Eating disorders:
recognising anorexia & bulimia and finding help

1. What are eating disorders?

Eating disorders are serious mental illnesses in which food, weight and body shape dominate a person's thinking, self-esteem and everyday life. They are not a diet that has “got out of hand”, and they are not a question of weak willpower or vanity.^¹

Overindulging now and then, or eating more mindfully for a while, is normal. It becomes an illness when thoughts about food and your body leave hardly any room for anything else, when starving, binge eating, vomiting or excessive exercise keep recurring, and when body and life suffer as a result. Anorexia is one of the mental illnesses with the highest mortality — which makes early help all the more important. The good news: with treatment, many of those affected recover, even if the road often takes time.^¹,²

2. Types: anorexia, bulimia, binge eating

There are also atypical forms, which do not meet all the criteria but need treatment just as much, and avoidant/restrictive food intake disorder (ARFID), in which the focus is not on shape or weight but, for example, on disgust at certain textures or fear of choking.^¹ The types can merge into one another over time. Binge eating disorder needs to be distinguished from obesity: not all excess weight is due to binge eating — and the binge eating needs its own treatment.^²

3. Warning signs and physical consequences

What to look out for

• Rigid rules around food — skipping meals, counting calories, cutting out whole food groups, only eating alone.
• Secrecy — going straight to the bathroom after eating, hidden supplies, food going missing, excuses at shared meals.
• Constant preoccupation with the body — frequent weighing or checking in the mirror, baggy clothes, disparaging remarks about one's own figure.
• Exercise as an obligation — training despite injury or illness, restlessness when a session is missed.
• Withdrawal and mood — irritability, low mood, withdrawing from friends, perfectionism at school or work.

Individual points prove nothing. If several come together, an open conversation is worthwhile — and so is professional advice.^³

What the body is signalling

In anorexia the body switches to energy-saving mode: constantly feeling cold, tiredness, low blood pressure and a slow pulse, periods stopping, hair loss, fine downy hair on the skin, constipation, concentration problems. In the long term there is a risk of bone loss, up to osteoporosis — even in young people. In bulimia, vomiting and laxatives lead to a loss of potassium and fluid that can throw the heart out of rhythm, along with damage to tooth enamel from stomach acid, swollen salivary glands and irritation of the oesophagus.^⁴

4. Causes and risk factors

There is no single cause. According to current knowledge, several factors work together:^¹

• Biological factors — eating disorders run in some families; a hereditary predisposition is considered established.
• Personality and mental health — perfectionism, low self-esteem, high demands on yourself, difficulties with emotions. Often there is also depression, anxiety disorders or obsessive-compulsive symptoms.
• Diets as a way in — many eating disorders begin with a seemingly harmless diet.
• Social environment — ideals of thinness, comments about weight and appearance, social media, sports with weight classes or an aesthetic focus.
• Distressing experiences — break-ups, bullying, assault or major upheavals can trigger or intensify an eating disorder.

5. Diagnosis: the first step

The first port of call can be your GP or paediatric practice, a counselling centre for eating disorders, or the psychotherapy consultation session (psychotherapeutische Sprechstunde), for which you do not need a referral. The diagnosis is based on a conversation and a physical examination.^¹,³

• Conversation: eating behaviour, thoughts about weight and shape, compensatory behaviour, mood — honestly and without judgement. It is about your situation, not about a number on the scales.
• Physical examination: weight and height, pulse, blood pressure, temperature, teeth, skin.
• Blood tests: electrolytes such as potassium, sodium and phosphate, blood count, kidney and liver values, blood sugar, thyroid.
• ECG: malnutrition and potassium deficiency can disturb the heart rhythm.
• Bone density: if anorexia has been present for some time.
• Ruling out other causes: unintentional weight loss can also come from an overactive thyroid, diabetes or bowel disease.
• Medication list: laxatives, water tablets, appetite suppressants and supplements belong on the table too — without shame, as they are medically important.

6. Treatment: what really helps

The core of any treatment is psychotherapy specific to the eating disorder. Ideally it is accompanied by medical care and nutritional counselling. The earlier it starts, the better the outlook. To be honest: anorexia in particular often lasts for years, relapses are common and patience is needed — but many people recover.^¹,²

Which setting and which method are right is decided by the treatment team and the treating practice together with you — for minors, together with the parents as well.

7. Medication: what it can do — and what it cannot

Medication plays a supporting role in eating disorders. The guideline does not see it as the sole or primary treatment.^¹

• Binge eating disorder: no medicine is specifically approved for it in Germany. Weight-loss injections do not treat the eating disorder; whether they make sense when someone is also overweight has to be weighed up by a specialist.
• Bone protection: according to current knowledge, the pill does not reliably protect the bones in anorexia. It produces a bleed that can mask the hormone deficiency — what is decisive is normalising nutrition and weight.
• Vitamins and minerals: supplements can make up for deficiencies but do not replace meals — the type and amount are set by the practice on the basis of blood tests.

Which medicine, at what dose and for how long is always decided by the treating practice. Antidepressants are not stopped abruptly but tapered off — see Stopping SSRIs and Stopping medications.

8. Medicines as a risk

In eating disorders, medicines are not infrequently misused — and even correctly prescribed medicines act differently than usual. This is a point that should be raised openly in treatment.^¹,⁴

Stomach acid from vomiting and a dry mouth as a side effect of some medicines put a double strain on the teeth. Dental check-ups are therefore part of the plan — tips in the guide Medications and dental health.

9. Family and friends: raising it without pressure

Anyone who is worried about someone often feels helpless. Pressure, control and discussions about calories usually make things worse. What tends to help:^³

• Concern, not reproach: talk in “I” statements about what you have noticed — “I'm worried because you hardly eat with us any more” — and not about weight or appearance.
• Choose a calm moment: not during or straight after a meal, not in front of others.
• Bear the defensiveness: denial and anger are common. Stay in touch — the conversation is often only the beginning.
• Offer concrete help: call a counselling centre together or go along to the first appointment.
• Act when minors are involved: parents carry responsibility and should involve the paediatric practice early; advice is also available from the Elterntelefon, the German helpline for parents, on 0800 111 0 550.
• Look after yourself: family and friends can get advice too — the BIÖG eating disorders helpline (0221 892031) is expressly there for them as well.

10. Everyday life and preventing relapse

• Create structure — regular meals according to the plan worked out together protect against hunger and binge eating.
• Know the early warning signs — skipping meals, more exercise, weighing more often. A written emergency plan says whom you call then.
• Reduce triggers — unfollow accounts that celebrate body ideals; delete diet and calorie apps.
• Take aftercare seriously — check-up appointments, blood tests, bone density and the dentist, even when you are feeling better.
• Be open about medicines — a complete medication plan, with no secret laxatives or water tablets, protects against dangerous combinations.
• Do not stay on your own — self-help groups and counselling centres provide support after therapy too.

An eating disorder is not a matter of character and not a sign of weakness. Seeking help is the bravest and most effective step — for those affected just as much as for the people around them.

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