The ABCDE tool for spotting signs of an eating disorder

by Nick Pollard BSc (Psych), MBPsS, FRSA.

“I hid the early signs from my parents, but my friends would have noticed if only they had known what to look out for, and how to help me.” (Dr Elizabeth McNaught).

Those are the words of my daughter, who is now a hospital doctor but who had nearly died from Anorexia Nervosa when she was 14 years old. These words are hugely motivating for me now as I work with her to help young people develop the knowledge and skills to spot the early signs of an eating disorder, and know how to respond appropriately.

Although eating disorders can develop at any age, the risk is highest for those aged 13 to 17, a time when communication between parent and child can become particularly strained. Add to this the fact that sufferers tend not to disclose the early stages, sometimes because they can’t believe they might be developing this disease, or because they view it as their friend and are therefore secretive about the signs and symptoms. Then we see how vitally important it is to invest in the awareness of all young people about this devastating illness, so that they are able to help their friends appropriately.

Many websites provide lists of signs and symptoms of eating disorders. But they can be long, hard to remember, and confusing.

Then one night, in her role as a hospital doctor, my daughter had an experience which gave her an idea for a simple tool to help people (teenagers especially) to spot the signs of an eating disorder in their friends and family:

“I often work in the Accident and Emergency department. One night a man brought in his elderly mother. ‘I’m really worried about her’ he said ‘I’ve seen the adverts on TV about strokes. You know… F.A.S.T. Look at her face, and her arm, and listen to her speech. I think she might be having a stroke.’ He was right, and because he had brought her in quickly we were able to treat her, and she did well.” (Dr Elizabeth McNaught)

That F.A.S.T. mnemonic is clearly very useful. It saves lives because it lodges in people’s minds and enables them to spot important signs. I know, from my own background in Cognitive Psychology, how such simple tools are effective in embedding memories. Indeed, my daughter tells me that, in medicine, doctors often use mnemonics to help them remember complex lists, such as the eleven major causes of pancreatitis (memorised as I GET SMASHED), or the process for assessing pain (memorised as SOCRATES).

So, combining her medical training, my background in cognitive psychology, and our joint lived experience, we sat down together to create a simple mnemonic for the signs and symptoms of an eating disorder, that would be easily memorable.

This was not an easy task, because of the added complication of the various types of eating disorders. We decided to focus on three of the most common forms listed in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5): Anorexia Nervosa, Bulimia Nervosa and Binge Eating Disorder. Whatever we created must not only be simple and memorable, it must also be applicable to all three of these diagnoses. After many different experiments, and trying out ideas with young people (our key target user) we finally settled on: ABCDE (Absence, Body, Control, Diet, Exercise).

As we did so, we consulted with experts in the field who encouraged us, such as:

“This provides simple, clear guidance to help identify early signs of an eating disorder. This is very important because detecting an eating disorder allows for early intervention and the best chance of a full recovery.” (Dr Karina Allen, Senior Clinical Psychologist and FREED-Up Project Manager, Eating Disorder Service, Maudsley Hospital London)

So, how does this ABCDE apply across Anorexia Nervosa, Bulimia Nervosa and Binge Eating Disorder? Before I address that, it is important to realise that the examples given below are just a few of the many different ways in which these complex and multi-factorial illnesses might manifest themselves (and we expect that other people will develop additional illustrative examples). Furthermore, although the sequence ABCDE is valuable for memorisation, the five signs and symptoms are not in any particular order of importance or occurrence. Indeed, a person in the early stages of an eating disorder might only exhibit some of these…

  • Anorexia Nervosa. Surprisingly they might be more interested in preparing and cooking food (to feed up other people) but may absent themselves when it comes to eating. They might find ways to avoid situations where they are expected to eat with other people, especially when the food is high in calories and/or they cannot control the type of food that is served (such as parties and restaurants).
  • Bulimia Nervosa. They might go straight to the toilet after a meal, in order to vomit the food they have eaten, or secretly use laxatives or exercise to compensate for the calorie intake.
  • Binge Eating Disorder. Because of the high levels of guilt and shame they typically binge secretly, away from other people, and might avoid close relationships for fear of being humiliated.
  • Anorexia Nervosa. They might develop a distorted body image (technically called Body Dysmorphia) where they become fixated on one or more self-perceived flaws in their body, typically related to its perceived size. They might become particularly sensitive to any real or imagined comments about body shape, their own or someone else’s, which trigger the ‘anorexic voice’ in their mind to tell them to lose more weight.
  • Bulimia Nervosa. Similarly, their sensitivity to their own thoughts or other people’s comments about body shape can drive the binge-purge cycle, as they use food to derive comfort but then feel compelled to remove the food through purging.
  • Binge Eating Disorder. Binge eating without purging can lead to weight gain. Subsequent real or imagined comments about body shape can compound the feelings of shame and self-disgust which paradoxically can lead to more binge eating as a means of seeking comfort in food.
  • Anorexia Nervosa. Even though they feel very hungry, they might try to control that feeling by finding ways to pretend to have eaten what they have actually given or thrown away. And they might seek to control the content and timing of meals as they are dominated by the ‘anorexic voice’ in their head.
  • Bulimia Nervosa. Although they are driven by a desire to lose weight, they might feel unable to control the desire to eat and therefore, having binged (often eating food that was previously avoided), they try to take control over what happens to that food by purging it as quickly as possible.
  • Binge Eating Disorder. Despite the intense feelings of guilt and shame about their secret binge eating, they feel unable to control the overwhelming desire to binge repeatedly, feeling unable to stop eating even when excessively full.
  • Anorexia Nervosa. They might claim to no longer like food which they previously enjoyed, or they might adopt restrictive food preferences such as clean-eating or veganism without the corresponding belief systems.
  • Bulimia Nervosa. Because of the drive to purge meals which they have eaten they might develop a preference for food which is easy to purge.
  • Binge Eating Disorder. The compulsion to binge, and the associated shame, can lead to unusual food acquisition such as buying binge food from multiple shops, and maintaining secret stores of food that can be accessed in private.
  • Anorexia Nervosa. They might exercise excessively and obsessionally, driving themselves to a point of exhaustion, and avoiding food if they don’t think they have exercised sufficiently.
  • Bulimia Nervosa. The purge element of the binge-purge cycle might include exercise as well as, or instead of, the use of vomiting or laxatives. Thus, their exercise is related to the amount they binge, and driven by their food intake rather than a reasoned and reasonable exercise programme.

Our hope is that this mnemonic might play a part in seeing a whole generation know how to spot the signs of eating disorders, and how to help.

To cite: Pollard NJ. (2019) The ABCDE tool for spotting the early signs of an eating disorder. The Family Files (FamilyMentalWealth.com), Issue 4.