Eating Disorders

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Photo by: Simone van den Berg

Eating disorders affect both the mind and the body. Although deviant eating patterns have been reported throughout history, eating disorders were first identified as medical conditions by the British physician William Gull in 1873. The incidence of eating disorders increased substantially throughout the twentieth century, and in 1980 the American Psychiatric Association formally classified these conditions as mental illnesses.

Diagnosis

Individuals with eating disorders are obsessed with food, body image, and weight loss. They may have severely limited food choices, employ bizarre eating rituals , excessively drink fluids and chew gum, and avoid eating with others. Depending on the severity and duration of their illness, they may display physical symptoms such as weight loss; amenorrhea ; loss of interest in sex; low blood pressure ; depressed body temperature; chronic , unexplained vomiting; and the growth of soft, fine hair on the body and face.

There are various types of eating disorders, each with its own physical, psychological , and behavioral manifestations. They are classified into four distinct diagnostic categories by the American Psychiatric Association: anorexia nervosa , bulimia nervosa, binge eating disorder , and eating disorder not otherwise specified.

Anorexia nervosa.

Clinically, anorexia nervosa is diagnosed as intentional weight loss of 15 percent or more of normal body weight. The anorexic displays an inordinate fear of weight gain or becoming fat, even though he or she may be extremely thin. Food intake is strictly limited, often to the point of life-threatening starvation. Sufferers may be unaware of or in denial of their weight loss, and may therefore resist treatment.

Peak ages of onset are between 12 and 13 and at age 17. Among women of menstruating age, menstruation ceases due to weight-related declines in female hormones .

This illness has two subtypes: the restricting type , in which weight loss is achieved solely via reduction in food intake, and the binge eating/purging type , in which anorexic behavior is accompanied by recurrent episodes of binge eating or purging.

Bulimia nervosa.

Bulimia nervosa is characterized by repeated episodes of bingeing followed by compensatory behaviors to prevent weight gain. Compensatory behaviors include vomiting, diuretic and laxative abuse, fasting, or excessive exercise. Like the anorexic, the typical bulimic has an unusual concern about body weight and weight loss. Unlike the anorexic, he or she is acutely aware of this condition and has a greater sense of guilt and loss of self control.

Bulimia typically develops during the late teens and early twenties. In contrast to the typically emaciated anorexic, most bulimics are of normal body weight, although weight may fluctuate frequently. Physically, the bulimic may have symptoms such as erosion of tooth enamel, swollen salivary glands, potassium depletion, bruised knuckles, and irritation of the esophagus.

To qualify for a clinical diagnosis of bulimia nervosa, binge eating and related compensatory behaviors must take place at least two times a week for a minimum of three months. Sufferers are classified into one of two subtypes: the purging type, which employs laxatives, diuretics , or self-induced vomiting to compensate for bingeing, or the nonpurging type, which relies on behaviors such as excessive exercising or fasting to offset binges.

Binge eating disorder.

Binge eating disorder is characterized by eating binges that are not followed by compensatory methods. This condition, which frequently appears in late adolescence or the early twenties, affects between 15 and 50 percent of individuals participating in diet programs and often develops after substantial diet-related weight loss. Of those affected, 50 percent are male.

Binge eating disorder is diagnosed when an individual recurrently (at least twice a week for a six month period) indulges in bingeing behavior. A clinical diagnosis also requires three or more of the following behaviors: (1) eating at an unusually rapid pace, (2) eating until uncomfortably full, (3) eating large quantities of food in the absence of physical hunger, (4) eating alone out of shame, and (5) feelings of self-disgust, guilt, or depression subsequent to bingeing episodes.

Eating disorder not otherwise specified.

The category eating disorder not otherwise specified (EDNOS) is used to diagnose individuals whose eating disorders are equally as serious as anorexia nervosa, bulimia nervosa, or binge eating disorder, but do not meet all of the diagnostic criteria for these illnesses. An example of EDNOS might be a female who fulfills all of the criteria for anorexia but is still having regular menstrual periods, or an individual with all of the signs of bulimia who binges and purges less than twice a week.

Prevalence

Originally considered to be a disease targeting affluent white women and adolescents, eating disorders are now prevalent among both males and females, affecting people of all ages and from many ethnic and cultural groups. As many as 70 million people worldwide are estimated to suffer from these conditions, with one in five women displaying pathological eating patterns.

Most eating-disorder research focuses on females, who represent 90 percent of all cases. The additional 10 percent are males, a group that is often underdiagnosed due a widespread misperception that this disease only affects females. This belief also makes males less likely to seek treatment, frequently resulting in poor recovery. Among males, body image is a driving factor in the development of eating problems. Gender identity may also play a role in the evolution of eating disorders, with homosexual males more prone to this disorder than the overall male population.

Risk Factors

Environmental, social, biological , and psychological factors all contribute to eating-disorder risk. Early childhood environment and parenting may have a substantial impact. Many sufferers report dysfunctional family histories, with parents who were either emotionally absent or overly involved in their upbringing. As a result, these children may not tolerate stress well, they may have low self-esteem, and they may have difficulty in interpersonal relationships. Children who have been abused either physically, sexually, or psychologically are also highly vulnerable to eating disorders, particularly bulimia. Those raised by eating-disordered parents may be at heightened risk due to repeated exposure to maladaptive food-related behaviors.

Professions, activities, and dietary regimens that emphasize food or thinness may also encourage eating disorders. For example, athletes, ballet dancers, models, actors, diabetics, vegetarians, and food industry and nutrition professionals may have higher rates of disordered eating than the general population. In addition to environmental and social influences, biological and psychological factors may also increase risk for eating disorders in some people. Low levels of serotonin , a neurotransmitter involved in appetite regulation and satiety, may be indicative of a predisposition to pathological eating behaviors. Similarly, as many as 50 to 75 percent of those who are diagnosed with eating disorders suffer from depression, a mental illness also associated with abnormalities in serotonin balance. Other psychiatric disturbances, such as bipolar depression, obsessive-compulsive disorder, seasonal affective disorder, post-traumatic stress disorder, attention-deficit–hyperactivity disorder, and addictive behaviors, are also common in people with eating disorders.

Causes

Societal influences also contribute to this illness. Increasingly, Westernized culture portrays thinness as a coveted physical ideal associated with happiness, vitality, and well-being, while obesity is perceived as unhealthy and unattractive. This has encouraged a growing sentiment of body dissatisfaction, particularly among young women. Endless images of unrealistically thin models and actors in all forms of media further promote body dissatisfaction—one of the strongest risk factors for the development of disordered eating.

Abnormal eating patterns are most likely to develop during the mid- to late teens, a period of considerable physical, psychological, and social change. While the exact events that lead to the evolution of these disorders are unknown, there are two common milestones that can trigger disordered eating, especially in those with a biological predisposition. The first is the occurrence of a traumatic event, such as the death of a loved one or a divorce. The other is the adoption of a strict diet, which may be even more pivotal than a personal trauma. In fact, rigorous dieting has been identified again and again as the most common initiating factor in the establishment of an uncontrollable pattern of disordered eating.

Treatment Modalities

Treatment is based on a combination of psychotherapy, medication, and nutritional counseling. Goals include restoration of healthy body weight, correction of medical complications, adoption of healthful eating habits and treatment of maladaptive food-related thought processes, treatment of coexisting psychiatric conditions, and prevention of relapse. Depending on the severity of the illness, therapy may be conducted on an outpatient, day treatment, or inpatient basis.

Outpatient therapy.

Outpatient therapy provided by practitioners specializing in eating disorders is appropriate for highly motivated patients within 20 percent of their normal body weight and whose illness is mild or just developing. Treatment consists of cognitive-behavioral therapy, intensive nutritional counseling, support-group referrals, and medical monitoring. At the outset of treatment, a contract is established, outlining an anticipated rate of weight gain (usually between 0.5 and 2 pounds per week), target goal weight, and consequences if weight gain is not achieved. Vitamin and mineral supplementation and the use of liquid supplements to facilitate weight gain may also be indicated.

Day treatment programs.

Day treatment programs are being used with increasing frequency in place of inpatient hospitalization. This form of therapy provides an intermediate level of care for patients who require frequent monitoring but do not require treatment twenty-four hours a day. It may be used for patients who are not responding to outpatient therapy or who are stepping down from inpatient hospitalization. Treatment, which may take place four or five days per week from morning until evening, is similar in structure to outpatient therapy, but is provided on a more intensive level.

Idealized images of thinness can cause body dissatisfaction, which may lead to eating disorders. Such disorders may also be encouraged by professions that require a certain body type, such as modeling or gymnastics.

[Photograph by George De Sota. AP/Wide World Photos. Reproduced by permission.]

Christy Henrich, a member of the U.S. gymnastics team, narrowly missed making the Olympics in 1988. Some say Henrich's anguish over that failure caused the eating disorder that killed her six years later, when she weighed less than fifty pounds.

[AP/Wide World Photos. Reproduced by permission.]

Inpatient hospitalization.

Inpatient hospitalization is indicated for patients whose eating disorder has reached life-threatening status. Criteria for admission to such programs are weight loss of 25 percent or more of ideal body weight or the presence of an eating disorder in a child or adolescent. It may also be necessary for individuals who are medically unstable. Usually, participants in inpatient programs are anorexic, although hospitalization for bulimia may be necessary if there is serious deterioration of vital signs, uncontrollable vomiting, or concurrent psychiatric illness.

The immediate goals of inpatient treatment are weight gain and stabilization of vital signs. In many cases, the patient is so fragile that complete bed rest is required. Eating is gently encouraged. In extreme medical situations refusal may be met with tube feeding or, in rare instances, intravenously.

Medication.

Medication is increasingly becoming a routine part of treatment for eating disorders. Antidepressants, particularly the selective serotonin reuptake inhibitors (SSRIs), are the most effective and most commonly used medication in treating this spectrum of illnesses. They are found to be of greatest benefit when used in combination with therapy, and are of little value if offered on their own. In the case of anorexia, these medications are most effective if employed after successful weight restoration is achieved, at which time they can be useful for relapse prevention and the treatment of coexisting psychiatric conditions. SSRIs are also used in preventing binge relapses among bulimics, although their effectiveness ceases once the medication is discontinued. Although antidepressants have also been employed in the treatment of binge eating disorder, outcomes have not been sufficiently positive to warrant recommendations for their use.

Outcomes

Individuals are usually considered to be ready to terminate therapy once they have achieved a healthy body weight and can eat all foods free of guilt or anxiety . For a complete recovery, extensive treatment may be required from six months to two years, and for as long as three to five years in cases where other psychiatric conditions are present. For some, eating disorders will be a lifelong struggle, with stressful or traumatic events triggering relapses that may require occasional check-in therapy to restore healthful eating patterns.

Of individuals with anorexia nervosa, 50 percent will have favorable outcomes, 30 percent will have intermediate results, and 20 percent will have poor outcomes. The prognosis for bulimics is slightly less favorable, with 45 percent achieving favorable outcomes, 18 percent having intermediate results, and 21 percent with poor results. Among both anorexics and bulimics, 5.6 percent will die of complications related to their illness. Those who receive treatment early in the course of their disease have a greater chance of full recovery on both a physical and an emotional level. A favorable prognosis is also likely with an early age at diagnosis, healthy parent-child relationships, and close supportive relationships with friends or therapists. With early identification and treatment, eating disorders can be prevented from becoming chronic and potentially lethal.

SEE ALSO Addiction, Food ; Anorexia Nervosa ; Bulimia Nervosa ; Eating Disturbances .

Karen Ansel

Bibliography

American Academy of Pediatrics (2003). "Policy Statement: Identifying and Treating Eating Disorders." Pediatrics 111(1):204–211.

American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders , 4th edition. Washington, DC: Author.

Berkow, Robert M., ed. (1997). The Merck Manual of Medical Information Home Edition. Whitehouse Station, NJ: Merck Research Laboratories.

Cassell, Dana, and Gleaves, David (2000). The Encyclopedia of Eating Disorders , 2nd edition. New York: Facts on File.

Costin, Carolyn (1996). The Eating Disorder Sourcebook. Los Angeles: Lowell House.

Pritts, Sarah D., and Susman, Jeffrey (2003). "Diagnosis of Eating Disorders in Primary Care." American Family Physician January 15.

Rome, Ellen S., et al. (2003). "Children and Adolescents with Eating Disorders: The State of the Art." Pediatrics 111:e98–e108.

Stice, Eric; Maxfield, Jennifer; and Wells, Tony (2003). "Adverse Effects of Social Pressure to Be Thin on Young Women: An Experimental Investigation of the Effects of 'Fat Talk.'" International Journal of Eating Disorders 34:108–117.

Woolsey, Monika M. (2002). Eating Disorders: A Clinical Guide to Counseling and Treatment. Chicago: American Dietetic Association.

Internet Resources

American Psychiatric Association (2001). "Men Less Likely to Seek Help for Eating Disorders." Available from <http://www.nlm.nih.gov/medlineplus>

American Psychiatric Association. "Practice Guideline for the Treatment of Patients with Eating Disorders." Available from <http://www.psych.org>

Anorexia Nervosa and Related Eating Disorders, Inc. (2002). "Males with Eating Disorders." Available from <http://www.anred.com/males.html>

Devlin, Michael J., and Walsh, Timothy B. (2000) "Psychopharmacology of Anorexia Nervosa, Bulimia Nervosa, and Binge Eating." American College of Neuropsychopharmacology. Available from <http://www.acnp.org/g>

National Eating Disorders Association (2002). "Males and Eating Disorders." Available from <http://www.nationaleatingdisorders.org>

National Eating Disorders Association (2002). "What Causes Eating Disorders?" Available from <http://www.nationaleatingdisorders.org>

Renfrew Center Foundation (2002). "Eating Disorders: A Summary of Issues, Statistics and Resources." Available from <http://www.renfrew.org>