Today is International No Diet Day. One of the questions many people have is how do you diagnose an eating disorder?

This occurs for people who become concerned about a friend, a child or themselves. Most people find going to the text books unhelpful as the categories can be confusing and varied. This is complicated further by the many variations of eating disorder that exist, e.g. anorexia, bulimia etc. All of which can present very differently and can be therefore difficult to spot.

The most challenging characteristic in identifying an eating disorder is that, by its very nature, the condition is a secretive. Therefore the sufferer is often the last person who will bring it to the attention of others. That’s not to say that someone who is suffering from an eating disorder does not want help, they often do. It’s just asking for help is a genuinely difficult task.

What is an eating disorder and how do we distinguish it from a healthy diet? The first thing to say is that this is difficult because many eating disorders start out as beginning a healthier diet but over time morph into something very different and far more sinister.

How do you know? By exploring the person’s ‘relationship’ with food, weight and shape. This will reveal the difference between a ‘dieter’ and someone with an ‘eating disorder’. For example, if you challenged someone on a diet to eat a Big Mac they would probably refuse. The basis for this refusal is that the dieter is acutely aware of the effort it will take to burn off the calories in the Big Mac and therefore will not want to do it. However, if you were to persist and offer the dieter €100 to eat the Big Mac they may well relent and agree to do it. When the dieter is eating the Big Mac they may well be concerned about the calories they will have to burn off afterwards but this will be based on a realistic assessment of the calories in a Big Mac and many of them may actually admit to enjoying it saying something like ‘I forgot how good this tastes!’. So basically when the dieter breaks their dieting regime they have an accurate assessment of the consequences and they respond accordingly. No problem.

The same is not true of the Eating Disorder sufferer. For the benefit of this example let’s say we repeated this experiment for an anorexia sufferer. In this situation someone with an established eating disorder many would most likely point blank refuse regardless of the motivator. Even if it was €1000 to eat a Big Mac they might still say no. This is because the anorexia sufferer has a ‘disproportionate’ understanding of food, weight and shape. They believe that one Big Mac may cause them to gain 7 kilos in weight and they might imagine that they could see the weight of what they had eaten on their legs or stomach almost immediately which is impossible. They would experience the act of eating it like a persecutory challenge. They would feel overwhelmingly guilty about doing it and sometimes become incredibly critical of themselves with a firm belief that the act of eating this will have catastrophic consequences which again are not based in reality.

Here anorexia has warped the person’s ‘relationship’ with food weight and shape. The anorexic voice in their head is now considered ‘the law’ and anorexia has performed a form of sort of ‘brain washing gospel’ that has the sufferer firmly in her grasp.

An eating disorder is a condition characterised by a need for control. It often occurs at a time in our lives when we are unhappy and when things are happening around us that feel ‘out of control’. A seemingly reasonable response to this is to ratchet down the things that we ‘can’ control. Our intake of food has been something we have controlled since we were only a couple of months old. We realised we could press our lips tight together or push away a spoon and no matter what others wanted us to do we had ‘control’. We knew that we had a power and the power of refusal is an effective way of getting your point across without ever having to say anything or confront anyone. Many eating disorders are a kind of return to that illusion of control, but what happens is that over time we lose the control of our decision making and the eating disorder takes control of all of our choices.

An eating disorder is not a diet gone wrong, it is not an overzealous act of vanity and it is not a problem that is developed to exasperate your parents. An eating disorder is a desperate attempt to regain control when you feel overwhelmed which becomes a lonely and tormenting journey which can isolate us from all of our supports. The anorexia voice may force the sufferer to decline any offers of help and deny that anything is wrong despite the person feeling desperate and alone. As friends and family we need to persist. The eating disorder will not welcome it, but over time your daughter, son or close friend will.

Offer support and try to understand as best you can how trapped the person feels and offer to help them to battle out of it ‘together’. And believe me it is a battle. However having spent 20 years supporting young people to beat anorexia, I know that this is a battle worth fighting.

By Colman Noctor
Child and Adolescent Psychoanalytical Psychotherapist, St. Patrick’s Mental Health Services, Dublin 8

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