their body</a>. They may also exercise excessively. Some may even turn to drugs to try and alter their body. </p>
<p>They can become consumed by thoughts about their body to the detriment of their schooling, socialising, work, family life and physical health, not to mention the financial impact. </p>
<p>Eating disorders are detrimental to a person’s <a href="https://healthtalk.org/eating-disorders/physical-symptoms">physical health</a> with increased risk of injury due to over exercising, rotting teeth due to purging, osteoporosis due to calcium loss and unstable hormones. They can be deadly, causing heart attack, malnourishment, liver and kidney issues, gastrointestinal disturbances, loss of fingers and toes due to poor circulation, as well as <a href="https://butterfly.org.au/news/suicide-up-to-31-times-more-likely-for-people-with-an-eating-disorder/">death by suicide</a>. </p>
<h2>Getting help early</h2>
<p>Early intervention is the key to <a href="https://www.australianacademicpress.com.au/books/details/289/No_Bodys_Perfect_A_helpers_guide_to_promoting_positive_body_image_in_children_and_young_people">fostering a positive body image</a> and self-esteem in young males. This involves recognition by parents, teachers and peers of unhealthy talk about and behaviour towards one’s body and eating. </p>
<p><a href="https://www.nationaleatingdisorders.org/warning-signs-and-symptoms">Warning signs</a> might include skipping meals, excessive time spent on grooming, social avoidance, body consciousness and appearing sad and anxious. Education in schools about eating disorders helps young people understand what eating disorders are and normalises help-seeking. </p>
<p>As adults, we need to be aware our talk about dieting and comments about people’s bodies is influential. So is modelling healthy eating and exercising behaviour. </p>
<p><div data-react-class="InstagramEmbed" data-react-props="{"url":"https://www.instagram.com/p/Cn08n63sQwI/?utm_source=ig_embed\u0026ig_rid=b656fc66-f3f9-40da-91ba-343fdd7b6b7f","accessToken":"127105130696839|b4b75090c9688d81dfd245afe6052f20"}"></div></p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/some-ozempic-users-say-it-silences-food-noise-but-there-are-drug-free-ways-to-stop-thinking-about-food-so-much-208467">Some Ozempic users say it silences 'food noise'. But there are drug-free ways to stop thinking about food so much</a>
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<p>Doctors and health professionals need to be better educated on warning signs and what to look out for in their male patients and clients. Teachers and parents can <a href="https://www.australianacademicpress.com.au/books/details/352/Practitioner_Guide_to_Psychological_Care_for_People_with_Eating_Disorders">learn more</a> and be on the look out for signs too. </p>
<p><a href="https://onlinelibrary.wiley.com/doi/full/10.1002/erv.2959">Early intervention</a> is backed by evidence but help often comes too late. People who get help early, particularly in their adolescent years <a href="https://jeatdisord.biomedcentral.com/articles/10.1186/s40337-023-00758-3">when eating disorders often first start</a>, have a good success rate with the right treating team. This usually consists of a doctor, psychologist, dietitian and psychiatrist. </p>
<p>Families and people with eating disorders can find treatments and support in both the <a href="https://butterfly.org.au/">public and private sectors</a>. <a href="https://www.cbte.co/what-is-cbte/a-description-of-cbt-e/">Enhanced cognitive behavioural therapy</a> is usually used. It involves changing destructive behaviours and thoughts around the body, self and eating so a person can become healthier and happier. <a href="https://www.eatingdisorders.org.au/wp-content/uploads/2019/04/EDV-Family-Based-Treatment.pdf">Family-based approaches</a> for children and adolescents are also used to counter behaviour such as food refusal. Of course, as with many mental health conditions, more <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/70-million-for-eating-disorders-and-childhood-mental-health">funding for more support services</a> is needed. </p>
<p>If you or someone you know may be suffering from an eating disorder getting help fast is important before the eating disorder really takes hold. If you are worried about a friend, talk to an adult, such as a teacher or school counsellor. Starting a conversation with someone to ask them if they’re OK, how they are feeling and showing a non-judgmental attitude is also key. The character of Nick <a href="https://www.youtube.com/watch?v=fQ3XXeCpYjc">models this</a> well on Heartstopper. </p>
<p>Education about and becoming more aware of this issue and knowing how to get help is critical. As is reducing the <a href="https://www.nationaleatingdisorders.org/blog/stigma-surrounding-men-eating-disorders">stigma</a> often associated with male eating disorders. </p>
<p><em>If this article has raised issues for you, consider contacting the <a href="https://butterfly.org.au/">Butterfly Foundation</a> on 1800 33 4673 or Lifeline on 13 11 14.</em></p><img src="https://counter.theconversation.com/content/211912/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Vivienne Lewis is a Clinical Psychologist working with people of both genders with eating disorders. She has recently written a book to assist health professionals and trainees working in this field called Eating Disorders – A practitioner’s guide to psychological care.
</span></em></p>Although under represented in research, about one third of people with an eating disorder are male. Netflix show Heartstopper explores this in season two.Vivienne Lewis, Assistant professor – Psychology, University of CanberraLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2073222023-07-05T20:05:54Z2023-07-05T20:05:54ZWhy eating disorder treatments only work half the time, according to a psychologist<figure><img src="https://images.theconversation.com/files/530809/original/file-20230608-29-mrpuo8.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1000%2C666&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/close-male-therapist-working-teenage-girl-2193299341">Shutterstock</a></span></figcaption></figure><p>No single treatment will work for all people with eating disorders. Even the most highly researched evidence-based treatment may work for some people, but less so for others. When such treatments do not work, it can provoke anxiety.</p>
<p>As part of <a href="https://doi.org/10.1186/s40337-019-0235-5">our research</a>, we spoke with one mother who was supporting her teenage daughter through anorexia nervosa. When current treatments were not working, the mother told us: </p>
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<p>We don’t really know what else we can do.</p>
</blockquote>
<p>But there may be other treatment options for people like her daughter. The issue is they’re not always available on Medicare.</p>
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Read more:
<a href="https://theconversation.com/binge-eating-is-more-common-than-anorexia-or-bulimia-but-it-remains-a-hidden-and-hard-to-treat-disorder-192596">Binge eating is more common than anorexia or bulimia – but it remains a hidden and hard-to-treat disorder</a>
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<h2>Medicare provides a menu of options</h2>
<p>In Australia, changes to Medicare mean people diagnosed with an eating disorder <a href="https://www.servicesaustralia.gov.au/eating-disorder-treatment-and-management-plans?context=20">may be eligible for</a> up to 40 sessions with a psychologist and up to 20 sessions with a dietitian a year. </p>
<p>This is a remarkable recognition of how eating disorders such as anorexia, bulimia or binge eating <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7575017/pdf/coip-33-521.pdf">impact people’s lives</a>, and for those who care for them. </p>
<p>This also recognises how difficult it can be to <a href="https://www.frontiersin.org/articles/10.3389/fpsyg.2017.02273/full">recover</a> from an eating disorder. This is particularly when aspects of the eating disorder are acceptable to the person, and become their way of dealing with the slings and arrows of life.</p>
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<p>Medicare provides <a href="https://insideoutinstitute.org.au/medicare/for-health-professionals">several options</a> for psychological interventions to treat eating disorders that are backed by research evidence. </p>
<p>These treatments include <a href="https://pubmed.ncbi.nlm.nih.gov/30520532/">family-based treatment</a> for adolescent eating disorders and <a href="https://pubmed.ncbi.nlm.nih.gov/30188385/">cognitive behavioural therapy</a> for adult eating disorders.</p>
<p>Such interventions work in the long term for <a href="https://doi.org/10.1002/wps.20465">around</a> <a href="https://jeatdisord.biomedcentral.com/articles/10.1186/s40337-023-00801-3">half</a> of people. </p>
<p>So what about the other half?</p>
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Read more:
<a href="https://theconversation.com/when-i-work-with-people-with-eating-disorders-i-see-many-rules-around-good-and-bad-foods-but-eating-is-never-that-simple-188803">When I work with people with eating disorders, I see many rules around 'good' and 'bad' foods – but eating is never that simple</a>
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<h2>It’s not just about evidence</h2>
<p>Think about <a href="https://psycnet.apa.org/record/2019-34830-000">psychotherapy</a> – also known as talking therapy – as a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4832531/">three-legged stool</a>.</p>
<p>One leg of the stool is the research evidence. Another is the clinician’s expertise. The third leg is preferences of the person having treatment. We need all three if the stool is to stay upright and the psychotherapy has a chance of working.</p>
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<a href="https://images.theconversation.com/files/531842/original/file-20230614-29-sipiun.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Yellow three-legged stool against yellow background" src="https://images.theconversation.com/files/531842/original/file-20230614-29-sipiun.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/531842/original/file-20230614-29-sipiun.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/531842/original/file-20230614-29-sipiun.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/531842/original/file-20230614-29-sipiun.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/531842/original/file-20230614-29-sipiun.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=425&fit=crop&dpr=1 754w, https://images.theconversation.com/files/531842/original/file-20230614-29-sipiun.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=425&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/531842/original/file-20230614-29-sipiun.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=425&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Think of psycotherapy as a three-legged stool.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/yellow-three-legged-chair-on-background-2182268591">Tharin kaewkanya/Shutterstock</a></span>
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<p>The current Medicare system allows clinicians to draw from the first leg – the research evidence. This works for some.</p>
<p>Then there’s the second leg, the clinician’s expertise. One welcome development is through the Australian & New Zealand Academy for Eating Disorders <a href="https://connected.anzaed.org.au/treatmentproviders/">credential</a> for professionals treating eating disorders.</p>
<p>What is less recognised in the current Medicare system, however, is the importance of the therapeutic relationship, such as whether the clinician works in a <a href="https://onlinelibrary.wiley.com/doi/10.1002/wps.20912">person-centred way</a> that takes into consideration the person’s preferences. </p>
<p>This could be tailoring treatment to the person’s unique needs, instilling hope for their recovery, and seeing the person as more than just the eating disorder. Think of these as the third leg of the stool. </p>
<p>These second and third legs help explain why even gold-standard, research evidence-based treatments do not work for everyone.</p>
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<strong>
Read more:
<a href="https://theconversation.com/how-many-people-have-eating-disorders-we-dont-really-know-and-thats-a-worry-121938">How many people have eating disorders? We don't really know, and that's a worry</a>
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<h2>What else could work?</h2>
<p>There are many psychological treatments for eating disorders that don’t have research evidence to back them. We cannot necessarily dismiss them as not working. They may have not yet been extensively researched. These <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6897497/pdf/nihms-1056078.pdf">emerging treatments</a> need more research evidence, <a href="https://www.mja.com.au/journal/2023/219/3/current-approaches-recognition-and-management-eating-disorders">including</a> which treatments work, for whom, and when. </p>
<p>Emerging treatments include those based on <a href="https://www.researchgate.net/publication/49705468_The_Application_of_Mindfulness_to_Eating_Disorders_Treatment_A_Systematic_Review">mindfulness</a>. These <a href="https://link.springer.com/article/10.1007/s12671-019-01216-5">may involve</a> people learning not to judge their thoughts and feelings as right or wrong, or good or bad. Instead, this therapy allows them to observe these thoughts and feelings by focusing on the present moment.</p>
<p>Others include <a href="https://iris.unito.it/bitstream/2318/1700926/1/2017_Eye%20Movement%20Desensitization%20and%20Reprocessing%20%28EMDR%29%20and%20eating%20disorders.pdf">therapies</a> <a href="https://www.cambridge.org/core/journals/advances-in-psychiatric-treatment/article/sensorimotor-approaches-to-trauma-treatment/D89DECA6078BBCF28669E8F76090197C">that address</a> both the eating disorder and adverse and traumatic life events, including the experience of the eating disorder itself.</p>
<p>We are also interested in, and are currently researching, <a href="https://jeatdisord.biomedcentral.com/articles/10.1186/s40337-022-00636-4">narrative therapy</a>. This explores aspects of the person that have been lost to the eating disorder, such as a valued sense of oneself. Reclaiming these aspects can give the person freedom to live a life no longer dominated by the eating disorder. </p>
<p>Until emerging treatments have more extensive research evidence, the Medicare system needs to mention them as valid treatment pathways when facilitated by experienced practitioners. This is particularly important if the most widely researched interventions do not work for someone.</p>
<p>Including emerging therapies, however, does not mean anything goes. To work out which of these emerging therapies might be eligible for Medicare funding in the future, we need greater consultation with people living with eating disorders, and the clinicians who treat them, to learn which emerging treatments work in practice.</p>
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<strong>
Read more:
<a href="https://theconversation.com/what-makes-a-good-psychologist-or-psychiatrist-and-how-do-you-find-one-you-like-120981">What makes a good psychologist or psychiatrist and how do you find one you like?</a>
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<h2>Join our study</h2>
<p>We are conducting a small study on narrative therapy for anorexia nervosa. This involves 40 sessions over 12 months to be conducted at Western Sydney University.</p>
<p>If you want to know more about participating in the study, email us at narrative@westernsydney.edu.au</p>
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<p><em>If you (or someone you know) needs care for an eating disorder, see your GP to be assessed for a Medicare <a href="https://www.servicesaustralia.gov.au/eating-disorder-treatment-and-management-plans?context=20">Eating Disorder Plan</a>. For support and more information about eating disorders, contact the <a href="https://butterfly.org.au">Butterfly Foundation</a> on 1800 33 4673 or <a href="https://kidshelpline.com.au">Kids Helpline</a> on 1800 551 800. If this article has raised issues for you, or if you’re concerned about someone you know, call Lifeline on 13 11 14. In an emergency, call 000.</em></p><img src="https://counter.theconversation.com/content/207322/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Janet Conti is affiliated with Western Sydney University as an Associate Professor of Clinical Psychology. She also works part-time in private practice as a Clinical Psychologist. She is currently a co-researcher in two research projects funded by the Butterfly Foundation and the Australian and New Zealand Academy of Eating Disorders (ANZAED).</span></em></p><p class="fine-print"><em><span>Tania Perich is affiliated with Western Sydney University as an Senior Lecturer in Psychology. She also works part-time in private practice as a registered psychologist.</span></em></p>When it comes to treating people with eating disorders, we may need to look more widely than what studies tell us work.Janet Conti, Associate Professor of Clinical Psychology, Western Sydney UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2010672023-03-31T12:23:17Z2023-03-31T12:23:17ZEating disorders among teens have more than doubled during the COVID-19 pandemic – here’s what to watch for<figure><img src="https://images.theconversation.com/files/517032/original/file-20230322-419-qse5vl.jpg?ixlib=rb-1.1.0&rect=30%2C46%2C5129%2C3380&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The traditional assumption that eating disorders primarily affect affluent white women has led to stigma, stereotyping and misunderstanding. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/asia-woman-feeling-sad-in-the-bedroom-royalty-free-image/1324460530?phrase=eating%20disorders%20in%20teens&adppopup=true">toondelamour/E+ via Getty Images</a></span></figcaption></figure><p>The COVID-19 pandemic has been <a href="https://doi.org/10.1016/j.jaac.2022.12.026">associated with worsening mental health</a> among teens, including increasing numbers of patients with eating disorders. In fact, research indicates that the number of teens with eating disorders <a href="https://doi.org/10.1001/jamapediatrics.2022.4346">at least doubled during the pandemic</a>. </p>
<p>This is particularly concerning given that eating disorders <a href="https://doi.org/10.1001/archgenpsychiatry.2011.74">are among the most deadly</a> of all mental health diagnoses, and teens with eating disorders are at <a href="https://doi.org/10.1016/j.copsyc.2017.08.023">higher risk for suicide</a> than the general population.</p>
<p>While experts don’t know exactly why eating disorders develop, studies show that <a href="https://doi.org/10.23750/abm.v93i3.13140">body dissatisfaction and desire for weight loss</a> are key contributors. This can make conversations around weight and healthy behaviors particularly tricky with teens and young adults.</p>
<p>As an <a href="https://profiles.umassmed.edu/display/30628475">adolescent medicine doctor</a> <a href="https://www.researchgate.net/scientific-contributions/Sydney-M-Hartman-Munick-2175760133">specializing in eating disorders</a>, I have seen firsthand the increases in patients with eating disorders as well as the detrimental effects of eating disorder stereotypes. I regularly work with families to help teens develop positive relationships with body image, eating and exercise.</p>
<p>Understanding the signs of a possible eating disorder is important, as studies suggest that timely diagnosis and treatment leads to <a href="https://doi.org/10.1002/eat.22840">better long-term outcomes</a> and to better chances of full recovery. </p>
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<figcaption><span class="caption">Excessive dieting and withdrawal from friends are two signs of disordered eating.</span></figcaption>
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<h2>Eating disorders defined</h2>
<p>Eating disorders, which <a href="https://doi.org/10.1038/s41380-021-01161-7">often start in adolescence</a>, include <a href="https://www.allianceforeatingdisorders.com/anorexia-nervosa/">anorexia nervosa</a>, <a href="https://www.allianceforeatingdisorders.com/bulimia-nervosa/">bulimia nervosa</a>, <a href="https://www.allianceforeatingdisorders.com/binge-eating-disorder/">binge eating disorder</a>, <a href="https://www.allianceforeatingdisorders.com/other-specified-feeding-or-eating-disorders/">other specified feeding and eating disorders</a> and <a href="https://www.allianceforeatingdisorders.com/avoidant-restrictive-food-intake-disorder-arfid/">avoidant restrictive food intake disorder</a>. Each eating disorder has specific criteria that must be met in order to receive a diagnosis, which is made by a professional with eating disorder expertise.</p>
<p>Research suggests that up to 10% of people will develop <a href="https://www.hsph.harvard.edu/striped/report-economic-costs-of-eating-disorders/">an eating disorder in their lifetime</a>. Medical complications from eating disorders, such as low heart rate and electrolyte abnormalities, <a href="https://doi.org/10.1186/s40337-023-00759-2">can be dangerous and result in hospitalization</a>, and malnutrition can affect growth and development. Many of the patients I see in clinic show signs of paused puberty and stalled growth, which can influence bone health, adult height and other aspects of health if not addressed quickly.</p>
<p>Teens are also at risk for disordered eating behaviors such as intentional vomiting, caloric restriction, binge eating, overexercise, the use of weight loss supplements and misuse of laxatives. </p>
<p>A recent study estimated that 1 in 5 teens may <a href="https://doi.org/10.1001/jamapediatrics.2022.5848">struggle with disordered eating behaviors</a>. While these behaviors alone may not qualify as an eating disorder, they may predict the <a href="https://doi.org/10.1016/j.jada.2006.01.003">development of eating disorders later on</a>.</p>
<p>Treatment methods for eating disorders are <a href="https://www.aedweb.org/resources/about-eating-disorders/treatment-options">varied and depend on multiple factors</a>, including a patient’s medical stability, family preference and needs, local resources and insurance coverage. </p>
<p>Treatment can include a team consisting of a medical provider, nutritionist and therapist, or might involve the use of a specialized eating disorder program. Referral to one of these treatment methods may come from a pediatrician or a specialized eating disorder provider.</p>
<h2>Unpacking misconceptions and stereotypes</h2>
<p>Traditional ideas and stereotypes about eating disorders have left many people with the impression that it is mainly thin, white, affluent females who develop eating disorders. However, research demonstrates that anyone can develop these conditions, regardless of age, <a href="https://doi.org/10.1016/j.eatbeh.2018.11.004">race</a>, <a href="https://doi.org/10.1186/s40337-022-00720-9">body size</a>, <a href="https://doi.org/10.1016/j.jadohealth.2015.03.003">gender identity</a>, <a href="https://doi.org/10.1007/s11920-017-0801-y">sexual orientation</a> or <a href="https://doi.org/10.1002/eat.22846">socioeconomic status</a>. </p>
<p>Unfortunately, stereotypes and assumptions about eating disorders have <a href="https://doi.org/10.1186/s40337-022-00730-7">contributed to health disparities</a> in screening, diagnosis and treatment. Studies have documented negative eating disorder treatment experiences among <a href="https://doi.org/10.1016/j.eatbeh.2021.101517">transgender and gender-diverse</a> individuals, <a href="https://doi.org/10.1002/eat.23402">Black and Indigenous</a> people and those <a href="https://www.nytimes.com/2022/10/18/magazine/anorexia-obesity-eating-disorder.html">with larger body size</a>. Some contributors to these negative experiences include lack of diversity and training among treatment providers, treatment plans without cultural or economic nutritional considerations and differential treatment when a patient is not visibly underweight, among others. </p>
<p>Contrary to popular assumptions, studies show teen boys are <a href="https://doi.org/10.1097%2FMOP.0000000000000911">at risk for eating disorders as well</a>. These often go undetected and can be disguised as a desire to become more muscular. However, eating disorders are just as dangerous for boys as they are for girls.</p>
<p>Parents and loved ones can play a role in helping to dispel these stereotypes by advocating for their child at the pediatrician’s office if concern arises and by recognizing red flags for eating disorders and disordered eating behaviors.</p>
<h2>Warning signs</h2>
<p>Given how common disordered eating and eating disorders are among teens, it is important to understand <a href="https://www.medainc.org/resources-2/about-eating-disorders/">some possible signs</a> of these worrisome behaviors and what to do about them.</p>
<p>Problematic behaviors can include eating alone or in secret and a hyperfocus on “healthy” foods and distress when those foods aren’t readily available. Other warning signs include significantly decreased portion sizes, skipped meals, fights at mealtime, using the bathroom immediately after eating and weight loss. </p>
<p>Because these behaviors often feel secretive and shameful, it may feel difficult to bring them up with teens. Taking a warm but direct approach when the teen is calm can be helpful, while letting them know you have noticed the behavior and are there to support them without judgment or blame. I always make sure to let my patients know that my job is to be on their team, rather than to just tell them what to do.</p>
<p>Teens may not immediately open up about their own concerns, but if behaviors like this are present, don’t hesitate to have them seen at their pediatrician’s office. Following up with patients who have shown signs of having an eating disorder and promptly <a href="https://www.nationaleatingdisorders.org/where-do-i-start-0">referring them to a specialist</a> who can further evaluate the patient are crucial for getting teens the help they may need. Resources for families <a href="https://www.feast-ed.org/">can be helpful</a> to navigate the fear and uncertainty that can come along with the diagnosis of an eating disorder.</p>
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<figcaption><span class="caption">Many misconceptions exist about eating disorders, including that they are about vanity or that people should just be able to stop.</span></figcaption>
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<h2>Focus on health, not size</h2>
<p>Research shows that <a href="https://doi.org/10.1097/MOP.0000000000000910">poor body image</a> and <a href="https://doi.org/10.23750/abm.v93i3.13140">body dissatisfaction</a> can put teens at risk for disordered eating behaviors and eating disorders. </p>
<p>Parents play an important role in the development of teens’ self-esteem, and research demonstrates that <a href="https://doi.org/10.1186/s40337-022-00561-6">negative comments from parents</a> about weight, body size and eating are associated with eating disorder-type thoughts in teens. Therefore, when talking to teens, it <a href="https://doi.org/10.1001/jamapediatrics.2013.78">can be beneficial</a> to take a weight-neutral approach, which <a href="https://doi.org/10.1002/ncp.10885">focuses more on overall health</a> rather than weight or size. I unfortunately have had many patients with eating disorders who were scolded or teased about their weight by family members; this can be really harmful in the long run.</p>
<p>One helpful strategy is to incorporate lots of variety into a teen’s diet. If doable, trying new foods as a family can encourage your teen to try something they haven’t before. Try to avoid terms such as “junk” or “guilt” when discussing foods. Teaching teens to appreciate lots of different kinds of foods in their diet allows them to develop a healthy, knowledgeable relationship with food. If you’re feeling stuck, you may want to ask your pediatrician about seeing a dietitian.</p>
<p>It’s important to remember that teens need <a href="https://doi.org/10.1111/nyas.13330">a lot of nutrition</a> to support growth and development, often more than adults do, and regular eating helps avoid extreme hunger that can lead to overeating. Letting teens listen to their bodies and learn their own hunger and fullness cues will help them <a href="https://doi.org/10.1007/s40519-020-00852-4">eat in a healthy way</a> and create healthy long-term habits.</p>
<p>In my experience, teens are more likely to exercise consistently when <a href="https://health.gov/our-work/nutrition-physical-activity/move-your-way-community-resources/campaign-materials/materials-kids-and-teens#videos">they find an activity</a> that they enjoy. Exercise doesn’t need to mean lifting weights at the gym; teens can move their bodies by taking a walk in nature, moving to music in their rooms or playing a pickup game of basketball or soccer with a friend or sibling. </p>
<p><a href="https://www.cdc.gov/physicalactivity/basics/pa-health/index.htm">Focusing on the positive things</a> exercise can do for the body such as improvements in mood and energy can help avoid making movement feel compulsive or forced. When teens are able to find movement that they enjoy, it can help them to appreciate their body for all it is able to do.</p><img src="https://counter.theconversation.com/content/201067/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sydney Hartman-Munick does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Eating disorders in teens are common and dangerous, and parents and loved ones play a crucial role in helping to both identify concerning behaviors and promote healthy ones.Sydney Hartman-Munick, Assistant Professor of Pediatrics, UMass Chan Medical SchoolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1955382023-03-09T13:39:49Z2023-03-09T13:39:49ZBody dysmorphic disorder is more common than eating disorders like anorexia and bulimia, yet few people are aware of its dangers<figure><img src="https://images.theconversation.com/files/513001/original/file-20230301-20-5yrxjp.jpg?ixlib=rb-1.1.0&rect=12%2C0%2C8231%2C4644&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Those with body dysmorphic disorder often check themselves – and their perceived defects.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/woman-with-bdd-body-dysmorphic-disorder-royalty-free-image/1360144717">Stevica Mrdja/EyeEm via Getty Images</a></span></figcaption></figure><p><em><a href="https://theconversation.com/el-trastorno-dismorfico-corporal-es-mas-frecuente-que-los-trastornos-alimentarios-como-la-anorexia-y-la-bulimia-pero-pocas-personas-son-conscientes-de-sus-peligros-202290">Leer en español.</a></em> </p>
<p>While eating disorders have been <a href="https://doi.org/10.1177/01454455870114005">widely publicized for decades</a>, far less attention has been given to a related condition called <a href="https://bdd.iocdf.org/about-bdd/">body dysmorphic disorder, or BDD</a>. </p>
<p>Body dysmorphic disorder is often hidden from public view due to the shame people feel about one or more parts of their body, yet it is a devastating, debilitating psychological condition. People with the disorder suffer from obsessive thoughts and repetitive behaviors related to their appearance.</p>
<p>Whereas people with eating disorders might view their underweight body as too fat, those with body dysmorphic disorder see themselves as ugly or disfigured even though they appear normal or attractive to others.</p>
<p>Body dysmorphic disorder is more common in both men and women than bulimia or anorexia. About <a href="https://doi.org/10.1017/s1092852900016436">2.5% of women and 2.2% of men</a> in the U.S. meet the criteria for body dysmorphic disorder – that’s higher than the prevalence of generalized anxiety disorder, schizophrenia or bipolar disorder in the general population.</p>
<p>For comparison, at any point in time, bulimia is seen in <a href="https://www.nationaleatingdisorders.org/statistics-research-eating-disorders">roughly 1.5% of women and 0.5% of men</a> in the U.S., and anorexia in <a href="https://www.nationaleatingdisorders.org/statistics-research-eating-disorders">0.35% of women and 0.1% of men</a>.</p>
<p>We are a team of communication and mental health researchers and clinicians from <a href="https://feartocourage.com/about-dr-eva-fisher/">Colorado State University Global</a>, <a href="https://faculty.medicine.hofstra.edu/2313-fugen-neziroglu">Hofstra Medical School</a> and the <a href="https://psychiatry.utoronto.ca/faculty/jamie-feusner">University of Toronto</a>. One of us, Eva Fisher, lived with the disorder for almost 15 years before getting help and recovering. My book, titled “The BDD Family,” provides insights into my <a href="https://feartocourage.com/thebddfamily-book/">daily struggles with body dysmorphic disorder</a> along with information about diagnosis and treatment. </p>
<p>In our view, body dysmorphic disorder needs to be better understood and publicized so that more people suffering from the condition can be properly diagnosed and treated. </p>
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<figcaption><span class="caption">Body dysmorphic disorder often involves a fixation on a single feature, like the shape or size of one’s nose, a mole or the shape or curvature of a certain part of the body.</span></figcaption>
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<h2>Comparison between BDD and eating disorders</h2>
<p>People with body dysmorphic disorder and those with eating disorders share similar negative emotions such as shame, disgust and anger about their appearance. They also engage in some similar behaviors, such as mirror checking, taking photos to check themselves, seeking reassurance from others about their appearance, and using clothing to camouflage or conceal perceived defects.</p>
<p>People who suffer from these disorders commonly avoid places and activities due to self-consciousness about their appearance. In addition, those with eating disorders and body dysmorphic disorder may lack the knowledge that <a href="https://doi.org/10.1016/j.psychres.2012.03.023">their body image beliefs are distorted</a>.</p>
<p>Depression is common in people with body dysmorphic disorder, and they have a <a href="https://doi.org/10.1017/S0033291720002998">higher rate of suicidality</a> than those with eating disorders, including thoughts about committing suicide and suicide attempts. Although both eating disorders and body dysmorphic disorder can be severe and life-threatening, people with body dysmorphic disorder on average <a href="https://doi.org/10.1016/j.bodyim.2009.03.001">experience more impairment in daily functioning</a> than those with eating disorders.</p>
<h2>A personal view</h2>
<p>My (Eva’s) body dysmorphic disorder symptoms started at age 16. Some causes could have been childhood bullying and perfectionism about my appearance. I would obsess about the shape and size of my nose for more than eight hours a day and constantly <a href="https://www.youtube.com/watch?v=UUkZGSIYcEw&t=23s">compare my appearance</a> to models in fashion magazines. </p>
<p>I was convinced that others were judging me negatively because of my nose, which I perceived to be fat and ugly. I hated my nose so much that I didn’t want to get married or have children because I feared they would inherit it.</p>
<p>Even after getting plastic surgery at age 18 to make my nose thinner, I still hated it. This is a very common outcome for people with the disorder who undergo cosmetic surgery procedures. </p>
<p>Research indicates that 66% of people with body dysmorphic disorder have <a href="https://doi.org/10.1016/S1740-1445(03)00003-2">received cosmetic or dermatological treatment</a>. However, even when people feel better about one part of their body after surgery, the <a href="https://doi.org/10.1093/med/9780190254131.003.0030">image obsession often moves</a> to <a href="https://global.oup.com/academic/product/body-dysmorphic-disorder-9780190254131?cc=ca&lang=en&">one or more other body parts</a>. </p>
<p>Some patients will have multiple procedures on the same body part. Other people are so disappointed by the results of their surgery that <a href="https://doi.org/10.1093/med/9780190254131.003.0013">they want to commit suicide</a>. </p>
<p>Tragically, many people with body dysmorphic disorder think about killing themselves, and others attempt to take their own lives. Approximately 80% of people with body dysmorphic disorder <a href="https://doi.org/10.1093/med/9780190254131.003.0013">experience lifetime suicidal ideation</a>, and 24% to 28% have attempted suicide. Often, they are young men and women who feel so hopeless about their perceived appearance defects that suicide seems like the only way to end their suffering.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/iYwfIhJY8TY?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Body dysmorphic disorder carries a high risk of suicide, and sometimes pursuing dermatological solutions can make the issues worse if the person isn’t satisfied with them.</span></figcaption>
</figure>
<h2>When appearance concerns become problematic</h2>
<p>So how is body dysmorphic disorder different from normal appearance concerns? Researchers have found evidence that while <a href="https://doi.org/10.1177/1073191119879241">appearance dissatisfaction can range in severity</a>, there is a distinct group of people with much higher appearance concerns, many of whom likely have the disorder. They feel much worse about their appearance than those with normal appearance concerns and experience greater anxiety, depression, shame and self-disgust about some aspects of their appearance.</p>
<p>About one-third of people with the disorder <a href="https://doi.org/10.1093/med/9780190254131.003.0006">obsess about their perceived flaws</a> for one to three hours a day, nearly 40% for three to eight hours a day and about a quarter for more than eight hours a day. Most people with body dysmorphic disorder know they spend <a href="https://global.oup.com/academic/product/body-dysmorphic-disorder-9780190254131?cc=ca&lang=en&">too much time thinking about their appearance</a>, but others with the condition mistakenly believe that it’s entirely normal to worry about their appearance for hours every day. </p>
<p><a href="https://doi.org/10.1093/med/9780190254131.003.0006">Common body dysmorphic disorder behaviors</a> include, from most to least common:</p>
<ul>
<li><p>camouflaging the perceived defects with clothing and makeup</p></li>
<li><p>comparing one’s appearance to others </p></li>
<li><p>checking one’s appearance in mirrors and other reflective surfaces</p></li>
<li><p>seeking cosmetic treatments such as surgery and dermatology</p></li>
<li><p>repeatedly taking photos to check one’s appearance</p></li>
<li><p>seeking reassurance from others about the perceived flaw or convincing others that it is unattractive </p></li>
<li><p>touching the perceived flaw</p></li>
<li><p>excessively changing clothes</p></li>
<li><p>dieting and skin picking to improve appearance</p></li>
<li><p>engaging in excessive exercise, including excessive weightlifting</p></li>
</ul>
<h2>Discovering the causes of body dysmorphic disorder</h2>
<p>The exact causes of body dysmorphic disorder are unknown. Possible developmental causes include <a href="https://doi.org/10.1017/s0033291711002741">genetic factors</a>, <a href="https://doi.org/10.1016/j.psychsport.2007.10.002">childhood bullying</a> and childhood teasing about appearance and competency, as well as <a href="https://doi.org/10.1016/j.comppsych.2021.152256">childhood maltreatment and trauma</a>. Other factors that could play a role include growing up in a family with an <a href="https://www.scientificamerican.com/article/imagined-ugliness/">emphasis on appearance</a>, perfectionist standards concerning appearance and exposure to <a href="https://doi.org/10.1176/appi.ajp.159.10.1788">high ideals of attractiveness</a> and beauty in the mass media. </p>
<p>Common personality traits among people with body dysmorphic disorder include perfectionism along with shyness, social anxiety, low self-esteem and <a href="https://doi.org/10.1016/j.cpr.2005.04.012">sensitivity to rejection and criticism</a>. </p>
<p>Researchers have found that people with the disorder may have abnormalities in brain functioning. For instance, one study found that people with body dysmorphic disorder, as well as those with anorexia, have an <a href="https://doi.org/10.1017/S0033291715000045">information processing bias</a> toward more detailed visual information rather than viewing images globally – in other words, seeing the trees rather than the forest. This suggests that abnormalities in the brain’s visual system could contribute to the distortions that those with body dysmorphic disorder and anorexia experience.</p>
<h2>Effective treatments</h2>
<p>Fortunately, there are effective treatments for people with body dysmorphic disorder. Cognitive behavioral therapy and medication <a href="https://doi.org/10.4103/psychiatry.IndianJPsychiatry_528_18">are both used to treat the disorder</a>. </p>
<p>During cognitive behavioral therapy, therapists work with patients to help them modify intrusive thoughts and beliefs about physical appearance and to eliminate problematic behaviors associated with body image, such as mirror checking and reassurance seeking. </p>
<p>Medications called selective serotonin reuptake inhibitors, or SSRIs, such as Prozac and Zoloft can <a href="https://doi.org/10.3928%2F00485713-20100701-05">reduce or eliminate cognitive distortions</a>, depression, anxiety, negative beliefs and compulsive behaviors. They can also increase levels of insight and improve daily functioning. </p>
<p>I (Eva) worked with a psychologist and psychiatrist to combat the depression and anxiety caused by my appearance concerns. Fortunately, both the <a href="https://bddfoundation.org/beating-bdd-podcast-27">medication and therapy</a> were effective in reducing my negative feelings and compulsive behaviors. </p>
<p>Two years after I started treatment, my symptoms lessened and became manageable. Today I facilitate <a href="https://feartocourage.com/bdd-resources/bdd-support-group/">two online support groups</a> and encourage people to learn more about the disorder. Group members provide support and comfort to others who understand their daily struggles. They also share advice about getting help for this common but little known body image disorder. </p>
<p>More information about diagnosis and treatment for body dysmorphic disorder is available on the <a href="https://bdd.iocdf.org/">International OCD Foundation BDD</a> site.</p><img src="https://counter.theconversation.com/content/195538/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Eva Fisher works for Colorado State University Global. She is affiliated with the International OCD Foundation.</span></em></p><p class="fine-print"><em><span>Fugen Neziroglu is affiliated with OCDNY, IOCD, ADAA. She has receved funding from Bio Haven Pharmaceutical Company. </span></em></p><p class="fine-print"><em><span>Jamie Feusner receives funding from the National Institutes of Health and the Klarman Family Foundation. He is affiliated with NOCD, Inc. </span></em></p>About a quarter of those with body dysmorphic disorder attempt suicide or struggle with ideas of suicide. Fortunately, medication and therapy have proved highly effective at treating the disorder.Eva Fisher, Communication Faculty Member, Colorado State University GlobalFugen Neziroglu, Clinical Assistant Professor of Psychiatry, School of Medicine, Hofstra UniversityJamie Feusner, Professor of Psychiatry and Clinician Scientist at the Centre for Addiction and Mental Health, University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1888032022-09-06T00:52:55Z2022-09-06T00:52:55ZWhen I work with people with eating disorders, I see many rules around ‘good’ and ‘bad’ foods – but eating is never that simple<figure><img src="https://images.theconversation.com/files/481521/original/file-20220829-24-owd2ms.jpg?ixlib=rb-1.1.0&rect=35%2C80%2C5955%2C3916&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://images.pexels.com/photos/3184192/pexels-photo-3184192.jpeg?cs=srgb&dl=pexels-fauxels-3184192.jpg&fm=jpg">Pexels</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>We usually think of eating as simple – a biological response to how hungry or full we feel. </p>
<p>But eating and enjoyment is a very complex process. Our upbringing, the influence of others such as family and friends, our emotions, media, education and our health status are <a href="https://www.eufic.org/en/healthy-living/article/the-determinants-of-food-choice#:%7E:text=Biological%20determinants%20such%20as%20hunger,family%2C%20peers%20and%20meal%20patterns">all strong influences</a> on how, what and when we eat. Then there is how food is cooked and prepared, our religious beliefs and values, and our access to food. </p>
<p>When I work with people with eating disorders, I frequently hear loved ones asking why sufferers don’t just eat like a “normal person”. They can’t understand why they struggle to eat. I try to explain eating is strongly influenced by the way we think about food, our bodies and ourselves. </p>
<h2>Experimenting with taste</h2>
<p>Sensory sensitivity can have a strong influence on our food preferences. This can be a factor for <a href="https://www.cdc.gov/ncbddd/autism/signs.html#:%7E:text=Autism%20spectrum%20disorder%20(ASD)%20is,%2C%20moving%2C%20or%20paying%20attention">people with autism</a>, who might be sensitive to how foods taste, feel, look or smell. </p>
<p>They might be hypersensitive to sensations others wouldn’t be bothered by. For example, they may not like the way a food feels in their mouth and so develop an aversion to that type of food. </p>
<p>Often this is called “<a href="https://pubmed.ncbi.nlm.nih.gov/27062194/">fussy eating</a>” where a person won’t eat certain foods. Hypersensitivity becomes a problem if it means a person is very restricted in what they will eat to the point where they may become malnourished or unhealthy as a result of their food choices. This can be annoying and concerning for families and loved ones. Specialist dietitians and psychologists may be able to <a href="https://dietitiansaustralia.org.au/health-advice/eating-disorders">work with people</a> with aversions and sensitivities.</p>
<p>People who are not autistic may maintain dietary restrictions and preferences too. Our <a href="https://www.wathi.org/food-identity-of-culture-and-religion-researchgate/#:%7E:text=People%20from%20different%20cultural%20backgrounds,a%20cultural%20or%20regional%20group">culture and familiarity</a> with certain foods affect our eating habits and enjoyment of food. How experimental we are with foods often depends on <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5331538/%E2%80%8B">how varied our diet has been</a> growing up. For example, when children are exposed to a limited variety of foods they are often less inclined to try unfamiliar foods as adolescents and adults due to a fear of the unknown. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/six-ways-to-improve-meal-times-with-your-children-76575">Six ways to improve meal times with your children</a>
</strong>
</em>
</p>
<hr>
<h2>Eating as a chore</h2>
<p>Some people avoid eating and take a long time to eat foods. In extreme cases, this is associated with <a href="https://www.eatingdisorders.org.au/eating-disorders-a-z/arfid/">restrictive eating disorders and food aversions</a>.</p>
<p>Food aversion is when a person doesn’t enjoy food or gets very little pleasure from eating. Meals may be seen as an inconvenience or chore. People may only eat highly processed foods such as takeaway or drive-through burgers. They might go long periods without eating if the limited food they like isn’t available. It’s like a <a href="https://www.eatingdisorders.org.au/eating-disorders-a-z/arfid/">phobia of eating</a>.</p>
<p>If people lose a lot of body weight due to their reluctance to eat or become unhealthy generally, treatment revolves around eating by the clock and setting a routine as well as desensitisation to food, which can make it more of a chore. Eating more socially with friends and making the eating experience more pleasurable can help.</p>
<p>Sometimes when meal times have been associated with negative experiences such as arguing at dinner time, the pleasure of eating with family can be lost. Pairing eating with pleasurable interactions is important for healthy eating. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/481517/original/file-20220829-26-gwf5rm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="burger and fries on a plate" src="https://images.theconversation.com/files/481517/original/file-20220829-26-gwf5rm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/481517/original/file-20220829-26-gwf5rm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/481517/original/file-20220829-26-gwf5rm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/481517/original/file-20220829-26-gwf5rm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/481517/original/file-20220829-26-gwf5rm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/481517/original/file-20220829-26-gwf5rm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/481517/original/file-20220829-26-gwf5rm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Fries then burger? Or burger then fries?</span>
<span class="attribution"><a class="source" href="https://images.pexels.com/photos/70497/pexels-photo-70497.jpeg?cs=srgb&dl=pexels-robin-stickel-70497.jpg&fm=jpg">Pexels/Robin Stickel</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<h2>Good foods and bad foods</h2>
<p>Food preferences can also be learnt. In eating disorders such as anorexia nervosa, people develop a lot of rules around what foods are “good” or “bad”. Usually we attach these <a href="https://www.mayoclinic.org/diseases-conditions/anorexia-nervosa/symptoms-causes/syc-20353591">value judgements</a> to low calorie or “healthy” foods. Eating these foods might make a person feel more comfortable and positive about themselves. If they eat “bad” foods, typically those high in sugar and carbohydrates, they might feel guilty and negative about their body and themselves. </p>
<p>When these beliefs become rigid and restrictive, <a href="https://ceed.org.au/resources_links/raves-a-step-by-step-approach-to-re-establishing-normal-eating/">re-education</a> can help people be more flexible with their eating such as being able to eat foods without guilt. I like to talk about all foods being “good” foods and focusing on their function in and for the body. For example, sugar helps give us energy, carbohydrates help us concentrate. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/treating-a-childs-mental-illness-sometimes-means-getting-the-whole-family-involved-169729">Treating a child's mental illness sometimes means getting the whole family involved</a>
</strong>
</em>
</p>
<hr>
<h2>Food as reward</h2>
<p>We also eat in response to our <a href="https://www.healthline.com/health/emotional-eating%E2%80%8B">emotions</a>. We might engage in “stress eating” to distract ourselves from a pressing problem, or eat treats to reward ourselves for doing something we don’t like. </p>
<p>When children are given lollies, ice cream or something else they really like to eat and perhaps don’t have very often for good behaviour or an achievement, food becomes a powerful reward. </p>
<p>The reverse action – being deprived of food, such as dessert, for poor behaviour – is also powerful. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/481524/original/file-20220829-13-4cjaya.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/481524/original/file-20220829-13-4cjaya.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/481524/original/file-20220829-13-4cjaya.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/481524/original/file-20220829-13-4cjaya.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/481524/original/file-20220829-13-4cjaya.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/481524/original/file-20220829-13-4cjaya.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/481524/original/file-20220829-13-4cjaya.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/481524/original/file-20220829-13-4cjaya.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Giving ice creams and treats as rewards for good behaviour can set up powerful associations.</span>
<span class="attribution"><a class="source" href="https://images.pexels.com/photos/675439/pexels-photo-675439.jpeg?auto=compress&cs=tinysrgb&w=1260&h=750&dpr=2">Pexels/Jean Balzan</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<h2>Complex associations</h2>
<p>So, the way we eat and what we eat is related to how we are feeling, who we are with, our experiences with food, our <a href="https://my.clevelandclinic.org/health/articles/10681-the-psychology-of-eating">associations</a> with particular types of foods, as well as our simple biological need for fuel and energy. </p>
<p>More than just a simple response to hunger, our <a href="https://my.clevelandclinic.org/health/articles/10681-the-psychology-of-eating">relationship with food</a> is a complex interplay of our emotions, our familiarity with food, our senses and our culture and upbringing.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/serving-up-choice-and-dignity-in-aged-care-how-meals-are-enjoyed-is-about-more-than-whats-on-the-plate-179669">Serving up choice and dignity in aged care – how meals are enjoyed is about more than what's on the plate</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/188803/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Vivienne Lewis does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Some eaters have strong sensory sensitivities. Others find eating a chore or develop rigid beliefs around ‘good’ and ‘bad’ foods.Vivienne Lewis, Assistant professor – Psychology, University of CanberraLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1714552021-12-01T21:55:31Z2021-12-01T21:55:31ZEating disorders have increased during COVID-19 — here’s how to recognize them and how to help<figure><img src="https://images.theconversation.com/files/435170/original/file-20211201-25-igjprx.jpg?ixlib=rb-1.1.0&rect=147%2C84%2C3251%2C2260&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Eating disorders have increased during the COVID-19 pandemic.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 175px; border: none; position: relative; z-index: 1;" allowtransparency="" src="https://narrations.ad-auris.com/widget/the-conversation-canada/eating-disorders-have-increased-during-covid-19-—-here-s-how-to-recognize-them-and-how-to-help" width="100%" height="400"></iframe>
<p>Eating disorders are the <a href="https://doi.org/10.1093/pch/3.3.189">third most common chronic condition in adolescence</a>, behind only asthma and obesity. They affect <a href="https://doi.org/10.1186/s40337-020-0277-8">four per cent of the population</a>, 90 per cent of whom are female, mostly teenagers and young adults. </p>
<p>With the COVID-19 pandemic, there has been a dramatic increase in eating disorders <a href="https://www.theglobeandmail.com/canada/article-worst-it-has-ever-been-increase-in-eating-disorder-cases-among-teens/">in Canada</a> and <a href="http://dx.doi.org/10.1136/archdischild-2020-319868">internationally</a>. A number of factors related to COVID-19 lockdowns and school closures — such as isolation from peers, disrupted routines, suspension of activities and increased stress and anxiety — may have contributed to this increase. </p>
<p>As a pediatrician with a significant portion of my practice dedicated to the care of those with eating disorders, I see that they are often misunderstood, sometimes leading to them being unrecognized. </p>
<p>We know that earlier treatment improves outcome, but we can’t treat what we don’t know exists. Those closest to someone who is struggling can be key in recognizing eating disorders, so let’s review some of the myths, learn how to recognize them and what to do if you suspect someone you care about has an eating disorder.</p>
<h2>Myth 1: Eating disorders are a choice</h2>
<figure class="align-center ">
<img alt="Illustration of a normal sized female figure reflected as much larger in a mirror" src="https://images.theconversation.com/files/435171/original/file-20211201-23-vd3dv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/435171/original/file-20211201-23-vd3dv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/435171/original/file-20211201-23-vd3dv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/435171/original/file-20211201-23-vd3dv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/435171/original/file-20211201-23-vd3dv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/435171/original/file-20211201-23-vd3dv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/435171/original/file-20211201-23-vd3dv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The malnourished brain can view what is objectively thin, as overweight.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>We can choose to eat less to lose weight, can’t we? Can’t you then choose to start eating more to get things back on track? Unfortunately, it’s not that simple. </p>
<p>When the body is malnourished, <a href="https://www.mayoclinic.org/diseases-conditions/anorexia-nervosa/symptoms-causes/syc-20353591">the brain is, too</a>. This changes the way the brain sees the body, and the way it sees food. </p>
<p>What is objectively seen as a small portion, the malnourished brain sees as way too much. What is objectively seen as thin, the malnourished brain sees as fat. The brain becomes more rigid around food: foods are either good or bad, with no in between. </p>
<p>Malnutrition also affects the gut: the stomach shrinks because it isn’t getting enough food, and the progress of this food through the intestines slows down to maximize how much nutrition is absorbed. This can make it physically uncomfortable to eat. </p>
<h2>Myth 2: Eating disorders only impact mental health</h2>
<p>Anorexia nervosa has the <a href="https://doi.org/10.1001/archgenpsychiatry.2011.74">highest mortality of any psychiatric illness</a>, and mortality risk increases with every decade that someone suffers with it. </p>
<p>Some of the mortality is from suicide, but some is from complications to physical health. In addition to the changes to the gut and brain, malnutrition can also affect the heart. When the body doesn’t get enough energy intake from food, it takes it from fat and muscle, including the heart. </p>
<p>Initially, this may present as dizziness, feeling cold due to lack of circulation and low energy, but with time, the heart slows down, sometimes to the point where it just stops.</p>
<p>In patients with bulimia nervosa, purging by inducing vomiting can cause dental enamel erosion, and the esophagus can become irritated from stomach acid coming up so frequently. Sometimes this causes heartburn. </p>
<p>The esophagus can also tear from the force of vomiting. A small tear can cause small amounts of bleeding, but sometimes these tears are large, and the bleeding is life-threatening. Vomiting can also create electrolyte imbalances, which can affect heart rhythm. These are just a few of the many physical effects of <a href="https://www.helpguide.org/articles/eating-disorders/anorexia-nervosa.htm">anorexia nervosa</a> and <a href="https://www.helpguide.org/articles/eating-disorders/bulimia-nervosa.htm">bulimia nervosa</a>.</p>
<h2>Myth 3: You need to be under-weight to have an eating disorder</h2>
<figure class="align-center ">
<img alt="Feet on a scale, with a tape measure tangled around the ankles" src="https://images.theconversation.com/files/435172/original/file-20211201-21-z8kc4a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/435172/original/file-20211201-21-z8kc4a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/435172/original/file-20211201-21-z8kc4a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/435172/original/file-20211201-21-z8kc4a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/435172/original/file-20211201-21-z8kc4a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/435172/original/file-20211201-21-z8kc4a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/435172/original/file-20211201-21-z8kc4a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">About 20-35 per cent of people with restrictive eating disorders have a history of being overweight.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>About 20 to 35 per cent of those with an eating disorder have a <a href="https://doi.org/10.3949/ccjm.87a.19034">history of being overweight</a>. When they lose weight, they are often praised for it, reinforcing any unhealthy strategies they may have used, encouraging them to continue. </p>
<p>Losing weight rapidly can cause the same serious problems with electrolytes or heart function as being significantly underweight.</p>
<h2>Recognizing risks</h2>
<p>There are <a href="https://www.nationaleatingdisorders.org/risk-factors">many things</a> that can contribute to an eating disorder. Genetics and family history play a role, and going through puberty is a time that can be particularly stressful. We also know that being teased about your weight, being in a home where weight is talked about a lot, a personal or family history of dieting (especially a mother) can increase the risk. <a href="https://www.nytimes.com/2021/10/22/technology/social-media-eating-disorders.html">Social media</a> and <a href="https://doi.org/10.1093/pch/8.5.287">media exposure</a> can also contribute.</p>
<p>Some <a href="https://www.nationaleatingdisorders.org/warning-signs-and-symptoms">clues that might signal the presence of an eating disorder</a> include:</p>
<p><strong>Dramatic changes in eating behaviours</strong></p>
<ul>
<li>Eliminating whole food groups </li>
<li>Becoming more rigid around food</li>
<li>Not eating around others</li>
<li>Cooking or baking, but not eating the food</li>
<li>Playing with food more</li>
<li>Breaking food into small pieces rather than taking bites</li>
<li>More focus on food labels/content</li>
<li>Spending lots of time in the bathroom, especially right after meals</li>
</ul>
<p><strong>Changes in exercise behaviour</strong></p>
<ul>
<li>Exercise becomes compulsive (for example, it’s not OK to miss a workout)</li>
</ul>
<p>While eating disorders can’t always be prevented, <a href="https://keltyeatingdisorders.ca/prevention/prevention-resources/">risks can be decreased</a>. Eating together as a family, avoiding weight talk and not labelling food as good or bad can all help. </p>
<p>Encouraging activity because it’s fun, not to change the way someone’s body looks, is also key. Remember that all bodies are good bodies, and you can have <a href="https://asdah.org/health-at-every-size-haes-approach/">health at every size</a>. </p>
<p>If you suspect someone you know has an eating disorder, talk to them about it. If their brain is malnourished, they may not be able to see the problem, so these conversations can be difficult. The <a href="https://nedic.ca/">National Eating Disorder Information Centre</a> is a great resource. As hard as it is, taking this step and getting them to their family doctor as soon as possible may save lives.</p><img src="https://counter.theconversation.com/content/171455/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ayisha Kurji does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Eating disorders are often misunderstood, but earlier treatment improves outcomes. Let’s dispel some myths, learn how to recognize eating disorders and what to do if someone you love is struggling.Ayisha Kurji, Assistant Professor, Pediatrics, University of SaskatchewanLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1686342021-11-02T12:25:45Z2021-11-02T12:25:45ZThe COVID-19 pandemic increased eating disorders among young people – but the signs aren’t what parents might expect<figure><img src="https://images.theconversation.com/files/429371/original/file-20211029-17-189kn2p.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C6720%2C6709&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">More time spent on social media can leave young adults feeling worse about their bodies.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/diverse-group-of-people-portraits-with-surgical-royalty-free-image/1278426537">Leo Patrizi/E+ Collection via Getty Images</a></span></figcaption></figure><p>Eating disorders <a href="https://doi.org/10.1016/j.jadohealth.2021.05.019">began to spike</a> among young people shortly after the onset of the COVID-19 pandemic.</p>
<p>Experts believe the increase occurred due to disruptions in daily living, emotional distress and more time spent on <a href="https://doi.org/10.1016/j.childyouth.2020.105659">social media</a> – which research has shown can lead to <a href="https://theconversation.com/facebook-has-known-for-a-year-and-a-half-that-instagram-is-bad-for-teens-despite-claiming-otherwise-here-are-the-harms-researchers-have-been-documenting-for-years-168043">lower self-esteem and negative body image</a>.</p>
<p>One peer-reviewed study indicates that eating disorder diagnoses <a href="http://www.doi.org/10.1192/bjp.2021.105">increased 15% in 2020</a> among people under 30 compared to previous years. Other studies have suggested that patients who already had an eating disorder diagnosis <a href="https://doi.org/10.1002/erv.2771">got worse during the pandemic</a>. The researchers reported an increase in eating disorder symptoms along with anxiety and depression.</p>
<p>Eating disorders include <a href="https://www.ncbi.nlm.nih.gov/books/NBK519712/table/ch3.t15/">anorexia nervosa</a>, <a href="https://www.ncbi.nlm.nih.gov/books/NBK519712/table/ch3.t16/">bulimia nervosa</a>, <a href="https://www.ncbi.nlm.nih.gov/books/NBK338301/table/introduction.t1/">binge eating disorder</a> and other specified feeding and eating disorders such as <a href="https://doi.org/10.1016/j.cppeds.2017.02.003">atypical anorexia</a>. The peak age of onset is <a href="https://doi.org/10.1016/S2215-0366(16)00081-X">15-25 years old</a>, but individuals can develop eating disorders <a href="https://doi.org/10.1007/s11920-019-1057-5">at any age</a>. </p>
<p>We are a <a href="https://uvahealth.com/findadoctor/profile/julia-f-taylor">physician</a> and a <a href="https://uvahealth.com/findadoctor/profile/sara-groff-stephens">psychotherapist</a> who <a href="https://www.researchgate.net/profile/Sara-Stephens">specialize in treating eating disorders</a> in teens and young adults. We’ve seen the increased demand for eating disorder services in our own clinic.</p>
<p>While eating disorders have historically been <a href="https://doi.org/10.1002/eat.22846">underdiagnosed in certain groups</a> – specifically males, racial/ethnic minorities, and people who are higher-weight, LGBTQ or from poorer backgrounds – the recent COVID-related increase in patients presenting for care has reinforced that no group is immune from them. </p>
<p>Here are three groups of young people who are often overlooked when it comes to eating disorders. </p>
<h2>1. Adolescent boys and young men</h2>
<p>Historical research on diagnosing eating disorders has focused on females. This has <a href="http://www.doi.org/10.1097/YCO.0b013e328365a34b">made it harder</a> for doctors, families and patients to recognize eating disorders in males. For example, adolescent boys may be more prone to focus on muscle strength and steroid use – indicators that are not captured in traditional, female-focused screening tools and diagnostic criteria. </p>
<p>However, newer research suggests that <a href="https://doi.org/10.1002/eat.22350">males may account for up to half</a> of all cases of eating disorders. While males have likely been underdiagnosed in all categories of eating disorders, male adolescents seem to be <a href="http://www.doi.org/10.1186/s40337-019-0261-3">more prone to avoidant restrictive food intake disorder</a>. This is a relatively new eating disorder that involves inadequate food intake but not distress about body shape or size. </p>
<p>Disordered eating – a pattern of problematic eating behaviors that include dieting, skipping meals and feelings of shame but does not meet formal criteria for an eating disorder diagnosis – is increasingly being self-reported by <a href="https://www.doi.org/10.2147/AHMT.S147480">male athletes</a>. This means high school coaches and athletic trainers are a potential source for increased awareness and recognition of problematic relationships with food or exercise in young males. </p>
<figure class="align-center ">
<img alt="Three teenage boys lift weights together in a gym in a garage" src="https://images.theconversation.com/files/429372/original/file-20211029-13-1rcqhp1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/429372/original/file-20211029-13-1rcqhp1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/429372/original/file-20211029-13-1rcqhp1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/429372/original/file-20211029-13-1rcqhp1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/429372/original/file-20211029-13-1rcqhp1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/429372/original/file-20211029-13-1rcqhp1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/429372/original/file-20211029-13-1rcqhp1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Overexercising and avoiding rest days can be signs of an eating disorder.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/diverse-group-of-people-portraits-with-surgical-royalty-free-image/1278426537">Thomas Barwick/DigitalVision via Getty Images</a></span>
</figcaption>
</figure>
<h2>2. Sexual and gender minorities</h2>
<p>Recent studies have also uncovered that disordered eating and eating disorders are <a href="http://www.doi.org/10.1007/s00787-018-1145-9">more common</a> among sexual and gender minority youth than among cisgendered heterosexual youth. This is thought to be related to higher rates of body dissatisfaction, stigma and victimization in those groups. </p>
<p>Psychologists believe the bias and discrimination that gay, bisexual and transgender youth face <a href="http://www.doi.org/10.1016/j.pcl.2016.07.003">increases their stress, negative thoughts and isolation</a>. This may lead to body dissatisfaction and eating disorders. </p>
<p>For <a href="http://www.doi.org/10.1007/s11920-019-1097-x">transgender youth in particular</a>, disordered eating and a focus on body shape and size may also be related to dissatisfaction with physical changes during puberty that are inconsistent with their gender identity. </p>
<h2>3. “Normal”-weighted youth</h2>
<p>Many eating disorders are not associated with being thin. This means that youth can develop serious medical complications related to their eating disorders regardless of their body size. </p>
<p>For example, adolescents with <a href="http://www.doi.org/10.1542/peds.2019-2339">atypical anorexia nervosa</a> meet the criteria for <a href="https://www.ncbi.nlm.nih.gov/books/NBK519712/">anorexia nervosa</a> – such as intense fear of gaining weight or becoming fat, and persistent behavior that prevents weight gain – but they are not underweight. However, they <a href="http://www.doi.org/10.1016/j.eatbeh.2021.101573">may require hospitalization</a> due to severe malnutrition and dangerous vital signs such as abnormally slow heartbeat or low blood pressure. </p>
<p>Similarly, individuals with <a href="https://www.ncbi.nlm.nih.gov/books/NBK519712/table/ch3.t16/">bulimia nervosa</a> – who binge eat and then use forced vomiting, laxatives or other unhealthy behaviors to avoid weight gain – can also have normal body mass index, or BMI. Yet they may develop <a href="https://www.doi.org/10.1542/peds.2020-040279">electrolyte abnormalities and severe gastrointestinal issues</a>.</p>
<h2>Noticing the signs</h2>
<p>Caregivers, coaches, health professionals and all those who interact with young people should remain aware of the increased rates of eating disorders brought on during the pandemic. </p>
<p>The signs that a youth may be developing disordered behaviors or a full eating disorder are not always obvious. For example, indications may include: an inability to take a rest day, or working out more than advised by a coach or athletic trainer; an intense focus on muscle building; avoiding eating in public; a sudden desire to eat “clean” or cut out certain food groups like dairy, meat or desserts; and use of steroids, diet pills or laxatives.</p>
<p>Eating disorders are devastating <a href="https://www.ncbi.nlm.nih.gov/books/NBK519712/">mental illnesses</a> that have massive <a href="https://www.hsph.harvard.edu/striped/report-economic-costs-of-eating-disorders/">social and economic costs</a>. They also carry among the highest <a href="https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/abs/excess-mortality-associated-with-eating-disorders-populationbased-cohort-study/6B3247F26A38BD5C72A592A7513FBE02">mortality rates</a> of all of the psychiatric diagnoses and wreak havoc on the lives of individuals and their loved ones. </p>
<p>Early intervention is important to reduce long-term illness and the emotional and physical devastation that can occur with eating disorders. Breaking down barriers for identification and treatment for all individuals – including boys, sexual and gender minority youth and kids across the weight spectrum – will improve outcomes for those who struggle with these significant illnesses.</p>
<p>[<em>Get our best science, health and technology stories.</em> <a href="https://theconversation.com/us/newsletters/science-editors-picks-71/?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=science-best">Sign up for The Conversation’s science newsletter</a>.]</p><img src="https://counter.theconversation.com/content/168634/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Boys, LGBTQ youth and people with normal body mass index are often overlooked when it comes to recognizing eating disorders, a physician and psychotherapist explain.Julia F. Taylor, Assistant Professor of Pediatrics, University of VirginiaSara Groff Stephens, Assistant Professor of Pediatrics, University of VirginiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1697292021-10-20T07:25:47Z2021-10-20T07:25:47ZTreating a child’s mental illness sometimes means getting the whole family involved<figure><img src="https://images.theconversation.com/files/427440/original/file-20211020-13-4eqe9r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/child-psychology-174171269">Shutterstock</a></span></figcaption></figure><p>Half of all adult mental health issues emerge before the age of 14, with 14% of Australian children aged four to 17 currently <a href="https://www.mentalhealthcommission.gov.au/mental-health-reform/childrens-mental-health-and-wellbeing-strategy">impacted by poor mental health</a>. </p>
<p>These are the drivers for the first National Children’s Mental Health and Well-being strategy, developed by the National Mental Health Commission and released by the government last week. </p>
<p>The strategy suggests viewing children’s mental health and well-being along a continuum of well–coping–struggling–unwell, and recommends focusing on support, prevention and early intervention before mental illness occurs. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/427457/original/file-20211020-20-qcq04n.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/427457/original/file-20211020-20-qcq04n.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=279&fit=crop&dpr=1 600w, https://images.theconversation.com/files/427457/original/file-20211020-20-qcq04n.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=279&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/427457/original/file-20211020-20-qcq04n.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=279&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/427457/original/file-20211020-20-qcq04n.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=350&fit=crop&dpr=1 754w, https://images.theconversation.com/files/427457/original/file-20211020-20-qcq04n.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=350&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/427457/original/file-20211020-20-qcq04n.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=350&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
<span class="attribution"><a class="source" href="https://www.mentalhealthcommission.gov.au/getmedia/5b7112be-6402-4b23-919d-8fb9b6027506/National-Children%E2%80%99s-Mental-Health-and-Wellbeing-Strategy-%E2%80%93-Report">The National Children’s Mental Health and Wellbeing Strategy</a></span>
</figcaption>
</figure>
<p>The strategy also calls for “integrated child and family well-being services to better support families”. This means focusing on <em>all</em> the environments in which a child lives, learns and plays. </p>
<p>So what does the strategy recommend? And why is it important to get family involved in children’s mental health care?</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/preventive-measures-are-as-important-to-the-mental-health-pandemic-as-they-are-to-covid-19-160082">Preventive measures are as important to the mental health pandemic as they are to COVID-19</a>
</strong>
</em>
</p>
<hr>
<h2>Supporting the child’s family, school and community</h2>
<p>The strategy recommends focusing on four key areas to improve Australian children’s mental health and well-being:</p>
<p><strong>1. Empowering families to play a role.</strong></p>
<p>This means having access to mental health information and education, and allowing parents to better identify the signs of poor mental health in their child. Families should be supported to access services in the community before their child becomes significantly unwell, potentially <a href="https://emergingminds.com.au/our-work/guiding-principles/prevention-early-intervention/">decreasing the need</a> for more acute support. </p>
<p><strong>2. Closing the gaps in access.</strong></p>
<p>More than 50% of children with mental health issues are not receiving professional support, highlighting a <a href="https://www.mentalhealthcommission.gov.au/getmedia/9ccb3072-3ec1-4cf4-95e4-7b1b91c21ff6/National-Children%E2%80%99s-Mental-Health-and-Wellbeing-Strategy-%E2%80%93-At-a-Glance">significant gap in access</a>. The strategy notes ways for services to better support families, including: </p>
<ul>
<li>improvements in system navigation so families can find the right help at the right time</li>
<li>building the system to support children with complex care needs, for example, by providing support to engage with multiple government agencies</li>
<li>upskilling the existing workforce to increase capacity. </li>
</ul>
<p><strong>3. Increasing the role for schools in supporting children’s well-being and mental health.</strong></p>
<p>This includes:</p>
<ul>
<li>creating a culture within schools where well-being is nurtured</li>
<li>providing targeted responses for at-risk youth</li>
<li>supporting the development of educators that are trained and equipped to deliver well-being support. </li>
</ul>
<p>While some of this work is <a href="https://education.nsw.gov.au/student-wellbeing/whole-school-approach/wellbeing-framework-for-schools">already underway</a>, the impacts of the COVID-19 pandemic, extended school absence and facial coverings on children cannot be underestimated.</p>
<p><strong>4. Use treatments based on evidence.</strong></p>
<p>Therapeutic treatments and supports should be based on scientific evidence from high quality research. </p>
<h2>Why involve the family?</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/427450/original/file-20211020-14-b5zxiz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/427450/original/file-20211020-14-b5zxiz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/427450/original/file-20211020-14-b5zxiz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/427450/original/file-20211020-14-b5zxiz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/427450/original/file-20211020-14-b5zxiz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/427450/original/file-20211020-14-b5zxiz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/427450/original/file-20211020-14-b5zxiz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Therapies are increasing involving parents and other family members.</span>
<span class="attribution"><a class="source" href="https://theconversation.com/preventive-measures-are-as-important-to-the-mental-health-pandemic-as-they-are-to-covid-19-160082">Shutterstock</a></span>
</figcaption>
</figure>
<p>While therapies for children vary according to the issue of concern, more and more are integrating families at various stages to increase their effectiveness. </p>
<p>Guidelines for the treatment of <a href="https://www.dovepress.com/oppositional-defiant-disorder-current-insight-peer-reviewed-fulltext-article-PRBM">oppositional defiant disorder</a> and <a href="https://www.nice.org.uk/guidance/ng69/chapter/Recommendations#treating-anorexia-nervosa">anorexia nervosa</a>, for example, typically include either parent management training or family therapy, or both.</p>
<p>So how do they work? Let’s take a closer look at these examples. </p>
<h2>Oppositional defiant disorder</h2>
<p>Young people with oppositional defiant disorder display a <a href="https://raisingchildren.net.au/guides/a-z-health-reference/odd">frequent and persistent pattern</a> of anger, irritability, arguing and defiance towards authority figures. </p>
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Read more:
<a href="https://theconversation.com/more-than-just-a-tantrum-heres-what-to-do-if-your-child-has-oppositional-defiant-disorder-96014">More than just a tantrum: here's what to do if your child has oppositional defiant disorder</a>
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<p><a href="https://www.dovepress.com/oppositional-defiant-disorder-current-insight-peer-reviewed-fulltext-article-PRBM">Parent management training</a> for the disorder focuses on spending quality time with your child, providing <a href="https://www.triplep-parenting.net.au/vic-uken/triple-p/">positive reinforcement</a> (such as praise) for desired behaviour and setting consistent limits for undesirable behaviour. </p>
<p>Family therapies vary, but typically ask all household members to attend sessions together. Discussion points may include understanding each family member’s views of the concern, identifying family strengths, exploring challenges and conflicts, encouraging consistency between parents and strengthening family bonds. </p>
<p><a href="https://www.wjgnet.com/2219-2808/full/v7/i1/9.htm">Research</a> combined with our own clinical experience suggests including parents and/or family members in treatment results in better outcomes for children that are maintained longer, and typically in fewer sessions. </p>
<h2>Anorexia nervosa</h2>
<p>Family support is the <a href="http://cedd.org.au/wordpress/wp-content/uploads/2014/09/Clinical-Practice-Guidelines-for-the-Treatment-of-Eating-Disorders-Developed-by-Royal-Australian-and-New-Zealand-College-of-Psychiatrists-RANZCP-2014.pdf">gold standard</a> in the <a href="https://www.nice.org.uk/guidance/ng69/chapter/Recommendations#treating-anorexia-nervosa">treatment</a> of anorexia nervosa and other eating disorders.</p>
<p>Anorexia nervosa is a psychological illness that results in low body weight and body image distortion. Young people with anorexia nervosa restrict the types and amount of food they eat and will often engage in extreme forms of weight loss, such as excessive exercise. </p>
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Read more:
<a href="https://theconversation.com/anorexia-spiked-during-the-pandemic-as-adolescents-felt-the-impact-of-covid-restrictions-169466">Anorexia spiked during the pandemic, as adolescents felt the impact of COVID restrictions</a>
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<p>Family-based therapy for anorexia nervosa supports treatment of the young person in their community, <a href="https://ceed.org.au/wp-content/uploads/2020/04/Family-Based-Treatment-FBT.pdf">rather than relying solely on hospital admission</a>. </p>
<p>Outcomes for young people tend to improve when their parent(s) are supported to better understand and manage the symptoms of the eating disorder.</p>
<h2>It’s about consistency and support</h2>
<p>Families are sometimes anxious about joining therapy, often due to fears regarding perceived blame. In reality, clinicians understand most families are doing the best they can with the resources they have. </p>
<p>By integrating parents and other family members in therapy, it is hoped young people will have consistent support between the therapy space and their home environment. Family members can also be important advocates and cheerleaders for their children, as well as challenging symptoms of concern. </p>
<p>Children’s lives and obligations are much broader than ever before. They typically spend a significant time outside of their family and school such as sporting groups, church, social activities and the online space. To provide truly targeted, child-centred care, services will need to consider all domains of the young persons’ world.</p><img src="https://counter.theconversation.com/content/169729/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Associate Professor Jade Sheen has received research grants from the Australian Government and Victorian Government.</span></em></p><p class="fine-print"><em><span>Amanda Dudley does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>By integrating parents and other family members in therapy, young people will have more consistent support between the therapist’s office and their home.Jade Sheen, Associate Professor, School of Psychology, Deakin UniversityAmanda Dudley, Psychologist and Lecturer, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1694662021-10-14T02:40:34Z2021-10-14T02:40:34ZAnorexia spiked during the pandemic, as adolescents felt the impact of COVID restrictions<figure><img src="https://images.theconversation.com/files/426090/original/file-20211013-19-1g00st2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-woman-alone-sitting-besides-river-1834505998">Shutterstock</a></span></figcaption></figure><p>The COVID-19 pandemic has changed the way we live, go to school or work, and socialise. It has also increased <a href="https://www.nejm.org/doi/full/10.1056/nejmp2008017">mental health concerns</a>, with a <a href="https://www.mdpi.com/1660-4601/17/6/2032">rise</a> in levels of distress, anxiety and <a href="https://journals.sagepub.com/doi/full/10.1177/0020764020915212">depression</a>. </p>
<p>Adolescents have been particularly affected. The shift to online learning and limitations on catching up with friends have disrupted both their educational and social routines, and many have missed important milestones. </p>
<p>Some young people have also changed their <a href="https://onlinelibrary.wiley.com/doi/full/10.1002/eat.23317">eating and exercise habits</a>. This includes those with eating disorders such as anorexia nervosa, a restrictive eating disorder that affects mainly adolescent girls. </p>
<p>We’ve seen an increase in the number of adolescents <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/jpc.15755">seeking treatment</a> for anorexia nervosa and other eating disorders, including a 63% jump at our clinic in Melbourne.</p>
<h2>What are the complications?</h2>
<p>Anorexia nervosa is often associated with ongoing physical and mental health problems. </p>
<p>Decreased bone density can leave people <a href="https://pubmed.ncbi.nlm.nih.gov/23706279/">at risk of fracture</a>, altered blood vessel properties may predispose them to <a href="https://pubmed.ncbi.nlm.nih.gov/29559196/">heart disease</a>, and fertility problems may be detected when patients <a href="https://www.jwatch.org/wh201109080000001/2011/09/08/long-term-effects-eating-disorders-fertility-and">attempt to have children</a>. </p>
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Read more:
<a href="https://theconversation.com/anxious-teenage-girls-at-higher-risk-of-eating-disorder-symptoms-127884">Anxious teenage girls at higher risk of eating-disorder symptoms</a>
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<p>Many people continue to battle with negative thoughts and feelings towards food even if they’re <a href="https://pubmed.ncbi.nlm.nih.gov/9356884/">able to reach a healthy body weight</a>. This can cause high levels of stress and anxiety on a daily basis. </p>
<p>Treatment for anorexia nervosa aims to address both the physical and mental health components of the illness. </p>
<h2>Rise in presentations mirrored restrictions</h2>
<p>My research, <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/jpc.15755">published recently in the Journal of Paediatrics and Child Health</a>, shows presentations to the Royal Children’s Hospital eating disorder service <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/jpc.15755">increased by 63%</a> during 2020 compared to the previous three years. Presentations went from an average of 99 in 2017-2019 to 161 in 2020. </p>
<p>The clinic mainly treats restrictive eating disorders, which affect the person’s ability to get enough nutrients to sustain the key functions of their body; anorexia nervosa accounts for 70-80% of patients each year. Patients range in age from nine to 18 years and more than 80% are female. </p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/covid-has-presented-unique-challenges-for-people-with-eating-disorders-theyll-need-support-beyond-the-pandemic-148903">COVID has presented unique challenges for people with eating disorders. They'll need support beyond the pandemic</a>
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<p>The increase in anorexia nervosa presentations in 2020 closely matched the implementation of COVID-19 restrictions. There was a rapid surge from May, which meant patients had to go on the waiting list for treatment. Numbers then started to decline from September, with the easing of restrictions. </p>
<p>We’re yet to analyse the numbers for 2021, but these are expected to be higher again.</p>
<h2>The role of COVID</h2>
<p>Restrictions play a key role in many individuals’ eating disorders. </p>
<p>Some 40% of anorexia nervosa patients at the Royal Children’s Hospital eating disorder service in 2020 reported COVID restrictions were the trigger for their disordered behaviours. </p>
<p>A further 13% of existing patients relapsed during lockdown. </p>
<p><a href="https://jeatdisord.biomedcentral.com/articles/10.1186/s40337-020-00295-3">Past research has shown</a> isolation, loneliness and boredom are key triggers for disordered eating. </p>
<p>In our study, COVID restrictions resulted in feelings of isolation and loneliness in one-third of the 2020 patients, and one-quarter reported boredom. </p>
<p>People who develop eating disorders typically have strict thoughts and feelings in relation to food and/or exercise. When they encounter external stressors, they revert to these behaviours <a href="https://bmcpsychiatry.biomedcentral.com/articles/10.1186/1471-244X-13-294">as a means of control</a>.</p>
<p>One-quarter of the patients in our study recognised changes to their normal routine during COVID restrictions contributed to developing an eating disorder. </p>
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Read more:
<a href="https://theconversation.com/disease-evolution-the-origins-of-anorexia-and-how-its-shaped-by-culture-and-time-54571">Disease evolution: the origins of anorexia and how it's shaped by culture and time</a>
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<p>Patients and their families also commonly voiced about fearing the “expected weight gain during isolation” and being “worried about getting fat and losing fitness”. </p>
<p>This may have contributed to initial weight loss, which is a another <a href="https://jeatdisord.biomedcentral.com/articles/10.1186/s40337-020-00295-3">trigger</a> for developing restrictive eating disorders.</p>
<figure class="align-center ">
<img alt="A person steps onto bathroom scales, their ankles and feet visible." src="https://images.theconversation.com/files/426327/original/file-20211014-23-wi9o2z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/426327/original/file-20211014-23-wi9o2z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/426327/original/file-20211014-23-wi9o2z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/426327/original/file-20211014-23-wi9o2z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/426327/original/file-20211014-23-wi9o2z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/426327/original/file-20211014-23-wi9o2z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/426327/original/file-20211014-23-wi9o2z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Weight loss is a trigger for eating disorders.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/feet-standing-on-electronic-scales-weight-1851139591">Shutterstock</a></span>
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<h2>But disorders weren’t more severe</h2>
<p>Despite an increase in anorexia nervosa presentations during the pandemic, there has been no increase in the severity of illness. Anorexia nervosa presentations throughout 2020 were actually less severe than in previous years. </p>
<p>There was also no change in the number of patients presenting to the eating disorder clinic experiencing depression or anxiety. </p>
<p>We’ve also seen similar increases in patient presentations for disordered eating and exercise behaviours <a href="https://nedc.com.au/research-and-resources/show/issue-69-the-impact-of-covid-19-on-eating-disorders">in other parts of Australia</a> during the pandemic.</p>
<h2>What does this mean for the future?</h2>
<p>The foundations for mental well-being are <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)00579-1/fulltext">formed during adolescence</a>, so access to timely, quality health care for emerging mental health problems is vital.</p>
<p>Since COVID restrictions can be a trigger, families should keep an eye on their children and adolescents to identify disordered behaviours. </p>
<p>Early and intense treatment is often crucial to recovery and maintaining this long-term. With restrictions on social interactions, families play a much bigger support role and should be empowered to assist the young person during this time of uncertainty.</p>
<p>There is also likely to be increased demand for eating disorder services moving out of lockdown, as more people who have developed disordered behaviours become ill and seek treatment. </p>
<p><em>If this article has raised issues for you or your child, you can call Lifeline on 13 11 14 or Kids Helpline on 1800 55 1800. Resources are also available at <a href="https://butterfly.org.au/">The Butterfly Foundation</a>.</em></p><img src="https://counter.theconversation.com/content/169466/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gabriella Springall receives funding from the Australian Commonwealth Government via the Research Training Program Scholarship scheme. </span></em></p>Presentations to a Melbourne eating disorder clinic jumped by 63% in 2020, as young people struggled with isolation, loneliness and boredom.Gabriella Springall, PhD candidate, Murdoch Children's Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1489032020-11-23T19:04:07Z2020-11-23T19:04:07ZCOVID has presented unique challenges for people with eating disorders. They’ll need support beyond the pandemic<figure><img src="https://images.theconversation.com/files/370024/original/file-20201118-21-de4bno.jpg?ixlib=rb-1.1.0&rect=26%2C4%2C3000%2C1989&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>COVID-19 has changed the way we live, work and interact with one another. It has also changed the way we move, exercise, shop, prepare food, and eat.</p>
<p>During the pandemic, we’ve seen marked increases in <a href="https://theconversation.com/covid-stress-syndrome-5-ways-the-pandemic-is-affecting-mental-health-147413">reports of mental distress</a> across the board. But Australian and international research suggests lockdown measures have presented unique challenges for people living with eating disorders.</p>
<h2>Eating disorders are complex mental illnesses</h2>
<p>Eating disorders include anorexia nervosa, bulimia nervosa, binge eating disorder and <a href="https://www.eatingdisorders.org.au/eating-disorders-a-z/other-eating-disorders-osfed/">other diagnoses</a>. They centre around disordered eating (for example, fasting and dieting, binge eating, or purging behaviours), and often include problems with body image.</p>
<p>Eating disorders are <a href="https://pubmed.ncbi.nlm.nih.gov/16815322/">frequently associated</a> with high levels of depression and anxiety.</p>
<p>For some people with these conditions, rigid routines (around exercise, food preparation or eating habits), are a way of coping with symptoms and distress.</p>
<p>It’s no secret the pandemic has significantly disrupted our usual routines. For example, working from home may have led people to be more sedentary, or allowed more time for exercise. Social distancing has meant we’ve spent less time seeing others and sharing meals.</p>
<figure class="align-center ">
<img alt="A man and a woman are eating in a cafe, but the man is disinterested in his food." src="https://images.theconversation.com/files/370027/original/file-20201118-23-1r93xtc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/370027/original/file-20201118-23-1r93xtc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/370027/original/file-20201118-23-1r93xtc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/370027/original/file-20201118-23-1r93xtc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/370027/original/file-20201118-23-1r93xtc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/370027/original/file-20201118-23-1r93xtc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/370027/original/file-20201118-23-1r93xtc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">People of different ages, genders and backgrounds can develop eating disorders.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
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</figure>
<p>COVID-19 restrictions and social distancing measures, though imperative to reduce the spread of the virus, have resulted in a <a href="https://openresearch-repository.anu.edu.au/handle/1885/213198">significant rise in psychological distress</a>, especially for people experiencing social isolation, reduced or uncertain employment, financial strain, or health concerns. </p>
<p>We know people with existing mental health problems have been <a href="http://www.blackdoginstitute.org.au/wp-content/uploads/2020/04/20200319_covid19-evidence-and-reccomendations.pdf">particularly vulnerable</a>. However, people with eating disorders are vulnerable not only to these mental stressors; but also to the physical changes to everyday routines, and social conversations about <a href="https://www.dailymail.co.uk/femail/article-8128075/People-share-hilarious-tweets-gaining-weight-quarantine.html">eating and body weight</a> which have popped up during lockdowns.</p>
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<strong>
Read more:
<a href="https://theconversation.com/how-many-people-have-eating-disorders-we-dont-really-know-and-thats-a-worry-121938">How many people have eating disorders? We don't really know, and that's a worry</a>
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<h2>What does the research say?</h2>
<p>Research <a href="https://pubmed.ncbi.nlm.nih.gov/32476175/">published early in the pandemic</a> predicted COVID-19 and the associated restrictions may increase eating disorder risk in a few important ways:</p>
<ul>
<li><p>disruptions to daily routines and reduced access to social supports </p></li>
<li><p>increased exposure to anxiety-provoking media (messages about possible links between high <a href="https://twitter.com/Mangan150/status/1253306208594784258?s=20">body mass index and COVID</a>, or <a href="https://www.dailymail.co.uk/femail/article-8128075/People-share-hilarious-tweets-gaining-weight-quarantine.html">joking on social media</a> about weight gain during lockdown)</p></li>
<li><p>increased use of videoconferencing where people are exposed to their own image on camera</p></li>
<li><p>anxiety about contracting COVID-19 — the authors suggested this may lead people with eating disorders to engage in dieting for perceived immune system benefits. </p></li>
</ul>
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Read more:
<a href="https://theconversation.com/greater-needs-but-poorer-access-to-services-why-covid-mental-health-measures-must-target-disadvantaged-areas-146306">Greater needs, but poorer access to services: why COVID mental health measures must target disadvantaged areas</a>
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<p>Australian researchers conducted what was to our knowledge the first <a href="http://dx.doi.org/10.1002/eat.23317">published study</a> on disordered eating behaviours during COVID-19. Participants with eating disorders reported a worsening of symptoms — they were restricting their food consumption, binge eating and engaging in purging behaviours more often. They also reported doing more exercise, and high levels of depression, anxiety and stress.</p>
<p>Studies from around the world have since shown similar results. They’ve also found people with eating disorders have <a href="https://www.medrxiv.org/content/10.1101/2020.05.28.20116301v2">reported increased fears</a> about not being able to find foods consistent with meal plans, while <a href="https://onlinelibrary.wiley.com/doi/full/10.1002/erv.2762">disruptions to routine</a> have led to heightened psychological distress and worsening of eating disorder symptoms.</p>
<p>It comes as little surprise demand for eating disorder support has increased significantly. The Butterfly Foundation — Australia’s leading support organisation for people affected by eating disorders and body image issues — has reported <a href="https://butterfly.org.au/news/urgent-need-for-eating-disorder-support-backed-by-federal-government/">a 57% increase</a> in calls to its helpline over the course of the pandemic. </p>
<p>Similarly, inpatient and outpatient services around Australia — particularly <a href="https://www.theaustralian.com.au/nation/politics/mental-health-crisis-one-million-lost-in-coronavirus-lockdown/news-story/fc8c1da341ca392166fce6aba9ca4f69">in Victoria</a> where residents experienced a prolonged second lockdown — have seen <a href="https://www.nedc.com.au/">demand increase</a>, resulting in longer wait lists for eating disorder services.</p>
<figure class="align-center ">
<img alt="A group counselling session." src="https://images.theconversation.com/files/370026/original/file-20201118-17-1ogapj4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/370026/original/file-20201118-17-1ogapj4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/370026/original/file-20201118-17-1ogapj4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/370026/original/file-20201118-17-1ogapj4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/370026/original/file-20201118-17-1ogapj4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/370026/original/file-20201118-17-1ogapj4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/370026/original/file-20201118-17-1ogapj4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">People with eating disorders are likely to need extra support beyond the pandemic.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
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</figure>
<h2>Looking ahead</h2>
<p>Although we still don’t know what the long-term psychological effects of COVID-19 will be, previous pandemics such as SARS have taught us these sorts of crises can result in <a href="https://www.sciencedirect.com/science/article/pii/S0929664610600873">long-term mental health impacts</a>, and may trigger the onset of mental illness, including depression and anxiety. </p>
<p>We don’t know yet conclusively whether the pandemic has triggered the onset of eating disorder symptoms or increased the incidence of these conditions. It doesn’t make it any easier that our understanding of the prevalence of eating disorders in Australia <a href="https://theconversation.com/how-many-people-have-eating-disorders-we-dont-really-know-and-thats-a-worry-121938">was poor</a> to begin with.</p>
<p>But it does seem highly likely that we will see such increases. The information we have so far suggests pandemic-related challenges can increase the risk for people with eating disorders, or those who may be vulnerable to developing them, in many and varied ways.</p>
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Read more:
<a href="https://theconversation.com/people-with-eating-disorders-saw-their-symptoms-worsen-during-the-pandemic-new-study-140487">People with eating disorders saw their symptoms worsen during the pandemic – new study</a>
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<p>In addition, some research suggests food insecurity is associated with increases in <a href="https://onlinelibrary.wiley.com/doi/abs/10.1002/eat.22735">eating disorders</a>, and <a href="https://onlinelibrary.wiley.com/doi/full/10.1002/eat.22990">binge eating</a> in particular. </p>
<p>So even if the pandemic is brought to an end with widespread vaccination, if the associated economic recession results in ongoing disruptions to food supply chains, or in impoverished households having limited or unreliable access to food, we may see further increases in eating disorders, well beyond the life of COVID-19. </p>
<p>It’s critical clinical services and support organisations provide extra support to these groups, not only during the pandemic, but for a significant amount of time after the crisis has resolved. This includes increased access to treatment, as well as online eating disorder supports like <a href="https://butterfly.org.au/chattokit/">chatbots</a>, and telephone hotlines.</p>
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<p><em>If this article has raised concerns about body image or eating disorders, please contact the Butterfly Foundation national hotline on 1800 334 673, or visit their <a href="https://butterfly.org.au/">website</a>.</em></p><img src="https://counter.theconversation.com/content/148903/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Laura Hart is affiliated with The Body Confident Collective, a not-for-profit community dissemination organisation focusing on body image. </span></em></p><p class="fine-print"><em><span>Andrea Phillipou does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Data from around the world, including Australia, indicate the pandemic has made things more difficult for people with eating disorders for a variety of reasons.Laura Hart, Senior Research Fellow, The University of MelbourneAndrea Phillipou, Senior Research Fellow, Swinburne University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1278842019-12-18T07:42:34Z2019-12-18T07:42:34ZAnxious teenage girls at higher risk of eating-disorder symptoms<figure><img src="https://images.theconversation.com/files/306663/original/file-20191212-85391-i88u0m.jpg?ixlib=rb-1.1.0&rect=11%2C11%2C7928%2C3737&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-beautiful-woman-wearing-casual-tshirt-1527449189">Aaron Amat/Shutterstock</a></span></figcaption></figure><p><a href="https://www.beateatingdisorders.org.uk/types/anorexia">Anorexia nervosa</a> is an eating disorder with one of the <a href="https://jamanetwork.com/journals/jamapsychiatry/fullarticle/1107207">highest mortality rates</a> of all psychiatric disorders. It is estimated that as many as <a href="https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-016-0766-4">4% of women</a> in the west will have the condition at some point in their life. </p>
<p>The illness, which usually starts in <a href="https://bmjopen.bmj.com/content/3/5/e002646">adolescence</a>, is difficult to treat. Only around <a href="https://www.ncbi.nlm.nih.gov/pubmed/28889819">half</a> of those treated recover, so preventing it is really important. However, to effectively prevent a disorder, you need to be able to identify the early signs.</p>
<p>Restrictive eating, restricting the number of calories or quantity of food consumed, is not only a core feature of anorexia but it is also an early symptom that precedes <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5215960/">anorexia onset</a>. In our <a href="https://onlinelibrary.wiley.com/doi/10.1002/erv.2714">latest study</a> we wanted to understand whether anxiety disorders predicted restrictive eating. </p>
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Read more:
<a href="https://theconversation.com/eating-disorders-early-warning-signs-identified-119886">Eating disorders: early warning signs identified</a>
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<p>We were interested in a particularly severe form of restrictive eating, which was fasting for an entire day for weight control (losing weight or avoiding weight gain). We assessed whether having an anxiety disorder predicted how likely people were to fast in the future, two years after the anxiety assessment.</p>
<p>Previously, researchers found that people with anorexia had <a href="https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.161.12.2215?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed">higher rates of anxiety disorders</a> compared with the general population. This led some scientists to suggest that restrictive eating may <a href="https://www.ncbi.nlm.nih.gov/pubmed/12655621">reduce anxiety</a> in people who are at risk of developing anorexia. The reduction in anxiety resulting from restrictive eating may then encourage restrictive eating to continue.</p>
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<img alt="" src="https://images.theconversation.com/files/306664/original/file-20191212-85404-1mmck9r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/306664/original/file-20191212-85404-1mmck9r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/306664/original/file-20191212-85404-1mmck9r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/306664/original/file-20191212-85404-1mmck9r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/306664/original/file-20191212-85404-1mmck9r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/306664/original/file-20191212-85404-1mmck9r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/306664/original/file-20191212-85404-1mmck9r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Restrictive eating may reduce anxiety.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/women-used-push-cake-plate-people-1278900526">best nj/Shutterstock</a></span>
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<p>Our research included 2,406 girls from the <a href="http://www.bristol.ac.uk/alspac/">Avon Longitudinal Study of Parents and Children</a>, a project studying the health and wellbeing of babies born in the early 1990s in Bristol. The participants’ anxiety disorders and fasting behaviour were measured three times between the ages of 13 and 18. Using this data, we were able to investigate the links between anxiety disorders and fasting across adolescence. </p>
<p>We found that girls who had anxiety disorders when they were aged 13 or 15 were twice as likely to report fasting two years later, compared with those without an anxiety disorder. We also found that girls who reported fasting were at increased risk of developing anorexia nervosa. Collectively, the findings point toward the possibility that having an anxiety disorder reflects a vulnerability for developing anorexia.</p>
<h2>Early warning, early intervention</h2>
<p>Outcomes of our study suggest who might be most at risk of an eating disorder, so it could be useful in highlighting people who might benefit from eating-disorder prevention efforts. </p>
<p>Our findings mirror observations in anorexia nervosa patients that worsening eating-disorder symptoms accompany increases in anxiety. It is important to recognise, however, that our findings don’t tell us about how anxiety disorder and eating-disorder symptoms are associated. In particular, outcomes do not necessarily reflect that anxiety disorders cause fasting.</p>
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Read more:
<a href="https://theconversation.com/understanding-body-signals-could-be-a-key-factor-in-eating-disorders-111559">Understanding body signals could be a key factor in eating disorders</a>
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<p>Clarifying whether the association we observed is causal is important. Should this be the case, it may be that targeting anxiety disorder symptoms is an effective way of reducing the chance of an eating disorder developing. </p>
<p>An alternative explanation for the patterns we see in our data is that anxiety disorders and restrictive eating are caused by the same things. This would also lead to the two occurring together in people.</p>
<p>Recent findings from a large scale study of the <a href="https://www.ncbi.nlm.nih.gov/pubmed/31308545">genetics of anorexia nervosa</a> supported there being common genetic risk factors for anorexia and anxiety disorders. We consider this possibility in our ongoing work, which is focused on better understanding exactly how anxiety disorder and eating-disorder symptoms are associated.</p>
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Read more:
<a href="https://theconversation.com/social-media-isnt-causing-more-eating-disorders-in-young-people-new-study-119959">Social media isn't causing more eating disorders in young people – new study</a>
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<p>Our study only included girls, so our conclusions may not apply to teenage boys. Future research should consider the presence of associations between anxiety disorder and disordered eating symptoms in boys and men. This will promote a fuller understanding of relationships between psychiatric symptoms and disorders across different groups in the population.</p><img src="https://counter.theconversation.com/content/127884/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Caitlin Lloyd completed the study as part of her PhD, which was funded by the Economic and Social Research Council.</span></em></p>Anxious teenage girls are more likely to fast – one of the symptoms of anorexia nervosa.Caitlin Lloyd, Senior Research Associate, Public Health, University of BristolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1219382019-08-18T20:01:44Z2019-08-18T20:01:44ZHow many people have eating disorders? We don’t really know, and that’s a worry<figure><img src="https://images.theconversation.com/files/288308/original/file-20190816-192258-1fydnj1.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C6000%2C3997&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Eating disorders disproportionately affect females and young people.</span> <span class="attribution"><span class="source">From shutterstock.com</span></span></figcaption></figure><p>Last week, federal health minister Greg Hunt announced that <a href="https://www1.racgp.org.au/newsgp/professional/cautious-welcome-for-new-integrated-mental-health">more than 60,000 Australians</a> will be asked about their mental health and well-being as part of the <a href="https://www.health.gov.au/sites/default/files/australia-s-long-term-national-health-plan_0.pdf">Intergenerational Health and Mental Health Study</a>.</p>
<p>The mental health survey will be run in 2020, with new data on how common mental illness is due the year after. This is a welcome announcement for the mental health sector, because information gathered in a survey like this can be used to shape policy reform.</p>
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Read more:
<a href="https://theconversation.com/if-were-to-have-another-inquiry-into-mental-health-it-should-look-at-why-the-others-have-been-ignored-105728">If we're to have another inquiry into mental health, it should look at why the others have been ignored</a>
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<p>But eating disorders, a major category of mental illnesses, <a href="https://jeatdisord.biomedcentral.com/articles/10.1186/s40337-018-0221-3">have been neglected</a> by all previous important data collection initiatives in Australia so far. Notably, they were missing from the last national mental health surveys in 1997 and 2007.</p>
<p>Eating disorders are not yet an official part of this new survey, but we understand they are being considered.</p>
<p>If people with eating disorders are not counted, they don’t count. In other words, we need to know who has these severe and debilitating conditions, and then work towards improving the treatment and supports available for them. </p>
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Read more:
<a href="https://theconversation.com/factcheck-qanda-do-eating-disorders-have-the-highest-mortality-rate-of-all-mental-illnesses-66495">FactCheck Q&A: do eating disorders have the highest mortality rate of all mental illnesses?</a>
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<h2>Surveys are important</h2>
<p>National surveys ask the public if they have experienced symptoms of various mental illnesses, either in their lifetime or during the past 12 months. </p>
<p>People who answer “yes” to particular clusters of symptoms are “diagnosed”, or assumed to have had the illness. </p>
<p>Asking the public about their symptoms is the best way to understand how common mental illnesses are. This is because most people with a mental illness <a href="https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/prevalence-comorbidity-disability-and-service-utilisation/5CA07F055732FB89FFD8F30D91076105">don’t seek treatment</a> and may never have had a diagnosis. So collecting data from health services or based on reported diagnoses doesn’t provide a full picture. </p>
<p>Also, for some mental illnesses, such as anorexia nervosa or psychosis, people might not realise they have a diagnosable illness. But they are likely to respond “yes” to direct questions about their experiences with body dissatisfaction or thinking difficulties.</p>
<h2>Eating disorders are more than just anorexia</h2>
<p>A person with <a href="https://www.nedc.com.au/eating-disorders/eating-disorders-explained/types/anorexia-nervosa/">anorexia nervosa</a> engages in dangerous behaviours to maintain a very low body weight, or to lose more weight. Although most people have heard of it, anorexia is not common. We know this from <a href="https://journals.lww.com/co-psychiatry/Fulltext/2016/11000/Review_of_the_worldwide_epidemiology_of_eating.4.aspx">other countries</a> who have previously studied the prevalence of anorexia in community surveys.</p>
<p>That being said, it’s very serious and can be fatal. It has the <a href="https://onlinelibrary.wiley.com/doi/full/10.1002/wps.20128">highest mortality</a> of all non-substance use mental disorders, and <a href="https://jamanetwork.com/journals/jamapsychiatry/article-abstract/1107207">one in five</a> of those deaths is by suicide.</p>
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Read more:
<a href="https://theconversation.com/disease-evolution-the-origins-of-anorexia-and-how-its-shaped-by-culture-and-time-54571">Disease evolution: the origins of anorexia and how it's shaped by culture and time</a>
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<p><a href="https://www.nedc.com.au/eating-disorders/eating-disorders-explained/">Other eating disorders</a> include bulimia nervosa, binge-eating disorder, and “other specified feeding and eating disorders” (OSFED), a catch-all group for those who don’t fit anywhere else. </p>
<p>People with <a href="https://www.nedc.com.au/eating-disorders/eating-disorders-explained/types/bulimia-nervosa/">bulimia nervosa</a> or <a href="https://www.nedc.com.au/eating-disorders/eating-disorders-explained/types/binge-eating-disorder/">binge-eating disorder</a> experience cycles of binge-eating, often after periods of restricting foods, which cause shame, guilt and discomfort. </p>
<p>Those with bulimia compensate for binge-eating through vomiting, fasting, exercise or other methods, while those with binge-eating disorder do not. </p>
<p>Binge-eating disorder is the <a href="https://www.sciencedirect.com/science/article/pii/S0195666316308327">most common</a> of all eating disorders and occurs more equally across men and women than other eating disorders. </p>
<p>As well as <a href="https://www.sciencedirect.com/science/article/pii/S1471015317302933">continued weight gain</a>, people with binge-eating disorder are more likely to experience <a href="https://onlinelibrary.wiley.com/doi/abs/10.1002/eat.10072">depression and anxiety</a>, and other significant <a href="https://onlinelibrary.wiley.com/doi/epdf/10.1002/eat.10072">health problems</a> (such as asthma, diabetes, and arthritis) than people with a high BMI (body-mass index) but no binge-eating disorder.</p>
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<img alt="" src="https://images.theconversation.com/files/288279/original/file-20190816-136208-kruapg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/288279/original/file-20190816-136208-kruapg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/288279/original/file-20190816-136208-kruapg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/288279/original/file-20190816-136208-kruapg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/288279/original/file-20190816-136208-kruapg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/288279/original/file-20190816-136208-kruapg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/288279/original/file-20190816-136208-kruapg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Binge-eating disorder is the most common eating disorder.</span>
<span class="attribution"><span class="source">From shutterstock.com</span></span>
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<p>One example of OSFED is <a href="https://www.psychologytoday.com/au/blog/eating-mindfully/201802/what-is-atypical-anorexia-nervosa">atypical anorexia nervosa</a> – when someone shows all the symptoms of anorexia and has lost a significant amount of weight but their BMI is in the “normal” or “high” range.</p>
<p>Eating disorders disproportionately affect females, <a href="https://www.ncbi.nlm.nih.gov/pubmed/27086237">young people</a>, <a href="https://link.springer.com/article/10.1007/s11920-017-0801-y">LGBTIQ individuals</a>, and those with <a href="http://web4.uwindsor.ca/users/j/jarry/main.nsf/032ecd0df8f83bdf8525699900571a93/aa9ed943e56182bf85256abe005bc3f6/$FILE/Stice%20(2002).pdf">a high BMI</a>.</p>
<p>People with eating disorders often have a negative body image, and a strong perception their self-worth is tied to their appearance or body weight. </p>
<h2>Burden of disease</h2>
<p>Every year in Australia, millions of years of healthy life are lost because of injury, illness or premature deaths in the population. This is known as “<a href="https://www.aihw.gov.au/reports/burden-of-disease/burden-disease-study-illness-death-2015/contents/table-of-contents">burden of disease</a>”. </p>
<p>Like national surveys, burden of disease studies are extremely important for planning and funding health services. They use prevalence statistics, or how many people per 100,000 Australians are assumed to have a particular illness. Given we don’t have good data on how prevalent eating disorders are, we likely underestimate their burden of disease. </p>
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Read more:
<a href="https://theconversation.com/to-the-bone-creating-eating-disorder-awareness-or-doing-harm-81092">To the Bone: creating eating disorder awareness or doing harm?</a>
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<p>The recently released <a href="https://www.aihw.gov.au/reports/burden-of-disease/burden-disease-study-illness-death-2015/contents/table-of-contents">Australian Burden of Disease Study 2015</a> lists eating disorders among the most burdensome illnesses for Australian females, being the tenth leading cause of total burden of disease for females aged 5-14 and women aged 25-44.</p>
<p>Importantly, the most common eating disorder – binge-eating disorder – <a href="https://journals.lww.com/co-psychiatry/Fulltext/2018/11000/Epidemiology_of_binge_eating_disorder.7.aspx">is not included in burden of disease studies</a>, meaning all these figures miscalculate the impact of eating disorders by a long way.</p>
<h2>Eating disorders are on the rise</h2>
<p>Despite our lack of prevalence data, there is evidence showing eating disorders are an increasing problem and should be regarded as a national priority.</p>
<p>Consecutive population surveys in South Australia showed the numbers of people with eating disorders <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0001541">climbed</a> over a ten-year period.</p>
<p>Annual <a href="https://www.missionaustralia.com.au/what-we-do/research-impact-policy-advocacy/youth-survey">youth surveys</a> demonstrate body image, the most potent risk factor for eating disorders, is year after year among the top concerns for young people. </p>
<p>A recent study on adolescents in the Hunter Valley region of NSW found <a href="https://www.newcastlestar.com.au/story/6264984/study-reveals-1-in-5-teens-have-experienced-an-impairing-eating-disorder/">one in five</a> had experienced an eating disorder. </p>
<h2>Treatment and prevention</h2>
<p>People with eating disorders <a href="https://www.cambridge.org/core/journals/psychological-medicine/article/health-services-use-in-eating-disorders/B9499FE558481D4E76A276845E866337">use more health services</a> than people with all other forms of mental illness, but <a href="https://www.sciencedirect.com/science/article/pii/S0272735811000523">often don’t receive appropriate and effective treatment</a>. They typically receive treatment for weight loss, depression or anxiety, but are rarely treated for their disordered eating.</p>
<p>Eating disorders were estimated to cost the health system <a href="https://thebutterflyfoundation.org.au/about-us/information-and-resources/paying-the-price/">A$99.9 million</a> in the year 2012 alone. </p>
<p>Better treatment and prevention of eating disorders would reduce the cost and the burden of disease. But we need the data to show where the treatment gaps are and how to fund better services.</p>
<p>There are many promising elements of the proposed Intergenerational Health and Mental Health Study. These include surveying multiple people in a family, gathering physical and mental health data, and a target of more than 60,000 Australians. But it’s time eating disorders were included.</p>
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Read more:
<a href="https://theconversation.com/therapy-for-life-threatening-eating-disorders-works-so-why-cant-people-access-it-77249">Therapy for life-threatening eating disorders works, so why can't people access it?</a>
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<img src="https://counter.theconversation.com/content/121938/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Laura Hart receives funding from Australian Rotary Health for research in eating disorders prevention and is a member of the Australia and New Zealand Academy for Eating Disorders.</span></em></p>As Australia considers its next national mental health survey, it’s crucial to include eating disorders. If we don’t have good data on how many people are suffering, we can’t come up with solutions.Laura Hart, Senior Research Fellow, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1199592019-08-12T10:06:51Z2019-08-12T10:06:51ZSocial media isn’t causing more eating disorders in young people – new study<figure><img src="https://images.theconversation.com/files/287084/original/file-20190806-84195-1hz5gak.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/woman-looking-photo-sharing-app-on-1118068088?src=Zz4dO-DhM7C-2GZeglLRug-1-5">Kaspars Grinvalds/Shutterstock</a></span></figcaption></figure><p>There is ongoing debate <a href="https://www.cambridge.org/core/journals/psychological-medicine/article/three-decades-of-eating-disorders-in-dutch-primary-care-decreasing-incidence-of-bulimia-nervosa-but-not-of-anorexia-nervosa/A7D48C30349392EA3D5EA731A5420699">about whether</a> eating disorders <a href="https://journals.lww.com/co-psychiatry/fulltext/2016/11000/Review_of_the_worldwide_epidemiology_of_eating.4.aspx">are more common</a> in modern society. <a href="https://onlinelibrary.wiley.com/doi/abs/10.1002/eat.22254">Some say that</a> as young people are both exposed to and share images of themselves in an unprecedented way on social media today, <a href="https://www.sciencedirect.com/science/article/pii/S2212267216301101?via%3Dihub">this affects</a> their body image and may have an impact on their eating too. <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/bjso.12161">Others</a> suggest that social media can help eating disorder recovery by <a href="https://www.youtube.com/watch?v=RsODMZN4VL8">providing platforms for people</a> to talk about their experiences and treatment. So which one is correct?</p>
<p>We know that rates of eating disorders are high. According to a large survey conducted in 2017, about <a href="https://files.digital.nhs.uk/FB/8EA993/MHCYP%202017%20Less%20Common%20Disorders.pdf">four in every 1,000</a> young people aged 5-19 years have an eating disorder <a href="https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-of-children-and-young-people-in-england/2017/2017">in England alone</a>. The <a href="https://bmjopen.bmj.com/content/3/5/e002646">most recent study</a> to look at trends in eating disorders in primary care showed that more people were being diagnosed with eating disorders year on year too. It found that the number of people being diagnosed with eating disorders increased from 32 to 37 in every 100,000 people aged 10-49 years between 2000 and 2009. But the GP data used in this research is now more than ten years old – dating from before the launch of platforms such as Instagram. </p>
<p>For our <a href="https://bmjopen.bmj.com/content/9/8/e026691.full">newly published research</a>, we decided to look again at these trends to find if the rise of social media had changed anything. We used a large primary care database covering about 7% of the population in England and specifically looked at the anonymised records of more than one million children and young people who visited their GP between 2004 and 2014. </p>
<p>We found that eating disorders recorded in primary care are nearly 11 times more common in females than males and twice as common in people aged 16–20 years old, than in the 11-15 or 21-24 age groups. They are also one and a half times as common in people from the most affluent areas compared to the least. </p>
<p>The most common type of eating disorder was not either of the two most well known – anorexia and bulimia nervosa – but eating disorders “not otherwise specified”. This means that they are eating disorders that don’t quite reach the threshold to be defined as anorexia or bulimia nervosa.</p>
<p>We also found that fewer young people are being diagnosed with eating disorders every year in primary care. Rates decreased most significantly for bulimia nervosa, less so for eating disorders not otherwise specified, and remained stable for anorexia nervosa. Decreases were seen in females, and the 16–24 age group too. Significant decreases were also found in young people from the most deprived areas, but not the most affluent (where rates are higher), further widening the difference between the two groups. </p>
<p>The numbers of males diagnosed with an eating disorder was too small for further breakdown, since less than 500 individuals were diagnosed over the 11-year study period. The number of both males and females with bulimia nervosa were particularly small too, although we did see a 50% decrease in females diagnosed.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/287085/original/file-20190806-84195-1tu8mw6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/287085/original/file-20190806-84195-1tu8mw6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/287085/original/file-20190806-84195-1tu8mw6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/287085/original/file-20190806-84195-1tu8mw6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/287085/original/file-20190806-84195-1tu8mw6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/287085/original/file-20190806-84195-1tu8mw6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/287085/original/file-20190806-84195-1tu8mw6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Social media has been both blamed for causing eating disorders and praised for helping some recover.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/teenage-girl-home-using-digital-tablet-715726888?src=R7chKRjHrJRzbu2h8C49hA-1-1">Monkey Business Images/Shutterstock</a></span>
</figcaption>
</figure>
<h2>Rates in context</h2>
<p>It’s not easy to unpick what these findings may mean and whether social media has played a part in these changing trends. Looking at bulimia nervosa alone, <a href="https://www.cambridge.org/core/journals/psychological-medicine/article/three-decades-of-eating-disorders-in-dutch-primary-care-decreasing-incidence-of-bulimia-nervosa-but-not-of-anorexia-nervosa/A7D48C30349392EA3D5EA731A5420699">some researchers suggest</a> that bulimia nervosa is a Western phenomena, based on a pressure to be thin, while anorexia nervosa is less culture bound, and exists across time, cultures and even species. </p>
<p>They say that a decrease in bulimia nervosa could be attributed to the normalisation of being overweight, which reduces the pressure to be thin and leads to a decrease in bulimia nervosa. In which case, it could be argued that social media is affecting the trend, although not in the way that some might assume. Rather than increasing eating disorders, the body positivity and range of body shapes and sizes seen on social platforms is helping young people accept their own selves. This may also explain why the decrease is more evident in more deprived areas where the <a href="https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(18)30045-8/fulltext">prevalence of obesity is higher</a>. </p>
<p>But this concept is highly contested. And it’s hard to escape the rise in social media use and the increasing concerns about weight and body image. The mechanism where this might lead to eating concerns and disordered eating seems sensible. But our study doesn’t currently support that. </p>
<p>However, we did also find an increase in the number of people receiving in-patient care for eating disorders in England, which could suggest that people are being diagnosed with eating disorders at a later, more advanced stage than previously, requiring in-patient admission. Eating disorders can be problematic conditions for doctors to identify, refer and manage for several reasons. </p>
<p>Some studies have shown that diagnoses are <a href="https://onlinelibrary.wiley.com/doi/abs/10.1002/eat.22065">less likely to be made</a> if there are no specialist services in the area, for example. Greater availability of child and adolescent mental health services, and lower thresholds for acceptance of referrals than in adult services for eating disorders, could explain why eating disorder diagnosis rates for 11 to 15-year-olds have remained stable over the study period, yet decreased for 16 to 24-year-olds. </p>
<p>While more research must be done to work out whether, and how, social media influences the onset and continuation of eating disorders globally, studies like ours are starting to unpick assumptions we might make about the links between the two. And ultimately will help us to focus on creating better prevention and online therapeutic tools for young people with eating disorders and those who may go on to develop them.</p><img src="https://counter.theconversation.com/content/119959/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ann John receives/ed funding from MRC, MQ, HQIP and Welsh Government. Ann John is a Trustee of the Mental Health Foundation.</span></em></p><p class="fine-print"><em><span>Sophie Wood receives/ed funding from MQ, HQIP, and the Department for Education. </span></em></p>Data from England has found no link between increased social media use and a rise in diagnosed eating disorders.Ann John, Clinical Professor of Public Health and Psychiatry, Swansea UniversitySophie Wood, Research Assistant, CASCADE, Cardiff UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1198862019-07-08T13:50:58Z2019-07-08T13:50:58ZEating disorders: early warning signs identified<figure><img src="https://images.theconversation.com/files/282732/original/file-20190704-51288-1vrn7dc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/anorexic-girl-covering-her-face-centimeter-513321970?src=5hzK_OUn3gcK4dM2NiK74g-1-2&studio=1">Photographee.eu/Shutterstock</a></span></figcaption></figure><p>More than <a href="https://www.jcpmh.info/wp-content/uploads/10keymsgs-eatingdisorders.pdf">1.6m people</a> in the UK alone are estimated to have an eating disorder such as anorexia or bulimia. These disorders predominantly affect vulnerable women, but <a href="https://theconversation.com/men-have-eating-disorders-too-and-often-cant-talk-about-them-25406">men can develop them too</a>, and most people are diagnosed during adolescence and early adulthood.</p>
<p>Early diagnosis and treatment are crucial for those with an eating disorder but many people <a href="https://www.sciencedirect.com/science/article/pii/S0272735898000129?via%3Dihub">do not always seek help</a> – and even when they look for help, treatment is difficult. Many are not <a href="https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/position-statements/ps03_19.pdf?sfvrsn=b1283556_2">diagnosed or treated in a timely way</a>. There are also only a few specialist centres for eating disorders in the country, and <a href="https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/college-reports/college-report-cr170.pdf?sfvrsn=974722c1_2">funding is scarce</a>. This is of particular concern as eating disorders have the <a href="https://jamanetwork.com/journals/jamapsychiatry/fullarticle/1107207">highest mortality</a> of <a href="https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/excess-mortality-of-mental-disorder/45A4F4869523062F276342D48914BB53">all mental illnesses</a>, both from physical causes and from suicide. </p>
<p>But <a href="https://doi.org/10.1192/bjp.2019.153">our research</a>, recently published in the British Journal of Psychiatry, found several health warning signs that point to a person developing an eating disorder, and these may help GPs diagnose and treat people with one of these conditions much earlier. </p>
<h2>Mental and physical health</h2>
<p>Using an anonymised database of GP and hospital records, we looked at the health of 15,558 people diagnosed with an eating disorder between 1990 and 2017 in Wales – 4,870 of these people were diagnosed with anorexia nervosa, 4,836 with bulimia nervosa and 5,852 with other eating disorders. These people were between the ages of ten and 65, the majority were female and most were diagnosed between the ages of 15 and 19. We found that as many as 24 in 100,000 people had a new diagnosis in 2017 alone. That is roughly one new patient per year in a medium sized GP practice with 5,000 patients.</p>
<p>We compared a subset of this group with controls from the general public in Wales. These people did not have eating disorders but were of the same age and gender. We specifically looked at the two years before the people with an eating disorder had been diagnosed, and three years afterwards to find out what other health conditions they had had during that time.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/282731/original/file-20190704-51278-193y3hk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/282731/original/file-20190704-51278-193y3hk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/282731/original/file-20190704-51278-193y3hk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/282731/original/file-20190704-51278-193y3hk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/282731/original/file-20190704-51278-193y3hk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/282731/original/file-20190704-51278-193y3hk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/282731/original/file-20190704-51278-193y3hk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Even when people seek help for an eating disorder, getting treatment is not easy.</span>
</figcaption>
</figure>
<p>In the two years prior to their diagnosis we found that people diagnosed with an eating disorder were more likely than their counterparts in the control group to have had other mental health disorders such as personality or alcohol disorders and depression. They were also more likely to seek help following an accident, injury or self-harm. </p>
<p>Our study showed that the people diagnosed with an eating disorder had been issued a higher amount of drug prescriptions for central nervous system drugs (such as antipsychotics and antidepressants), gastrointestinal drugs (constipation relief, for example) and dietetic supplements (such as multivitamins) in comparison to the general population. These higher rates of conditions and medications were apparent for the three years following diagnosis too.</p>
<h2>Support in the community</h2>
<p>There are limits to this research, however. For example, we were only able to look at diagnosed cases of eating disorders. As mentioned above, despite people with these disorders having higher rates of seeking medical help for other things like self-harm, many still ultimately try and hide their eating disorder, and they can be very difficult for doctors to diagnose. It is thought that the real number of people affected by an eating disorder is much higher than the amount that are treated for them.</p>
<p>Our study does suggest, however, that the majority of people with eating disorders are already being – and can be – treated by their GPs and not in specialist clinics which have limited space. And by linking together warning signs like self-harm and use of certain medications, we hope GPs will be able to identify further people at risk of eating disorders.</p>
<p>Our work also emphasises the need to provide healthcare professionals with the training and support to give early treatment in the community. By seeking to help those with eating disorders early on, we can prevent great suffering and a loss of lives. </p>
<p>If anything in this article causes distress or concern about eating disorders, visit the <a href="https://www.beateatingdisorders.org.uk/">BEAT website for more information and support</a>. We have also created a <a href="https://apps.apple.com/gb/app/diet-or-disorder/id1220894592">free bilingual app</a> with the NHS – <a href="https://play.google.com/store/apps/details?id=uk.co.rolleragency.swansea">Diet or Disorder</a> – to support and empower anyone who is worried that they or someone the care about might have an eating disorder.</p><img src="https://counter.theconversation.com/content/119886/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sinead Brophy receives funding from Welsh Assembly Government, MRC, ESRC. </span></em></p><p class="fine-print"><em><span>Joanne Demmler does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>New research has found several physical and mental health indicators that often appear before an eating disorder diagnosis.Joanne Demmler, Lecturer in Health Data Science, Swansea UniversitySinead Brophy, Professor in Public Health Data Science, Swansea UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1022262018-08-30T10:48:09Z2018-08-30T10:48:09ZAnorexia more stubborn to treat than previously believed, analysis shows<figure><img src="https://images.theconversation.com/files/233901/original/file-20180828-86120-1rv531r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People with anorexia nervosa often see themselves as overweight when in fact they are not. This image depicts a young, thin woman who sees herself as larger than she is.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/girl-looks-her-reflection-mirror-think-1082529335?src=BZC7S0VCDce-tFeSlLOl_g-1-6">Tatyana Dzemileva/Shutterstock.com</a></span></figcaption></figure><p>Anorexia nervosa is a psychiatric illness that primarily effects young people during their adolescence. While anorexia is relatively uncommon, affecting about 1 percent of the population, it can be lethal. Indeed, despite its relatively early onset, anorexia can <a href="https://onlinelibrary.wiley.com/doi/abs/10.1002/eat.22736">last for several decades for more than half of those afflicted</a>. It can lead to many associated psychiatric and medical risk factors, which in part explains why anorexia has the <a href="https://jamanetwork.com/journals/jamapsychiatry/fullarticle/1107207">highest mortality rates of any psychiatric disorder</a>.</p>
<p>Those who suffer with anorexia have a powerful fear of weight gain and a cruelly distorted self-perception. As a result, some restrict caloric consumption to fewer than 400 calories per day, which is less than a quarter of what is typically recommended for adolescents. Those with anorexia may quickly become emaciated and lose more than 25 percent of their typical body weight. This rapid weight loss causes cardiac <a href="https://journals.lww.com/co-psychiatry/fulltext/2006/07000/Medical_complications_of_anorexia_nervosa_and.19.aspx?casa_token=SYnsKsPLkfgAAAAA:YUVpAmefWIbmLdPPzCkFwTf7gTBEzjS-5UAfo6z3eGzfidq2xqmXVyHo_RrxI2JEvyGB1wg0uuokFIHIJqzekjtR">abnormalities, structural and functional brain alterations, irreparable bone disease, and in some instances, sudden death</a>.</p>
<p>The effective treatment of anorexia is therefore very important.</p>
<p>I have specialized in the treatment of anorexia nervosa for 10 years, and my National Institute of Mental Health-funded program of research is exclusively focused on understanding the mechanisms of anorexia nervosa, with a view to informing precise treatment approaches. Colleagues and I recently completed the largest <a href="https://www.cambridge.org/core/journals/psychological-medicine/article/treatment-outcomes-for-anorexia-nervosa-a-systematic-review-and-metaanalysis-of-randomized-controlled-trials/AB05A8856C66EA5AD99AD9B2DF1C1F80">meta-analysis</a> ever undertaken of outcomes for existing treatments for anorexia. Our analysis revealed major flaws in the way people are currently treated for this illness. </p>
<h2>Changing the brain, not the body</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/233903/original/file-20180828-86126-cn3hno.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/233903/original/file-20180828-86126-cn3hno.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/233903/original/file-20180828-86126-cn3hno.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/233903/original/file-20180828-86126-cn3hno.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/233903/original/file-20180828-86126-cn3hno.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/233903/original/file-20180828-86126-cn3hno.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/233903/original/file-20180828-86126-cn3hno.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A therapist and patient in a counseling session. A recent analysis found that a type of therapy called cognitive behavioral therapy may not work.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/psychologist-having-session-her-patient-office-572935282?src=CTkwCYQr8A-yyRXUjRxALw-1-3">wavebreakmedia/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>We pooled the findings from 35 randomized controlled trials between 1980-2017, which cumulatively assessed the outcomes of specialized treatments, such as cognitive behavioral therapy, in over 2,500 patients with anorexia. An important aspect of our study was that it examined outcomes according to both weight, and the core cognitive symptoms of anorexia, such as fear of weight gain and a drive for thinness. This differs from traditional assessments of whether treatments are effective, which have typically only focused on patient weight. </p>
<p>I am sad to say that what we found was bleak. In essence, specialized treatments for anorexia, such as cognitive behavioral therapy, family-based treatment and emerging medication treatments, appear to have few advantages over standard control treatment-as-usual, such as supportive counseling. In fact, the only advantage of specialized treatments, relative to control treatment-as-usual conditions, was a greater chance of having a higher weight by the end of treatment. We found no difference in body weight across specialized versus control treatments at follow-up. </p>
<p>In addition, we found no difference in the core cognitive symptoms of anorexia between specialized versus control treatments at any one point. This means that, even if a treatment helps restore normal weight, a focus on thinness and an unease around eating is common, and a relapse into low weight is likely. Equally importantly, specialized treatments do not appear to be more tolerable to patients, with comparable rates of patient dropout to control treatments.</p>
<p>When we analyzed time trends within these data over the last four decades, we found that the outcomes of specialized treatment are not incrementally improving over time.</p>
<h2>More than weight</h2>
<p>These findings are sobering. The notion that our best efforts to advance treatment outcomes over the last four decades have failed to move the needle is cause for grave concern. </p>
<p>However, an important outcome of this study lies in giving those of us who study and treat anorexia a better idea of how we might move the needle. We believe these findings speak to an urgent need to better understand the neurobiological mechanisms of anorexia. We can no longer assume that improvements in patient weight ought to be the terminal goal of treatment for anorexia, and will confer improvements in cognitive symptoms. While weight normalization reduces the acute risk of complex medical events, ongoing fear of weight gain and food intake will likely mean future bouts of low weight and starvation. </p>
<p>We have reached a plateau in the treatment of anorexia. Future research endeavors must elucidate the precise mechanisms that underpin cognitive symptoms of anorexia, and altering these mechanisms must become the goal of treatment.</p><img src="https://counter.theconversation.com/content/102226/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stuart Murray received funding for this research from the National Institute of Mental Health. Also, he receives royalties from Oxford University Press and Routledge publishers for books relating to the treatment of eating disorders.</span></em></p>Anorexia nervosa can be a deadly disease. A recent analysis of several studies showed that it may be even harder to treat than previously believed. But the news isn’t all bad.Stuart Murray, Assistant Professor of Psychiatry, University of California, San FranciscoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/992622018-07-12T10:24:53Z2018-07-12T10:24:53ZDoes thinking you look fat affect how much money you earn?<figure><img src="https://images.theconversation.com/files/227240/original/file-20180711-27027-9hsswi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Is the scale telling the truth?</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/cropped-image-woman-feet-standing-on-604196501?src=sFopdWh9s_6XEvAb68uQrA-1-71">VGstockstudio/Shutterstock.com</a></span></figcaption></figure><p>Two things people often think about are <a href="https://www.nbcnews.com/better/money/americans-think-about-money-work-more-sex-survey-finds-n424261">money</a> and <a href="https://www.allure.com/story/national-judgement-survey-statistics">their appearance</a>. Past research has shown that there is a correlation between the two: <a href="https://www.uni-muenster.de/imperia/md/content/psyifp/aeechterhoff/wintersemester2011-12/vorlesungkommperskonflikt/hamermesh_beautylabormarket_amereconrev1994.pdf">People subjectively considered attractive earn more</a>.</p>
<p>And body weight plays a major role in attractiveness. A person’s body mass index – which adjusts a person’s weight for their height – and their success in the workplace <a href="https://wol.iza.org/articles/obesity-and-labor-market-outcomes/long">are linked</a>. Put simply, thin people, especially women, are rewarded more than their larger colleagues. But those studies only considered how other people perceive you. </p>
<p>In <a href="http://www.sciencedirect.com/science/article/pii/S1570677X17302617">our research</a>, we looked at the flip side: Does our own perception of our bodies, even when incorrect, make a difference? In other words, does thinking you look fat or skinny affect your wages? </p>
<p>Knowing if a worker’s own perception of his or her weight makes a difference – rather than only the employer’s – could help determine the best way to mitigate the impact of weight discrimination on earnings. In addition, a better understanding of gender differences in weight perception might help explain the persistent <a href="https://theconversation.com/us/topics/gender-wage-gap-11006">gender wage gap</a>. </p>
<h2>Pressure to ‘look good’</h2>
<p>Americans spend billions of dollars each year on making minor changes to their appearance with <a href="http://www.npd.com/wps/portal/npd/us/news/press-releases/2017/us-prestige-beauty-industry-adds-1-billion-in-sales-grows-6-percent-in-2016/">makeup, hair dye and other cosmetics</a>. We also spend billions trying to change our weight with diets, <a href="http://www.clubindustry.com/studies/ihrsa-reports-57-million-health-club-members-276-billion-industry-revenue-2016">gym memberships</a> and <a href="http://www.plasticsurgery.org/documents/News/Statistics/2016/cosmetic-procedures-average-cost-2016.pdf">plastic surgery</a>.</p>
<p>Trying to live up to the pervasive images of “perfect” models and movie heroes has a dark side: body-shaming, anxiety and depression, as well as unhealthy strategies for weight loss or muscle gain. For example, anorexia nervosa involves the extreme over-perception of weight and <a href="http://www.nationaleatingdisorders.org/statistics-research-eating-disorders">claims the lives of roughly 10 percent of its victims</a>. It also has a financial cost. Having an eating disorder boosts annual health care costs <a href="http://www.sciencedirect.com/science/article/pii/S2211335514000230">by nearly US$2,000</a> per person.</p>
<p>Why is there both external and internal pressure to look “perfect”? One reason is that society rewards people who are thin and healthy looking. Researchers have shown that body mass index is related to wages and income. Especially for <a href="https://wol.iza.org/articles/obesity-and-labor-market-outcomes/long">women</a>, there is a clear penalty at work for being overweight or obese. Some studies have also found an <a href="https://www.forbes.com/sites/freekvermeulen/2011/03/22/the-price-of-obesity-how-your-salary-depends-on-your-weight/#431b14393d9a">impact for men</a>, though a less noticeable one.</p>
<h2>Does weight perception matter?</h2>
<p>While the research literature is clear that labor market success is partly based on how employers and customers perceive your body image, no one had explored the other side of question. Does a person’s own perception of body image matter to earnings and other indicators of success in the workplace?</p>
<p>In simple terms, does it change your wages if you think of yourself as overweight when you are not? Or if you think of yourself as skinny, when in reality you are not, does this misperception affect your ability to find and keep a job?</p>
<p>We were interested in answering these questions because it is often easier to fix your own view of yourself than to fix the entire world’s.</p>
<p><a href="http://www.sciencedirect.com/science/article/pii/S1570677X17302617">Our study</a> answered this question by tracking a large national random sample of the first wave of U.S. millennials, born in the early 1980s. We followed about 9,000 of them starting in 1997 when they were teenagers and ending 15 years later when the oldest was 31. Our research followed these respondents over a critical time period when bodies change from teenage shape into adult form and when people build their identities.</p>
<p>The survey asked respondents to report their actual weight and height. It also asked each to classify themselves each year as “very overweight,” “overweight,” “about the right weight,” “slightly underweight” or “very underweight.” This enabled us to compare each person’s clinically defined BMI category, such as being underweight, with his or her perception. </p>
<p>As in other research, women in our sample tend to over-perceive weight – they think they’re heavier than they are – while men tend to under-perceive theirs.</p>
<h2>What other people think matters more</h2>
<p>While self-perceived weight, especially when incorrect, can influence <a href="http://www.ncbi.nlm.nih.gov/pubmed/20919592">self-esteem</a>, <a href="http://www.emeraldinsight.com/doi/abs/10.1108/JPMH-11-2013-0071">mental health</a> and health behaviors, we found no relationship between the average person’s self-perception of weight and labor market outcomes like wages, weeks worked and the number of jobs.</p>
<p>In other words, it’s not what you think about your appearance that matters in the workplace, it’s just what other people think. Worrying if eating another cookie will make you look fat may harm your self-esteem, but thinking you’re overweight likely will not affect your earnings.</p>
<p>Because we find that women earn lower wages than men do even when accounting for weight perception differences, it appears the well-known gender pay gap is not due to differences in self-perceived weight.</p>
<p>While the continued gender penalty in the labor market is frustrating, <a href="https://www.sciencedirect.com/science/article/pii/S1570677X17302617">our finding</a> that misperceived weight does not harm workers is more heartening. Weight misperception is common, but thinking you’re heavier or lighter than you are doesn’t dampen earnings.</p>
<p>At the same time, it’s important to remember that although self-perceived weight doesn’t appear to affect wages, it still takes a toll on mental and physical health.</p>
<p>Passing over heavier workers to hire or promote less productive but thinner workers is inefficient and unfair. Our results indicate that expanding efforts to reduce discrimination on the basis of body weight in the workplace is important. </p>
<p>Since employers’ perception of weight is what matters in the labor market, policies to reduce the social stigmatization of body weight, such as curbing <a href="https://www.cnn.com/2016/04/15/health/fat-shaming-feat/index.html">body-shaming</a>, make sense. Changing discrimination laws to include body type as a category would also help. For example, <a href="http://time.com/4883176/weight-discrimination-workplace-laws/">Michigan is the only state</a> that prohibits discrimination on the basis of weight and height. </p>
<p>We believe expanding such protections would make the labor market more efficient and fair.</p><img src="https://counter.theconversation.com/content/99262/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A new study explores whether how we perceive our body weight affects our prospects in the job market and at work.Patricia Smith, Professor of Economics, University of MichiganJay L. Zagorsky, Senior lecturer, Boston UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/909102018-02-08T00:15:43Z2018-02-08T00:15:43ZThin, white, female: How people document eating disorder recovery on Instagram<figure><img src="https://images.theconversation.com/files/205193/original/file-20180207-58179-14a4w7o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Research shows that Instagram photos tagged with #eatingdisorderrecovery tend to feature thin, young, white, women. They also show stylized versions of food, reflecting a certain class status and engagement with “foodie” cultures.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>When you picture someone with an eating disorder, who do you picture? </p>
<p>As a researcher and PhD candidate in family relations and human development, I have asked this question of audiences ranging from high school students to community groups to tenured professors, and the answer remains largely the same: A thin, young, white, privileged, heterosexual, cisgender woman.</p>
<p>Despite <a href="https://doi.org/10.1300/J086v19n04_02">accumulating evidence</a> that eating disorders can impact anyone, eating disorders continue to be presented — in <a href="https://www.ncbi.nlm.nih.gov/pubmed/17521841">the media</a>, in <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3779913/">public discourse</a>, in <a href="https://www.ncbi.nlm.nih.gov/pubmed/11746286">doctors’ offices</a> and even in much of the research literature — in stereotypical ways. </p>
<p>These stereotypes can lead to the <a href="https://www.ncbi.nlm.nih.gov/pubmed/12210665">under-recognition</a> and under-diagnosis of eating disorders in other populations and <a href="http://www.brown.uk.com/eatingdisorders/cachelin.pdf">lack of treatment</a>. </p>
<p>This week is <a href="http://nedic.ca/news/eating-disorder-awareness-week">Eating Disorder Awareness Week</a> in Canada, with a theme of “<a href="http://nedic.ca/news/one-size-does-not-fit-all-edaw2018">One size does NOT fit all</a>,” to emphasize the diversity of people who suffer from eating disorders. The #7BillionSizes campaign led by the <a href="http://nedic.ca/">National Eating Disorder Information Centre (NEDIC)</a>, asks for large-scale change in the conversations we have about eating disorders. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"960559394315522051"}"></div></p>
<p>Such social media campaigns can help to reduce the significant <a href="https://guilfordjournals.com/doi/abs/10.1521/jscp.1995.14.4.315">shame</a> and <a href="http://onlinelibrary.wiley.com/doi/10.1002/eat.20760/full">stigma</a> associated with experiencing a mental illness, particularly one so often framed as “a thin white woman’s disease.”</p>
<p>But how do people with eating disorders represent themselves on social media? Do online communities provide valuable space for supportive community, or do they reinforce the stereotypes of our wider discourse?</p>
<h2>Marginalized bodies in a slimming world</h2>
<p>Much of my research has focused on representations of eating disorders, and the impact they have on those attempting to recover. </p>
<p>People in recovery often struggle to find their footing in a world that is fixated on slimming. Often, they engage in eating and exercise patterns that feel profoundly “<a href="http://onlinelibrary.wiley.com/doi/10.1002/casp.2240/abstract">counter-cultural</a>” — eating a piece of cake for therapeutic reasons may sound amazing to someone without an eating disorder, but can be incredibly difficult for someone in recovery, particularly when they are not visibly ill.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/205195/original/file-20180207-58148-1g2n707.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/205195/original/file-20180207-58148-1g2n707.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/205195/original/file-20180207-58148-1g2n707.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/205195/original/file-20180207-58148-1g2n707.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/205195/original/file-20180207-58148-1g2n707.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/205195/original/file-20180207-58148-1g2n707.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/205195/original/file-20180207-58148-1g2n707.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>People in large bodies, people of colour, people of different genders, people with disabilities, and others who are socially marginalized do not often find themselves in the picture of “the person with the eating disorder,” let alone “the recovered person.” </p>
<p>They often face double or triple stigma, living in bodies that are not made welcome in a society with <a href="https://doi.org/10.1080/21604851.2017.1286906">narrow standards</a>. Their bodies are subject to increased scrutiny, which can compound the challenges of recovery.</p>
<p>Even in the clinical and research communities, we still lack a consensus definition of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2829357/">what eating disorder recovery actually means</a>. And while many studies speak to the <a href="http://journals.sagepub.com/doi/abs/10.1177/1049732314524029">possibility of recovery</a>, research also shows that many individuals have a hard time <a href="https://www.ncbi.nlm.nih.gov/pubmed/21182163">imagining their own recoveries</a>. </p>
<p>Individuals may feel reduced to their eating disorders — forever marked, in the eyes of the public and health professionals, by distressing relationships with food.</p>
<h2>Recovering on Instagram</h2>
<p>Seeking alternatives, people often express their own recoveries on social media. By establishing recovery communities online, they may find a space that does not exist elsewhere — a community to support the process of acting counter-cultural.</p>
<p>But, do these communities simply serve as another metric against which people must measure themselves? How diverse are the bodies, and recoveries, represented in social media?</p>
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<img alt="" src="https://images.theconversation.com/files/205029/original/file-20180206-14083-ds935q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/205029/original/file-20180206-14083-ds935q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/205029/original/file-20180206-14083-ds935q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/205029/original/file-20180206-14083-ds935q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/205029/original/file-20180206-14083-ds935q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/205029/original/file-20180206-14083-ds935q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/205029/original/file-20180206-14083-ds935q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Health is often equated with thinness in our society, leading to discrimination against other kinds of bodies.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>My advisor, Dr. Carla Rice, and I undertook <a href="http://www.mdpi.com/2076-0760/6/3/68">an analysis of 1056 images of “eating disorder recovery” on Instagram</a>. </p>
<p>We found that people using Instagram to document their recovery processes did appear to be engaging in community-building on the social media platform. </p>
<p>However, the kinds of recovery represented retained the stereotypical trappings of the experience of eating disorders. </p>
<p>Most posts continued to feature thin, young, white, women. Further, they frequently featured stylized versions of food, reflecting a certain class status and engagement with “foodie” cultures, as well as focusing on food in eating disorders, which are about more than food.</p>
<h2>Neither too thin nor too fat</h2>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/23421694">Studies</a> have identified how “healthy eating” curricula in schools can increase the incidence of eating disorders. </p>
<p>Our analysis revealed how easily health can become entangled with particular ways of eating. Often, hashtags like “<a href="https://www.instagram.com/explore/tags/eatingdisorderrecovery/">#EatingDisorderRecovery</a>” were used alongside “<a href="https://www.instagram.com/explore/tags/cleaneating/">#CleanEating</a>” and “<a href="https://www.instagram.com/explore/tags/healthyfood/">#HealthyFood</a>.” </p>
<p>This coincidence of hashtags within the eating disorder recovery context raises questions about the challenge of navigating that place between healthy and ill — and the kinds of bodies we imagine existing in these places.</p>
<p><div data-react-class="InstagramEmbed" data-react-props="{"url":"https://www.instagram.com/p/Be2z3d8l9jo","accessToken":"127105130696839|b4b75090c9688d81dfd245afe6052f20"}"></div></p>
<p>We cannot ignore how health is often judged based on how a person appears. In our society, <a href="http://onlinelibrary.wiley.com/doi/10.1002/casp.1096/full">health is often equated with thinness</a> in a way that can lead to significant discrimination against people in large bodies and <a href="http://ajph.aphapublications.org/doi/abs/10.2105/ajph.2009.159491">worse health outcomes</a> for those individuals. </p>
<p>People with eating disorders negotiate their recoveries in a world that values restrained eating. It is not surprising, then, that their hashtags reflect a wider societal confusion about how to be healthy, and what health “looks like.”</p>
<p>Those in recovery are also faced with the challenge of “proving” their recoveries by enacting a body that is neither too thin nor too fat. </p>
<p>In our study, we saw replication of stereotypes about whose bodies are considered eating disordered and recovered. Only one image of a non-feminine-performing body was present. </p>
<p>Most users appeared to be white and thin (but not emaciated). Many of the messages conveyed in captions centred around appealing to the male gaze, gesturing at heterosexuality.</p>
<h2>Challenging perfection, with real-life impact</h2>
<p>Could these representations of recovery serve to reinforce a particular kind of recovery? While the overall picture of recovery in these images was quite narrow, we hesitate to condemn the Instagram community as unhelpful to those in recovery.</p>
<p>Some users did engage with Instagram as a way of challenging the perfection and self-management demanded of all of us, particularly when it comes to health. </p>
<p>They used hashtags in unexpected ways, for instance tagging a photo of a dessert “#HealthyEating.” They commented on others’ posts, offering reassurance and community to others working to live recovered lives.</p>
<p>However, in order for such communities to be truly transformational — to challenge the stereotypical representations of eating disorders and recovery — they would need to present a wider range of bodies and practices. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/205192/original/file-20180207-88784-1s35qd9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/205192/original/file-20180207-88784-1s35qd9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=285&fit=crop&dpr=1 600w, https://images.theconversation.com/files/205192/original/file-20180207-88784-1s35qd9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=285&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/205192/original/file-20180207-88784-1s35qd9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=285&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/205192/original/file-20180207-88784-1s35qd9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=358&fit=crop&dpr=1 754w, https://images.theconversation.com/files/205192/original/file-20180207-88784-1s35qd9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=358&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/205192/original/file-20180207-88784-1s35qd9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=358&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption"></span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>They would need to integrate the #7BillionSizes of people with eating disorders and in recovery, and recognize that #OneSizeDoesntFitAll.</p>
<p>In the meantime, we can take inspiration from those working to challenge representations of eating disorders: <a href="http://www.transfolxfightingeds.org/">Trans Folx Fighting Eating Disorders</a>, <a href="https://twitter.com/NalgonaPride">Nalgona Positivity Pride</a> and others working in the social justice space offer a blueprint. </p>
<p>This work has real-life impacts — opening up access to treatment, creating appropriate treatment where it does not exist, and generally making life easier for the some half a million Canadians who struggle with eating disorders.</p><img src="https://counter.theconversation.com/content/90910/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrea Lamarre received funding for her PhD from the Canadian Institutes of Health Research through the Vanier Doctoral Scholar Program, followed by the Ontario Ministry of Health and Longterm Care. The research discussed in this article was not directly funded through these programs. Views expressed in the articles referred to herein are the views of the authors and do not necessarily reflect those of the funders. Andrea volunteers for the National Initiative for Eating Disorders, the Academy for Eating Disorders, and the Association for Size Diversity and Health.</span></em></p>Instagram can offer a supportive online community to people recovering from eating disorders. It can also reinforce stereotypes of eating disordered bodies.Andrea Lamarre, PhD candidate in the Department of Family Relations and Applied Nutrition, University of GuelphLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/847602017-10-10T22:46:56Z2017-10-10T22:46:56ZHow parents can conquer fear and guilt to help kids with eating disorders<figure><img src="https://images.theconversation.com/files/189255/original/file-20171006-25784-1xpe0bg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">New research shows that even previously obstructive parents can be coached into providing vital support for their children with eating disorders.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Lydia is seriously underweight and suffering from medical complications from an eating disorder. She is in hospital. Her treatment team recruits her mom to help Lydia gain weight through meal support. Lydia and her mom sit down for their first meal together. </p>
<p>Halfway through the meal, mom anxiously takes the dinner roll from her daughter’s tray and hides it in her purse. She tells her daughter: “You can skip the bread today. One step at a time.” </p>
<p>Is Lydia’s mom unmotivated to support her daughter’s recovery? Is she uncaring? Or does she just not get it?</p>
<p>In the 10 years I’ve been working as a psychologist in the field of eating disorders, I have encountered all too many variations of the scenario described above. Using the wrong lens, we could conclude that mom is just not going to cut it as a recovery ally. Actually, what our research shows is that <a href="http://www.tandfonline.com/doi/abs/10.1080/10640266.2015.1133210">underlying these problematic patterns of support are deep fears</a>. </p>
<p>And not just any fears. Parents like Lydia’s mom fear that if they do the wrong thing, or if their child is pushed too hard and too fast with recovery, that they will experience too much distress. That this will catapult them into depression, self-harm behaviours or every parent’s nightmare — suicide. More often than not, and consciously or not, these parents feel stuck between a rock and a hard place. </p>
<p>Our research also shows that with some targeted support, many parents can transform their fears and associated behaviours to play a very positive role in the treatment of their child’s eating disorder — even if at first, it doesn’t seem so.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/189623/original/file-20171010-17715-a1b45z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/189623/original/file-20171010-17715-a1b45z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/189623/original/file-20171010-17715-a1b45z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/189623/original/file-20171010-17715-a1b45z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/189623/original/file-20171010-17715-a1b45z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/189623/original/file-20171010-17715-a1b45z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/189623/original/file-20171010-17715-a1b45z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The research demonstrates that parents can support their kids to recovery - from childhood through adulthood.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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</figure>
<h2>Struggles with fear and self-blame</h2>
<p>Eating disorders are associated with <a href="https://link.springer.com/article/10.1007/s11920-012-0282-y">high rates of illness and premature death</a>. They seriously <a href="http://www.sciencedirect.com/science/article/pii/S0272735810001303">impair one’s quality of life</a> and are considered <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3879222/">very difficult to treat</a>. Although parents are regarded as <a href="http://onlinelibrary.wiley.com/doi/10.1002/eat.20751/full">important agents of healing when the patient is a child or adolescent</a>, this is not necessarily the norm when the individual with the eating disorder is over the age of 18 or when parents are thought to be obstructive, as in Lydia’s case above. </p>
<p>In fact, when parents are critical or enabling of their loved one’s symptoms, it isn’t uncommon for them to be kept on the outskirts of the recovery process, if they’re involved at all. </p>
<p>Our research shows that a parent’s fear for their loved one’s safety can create obstructive behaviours. So can feelings of self-blame. In this field of research and clinical practise, we now know with confidence that parents do not cause eating disorders. <a href="http://www.tandfonline.com/doi/abs/10.1080/09638230500347889">Family patterns can play a role, yes,</a> but so can <a href="https://books.google.ca/books?hl=en&lr=&id=5aSXQGSX_7QC&oi=fnd&pg=PA59&dq=Jacobi,+C.+%26+Fittig,+E.+(2010).+Psychosocial+risk+factors+for+eating+disorders.+&ots=JBzH2TN7Fb&sig=X5KTomnhoiyeg5hPj1EdqAkZIsk#v=onepage&q&f=false">the influence of genetics, the media, peers and many other factors </a>we are just now beginning to uncover. And then there are the inter-relationships among these different variables. It is complicated to say the least. </p>
<p>Regardless, most parents still carry within them a story of self-blame for their loved one’s illness. Their neighbours, friends and family members may too. Ask yourself this question: If you thought you were responsible — even a little bit — for your child’s illness, would you not hesitate to be involved? Just in case? Another rock and a hard place. </p>
<h2>All parents can be recovery coaches</h2>
<p>And so what to do? Along with a colleague, I developed <a href="http://onlinelibrary.wiley.com/doi/10.1002/cpp.1933/full">Emotion-Focused Family Therapy</a> — a treatment model designed to help parents support their child’s physical and emotional recovery from an eating disorder. Trained clinicians equip parents with concrete strategies to respond to their child’s behaviours and emotions, including outbursts, feelings of despair, even total silence, and in particular when these interfere with meals. </p>
<p>When those feelings of fear and self-blame do take hold of the parent, and they undoubtedly do at some point throughout the recovery journey, the EFFT clinician brings in specific techniques to help parents to move through these “emotional blocks.” They then help them get back on track to supporting their loved one in a good way. </p>
<p>We recently tested this process during a brief intervention with parents who have children with an eating disorder. More than 100 parents from across Canada <a href="http://www.tandfonline.com/doi/abs/10.1080/14779757.2017.1330703">attended a two-day caregiver workshop</a> without their loved one present. They were taught to support their child with meals and with the emotional pain underlying the eating disorder, including healing their family relationships if necessary. They were also supported to move through their fears and self-blame. </p>
<p>Sure enough, participation in the workshop led to a decrease in these feelings. This then led to an increase in the parents’ belief in their role as their children’s recovery coaches. Most importantly, they also expressed willingness to go home and practise all that they had learned, and with a newfound confidence. We believe this is great news for clients and families and even for the clinicians who support them.</p>
<p>In fact, it offers more proof that parents are doing the best they can with what they have, and that they need — no, deserve — professional support when their emotions take over, a very normal experience when faced with a life-threatening illness.</p>
<h2>Neurologically wired for life</h2>
<p>Parents and children are neurologically wired, and for life. This supports the idea that we should be involving parents more, not less. No matter if the child is 14 or 40, and no matter if the parent has made mistakes in the past or the relationship is strained. </p>
<p>In fact, when tensions are high in the family, recovery can be more challenging for the individual with the eating disorder — a good reason to work with all involved. </p>
<p>It also means though that if parents can be supported to act as their child’s recovery coach, their efforts — even if on a much smaller scale and imperfect — will be far more powerful than any therapist. And that’s a great reason to work with all involved.</p><img src="https://counter.theconversation.com/content/84760/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Adele Lafrance does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A new psychological intervention can help any parents - even those crippled by fear and self-blame - to become powerful recovery coaches to children with eating disorders.Adele Lafrance, Associate Professor of Psychology, Laurentian UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/815212017-07-26T09:18:05Z2017-07-26T09:18:05ZTo The Bone: Why Netflix’s portrayal of eating disorders has got it all wrong<figure><img src="https://images.theconversation.com/files/179596/original/file-20170725-11526-1wnciz9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Lily Collins in To the Bone.</span> <span class="attribution"><span class="source">Netflix</span></span></figcaption></figure><p>Not many films come with a health warning. But the recent Netflix film <a href="https://www.netflix.com/gb/title/80171659">To The Bone</a>, which tells the story of 20-year-old Ellen – played by Lily Collins – and her journey through treatment for anorexia, has received just that. The UK’s national eating disorder charity <a href="http://www.bbc.co.uk/newsbeat/article/40553260/new-netflix-film-about-anorexia-divides-eating-disorder-activists">Beat</a> said in a statement:</p>
<blockquote>
<p>We would strongly urge anyone that might be at risk of an eating disorder to think very carefully before watching this film. </p>
</blockquote>
<p>There have also been calls to <a href="http://www.digitalspy.com/movies/news/a833096/netflix-to-the-bone-movie-lily-collins-calls-to-be-banned/">ban</a> the film because of fears the film might incite eating disorders, or make someone’s problem worse. </p>
<p>Eating disorder sufferers – particularly young girls – have long been presented as especially “vulnerable” to the power of media images and messages. The “anorexic” is often shown as not simply vain, but also unable to separate image from “reality”. And research has shown that people diagnosed with anorexia are routinely presented as being “<a href="https://www.ncbi.nlm.nih.gov/pubmed/16864373">suggestively vulnerable</a>” – that is more likely to be influenced by media images, particularly images of (often unttainable) bodies.<br>
But while these cautions most likely come from a place of genuine concern, they can often have the opposite effect and further trivialise anorexia. </p>
<h2>Models in magazines</h2>
<p>Unwittingly or otherwise, debates such as those over To The Bone perpetuate the idea that girls can be “infected” with anorexia by looking at images of very slim (or starved) bodies – and that this is where the crux of anorexia lies. </p>
<p>But as my own research with people who have experience of an eating disorder shows, not only do such ideas massively simplify the complex reasons why anorexia may develop, they also trivialise it. As one of the people in my research group explained: </p>
<blockquote>
<p>So [it is] less like, well there’s a model, a skinny model in a magazine, looking at that, you’ve been looking at that too much and so you just wanna be like them … I don’t agree with that at all. I think that completely trivialises it.</p>
</blockquote>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/705yRfs6Dbs?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
</figure>
<p>One of the key problems is that there is inadequate understanding of the social and cultural aspects of eating disorders – both in wider society and the media – as well as in the treatment of eating disorders. </p>
<p>Eating disorders are now understood to combine biological, psychological and social factors, and yet the “social” part of the equation is still often marginalised in treatment. So although eating disorders have historically been recognised as primarily affecting girls and <a href="http://www.independent.co.uk/news/uk/five-hundred-years-of-eating-disorders-reflect-womens-lack-of-power-liz-hunt-reports-that-anorexia-2320545.html">women</a> in Western societies, contemporary eating disorder treatment does little to look at the relationship between eating problems and cultural constructs of <a href="http://journals.sagepub.com/doi/abs/10.1177/0959353516654503">femininity</a> – notwithstanding the “obvious” fact that most patients are female.</p>
<p>This is despite the wealth of evidence from <a href="http://us.karnacbooks.com/product/hunger-strike-the-anorectics-struggle-as-a-metaphor-for-our-age/20090/?MATCH=1">feminist</a> approaches over the last 40 years which point to the significance of society – and especially <a href="https://en.wikipedia.org/wiki/Feminist_Perspectives_on_Eating_Disorders">gender</a> roles – in the development of eating issues. </p>
<p>These approaches also aim to move beyond the idea of eating disorders as “body image” problems caused by reading too many women’s magazines – and instead look at the complex ways eating disorders might play out inequalities between genders on a broader scale.</p>
<h2>Societal expectation</h2>
<p>Some of the objections raised about To The Bone claim that it glamorises anorexia, and that it privileges the conventional stereotype of a young, white, fragile “waif”. I for one would like to see more representations that challenge and expand our understanding of what eating disorders “are” in terms of social and cultural identity, and how they might address the stigmatisation and trivialisation of eating disorders, and improve treatment. I don’t see this in To The Bone. </p>
<p>In fact, as the Guardian journalist, <a href="https://www.theguardian.com/film/2017/jul/12/to-the-bone-confirms-there-are-almost-no-good-movies-about-anorexia">Hadley Freeman’s</a> excellent article on the film observes, it perpetuates some of the same gender inequities that are behind eating disorders in the first place. Consider, for example, the fact that Keanu Reeves plays “the brilliant, patriarchal medical professional who can fix women”.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/179597/original/file-20170725-11177-stafja.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/179597/original/file-20170725-11177-stafja.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/179597/original/file-20170725-11177-stafja.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/179597/original/file-20170725-11177-stafja.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/179597/original/file-20170725-11177-stafja.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/179597/original/file-20170725-11177-stafja.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/179597/original/file-20170725-11177-stafja.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Keanu Reeves as Dr William Beckham in To The Bone.</span>
<span class="attribution"><span class="source">Netflix</span></span>
</figcaption>
</figure>
<p>The title To The Bone suggests something about getting to the “truth” of anorexia. Such a possibility is inevitably flawed, as there are many different ways “anorexia” can be viewed and many different experiences of having anorexia. </p>
<p>As someone who lived with the horrifying and debilitating realities of anorexia for over 20 years, I certainly found little sense of my “truth” here. And I’m mad as hell that nobody talked to me about gender during all the time that I was in treatment, or tried to understand what I might have been struggling against. I had to figure this out myself – five years after I was discharged from in-patient treatment. I now know that my anorexia was bound up very clearly with expectations surrounding what it meant to be a “woman”, and all that adult femininity may entail. It wasn’t rocket science. </p>
<p>I still hope for a film that can show such understandings. But in a climate where feminism is as much <a href="http://www.telegraph.co.uk/women/12045740/Todays-feminists-are-so-out-of-touch-with-how-most-women-live-they-might-as-well-be-on-another-planet.html">vilified</a> as welcomed, and with the skinny female body still being spectacularly fetishised in a film that purports to portray the “true” horrors of anorexia, I may well have a long wait ahead of me.</p><img src="https://counter.theconversation.com/content/81521/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Su Holmes does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Netflix’s new film To The Bone simplifies the social causes of anorexia.Su Holmes, Reader in TV Studies, University of East AngliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/791972017-06-22T20:05:23Z2017-06-22T20:05:23ZShould ‘pro-ana’ websites be criminalised in Australia?<figure><img src="https://images.theconversation.com/files/174653/original/file-20170620-24868-a5sy3z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">In Australia, there is little regulation of pro-ana material.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Anorexia nervosa is a mental illness characterised by a distorted body image, an extremely low body weight, and a <a href="https://www.eatingdisorders.org.au/eating-disorders/anorexia-nervosa">fear of gaining weight</a>. While anorexia affects all people, it is significantly more prevalent among women.
Even though it is relatively rare, its effects are devastating. </p>
<p>Anorexia is <a href="https://www.ncbi.nlm.nih.gov/pubmed/23625628">notoriously difficult to treat</a>. Across all mental illnesses, it has <a href="http://www.tc.columbia.edu/publications/gsjp/gsjp-volumes-archive/36307_6Johnson.pdf">the highest rate of mortality</a>, so research in this area is crucial. </p>
<p>It is not possible to determine a single cause of anorexia. Nevertheless, risk factors associated with the disease are well known. These include genetics, psychological predisposition, and social or cultural factors.</p>
<p>Increasingly, our social and cultural interactions take place online. It is, therefore, not surprising that online interactions intersect with mental illnesses generally, and anorexia specifically. This is particularly when taking into account that the average person who suffers from anorexia tends to be relatively young.</p>
<p>“Pro-ana” websites endorse anorexia as a positive choice, as opposed to a mental illness. Other variants include “pro-mia” websites, which endorse bulimia. These sites predominantly target women. </p>
<p>They promote a very thin body as the type that women must have. They give advice about how to become anorexic, how to hide an eating disorder from others and how to diet. The websites contain images of extremely thin women, which are sometimes altered to make the women appear thinner.</p>
<p>These websites have a long history. In 2001, Time Magazine noted the existence of <a href="http://content.time.com/time/health/article/0,8599,169660,00.html">400 such sites</a>. Efforts to eradicate these sites are just as old. AOL and Yahoo <a href="https://hal.archives-ouvertes.fr/hal-00780295/document">tried to ban pro-ana material that same year</a>. </p>
<p>These attempts have not been successful. Rather, the “survival” of such networks has required adaptation.</p>
<p>In practice, this involves these networks “<a href="https://hal.archives-ouvertes.fr/hal-00780295/document">turning inwards</a>”, as “subgroups of ana-mia bloggers will exchange messages, links and images among themselves and exclude other information sources”. Present estimates suggest there may be millions of pro-ana websites. </p>
<p>Like other online interactions, pro-ana websites have become integrated with social media. </p>
<h2>The present legal framework</h2>
<p>In Australia, there is little regulation of pro-ana material. There are general criminal offences that relate to <a href="https://www.slp.wa.gov.au/statutes/swans.nsf/%28DownloadFiles%29/Criminal+Code.pdf/$file/Criminal+Code.pdf">causing bodily harm</a>. This includes causing a person to have a disease or disorder. It follows that anorexia, while a mental illness, might nevertheless constitute bodily harm.</p>
<p>However, it is not likely that these offences will criminalise the publication of pro-ana material. The causes of anorexia are complex and multifaceted. Criminal prosecution usually requires proof that an action caused a particular outcome. Where many complex factors contribute to an outcome, it is difficult to prove causation in a criminal court.</p>
<p>Some jurisdictions have offences of “<a href="https://www.slp.wa.gov.au/statutes/swans.nsf/%28DownloadFiles%29/Criminal+Code.pdf/$file/Criminal+Code.pdf">hastening death</a>”. These provisions criminalise making a “<a href="https://jade.io/j/?a=outline&id=10782">substantial contribution</a>” to a death. Where it can be shown that pro-ana material contributed to death, by accelerating the progression of anorexia for example, criminal liability may follow. However, prosecution in such a case remains very difficult.</p>
<h2>The French legislation</h2>
<p>France has been an international leader in <a href="http://researchonline.nd.edu.au/cgi/viewcontent.cgi?article=1011&context=undalr">laws that relate to body image</a>. In 2015, the French government modified its Public Health Code to include an article that states:</p>
<blockquote>
<p>[c]ausing a person to seek excessive leanness by encouraging prolonged food restrictions which result in exposing the person to life-threatening danger or in directly compromising their health, is punishable by one year in prison and a fine of €10,000.</p>
</blockquote>
<p>The French MPs who proposed the law, Maud Olivier and Catherine Coutelle, <a href="http://www.dailymail.co.uk/news/article-3023026/France-cracks-pro-anorexia-websites-encourage-young-women-weight-low-possible.html">stated that</a> “certain sites known as pro-ana can push people into a vicious circle of anorexia and authorities cannot do anything about it”.</p>
<p>Other countries have also <a href="http://www.thedailybeast.com/articles/2014/08/30/should-pro-ana-sites-be-criminalized.html">proposed similar bans</a>. In Australia, former federal MP Anna Burke has advocated following France’s lead and <a href="http://www.smh.com.au/news/national/call-to-ban-anorexia-websites/2008/04/16/1208025283081.html">banning such websites in Australia</a>.</p>
<h2>Issues with criminalisation</h2>
<p>Pro-ana websites are commonly interactive. The line between a consumer and a producer of social media is blurry. Laws to prohibit pro-ana material would likely also capture the behaviour of visitors to these sites who interact with them. </p>
<p>A considerable proportion of women who seek out pro-ana websites report suffering from an eating disorder. Visitors to these websites commonly report that they are seeking support in relation to those disorders, often after traditional therapies have been unsuccessful. </p>
<p>Similarly, most publishers of pro-ana websites are women who themselves suffer from the illness. If creating pro-ana websites is criminalised, then it could make it more difficult for the creators to seek the help that they need to recover. </p>
<p>Much of the content of pro-ana websites is shocking. Telling readers to “stop eating until they take you to the hospital” is disturbing. This line might be hyperbole. It might be evidence of the disordered thinking typical of anorexia. In either case it evokes a strong reaction.</p>
<p>Yet, similar material is found elsewhere in the public space. The common pro-ana motto, “nothing tastes as good as skinny feels”, is attributed to <a href="http://www.independent.co.uk/news/people/news/kate-moss-in-quotes-nothing-tastes-as-good-as-skinny-feels-and-other-career-defining-statements-by-9061975.html">supermodel Kate Moss</a>. That line, and variations on it, are used in <a href="http://melindatankardreist.com/2012/04/nothing-tastes-as-bad-as-lorna-jane-co-opting-pro-anorexia-slogan-for-ad-campaign/">marketing material by clothing retailers</a>. </p>
<p>Images used by pro-ana websites are most often taken from other sources. They include photos from fashion and women’s magazines, celebrities and well-known models. These images – shocking in the context of pro-ana websites – are ubiquitous in the public space.</p>
<p>Public comment advocating extreme thinness in women is also common. Radio shock-jock Kyle Sandilands used his nationally syndicated show to tell a woman: <a href="http://www.dailymail.co.uk/tvshowbiz/article-3700555/Overweight-Kyle-Sandilands-says-likes-women-starving-look-fat-shames-Adele.html">“I like the starving look … 60kgs is pushing it.”</a> </p>
<p>Internationally syndicated celebrity MD Dr Oz’s show is broadcast on free-to-air TV in Australia. It featured Camille Hugh’s book, The Thigh Gap Hack. That book promised women “the shortcut to slimmer, feminine thighs every woman secretly desires” by techniques such as the trademarked “hunger training”. This technique encourages women to skip meals and instead “listen” to their body for signals of “true” hunger. </p>
<p>Proposals to criminalise pro-ana websites would make it an offence to collect and collate images, slogans and “tips” that are commonly used to market to women. These laws would criminalise this behaviour when done by women in a pro-ana context, but not when done to women. This seems deeply problematic.</p>
<h2>Alternatives to criminalisation</h2>
<p>The alternative to criminalisation is to use online platforms to deliver health information. For example, searching “pro-ana” on social media site tumblr returns the following page:</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/174641/original/file-20170620-10641-njuusd.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/174641/original/file-20170620-10641-njuusd.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=634&fit=crop&dpr=1 600w, https://images.theconversation.com/files/174641/original/file-20170620-10641-njuusd.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=634&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/174641/original/file-20170620-10641-njuusd.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=634&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/174641/original/file-20170620-10641-njuusd.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=796&fit=crop&dpr=1 754w, https://images.theconversation.com/files/174641/original/file-20170620-10641-njuusd.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=796&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/174641/original/file-20170620-10641-njuusd.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=796&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Social media website tumblr offers support to users who search common pro-ana terms.</span>
<span class="attribution"><span class="source">from www.tumblr.com</span></span>
</figcaption>
</figure>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/24132789">Research on internet search habits</a> found that explicit reference to a celebrity’s eating disorder in traditional media reports decreased the rate at which people searched for material relating to anorexia. This suggests that alternative messaging, rather than criminalisation, may have merit. </p>
<p>Another possible alternative is to add some sort of warning on these pages about the dangerous content and the harm that may come from viewing them. </p>
<hr>
<p><em>If you, or anyone you know, is suffering from an eating disorder, you can <a href="https://thebutterflyfoundation.org.au/">contact the Butterfly Foundation</a> for assistance by calling 1800 334 673.</em></p><img src="https://counter.theconversation.com/content/79197/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tomas Fitzgerald has received funding from the WA Bar Association. He is a member of WA Labor.
</span></em></p><p class="fine-print"><em><span>Marilyn Bromberg has received funding from the Telethon-Perth Children's Hospital Research Fund, as part of a research team. She volunteers as a lawyer for the Fremantle Community Legal Centre and as a judge for the mock trials of high schools students, organised by the Law Society of Western Australia. </span></em></p>Criminalising websites that celebrate extreme, unhealthy thinness is deeply problematic.Tomas Fitzgerald, Senior Lecturer in Law, University of Notre Dame AustraliaMarilyn Bromberg, Senior Lecturer in Law, The University of Western AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/772492017-05-08T06:32:07Z2017-05-08T06:32:07ZTherapy for life-threatening eating disorders works, so why can’t people access it?<figure><img src="https://images.theconversation.com/files/168259/original/file-20170508-7669-1g3ctqy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Eating disorders are among the leading causes of hospitalisation for mental-health-related issues in Australia.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>Eating disorders are complex mental illnesses that have one of the highest death rates of any psychiatric disorder. Among people with <a href="https://www.eatingdisorders.org.au/eating-disorders/anorexia-nervosa">anorexia nervosa</a> – who commonly deprive themselves of food due to an obsessive fear of gaining weight – this rate is <a href="https://www.ncbi.nlm.nih.gov/pubmed/26767344">more than five times greater</a> than in the general population.</p>
<p>All eating disorders are associated with significant, wide-ranging physical <a href="https://thebutterflyfoundation.org.au/assets/Uploads/Butterfly-report-Paying-the-Price-Executive-Summary.pdf">health complications</a> such as starvation, cardiac arrest (sudden loss of heart function), kidney problems, food intolerance and fits. These are among the <a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=10737419259">leading causes of hospitalisation</a> for mental-health-related issues in Australia. </p>
<p>Because serious medical complications so frequently accompany eating disorders, they defy classification solely as mental illnesses. They should be viewed as complex health-care issues requiring urgent and multidisciplinary care. </p>
<p>Yet many health-care providers have not been provided with enough basic education and training to be able to recognise and respond appropriately to someone presenting with an eating disorder. So despite their severity, eating disorders <a href="http://www.abc.net.au/news/2017-05-04/australian-health-system-failing-patients-with-eating-disorders/8485300">often go unrecognised</a>. </p>
<p>This leads to substantial economic costs for the Australian health system and <a href="https://thebutterflyfoundation.org.au/assets/Uploads/ButtInsights-BOOK1-online-nov5-FINAL-20161107.pdf">devastating effects for sufferers</a>, loved ones and the communities that surround them. </p>
<h2>What are eating disorders?</h2>
<p>Eating disorders have been around through recorded history. Even an ancient Egyptian tomb painting depicts a noble <a href="http://onlinelibrary.wiley.com/doi/10.1002/1098-108X(199301)13:1%3C129::AID-EAT2260130116%3E3.0.CO;2-Y/full">self-inducing vomiting</a>.</p>
<p>There are several types of eating disorders. These include anorexia nervosa, bulimia nervosa and binge eating disorder. Collectively, <a href="https://www.eatingdisorders.org.au/eating-disorders/what-is-an-eating-disorder">these are characterised</a> by abnormal eating behaviours, poor body image, overemphasis on weight and shape, and extreme weight-control behaviours.</p>
<p>In the case of anorexia, such behaviours lead to severe weight loss and often life-threatening complications. Vomiting, laxative abuse and excessive exercise can be features of both anorexia and bulimia, as can binging and purging. </p>
<p>Unlike the severe weight loss associated with anorexia, bulimia is characterised by the presence of binging and usually purging at a relatively normal weight. Binge eating disorder features frequent binging, in the absence of purging or other compensatory behaviours, which often leads to significant weight gain.</p>
<p>Eating disorders are also <a href="https://www.ncbi.nlm.nih.gov/pubmed/16815322">commonly accompanied</a> by low self-esteem, guilt and disgust, along with depression, severe anxiety and <a href="https://theconversation.com/factcheck-qanda-do-eating-disorders-have-the-highest-mortality-rate-of-all-mental-illnesses-66495">suicide risk</a>.</p>
<h2>Who gets eating disorders?</h2>
<p>There are psychological, environmental and biological (including genetic) <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3933432/">risk factors for developing eating disorders</a>. A genetic predisposition in combination with poor body image is one of the <a href="https://www.ncbi.nlm.nih.gov/pubmed/26095891">strongest predictors</a> of disordered eating.</p>
<p>Poor body image has been <a href="https://www.missionaustralia.com.au/documents/research/young-people-research/677-mission-australia-youth-survey-report-2016">reported in</a> nearly half of Australian women and over one-third of Australian men. Disturbingly, the rate of body-image concerns is even greater in children and adolescents. A <a href="https://aifs.gov.au/publications/family-matters/issue-95/growing-australia-longitudinal-study-australian-children">study of Australian children</a> found up to 61% of girls and boys between the ages of eight and 11 are trying to control their weight.</p>
<p>Around 10% of the Australian population will <a href="http://www.nedc.com.au/files/pdfs/National%20Framework%20An%20integrated%20Response%20to%20Complexity%202012%20-%20Final.pdf">experience an eating disorder</a> in their lifetime, and the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2212110/">rate is increasing</a>. For example, one study observed a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2212110/">two-fold increase</a> in disordered eating between 1995 and 2005 in South Australia. And a more recent study in the same state observed a <a href="https://www.ncbi.nlm.nih.gov/pubmed/23144886">more than two-fold increase</a> in extreme dieting and binge eating between 1998 and 2008.</p>
<p>While the reasons for this increase have not yet been fully explored, they <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2212110/">may be related to</a> increasing concerns about weight in the general Australian population.</p>
<p>Contrary to the long-held belief eating disorders are the domain of wealthy young females, the <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-14-943">greatest increase has been observed</a> in older people, males and those in lower socio-demographic groups. </p>
<p>This <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-14-943">may be due</a>, at least in part, to inadequate access to treatment, differences in people seeking treatment, or detection in under-represented groups, and stigma surrounding the development of a disorder commonly associated with a specific (different) group in the community.</p>
<h2>How are they treated?</h2>
<p>A number of evidence-based treatments are available for eating disorders. It is important to note that no single approach will be effective for all individuals. </p>
<p>People who are unable to access effective treatment early <a href="http://www.nedc.com.au/files/pdfs/National%20Framework%20An%20integrated%20Response%20to%20Complexity%202012%20-%20Final.pdf">experience greater</a> duration and severity of illness. They then <a href="https://www.ncbi.nlm.nih.gov/pubmed/21345418">need more complex, prolonged treatment</a>. </p>
<p>Structured, psychological therapies are considered the cornerstone of treatment for eating disorders. For adolescents with anorexia, this takes the form of family-based therapy. This involves helping the whole family support the person with the disorder.</p>
<p>In adults with eating disorders, <a href="https://www.ncbi.nlm.nih.gov/pubmed/19074978">evidence shows</a> a minimum of 20 sessions of cognitive behaviour therapy (CBT) – which <a href="https://theconversation.com/explainer-what-is-cognitive-behaviour-therapy-37351">challenges learnt ways of thinking</a> – is necessary. In severe cases of anorexia, at least 40 CBT sessions that include a strong emphasis on <a href="https://www.aedweb.org/downloads/Guide-English.pdf">restoring healthy eating attitudes</a> and behaviours are required. </p>
<p>A multidisciplinary team is best equipped to address the complex nutritional, medical and psychological needs of someone with anorexia. </p>
<h2>Increasing funding to improve outcomes</h2>
<p>The total <a href="https://thebutterflyfoundation.org.au/assets/Uploads/Butterfly-report-Paying-the-Price-Executive-Summary.pdf">social and economic costs</a> of eating disorders in Australia exceed A$69 billion per year. These costs can be reduced with early detection.</p>
<p>Most people with eating disorders go a <a href="https://www.ncbi.nlm.nih.gov/pubmed/16864242">long time</a> before receiving adequate care. One <a href="https://www.ncbi.nlm.nih.gov/pubmed/21383252">study of over 10,000 adolescents</a> found that, while nearly 90% of those with an eating disorder contacted a service provider for help, in only a minority (3-28%) of cases were the services specifically for their eating disorder. </p>
<p>Factors such as denial, shame, stigma and a lack of recognition of eating disorder symptoms by health-care professionals are likely contributors to this discrepancy.</p>
<p>Medicare provides Australians with <a href="http://www.health.gov.au/internet/main/publishing.nsf/content/mental-ba-fact-pat">funding for ten sessions</a> with an allied mental-health professional (such as a psychologist or social worker). This is below the minimum treatment recommendation of 20 sessions for all eating disorders.</p>
<p>We should not accept a system that prevents people with a severe life-threatening mental illness from accessing a treatment that is available, effective and will save costs in the long term. </p>
<p>Federal Health Minister Greg Hunt <a href="http://www.news.com.au/national/breaking-news/mayday-to-stop-eating-disorder-deaths/news-story/8372f9536f3c23fec3f0cfe3d5809002">recently requested</a> the Medicare Benefits Schedule Review Taskforce investigate increasing Medicare coverage to treat people with an eating disorder. We urgently need early identification of eating disorders and the delivery of quality, targeted treatments at evidence-supported durations.</p>
<p><em>This article was co-authored by Tina Peckmezian, Principal Research Officer at The Butterfly Foundation.</em></p>
<hr>
<p><em>If this article has raised concerns for you or anyone you know, call <a href="http://www.lifeline.org.au">Lifeline</a> 13 11 14, <a href="http://www.suicidecallbackservice.org.au">Suicide Call Back Service</a> 1300 659 467 or <a href="http://www.kidshelp.com.au">Kids Helpline</a> 1800 55 1800.</em></p>
<p><em>People with eating disorders or their families can get help at the <a href="https://thebutterflyfoundation.org.au/">Butterfly Foundation</a>, 1800 33 4673, or The <a href="http://www.nedc.com.au">National Eating Disorders Collaboration</a>.</em></p><img src="https://counter.theconversation.com/content/77249/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Richard Newton is a board member of the Butterfly Foundation. In the last 5 years he has participated in advisory boards or is on the speakers bureau for the following pharmaceutical companies; Shire, Lundbeck, Servier , Astra Zeneca and Janssen, </span></em></p>Federal Health Minister Greg Hunt has asked the Medicare review taskforce to consider increasing the number of subsidised mental health sessions for those with eating disorders. Why is that necessary?Richard Newton, Associate Professor, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/664952016-10-10T03:25:02Z2016-10-10T03:25:02ZFactCheck Q&A: do eating disorders have the highest mortality rate of all mental illnesses?<figure><img src="https://images.theconversation.com/files/141019/original/image-20161009-2652-mlk4.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Labor MP Mark Butler, speaking on Q&A.</span> <span class="attribution"><span class="source">Q&A</span></span></figcaption></figure><p><strong>The Conversation is fact-checking claims made on Q&A, broadcast Mondays on the ABC at 9:35pm. Thank you to everyone who sent us quotes for checking via <a href="http://www.twitter.com/conversationEDU">Twitter</a> using hashtags #FactCheck and #QandA, on <a href="http://www.facebook.com/conversationEDU">Facebook</a> or by <a href="mailto:checkit@theconversation.edu.au">email</a>.</strong></p>
<hr>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/wwwxJhmTZuE?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Excerpt from Q&A, October 3, 2016.</span></figcaption>
</figure>
<blockquote>
<p>At the less serious end, in terms of loss of self-esteem and self-confidence, but more serious end, poor diet and so on, and at the very serious end, eating disorders, which are the mental illness type which has the highest mortality rate. – Shadow Minister for Climate Change and Energy, Mark Butler, <a href="http://www.abc.net.au/tv/qanda/txt/s4528828.htm">speaking</a> on Q&A, October 3, 2016.</p>
</blockquote>
<p>Shadow Minister for Climate Change and Energy, Mark Butler, told Q&A that “eating disorders … are the mental illness type which has the highest mortality rate”. </p>
<p>Is that true?</p>
<h2>Checking the source</h2>
<p>When asked to provide sources to support his statement, a spokesperson for Mark Butler pointed The Conversation to the <a href="http://www.nedc.com.au/eating-disorders-in-australia">National Eating Disorders Collaboration</a> website, which says:</p>
<blockquote>
<p>The mortality rate for people with eating disorders is the highest of all psychiatric illnesses and over 12 times that seen in people without eating disorders. </p>
</blockquote>
<p>The National Eating Disorders Collaboration is linked to the federal Department of Health, and brings together people and organisations with an expertise and/or interest in eating disorders. So it is quite a reliable source.</p>
<p>However, we can also test his statement against publicly available research.</p>
<h2>Do eating disorders have the highest mortality rate of all mental illness types?</h2>
<p>Many <a href="http://ajp.psychiatryonline.org/doi/pdf/10.1176/appi.ajp.2009.09020247">studies</a>, <a href="http://onlinelibrary.wiley.com/doi/10.1002/wps.20128/full">meta-reviews</a> and <a href="http://jamanetwork.com/journals/jamapsychiatry/article-abstract/1107207">meta-analyses</a> reveal the <a href="http://archpsyc.jamanetwork.com/article.aspx?articleid=1107207&version=meter+at+null&module=meter-Links&pgtype=article&contentId=&mediaId=&referrer=&priority=true&action=click&contentCollection=meter-links-click">high mortality rates</a> for eating disorders, <a href="http://archpsyc.jamanetwork.com/article.aspx?articleid=207163">in particular anorexia nervosa</a>. (Meta-analyses and meta-reviews involve researchers reading and compiling the results from many studies and use complex statistics to identify bigger trends).</p>
<p>Is it the highest? It depends a bit on what you mean by “mental illness type”. It’s definitely among the highest.</p>
<p>The <a href="http://onlinelibrary.wiley.com/doi/10.1002/wps.20128/full">most recent meta-review</a> published in 2014 found that while the mortality ratio for eating disorders is higher than for most other psychiatric disorders, some <a href="https://www.drugabuse.gov/publications/media-guide/science-drug-abuse-addiction-basics">substance use disorders</a> had higher mortality ratios.</p>
<p>The <a href="http://www.dsm5.org/Pages/Default.aspx">Diagnostic and Statistical Manual of Mental Disorders</a> (DSM) published by the <a href="https://www.psychiatry.org/">American Psychiatric Association</a> and used internationally to classify and diagnose mental disorders, defines <a href="http://www.dsm5.org/documents/substance%20use%20disorder%20fact%20sheet.pdf">substance use disorders</a> as psychiatric condition. It <a href="http://dsm.psychiatryonline.org/doi/abs/10.1176/appi.books.9780890425596.dsm10">defines</a> eating disorders as:</p>
<blockquote>
<p>… characterised by a persistent disturbance of eating or eating-related behaviour that results in the altered consumption or absorption of food and that significantly impairs physical health or psychosocial functioning. </p>
</blockquote>
<p>Eating disorders defined in the DSM-5 include anorexia nervosa, bulimia nervosa and binge-eating disorder, <a href="http://www.dsm5.org/Documents/Eating%20Disorders%20Fact%20Sheet.pdf">among</a> <a href="http://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425596.dsm10">others</a>. Eating disorders affect <a href="http://www.eatingdisorders.org.au/key-research-a-statistics">men and women of all ages</a>, with the highest incidence among girls and women. <a href="http://www.nedc.com.au/eating-disorders-in-australia">Many cases</a> emerge in adolescence. </p>
<p>It’s worth noting that there are some overlaps between eating disorders and <a href="http://onlinelibrary.wiley.com/doi/10.1002/1098-108X(199407)16:1%3C1::AID-EAT2260160102%3E3.0.CO;2-T/full"> substance use disorders</a> as well as <a href="https://books.google.com.au/books?hl=en&lr=&id=mM7SAgAAQBAJ&oi=fnd&pg=PA193&dq=depression+eating+disorders+comorbidity&ots=GyajwIogyV&sig=1kKOybyI4Rf093oztj9bOVJmhUw#v=onepage&q=depression%20eating%20disorders%20comorbidity&f=false">anxiety and depression</a>. It’s not always clear what caused what, or what the cause of death was because a person may have <a href="https://www.researchgate.net/profile/Dara_Greenwood/publication/12517510_Mortality_in_eating_disorders_A_descriptive_study/links/0deec52496fbc86eb0000000.pdf">many physical and psychological conditions</a>. </p>
<h2>What does the research show?</h2>
<p><a href="https://thebutterflyfoundation.org.au/assets/Uploads/Butterfly-report-Paying-the-Price-Executive-Summary.pdf">A report</a> written by <a href="http://www.deloitteaccesseconomics.com.au/">Deloitte Access Economics</a> for the <a href="https://thebutterflyfoundation.org.au/about-us/">Butterfly Foundation</a> estimated that there were 913,986 people in Australia with eating disorders in 2012. That’s 4% of the population. The report estimated that 1,829 people died from eating disorders in Australia in 2012. </p>
<p>A number of international reviews and meta-analyses comparing mortality rates of psychiatric disorders show that substance use disorders and eating disorders have the highest risk of death.</p>
<p>The <a href="http://onlinelibrary.wiley.com/doi/10.1002/wps.20128/full">most recent meta-review</a>, published in 2014, summarised data and findings from research of over 1.7 million patients. The authors estimated (in Table 1 of the study <a href="http://onlinelibrary.wiley.com/doi/10.1002/wps.20128/full">here</a>) that the mortality risk is higher for opioid use, cocaine use, and amphetamine use than for anorexia nervosa. The authors said that:</p>
<blockquote>
<p>All disorders had an increased risk of all-cause mortality compared with the general population, and many had mortality risks larger than or comparable to heavy smoking. Those with the highest all-cause mortality ratios were substance use disorders and anorexia nervosa.</p>
</blockquote>
<p><a href="http://bjp.rcpsych.org/content/173/1/11.full-text.pdf+html">A systematic review</a> published by British researchers in 1998 compared the mortality rates of 27 mental disorders. It also found that eating disorders had among the highest risks of premature death among both genders, but prescription and legal drug abuse, opioid abuse were higher in some analyses. </p>
<p>A <a href="http://archpsyc.jamanetwork.com/article.aspx?articleid=1107207&version=meter+at+null&module=meter-Links&pgtype=article&contentId=&mediaId=&referrer=&priority=true&action=click&contentCollection=meter-links-click">meta-analysis</a> of mortality rates in eating disorders published in 2011 reported that anorexia nervosa had a significantly higher mortality ratio than <a href="http://www.sciencedirect.com/science/article/pii/S0920996499001917">schizophrenia</a> and <a href="http://archpsyc.jamanetwork.com/article.aspx?articleid=481814">bipolar disorder</a>.</p>
<p>A <a href="http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.462.2442&rep=rep1&type=pdf">1995 meta-analysis</a> of 42 studies of eating disorder case reports noted that:</p>
<blockquote>
<p>The aggregate annual mortality rate associated with anorexia nervosa is more than 12 times higher than the annual death rate due to all causes of
death for females 15-24 years old in the general population (0.00045 deaths per year) and more than 200 times greater than the suicide rate in the general population (0.00002 suicides per year).</p>
</blockquote>
<h2>What are people with eating disorders dying from?</h2>
<p>Deaths associated with eating disorders are typically caused by medical complications (such as cardiovascular issues and multiple organ failure), suicide or complications relating to substance use. </p>
<p>A <a href="http://ajp.psychiatryonline.org/doi/pdf/10.1176/appi.ajp.2009.09020247">United States study</a> reported on the causes of death in a group of eating disorder patients between 1979 and 1997. Of the 52 deceased patients, 20 died from medical causes, 13 died from suicide, 10 died from causes related to substance use, and nine died from “traumatic causes” (which was not further defined in that study). <a href="https://www.researchgate.net/profile/Dara_Greenwood/publication/12517510_Mortality_in_eating_disorders_A_descriptive_study/links/0deec52496fbc86eb0000000.pdf">Examples</a> of deaths from medical causes include acute alcohol intoxication, cardiorespiratory issues, issues with the liver and other major organs, and pneumonia.</p>
<p>Although high rates of mortality are reported for eating disorder patients, there are a large proportion of people with these conditions who go on to engage in successful treatment, and recover. Inpatient or outpatient treatment <a href="http://www.indianjpsychiatry.org/article.asp?issn=0019-5545;year=2010;volume=52;issue=2;spage=174;epage=186;aulast=Chakraborty">usually involves</a> a combination of nutritional management, psychotherapy, and medication.</p>
<h2>Verdict</h2>
<p>Mark Butler was broadly correct. Many studies show that eating disorders are among the mental illness types with the highest mortality rate. </p>
<p>Is it the highest? It’s hard to say for sure. <a href="http://onlinelibrary.wiley.com/doi/10.1002/wps.20128/full">Two</a> <a href="http://bjp.rcpsych.org/content/173/1/11.full-text.pdf+html">studies</a> that compile much of the research in this area confirm that substance use disorders and eating disorders have the highest mortality risk of all psychiatric conditions. </p>
<p>Some patients may experience more than one psychiatric disorder. It’s not always clear what role an eating disorder may have had in a person’s death, as there may be many influencing factors. </p>
<p>So it is hard to make a clear statement about which psychiatric conditions have the highest mortality rate of all. <strong>– Zali Yager.</strong></p>
<hr>
<h2>Review</h2>
<p>This is a sound analysis. It is worth noting that <em>all</em> eating disorders are associated with elevated mortality and suicide, as sometimes the general public fixate on anorexia nervosa. <strong>– Tracey Wade.</strong></p>
<hr>
<p><em>If this article has raised concerns about eating disorders, please contact the Butterfly Foundation national hotline on 1800 33 4673; or visit <a href="https://thebutterflyfoundation.org.au/">their website</a> for support and resources for eating disorder sufferers and their families and carers.</em></p>
<p><em>If this article has raised issues for you or if you’re concerned about someone you know, call Lifeline on 13 11 14.</em></p>
<hr>
<p><div class="callout"> Have you ever seen a “fact” worth checking? The Conversation’s FactCheck asks academic experts to test claims and see how true they are. We then ask a second academic to review an anonymous copy of the article. You can request a check at checkit@theconversation.edu.au. Please include the statement you would like us to check, the date it was made, and a link if possible.</div></p><img src="https://counter.theconversation.com/content/66495/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Zali Yager receives funding from the Australian Research Council, Australian Anti-Doping Association, and Oregon Health and Science University. She is a member of the Academy for Eating Disorders and has previously collaborated with the Butterfly Foundation on research projects.
</span></em></p><p class="fine-print"><em><span>Tracey Wade does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Shadow Minister for Climate Change and Energy Mark Butler told Q&A that eating disorders “are the mental illness type which has the highest mortality rate”. We check the research.Zali Yager, Associate Professor in Health and Physical Education, Victoria UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/624282016-08-07T20:09:56Z2016-08-07T20:09:56ZSize is largely in the mind: how your body image can change in two minutes<figure><img src="https://images.theconversation.com/files/132718/original/image-20160802-17173-1fyvo6e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many not only feel dissatisfied with their bodies, they actually believe they are heavier than they really are.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>Have you ever looked at yourself in a full-length mirror and wished you looked more like the beautiful people who grace the covers of glossy magazines? If so, you are by no means alone. </p>
<p>Body dissatisfaction is so prevalent that some academics have referred to it as <a href="https://www.researchgate.net/publication/232553767_Women_and_weight_A_normative_discontent">“normative discontent”</a>. Many of those affected not only feel dissatisfied with their bodies, they actually believe they are heavier than they really are – a phenomenon known as body size misperception.</p>
<p>Our <a href="http://journal.frontiersin.org/article/10.3389/fnins.2016.00334/full">recent study</a> found that people’s perception of their own and others’ body weight could change in as little as two minutes. </p>
<p>Participants were asked to view images of people that had been digitally manipulated to appear lighter or heavier than they actually were and decide whether these images looked fatter or thinner than “normal”. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/131565/original/image-20160722-21879-1akd42q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/131565/original/image-20160722-21879-1akd42q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=972&fit=crop&dpr=1 600w, https://images.theconversation.com/files/131565/original/image-20160722-21879-1akd42q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=972&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/131565/original/image-20160722-21879-1akd42q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=972&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/131565/original/image-20160722-21879-1akd42q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1221&fit=crop&dpr=1 754w, https://images.theconversation.com/files/131565/original/image-20160722-21879-1akd42q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1221&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/131565/original/image-20160722-21879-1akd42q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1221&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Measurements of Miss America contestants have been decreasing for decades.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/newyork/3228731310/in/photolist-5Vj6kd-8hAYF2-5h8HDk-eNy1Py-pnUnGn-9TdDn2-dKRg2z-EKKL9-4dTQJ-e79dSP-adYvdp-c8d3tE-rpNCLS-5hd62G-9comLi-a7nibz-5hd5XG-5h8HHx-e2ePU9-vMjnxz-5Vj6hu-667JRy-5VeJfx-5VeJ6D-5h8HVK-eBQvA-5hd64d-5h8HUe-5hd5W3-5Vj6i1-5Vj6iJ-5h8HKe-a3KkCx-5hd5R5-5VeJ4k-7Da5yr-ip5g4t-bSHFUF-5Vj6c3-5VeJ7p-5Vj6fA-7oqBN9-5Vj5VQ-5Vj5YW-5Vj5Q3-4F4X4g-5Vj5MN-5h8HEK-5Vj63d-ftqE1w">Cyril Attias/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>After 120 seconds of exposure to manipulated thin bodies, the original-sized body images looked abnormally large to participants while the thinner images were rated as normal. </p>
<p>The opposite was also true: exposure to heavier bodies made participants see original body sizes as skinny.</p>
<h2>Chasing the thin ideal</h2>
<p>It is hardly news that many are negatively affected by the thin, supposedly ideal images propagated by the media. </p>
<p>The connection between social pressure to be thin exerted by these images and feelings of body dissatisfaction – a risk factor for developing eating disorders such as anorexia nervosa – was first made by <a href="https://books.google.com.au/books/about/Eating_Disorders.html?id=xM7x05fvUHAC&redir_esc=y">German psychologist Hilde Bruch</a> in the 1970s. </p>
<p>Then, in 1980, a study showed that the measurements of <a href="http://river-centre.org/wp-content/uploads/2014/12/1980-Garner-Sociocultural-Playboy.pdf">Miss America contestants and Playboy centrefold models</a> between 1959 and 1979 were decreasing, supporting claims that the media’s “thin is beautiful” message was spreading.</p>
<p>Although many studies in the intervening decades have confirmed this link, there is still relatively little understanding of the brain mechanisms underlying the perception of our own bodies in relation to what we see on TV and in magazines.</p>
<h2>Retuning the brain</h2>
<p>Since the time of Aristotle, it has been known that prolonged viewing of certain stimuli can cause after-effects that alter the perception of subsequently viewed objects. Often, the after-effect produces an appearance that neutral stimuli are in a sense opposite to the original stimulus to which the observer was overexposed. </p>
<p>One famous example is the <a href="http://www.michaelbach.de/ot/mot-adapt/index.html">motion after-effect</a> – also known as the waterfall illusion. Here, exposure to movement in a particular direction, such as the downward motion of a waterfall, can cause stationary rocks beside the waterfall to appear to move in the opposite direction, that is upwards. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/EyWT9IIXV3s?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Keep staring at the dot in the middle to experience the motion after-effect.</span></figcaption>
</figure>
<p>Similar effects can be seen for <a href="http://www.cell.com/current-biology/fulltext/S0960-9822(08)01346-8">other object properties</a>, such as <a href="https://freudforthought.wordpress.com/2015/10/29/colour-after-effects/">colour</a>. As these phenomena have been studied for centuries, their physiological basis is pretty well understood. After-effects are accompanied by a reduction in responsiveness of neurons in the visual areas of the brain. </p>
<p>These reductions were once assumed to be the result of tiredness of the overworked cells, but more modern theories propose that the change in brain activity serves to <a href="https://global.oup.com/academic/product/fitting-the-mind-to-the-world-9780198529699?cc=au&lang=en&">tune our perceptual systems</a> to the environmental conditions. This gives us a frame of reference for what is normal or expected as determined by our visual diet throughout our lives.</p>
<p>Although early studies concentrated on simple stimuli, such as motion or colour, our recent investigations have shown that higher-level properties, such as body size and shape, can cause similar after-effects. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/132905/original/image-20160803-12196-rlv82n.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/132905/original/image-20160803-12196-rlv82n.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/132905/original/image-20160803-12196-rlv82n.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=300&fit=crop&dpr=1 600w, https://images.theconversation.com/files/132905/original/image-20160803-12196-rlv82n.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=300&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/132905/original/image-20160803-12196-rlv82n.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=300&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/132905/original/image-20160803-12196-rlv82n.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=377&fit=crop&dpr=1 754w, https://images.theconversation.com/files/132905/original/image-20160803-12196-rlv82n.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=377&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/132905/original/image-20160803-12196-rlv82n.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=377&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Stare at the cross on the left for around 30 seconds without moving your eyes. Then transfer your gaze to the cross on the right. You should see an after-effect of the complementary colour in the circles even though they are actually white. As they are opposite colours, the positions of the red and green circles will swap, as will the positions of the blue and yellow circles.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>It is likely that the neural adaptation associated with these after-effects is the underlying physiological basis of body-size misperception.</p>
<p>Our recent study showed that after-effects could actually transfer from others’ bodies to the perception of one’s own. That is, viewing abnormally thin versions of other people’s bodies caused participants to see themselves as heavier than they actually were and vice versa. </p>
<p>While this observation fits nicely with the narrative connecting media exposure with body-size misperception in the real world, it also suggests that mechanisms mediating the perception of one’s own and others’ body size and shape are overlapping.</p>
<h2>Variety is the spice of life</h2>
<p>Body image is a complex construct, but a better understanding of these mechanisms opens new avenues for a fuller understanding of body size misperception, including how best to manage severe forms of this problem.</p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/132709/original/image-20160802-17185-qsaj7a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/132709/original/image-20160802-17185-qsaj7a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/132709/original/image-20160802-17185-qsaj7a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/132709/original/image-20160802-17185-qsaj7a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/132709/original/image-20160802-17185-qsaj7a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/132709/original/image-20160802-17185-qsaj7a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1005&fit=crop&dpr=1 754w, https://images.theconversation.com/files/132709/original/image-20160802-17185-qsaj7a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1005&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/132709/original/image-20160802-17185-qsaj7a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1005&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Prolonged viewing of certain stimuli can cause after-effects that alter the perception of subsequently viewed objects.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/ktlindsay/2322037166/in/photolist-4xc3Ky-agVZmS-9NGabs-9Nv8dj-94mRTB-piBBzb-cs67WA-2AwseV-6zBbzK-9NJKMw-oB3bT-57B6Ah-7k3VYy-7Tc2-cs63Pu-2uaJi-cnsaB-bb8aq-eZDagg-f1xMJ7-78o3rm-c3ium-6uzPfH-4RSFBR-5As971-5Yj8JC-bjPubC-cs66ed-cs64rb-9NC5eF-4FNbRj-bi3gdT-4FNbSA-4TQ7Sn-9NGcbW-4FJ1hB-dR8rms-4FJ1tF-4FNbAy-5afKQf-9NDtMv-93Psrw-3LLqem-fwtCwt-dBCVtz-q7vxh-cs677u-bi3fbi-cs66GN-6MVoSa">kT LindSAy/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>To give one example, group treatment of people with anorexia nervosa, as commonly occurs in specialist treatment facilities, may be inadvisable given that exposure to extreme body shapes of other sufferers can exacerbate the misperception of one’s own body size.</p>
<p>But what should be the advice for us, the dissatisfied mirror-gazers in the general population? While a healthy lifestyle brings many benefits, a strict diet will not correct the misperception of one’s own body size.</p>
<p>Instead, the over-sized person you see in the mirror may be more effectively beautified by changing your visual diet. In visual stimuli, as in food, moderation (of skinny celebrities) is key. And, of course, variety (in terms of shape and size) is the spice of life.</p><img src="https://counter.theconversation.com/content/62428/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kevin Brooks does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Staring at one thing for a long time can cause you to see the next thing in the opposite fashion. This neural adaptation could be the underlying physiological basis of body-size misperception.Kevin Brooks, Associate Professor in Human Visual Perception, Macquarie UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/545712016-04-27T20:13:02Z2016-04-27T20:13:02ZDisease evolution: the origins of anorexia and how it’s shaped by culture and time<figure><img src="https://images.theconversation.com/files/119413/original/image-20160420-25595-iszbp6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Anorexia is often seen as an assertion of autonomy and control by a young woman who is engaged in a battle with her family and therapists. </span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/goldilockphotography/8178009129/">Mary Lock/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span></figcaption></figure><p>There are fashions in diseases, as in anything else. It’s understandable that a new, infectious and life-threatening malady could preoccupy us, such as cholera in the 19th century or Ebola in recent times. </p>
<p>It is harder to see why a panic erupts around a diagnosis that’s a century old, but a telegenic celebrity death can help. When the singer Karen Carpenter <a href="http://www.nydailynews.com/entertainment/music/day-singer-karen-carpenter-died-anorexia-1983-article-1.2520407">died aged 32 in 1983</a>, her heart gave out because of complications due to anorexia. Her death is widely credited with pushing eating disorders into the public consciousness.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/119415/original/image-20160420-25621-mhvnk9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/119415/original/image-20160420-25621-mhvnk9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/119415/original/image-20160420-25621-mhvnk9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/119415/original/image-20160420-25621-mhvnk9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/119415/original/image-20160420-25621-mhvnk9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/119415/original/image-20160420-25621-mhvnk9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/119415/original/image-20160420-25621-mhvnk9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Karen and Richard Carpenter with President Richard Nixon in 1972.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Nixon_meeting_with_Karen_and_Richard_Carpenter_-_NARA_-_194770.tif">Robert Leroy Knudsen</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Karen Carpenter was not the first famous young woman to starve to death. Sarah Jacob, “the Welsh Fasting Girl”, was once a national craze across Britain. She died at her parents’ farm in December 1869 in front of a team of nurses who had been sent from London to Carmathenshire to monitor her. </p>
<p>Sarah was believed by her family and her local clergyman to eat nothing at all. Her parents agreed to have her watched to make sure she was not secretly eating, but their faith in her was strong enough that they refused to have her force-fed. </p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/119420/original/image-20160420-25634-1xlj4nu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/119420/original/image-20160420-25634-1xlj4nu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=919&fit=crop&dpr=1 600w, https://images.theconversation.com/files/119420/original/image-20160420-25634-1xlj4nu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=919&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/119420/original/image-20160420-25634-1xlj4nu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=919&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/119420/original/image-20160420-25634-1xlj4nu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1155&fit=crop&dpr=1 754w, https://images.theconversation.com/files/119420/original/image-20160420-25634-1xlj4nu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1155&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/119420/original/image-20160420-25634-1xlj4nu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1155&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The Welsh Fasting Girl was a national craze in the 19th century.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Complete_history_of_the_case_of_the_Welsh_fasting-girl_Wellcome_L0005324.jpg">Wellcome Trust</a></span>
</figcaption>
</figure>
<p>As with other fasting girls, her alleged ability to live without food was taken by her supporters as a sign of special spiritual status, and seen by materialist physicians as evidence of hysteria and deceit.</p>
<p>Did Sarah Jacob, like Karen Carpenter, die of anorexia? </p>
<p>The diagnostic label “anorexia nervosa” was not coined until shortly after Sarah Jacob died, but of course a disease can exist prior to being named. She did not have all the symptoms associated with the modern diagnosis, but most mental disorders vary from patient to patient. </p>
<p>Anorexia is often seen as an expression of will – an assertion of autonomy and control by a young woman who is engaged in a battle with her family and therapists. If that’s the crucial point about anorexia then maybe Sarah Jacob was anorexic. Her fast turned her whole domestic world upside down and she maintained it right to the end. </p>
<p>In her 1988 history of anorexia, <a href="http://www.goodreads.com/book/show/414167.Fasting_Girls">Fasting Girls</a>, Joan Jacobs Brumberg, noting the presence of the medical team watching in her room, asserted that Sarah was “killed by experimental design”. But maybe she died of pride.</p>
<p>If the assertion of will, over both one’s own appetite and the authority of others, is the heart of anorexia, then perhaps we can push its history back further. In <a href="http://press.uchicago.edu/ucp/books/book/chicago/H/bo5954712.html">Holy Anorexia</a> (1985), Rudolph Bell argued that anorexia shaped the lives of many medieval saints and other holy women, who ate next to nothing. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/119417/original/image-20160420-25615-246wwm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/119417/original/image-20160420-25615-246wwm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=786&fit=crop&dpr=1 600w, https://images.theconversation.com/files/119417/original/image-20160420-25615-246wwm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=786&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/119417/original/image-20160420-25615-246wwm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=786&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/119417/original/image-20160420-25615-246wwm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=988&fit=crop&dpr=1 754w, https://images.theconversation.com/files/119417/original/image-20160420-25615-246wwm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=988&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/119417/original/image-20160420-25615-246wwm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=988&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Was Saint Catherine of Siena anorexic?</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/Saint_Catherine_of_Siena#/media/File:Giovanni_Battista_Tiepolo_096.jpg">Giovanni Battista Tiepolo</a></span>
</figcaption>
</figure>
<p>Saint Catherine of Siena fasted for days, far beyond what was expected of even the most pious young women in 14th-century Italy. She did so even when the male priests she was supposed to defer to expressly told her to eat something, on the grounds that her spiritual husband, Jesus himself, outranked them. </p>
<p>For Bell, it is Catherine’s assertion of her will – she sent angry letters to the Pope – that marks her out and puts her in a long line of anorexics extending to the present day. </p>
<p>Brumberg attacks Bell for assuming that female psychology has not changed over the centuries and that the past and present are the same. </p>
<p>But that’s unfair. It is certainly possible to acknowledge that both psychology and culture have changed dramatically over the years while also thinking that two people share enough relevant symptoms and personality features to justify applying the same diagnostic label to them both even if they lived centuries apart. </p>
<p>But obviously not just any remote similarity is enough, so how can we decide? </p>
<p>Archaeologists can find on ancient skeletons the traces of familiar diseases, but there is no physical marker to point to that would decide whether a mental illness was present in the middle ages. </p>
<p>Clearly, young women (and men) have been dramatically restricting their calorie intake for centuries, but not all the symptoms of modern anorexia have always been present, and some saintly behaviours are no longer associated with eating disorders.</p>
<p>Similarly, melancholy has a very long history, and many scholars see modern depression as essentially the same thing.</p>
<p>But modern clinical depression has dropped the distinction between melancholy, which has no obvious cause, and ordinary sadness, which is a reasonable response to the tragedies of life. “Depression” pathologises parts of our mental life that “melancholy” treated as normal – is it the same disease, or not?</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/119424/original/image-20160420-25625-u4thjp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/119424/original/image-20160420-25625-u4thjp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/119424/original/image-20160420-25625-u4thjp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/119424/original/image-20160420-25625-u4thjp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/119424/original/image-20160420-25625-u4thjp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/119424/original/image-20160420-25625-u4thjp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/119424/original/image-20160420-25625-u4thjp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Over the centuries our brains have been sculpted by our cultural selection.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-397005040/stock-photo-feeling-depressed.html?src=LvDZyzIupppuCJoj0fHMhQ-4-124">KieferPix/Shutterstock</a></span>
</figcaption>
</figure>
<p>Well, if you think mental illness is above all a problem with a neurological system, then there might seem to be an easy answer. The disease label refers to what is going wrong within your brain, and the cultural context just supplies the input and output. </p>
<p>Take an anorexic brain and plug it into 14th-century Italy and you get one set of symptoms. Plug it into modern Western societies and you get another. The different symptoms are reflections of different cultures acting on the brain. </p>
<p>Joel and Ian Gold, in <a href="http://www.goodreads.com/book/show/13260387-suspicious-minds">Suspicious Minds</a>, have discussed the emergence of what they consider to be a new form of psychopathology – the “Truman Show delusion” – in which, like the hero of the movie of that name, subjects imagine themselves as the star of a reality TV show. The existence of the show is known but kept secret by their friends. </p>
<p>The Golds argue that the delusion was caused by the rise of new forms of media and an attendant loss of privacy. It’s what you get when a paranoid brain deals with the contemporary social world, whereas perhaps a few hundred years ago these subjects would have been afraid of witches, not TV producers.</p>
<p>It’s a simple picture, and the brain-based concept of mental illness has great power. But culture shapes the brain in ways that makes the simple opposition too stark – London taxi drivers have extra-large hippocampuses, which have grown from use (it keeps a mental map of your surroundings) like the muscles of an athlete. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/119423/original/image-20160420-25639-fmg2u5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/119423/original/image-20160420-25639-fmg2u5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/119423/original/image-20160420-25639-fmg2u5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/119423/original/image-20160420-25639-fmg2u5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/119423/original/image-20160420-25639-fmg2u5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/119423/original/image-20160420-25639-fmg2u5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/119423/original/image-20160420-25639-fmg2u5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">London taxi drivers have extra-large hippocampuses.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/martinvars/6761505109/">martinvarsavsky/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Over the centuries our brains have been sculpted by our cultural selection just as by natural selection, and mental illness has been shaped accordingly. </p>
<p>At different times, different aspects of a syndrome will predominate, to be succeeded by others as the culture shifts. Historians need to argue about how to apply the labels, but the history of human society is reflected in the ways our minds go wrong.</p>
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<p><em>This is the second instalment in our <a href="https://theconversation.com/au/topics/disease-evolution">disease evolution</a> package. Click here to read the first: <a href="https://theconversation.com/disease-evolution-our-long-history-of-fighting-viruses-54569">Disease evolution: our long history of fighting viruses</a>.</em></p><img src="https://counter.theconversation.com/content/54571/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dominic Murphy receives funding from the Australian Research Council. </span></em></p>Young women (and men) have been dramatically restricting their calorie intake for centuries, but not all the symptoms of modern anorexia have always been present.Dominic Murphy, Director, Unit for History and Philosophy of Science, University of SydneyLicensed as Creative Commons – attribution, no derivatives.