Rasika Karkare 
Eating disorders are complex mental health conditions characterised by persistent and severe disturbances in eating patterns and behaviours. These abnormal eating patterns are typically associated with distressing thoughts and emotions, often leading to concerns about body weight and shape. Eating disorders can affect the physical, psychological and emotional health of a person, sometimes even leading to life-threatening consequences. The various forms of eating disorders include anorexia nervosa, bulimia nervosa, binge eating disorder, and avoidant restrictive food intake disorder.
This article explores the psychological causes of anorexia, the link between eating disorders and sleep, the prevalence of eating disorders in India, and the gender differences in how these disorders manifest.
The Psychological Causes of Anorexia
Anorexia nervosa is a severe eating disorder marked by a strong fear of gaining weight, distorted body image, and self-imposed starvation that results in significant weight loss. It is a complex condition with multiple causes, including genetic, biological, psychological, and social factors. Psychological factors, on the other hand, play a significant role in the development and maintenance of anorexia. Some of the psychological causes and contributing factors are as follows:
Low Self-Esteem
According to available research, people suffering from eating disorders commonly have low self-esteem, which contributes to both the development and maintenance of the condition. This is because many people with anorexia have a constant desire for external validation. They may believe that achieving a specific body shape or weight will make them more socially acceptable and boost their self-esteem.
Perfectionism
Anorexia is often associated with perfectionism. Individuals with anorexia may hold unrealistically high standards for themselves when it comes to their body and physique. This might even lead them to have strict and almost unattainable goals for themselves regarding their eating habits as well.
Body Image Issues
Research has shown that people suffering from eating disorders are often dissatisfied with their bodies. The societal pressure to have 'thin' and 'ideal' bodies can make people feel unhappy with their bodies and worried about their weight, contributing to the development of anorexia nervosa.
Cognitive Inflexibility
Cognitive flexibility refers to a person's ability to switch between different cognitive tasks or mental processes. It involves the capacity to adapt one's thinking and behavior in response to changing situational demands. Anorexia nervosa has been consistently linked with poor cognitive flexibility, making it difficult for suffering people to change their thoughts regarding their body and diet.
Childhood Experiences
Certain childhood experiences can contribute to the development of anorexia in adulthood. These are experiences of trauma, abuse, and being a subject of teasing/bullying. People who report being teased about their appearance or body shape tend to have a higher risk of developing anorexia. Other experiences include parents or family members setting ideal body standards for their children or shaming them for their weight or eating habits.
Low Self-Directedness
Self-directedness refers to the ability to shape our behaviors in line with our personal values and long-term goals. People with anorexia often exhibit lower levels of self-directedness, which can lead to impulsive actions that help to address immediate concerns, such as skipping meals to address body image issues. Although this may provide temporary relief, it hinders long-term recovery and perpetuates the illness.
Other Mental-Health Conditions
The development of anorexia among individuals has also been linked to other mental health conditions. Research suggests that almost 8% of people with anorexia could have autism symptoms as well. Additionally, anorexia has also been linked to obsessive-compulsive traits, with research suggesting that almost 10% of patients with anorexia also receive a diagnosis of OCD. Conversely, about 11% of individuals primarily diagnosed with OCD have a coexisting eating disorder. There is also an overlap of symptoms between the two, as people with anorexia often spend a lot of time obsessing about their body, weight, and eating habits, leading to compulsive rituals like exercising and dieting.
Need for Control
Research suggests that anorexia can be a way for individuals to regain a sense of control over their lives, especially when they feel overwhelmed or unable to manage other aspects of their lives. Restricting food intake may be a way to exert control over their bodies.
Do Eating Disorders Cause Insomnia?
If left untreated, eating disorders can impact various aspects of a person's life, from physical and mental well-being to sleep. In fact, research has identified a strong and complex relationship between eating disorders and sleep.
How Are Sleep And Eating Disorders Linked?
Studies show that there is a significant link between eating disorders and sleep. Multiple studies have shown that insufficient sleep is a significant feature of almost all eating disorders. Almost 57% of people suffering from eating disorders report experiencing some form of sleep problems, such as difficulties falling asleep, hypersomnia, parasomnia and early morning or midsleep awakenings.
Supporting these findings, a study conducted in 2023 found that patients with anorexia spend more time awake during the night and have more sleepless nights as compared to those without anorexia.
A study conducted in 2012 reported that mothers suffering from Binge Eating Disorder (BED) during or before pregnancy are more likely to experience sleep problems during pregnancy and may also report dissatisfaction with sleep 18 months after giving birth.
Another study from 2012 had similar conclusions, where it was found that Binge eating in women was associated with sleep problems such as poor or disturbed sleep, difficulty falling asleep and sleepiness at work.
A study in 2018 investigated sleep patterns in women with anorexia and bulimia nervosa. The results of the study indicated that both anorexia and bulimia were linked to significantly worse sleep quality compared to a healthy control group, which suggests that there is a strong link between eating disorders and sleep issues.
Another study from 2021 found that poor sleep was associated with symptoms of anorexia in women. The interesting finding was that the severity of anorexia symptoms was directly proportional to the severity of sleep issues, suggesting a link between the two.
Thus, there is a lot of evidence suggesting that eating disorders can lead to sleep issues as well.
Why Do Eating Disorders Cause Sleep Disturbances?
Eating disorders can lead to sleep disturbances due to multiple reasons, such as:
Hormonal Imbalance
Changes in appetite and eating disorders can impact the production of hormones that regulate the body's sleep-wake cycles. For example- malnutrition in anorexia may impact brain function, altering the production of hormones that control sleep and wakefulness.
Disrupted Circadian Rhythm
Certain eating disorders, like anorexia, and night-eating syndrome (an eating disorder that involves food consumption at night instead of during the day), can disturb the body's natural sleep cycle, making it difficult for people to maintain a healthy sleep schedule.
Comorbidity
Eating disorders often co-occur with anxiety and depression, both of which are known to cause insomnia. The stress and worry associated with these conditions can make it difficult to fall asleep or stay asleep.
Eating Disorders: Statistics in India
While the global understanding of eating disorders has grown, the Indian context remains relatively underexplored. Let's look at the prevalence of eating disorders in India.
Eating Disorders In India
Although it is difficult to get the exact data for the prevalence of eating disorders in India, the latest data published in the National Mental Health Survey, 2015 indicates that eating disorders affect almost 2 to 2.4% of the Indian population. Apart from this, other surveys conducted by licensed therapists report that the prevalence of eating disorders among the Indian population is 2-3% with a higher prevalence in women.
Research on Eating Disorders In the Indian Population
While there hasn't been a lot of research on eating disorders in India, the findings have been interesting. Adolescents and young adults have frequently been studied in the context of eating disorders. Let's look at the findings so far:
Research was conducted in the city of Bangalore in 2011 to study if eating disorders were on the rise in urban India. This study involved interviewing psychiatrists to find out if there was a rise in cases of eating disorders. The study found that almost 66% of the psychiatrists had seen at least one case of Eating Disorder in the last one year, suggesting that eating disorders were not uncommon in the urban population.
Research on Adolescent Females
Another study from 2013 looked at the prevalence of eating disorders in adolescent females in India. 120 females between the ages of 13-17 were a part of this study. The results found that almost 26.67% of participants in the study had disturbed eating attitudes and behaviours putting them at risk for developing an eating disorder. The study also found that characteristics such as dissatisfaction with one's body, perfectionism and occurrence of negative life events are associated with an increased risk of eating disorders.
Research on Students
A study published in 2018 studied the prevalence of eating disorders in the student population in Mysore. The study included 70 students between the ages of 15-25 years. The research concluded that 26.06% of students surveyed showed signs of abnormal eating attitudes, suggesting a significant prevalence of eating disorders in the Mysore student population.
Eating Disorders In Medical Students
Research published in 2021 on the prevalence and risk of eating disorders in medical students in South India found that almost 13% of the total 332 students were at risk of developing an eating disorder, with the risk being equally prevalent in both males and females. Additional findings indicated that high stress and concerns around body shape are associated with eating disorders. These findings suggest that eating disorders may be highly prevalent among medical students.
Another study on 472 undergraduate students from Kerela, published in 2021, found that 19.1% of all participants were at high risk for developing an eating disorder. The research also found that body shape concerns and symptoms of stress, anxiety or depression were significantly associated with the risk of eating disorders among the medical students. This supports the previous findings and indicates that medical students may be vulnerable to eating disorders.
How Are Male Eating Disorders Different From Female Eating Disorders?
While it is commonly assumed that eating disorders affect only women, men are also at risk of being diagnosed with them. Almost one in three people suffering from an eating disorder is male, making it quite a significant number. It is also important to note that even though men and women go through the same symptoms of eating disorders, they impact both genders in different ways.
Gender Differences In Eating Disorders
There are differences in how eating disorders manifest in men and women. They are:
Types of Disorders
The symptoms of eating disorders are likely to be the same among males and females, with no major differences; however, the types of eating disorders in both genders may differ. While women are more likely to be diagnosed with anorexia nervosa or bulimia, research suggests that Binge Eating Disorder (BED) or binge eating is a common behaviour among men. Binge Eating Disorder is characterized by chronic and compulsive overeating.
Body Image Issues
Body image issues are common in both males and females with eating disorders, but how these issues manifest is vastly different. While females are often pressured to maintain thin bodies, men may be under pressure to maintain more muscular bodies. Research conducted in 2015 suggests that men concerned with their physical appearance will likely indulge in harmful dietary behaviours. Over time, men's preoccupation with their physical appearance can lead to muscular dysmorphia, a symptom of body dysmorphia. People with muscular dysmorphia are likely to perceive their bodies as smaller or weaker than they are, leading to a distorted body image.
Triggers
The triggers and onset of eating disorders can also differ based on gender. Men may be more prone to developing eating disorders if they are from sports or fitness-related fields. Research suggests that male athletes are more likely to suffer from muscular dysmorphia. In contrast, societal expectations related to appearance and the media's portrayal of ideal bodies may play a more important role in the development of eating disorders in females.
Treatment-Seeking
The number of women and men seeking treatment for eating disorders differs vastly. Research suggests that men are less likely to seek treatment for eating disorders due to feelings of embarrassment, as eating disorders are typically associated with women. In contrast, women are more open to seeking treatment for eating-related difficulties.
Recent research also suggests that men are likely to improve quickly as compared to women in the treatment of eating disorders. However, further studies are necessary to validate these findings.
Comorbidity
A study conducted in 2010 suggests that men with eating disorders are likely to struggle with alcoholism, while women with eating disorders are more likely to struggle with major depression.
Conclusion
Eating disorders are multifaceted conditions influenced by biological, psychological, and social factors. They can be difficult to manage, both physically and emotionally, and share a circular and complex relationship with sleep — there is ample evidence to suggest that eating disorders like anorexia, bulimia and binge eating can cause sleep disturbances by disrupting the hormonal balance in the body, and sometimes sleep issues can worsen the symptoms of an eating disorder.
Recent studies also indicate that eating disorders may be on the rise in India, particularly among students and young adults, highlighting the need for additional research and awareness. Furthermore, recognizing the differences between male and female eating disorders is crucial for making the correct diagnosis and providing appropriate support. Irrespective of gender, eating disorders are a major concern, but there are treatments to manage and overcome them. If you or someone you know is suffering from an eating disorder, it is advisable to seek treatment as soon as possible.
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