Eating disorders and other mental health issues

Korey Baruta:

I sort of developed these coping mechanisms of controlling what I ate as a means of sort of dealing with the amount of anxiety and anxious thoughts.

Tim Conway:

I guess my OCD took on that; therefore became obsessed with how I looked and how I looked on the scales.

Emily Unity:

I think it’s that we’re not really aware of it, or we don’t have the language to talk about it. And, I feel lucky enough that I do now.

Sam Ikin:

This is the Butterfly Podcast from your friends at Butterfly, your national voice for body image issues and eating disorders. I’m Sam Ikin. Thank you so much for joining us.

Prof Richard Newton:

It’s very, very unusually in my experience with people with an eating disorder to only have an eating disorder.

Sam:

In this episode, we’re talking about how eating disorders so often occur with other mental illnesses. And when I say often, I mean, 97% of the time, that’s according to current research. Eating disorders are often complex with different causes for different people, but more often than not, the eating disorder exists alongside other conditions.

Prof. Phillipa Hay:

One of my very early research projects was uncovering a hidden eating disorder.

Sam:

The scientists give disorders that occur alongside others, the rather unappealing term of co-morbidities. I prefer to say co-occurring conditions. I don’t know, it just sounds less morbid.

Prof. Hay:

My name Professor Phillipa Hay. I’m an academic psychiatrist and I work at the Western Sydney University, and also in the public sector in the Camden and Campbelltown Hospital in Sydney.

Sam:

Professor Hay says that it’s very common for people who are looking for treatment for one kind of mental health condition to also be experiencing others that they’re not even aware of.

Prof. Hay:

A sort of textbook response to the co-occurring mental health issues is that the most common are indeed anxiety disorder—social anxiety in particular—and mood disorders and depression, but they also co-occur with people’s life experience. And, everybody brings a unique experience to their eating disorder. They are all individuals in their own capacity and they have their own stories, their own narratives to tell. And, we know that there’s many common factors in those stories.

Emily:

I honestly find it quite surprising to hear from a lot of people that they don’t have comorbidities. I think it’s more so that we’re not really aware of it, or we don’t have the language to talk about it and I feel lucky enough that I do now.

Sam:

This is Emily. She is a 24-year-old from Perth who, among other things, has quite a following, is a gamer who streams her video games online.

Emily:

I was diagnosed with a major depressive disorder and generalized anxiety disorder when I was about 13. I’ve had like a variety of other diagnoses along the way, but those are the two main ones that I’d say I identify with the most and that I still experience on a pretty consistent basis. I’d say that those two are definitely very tied to my experience with eating disorders and just my general experience of life really.

Sam:

Yeah.

Emily:

And this isn’t really like a mental health disorder, but I think also my experience with struggling with domestic violence has definitely influenced my eating disorders as well, so that’s a bit of a co-morbidity, I suppose. I remember when I was a lot younger, I grew up surrounded by everyone’s expectations and I always felt like there was this pressure to be someone that I really wasn’t. And, I just really spent so much of my time and effort trying to shape myself into something that other people wanted me to be.

Emily:

And along the way, I sort of lost sight of who I wanted to be as well. And it was sort of like an unachievable goal, like it felt very impossible. Like no matter how hard I tried, I would always end up disappointing someone. And, I would get very upset at myself about it and very hard at myself. And it got to the point when even when other people weren’t around, I would become very, very self-critical. And, I started not just picking apart pieces of myself, but very actively hating myself. I felt like that was this growing emptiness inside of me and I tried to fill it with different achievements, different friends, family, work, study, and it just felt like it could never really be filled.

Sam:

When she was 14 years old, Emily was at the point of being suicidal. But fortunately, it wasn’t too late. She was diagnosed with major depressive disorder and generalized anxiety disorder. And luckily, she was able to find the right support when she needed it and she began the slow process of recovering.

Emily:

My first experiences of eating disorders, I didn’t think I understood at all. I felt like they were much more of a physical condition, similar to like how you get sick from a cold or something. And, I felt like it wasn’t appropriate to talk about in therapy and I sort of fell into it unconsciously. So, the first thing that I experienced was a period where I went through anorexia and it was sort of looking back, it was caused by a lot of my anxiety about being physically present in a space and what other people thought of me. I thought that I definitely wasn’t skinny enough or pretty enough. And I felt if I ate less, that would help.

Emily:

I also had anxiety around eating in public and lots of anxious thoughts around like, you need to exercise, and I just kept pushing myself over and over again to try to become this person that I felt like other people wanted me to be or I wanted me to be. And, it was just a constant pressure from within myself. That was really hard. And, I definitely think whilst my anxiety contributed to it in that way, my depression was like a whole other force. It was like this really intense lack of motivation and very defeatist. I found it really hard to eat sometimes because I just didn’t see the point of doing anything. I really neglected my hygiene, my self-care, just motivation for anything.

Prof. Newton:

By and large, co-occurring mental health issues is the rule. It’s very, very unusual in my experience for people with an eating disorder to only have an eating disorder. My name’s Richard Newton, I’m a Professor of Psychiatry at Monash University, and also work as a Clinical Director of a mental health service here in Victoria. I think the evidence is really quite strong that in eating disorders, those co-occurring mental health issues are unusually highly prevalent. That depression with rates of up to 80%, whereas in the general population the co-occurrence of depression with other illnesses might be 20 to 30% higher rates of trauma than the general population, much higher rates of anxiety, much higher rates of psychosis, Sam, than people really think about. There is also quite a significant, not high, quite significant co-occurrence of schizophrenia, and other psychotic like illnesses alongside eating disorders.

Sam:

In a large U.S. study, 94% of individuals hospitalized for an eating disorder were also diagnosed with a mood disorder, including major depression.

Prof. Newton:

Eating disorders are driven very often by low self-esteem, high levels of anxiety, high levels of emotional sensitivity, as well as depression and obsessive compulsive disorder. Previous experiences of trauma—often of different types—over a prolonged period of time.

Sam:

We’ll come back to the professor in a minute, but first I’d like you to meet Tim.

Tim:

I live in Newcastle. I worked for an NDIS company in the city called Dynamic Ability Support. I’m a team manager there, where I look after about 16 workers and about 69 clients. And, I have a lived experience with OCD, which then developed into anorexia. When I was 8 years old, I had high levels of anxiety. I was always terrified of an axe murderer when I was staying over at my friends’ houses. And, I could just never stay at my friends’ houses and I’d have to come home in tears. So, my parents took me to different doctors, different psychologists and they kind of just diagnosed me with OCD and anxiety. And from there, it kind of manifested into absolute terror, being terrified of germs, and then my parents dying. And from that, I sort of tap my feet and constantly wash my hands. And in winter, my hands just get so sore, and cracked and bloody, and flicking light switches on and off. So, it’s been a rough ride being terrified of various things and sort of completing different rituals.

Sam:

It wasn’t until he was a young adult that Tim began to have body image issues, which then began to interact with the OCD that he was experiencing.

Tim:

On my 21st birthday, I saw the photos from it and I was just kind of… I don’t really like how I look, and then sort of went from joking between friends and they would say I was too large and just constant joking about that. And then, I guess my OCD took on that as being scared about becoming overweight. So, I engaged in behaviors and therefore became obsessed with how I looked and how I looked on the scales.

Sam:

You lived with the OCD for quite a while before it became an eating disorder.

Tim:

Yes. So, I was diagnosed when I was 8 years old, and then I was diagnosed with an eating disorder around 23, 24.

Sam:

How do you think that the OCD is connected with your anorexia?

Tim:

I think it’s just the obsessiveness. Obsessive about sort of doing my rituals a certain way. It’s also about doing things constantly the same way for an end goal. So with my OCD, I would flick lights on and off and tap my feet, hop into bed constantly, just so my parents would be safe. My mind would tell me if I didn’t get undressed 15 times that my parents would be killed in a car crash. So, I think it sort of ties in with my eating disorder by, if I eat something, then something bad will happen. So, I think they’re quite closely linked.

Sam:

Tim’s story takes us back to Professor Phillipa Hay at Western Sydney University. She tells us that a lot of long-term mental illnesses stem from some form of childhood trauma or what she calls invalidating experiences.

Prof. Hay:

So experiences during that time, which have not supported them to develop a strong sense of self-esteem, a strong and robust belief in themselves and sense of who they are in the world. And if that is not there or has not been there sufficiently during those years of childhood and adolescence, people may find that they turn to other ways of coping with emotional distress in what in psychiatric parlance we call coping mechanisms. And, they may be things like self-harm and they may be things like substance use, they may be things like eating disorders.

Sam:

By understanding how the co-occurring conditions interact or feed off each other. Professor Newton says it’s possible to work out what the causes and triggers are. And when we understand the causes and triggers, we can also understand and address the eating disorder.

Prof. Newton:

Some co-occurring mental health issues are somewhat, to very effectively, mitigated and reduced, as far as the person with an eating disorder is concerned, by the eating disorder. If you feel empty, and hopeless and despairing, and one of the things that you can do is to nurture yourself by eating, then you eat. And so, one of the things that binge eating does is it helps people fill themselves with something, even though it then becomes quite an aggressive self-harming, hurtful attack on themselves. Again, because driven low self-esteem, and guilt, and a sense that the person is to punish themselves.

Korey:

Hi, my name is Korey. I am an accredited practicing dietician with lived experience of anorexia nervosa, having now recovered and practicing as a dietician. Growing up and going through school, there was lots of additional pressures or stressors, things that triggered me a lot, whether that be assignments or tests at school, things that I used to strive and put my all into, because I was also a perfectionist and very high achieving. Being able to sort of channel my anxious energy into things that I could do sort of allowed me to, well, gave a false, I guess, a sense of control over my life or things that were going on for me. Which I guess then later in my high school years, when I was completing my final years and my studies to then to get into university, there was an immense amount of stress that I put on myself, which really aggravated my anxiety disorder.

Korey:

I sort of developed these coping mechanism of controlling what I ate as a means of dealing with the amount of anxiety, and anxious thoughts and energy I held onto. So, I sort of channeled that into the food I ate and controlling what I ate, how much I ate, and that sort of gave me a false sense of comfort or control over the hecticness of my life. It was then, I guess that without me really knowing, these behaviors became more obsessive and became compulsions, things I couldn’t really control. And soon enough, I ended up developing an eating disorder. I mean, in a way, both diagnoses were quite shocking, but the thing that really got to me or was like a shock was the fact that I had this generalised anxiety disorder, that I’d never really known about, but had pretty much been consistent throughout my entire life. And it was only later, sort of through my recovery and working with my therapists and my doctors that I realised that the anxiety was actually the core crux of what fueled my eating disorder.

Sam:

We’ve covered most of the co-occurring conditions, which appear alongside eating disorders, anxiety, obsessive compulsive disorder, mood disorders including depression. But there’s another one that clinicians see quite a lot, and that’s post-traumatic stress disorder. Approximately one in four people with an eating disorder have symptoms of PTSD.

Prof. Newton:

And, we think about PTSD as being something that people who’ve been in combat or first emergency responders might have, but it’s actually common in people with recurrent episodes of other traumas, sexual trauma, physical trauma, etc. And one of the things, I think we don’t talk about is the trauma of being unwell as a cause of PTSD, and also the trauma of getting treatment. And when you sit and hear people talk about their experiences with treatment of eating disorders, so many of them describe very clear cut PTSD symptoms, flashbacks, recurring nightmares, avoidance of treatments because they’ve genuinely and realistically experienced… Some of the treatment experiences are quite traumatic to them.

Sam:

I need to point out here that Professor Newton’s talking about past treatments from the bad old days, before the emergence of the modern approach that we talk about on this podcast, fueled by the growing number of studies that are helping us understand how people recover.

Prof. Hay

I was involved in a randomized control trial for people who had so-called failed other treatments, and had seven years’ experience of illness, at least with anorexia nervosa. We had a different approach to our goals of outcome. And, our main outcome was improvement in the person’s quality of life. So, that really became the focus and the talking point for when people engage in the therapy. We certainly had other outcomes related to the person’s physical health, and their emotional health and their eating disorder symptoms, but quality of life was the main focus. And, one of the most interesting things in that trial was not only that it worked, we could confidently say it was a treatment that worked, that helped people, but also, it was a treatment that people engaged in and stayed with in a much higher rate than in other treatment trials for people with anorexia nervosa

Sam:

Informed and compassionate carers, peer workers, psychologists and counselors can play a key role in helping someone recover. And for Korey, the quality-of-life approach is what worked for her.

Korey:

I had extensive support from doctors, psychiatrists, psychologists, dieticians, physicians, OTs, so many different people, and I had a really great team who understood me really well. And, I guess working with psychologists to work out what was going on for me, what were the drivers of my eating disorder, which was then sort of when there was the revelation of, it’s pretty much driven by my anxiety, which has been present for a lot of my life. So I guess, I had this treatment for my anxiety, alongside my eating disorder whilst inpatient. But as I got better physically and with my eating, I was discharged and I continued seeing my therapists as an outpatient back at home. And yeah, I engaged in lots of CBT, psychotherapy. I’ve been on incredible amount of medications for my anxiety to help dampen the symptoms to allow it to be at a manageable level.

Prof. Newton:

When you trying to help people find a way to recover, I think you absolutely have to validate some of the functions that the eating disorder serves in their life, and then explore with them other ways that they may be able to achieve those functions that are better for them. Because in my experience, even though, so ambivalence and being really intensely ambivalent about recovery is usual, I don’t know that I’ve ever met anybody with an eating disorder, and that might be because people come to see me when they want to get better. But even in circumstances where people haven’t necessarily voluntarily come to see me, one should listen carefully to people and explore things with them. Everybody that I’ve ever spoken to would prefer not to have an eating disorder, if they could have find a way out of it, to meet their other needs.

Sam:

Another thing that we know really helps, and we say this every episode is talking about it. Of all the treatment that Emily’s been through, she says the most important thing is an understanding of how to care for yourself.

Emily:

And so, it’s been about 10 years of therapy, different traditional types and different medications as well. And, I definitely say my recovery has been… It’s been very non-linear; it’s been a very weekly journey and trying different things. And, I think that healing looks very different for everyone. But for me, it was finding the people that really understood what I was feeling, because they had lived it. So people shared lived experience, people like peer workers, like friends that can really talk about these sorts of things. It’s been amazing to find a found family. And people that really understand and are very open-minded about it and accept that this is who I am, and I am going to have my ups and downs, but it’s still just me.

Tim:

Well, my brother’s always been… My brother and I are best mates. So, to have him there has always been great. I’ve always had such a supportive network in both mental health issues. I think that for someone to have such a good support network makes things probably a lot easier, getting treatment, realising there’s an issue. I’m very lucky that my brother’s new wife is a nurse, so she could see that there was something very wrong and then something needed to be done. So, I know a lot of people are not as fortunate as me, but I wish they were. I think a good support network, as I said, is pivotal to getting better.

Prof. Hay:

We know that there are many other things other than just a specific eating disorder treatment, sometimes that help people on that path to recovery. And that’s really, where I think it’s interesting at the Butterfly Foundation. And, peoples lived experience around Australia have been looking at different ways of managing eating disorders, and perhaps drawing on some of that lived experience that recovery may be more likely to occur in environments that are supportive, that are validating for the person. And, I think that’s really perhaps something, I may be speaking out of school here, but something that may have been behind the development, for example, of residential programs, or alternative programs to the sort of hospital-based programs that are the usual on offer for people with eating disorders.

Sam:

If you need support for an eating disorder, you can call the Butterfly National Helpline over the phone on 1800-33-4673. You can use a web chat at butterfly.org.au or email support@butterfly.org.edu.

Sam:

For other conditions, there’s lifeline 13 11 14, for crisis support 24 hours a day, seven days a week. Or Kids Helpline, 1800-551800 anytime for any reason. The Butterfly Podcast is an Ikin Media Production for Butterfly Foundation. With special thanks in this episode to Professor Phillipa Hay, Professor Richard Newton and Emily, Tim, and Korey for bravely sharing their stories. I’m Sam Ikin. And please remember, regardless of the mental health condition, talking helps. So if you know somebody who you think could benefit from listening to this podcast, please share it with them. They’ll find it in all of the good podcast apps.