An in-depth report on the treatment and prevention of eating
disorders.
Alternative
Names
Anorexia; Bulimia; Binge
eating
Treatment:
Treatment goals for eating disorders include:
The
first major difficulty in treating eating disorders is resistance by everyone
involved:
It is
very important that the patient and any close friends and relatives be informed
about the serious potential of these conditions and the importance of receiving
immediate help.
A
multidisciplinary team approach with consistent support and counseling is
essential for long-term recovery from all severe eating disorders. Depending on
the severity and type of disorder, team members may include:
All
should be skilled in treating eating disorders. Studies have found that people
treated by such specialists have a lower mortality rate than those treated only
as psychiatric patients.
Getting Rid of Unrealistic
Expectations
Patients may drop out of programs if they have unrealistic
expectations of being "cured" simply through the therapists' insights. Before a
program begins, the following possibilities should be made clear:
Although the outcome for bulimics is generally more
favorable than for anorexics, long-term studies are showing recovery in many
people treated for anorexia. Studies indicate that about 70% of people with
bulimia and 27 - 50% of patients with anorexia nervosa are free from eating
disorders within 10 years of treatment.
General Treatment Approaches
Psychotherapies. Eating
disorders are nearly always treated with some form of psychiatric or psychologic
treatment. Depending on the problem, certain psychologic approaches may work
better than others.
Medications. Various medications
may be helpful for patients depending on the type of eating disorder,
psychiatric state, and severity of the condition.
Nutritional Rehabilitation. Nutritional counseling can help
patients regain weight and learn normal expectations concerning hunger and
eating patterns.
Choosing a Treatment Site
The
patient ' s condition, social circumstances, and health insurance coverage
determine the type of treatment facility -- inpatient hospitalization,
residential hospitalization, partial hospitalization, or outpatient care. Weight
is not the sole determining factor. The patient ' s overall physical condition,
psychological state, behavior patterns, and family support are all factors.
Patients and their families should discuss with their doctors the various
options available and how structured and intense the treatment should
be.
Highlights:
Eating Disorders Overview
- Eating disorders
typically occur among young women.
- Bulimia nervosa
involves a pattern of bingeing and purging. Many people with bulimia nervosa
also suffer from depression.
- Anorexia nervosa
involves a pattern of self-starvation. Patients often have an accompanying
anxiety disorder (such as obsessive compulsive disorder) or depression. Patients
who have anorexia and depression have a high risk for suicide.
Complications of Bulimia Nervosa
Many
medical problems are directly associated with bulimic behavior,
including:
- Tooth erosion,
cavities, and gum problems
- Water retention,
swelling, and abdominal bloating
- Acute stomach
distress
- Low potassium
levels
- Irregular
menstrual periods
- Swallowing
problems and esophagus damage
Complications of Anorexia Nervosa
Anorexia nervosa can increase the risk for serious health
problems such as:
- Hormonal changes,
including reproductive, thyroid, stress, and growth hormones
- Heart problems
such as abnormal heart rhythm
- Electrolyte
imbalance
- Fertility
problems
- Bone density
loss
- Anemia
- Neurological
problems
Treatment of Bulimia Nervosa
- Bulimia nervosa
is treated with a combination of psychotherapy and medication.
- Cognitive
behavioral therapy, which is given along with nutritional counseling, is the
preferred psychotherapeutic approach.
- Selective
serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac), are the
first choice for drug therapy.
Treatment of Anorexia Nervosa
- Unlike bulimia
nervosa, anorexia nervosa does not respond as well to drug treatment, although
SSRIs are sometimes used as an adjunct to psychotherapy.
- Therapy that
includes the entire family -- not just the patient -- is an important part of
the treatment process, as is nutritional education.
- Patients who are
severely underweight and who have other physical risks may need to be
hospitalized while weight is restored. Recovery is a long process that can take
5 - 6 years to achieve.
Introduction:
Eating disorders are behavioral problems brought on by a
complex interplay of factors, which may include emotional and personality
disorders, family pressures, a possible genetic or biologic susceptibility, and
a culture in which there is an overabundance of food and an obsession with
thinness. There are four general categories of eating disorders:
- Bulimia
nervosa
- Anorexia
nervosa
- Binge
eating
- Eating disorders
not otherwise specified
These
are not new disorders. Although anorexia nervosa was first defined as a medical
problem in the late 1800s, descriptions of self-starvation have been found even
in medieval writings.
Bulimia Nervosa
Bulimia nervosa is more common than anorexia, and it usually
begins early in adolescence. It is characterized by cycles of bingeing and
purging, and typically takes the following pattern:
- Bulimia is often
triggered when young women attempt restrictive diets, fail, and react by binge
eating. (Binge eating involves consuming larger than normal amounts of food
within a 2-hour period.)
- In response to
the binges, patients compensate, usually by purging, vomiting, using enemas, or
taking laxatives, diet pills, or drugs to reduce fluids.
- Patients then
revert to severe dieting, excessive exercise, or both. (Some patients with
bulimia follow bingeing only with fasting and exercise. They are then considered
to have non-purging bulimia.)
- The cycle then
swings back to bingeing and then to purging again.
- Some studies have
reported that patients with bulimia average about 14 episodes of binge-purging
per week. To be diagnosed with bulimia, however, a patient must binge and purge
at least twice a week for 3 months. (Some doctors believe that going through the
cycle only once a week is sufficient for a diagnosis.)
- In some cases,
the condition progresses to anorexia. Most people with bulimia, however, have a
normal to high-normal body weight, although it may fluctuate by more than 10
pounds because of the binge-purge cycle.
Young
people who occasionally force vomiting after eating too much are not considered bulimic, and most of the
time this occasional unhealthy behavior does not continue beyond
youth.
Anorexia Nervosa
The
term "anorexia" literally means absence of appetite. Anorexia nervosa involves
an aversion to food that leads to a state of starvation and emaciation. It is a
very serious illness that some doctors believe is an entirely different
condition from bulimia and should be not be diagnosed as a simple eating
disorder.
Facts
associated with anorexia nervosa:
- At least 15% to
as much as 60% of normal body weight is lost.
- The patient with
anorexia nervosa has an intense fear of gaining weight, even when severely
underweight.
- Individuals with
anorexia nervosa have a distorted image of their own weight or shape and deny
the serious health consequences of their low weight.
- Women with
anorexia nervosa miss at least three consecutive menstrual periods. (Women can
also be anorexic without this occurrence.)
Patients with this condition are often characterized as
anorexia restrictors or anorexic bulimic patients. Each type is equally
prevalent.
- Anorexia
restrictors reduce their weight by severe dieting.
- Anorexic bulimic
patients maintain emaciation by purging. Although both types are serious, the
bulimic type, which imposes additional stress on an undernourished body, is the
more damaging.
Severe anorexia is common in the elderly, who may experience
weight loss because of social isolation, impaired gastrointestinal function, or
loss of certain chemicals related to the feeding drive. Such age-related
anorexia, however, is not synonymous with anorexia nervosa, which is a
psychologic disorder.
Binge Eating (Binge Eating
Disorder)
Bingeing without purging is characterized as compulsive
overeating (binge eating) with the absence of bulimic behaviors, such as
vomiting or laxative abuse (used to eliminate calories). Binge eating usually
leads to becoming overweight.
To be
diagnosed as a binge eater, a person typically has the following
characteristics:
- Bingeing at least
twice a week for 6 months
- Consuming 5,000 -
15,000 calories in one sitting
- Eating three
meals a day plus frequent snacks
- Overeating
continually throughout the day, rather than consuming large amounts of food
during binges
Since
binge eating disorder is generally associated with weight gain, it will not be
further discussed in this report. [For more information, see In-Depth
Report #53: Weight control and diet.]
Eating Disorders Not Otherwise
Specified
A
fourth category called eating disorders not otherwise specified (NOS) has been
established to define eating disorders not specifically defined as anorexia or
bulimia. This category includes:
- Infrequent
binge-purge episodes (occurring less than twice a week or having such behavior
for less than months)
- Repeated chewing
and spitting without swallowing large amounts of food
- Normal weight and
anorexic behavior
Such
patients tend to be older at diagnosis. Although less serious than other eating
disorders, these patients still face similar health problems, including a higher
risk for fractures and other conditions.
Risk Factors:
Many
factors contribute to the risk of developing an eating disorder. In the United
States, about 7 million females and 1 million males suffer from eating
disorders.
Age
Eating disorders occur most often in adolescents and young
adults. However, they are becoming increasingly prevalent among young children.
Eating disorders are more difficult to identify in young children because they
are rarely suspected.
Gender
Studies indicate that eating disorders occur predominantly
among girls and women. About 90 - 95% of patients with anorexia nervosa, and
about 80% of patients with bulimia nervosa, are female.
Ethnic Factors
Most
studies of individuals with eating disorders have been conducted using Caucasian
middle-class females. However, eating disorders also affect people of other
races.
Socioeconomic Factors
Living in any economically developed nation on any continent
appears to pose a risk for eating disorders. Within nations, eating disorders
can affect people of all socioeconomic levels.
Personality Disorders
People with eating disorders tend to share similar
personality and behavioral traits, including low self-esteem, dependency, and
problems with self-direction. Specific psychiatric personality disorders may put
people at higher risk for eating disorders.
Avoidant Personalities. Some
studies indicate that many patients with anorexia nervosa have avoidant
personalities. This personality disorder is characterized by:
- Being a
perfectionist
- Being emotionally
and sexually inhibited
- Having less of a
fantasy life than people with bulimia or those without an eating
disorder
- Being perceived
as always being "good," not being rebellious
- Being terrified
of being ridiculed or criticized or of feeling humiliated
People with anorexia are extremely sensitive to failure, and
any criticism, no matter how slight, reinforces their own belief that they are
"no good".
Obsessive-Compulsive
Personality. Obsessive-compulsive personality defines certain character
traits (being a perfectionist, morally rigid, or preoccupied with rules and
order). This personality disorder has been strongly associated with a higher
risk for anorexia. These traits should not be confused with the anxiety disorder
called obsessive-compulsive disorder
(OCD), although they may increase the risk for this disorder.
Borderline Personalities.
Borderline Personality Disorder (BPD) is associated with self-destructive and
impulsive behaviors. People with BPD tend to have other co-existing mental
health problems, including eating disorders.
Narcissistic Personalities.
Studies have also found that people with bulimia or anorexia are often highly
narcissistic and tend to:
- Have an inability
to soothe oneself
- Have an inability
to empathize with others
- Have a need for
admiration
- Be hypersensitive
to criticism or defeat
Accompanying Emotional
Disorders
Many
patients with eating disorders experience depression and anxiety disorders.
Depression, anxiety, or both is also common in families of patients with eating
disorders. It is not clear if emotional disorders, particularly
obsessive-compulsive disorder (OCD), cause the eating disorders, increase
susceptibility to them, or share common biologic cause.
Obsessive-Compulsive Disorder
(OCD). Obsessive-compulsive disorder is an anxiety disorder that occurs in
up to two thirds of patients with anorexia and up to one third of patients with
bulimia. In fact, some doctors believe that eating disorders are variants of
OCD. Obsessions are recurrent or persistent mental images, thoughts, or ideas,
which may result in compulsive behaviors (repetitive, rigid, and self-prescribed
routines) that are intended to prevent the manifestation of the obsession. Women
with anorexia and OCD may become obsessed with exercise, dieting, and food. They
often develop compulsive rituals (weighing every bit of food, cutting it into
tiny pieces, or putting it into tiny containers). The presence of OCD with
either anorexia or bulimia does not, however, appear to have any influence on
whether a patient improves or not.
Obsessive-compulsive
disorder is an anxiety disorder characterized by an inability to resist or stop
continuous, abnormal thoughts or fears combined with ritualistic, repetitive,
and involuntary defense behavior.
Other Anxiety Disorders. A
number of other anxiety disorders have been associated with both bulimia and
anorexia, including:
- Phobias. Phobias often precede the onset of
the eating disorder. Social phobias, in which a person is fearful about being
humiliated in public, are common in both types of eating
disorders.
- Panic Disorder. Panic disorder often
follows the onset of an eating disorder. It is characterized by periodic attacks
of anxiety or terror (panic
attacks).
- Post-Traumatic Stress Disorder. Many women
with serious eating disorders report a past traumatic event, and many exhibit
symptoms of post-traumatic stress disorder (PTSD) -- an anxiety disorder that
occurs in response to life-threatening circumstances.
Depression. Depression is common
in people with eating disorders, for both anorexia and bulimia. Major depression
is unlikely to be a cause of eating disorders, however, because treating and
relieving depression rarely cures an eating disorder. In addition, depression
often improves after anorexic patients begin to gain weight.
Being Overweight
Extreme eating disorder behaviors, including use of diet
pills, laxatives, diuretics, and vomiting, are reported more often in overweight
than normal weight teenagers.
Body Image Disorders
Body Dysmorphic Disorder. Body
dysmorphic disorder (BDD) involves a distorted view of one's body that is caused
by social, psychologic, or possibly biologic factors. It is often associated
with anorexia or bulimia, but it can also occur without any eating disorder.
People with this disorder commonly suffer from emotional disorders, including
obsessive-compulsive disorder and depression. As part of obsessive thinking,
some people with BDD may obsess about a perceived deformity in one area of their
body, and may repeatedly seek cosmetic surgery to "correct" it. People with BDD
are also at higher risk for suicidal thinking and attempts.
Muscle Dysmorphia. Muscle
dysmorphia is a form of body dysmorphic disorder in which the obsession involves
musculature and muscle mass. It tends to occur in men who perceive themselves as
being underdeveloped or "puny," which results in excessive body building,
preoccupation with diet, and social problems. Such individuals are prone to
eating disorders and other unhealthy behaviors, including the use of anabolic
steroids.
Excessive Physical Activity
Highly competitive athletes are often perfectionists, a
trait common among people with eating disorders.
Female Athletes. Excessive
exercise is associated with many cases of anorexia (and, to a lesser degree,
bulimia). In young female athletes, anorexia postpones puberty, allowing them to
retain a muscular boyish shape without the normal accumulation of fatty tissues
in breasts and hips that may blunt their competitive edge. Many coaches and
teachers compound the problem by overstressing calorie counting and loss of body
fat.
In
response, people who are vulnerable to such criticism may lose excessive weight,
which has been known to be deadly even for famous athletes. The term "female
athlete triad" is a common and serious disorder that affects young female
athletes and dancers. It includes:
- Eating disorders,
including anorexia
- Amenorrhea
(absent or irregular menstruation)
- Osteoporosis
(bone loss, which is related to low weight)
Male Athletes. Male wrestlers
and lightweight rowers are also at risk for excessive dieting. Many high school
wrestlers use a method called weight-cutting for rapid weight loss. This process
involves food restriction and fluid depletion by using steam rooms, saunas,
laxatives, and diuretics. Although male athletes are more apt to resume normal
eating patterns once competition ends, studies show that the body fat levels of
many wrestlers are still well below their peers during off-season and are often
as low as 3% during wrestling season.
Men and Women in the Military.
Studies also show a higher-than-average risk for eating disorders in men and
women in the military. A study of eating behavior on one Army base reported that
8% of the women had an eating disorder, compared to 1 - 3% in the civilian
female population.
Vegetarianism
In
general, vegetarianism, with careful planning, is a healthy practice for both
adults and adolescents. Studies report, however, that vegetarianism in
adolescence may be a risk factor for eating disorders in both males and females.
Vegetarian teens have been found to be twice as likely to diet frequently, four
times as likely to intensively diet, and eight times as likely to use laxatives
as their non-vegetarian peers.
These
studies do not mean that being a vegetarian equates with having an eating
disorder. They do suggest, however, that parents with children who suddenly
become vegetarians should be sure that their children are eating a balanced meal
with sufficient protein, calories, and important minerals, such as calcium.
Parents also might suspect anorexic behavior in their child under certain
conditions:
- If the child has
stopped eating meat only to avoid fat rather than from other motives, such as
love of animals or to improve health.
- If the vegetarian
diet coincides with rapid weight loss.
- If the child
avoids important vegetable products because of calories (such as whole grains)
or because of fats and oils (such as tofu, nuts, and dairy
products).
Diabetes or Other Chronic
Diseases
Early Puberty
There
is a greater risk for eating disorders and other emotional problems for girls
who undergo early menarche and puberty, when the pressures experienced by all
adolescents are intensified by experiencing these early physical changes,
including normal increased body fat.
Eating disorders may be more common in
teenagers with chronic illness, such as diabetes or asthma. Some recent research
suggests an endocrinological link between obesity, diabetes, and eating
disorders.
Diabetes. Eating disorders are
particularly serious problems for people with either type 1 or type 2
diabetes.
- Binge eating
(without purging) is most common in type 2 diabetes and, in fact, the obesity it
causes may even trigger this diabetes in some people.
- Both bulimia and
anorexia are common among young people with type 1 diabetes. The combination of
diabetes and an eating disorder can have serious health consequences. Some women
with diabetes often omit or underuse insulin in order to control weight. If such
patients develop anorexia, their extremely low weight may appear to control the
diabetes for a while. Eventually, however, if they fail to take insulin and
continue to lose weight, these patients develop life-threatening
complications.
Causes:
There
is no single cause for eating disorders. Although concerns about weight and body
shape play a role in all eating disorders, the actual cause of these disorders
appear to result from many factors, including cultural and family pressures and
emotional and personality disorders. Genetics and biologic factors may also play
a role.
Negative Family Influences
Negative influences within the family may play a major role
in triggering and perpetuating eating disorders. Some studies have produced the
following observations and theories regarding family influence.
- Parental Behaviors or Attitudes. Poor
parenting by both mothers and fathers has been implicated in eating disorders.
One study found that 40% of 9- and 10-year-old girls trying to lose weight
generally did so with the urging of their mothers. A maternal history of eating
disorders can be a factor in development of eating disorders in young girls,
while paternal criticism of weight can lead to bingeing and purging in young
males.
- Family History of Addictions or Emotional
Disorders. Studies report that people with either anorexia or bulimia are
more likely to have parents with alcoholism or substance abuse than are those in
the general population. Parents of people with bulimia appear to be more likely
to have psychiatric disorders than parents of patients with
anorexia.
- History of Abuse. Women with eating
disorders, particularly bulimia, appear to have a higher incidence of sexual
abuse. Studies have reported sexual abuse rates as high as 35% in women with
bulimia.
- Family History of Obesity. People with
bulimia are more likely than average to have an obese parent or to have been
overweight themselves during childhood.
The
most positive way for parents to influence their children's eating habits and to
prevent weight problems and eating disorders is to have healthy eating habits
themselves.
Genetic Factors
Anorexia is eight times more common in people who have
relatives with the disorder, and some doctors believe that genetic factors are
the root cause of many cases of eating disorders. Twins had a tendency to share
specific eating disorders (anorexia nervosa, bulimia nervosa, and obesity).
Researchers have identified specific chromosomes that may be associated with
bulimia and anorexia. In particular, regions on chromosome 10 have been linked
to bulimia as well as obesity. Some evidence has reported an association with
genetic factors responsible for serotonin, the brain chemical involved with both
well-being and appetite. Researchers have also pinpointed certain proteins such
as brain-derived neurotrophic factor (BDNF). This protein may influence an
individual's susceptibility to developing an eating disorder.
Cultural Pressures
The
approach to food in Western countries is extremely problematic. Enough food is
produced in the U.S. to supply 3,800 calories every day to each man, woman, and
child, far more than are needed for good nutrition. Obesity is a global
epidemic, and few people living in this over-fed and sedentary culture eat a
meal guiltlessly.
One
interesting anthropologic study reported the following observations:
- During historical
periods or in cultures where women are financially dependent and marital ties
are stronger, the standard is toward being curvaceous, possibly reflecting a
cultural or economic need for greater reproduction.
- During periods or
in cultures where female independence has been possible, the standard of female
attractiveness tends toward thinness.
The
response of the media to the cultural drive for thinness and the overproduction
of food both likely play major roles in triggering obesity and eating
disorders.
- On the one hand,
advertisers heavily market weight-reduction programs and present anorexic young
models as the paradigm of sexual desirability.
- Clothes are
designed and displayed for thin bodies in spite of the fact that few women could
wear them successfully.
- On the other hand,
the media floods the public with attractive ads for consuming foods, especially
"junk" foods.
Hormonal Abnormalities
Hormonal abnormalities are common in eating disorders and
include chemical abnormalities in the thyroid, the reproductive regions, and
areas related to stress, well-being, and appetite. Many of these chemical
changes are certainly a result of malnutrition or other aspects of eating
disorders, but they also may play a role in perpetuating or even creating
susceptibility to the disorders.
The
primary setting of many of these abnormalities originate in a small area of the
brain called the limbic system. A specific system called
hypothalamic-pituitary-adrenal axis (HPA) may be particularly important in
eating disorders. It originates in the following regions in the
brain:
- Hypothalamus. The
hypothalamus is a small structure that plays a role in controlling our behavior,
such as eating, sexual behavior and sleeping, and regulates body temperature,
emotions, secretion of hormones, and movement.
The pituitary
gland. The pituitary gland is involved in controlling thyroid functions, the
adrenal glands, growth, and sexual maturation.
Amygdala. This
small almond-shaped structure lies deep in the brain and is associated with
regulation and control of major emotional activities, including anxiety,
depression, aggression, and affection.
Stress Hormones. The HPA systems
trigger the production and release of stress hormones called glucocorticoids,
including the primary stress hormone cortisol. Chronically elevated levels of
stress chemicals have been observed in patients with anorexia and bulimia.
Cortisol is very important in marshaling systems throughout the body (including
the heart, lungs, circulation, metabolism, immune systems, and skin) to deal
quickly with any threat.
Release of Neurotransmitters. The
HPA system also releases certain neurotransmitters (chemical messengers) that
regulate stress, mood, and appetite and are being heavily investigated for a
possible role in eating disorders. Abnormalities in the activities of three of
them, serotonin, norepinephrine, and dopamine, are of particular interest.
Serotonin is involved with well-being, anxiety, and appetite (among other
traits), and norepinephrine is a stress hormone. Dopamine is involved in
reward-seeking behavior. Recent research suggests that people with anorexia have
increased activity in the brain's dopamine receptors. This overactivity may
explain why people with anorexia do not experience a sense of pleasure from food
and other typical comforts.
Ghrelin. High levels of ghrelin, a hormone that increases the
feeling of hunger and slows metabolism, have been noted in patients with
anorexia and bulimia.
Low Levels of Reproductive
Hormones. The hypothalamic-pituitary system is also responsible for the
production of important reproductive hormones that are severely depleted in
anorexics. Although most doctors believe that these reproductive abnormalities
are a result of anorexia, others have reported that in 30 - 50% of people with
anorexia, menstrual disturbances occurred before severe malnutrition set in and
remained a problem long after weight gain, indicating that
hypothalamic-pituitary abnormalities may precede the eating disorder
itself.