What are Anorexia Nervosa and Bulimia Nervosa?

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Provincial Specialized
Eating Disorders Program
for Children and Adolescents

What are Anorexia Nervosa
and Bulimia Nervosa?

Ronald S. Manley, PhD, R. Psych.

Anorexia Nervosa

There are two types of anorexia nervosa:
1. The first type is a restricting form and is characterized by the following:
• These individuals are below normal weight and usually have
increasing weight loss which is pursued through restriction of caloric
• Many such individuals engage in marathon bouts of over-exercising in
an attempt to burn off unwanted calories.
• Individuals typically become quite preoccupied with eating, food, and
calories; or even with cooking for others.
• Often various rituals are developed around food, such as cutting food
into tiny pieces and prolonging the time required to eat.
• There is frequently a body image disturbance such that the individual
feels fat and may see herself as fat even though she may be very thin.
• Various types of unrealistic thinking patterns are often a strong feature
of someone with anorexia nervosa or bulimia nervosa. For example,
the individual may think that “Everything is okay if I am thin.”
Perfectionistic thinking and all-or-nothing thinking are additional
2. The second type of anorexia nervosa is the binge-eating/purging type. It
is also characterized by the above features but in addition includes binge
eating (bulimia), purging, or both of these behaviours. Purging refers to
an attempt to rid oneself of the unwanted food eaten or to avoid the
effects of having eaten, mainly the fear of weight gain. Self-induced
vomiting is a form of purging behaviour.

What are Anorexia Nervosa and Bulimia Nervosa?
Ronald S. Manley, PhD

Diagnosis of anorexia nervosa
Note that the
Official critieria for the diagnosis of anorexia nervosa require that
female and male
the individual refuses to keep her weight at least at a minimally
pronouns he/she
are used
normal weight for her age and height. Not every thin person has
this illness but it should be remembered that one does not have to
be extremely skinny to suffer from anorexia nervosa.
Apart from weight loss itself, the person may have not gained weight appropriately
during the adolescent period of growth. Risk factors, as outlined later, are
sometimes present well before the actual weight loss occurs. It is recognized that
use of adult criteria for diagnosis may not always be appropriate for the younger
age group. In general, it is felt that the earlier anorexia nervosa is identified and
treated, the better the outcome is likely to be.
Additional facts about anorexia nervosa
• Bulimia has been reported to occur in up to half of individuals struggling
with anorexia nervosa.
• It is estimated that anorexia nervosa afflicts about 1 in 200 teenage
• Anorexia nervosa typically develops during the adolescent years. This is
likely in part due to the fact that the teenagers are very self-conscious of
their bodies and there are many culturally-based demands to conform to
society’s goals for young persons.
• Over the past decade, there have been an increasing number of reports
on the appearance of anorexia nervosa in the 8–14 year old age range, or
before the individual has undergone the changes of puberty.
Males and anorexia
• Although up to about 10% of individuals with anorexia nervosa are males,
the remaining 90% are females, perhaps in part because the pressure to
be thin in our society is aimed mainly at women. However, there has been
increasing concern about the media’s representation of preferred body
shapes for males and its influence on boys and young men.

Bulimia nervosa
Bulimia nervosa is an eating disorder whose main feature is episodic binge-eating
followed by efforts to compensate for, or prevent, weight gain resulting from the
• These individuals typically feel a sense of loss of control over their eating
during the binge eating episodes, and are often fearful of not being able to
stop a binge episode.


What are Anorexia Nervosa and Bulimia Nervosa?
Ronald S. Manley, PhD

• Individuals may attempt to avoid weight gain through purging behaviours or
through the pursuit of vigorous exercise, or fasting.
• Individuals struggling with bulimia nervosa are typically within an average
weight range, although their weight may fluctuate widely at different times.
• The prevalence of bulimia nervosa is about 1–3% of female adolescents and
young women.
• Bulimia nervosa is typically a disorder seen in mid- to late adolescence a in
young adults. While there have been reports of bulimia nervosa in very early
adolescents, it is generally rare in this age group.

Why these are serious symptoms
Anorexia nervosa and bulimia nervosa can have serious medical and psychological
complications. These may include:
• Menstruation may stop or become irregular.
• Dizziness, lack of energy, and malaise (a general feeling of unwellness) are
often secondary to low blood pressure and/or dehydration.
• Possibly weakening of bones related to the malnutrition.
• Symptoms of starvation (dry skin, feeling cold, loss of hair, depression,
anxiety, difficulty concentrating).
• Growth delays or possible stunting of growth for children and adolescents.
• Tooth decay, tooth loss, and gum disease due to repeated vomiting.
• Electrolyte disturbances (abnormalities in those substances which contribute
to the maintenance of bodily functioning) such as low potassium levels, which
can lead to heart, neurological, and generalized muscle problems.
• High risk of heart irregularities which can cause death.
• Feelings of ineffectiveness, inadequacy, depression.
• Some may have thoughts about suicide.
These complications are very serious and requir
e prompt professional a

What causes anorexia nervosa and bulimia nervosa?
There is not one cause for eating disorders. A current view is that the causes are
multidimensional—that is, many factors may act together and cause someone to
have one of these eating disorders. Researchers consider risk factors to be related to
the individual, the family, and the culture.


What are Anorexia Nervosa and Bulimia Nervosa?
Ronald S. Manley, PhD

Individual factors
• The individual is someone who has felt inadequate, perhaps for a long
time, with low self-esteem and self-doubt. He may not know what is the
best weight range for himself and may use weight “numbers” as a
measure of his self-esteem.
• Perfectionism is also quite common. Individuals with eating disorders are
often very sensitive to the needs of others, yet have difficulty recognizing
and expressing their own needs and feelings.
Family factors
In some cases, patterns of family interaction may have contributed to the
development of an eating disorder. However, conflictual interactions and
communication patterns among family members may be the rest of coping with a
member who has a serious illness.
Cultural factors
These include the various pressures that women and men experience in our
society. Women, for example, are often expected to be attractive, assertive,
actively pursuing a career, and a super-mom as well.
These pressures occur within a society that stresses that “thin is beautiful.” As a
result of these pressures, in our society the decision of a young woman to diet is
not unusual and she is often initially supported by friends and family in her
attempts to lose weight. However, for some women, with the individual and family
factors mentioned above, dieting can lead to a serious eating disorder.

Some things to consider…
For the client
1. It is important to realize that thinking and feeling that nothing is wrong is often
part of having an eating disorder.
• Although you likely experience considerable anxiety around gaining
sing weight, you may not
weight and you wish to continue lo
see this as
a problem.
• It takes a great deal of courage to seek help and develop a relationship
of “working together” with a counsellor or therapist. Getting assistance
does not have to represent a loss of control.
2. Although you may not be able to overcome these problems on your own, it is
important to realize that you can be helped and that an eating disorder can be


What are Anorexia Nervosa and Bulimia Nervosa?
Ronald S. Manley, PhD

• If you have been suffering from anorexia nervosa or bulimia nervosa
for some time, it is normal to feel disheartened and doubtful that
anyone could understand the experiences that have been very real for
• Living with anorexia nervosa or bulimia nervosa can be a devastating
experience, and it is easy to be confused by the various thoughts and
feelings which you might have. However, there are other show can
understand what you have been going through.
3. Some of your experiences may be due to the fact that your body has been
going without food for some time.
• Many of the symptoms of an eating disorder may be due to the
starvation state itself. This is similar to living in an area where food is
scarce, as your body does not know the reasons why you are not
• These symptoms may include both physical aspects (such as drying
skin, hair loss) and psychological aspects (such as feelings of
irritability or depression). Once this stage has been reached, it is often
very difficult to reverse on your own.
4. Binge eating and purging are not diseases but are behaviours which can vary
in severity and frequency. Many circumstances can lead to a binge—including
repeated caloric restriction (dieting) and difficult feelings such as loneliness,
inadequacy, and anger.
When binge episodes are followed by purging it is usually more serious and
may be more distressful for you. You may feel both helpless and hopeless
about change.
However, it is very important to realize that it is not you that is at fault but
rather that these behaviours have become ways of coping for you.
5. It can be very helpful to question societal pressures to be thin. Media
portrayals of body shapes are usually highly unrealistic and can be damaging
to your feelings of self-esteem. It is possible to examine these messages
critically and decide for yourself what is in your own best interest.
6. If you are an older teenager, investigate whether there are any self-help
groups that you might wish to attend. These groups can serve to reduce
feelings of isolation and the idea that “I must be the only one going through
this.” Such a group can provide valuable information as well as help in seeking


What are Anorexia Nervosa and Bulimia Nervosa?
Ronald S. Manley, PhD

7. Many individuals with an eating disorder say that they feel like there are to
parts to them – one part may desperately want to help, but the other (eating
disorder part) tries to stop them form seeking assistance or treatment.
• You likely have very mixed feelings about seeking or receiving
treatment. Find ways to support and strengthen that part of you that
wants to get better and to have a life free from anorexia or bulimia.
• Consider asking a friend or family member to accompany you to
appointments and to provide support for you during further treatment.

For the family
If you think someone in your family may have or may be developing anorexia nervosa
or bulimia nervosa, it is important to seek professional assistance. A good place to
begin is with an assessment by your family doctor, who can make a referral for more
specialized evaluation and treatment if needed.
1. Often families go through several stages as their daughter (or son) continues to
lose weight, including an initial awareness of some weight loss to considerable
concern, anxiety, fear, and even disbelief at the extent to which the weight loss
has progressed.
• It is important to seek help as early as possible and not to ignore the
possible consequences of chronic dieting behaviour.
Do not regard the appearance of some of the signs and symptoms
described earlier as “only a phase she’ll grow out of,” but as a signal that
should be so
ught as soon as possible.
2. If your daughter or son has an eating disorder, it is important not to become
caught up in self-blame.
• Although family issues may be related to the development of anorexia
nervosa and bulimia nervosa, feelings of self-blame to not help to promote
the recovery process. In the same way, blaming the individual herself will
not be helpful and may serve only to further lower her feelings about
herself as a person.
• For these re
could be very he
asons it
lpful for the family as well as the
individual to view the anorexia or the bulimia as the problem, rather than
• It is important for family members to take responsibility for supporting the
individual in his efforts to recover. In early onset and adolescent eating
disorders, it
t parents—even if separated—be able to work
is crucial tha
together to facilitate their son or daughter’s recovery.


What are Anorexia Nervosa and Bulimia Nervosa?
Ronald S. Manley, PhD

3. It is very upsetting for a family to be faced with a daughter or son who is unable to
eat. It is normal to have feelings of frustration, anger, fear, and guilt. It is helpful
for family members to recognize and acknowledge these feelings as they can
serve to motivate families to seek help. It is important that these feelings be
discussed with involved health care professionals.
4. If you have a daughter with an eating disorder, it is likely that you have tried many
strategies to encourage her to eat. These strategies often run the course from
continual bitter arguments at the dinner table, to repeated pleading, and even
• It is important to realize that weight gain can be a terrifying experience for
your daughter. It will likely not be an easy process for her to undertake
recovery and let go of the eating disorder.
• Recovery can feel like a great risk for her, which may mean confronting
tremendous fears. Increasing pressure to eat may result at best in only
temporary success.
• It may be best to let your daughter keep the rituals and behaviours for the
time being as they may enable her to feel “safe.”
• Direction about how to best manage these issues and meal times and
upsets at home should be provided by the clinical treatment team.

Thoughts and feelings
Unrealistic thoughts and attitudes are often part of anorexia and bulimia. For
example, the person with an eating disorder may have the following thoughts:
If I begin to eat normally, I’ll lose all control and become fat…
Unless I lose another five pounds, I’ll never be happy…
I’ll always be depressed and lonely. No one could ever understand
what it is like…
No one would ever really like me as a person…
As someone develops anorexia nervosa or bulimia nervosa, his thoughts increasingly
come to be dominated by concerns of food, eating, weight, shape, self-doubt, and
ds of though
s. These kin
ts can have a profound effect on the way he
Learning to unravel the relationships between thoughts and feelings plays a major
role in the treatment of depression and anxiety, and it is important as well in the
treatment of eating disorders.


What are Anorexia Nervosa and Bulimia Nervosa?
Ronald S. Manley, PhD

Learning alternative ways of thinking and feeling about yourself is an important
component of the recovery process. A therapist can help you to understand your
thoughts and feelings and the relationships between them.
Seeking help
Finding someone or a team of health care staff you feel comfortable with, and can
trust, will be an important part of obtaining help.
Part of this tr
n collaborati
ust will mean developing a relationship based o
on with
health care professionals who understand your experiences.
It is important to feel that you can work together on a variety of concerns and issues,
and not just weight gain or preoccupations with food.


Ronald Manley, PhD, R. Psych. is a psychol
st with
the Provincial Specialized Eating
Disorders Program at BC Children’s Hospital
uver BC, Canada which is part of
the Children’s & Women’s Health Centre of British Columbia; he is also a Clinical
Assistant Professor, Department of Psychiatry, University of British Columbia.


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