Eating Disorders

Introduction

Even as Americans are becoming heavier than ever before, our society continues to place value on thinness and almost everyone worries about their weight at least occasionally. However, people with eating disorders take those weight concerns to extremes, developing abnormal eating habits that threaten their well-being and even their lives.

Simply put, eating disorders can be deadly. Self-starvation, binging and purging, or overly-excessive exercise because of an irrational fear of becoming fat may not just be a "fad" that one will easily outgrow. Many times, eating disorders are lifelong battles.

What is it?

An eating disorder is defined as a continual disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food, significantly impairing physical health or psychological and social functioning.

Eating disorders are often long-term problems, which can cause immeasurable suffering for victims and their families. There are generally two recognized types of eating disorders:

  1. Anorexia Nervosa (AN) - This disorder's name means "loss of appetite." In reality, the person has not actually lost their appetite, but chooses to deny the hunger because of an unreasonable fear of becoming fat. If left untreated, anorexia nervosa can be fatal, with an estimated fatality rate of 6% in serious cases.

    2. Individuals with anorexia nervosa can be further categorized based on their eating behaviors.

    • Restrictive Type: Individuals with this specific type of anorexia nervosa limit the amount of food they eat, typically eliminating foods that contain fat. These individuals also tend to exercise excessively to assist in weight loss.

    • Binge Eating/Purging Type: These individuals are first diagnosed with the restrictive type of anorexia nervosa and then begin to regularly engage in the binge eating and purging behaviors that are more commonly linked with bulimia nervosa. (For definitions of binge eating and purging, see the section on bulimia nervosa.)

  2. Bulimia Nervosa (BN) - This eating disorder is described by repeated episodes of binge eating, during which large amounts of food are consumed in a short period of time (sometimes as many as 20,000 calories). To be diagnosed with bulimia nervosa, binge eating needs to occur at least twice every week for a 3-month period. As a result of the repeated binge eating, the person often feels depressed and guilty.

    3. Individuals with bulimia nervosa can be further categorized based on their purging behaviors.

    • Purging Type: Individuals with this specific type of bulimia nervosa will have an episode of binge eating followed by self-induced vomiting, abuse of laxatives and/or diuretics (water-pills) to avoid gaining weight from the binge.

    • Non-Purging Type: Individuals with this specific type of bulimia nervosa will have an episode of binge eating and then use other behaviors to offset the behavior, such as fasting or excessive exercise. Individuals with this type of bulimia nervosa do not regularly engage in self-induced vomiting or the misuse of laxatives and/or diuretics.

    Many times it is difficult to differentiate between anorexia nervosa and bulimia nervosa. Every individual who resorts to binge eating and purging may not be classified as bulimic because of the subgroup of patients diagnosed with anorexia nervosa who may also display these behaviors. Furthermore, a large percentage of individuals may have both eating disorders at the same time. It has been estimated that 50% of anorexics will develop bulimia nervosa and that 30% to 40% of bulimics will develop anorexia nervosa.

  3. Binge Eating Disorder (BED) - This eating disorder is characterized by recurrent consumption of large amounts of food without purging, fasting, or excessive exercise. The difference between binge eating disorder and non-purging type bulimia nervosa is the behavior that takes place after binge eating. In non-purging type bulimia nervosa after binge eating the individual will try to offset their calorie consumption by fasting or excessive exercise. In binge eating disorder the individual does nothing to offset the calorie consumption. The person eats to a point of uncomfortable fullness. Binge eaters focus less on their body image than people with anorexia nervosa and bulimia nervosa. A binge eater often eats alone and has feelings of shame or guilt after binging. Consequences of binge eating include death (approximately 300,000 deaths per year), obesity, and depression.

What causes it?

The exact cause of eating disorders is unknown; however, physical, psychological, personal, and social issues have been associated with triggering eating disorders.

The social pressure to be thin affects everyone to some extent. Society is flooded with messages on TV, in the movies, in magazines, on billboards, and on the Internet that thinness brings beauty, success, and happiness. These messages can also come from an individual's family structure, culture, and way of life. Social and cultural pressures along with a low self-esteem are thought to be the major causes for the development of anorexia nervosa and bulimia nervosa.

No one factor causes an eating disorder, but a few or a combination of factors may increase the risk. Here are some common psychological factors that may contribute to developing eating disorders:

For anorexia:

  • fear of growing up
  • inability to separate from the family
  • need to please or be liked
  • perfectionism
  • need to control
  • need for attention
  • lack of self esteem
  • high family expectations
  • parental dieting
  • family discord
  • temperament - often described as the "perfect child"
  • teasing about weight and body shape

For bulimia:

  • difficulty regulating mood
  • more impulsive - sometimes with shoplifting, substance abuse, etc.
  • sexual abuse
  • family dysfunction

    If individuals are at risk of developing an eating disorder, sometimes all it takes to put the ball in motion is a trigger event that the individual does not know how to handle. A trigger could be something as seemingly harmless as teasing or as devastating as rape. Triggers often happen at a time in an individual's life when there is an increased demand on the resources of an individual who is already unsure of his or her ability to meet expectations. Such triggers may include puberty, starting a new school, beginning a new job, death of a friend or loved one, divorce in the family, marriage, family problems, or the breakup of an important relationship.

    However, the most common trigger of eating disorders is dieting. When individuals who are at risk of developing an eating disorder excessively diet, making themselves constantly hungry, they may respond by overeating. These individuals then become panicky about the possibility of weight gain and then vomit, exercise excessively, or otherwise purge to get rid of the calories. Feeling guilty and perhaps horrified at what they have done, they swear to "be good." This usually means more dieting, which leads to more hunger, and repeats the cycle.

    Who has it?

    Currently, it is estimated that 7 million women and 1 million men suffer from an eating disorder. Eating disorders have reached epidemic levels in America in all segments of society; however, eating disorders are most common in individuals who have a higher social or economic background. This may be due to the fact that these individuals are continually striving to achieve the social standards of thinness in order to be accepted into their chosen career or lifestyle.

    Almost all (86%) anorexics and bulimics begin their eating disorder related behaviors by the age of 20; however, reports that eating disorders are occurring in children 8 to 11 years of age are on the rise. Also, adults are not immune to eating disorders. A significant number of newly diagnosed anorexics and bulimics are in their upper 20s, 30s, and 40s.

    It is estimated that about 6% of persons with serious cases of eating disorders die and only 50% report being cured. Therefore, it is a debilitating disease that has consequences if it is not realized (by the individual or people around them) and treated correctly.

    What are the risk factors?

    Risk factors are characteristics that can make you more likely to develop a condition. The risks associated with developing an eating disorder are related to the following:

    • Family history of anorexia nervosa or bulimia nervosa
    • Less than 20 years of age
    • Female gender
    • Participating in activities that focus on weight, appearance, and lean body mass (for example, ballet, modeling, gymnastics, acting, figure skating, running, diving)
    • Existing psychiatric illness such as obsessive-compulsive disorder (a type of anxiety distinguished by patterns of repetitive thoughts and behaviors) or depression.
    • Presence of personality traits such as being a perfectionist (having the best or expecting the best at all times) and low self-esteem

    What are the symptoms?

    The main symptom of anorexia nervosa is self-induced starvation. The main symptom of bulimia nervosa is binge eating with purging. The main symptom of binge eating is out of control eating without purging. These disorders may become a compulsive addiction such as alcoholism. Most patients with anorexia nervosa, bulimia nervosa, and binge eating disorder report psychological impairments (mainly depression), shame, guilt, and withdrawal from social events.

    Because many people are concerned about their weight, most people diet at least once in a while; however, it may be difficult to distinguish between normal dieting behaviors and abnormal dieting behaviors that could develop into a serious eating disorder. Not every individual will show all of the characteristics listed below for anorexia nervosa and bulimia nervosa, but people with eating disorders may clearly show several of them.

    Signs of anorexia nervosa may include the following:

    • Intentional self-starvation associated with weight loss
    • Intense, persistent fear of gaining weight
    • Refusal to eat, except tiny portions
    • Pretending to eat and trying to hide that you are not eating from others
    • Continuous dieting
    • Excessive facial/body hair due to inadequate protein in diet (malnutrition)
    • Abnormal, rapid weight loss
    • Hair loss - mainly on the head
    • Dry, cracked, or discolored skin
    • Sensitivity to cold temperatures
    • Absent or irregular menstruation

    Signs of bulimia nervosa may include the following:

    • Constantly thinking about food
    • Binge eating, usually in secret
    • Vomiting after binging
    • Abuse of laxatives, diuretics, diet pills
    • Denial of hunger
    • Denial of induced vomiting
    • Swollen salivary glands

    Anorexia nervosa and bulimia nervosa are closely related and several characteristics of the two eating disorders often overlap.

    Signs associated with both anorexia nervosa and bulimia nervosa may include the following:

    • Poor body image (constant thoughts of thinness)
    • Malnutrition
    • Anxiety
    • Lethargy (sluggish, inactive, or slow moving)
    • Decreased concentration
    • Abdominal pain
    • Constipation/diarrhea
    • Bloating
    • Compulsive exercise (a person feels compelled to exercise and struggles with guilt and anxiety if she or he doesn't exercise)

    If continued, the starving, binge eating, and purging can lead to irreversible physical damage and even death. Eating disorders can affect every cell, tissue, and organ in the body. The following is a list of some of the physical and medical dangers associated with anorexia nervosa and bulimia nervosa.

    • Malnutrition (can lead to loss of muscle and bone density [osteoporosis] resulting in dry, brittle bones)
    • Severe dehydration, which can result in kidney failure and chemical imbalances (can lead to seizures, irregular heartbeats and possibly heart failure and death)
    • Tearing of the esophagus from excessive vomiting
    • Chronic irregular bowel movements and constipation as a result of laxative abuse
    • Potential for a ruptured stomach during periods of binge eating
    • Tooth decay and gum erosion from stomach acids released during frequent vomiting
    • Irregular menses or absence of menstruation
    • Abnormally low blood pressure

    How is it treated?

    There are many factors that contribute to the development of an eating disorder, and because each individual's situation is different, the "best treatment" must be tailored for that individual. The process begins with an evaluation by a physician or psychiatrist. From there, a variety of approaches are used to treat individuals with anorexia nervosa and bulimia nervosa.

    The intensity of the treatment required and the need for outpatient (appointments with a doctor at an office) or inpatient (hospitalization) therapy should be determined based on the severity of the individual's disease. Determining the seriousness of the associated medical complications and psychological problems will lead to the evaluation of disease severity.

    Hospitalization may be needed for those individuals who exhibit the following:

    • A significant weight loss (more than 30% less than normal weight); particularly if the weight loss has been recent and rapid
    • Medical complications such as seizures, heart failure, or irregular heart rhythms
    • Chemical imbalances or dehydration
    • An overriding psychiatric problem such as depression or thoughts of suicide
    • No response to outpatient treatment after 3 to 4 months

    The goals of outpatient treatment of eating disorders are nutritional rehabilitation (balanced diets), weight restoration, stopping weight loss behaviors, improvement in eating behaviors, and improvement of psychological and emotional states. The goals for hospitalized individuals are the same as outpatient management but with increased intensity. If a patient is admitted to the hospital for treatment, resolving medical complications and stabilizing nutritional status are the first and most important goals. If severe weight loss and malnutrition are apparent, intravenous feeding (receiving nutrition through one's veins) will be needed.

    Psychotherapy


    Once the malnutrition has been corrected and the individual begins to experience weight gain, psychotherapy can be used to help individuals overcome low self-esteem and address distorted thought and behavior patterns. Psychotherapy is a form of behavioral therapy that focuses on the individual's emotional and psychological well-being. Forms of psychotherapy include psychodynamic, cognitive, family, and group therapy.

    • Psychodynamic therapy is a general name for approaches that attempt to get the individual to surface his or her true feelings and then to understand those feelings. This therapy focuses on the basic assumption that everyone has an unconscious mind (sometimes called the subconscious) and that feelings held in the unconscious mind are often too painful to be faced. Psychodynamic therapy helps the individual to deal with subconscious feelings.

    • Cognitive therapy focuses on changing negative thoughts and behaviors and recognizing what triggers them. Cognitive therapy may focus on weight restoration with meal planning, assistance with developing regular eating patterns, and discouraging the use of dieting. This type of behavioral therapy provides a structured, safe, and supportive environment to discuss the foods the individual fears most.

    • Family therapy is important for patients who live at home because family dynamics play an important role in eating disorders. Parents and siblings can be deeply affected by the presence of an eating disorder within the family and need an outlet to understand the disease and recovery process. Family therapy provides a meeting place to communicate concerns and needs between the family and the patient.

    • Group therapy, when the individual is ready, this can be an important source for peer support. Goals of group therapy typically include the following: (1) exploring underlying emotional conflicts that may be expressed by eating behaviors, (2) sharing problem solving and effective coping strategies, (3) developing realistic weight goals and a healthy relationship with food, and (4) improving interpersonal communications. These groups often focus on exploring the roots and influences of negative body image on the individual and work towards body acceptance.

    Nutritional Therapy

    A professional nutritionist or dietician can help patients learn how to manage their weight effectively. Individualized guidance and a meal plan that provides a framework for meals and food choices (but not a rigid diet) are helpful for most individuals. Nutritionists can also help individuals better understand how their eating disorders can create serious medical problems.

    Drug Therapy

    Drug therapy in the treatment of anorexia nervosa and bulimia nervosa should be used in combination with psychotherapy and nutritional therapy.

    For anorexia nervosa, medications are used most frequently after weight and normal eating behaviors have been restored. Medications including certain antidepressants, antipsychotics, and gastrointestinal stimulants are used to treat psychiatric and gastrointestinal symptoms that may coincide with eating disorders. Also calcium plus vitamin D supplementation is recommended for people with low bone mineral density (BMD) because of their high risk of developing bone loss and/or osteoporosis.

    For bulimia nervosa, medications are used to reduce the frequency of disturbed eating behaviors such as binge eating and vomiting. Medications are often used to improve symptoms that may accompany depression, anxiety, or obsessive behaviors. The medications used in the treatment of bulimia nervosa include antidepressants, the antipsychotic drug lithium, and the anticonvulsant drug topiramate (brand name: Topamax). Although lithium is now falling out of favor due to ineffectiveness in bulimia nervosa, its side effect of weight gain, and need of frequent blood monitoring to avoid toxic drug levels. The long-term benefits of using antidepressants for bulimia nervosa are unclear, as relapse rates are high with up to 80% of patients relapsing.

    For binge-eating, medications are used to reduce the frequency of binging and also to cause weight loss in binge eaters who are obese. The medications used in the treatment of binge-eating include antidepressants, anticonvulsants topiramate and zonisamide, and the appetite-suppressant sibutramine (brand name: Meridia).

    To learn more about the drugs used to treat eating disorders, click on the drug class links below.

    Although eating disorders are treatable and many people recover from them, recovery is a complex process that can take several months or even years. Some individuals do better than others - the success often depends on the individual's drive to seek help and reach out to their support system. Seeking treatment from physicians and psychiatrists typically offers the greatest success in the recovery process.

    Helping Yourself

    If you are concerned that someone you know may have an eating disorder, watch for the following warning signs:

    • Abnormal food behaviors such as skipping meals, putting only tiny portions on their plate, unwillingness to eat in front of other people, eating in ritualistic ways (the same foods, the same times, or eating foods in the same order), and mixing strange food combinations. The individual may also chew mouthfuls of food but spit them out before swallowing.
    • Social withdrawal - The individual tries to please everyone and withdraws when this is not possible.
    • Feelings - The individual may have trouble talking about feelings, especially anger. She or he may become moody, irritable, cross, or touchy.
    • Negative body image - The individual has frantic fears of weight gain and obesity, spends a great deal of time inspecting oneself in the mirror and usually finds a portion of the body to criticize. She or he wears baggy clothes, sometimes in layers, to hide the increasing thinness and to stay warm. Often the individual worries about clothing size and complains that she/he is fat even though others truthfully say this is not so.
    • Thoughts and beliefs - The individual has lost the ability to think logically, evaluate reality objectively, concentrate, and correct undesirable consequences of choices and actions. The individual becomes irrational and denies that anything is wrong and is often envious of thin people.
    • Exercise behaviors - The individual exercises excessively and compulsively.
    • Disturbed sleep patterns - The individual has difficulty sleeping, falling asleep or spends too much time sleeping.

    What can I do if I suspect an eating disorder?

    First, understand that eating disorders are serious medical and psychological problems. They are not just a fad, a phase, or odd behavior. Eating disorders require that same level of treatment as any other serious disease, because they effectively cripple the mind and heart with body dissatisfaction, perfectionism, and the need for control. You will need the help of physicians, psychologists, and other mental health therapists who have been trained to work with these individuals. These individuals deserve and require professional evaluation, diagnosis, and treatment.

    Recovery means much more than replacing dieting, binge eating, and purging with healthy eating. It means identifying the underlying reasons that have brought the individual to disordered eating and then resolving them. This process requires skill, sensitivity, and training of medical and mental health professionals.

    Does that mean there is nothing you can do to help a loved one? No. There are many things you can do as a friend, a parent, a spouse, a partner, or a sibling for someone suffering from an eating disorder. Your primary focus should be to encourage the individual to discuss the problem with a physician or counselor. If, after an evaluation, ongoing treatment is advised, encourage the person to begin and continue treatment until the eating disorder is resolved. Typically, the biggest obstacle will be convincing the person to do this because at first she or he will deny there is a problem. She or he will fear weight gain, be ashamed, and not want to admit what is going on. The individual has used the eating disorder to protect, hide, comfort, and empower herself or himself. Arriving at a new and healthier perspective is the first challenge on the road to recovery and you can be there to help guide that person.

    Where can I find help?

    Finding a counselor, physician, and treatment team that you trust, and with whom you can work effectively, is an important part of the recovery process. Here are some tips to get you started.

    • If you are in crisis, go to a hospital emergency room or call a crisis hotline. Find the number in the yellow pages under "Crisis Intervention."
    • If you are not in crisis, ask your family doctor for an evaluation and referral. Don't let embarrassment stop you from telling the physician all the details.
    • You can also ask people you trust, and who have been in your situation, for the names of physicians and counselors they found helpful.
    • If you are a student, check with the school counseling center. Services may be low cost or free.
    • If your income is limited, or if your insurance will not cover treatment for eating disorders, look for community service agencies in the "Counselors" section of the yellow pages. The organizations listed there may not provide formal eating disorders programs, but they do offer basic assistance to people who have few other options.

    What is on the horizon?

    Scientists and others continue to investigate the effectiveness of psychological and social interventions, medications, and the combination of these treatments with the goal of improving outcomes for people with eating disorders. Other studies are investigating the neurobiology (the study of how the brain works) of emotional and social behavior related to eating disorders and the neuroscience of feeding behavior. From these studies, scientists have learned that both appetite and energy expenditure are regulated by a highly complex network of nerve cells and molecular messengers called neuropeptides. These and future discoveries will provide potential targets for the development of new medications for eating disorders.

    A recent study published in the April 2005 American Journal of Psychiatry showed how frequently a person crosses over from anorexia nervosa to bulimia nervosa and vice versa. This small study showed that patients with anorexia nervosa switched to bulimia nervosa 36% percent of the time within 15 years, while persons with bulimia nervosa developed anorexia nervosa 27% of the time. This new information may shed some light on possible reasons for treatment failure and how to improve outcomes in these patients. A new study published in 2008 looked at characteristics of people who had anorexia nervosa-restricting type and later developed bulimia nervosa. It found that these individuals were usually obese, had been obese in the past, depressed, and/or had low self-directedness. This information could help doctors and even family members to realize earlier on if the person may be at risk if they have anorexia nervosa-restricting type and one or a combination of these factors.

    References

    American Psychiatry Association Home Page. Available at http://www.psych.org. Accessed May 18, 2006, April 4, 2007, and March 31, 2008.

    Eating Disorder Home Page. Available at http:/www.eating-disorder.com. Accessed May 18, 2006, April 4, 2007, and March 31, 2008.

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    Fairburn CG. Risk factors for binge eating disorder: a community-based, case-control study. Arch Gen Psychiatry 1998;55:425-32. Foster DW. Anorexia Nervosa and Bulimia Nervosa. In: Harrison's Principles of Internal Medicine. 14th ed. Fauci AS, Kasper DL, Hauser SL eds. St. Louis ;McGraw-Hill;1998:462-5.

    Lifespan Organization Home Page. Available at http://www.lifespan.org. Accessed May 18, 2006, April 4, 2007, and March 31, 2008.

    Marken PA, Sommi RW. Eating Disorders. In: Pharmacotherapy A Pathophysiologic Approach. 6th ed. Dipiro JT, Talbert RL eds. Stamford, CT;Appleton and Lange: 2005: 1147-1155.

    National Association of Anorexia Nervosa and Associated Disorders Home Page. Available at http:/www.anad.org. Accessed May 18, 2006, April 13, 2007, and March 31, 2008.

    National Eating Disorders Association. News Release: The Changing Face of Eating Disorders Available at: http://www.nationaleatingdisorders.org/p.asp?WebPage_ID=805 Accessed May 22, 2006, April 4, 2007, and March 31, 2008.

    Nishimura H, Komaki G, Ando T, et al. Psychological and weight-related characteristics of patients with anorexia nervosa-restricting type who later develop bulimia nervosa. BioPsychoSocial Medicine; 2008 Feb 12;2:5.

    Powers PS, Santana CA. Eating disorders: a guide for the primary care physician. Prim Care 2002;29:81-9.

    Walsh BT. Eating Disorders. In: Psychiatry. 1st ed. Tasman ed. W.B. Saunders Company;1997:1202-17.

    Women's Health Channel Home Page. Available at http:/www.womenshealthchannel.com. Accessed May 18,2006.

    Eating Disorders Health Condition Last Updated: April 2008

    Note: The above information is intended to supplement, not substitute for, the expertise and judgment of your physician, pharmacist, or other healthcare professional. It is not intended to diagnose a health condition, but it can be used as a guide to help you decide if you should seek professional treatment or to help you learn more about your condition once it has been diagnosed.

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