The daily battle against anorexia

20-year-old Miriana Testaferrata de Noto has a history of eating disorders, one she is impressively open about, and one which has shaped much of her life so far. 

“Going through and defeating an eating disorder is something to be proud of and I feel it defines me now,” Miriana told MaltaToday.

Although still young, Miriana has been through almost the entire spectrum of eating disorders, starting with binge eating, moving on to bulimia, and anorexia, with occasional bouts of orthorexia – an obsession with healthy foods. 

“Ultimately it’s a cycle of guilt,” she said, adding that the disorder was a response to external factors in her life, particularly stress and anxiety about school examinations. 

“I would binge-eat one day because of anxiety, then feel guilty the next day and force myself to throw up through excessive exercise, or sometimes I would fast, if not try both at the same time,” she said, adding that the disorder subsequently became a way for her to stay in control. 

“The external factors causing my anxiety couldn’t be helped so I thought I was staying in control by modifying my eating patterns,” she said, adding that at the height of her condition when she was about 15, there were days where she couldn’t muster enough energy to get out of bed.

Besides the physical effects, like a lack of energy and pain due to excessive acid in her stomach, Miriana explained that anorexia slowly started taking over various aspects of her life, including her social and academic life. 

“I began to miss out on occasions for social interaction because they would revolve around food and dinners, and I also began missing out on lessons because I became so weak. 

“I ultimately had to drop out of Junior College and I needed therapy to get back on track,” she said, adding that seeing her grades slip and eventually having to leave school, made her feel like a failure. 

Loneliness compounded her anxiety, but Miriana also began to actively avoid her old friends because she was aware that they would see the difference in her appearance and call her out on it. “Although I was proud of looking increasingly skinny, I think I was always aware that I wasn’t going about it the right way, and there were moments where I questioned why I was living – or rather – existing the way I was.”

Despite this awareness, she persisted in losing weight – anorexia was like a voice that was ever present in her mind.

“It is a daily struggle, and it never goes away entirely. Therapy helped me realise that learning to ignore and stifle the voice is a long process, and that it’s ok to relapse sometimes.

“What made me finally realise I needed therapy was seeing the concern in my family’s eyes,” she said, describing her parents and two siblings as an “incomparable support system”.

“They were there for me at the worst of times and they lived through the disorder alongside me. However, I don’t think anyone should seek help unless they really want it.”

After she sought out help, it was only a matter of months before her health was back on track, but even then, it was only because she was truly determined to change herself.

“Recovery is one of the hardest things I have had to go through so far, both physically and emotionally, and I wouldn’t have managed to get through it and benefit from it properly unless I was truly willing to let it change me,” adding that however hard it had turned out, she was convinced she had discovered many of her strengths through it. 

Although two years have passed since the start of therapy at 18, anorexia remains a daily struggle: Miriana keeps trying to to avoid triggers like stepping on a weighing scale. “Although I’ve stopped going to therapy now, I know what to avoid, and I also know how to recognise the signs of when my anxiety gets too much for me to handle alone.”

She still goes for one-off therapy sessions every now and then. One of the most important things to keep her as distant from the disorder as possible is keeping herself busy, and now she pursues a degree in European Studies at the University of Malta, apart from regaining her social life.

“I understand that some people find it hard to talk about their experience, but for me, it’s freeing to share my experience with others… being open about my history has also helped me make more friends. I know that as I was recovering I found other people’s experiences inspiring and they encouraged me to pursue the process, however difficult it was.

Sitting opposite me on a bench at University and sipping her coffee as she told me her story, it is hard to connect Miriana’s struggles with the determined girl in front of me. That, to her, is pretty much the point of raising awareness: eating disorders can affect anyone and sufferers deserve sensitivity and support because most of the time they feel like they are alone.

Clinical psychologist and psychotherapist Dorothy Scicluna in fact said that the disconnection from each other and loneliness that most teens experience might lead to self-destructive behaviours such as self-harm. Some revert to food as a means of coping and this makes them more vulnerable to eating disorders, with some forms of eating disorders involving self-destructive behaviours or being seen as such.

“Eating disorders [EDs] are serious mental illnesses and once a person is affected their life is interrupted until recovery is achieved. It typically starts when a person is overly concerned with weight and shape to the point that they try to alter their weight or shape through restricting their food intake or through excessive exercise.”

Similarly to Miriana’s experience, Scicluna says eating disorders  often fall​ ​along a spectrum and ​one diagnosis will merge into another.

Local surveys indicate that different disorders affect different age groups, with a survey presented in a paper by Anton Grech from Mount Carmel Hospital’s department of psychiatry, on a randomized sample of 6,000 people showing that anorexia remains the most common eating disorder for the younger age groups with a 1.3% occurrence among 18-29year olds.*

Although Malta seems to have a higher rate of binge eating disorders when compared to the rates of other European countries, this was probably due to the fact that the country has high obesity rates.

“Although we traditionally associate eating disorders with women, recent research is indicating that men seem to be ​affected too. It might be less apparent because they might be ​embarrassed to discuss having such issues. The most common ED among men seem to be​ binge eating disorder and anorexia athletica (sports anorexia) also referred to as hypergymnasia, which is characterized by excessive, obsessive exercise.”

Scicluna points out that former sufferers have to keep their behaviours and dieting practices in check for a good number of months after treatment.  “There will be little lapses and the person should not feel scared, but instead take these as further learning curves.”

Awareness has grown over the years, and although there are few professionals specialised in the subject locally, interest in the matter was growing. “Psychologists and psychotherapists offer a range of psychotherapies that can help the person understand the root of their eating problem,” Scicluna said.

Nutritionists and dieticians had also been immensely helpful in recommending food intakes and preventing the development of disorders.

“Our general hospital also offers medical care when necessary, and there is also Dar Kenn ghal Sahhtek, which offers a residential programme for eating disorders and obesity.

“More should be done to normalise mental health issues and remove the sense of shame that often shrouds them. I would be very happy to see the set-up of an eating disorders unit at Mater Dei hospital along with maybe more help being offered on a community level, perhaps at health care centres,” Scicluna added.

Eating disorders

There are three main disorders: Anorexia Nervosa, Bulimia Nervosa and Binge Eating Disorder. 

Anorexia nervosa happens when a person becomes visibly and significantly underweight as a result of restricting their food intake. If these restrictions are unsuccessful, sufferers would typically experience a binge of eating a series of foods in a rapid way followed by a sense of shame and disgust.

When the person does not compensate for the binges, the person is suffering from binge eating disorder. 

Here the person will typically start to gain weight rapidly, but if the person throws up the food, or uses laxatives or excessive exercise to compensate for the binge then the person suffering from bulimia nervosa.

Very often the person suffering from bulimia nervosa will have an average weight. “There are several consequences to these conditions, and they lead people to lose sight of their own life,” Scicluna says. Very often, sufferers will lose track of their life goals and their psychological and life development is often interrupted. 

“There are also physical and psychological consequences, with most physical symptoms being reversible when weight is restored and the body is being fed the right nutrients.”

Other symptoms, such as achieving a regular menstrual cycle, may take longer. “A positive consequence happens when the person decides to embark on a path of recovery through psychotherapy. This offers an opportunity for growth and insight. The person will also learn a lot about the body, how it works and they will also become quite knowledgeable in the area of nutrition. Some sufferers develop careers related to nutrition or psychology once recovered.”

* (The results of a telephone based survey conducted between May and June 2012. A randomized sample of 6,000 people aged between 15 and 50 years of age. Results show that 2.9% of respondents have suffered from an eating disorder at some point in time, 2% had suffered an eating disorder in the past and 0.9% were suffering at the time of the study. 

According to the study, Binge Eating was the most common eating disorder with 55.8%, followed by Anorexia with 34.3% and Bulimia with 13.3%. However, according to the study, persons aged 18-29 were more likely to suffer from Anorexia and people aged between 30-44 were more likely to suffer from binge eating.)