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Eating disorders Medical students with "disordered eating"need to be supported not judged It is the run up to the exams, and you have just munched your way through a whole packet of chocolate biscuits while revising pharmacology. Does this mean you have an eating disorder? Well, a lot depends on what you do next. If you realise that you are nervous and bored and eating for comfort but do not worry too much about the excess calories you have just eaten, you are "normal." If you vow to get yourself into a training regimen after the exams and live only on mineral water, salads, and cottage cheese for the next month, you might be borderline normal. However, if you rush to the toilet and stick your fingers down your throat, feeling guilty and panic stricken, then you may be at risk of developing an eating disorder. Eating disorders - anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified (EDNOS) - are bad news. They cause much mental as well as physical damage1 2 and tend to become chronic.3 4 Anorexia nervosa causes more deaths than any other psychiatric illness, mostly through suicide and cardiac arrhythmias,5 and eating disorders in general are the third most common chronic illness in young adults after asthma and obesity.6
They are also difficult to diagnose and treat. People with eating disorders rarely admit that they have one, as they often feel ashamed. This means that their lives become entrenched in secrecy and deception, which makes them feel even more guilty. If this sounds vaguely familiar (such as with alcoholics and drug addicts) it is because the driving force behind these behaviours is often the same. In most cases eating disorders are not really about diet fads at all, though they might begin that way.7 They are often not disorders in their own right but a symptom of underlying problems. It is usually fairly easy to spot a severely anorexic person who is seriously underweight, but what about a normal weight person with bulimia? Is it normal to consume eight days' worth of food in about two hours and then try to vomit it all up again or purge it away with laxatives? Up to 5% of the population may be bulimic,8 and many of them have had the disorder for at least four years.9 And then there is EDNOS. This category includes a varied group of people who clearly have disordered patterns of eating or perceptions about their size and weight but who may not meet the strict diagnostic criteria for anorexia or bulimia nervosa. It might include someone who is on a permanent diet but who occasionally snaps and binges on chocolate or someone who starves all day after a big meal the night before or who exercises excessively to burn off the extra calories. Such examples sound very familiar don't they?
My point is that sometimes a strict diagnosis is only academic. Does it matter that people don't meet all the criteria for an eating disorder when they definitely have a problem with food or with their body size and shape? I therefore prefer to use the term "people who have disordered eating" rather than "people who have eating disorders." Unfortunately many people with disordered eating are often unfairly judged. Eating disorders are wrongly thought to be the self inflicted whims of silly and selfish people, thus trivialising the serious coping mechanisms that they really are. People with an eating disorder often use it as a way of ignoring all the other problems in their lives that they don't want to deal with. Most of the time, the issue is purely about control. Because they can't control many of the things going on in their lives - studying, exams, relationships, etc - they control the only thing that they can - food. In reality, the problem is often not really about food at all (see Clare Lindsay's article, p 239).
People with disordered eating are often sensitive, perfectionists, and high achievers. Is it any wonder then that medical schools seem to be full of them? In many cases the stresses of studying medicine contribute to the development of disordered eating Yet medical students with disordered eating are often told that they "should know better," thus making them feel even more guilty and ashamed. What they need is support and help. Some general practitioners are more sympathetic than others, but student health staff are usually well clued up about eating disorders and will readily refer you to a counsellor if you are brave enough to admit that you have a problem. You might have to wait for a while, and so you might want to try a self help guide while you are waiting.
If you are worried about your own or a fellow student's situation then don't despair. There are many organisations, individuals, and self help groups and books that can help. Such help is often not from the medical profession itself, but perhaps this is just as well. Doctors would medicalise the conditions, which are usually deeply psychological and need counselling and support rather than investigations and drugs.However, a bit more understanding and empathy wouldn't go amiss. Rhona MacDonald editor, studentBMJ I did a masters degree in Public Health project on the management of eating disorders in primary care and have professionally counselled many people of all ages with disordered eating. Help available:
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