A Study Guide on Eating Disorders

C O N T E N T S

INTRODUCTION

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UNDERSTANDING PROBLEM EATING

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EATING DISORDERS TODAY

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a) Foreword b) About the author c) Tips on how to use this guide d) Terminology

a) Our relationship with food b) History of problem eating - an overview c) Overcoming ignorance and offering hope

ANOREXIA NERVOSA a) Understanding anorexia b) More practical ideas for understanding anorexia c) Diagnosis and symptoms of anorexia

BULIMIA NERVOSA

O F

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a) Understanding bulimia b) Diagnosis and symptoms of bulimia

BINGE EATING DISORDER (BED)

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T A B L E

a) Understanding binge eating disorder b) Diagnosis and symptoms of binge eating disorder

PICA DISORDER

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a) Understanding pica disorder b) Diagnosis and symptoms of pica disorder

TREATMENT AND HELP a) Treatments b) Other forms of help c) Useful contacts and useful informatiom

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MEET THE AUTHOR

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MARA COSTEA

I am a high school student currently in my junior year, passionate about raising awareness around eating disorders in my community. As a mealtime volunteer at St. Mary’s Hospital in London, I have firsthand experience with individuals struggling with these disorders. Additionally, I frequently collaborate on research projects with top universities across the UK to deepen my understanding and educate others about this critical issue.

I believe that eating disorders are often overlooked and misunderstood due to the stigma surrounding them. Many people mistakenly believe that problem eating is voluntary, done for attention, or simply a matter of not wanting to eat. Through this guide, I aim to shed light on the realities of living with an eating disorder and challenge these misconceptions.

I am always open to discussing any questions you may have about eating disorders, so please feel free to reach out if you would like to learn more. In the future, I plan to major in neuroscience to explore the complexities of the human brain and its physical and chemical effects further. My ultimate goal is to pursue a career in this field and find effective ways to mitigate the impact of eating disorders on our society.

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Foreword from the author From the author

I crafted this study guide to help you. I don’t know who you are, where you come from, or what background you have, but I know you are young and have struggled with something at some point in your life. Now, it is wrong for me to assume that - although I have yet to encounter someone completely content with their past - but if you claim to be in that position, this study guide remains relevant to you. My mission is to educate you on what the rest of the population may be going through, sharing how eating problems are often overlooked or generalised. Maybe helping you discover that the reason your best friend couldn’t come that day was not because their parents didn’t approve. There might be underlying factors at play, and I’m here to assist you in recognizing and addressing them.

The human brain is marvellously complicated; even calling it complicated could be a very restrictive way to put things, but the infinite number of ways that this vital organ functions is overwhelming, and it is something that occupies my mind every single day.

Through the realm of these pages of compiled hard work, I hope to deliver my ongoing passion to you; I will help you facilitate your exploration and learning journey, preventing future generations from becoming ignorant of what young minds are battling these days: whether it is sorting inner dynamics, familial bonds, fostering friendships, or helping heal others’ relationships through informative insights.

Moreover, I tried to make this guide your haven: a space where you can feel understood while gaining valuable knowledge. There are many informative guides on the market exploring these topics, but I made this one special through its design, contents and hours of work put into it. Feel free to read it however you like: take notes, annotate the margins, and make it yours! Flick through the pages, find the topic that you want to know more about, and read it from beginning to end, end to beginning, it is entirely up to you.

Much like the intricacies of the human brain, the possibilities are limitless! Create your routine and adapt your learning to your style or needs. I want this to be as comfortable as possible for you.

I do want to add that my ultimate goal was to reach as many people as possible, so I hope that the accessibility of the guide will help with that. To ensure its reliability and depth, I did a very substantial amount of research: research based on secondary sources such as articles and case studies, but also primary research on interviews and anonymous forms so that you don’t have to. Everything you require has been meticulously gathered and organised within this single creation.

As a disclaimer, this guide is not for diagnosis and is in no way, shape or form an expert’s professional view. Please, if you or someone you love is in danger, contact emergency services and seek professional help immediately. I i;s essential to recognise when professional intervention is necessary for proper treatment and care. At the end of this guide, you can find emergency contacts or spaces where you can learn even more about mental disorders.

Finally, I want to express my heartfelt gratitude to you. I don’t know who you are, where you come from, or what background you have, but I know that by just picking up this guide, you are actively doing something noble for yourself or someone you love. Enjoy!

TIPS ON HOW TO USE THIS GUIDE

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Below are some tips that you may want to take into consideration when flicking through the study guide. Of course, you do not have to follow them, but I believe they would be useful in having a much more pleasant experience, helping you make the most of your learning: Choose a suitable time of day and location for when you are reading this guide.

Do avoid reading before bed, or when you are alone, in case this could bring back or trigger unpleasant memories.

Do annotate, highlight, and keep the information or concepts you think you may want to remember or look back on.

After each reading session, try to wind down and do something you find relaxing.

Let it be an activity not too over-stimulating and pick something that would allow you sit with your thoughts and reflect on what you have read.

TERMINOLOGY 1. Anorexia Nervosa: Intense fear of weight gain and severe restriction of food intake.

2. Anxiety: Excessive worry or fear impacting daily life.

3. Binge Eating Disorder: Repeated episodes of eating large amounts of food without purging.

4. Bigorexia: Obsession with muscle size, leading to excessive exercise and dieting.

5. BMI (Body Mass Index): Measure of body fat based on height and weight.

6. Body Dysmorphia: Obsessive focus on perceived body flaws.

7. Bulimia Nervosa: Cycle of binge eating followed by purging.

8. Drunkorexia: Restricting food to offset calories from alcohol.

9. Insula: Brain region involved in body awareness and eating regulation.

10. OCD (Obsessive-Compulsive Disorder): Recurrent, intrusive thoughts and repetitive behaviors.

11. Orthorexia Nervosa: Obsession with healthy eating to an unhealthy extent.

12. Pica Disorder: Eating non-food substances.

13. Pregorexia: Extreme dieting and exercise during pregnancy to limit weight gain.

14. PTSD (Post-Traumatic Stress Disorder): Anxiety disorder from experiencing trauma.

MARA COSTEA

UNDERSTANDING PROBLEM EATING

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Understanding problem Eating The term “problem eating” may be unfamiliar to some people, and you may have picked this guide already knowing what it is, or you want to know what it is. Either way, it is important that we clearly understand its meaning. “Problem eating” is a term which encapsulates any negative thoughts towards food. As innocent as they might be or as severe, they all fall into this category. It is the inability to have that food freedom you had as a young child when eating an entire tub of ice cream was your dream and was in no way something to be worried about.

Problem eating could have meaning to things unrelated to eating at all. Such as eating at a fixed hour, eating with a specific utensil, having a “meal plan” that you ought to stick to, and the list continues. It is that thing that stops you from living your life because your brain is trying to control your food intake or simply the experience in some shape or form.

Something which is often overlooked and not many people know about is the difference between disordered eating and eating disorders. Eating disorders are the result of disordered eating and are found at the extremity of the risk spectrum.

Disordered eating is common in the cases of athletes striving for a certain weight to qualify for a competition, brides losing a few pounds to fit in their wedding dresses or altering weight to decrease the risks of an important surgery coming up.

These are all examples of disordered eating. When the goal is achieved, some people forget about their lifestyle changes and go back to their balanced diet while some continue to practice these disordered habits, becoming the victims of psychological effects, where they ought to receive professional care.

These effects link to 4 main feelings that the person wants to experience: comfort, celebration, reward, or punishment.

Whatever the victim desires will provoke them into creating disordered decisions around food. Their actions release endorphins, dopamine and other chemicals that result in feelings of well-being, temporarily alleviating stress and pain.

Eating disorders are so dangerous because they affect how we are physically, mentally, emotionally and behaviourally. Something important is that eating disorders could affect everyone, however there are groups of people more at risk than others: females, adolescents, perfectionists, those who are competitive, worry about others’ opinions, have poor coping strategies, and those under intense pressure to succeed, have family members with eating disorders, promotion of dieting in your surroundings, having suffered trauma, confusion around sexual identity, and the list continues. The science behind eating disorders is based on the “feasting and fasting” concept. This alteration between the two leads to changes in the dopamine receptors, so it is almost like developing an addiction, in this case, not around drugs or alcohol, but around food.

Eating disorders today a) Our relationship with food The odd thing about food in eating disorders is that it is both the problem and the solution.

Today, we are all faced with the challenge of making a choice.

Humans have developed so much, that we have access to all types of food all year round. That means that we are exposed to this overwhelmingly complex list of choices, making us doubt whether we have chosen the right one. That causes us to check the nutritional information section, starting to consider calorie labels and macronutrient scores. Without even knowing it, we fall prey to the eating disorders. For example, yes soya is great!

But we should in no way replace everything else in our diet with it. True, it is rich in proteins, so it would be a perfect addition to a meal, but over-consuming it will deprive us of the key minerals and nutrients that other foods offer us. Imagine a world where there was no advertisement for the foods that you have in your fridge. Would its contents differ in any way? Most probably, yes.

MARA COSTEA

UNDERSTANDING PROBLEM EATING

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I want to tell you right now that these videos are highly unrealistic and most of the time far from reality, but it is sometimes difficult to realise that on our own. I still struggle with this myself, and if you do as well, I advise you from taking a break from social media. It could promote your well-being significantly. There is hope, however, as there has been a significant increase in body-positive influencers and their comeback at diet culture, promoting proper nourishment and care for our bodies to function accordingly.

Moreover, our choices are impacted by the way these products are promoted. TV commercials, YouTube ads, and influencer sponsorships all are designed to influence our choices by making us believe that their food item is all that we have been missing.

We listen and we purchase. Ironically enough, foods that have lately been labelled as “superfoods” are causing malnourishment, due to our consumption of them and them only.

I think we are all familiar with the introduction of “the meal deal” where a very nutrient-packed whole-meal sandwich has been paired with a bag of crisps and a sugary drink for a much cheaper price. That, of course, is attractive, because you get your money’s worth, but this is not necessarily a healthier option.

Conversely, it is the opposite. This is evidence of how societal changes impact our food intake in so many ways. Another example can be the increasing popularity of microwaves and air fryers or other quick and easy-to-use appliances. All these cause us to become victims to the 3-minute pre-prepared frozen meals that they sell for very cheap prices. This leads to a decrease in wholesome, home-cooked meals, leading to unhealthy and imbalanced diets, inducing problem eating.

A topic that I wanted to approach was food culture and the media. I will not sit here and say that the media is the main reason why eating disorders are peaking now, but it has had a huge impact on new generations and how they view food. The size 0 models online, exposing their “what I eat in a day” videos, along with their so-called “advice” on how to lose weight fast and easily, are all very harmful to us. Also mentioning their video intros of showing their flat stomach bodies create this idea of “if you eat like this, you will look like this”.

All these factors are reasons why somebody may fall prey to an eating disorder, but to summarize, problem eating can also be caused by genetics and hormones, environment, life events or society and culture. Keep in mind that this is just an overview, and it is crucial to remember that there is no concrete reason for problem eating. It can be labelled as a complex combination of mental or physical factors.

Most importantly, remember that every situation is different.

a) The history of problem eating – an overview Problem eating is not a new concept and has been around for a really long time. In fact, scrolls and hieroglyphics from ancient times, contain evidence of negative behaviours and ideas towards food, such as purging or self-starvation.

During those times, it was incredibly popular to religiously fast, leading to what we call today anorexia nervosa (which we will explore later on). It is important to add that both males and females were victims at the time. In fact, a concept of anorexia mirabilis was something that has been recently discovered to have been an issue in the early ages. It entitles the idea of a miraculous loss of appetite, acting as a symbol of purity and holiness. This of course led to frequent premature deaths. Their efforts were to prove that to them, the spirit was more important than the body.

Although there are different reasons for which eating disorders are developed nowadays, all circle around the yearn for selfcontrol. Whether it is to look a certain way, or prove a point, it all leads to the similar, if not identical, consequences.

Bulimia has also been around for a while. It is believed that it was first introduced in Rome when they used the “vomitorium” approach in order to eat as much food as possible and enjoy every single dish. It consisted of eating until you were full, to then induce vomiting and consume even more food. Many people suffered from this disease; in fact, princess Diana claimed to have had issues herself, which raised awareness to the public.

MARA COSTEA

UNDERSTANDING PROBLEM EATING

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Anorexia Nervosa, first labelled as “anorexia hysterica” by Queen Victoria’s physician, was actually a disease that included women only, hence the name change. Binge Eating disorder is mostly having to do with greed and inability to control yourself when having a meal. It often includes incredibly voluminous intake of foods in very short periods of time, followed by guilt. This was not classified as a distinct eating disorder up until 2013, which, thankfully has happened, since people can now receive proper treatment.

Pica disorder is when someone ingests non-food items on a regular basis. In some cultures, even today, people eat clay, chalk, or other earthy substances, in order to gain nutrients from them.

This is not considered to be part of this disorder. It is important to add that there is little evidence of Pica Disorders in the past.

Avoidant restrictive food intake disorder has been very common in young children and is often viewed as a phase of growing up, which most surpass. However, when the avoidance of certain food groups due to their textures or colours becomes a natural occurrence and a habit in one’s life, the person may as well become diagnosed. It has been around for a very long time, most commonly in children whose relationship with food is in the process of development.

For the purpose of anyone struggling with any sort of distress around food but are not ticking the boxes of symptoms of certified disorders, this category has been formed. A good example could be someone that has lost a very significant amount a weight due to extreme restriction but is still at a normal BMI for height and gender. They meet all the criteria for being diagnosed with anorexia, but since they are not severely underweight, they cannot classify in this category.

Unspecified feeding or eating disorders are the ones that cannot be diagnosed into one concrete diagnosis. It often is the case that they are also referred to as new forms of problem eating, such as orthorexia nervosa, bigorexia, drunkorexia or pregorexia.

Orthorexia nervosa is found in individuals that become overly preoccupied with what they consume and what they put into their bodies. They develop a phobia of certain food groups or food items that they speculate may impact they health in a negative way. This is not yet classified as a disorder, but that does not mean that it is harmless. Besides the social struggles that these people face, as they are unable to meet with friends or spontaneously decide to get pizza, they could become malnourished, this having the potential of becoming fatal.

Bigorexia is often met in body builders and professional athletes that have unrealistic views of what their muscle size is, or the proportion of fat in their bodies. It has to do with extreme body dysmorphia (having a distorted perception of what you look like e.g. sufferers of anorexia perceiving themselves as fat, despite their emaciation) and can lead to severe psychological issues, in worst case scenarios being a powerful enough reason for suicide. It is very common, but not limited to, males.

Drunkorexia, however can be very common in females that are preoccupied by their weight but want to continue living a “good life”, hence why they severely restrict their calorie intake, so that they can drink without worrying about gaining weight. It is obvious that this could lead to drinking problems, alcoholism, diabetes or even dementia.

MARA COSTEA

UNDERSTANDING PROBLEM EATING

Pregorexia is one other eating issue which is evident to be met in pregnant ladies with an extreme fear of gaining pregnancy weight.

This can lead to severe consequences for the mother, but the child as well. Causes include genetical predisposition, as well as chemical and hormonal imbalances.

a) overcoming ignorance and offering hope Eating disorders are incredibly impactful on sufferers. They invade their lives and takeover their minds with greed and zero mercy. Without question, the sufferer is the one that experiences most severe impact; however, their family’s struggles are definitely underrated.

To help you grasp the idea of what it can feel like to have someone you love struggling with such an issue, it is like constantly walking on eggshells in your own home. Any sort of discussion regarding food, weight or getting back on track leads to some sort of disagreement or tantrum.

Something like an eating disorder puts on hold family outings, having people over, going on vacations or just living your everyday life and working towards your own goals. It is definitely a mental illness which is arguably most severe, as it takes over your entire life. Therefore, in the UK, there are countless services and helplines that are accessible and free of charge.

Moreover, people struggling with a similar issue to you create regular meeting times and discuss about their feelings openly.

This is incredibly helpful, but such services are not very common internationally. If you do not like in the UK, the USA, or at least a developed country, it is highly unlikely for you to find services that are available to you. A solution could be doing them remotely, across countries, so there are always options and there is no need for discouragement.

Unfortunately, the people around us are highly uneducated on the topic of eating disorders. So many still believe that having an eating disorder is a choice, a lifestyle you are willing to have, a lack of self-control or a desperate want for attention. This, of course, could not be further from the truth and us, an educated and informed generation, should raise awareness even further.

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My family did not know anything about eating disorders before we had to go through it ourselves, and although I am ashamed to say it, we probably would have ended up having similar beliefs about this struggle. Therefore, what I wish from the future is for people to become educated on the topic without having to go through it themselves.

As mentioned earlier, there are so many facilities for people struggling with eating disorders and there is so much help available, however although it is not the best thing to say, it is the brutal reality that “specialists” of these organisations are not in fact properly trained for what they are doing. Of course, take this with a pinch of salt, and do seek help if you require it, but I often heard stories about people that had gone to their GP only to have been turned down because their BMI was not “unhealthy” or they should just “go home and eat”.

To fix this, specialists must be trained a lot better, and I think the topic of eating disorders should be even introduced in schools; either creating support groups to have lunch together, or educating every student on what this entitles. There not being enough awareness risen, sufferers go by the principle of “not being sick enough”, which should definitely not be the case. The deeper you get into an eating disorder, the harder it is to escape it. If you go to the doctor for smoking problems, they will not send you away because your lungs are “not damaged enough”, right? Then why does this happen with eating disorders?

MARA COSTEA

ANOREXIA NERVOSA

To fix this, specialists must be trained a lot better, and I think the topic of eating disorders should be even introduced in schools; either creating support groups to have lunch together, or educating every student on what this entitles. There not being enough awareness risen, sufferers go by the principle of “not being sick enough”, which should definitely not be the case. The deeper you get into an eating disorder, the harder it is to escape it. If you go to the doctor for smoking problems, they will not send you away because your lungs are “not damaged enough”, right? Then why does this happen with eating disorders?

Did you know?

Eating disorders can definitely be treated, with proper care, love and, of course, nourishment.

Therefore, a suffering individual can go back to living a normal life after they have struggled. However, although organ function, body weight and relationship with food is fixed, there is a part of our brain – insula, that remains affected. When depriving the body of food, this part of the brain (responsible for perceiving taste, controlling anxiety, receiving hunger and satiety cues) shrinks and is damaged, having the inability to return to normal and therefore being passed on to future generations.

I want to wrap up this section by telling you that there is hope!

Many doctors have proven that the earlier you get help, the easier the recovery will be, and although eating disorder rates have significantly increased during the 21st century, the people coming forward and claiming to have struggled at some point, has increased as well. That is proof that you are not alone, and there are so many people ready to help you. What I found helpful was following people online going through the same exact problem.

Many youtubers and Instagram users share their stories and whenever it is hard to feel understood, make sure to give their profiles a visit, as their platforms are definitely a safe space for you.

At the end of the study guide, I have shared some of my favourite creators.

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Anorexia Nervosa i.Understanding anorexia

Anorexia nervosa is a mental illness that is composed of an extreme control of appetite. Common sufferers are adolescents; normally females, but can also be males, both of all ages. It is often found in people that are high-achievers and perfectionists, sensitive to criticism and life changes. It is common for anorexia to appear in their lives during unpredictable times where they are incredibly overwhelmed and feel out of control towards their life decisions, hence why they start taking it towards their food intake. Although these are the most common reasons, it is important to remember that every person experiencing this mental illness is different and can have completely unique motives for which they have reached this point in their lives.

Some include looking more attractive, receiving admiration for their willpower towards restriction, feeling unworthy and shrinking themselves despite having a strong desire to disappear.

It must be kept in mind that the initial admiration that they receive from those around, for perhaps looking more toned despite losing a few pounds, is just feeding their anorexic voice, leading them to continual downfall. Therefore, if someone’s weight fluctuates, try not to mention it admiratively. Be precautious and make sure they know you are there to support them. There is a quick escalation in the choices made by people that suffer from anorexia, the deeper they are into the disease.

This means that they are less likely to make rational decisions in regard to their health, which is known as volition attrition.

People struggling with anorexia are under the influence of what we call “the anorexic voice”. This is the “voice” in their heads that leads them to take irrational decisions about their health. They often create weight goals, unhealthy habits, or calorie limits, becoming obsessed about food. Once their goals are reached (e.g. a certain weight, a certain number of calories in a day), new goals are created, but the enemy is never satisfied. It is a vicious cycle that we can only prevent by tackling the problem early.

MARA COSTEA

ANOREXIA NERVOSA

Secrecy and social isolation – People who suffer often drastically change their personalities. All they start to care about is how they look or how much they are eating, starting to become selfish and ignorant. This leads to habits such as lying to loved ones about their food intake, hiding it, or in worst cases even throwing it away. This leads to a strict avoidance of social gatherings and interactions with friends. They start to view these events where food is involved, as others’ efforts to make them gain weight, which, of course is irrational. They end up staying alone, their only companion left being that anorexic voice.

i.Practical ideas for understanding anorexia.

Understanding anorexia for people that have a loved one under its influence involved being prepared to: 1.

Give the sufferer time, patience, and support. At the beginning, there is no doubt that the sufferer feels as though they are doing the right thing, and they will not listen to your concerns. Therefore, try to be as understanding as you can with them, ensuring that you acknowledge what they are feeling. It is crucial to create a safe environment for them, so that as they realise that they are in the wrong, they will be ready to confide in you.

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1. Do not criticise them in any way! Sufferers of anorexia already criticise themselves and have a very abysmal view towards their own person, so by laying out things that they are doing wrong, will only alleviate their behaviours, as they will feel bullied and as though they are a disappointment to you. In other words, they will feel as though there are even more reasons for which it is worth restricting for.

2. Never get aggressive or strict when it comes to moments of relapse. Continue to praise their hard work and encourage them to get back on track. If there is one thing you should remember, it is that recovery is often non-linear, and no person in the recovery process will have a perfect trajectory.

3. Resist the urge to take total control over the situation. This will lead to small, forced victories, but in the long run, it will have no impact if the sufferer is not the one that truly wants to recover.

Keep in mind that you are only temporarily with the sufferer, whilst the anorexic voice is permanently there. Inducing a challenge against the sufferer’s will, is going to lead to nowhere since they will find other places to restrict from, in order to “make up” for it.

i.Diagnosis and symptoms of anorexia Before confirming that someone struggles with anorexia, there are many things to consider.

Therefore, simply seeing a very underweight individual, does not mean that they struggle with this mental illness. For example, they can have health conditions where, despite having balanced meals, they do not have the ability to get the required nutrients, having no time/resources to cook, etc.

These people may be severely underweight, but it is in no way due to a strong desire of weight loss.

1. Ensure that you help them realise that there are two voices in one’s mind: the anorexia and their true self; in order to destroy the damaging voice, you should project their own voice. Remind them of their talents, their goals, their achievements. Let them realise that without health and proper fuel, they will lose all of those things. The disparity between the two voices is the reason why we refer to them as “sufferers of anorexia” rather than “anorexics”.

In order to diagnose someone as a sufferer from anorexia, they should meet all of the following criteria:

·Intense fear of weight gain ·Significantly lower body weight than their height, sex, and age. ·Denial of the dangers they are prone to experiencing despite their low body weight and malnutrition.

MARA COSTEA

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BULIMIA NERVOSA

Anorexia can be of two types: restricting type, and binge eating/purging type. Restrictive anorexia is the most common type, and it involves extreme calorie restriction through odd habits that the individual has developed. This includes eating only a certain number of calories in a day, excluding certain food groups or colours from their diets or any other way that seems problematic. If faced with consuming these “forbidden” foods, the sufferers will experience intense distress. Binge eating/purging anorexia is less frequent and still involves extreme restriction, but at some point when starvation feels too difficult, they binge. That triggers strong emotions of guilt, which lead them to purge or over exercise in order to cut the calories that they have consumed.

Warning signs and symptoms – Below are the most common symptoms found in suffering individuals. Some of them are found in late stages of the illness, so keep that in mind when reading them: ·Psychological signs: depression, suicidal ideation, refusal to acknowledge dangers associated with their low weight, distorted thoughts due to their errored perception of their bodies, escalation of obsessive behaviours, secretiveness, difficulty concentrating, low self-esteem, self-criticism, moodiness, irritability and sensitivity, perfectionism, withdrawal from relationships and social interactions, indecisiveness.

·Physical signs: weight loss, reduction in white blood cell count, anaemia, electrolyte and mineral deficiencies, thinning of hair, stomach pains, swelling of hands, face or feet, dry skin, chapped lips, brittle fingernails, poor circulation and always feeling cold, reduced metabolism, bad breath and tooth decay caused by vomiting, loss of teeth due to jawbone weakening, dizziness, bloating, amenorrhoea (interrupted menstruation), insomnia, low blood pressure and slow heart rate, impotence in men, downy hair over body and face, loss of libido, headaches, osteoporosis, reduced immune system, frail appearance. ·Behavioural signs: repeated weighing, body checking, refusal of eating in public, avoidance of certain foods, skipping meals, taking , laxatives or weight control pills, hiding or throwing away food, obsessive reading and watching food related things, constant excuses to why they are not eating, cutting up food in tiny pieces before swallowing, self-harm, substance abuse, wearing baggy clothes, lying about weight, strict dieting, disappearing after meals to go to the toilet, pretending they have already eaten, over-exercising.

Bulimia Nervosa i.Understanding bulimia “Bulimia” translates from Greek as “hunger of an ox”; sufferers experience fluctuations between extreme restriction and binge eating episodes, followed by fasting, purging or laxative consumption. Just as anorexia, mostly females suffer with this disease, but in a recent study, 20% are men, an increase from the logged 10%, meaning that more are coming forward, which means that awareness has been highly successful. Causation of bulimia can be due to other disorders such as OCD (obsessive-compulsive disorder), PTSD (post-traumatic stress disorder), or childhood trauma. Sufferers are often also perfectionists and suffer from anxiety or depression. Just as anorexia, bulimia is believed to be hereditary, as research has proven that it is 4 times more likely to develop the disorder if a member from your immediate family already experienced it. This however is not certain and can be a mix of both nature and nurture.

Dieting is often the starting point of the illness, and just as anorexia, it could be due to the desire of meeting others’ expectations or fitting in.

Contrary to anorexia, it could develop due to bullying, being overweight and having experienced parental loss or separation.

Did you know?

sufferers of bulimia could have been previously sufferers of anorexia, and vice versa. This is known as bulimarexia and is often met by sufferers that run on both cycles.

Sufferers of bulimia are much more difficult to identify, given their normal, to slightly exceeding weight. Although the individuals are not severely underweight and therefore not at certain risks, the illness is still very dangerous, having serious psychiatric side-effects. Similar to anorexia, bulimia starts by a “so-called” harmless diet, but when restriction becomes too extreme, and starvation happens, the person experiences the urge to binge. Bingeing is the act of consuming very large amounts of food in very short periods of time. Normally, a bingeing episode involves the consumption of between 3000 and 5000 calories in the range of an hour. This can cause many physical issues to the digestive tract, which include peptic ulcers and pancreatitis.

Caught up in the episode, the sufferer will no longer feel in control, and it is common for them to start consuming frosted, uncooked, or even food that has been disposed of.

MARA COSTEA

BULIMIA NERVOSA

. Consuming so many calories in such a little period of time, leads to extreme discomfort, guilt and shame, which triggers their purging or excessive exercising habits, so that they dispose of the extra calories.

Purging methods range from self-induced vomiting, laxatives, weight loss pills or diuretics. Self-induced vomiting is met a few times a day in sufferers, or even a few times a week. This can be recognised by identifying bruised hands caused by forcing them down the throat, yellow and sensitive teeth due to the acidic vomit, as well as abnormal nerve and muscle function due to a severe decrease in electrolytes.

Laxatives are used to increase the frequency of bowel movements, but taking them over and over again, means that the dosage needs to be increased in order to get the same effects, due to the body getting used to the substances. Many laxatives contain the chemical phenolphthalein which damages blood cell production and damages bone marrow. Sufferers also start to experience severe bloating and constipation due to the damage of the bowel muscles.

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Warning signs and symptoms: ·Psychological signs: include preoccupation with body size and weight, mood swings, hyperactivity, irritability, feeling out of control when eating, obsession with food and dieting, experiencing shame and guilt about eating behaviours, personality change, tremendous fear of weight gain, isolation and loneliness, low self-esteem.

·Physical signs: slow pulse and low blood pressure, brittle nails, bleeding and receding gums, mouth sores, calluses on knuckles, tooth decay, yellow teeth, bad breath, irregular menstrual cycles, vision disturbances, heart palpitations, loss of mental activity and memory, cold sweats, fatigue, thinning hair, weight fluctuations, but within normal range, sore throat, bowel problems, stomach pain, acid reflux, swollen hands and feet, broken eye vessels, dehydration, sleep problems, heart and kidney problems.

Finally, diuretics are like laxatives, but instead, they increase the frequency of urination. These are actually quite ineffective in weight loss, the consequence being the loss of water that the body really needs, which causes serious kidney problems and dizziness.

Sufferers enter a vicious cycle: they restrict, they binge, they purge and so on. Supplying the food that they binge on is also an important factor, and it can therefore become very pricey. Similar to drug addicts, sufferers can start stealing food or money from loved ones, but instead of drugs, the substance of abuse is food, which is in no way illegal.

i.Diagnosis and symptoms of bulimia A diagnosis is given only if all of the following criteria are met: -Repeated episodes of compulsive eating during very short periods of time, and feeling out of control when doing so. This is known as bingeing.

-Acts of attempt to get rid of the extra calories consumed. (e.g. taking laxatives, purging, diuretics, etc.)

-The two acts must occur at least once a week for a minimum of three months to be considered.

-The individual’s self-evaluation being based on their weight and appearance.

-The disturbance does not occur exclusively during episodes of anorexia.

·Behavioural signs: rigid dieting, binge eating in secret, vomiting, hesitance to socialise, compulsive exercising, eating at night, hiding huge quantities of food, use of laxatives and diuretics, planning binges, disappearing straight after meals, spending considerable time in the loo, blocking lavatories and sinks, excessive use of air fresheners, disappearance of food, running out of money due to excessive spending for binges, always being surrounded by food packaging, frequent wearing of baggy clothes, eating in secret, lying about where food has gone, denial about being hungry, alternating between fasting and overeating.

MARA COSTEA

BINGE EATING DISORDER

Binge Eating disorder i.Understanding binge eating disorder.

Binge eating disorder (BED) is a form of addiction to food, in which it is difficult to restrain oneself from eating. The main cause is normally low self-esteem, food becoming a substitute for certain emotions that are lacking. Food becomes the only reliable source of temporarily relieving unhappiness and numbing the pain. People suffering from this disorder will eat regardless of whether they are hungry or full. This disorder is very similar to bulimia, but for this, there is no intention of compensatory behaviour (laxatives, diuretics, etc.).

Therefore, the weight of a person suffering from BED is often ranging from slightly overweight to severely obese. A trait of sufferers is that they hoard food or hide it. Unfortunately, the sufferers’ life starts to revolve around the idea of food. From the moment they wake up to the moment they fall asleep, all they can do is plan their binges, or fixate towards items in the kitchen. The craving for pushing down their emotions, can only be fulfilled once they consume the food, hence the consequences of this mental issue are severe.

The number of BED cases is very alarming, in the UK, there being 12 million reported sufferers. There is a very similar number of males and females that live with this illness, but women are slightly over. This may be because of the societal expectations, which may lead to them being more likely in reporting their cases, skewing the results.

BED is random and can affect anyone, of any age, although it is more common in adults than in young people. It starts from feeling unworthy, so it is common in people that grew up overweight and bullied, food being the thing that they turn themselves to so that it decreases the impact of their feelings. Just like anorexia, it could be a result of genetics.

Nurture and development of BED is commonly found in individuals whose households promoted food as a way to show love, affection, and approval, hence the trait of feeling that you have to “deserve” food. Moreover, in households where food is commonly used as a way to relieve boredom or sadness, or even where it is used as a punishment. This, again, makes people feel as though they need to deserve food. This is also common when people promote dieting, weight loss and restriction.

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BED has many harmful consequences. Since most of the population suffering from it is mostly obese, this illness comes with the complications faced by side effects associated with it. For example, type 2 diabetes, heart disease, cancer, sleep apnoea, high blood pressure, gallbladder disease, high cholesterol, adrenal exhaustion fatigue or osteoarthritis. These risks are associated with physical wellbeing, but psychological ones are also major.

These include confusion, low self-esteem, guilt due to lack of selfcontrol, and increased susceptibility to developing depression.

Sufferers start to feel as though they cannot socialise anymore due to their embarrassment and shame. This causes them to selfisolate, which is a major trigger for comfort eating. This generates the vicious cycle that it is really difficult to get out of.

It must be known that BED is not an illness that all overweight people experience. People that are overweight may “binge”, in terms of having huge amounts of calories in one sitting, but they can be perfectly comfortable with that, therefore not experiencing guilt or shame. However, not having the diagnosis and in result the psychological signs, this does not make them immune to all the physical health risks that they are prone to.

It is important to know what small steps sufferers can take in order to start their journey towards recovery and build a healthier relationship with food. Some strategies include: ·Meal planning and sticking to a list when grocery shopping but ensuring to not limit yourself from certain food groups, labelling others as “bad” or “forbidden”. ·Have healthy snacking options ready and prepared for yourself. ·Do not shop when feeling hungry. ·Talk with a friend and ask them to join you when shopping. It will help you make right choices and avoid over-purchasing items that you are likely to over-consume. ·Go on frequent shopping trips to minimise food that is bought.

MARA COSTEA

BINGE EATING DISORDER

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·Try not to divide your attention when eating. Turn the TV off and any other distraction that may affect the amount of food you eat. ·Use smaller plates. It gives the illusion that you are having more food, which will end up satisfying yourself. ·Take the time and effort to frequently prepare your own meals from scratch. You are less likely to quickly eat the food. You will want to savour it and enjoy what you have prepared. ·Put down your cutlery after each bite for about 10 seconds. This ensures that you will have a normal eating pace and will mean that you are less likely to binge. ·Try and focus hard on how your food smells and looks. This will help you enjoy every part of your meal, meaning that you are more likely to slowly eat it. ·Eat small bite-sized pieces of food rather than loading your cutlery.

Ensure that you chew for at least 8 seconds to maintain that slow pace. ·Drink plenty of water to help digestion as well as feel fuller. ·Never go on unsustainable diets, depriving yourself of major food groups, as that will increase the cravings, have treats, and allow yourself to eat normally, but try and portion it. ·Relapsing is normal, so don’t be let down if that happens to you.

We are all humans, and you can get back on track. ·Practice mindfulness and focus whether you are hungry or have emotional cues. This will help to listen to your body and get into the habit of having food when your body needs it.

i.i.Diagnosis and symptoms of binge eating disorder.

A diagnosis is only given if all criteria below are met: -Eating very voluminous amounts of food in very short periods of time, and feeling out of control when doing so, unable to stop or limit themselves.

-Eating until uncomfortably full/eating large amounts of foods despite not being hungry/eating very rapidly than normal/eating alone due to shame/self-disgust/depression -Considerable distress about bingeing -Bingeing at least once a week for three months -No compensatory behaviours after binges

i.i.Warning signs and symptoms: ·Psychological signs: preoccupation with food, anxiety, depression, low self-esteem, feeling unattractive, guilt and self-disgust, feeling out of control when eating, suicidal ideation, seldom feeling satisfied, sugar cravings. ·Physical signs: sleep apnoea, headaches, acne, fungal infections, high blood pressure, kidney problems, weight gain, sweating, tremors, back pain, asthma, stroke, irregular menstrual cycle, pregnancy complications, osteoarthritis, heart disease, gall bladder disease, type 2 diabetes, high cholesterol, mobility issues, hypertension. ·Behavioural signs: eating very fast, eating until uncomfortable, eating when not hungry, eating secretly, frequent binges, purchasing vast food quantities, eating alone, hiding food, eating of frozen/uncooked/disposed of foods, stress eating, eating at night.

Pica Eating disorder i.i.Understanding pica disorder In Pica disorders, individuals suffer from consumption of items that are not meant to be consumed. Over time, there have risen different categories for each case of items consumed: -Amylophagia – consumption of starch -Geophagia - consumption of soil substances -Papophagia - consumption of ice -Coprophagia - consumption of faeces -Xylophagia - consumption of wood -Urophagia - consumption of urine -Trichophagia - consumption of hair -Hylophagia - consumption of glass -Lithophagia - consumption of pebbles -Mucophagia - consumption of mucus

MARA COSTEA

PICA EATING DISORDER & TREATMENT AND HELP

These categories are only the most common ones that have been reported, but there are many other things that sufferers consume.

Some examples are cigarette butts, glue, buttons, sponges, magnets, etc.

Pica disorder is often met in individuals that face intellectual disabilities, but are also very common in pregnant women, in their efforts to satisfy cravings.

Pregnancy cravings are often harmless, as they consist in common food items, such as chocolate, salty food, odd combinations, etc.

These, once satisfied, are in no way affecting their way of life and is therefore not an obstacle to their everyday lives. However, sometimes, the craving is not a healthy to consume item.

Sometimes the item represents something inedible which, once consumed will cause health problems.

Lots of pregnant women are hesitant to talk to their doctor about their cravings because it is often so strong that they cannot imagine not satisfying it, or they are simply ashamed of the abnormality of it. It is very important that Pica disorder is a mental illness, and it should be treated. If you or someone you know feels as though they may have the illness, they should contact their doctor immediately.

It is very unknown on the causes of Pica disorder since so little sufferers report it, but suspicions include nutrient deficiencies, parental neglect, or abuse. It is unusual since the nutrient deficiencies do not lead to a craving that has that certain mineral, therefore there is not a lot of certainty in this claim; another close link of Pica has been OCD (obsessive compulsive disorder).

Dangers of pica disorder are really severe and can lead to worm infestations, parasitic infections from soil and faeces, poisoning and gastrointestinal problems. Pica disorder can very often lead to death in severe cases.

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i.i.i.Diagnosis and symptoms of pica disorder Now that we have looked at common disorders, it is essential to understand that proper treatment is necessary, regardless of what you may be struggling with. Therefore, the next section of the study guide will focus on recovery and returning to living a normal, healthy lifestyle.

Firstly: BMI. In eating disorders, BMI is a very important factor.

Whether it is specialists’ ways to bring an individual to a normal weight, or disordered thoughts telling you that you are not enough, it is a very misleading measure. In fact, the measurement was developed in order to compare population averages, and not for self-diagnosis. It does not consider muscle and fat mass as separate things, meaning that a very muscular and fit person may appear as overweight when that clearly is not the case. In eating disorders, it could be very triggering to use BMI calculators and measurements, so, although I am not a specialist, I do not recommend using those.

Treatment and help a) Treatments I do want to mention that although I understand that it is incredibly difficult for the loved ones of a suffering individual to see them struggling, recovery is only possible he/she accepts the help and acknowledges that they have a problem. Their cooperation is crucial and without that, no forcing of any kind, even if well-intended, will get them to reach recovery.

They will always find a way to cut corners and act contrary to what everyone else suggests. Moreover, once agreed to take on the journey of recovery, families must keep in mind that every experience is rather unique. Different people require different treatments and not everything works for everyone. Reason why, at the beginning, a lot of therapies can be experimented with in order to find the right one.

I understand it is comforting to read others’ stories, and try to follow their footsteps, but, from experience, it will never work out if you try to stick to that yourself. Finally, this road will not be easy.

Even though the person recovering will start to make good progress, there is a high chance of relapse.

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TREATMENT AND HELP

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Do not let that discourage you. It is normal and in fact, those are the moments that your loved one needs most support.

Types of therapies and treatments

Ensure to let them know you are there for them. Also, be aware that it is a long process, and however long it will take, it will all be worth it. Trust me.

An option to begin the recovery journey is CAT (cognitive analytic therapy). This requires the sufferer to work along with the practitioner in order to recognise the good and the bad in their lives. It often needs to be practiced for around 20 hourly sessions in order to see results. These therapies can be very creative, as they can involve drawing, journaling or even movement. Normally, there will be three key stages:

Treatment starts with inpatient eating disorder hospitalisation for most people. It is crucial when the person suffering is in danger of serious health issues. Once they are discharged, it is very common for them to be treated as an outpatient, monitorised by an eating disorder service. That is what will provide them with the support that they need in order to ensure that they are maintaining good progress. Once, weight starts to restore, and the individual is no longer at high risk of complications, they will be advised to join therapy groups, individual therapy, self-help sessions and sometimes even family therapy. That can help everyone around listen to everyone’s point of view and become more understanding of what their actions may have on others’ feelings. In the UK eating disorder services and therapy facilities are very over-subscribed, hence it may be a good idea to turn to private healthcare if the financial possibilities allow that.

However, if not, if the situation is severe, do not wait and seek A&E help.

This form of therapy is highly effective for in individuals suffering with eating disorders. It helps the sufferer focus on the present moment and the future, which is very important, as eating disorders mostly arise from past trauma. Many anorexia sufferers have managed to make good progress with this therapy, and there also starts to be success in bulimia sufferers.

1.The formulation phase: this is a phase when the individual’s background is established. This is in terms of family, experiences, success, and failures. It is so that the practitioner gets an idea of you and where problems may have rooted from.

2.The reformulation letter phase: This is a very active phase when both the patient and practitioner work along and start approaching the problems with solutions. This is mainly consisting of identifying patterns in behaviours and learning what triggers them, ultimately learning to avoid them.

3.The ending phase: This is part of the process when both the practitioner and the patient start to accommodate with the transition phase that comes with the end of therapy. This is so that it will not appear as a shock to either party and they can become comfortable with continuing their lives without that support.

Another form of treatment is BBT which is cognitive behavioural therapy. This therapy is based on helping us recognise the fact that how we feel is mainly based on what we think, which ultimately affects how we behave. It is proven to be highly effective in anorexia and bulimia sufferers, as it focuses on relaxation and how to tackle emotions on a day-to-day basis. The therapist will help recognise habits that trigger irrational thoughts that the patient may have. This is done with the help of a journal where the patient gets to log their eating patterns and ultimately be helped to identify reasons for points of relapse. For example, very stressful times or meeting someone’s expectations may trigger disordered behaviours. Moreover, as we saw in the previous chapters, individuals suffering often set certain limits on what they are able or not able to eat. The therapist will listen to these implemented limits and will start to change them gradually so that recovery can eventually be established. This form of therapy also uses the food journal approach. Logging in intake and behaviours, will start to reveal reasons to why disordered habits take place.

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TREATMENT AND HELP

Next, we will be looking at counselling and psychotherapy. This form of therapy is also referred to talking therapy. Talking therapy is made so that a safe environment will be created for the sufferer where they can confide in their professionally trained practitioner, exposing their past, and how they feel. This is very intimate, and it is very important for the patient to not feel judged in any way.

Through communicating and feeling, it is believed for the sufferer to find the solutions themselves. They will start to feel open to their counsellor and will very well get along with them, as it is not in their interest for the sufferer to get well.

This means that there will not be pressure and the focus will shift a little bit. The time taken for the patient to reach a point of recovery is unknown, It is very much dependent for the patient’s personality and how aware they can be, or how open they can be.

Specialist treatment centres are also an option. In the case for eating disorders specifically, these centres are either for inpatients or outpatients, meaning that the sufferer will either be required to always stay supervised (inpatient) or just during the day (outpatient). These services are tailored to each individual and they do require payments, but these can vary.

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Highly trained specialists will focus on the patient’s Family participation and nutritional support are also highly encouraged. physical and mental health, helping them implement healthy habits into their routines, helping them move away from their disordered selves. Some institutions may even conduct biochemical tests so that they ensure optimisation of recovery.

Next, we can consider interpersonal psychotherapy. This involves shorter term therapy that consists of stages which are very similar to CAT. The entire process can last up to 20 weeks, with each stage at 3-4 weeks long. Initial, intermediate, and final phases are the same as CAT, with few but minor differences. The method has been adopted from depression treatment therapy but has been adapted for eating disorders. It very commonly heals BED but can work for anorexia and bulimia patients. It focuses on four main goals. There are role transitions, interpersonal deficits, grief, and interpersonal disputes. The sufferer eventually learns to escape destructive behaviours that have “helped” maintain the eating disorder patterns.

Medication and medical interventions are also effective ways to start one’s journey and are often coming hand in hand with other forms of therapies. These are often used when sufferers also show signs of depression. It is very common for patients to experience depression, hence the medication.

Accompanying eating disorders is also OCD, as we saw earlier, which can be tackled by taking anxiety treatment. Moreover, treating the side-effects of insomnia can be with sleep medication.

In the case of obese binge eating sufferers, surgical procedures may be necessary, as their weight is of great risks. This involves stomach shrinkage, making it impossible for them to consume large amounts of food. For anorexia sufferers, surgical procedures are not required, but refeeding is, therefore supervision is also required in their case.

An important key fact is that refeeding a malnourished body too quickly can cause the sufferer to experience refeeding syndrome.

This can develop pulmonary, neuromuscular, haematology, electrolyte, and cardiac complications. There is also a risk of death if developing cardiac arrythmia.

Death can also be a risk in result of confusion convulsions of the patient or lapsing into a coma.

MARA COSTEA

TREATMENT AND HELP

An important factor that many people are curious about is the sectioning process. This is when the sufferer refuses help from professionals, refuses to eat (in anorexia) and is at very high risk of death. In that case, they lose their liberty and end up in the hands of professionals. Moreover, the sectioning process that leads from.

Seclusions from the community is in the case of the ones around the sufferer are at risk (e.g. a parent suffering from anorexia and owns full custody of their child. The disease is likely to interfere with the child’s well-being, reason why sectioning is required).

The sectioning process is elaborate and has several steps. Firstly, a mental health assessment will take place by a medical team, a family member, or the emergency services. Then, a minimum of these people decides that detention is the only possible option.

These people are either doctors and/or approved mental health professionals. The assessment will take into consideration medical risk, psychological risk, psychosocial risk and insight/capacity or motivation. The decision is then taken, but the family of the sufferer may appeal the decision taken, in which case, they will give a three day written notice to the health managers. After being sectioned, the individual will be entitled to free aftercare once discharged.

As mentioned earlier, it is quite dangerous to undergo refeeding of This sectioning only happens when the professionals believe that the individual is in a position where they are unable to make a rational decision and are self-imposed starvation. In extreme cases, the refeeding process will not be natural and will require a naso-gastric tube, which feeds the nutrients directly to the stomach. If there is one thing that is ought to be remembered it is that refeeding of an anorexia sufferer should never be done without professional supervision.

b) other forms of help Firstly, a very helpful resource of help is nutritional support. This required very commonly in individuals suffering with anorexia.

Since, they have severely restricted for such a long time, they develop very unrealistic ideas about how much food is healthy to be consumed, or what a balanced diet should look like. Therefore, a nutritionist can help with that. They will help the recovering individual to meal plan and take good decisions surrounding food intake. Beside changing diet, a suffering individual will also receive help on how to differentiate between listening to hunger cues or emotionally eat.

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Joining self-help groups is also a very proactive step in one’s recovery journey. Meeting up with a few people that are going through what you are going through can be very reassuring and can impose the idea that you are not alone in your recovery.

You can share experiences, ideas and thoughts or feelings with everyone around you, without the fear of being judged, as it is a confidential and judgment-free space.

Many self-help groups have libraries and very useful resources on helping the members with documentation and learning more and more about the disorders.

Documentation is therefore encouraged and all of these small things that self-help groups stand by, are frequently very motivating for suffering individuals.

Complementary therapies Acupuncture is not a solution for eating disorders, but it is definitely an approach that once taken, can improve mental and physical health. The positioning of fine needles around the body in areas of target organs, is believed to restabilise the body’s energy flow and therefore bring a sense of relaxation and calmness, helping with mental difficulties. ACT or “acceptance and commitment therapy” is another alternative and involves the practicing of mindfulness in order to come to terms with one’s body image and behaviours around food.. It helps them recognise patterns that trigger their compulsive disorders from a psychological point of view. It is slightly less common, but still proves to be effective in along with proper treatments.

Hypnotherapy is a way of inducing a form of locked attention, helping the sufferer focus on their problem in a very heightened state of concentration. Methods of relaxation enable the patients to use their right side of the brain more effectively which will help them in making more rational decisions. Meditation is also very widely used in suffering individuals. It involves relaxation, as a result, starting to come to terms with one’s body. It promotes selfhealing by activating self-awareness, enabling the sufferer to arrest destructive eating disorder habits. In this category, yoga falls as well.

People suffering with anorexia often abuse working out, and continue pushing themselves despite having bruises, cuts or feeling extremely fatigued and tired due to malnourishment. Therefore, the low impact sport, yoga, helps the body remain mobile and flexible, without an overwhelming effort being made. It also helps relax and connect with your body, becoming more appreciative of it.

Useful Contact Numbers Adult Helpline: 0808 801 0677 Youthline: 0808 801 0711 Studentline: 0808 801 0811 Helpline: 116 123 (Available 24/7) Infoline: 0300 123 3393 Text: 86463 Parents Helpline: 0808 802 5544 Helpline: 0808 808 4994

Useful Recovery Accounts @romitchell @jayciesdiary @livvgrace @lilith.marie.xx

References

https://jeatdisord.biomedcentral.com/? gad_source=1&gclid=CjwKCAjwmYCzBhA6EiwAxFwfgKtPK-bp9jeZFmnuBwt5UGMk0evfxgfOnoHavA_YZpjQ7YBS_vjeBoCJ78QAvD_BwE https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6370446/ https://www.mayoclinic.org/diseases-conditions/eating-disorders/symptomscauses/syc-20353603