I felt so unhappy with myself. I felt like a failure," says Abby* of her time at a high-flying grammar school. It was during her years in what she describes as an extremely competitive environment that she developed an unhealthy relationship with food.
"Pressure came at us from all directions: from the school, from parents and from pupils themselves."
Abby's experience accords with the widespread perception that eating disorders are more common among pupils at academically high-achieving schools. But is this view based on an unhelpful myth or does it point to the need for awareness of the vulnerability of a particularly at-risk group?
The statistics around eating disorders, although far from comprehensive, are startling. A survey conducted by the NHS Information Centre in 2007 found that 20 per cent of women between the ages of 16 and 24 screened positive for an eating disorder. The same survey also found that 6.4 per cent of adults displayed signs of an eating disorder, a quarter of them male.
At least one expert thinks that the pressures are particularly intense at private schools, where pupils feel that they have to conform to the stereotype of the straight-A student. Professor Carrie Paechter of Goldsmiths, University of London, told the Girls' Schools Association annual conference at the end of last year that too many independent schoolgirls lead "overscheduled" and stressful lives in pursuit of perfection and a desire to "live up to expectations".
However, eating disorder charity Beat points to a lack of data detailing how many people in the UK have an eating disorder, and little recent research has been conducted into the incidence of disordered eating among high-achieving young people.
"People who have competitive, high-achieving and perfectionist traits, combined with low self-esteem, are more likely to develop eating disorders, and these traits might be more likely to occur in those who are successful academically," says Susan Ringwood, chief executive of Beat. "So the hard- wired nature of the illness is more likely to exist in more academic institutions."
And when these traits are combined with an environment in which there is pressure to achieve the top grades, disordered eating is more likely to develop.
"If these people are in an environment where competitiveness and perfectionism are prized, they are more likely to strive," Ringwood says. "It won't cause the eating disorder, but for some people it can undoubtedly increase their vulnerability."
Abby, now 30, is certain that her illness was triggered by a pressured school environment. She had excelled at junior school and passed her 11- plus but was placed in lower sets when she arrived at secondary school, and her self-esteem plummeted. She began to develop an unhealthy relationship with food when she was 13.
Abby says there was a big focus on league tables and academic performance at her school. "The school was extremely competitive and there was a great amount of pressure placed upon us to succeed," she says.
After she lost a significant amount of weight, her parents took her to the GP, who referred her to a child and adolescent psychiatrist. But her school showed little understanding of her illness, Abby found. She recalls her distress during her GCSEs, when the emphasis appeared to be only on getting her through her exams.
"They wouldn't let me complete my exams unless I agreed to sit with a teacher and eat before them," she says. "I refused, but a meeting was called with my parents and I was forced to consume an energy drink prior to each exam. I struggled to sit still during the exams; I couldn't cope with the thought of having drunk 200 calories and then being seated for a period of time.
"No one understood that this could actually make it worse for me, and I felt the concern was placed upon my ability to complete the exam successfully."
Abby gained good GCSEs, despite her illness. After being in treatment for 15 years, she has recovered from her eating disorder and has worked on her perfectionist traits, learning to accept excellence instead of perfection.
Nicola Byrom, 25, started to develop problems around eating while she was attending an independent girls' boarding school at the age of 13. She says her school was a competitive environment, but she thinks competition is inevitable in a school that educates a large number of high-achievers.
"The pressure came from each other rather than the school," she says. "Any school that has selection criteria automatically takes a bunch of people who are bright and capable, and that distorts everyone's perception of what is good and what isn't. Everyone got an A or an A* at GCSE and it became normal.
"You always want to stand out for something and when you have an able group of people around you it becomes harder and harder."
Competitiveness in itself is not a problem, says Deanne Jade, founder and principal of the National Centre for Eating Disorders. But a competitive environment can lead to comparison and high ideals, including about appearance.
"Wherever you get an environment in which there is a striving for perfection, it's going to activate anxiety in people who are already perfectionists and they're going to try to cope with that by losing weight and striving to look thin," Jade says.
The trap of expectations
Family can also have an influence on the development of eating disorders in young people, Jade adds. Coming from a successful, high-achieving family can make children feel under pressure to live up to their family's expectations.
"Eating disorders are about many things, and two risk factors are intrinsic competitiveness in the child and family style," Jade says. "A competitive child is more likely to feel bad if they don't succeed and blame themselves and to feel failure, that they're letting their parents down if they're paying for their education. Parental pressure can be a problem, if the child feels they have to live up to being part of `the perfect family'."
For Emily*, 22, her eating problems began while she was studying for her A levels at boarding school. She believes that parents are often in denial when their children develop problems: they cannot conceive that it could be something that would happen in their family.
"I sometimes think that parents, including those with children at independent boarding schools, many of whom come from an upper-middle-class background, believe that illnesses such as anorexia will never happen to their children; they think it's the sort of thing that happens to others," she says.
So parents can project perfectionism on to their children, perhaps inadvertently exacerbating problems through an unwillingness to accept weakness. "Parents can be the main problem because they can't accept there is anything wrong and they say: `Come on, get a grip.' And, of course, if it was as easy as that nobody would suffer," Emily says.
Emily is clear that her time at boarding school did not cause her eating disorder. She missed home and hated being so far away from her family, but she says her school was supportive and did everything it could to help her. She describes the pastoral support she received as "second to none" and says that if she wanted to talk there was always someone she could go to.
"I think the private school system is probably better at dealing with eating disorders than state schools: it is more likely to be noticed," she adds.
At boarding schools, in particular, it may be more difficult for young people to conceal disordered eating because of the increased exposure to school staff. "Staff in independent schools have more responsibility towards their pupils because they have more contact with them, so they have more opportunity to influence them," says Ringwood.
So it is crucial that teachers and housemasters and housemistresses are aware of the warning signs of eating disorders. And independent schools would argue that they are well placed to deal with any problems.
"Girls' schools are expertly attuned to spotting and managing the emotional issues that affect teenage girls," says Sheila Cooper, the former executive director of the Girls' Schools Association. "All good schools have highly evolved support mechanisms in place to spot early signs and to work with pupils and parents to resolve the core issues and prevent symptoms from escalating. The key is making sure there are plenty of formal and informal opportunities for communication."
It is important that young people do not believe that only one aspect of themselves is valued, says Ringwood. Schools should find ways to celebrate pupils' achievement beyond academic results.
"Some environments are more toxic for some people because of their vulnerabilities," she says. "If only one aspect of them is valued, for example ballet or their academic success, it does place them more at risk. If an independent school does place emphasis on one aspect, that could be a problem, but I think most are good at providing breadth."
Byrom credits her school for providing a range of activities, some of which aided her recovery. "At the start of the sixth form someone encouraged me to get involved in an engineering project, which was exciting," she says. "Lots of people at my school were sporty and I never was, so having the chance to do something on my own in a technology block was great."
Byrom took a year out in her first GCSE year and her school supported her studies at home and was flexible about her returning to school. She is currently doing a PhD at the University of Oxford and has set up a charity, Student Run Self Help, which organises support groups for people to share their experiences of mental health issues at universities across the country.
"I always felt I didn't have enough people to talk to at school who knew what it was like," Byrom says. "At our support groups people can get together and share their experiences."
With academic rigour high on the government's agenda, schools may feel under greater pressure to achieve results. However, it is crucial that schools find time to celebrate pupils' other achievements and that young people learn that there is more to life than exam scores.
"It's important to have breadth to the curriculum beyond academic learning," says Ringwood. Schools should develop the whole person by helping pupils to become more emotionally resilient, working around body image and helping young people to develop a balanced outlook, she adds. "Good schools engage with their communities and help pupils to see the world beyond their doors."
* Names have been changed
Eating disorders - model policy
This eating disorders policy has been developed in collaboration with teachers. It is designed as a practical tool to help school staff recognise the warning signs of eating disorders and help schools put a clear procedure in place for managing and supporting cases of eating disorders. bit.lyEDpolicy
Bulimia warning signs
A PowerPoint that can be used for staff training on bulimia, which is often the hardest eating disorder to spot.
BBC class clips video: Dr Leanne Hayward looks at why people develop eating disorders and what help and support they might need.
PSHE eating disorders - anorexia
A PowerPoint and resources for a lesson on eating disorders and anorexia. bit.lyEDPSHE
Understanding health conditions - mental health
Activities to help students understand anorexia and bulimia. bit.lyEDmentalhealth.
Photo credit: Alamy