Eating Disorders: Anorexia and Bulimimia

Eating disorders are devastating behavioral maladies 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. Eating disorders are generally categorized as bulimia nervosa, anorexia nervosa, and eating disorders not otherwise specified. These are not new disorders. Although anorexia nervosa was first defined as a medical problem in 1873, descriptions of self-starvation have been found in medieval writings.

Bulimia Nervosa.

Bulimia nervosa, which is more common than anorexia, is characterized by cycles of bingeing and purging. Bulimia nervosa usually begins early in adolescence when young women attempt restrictive diets, fail, and react by binge eating. In response to the binges, patients purge by vomiting or by taking laxatives, diet pills, or drugs to reduce fluids. Patients may also revert to severe dieting, which cycles back to bingeing if the patient does not go on to become anorexic. Eating binges prior to purging average about 1,000 calories, but intake during a binge can be as high as 20,000 or as low as 100 calories. Patients diagnosed with bulimia average about 14 episodes of binge-purging per week. People with bulimia that does not progress to anorexia have a normal to high-normal body weight, but it may fluctuate by more than 10 pounds because of the binge-purge cycle.

Anorexia Nervosa.

Anorexia nervosa leads to a state of starvation and emaciation, losing at least 15% to as much as 60% of their normal body weight. Half of these patients, known as anorexia restrictors, reduce weight by severe dieting; the other half, 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.

Eating Disorders Not Otherwise Specified.

A third category called eating disorders not other specified (NOS) was established to define eating disorders not specifically defined as anorexia and bulimia. This category includes binge eating without purging, infrequent binge-purge episodes (occurring less than twice a week or such behavior lasting less than three months), repeated chewing and spitting without swallowing large amounts of food, or normal weight in people who exhibit anorexic behavior. [For more information on bingeing without bulimia, see Well-Connected Report #53 Obesity.]

WHO DEVELOPS EATING DISORDERS?

Gender and Age .

One study reported that two-thirds of high school students were on diets, although only 20% were actually overweight. Another study of teenagers in Connecticut reported that 6.8% of girls and 2.8% of boys had an eating disorder. Although 90% of reported cases are in women, the rate in men appears to be increasing. Men are more apt to conceal an eating disorder than are women, so the incidence may be underreported. One study of Navy men reported a 2.5% prevalence of anorexia, 6.8% of bulimia, and 40% of eating disorders not-otherwise-specified. A study of civilian men with eating disorders reported that 42% of those with bulimia were homosexual or bisexual while 58% of the men with anorexia reported that they were asexual. Both men and women are at higher risk for eating disorders if they suffer from depression, personality disorder, or substance abuse.

Bulimia has increased at a greater rate than anorexia over the past several years. Estimates of the prevalence of bulimia nervosa among young women range from about 3% to 10%. Some experts claim this problem is grossly underestimated because many people with bulimia are able to conceal their purging and do not become noticeably underweight. Some studies report that 80% of female college students have binged. Young people who occasionally force vomiting after eating too much, however, are not considered bulimic, and most of the time this occasional unhealthy behavior does not continue beyond youth.

Ethnic and Socioeconomic Factors.

Most studies of individuals with eating disorders have been conducted using white middle-class females. There is some indication, however, that African American girls and young women may be at particular risk for eating disorders because of poor body images caused by cultural attitudes that denigrate the physical characteristics of minorities. Living in economically developed nations on any continent appears to pose more of a risk for eating disorders than belonging to a particular ethnic group; symptoms remain strikingly similar across high-risk countries. Oddly enough, within developed countries there appears to be no difference in risk between the rich and the poor. In fact, those in lower economic groups may be at higher risk for bulimia. City living is a risk factor for bulimia but not for anorexia. In one test, people with eating disorders scored significantly higher on IQ tests than average. People with bulimia, but not anorexia, had higher nonverbal than verbal scores.

Personality Disorders.

Linked to eating disorders are specific personality disorders: avoidant personality in anorexia; borderline personality in bulimia; and narcissism in both . It should be noted that all these traits may be found in either eating disorder. One study indicated that women with both eating disorders tended to be less optimistic, to worry more, and to deny negative issues when solving problems than were women without eating disorders. In general, women with eating disorders had a much more difficult time dealing with stress than other women.

Avoidant Personalities. Some studies indicate that as many as a third of anorexia restrictors have avoidant personalities; that is, they tend to be perfectionists and are emotionally and sexually inhibited. They also often have less of a fantasy life than people with bulimia or without eating disorders. They rarely rebel and are usually perceived as always being "good". They are terrified of being ridiculed and feeling humiliated. Achieving perfection, with all that involves, is the only way to achieve love; this means becoming trouble-free and demanding nothing (including food). Part of this need for perfection is an ideal image of thinness that can never be achieved. People with anorexia are extremely sensitive to failure, and any criticism--no matter how slight--reinforces their own belief that they are "no good". Because love is never obtained through attempts to be perfect, a sense of failure is inevitable. One expert described her anorexic patients as having a total lack of self--well beyond low self-esteem. The process of not-eating, then, becomes an act of passive revenge on those whose love is always out of reach: "See? I am slowly disappearing, and you will be very sad when I am gone."

Borderline Personalities. Studies indicate that almost 40% of people who have bulimic anorexia--who lose weight by bingeing and purging--were borderline personalities. Such people tend to have unstable moods, thought patterns, behavior, and self-images. They cannot stand to be alone, they demand constant attention, and they have difficulty controlling impulsive behavior. People with borderline personalities have been described as causing chaos around them by using emotional weapons such as temper tantrums, suicide threats, and hypochondria. They idealize people and are often disappointed and rejected. Some research has suggested that the severity of this personality disorder predicts difficulty in treating bulimia and might be more important than the presence of psychological problems, such as depression.

Very Physically Active People.

Strongly competitive athletes are often perfectionists, a trait common among people with eating disorders. Women in "appearance" sports, including gymnastics and figure skating, and in endurance sports, such as track and cross-country are at particular risk for anorexia. Success in ballet also depends on the development of a wiry and extremely slim body. Estimates for episodes of eating disorders among such athletes and performers range from 15% to 60%.

Male wrestlers and light-weight rowers are also at risk for excessive dieting. One-third of high school wrestlers use a method called weight-cutting for rapid weight loss; this process involves food restriction and fluid depletion using steam rooms, saunas, laxatives, and diuretics. Although male athletes are more apt to resume normal eating patterns once competition ends, studies are showing 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.

Chronic Diseases.

According to a recent survey, 10.3% of teenage girls and 6.9% of boys with chronic illness, such as diabetes or asthma, had an eating disorder. Eating disorders are serious problems in people with diabetes; both males and females with either type 1 or type 2 diabetes have a lifetime risk of about nearly 6%. Binge eating (without purging) is most common in type 2 diabetes and, it may even be a trigger for the condition, which is often associated with obesity. In type 1 diabetes, both bulimia and anorexia are common. One study reported that over a third of diabetic women omitted or underused insulin in order to control weight. If such insulin-dependent 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 regain weight, these patients will die.

Early Puberty.

One study of girls without eating disorders reported that before puberty, girls ate quantities of food appropriate to their body weight, were satisfied with their bodies, and depression increased with lower f ood intake. After puberty, girls ate about three-quarters of the recommended calorie intake, had a poorer body self-image, and depression increased with higher food intake. New research suggests that girls as young as ten years old associate being teased or socially victimized by peers with being ugly or fat regardless of their actual physical characteristics. Such poor body images can often lead to eating disorders. It is not surprising, then, that there is a greater risk for bulimia and other emotional disorders in girls who undergo early puberty, when the pressures experienced by all adolescents are intensified further by anxiety-provoking attention on their early changing bodies.

WHAT CAUSES EATING DISORDERS?

Causes That Trigger Eating Disorders.

Emotional Disorders.

Between 40% to 96% of all eating-disordered patients experience depression and anxiety disorders; depression is also common in families of patients with eating disorders. Bulimic patients are more likely to report having emotional disorders and dysfunctional families than are anorexic-restrictor patients. It is not clear, however, whether emotional disorders are causes, results, or both, of eating disorders.

Some experts claim that depression does not play a causal role, particularly in anorexia, because eating disorders are rarely cured when antidepressant medication alone is the treatment. The severity of the eating disorder is also not correlated with the severity of any existing depression. In addition, depression often improves after anorexic patients begin to gain weight. On the other hand, a number of studies have detected in some people with severe anorexia and bulimia abnormal levels of certain neurotransmitters (chemical messengers in the brain), particularly serotonin, that are associated with depression and obsessive-compulsive disorder. These neurotransmitters remain unstable even in recovering patients. Studies are finding that low blood levels of the amino acid tryptophan, a component in food that is essential to the production of serotonin, can produce depression and may also contribute to bulimia. During the dieting stage between binges, people are often irritable, depressed, and may be more apt to express personality disorders. Positive feelings can only be restored by another binge; so the pattern continues. Eating sweets increases serotonin.

Seasonality often affects both depression and eating disorders. In many people, depression is more severe in darker winter months. Similarly, a subgroup of bulimic patients suffer from a specific form of bulimia that worsens in winter and fall; such patients are more apt to have started bingeing at an earlier age and to binge more frequently than those whose bulimia is more consistent year round. Onset of anorexia appears to peak in May, which is also the peak month for suicide.

Anxiety disorders are very common in anorexia and bulimia. Phobias and obsessive-compulsive disorder (OCD) usually precede the onset of the eating disorder, while panic disorder tends to follow. Social phobias, in which a person is fearful about being humiliated in public, are common in both eating disorders. People with anorexia are especially prone to obsessive-compulsive disorder. Obsessions are recurrent or persistent mental images, thoughts, or ideas, which may result in compulsive behavior--repetitive, rigid, and self-prescribed routines that are intended to prevent the manifestation of the obsession. Women with anorexia may become obsessed with exercise, dieting, and food. They often develop compulsive rituals--e.g., 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 appear to have a negative effect on long-term outlook, although improvement in the eating disorder usually parallels improvement in the anxiety disorder.

Family Influences and Genetic Factors.

Negative Family Factors. Negative factors within the family, possibly both inherited and environmental, play a major role in triggering and perpetuating eating disorders. One study found that 40% of 9 to 10 year-old girls try to lose weight, generally with the urging of their mothers. Some studies have found that mothers of anorexics tend to be over-involved in their child's life, while mothers of bulimics are critical and detached. Although mothers may have a strong influence on their children with eating disorders, fathers and brothers who are overly critical may also play a role in the development of anorexia in girls. Studies report that people with either eating disorder are more likely to have parents with alcoholism or substance abuse than are those in the general population. Women with eating disorders appear to have a higher incidence of sexual abuse; studies have reported sexual abuse rates as high as 35% in women with bulimia. One study of 294 women with serious eating disorders reported that 74% of them recalled a traumatic event and more than half exhibit symptoms of post-traumatic stress disorder (PTSD), which is an anxiety disorder that occurs in response to violent circumstances. People with bulimia are also more likely than people with other psychiatric disorders to have an obese parent or to have been overweight themselves during childhood.

Problems Surrounding Birth. In some people with anorexia, there was a high incidence of problems during the mother's pregnancy or after birth, which may have played a role in the later development of eating disorders. These problems include infections, physical trauma, seizures, low birth weight, and older maternal age. People with anorexia often had stomach and intestinal problems in infancy. According to one theory, eating disorders may be fostered in children if parents fail to provide a safe and secure foundation in infancy. In such cases, children experience so-called insecure attachments and are more likely to have greater weight concerns and low self esteem than are those with secure attachments.

Genetic Factors. Anorexia is eight times more common in people who have relatives with the disorder, but experts do not know precisely what the inherited factor might be. A genetic propensity toward thinness caused by a faster metabolism and accompanied by cultural approval could predispose some people to develop anorexia. An inherited propensity for obesity could also trigger eating disorders. Relatives of patients with anorexia or bulimia are themselves at increased risk for eating disorders (although not the full-blown forms), major depressive disorder, and obsessive compulsive disorder (OCD). Researchers are investigating genetic components of systems influencing certain neurotransmitters (chemical messengers in the brain).

Cultural Influences.

Attitudes toward Weight. When one includes obesity, it becomes indisputable that unhealthy eating behavior is epidemic in America. The social pressures of Western culture certainly play a major role in triggering eating disorders. On the one hand, advertisers heavily market weight-reduction programs and present anorexic young models as the paradigm of sexual desirability; on the other hand, the media floods the public with ads for junk foods. Clothes are designed and displayed for thin bodies in spite of the fact that few women could wear them successfully. Although at highest risk are those whose entire sense of self is based on outside approval and physical appearance, few women are immune to these influences. One interesting anthropologic study reported that during times and in cultures in which women are financially dependent and marital ties are stronger, the standard is toward being curvaceous, possibly reflecting some cultural or economic desire for greater reproduction. During historical periods or in cultures where female independence has been possible, however, the standard of female attractiveness tends toward thinness. Once a person has achieved emaciation, a sense of accomplishment and status can be primary motivators for perpetuating anorexia. Weight loss brings a feeling of triumph over helplessness. In a country where obesity is epidemic, young women who achieve thinness believe they have accomplished a major cultural and personal victory; they have overcome the temptations of junk food and, at the same time, created body images idealized by the media. This false sense of accomplishment is often reinforced by the envy of their heavier friends who may perceive the anorexic patients as being emotionally stronger and more sexually attractive than they are.

Excessive Athleticism . The cultural attitude toward physical activity is a fitting companion to the disordered attitude regarding eating. Americans are encouraged to admire physical activity only as an intense competitive effort that few can attain, leaving most people in their armchairs as spectators. In the small community of athletes, excessive exercise plays a major role in many cases of anorexia (and, to a lesser degree, bulimia). The term "female athlete triad" is now used to describe the presence of menstrual dysfunction, eating disorders, and osteoporosis, an increasingly common problem in young female athletes and dancers. Anorexia postpones puberty, allowing young female athletes to retain a muscular boyish shape without the normal accumulation of fatty tissues in breasts and hips that may blunt their competitive edge. Coaches and teachers compound the problem by encouraging calorie counting and loss of body fat and by over-controlling the athletes' lives. Some are even abusive if their athletes go over the weight limit and humiliate them in front of team members or exact punishments. In people with personality disorders that leave them vulnerable to such criticism, the effects may cause them to lose excessive weight, which has been known to be deadly even for famous athletes.

Biologic and Medical Factors.

Hypothalamic-Pituitary Abnormalities. There is some question as to whether the typical abnormalities observed in the neurological and hormonal systems of people with eating disorders are results or causes of the disorders. The primary setting of these abnormalities originate in a tiny area of the brain known as the hypothalamus, an area which regulates the pituitary gland, sometimes known as the master gland because of its importance in coordinating the nervous and hormonal systems. Imaging studies of the brains of anorectic patients have found high levels of proteins called corticotropin-releasing factors, which are released during periods of stress and block the substance neuropeptide Y, a powerful appetite stimulant. Such appetite-related chemicals may serve as the biologic links between extreme stressful conditions in a young person's life and the later development of anorexia, although some imaging studies indicate that these abnormalities occur after anorexia has developed. More work is needed. Another study links unstable, usually low, levels of leptin with anorexia; this substance is under scrutiny for its role in obesity.

The hypothalamic-pituitary system is also responsible for the production of important reproductive hormones that are severely depleted in anorectics, resulting in menstrual cessation. High levels of the male hormone testosterone have also been detected in women with eating disorders. Although most experts believe that these reproductive abnormalities are a result of anorexia, others have reported that in 30% to 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 precede the eating disorder itself.

Infections. Research has found a link between anorexia and group A beta-hemolytic streptococcal (GABHS) bacteria, the cause of strep throat. GABHS has already been identified as a trigger of a rare form of obsessive-compulsive disorder (OCD) in children; OCD and anorexia share many behaviors. Epstein Barr, the virus that causes mononucleosis has also been associated with the development of anorexia. One theory to explain these links is that antibodies triggered by the organisms may damage the brain in the process of fighting the infection. Antibiotics, immunological therapy, and an experimental vaccine for rheumatic fever may even help treat anorexia in such patients.

Biologic Factors for the Perpetuation of Bulimia Nervosa. Studies on animal behavior and prisoners of war suggest that chronic food restriction (such as severe dieting) often leads to a pattern of bingeing that persists even decades after regular food supplies are restored. Biologic factors may be responsible for this insidious cycle. Some experts believe that the metabolism adapts to the bulimic cycle of bingeing and purging by slowing down, thereby increasing the risk of weight gain from even normal calorie intake. The process of vomiting and use of laxatives may stimulate the production of natural opioids--narcotics in the brain that cause an addiction to the bulimic cycle.

Biologic Causes for the Perpetuation of Anorexia Nervosa. Hunger often intensifies depression, which can further reduce self-esteem and confidence, increasing the need for renewed vigilance over weight control, thus perpetuating the cycle. On the other hand, some experts believe that certain anorectic people inherit an unusual amount of natural narcotics that are released in the brain under conditions of starvation and may promote an addiction to the starved state. Starvation can also give a false sense of fullness due to reduced stomach activity, making it increasingly easy not to eat.

HOW SERIOUS ARE EATING DISORDERS?

Complications of Bulimia Nervosa without Anorexia.

Long Term Outlook . There are few major health problems for bulimic people who maintain normal weight and do not go on to become anorexic. In general, the outlook is better for bulimia than for anorexia. It should be noted, however, that in one study of bulimic patients undergoing therapy, after six years the mortality rate was 1%. Another study found that 20% of women with bulimia were still battling the disorder after ten years.

Medical Problems. Teeth erosion, cavities, and gum problems are common in bulimia. Bulimic episodes can also result in water retention and swelling and abdominal bloating. Occasionally, the binge-purge process results in loss of fluid and low potassium levels, which can cause extreme weakness and near paralysis; this is reversed when potassium is given. Dangerously low levels of potassium can result in lethal heart rhythms. Acute stomach distress and even rupture of the esophagus, or food pipe have been associated with cases of forced vomiting. In rare cases, the walls of the rectum can become so weakened by purging that they protrude through the anus; this is a serious condition that requires surgery.

Self-Destructive Behavior. Women with bulimia are prone to depression and are also at risk for dangerous impulsive behaviors, such as sexual promiscuity and kleptomania, which have been reported in half of those with bulimia. Alcohol and drug abuse is more common in women with bulimia than it is in the general population or in people with anorexia. In one study of bulimic non-anorexic women, 33% abused alcohol and 28% abused drugs, with 18% overdosing repeatedly. Cocaine and amphetamines were the drugs most often abused. In the same study, other types of self-destructive behavior were common, including self-cutting and stealing. It has been reported that many teenage girls smoke in the belief that it helps prevent weight gain.

Over-the-Counter Medications. Women with bulimia frequently abuse over-the-counter medications such as laxatives, appetite suppressants, diuretics, and drugs that induce vomiting--usually ipecac. None of these drugs is without risk. For example, ipecac poisonings have been reported, and some people become dependent on laxatives for normal bowel functioning. Diet pills, even herbal and over-the-counter medications, can be hazardous, particularly if they are abused.

Complications of Anorexia Nervosa.

Long Term Outlook. At this time no treatment program for anorexia nervosa is completely effective. In a recent study, although most women with anorexia nervosa recovered after treatment, many remained very thin and displayed traits characteristic of the disorder, including perfectionism and a drive for thinness, that could keep them at risk for recurrence of the eating disorder. Even in those who recover, one study indicated that recovery took between four and nearly seven years. Those at highest risk for poor outcome were people who had accompanying severe psychological disorders.

Risk of Death. Many studies of anorexic patients have reported death rates ranging from 4% to 20%. The risk for early death is twice as high in bulimic anorexics as it is in the anorexic-restrictor types. Patients who are at the lowest weights when they are first treated are in the greatest danger. Suicide has been estimated in some studies to comprise as many as half the deaths in anorexia; although, in one study, suicide rates were lower in women with anorexia (1.4%) than in those with depression (4.1%). The study, however, only looked at death records of all women, which listed accompanying anorexia but which might have missed many unrecorded cases of anorexia. Other risk factors for early death include being sick for more than six years, previous obesity, personality disorders, and dysfunctional marriages. Males with anorexia are at particular risk for life-threatening medical problems, probably because they are diagnosed later than are females.

Heart Disease. Heart disease is the most common medical cause of death in people with severe anorexia. The heart can develop dangerous rhythms, including slow rhythms known as bradycardia. Blood flow is reduced and blood pressure may drop. In addition, the heart muscles starve, losing size. Cholesterol levels tend to rise. Heart problems are a particular risk when anorexia is compounded by bulimia and the use of ipecac, the drug that causes vomiting.

Electrolyte Imbalances. Minerals such as potassium, calcium, magnesium, and phosphate are normally dissolved in the body's fluid. Calcium and potassium are particularly critical for maintaining the electric currents that cause the heart to beat regularly. The dehydration and starvation of anorexia can reduce fluid levels and mineral content, a condition known as electrolyte imbalance, which can be very serious and even life-threatening unless fluids and minerals are replaced.

Reproductive and Hormonal Abnormalities. Anorexia causes low levels of reproductive hormones, changes in thyroid hormones, and increased levels of the stress hormones. Long-term irregular or absent menstruation (amenorrhea) is common, which eventually may cause sterility and bone loss. Low weight alone may not be sufficient to cause amenorrhea; extreme fasting and purging behaviors may play an even stronger role in hormonal disturbance. Children and adolescents with anorexia may also experience retarded growth due to reduced levels of growth hormone. Resumption of menstruation, indicating restored estrogen levels, and weight increase improves the outlook, but in severe anorexia, even after treatment, normal menstruation never returns in 25% of such patients. Women who become pregnant before regaining normal weight face a poor reproductive future, with low birth weights, frequent miscarriages, and a high rate of children with birth defects. Loss of bone minerals (osteopenia) and osteoporosis caused by low estrogen levels and increased steroid hormones result in bones becoming porous and subject to fracture. Up to two-thirds of children and adolescent girls with anorexia fail to develop strong bones during this critical growing period; one study reported that after eleven years, low bone density persisted in 85% of women who had been anorexic as adolescents but had regained normal weight and menstruation. Only restoring regular menstruation as soon as possible can protect against permanent bone loss; weight gain is not enough. The longer the eating disorder persists the more likely the bone loss will be permanent. Patients who are rehabilitated at a young age (15 years or younger) are more likely to achieve normal bone density.

Neurological Problems. People with severe anorexia may suffer nerve damage and experience seizures, disordered thinking, loss of feeling, or other nerve problems in the hands or feet. Brains scans indicate that parts of the brain undergo structural changes and abnormal activity during anorexic states; some of these changes return to normal after weight gain, but there is evidence that some damage may be permanent.

Complications in Diabetic Adolescents.

Eating disorders are very serious in young people with type 1 diabetes. Hypoglycemia, or low blood sugar, is a danger in anyone with anorexia, but it is a particularly dangerous risk in those with diabetes. A recent study found that 85% of young women with diabetes and eating disorders had retinopathy--damage in the retina in the eye, which can lead to blindness. It also reported that eating disorders persisted in such young people, increasing the risk for other acute and chronic diabetic complications.

WHAT ARE THE SYMPTOMS OF EATING DISORDERS?

Symptoms of bulimia may be very subtle, since women with this disorder practice it in secret, and, although they may be underweight, they are not always anorexic. In general, people with bulimia are preoccupied with food and may abuse laxatives, diet pills, emetics (drugs that induce vomiting), or diuretics (medications that reduce fluids). As with anorexia, those with bulimia may also be compulsive exercisers. The strain of vomiting can sometimes cause broken blood vessels in the eyes and cause salivary glands to swell making them appear as pouch-like areas below the corners of the mouth. Teeth are prone to cavities and to erosion of enamel from excessive acid; gums may be diseased, and rashes and pimples may break out on the skin. Repeated self-induced vomiting in which a person thrusts the hand down the throat can also produce small cuts and calluses across the tops of finger joints.

The primary symptom of anorexia is major weight loss from excessive and continuous dieting, which may either be restrictive dieting or binge-eating and purging. Symptoms may be subtle in young women who have both diabetes and eating disorders; such people may have normal weight or even be overweight and still be anorectic. Anorexic behavior in vegetarians should be suspected under certain conditions: if the person has stopped eating meat only to avoid fat rather than from other motives, such as love of animals; if vegetarian diet coincides with rapid weight loss; and if the person is avoiding certain foods, such as tofu, nuts, and dairy products, that contain oils or fats. In women, menstruation may be infrequent or absent. Often, compulsive exercising coupled with emaciation leads to orthopedic problems, particularly in dancers and athletes; this may be the first sign of trouble that forces such patients to seek medical help. The skin may be dry and covered with fine hair, and normal scalp hair may be thin. The feet and hands may be cold or sometimes swollen. The stomach is often distressed after eating and is often bloated. Thinking may be confused or slowed, and an anorexic patient may have poor memory and lack judgment.

Possibly, the most bewildering symptom of both eating disorders is the distorted body image. Although people typically associate distorted body image with severe anorexia, one study indicated that distortion is more likely in people with bulimia than in anorexia. The study indicated that people with bulimia are more likely to overestimate their size; there is a greater disparity between what they want to look like and what they think they look like than in people with anorexia or with no eating disorders. People with bulimia are particularly likely to describe their own bodies as larger than they are when food images are present. In another study, people with anorexia tended to have an accurate perception of their upper body, but overestimated the size of their abdominal and pelvic area.

WHAT WILL CONFIRM A DIAGNOSIS OF EATING DISORDERS?

The first step is to admit the existence of an eating disorder. Often, the patient needs to be compelled by a parent or others to see a doctor. Because the patient may deny and resist the problem, it is recommended that a supportive companion be present during part of the interview to offer additional information on the patient's eating history and to help offset any resistance or denial the patient may express. It is, unfortunately, extremely difficult for parents as well as the patient to admit that a problem is present. For example, because food is such an intrinsic part of the mother/child relationship, a child's eating disorder might seem like a terrible parental failure. It is extremely important to overcome these feelings and to inform the physician of any suspicious weight loss or behavioral problems related to food.

Diagnosing Bulimia Nervosa.

In spite of the prevalence of bulimia, in one study only 30% of Midwest family physicians had ever diagnosed bulimia in a patient. Younger and female physicians are more likely to detect bulimia. A physician should make a diagnosis of bulimia if there are at least two bulimic episodes per week for three months. Based on other symptoms and history, the physician would then categorize the patient as being either (1) a purging type who uses self-induced vomiting or medications to get rid of the food or water or (2) a non-purging type who fasts or exercises excessively.

Diagnosing Anorexia Nervosa and its Complications.

Generally, an observation of physical symptoms and a personal history will quickly confirm the diagnosis of anorexia. The standard criteria for diagnosing anorexia nervosa are: the patient's refusal to maintain a body weight normal for age and height; intense fear of becoming fat even though underweight; a distorted self-image that results in diminished self-confidence; denial of the seriousness of emaciation and starvation; and in women, the loss of menstrual function for at least three months. The physician then categorizes the anorexia as being either restricting (severe dieting only) or anorexia bulimia (binge-purge behavior). Because the disorder rarely shows up in men, physicians may not be on the look out for it in male patients, even if they show classic symptoms of anorexia. Physicians should be very aware of these symptoms in anyone, particularly in athletes and dancers. Once a diagnosis is made, physicians should immediately check for any serious complications of starvation. They should also rule out other medical disorders that might be causing the anorexia, including chronic fatigue syndrome, Crohn's disease, hyperthyroidism, Addison's disease, cancer, tuberculosis, anemia, and celiac disease. In all cases, tests should include a complete blood count, tests for electrolyte imbalances and protein levels, an electrocardiogram and a chest x-ray, and tests of liver, kidney, and thyroid problems. Low potassium levels indicate that the disorder is more likely to be accompanied by the binge-purge syndrome. Depending on the severity of the anorexia, other tests may be needed, such as a bone-density test or other types of x-rays and imaging techniques.

HOW ARE EATING DISORDERS TREATED?

The first major difficulty in treating eating disorders is often the resistance of the anorexic patient, who believes that the emaciation is normal and even attractive, or the bulimic patient who feels that purging is the only way to prevent obesity. Even worse, the anorexic condition may be encouraged by friends who envy thinness or by dance or athletic coaches who encourage low body fat. (It might help some young women to tell them about a recent survey of college students, in which slightly over half of men preferred not to date a woman with an eating disorder.) The family itself may deny the problem and be obstructive or manipulative, adding to the difficulties of treatment. 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.

Patients may drop out of programs if they have unrealistic expectations of being "cured" simply through the therapists' insights. Before a program begins, it should be made clear that the process is painful and requires hard work on the part of the patient and family. A number of therapeutic methods are likely to be tried until the patient succeeds in overcoming these difficult disorders. Relapse is common and should not be greeted with despair. In one study, after six years, only about 10% of bulimic patients failed to respond to treatments. Bulimia is best treated with a combination of antidepressants and cognitive therapy. Outcome in bulimia is generally more favorable than in anorexia; even after recovery, women with anorexia often retain an impaired sense of body shape. Long-term studies, however, are showing recovery even in most people treated for anorexia. One study showed that for those with early onset anorexia family therapy worked best and for those with late onset anorexia individual supportive therapy was most effective.

Initial Treatment.

Most moderately to severely ill anorexic patients are admitted to the hospital for initial treatment, particularly under the following circumstances: if weight loss continues even under outpatient treatment; if weight is 30% below the minimum needed to maintain health; if disturbed heart rhythms occur; if depression is severe or the patient is suicidal; if potassium loss is severe or blood pressure is extremely low. Experts advise 10 to 12 weeks for full nutritional recovery. Patients used to stay several months in the hospital, but now insurance companies in the U.S. rarely cover more than 15 days, which, unfortunately, is not usually sufficient for the patient to reach ideal body weight and certainly isn't long enough to make major changes to entrenched behavior. One study has reported that outpatient therapy and nutritional counseling was as effective as hospitalization over the long term, but others have documented the need for prolonged inpatient treatment. Patients with bulimia rarely need hospitalization unless the binge-purge cycle has led to anorexia, drugs are needed for withdrawal from purging, or major depression is present.

Weight Gain. In addition to immediate treatment of any serious medical problem, the goal of therapy for the anorexic person is to increase weight. The weight goal is strictly set by the physician or health professional, usually one to two pounds a week. This goal is absolute, no matter how convincingly the patient (or even family members) may argue for a lower-weight goal. Patients who are severely malnourished should begin with a calorie count as low as 1,500 calories a day, in order to reduce the chances for stomach pain and bloating, fluid retention, and heart failure. Anorexic patients often have a higher metabolism than normal individuals, and more calories were required to put on weight. Eventually, the patient is given foods containing as many as 3,500 calories or more a day. Dietary supplements are not usually recommended, because the patient should resume normal eating patterns as soon as possible. Although eating is the problem, discussions of the disorder are never held during meals, which are times for relaxed social interaction. Tube or intravenous feeding is rarely needed or recommended unless the patient's condition is life-threatening. Such invasive feeding measures should never be used as a form of punishment during behavioral therapy. Research indicates that in some cases severe dieting may cause the metabolism to adapt to malnutrition and resist the effects of overfeeding, so that some patients have difficulty gaining weight even when being fed adequately.

Exercise. For those with anorexia, excessive exercise is often a component of the original disorder. During the recovery program, very controlled exercise regimens may be used as both a reward for developing good eating habits and as a way to reduce the stomach and intestinal distress that accompanies recovery. Exercise should not be performed if severe medical problems still exist and if the patient has not gained significant weight.

The Team Approach.

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 physicians specializing in relevant medical complications, dietitians, behavioral-cognitive therapists, psychotherapists, or nurses. 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. One study reported significant success when anorexic patients with an average age of 22 were treated in a pediatric unit using a team approach. After almost two years, although half the patients developed binge-eating patterns, their average weight was 96% of ideal, resumption of menstruation occurred in 80% of patients, and no patient who wished to become pregnant had failed to conceive.

Nutritional Therapy. Dietitians should offer strategies for planning meals and educate the patients and parents on the objective goals of nutritional care (e.g., the specific weight goals) and the serious health effects of the binge-purge cycle and severe dieting. The dietitian should also be in close communication with the other professionals on the team to integrate the results of behavioral and interpersonal work with the process of developing good nutritional habits.

Cognitive Behavioral Therapy. Cognitive-behavioral therapy works on the principle that a pattern of false thinking and belief about one's body can be recognized objectively and altered, thereby changing the response and eliminating the unhealthy reaction to food. It is the first line of therapy for most patients with eating disorders and is particularly effective for bulimia, especially when combined with antidepressants. (Severe depression, in fact, reduces the chances for success using this method.) The process takes four to six months during which the patient builds up to three meals a day, including foods that the patient has previously avoided. During this period, the patient monitors the daily dietary intake and any binges or purging. First, the patient must learn how to recognize any habitual unhealthy reactions and negative thoughts toward eating while they are occurring. Any lapses should be observed objectively and without self-criticism and judgment . By reporting and discussing these responses with a cognitive therapist, eventually the patient is able to discover the false attitudes about body image and the unattainable perfectionism that underlie the opposition to food and health. At this point, the patient can challenge these entrenched and automatic ideas and responses and begin replacing them with a set of realistic beliefs along with actions based on reasonable self-expectations. People who recover from anorexia still retain a strong need for order and precision; these traits, which were risk factors for the disorder to begin with, are also strong qualities that can be used to rebuild a very meaningful life.

Interpersonal Therapy. Interpersonal therapy deals with the depression or anxiety that might underlie the eating disorders along with social factors that influence eating behavior. This therapy does not deal with weight, food, or body image at all. The goals are to express feelings, to discover how to tolerate uncertainty and change, and to develop a strong sense of individuality and independence. Interpersonal therapy also addresses sexual issues and any traumatic or abusive event in the past that might be a cause of the eating disorder. An analysis of studies found that it usually doesn't work for people who binge and who have failed cognitive therapy.

Family Therapy. Because of the major role family attitudes play in eating disorders, it can be argued that one of the first steps in treating the anorexic patient is to also treat the family. The feelings of intense guilt and anxiety that caregivers experience are probably similar to those produced by living with a person who is suicidal. An over-involved parent may even support the patient's eating disorder [out of fear of her anger or grief] or because of the parent's own identification with the cultural values of thinness . In such cases, it is extremely important that the family fully understand the danger of this disorder and that they are collaborating in their child's illness--or even death--by encouraging this state. If the patient is hospitalized, experts recommend that family therapy start after the patient has gained weight but before discharge and should usually continue after the patient has left the hospital. Such therapy is particularly useful for younger patients for whom the family is still a strong influence.

Drug Therapy.

Drug Therapy for Bulimia Nervosa. Because of the high incidence of depression in patients with bulimia, antidepressant medication is often recommended. A one-year study determined, however, that when an antidepressant was used without accompanying cognitive-behavioral therapy, the success rate was only 18%. The most common antidepressants prescribed for bulimia are imipramine (Tofranil), desipramine (Norpramin), and drugs known as selective serotonin reuptake inhibitors (SSRIs), which include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), venlafaxine (Effexor), and fluvoxamine (Luvox). About 20% withdraw from treatment because of side effects. Prozac is effective at higher doses (60 mg) but has little impact on the binge-purge cycle at low doses (20 mg). Some trials are using naltrexone or naloxone, medications that are used against drug addiction, and one indicated that it reduced bingeing. Researchers hope that such drugs will reduce natural opioids that may be released during binges.

Drug Therapy for Anorexia . No drug therapy has been proven to be very effective in treating anorexia or the depression that usually accompanies and perpetuates the disorder. The effects of starvation intensify side effects and reduce the effectiveness of antidepressant drugs. In addition, most antidepressants suppress appetite and contribute to weight loss. SSRI antidepressants [ see above ] are now recommended as the first line of treatment for obsessive-compulsive disorder and may help some people with anorexia who also have OCD. In one study, however, Prozac, the most commonly prescribed SSRI, offered no long-term benefits compared to intensive and sustained team efforts. Some physicians recommend cyproheptadine (Periactin), an antihistamine, that may stimulate appetite. There is no evidence to date, however, that any drug treatment has particular benefit for anorexia nervosa, and, in most cases, depression and thought disorders improve with weight gain.

Restoring Hormonal Function and Bone Density . Normalizing reproductive hormone balances is more important than weight gain in restoring menstrual function. The use of estrogen therapy to reverse osteoporosis, however, has been discouraging. One study reported that an estrogen-progesterone combination increased bone density in women with exercise-induced menstrual disorders after two years, while another found no positive effect from estrogen therapy on bone growth in women with severe bone loss from abnormal menstruation (this group included both those who exercised and those who did not).

Other Approaches.

A study on women with bulimia showed that they had a high susceptibility to hypnosis, suggesting that it might be beneficial as part of their treatment. People with anorexia, on the other hand, seem to be very resistant to the state of vulnerability required in this process. Some researchers have noted an association between bulimia and seasonal affective disorder (depression that intensifies in the darker winter months); this suggests that therapy using intense directed light may be useful. A one-week experiment using light improved depression in bulimic subjects, although there was no change in binge-purging behavior. A technique called guided imagery reduced frequency of binges and vomiting by almost 75% in one study; this method uses audio tapes to evoke images that will reduce stress and help achieve specific goals. Although women with eating disorders are ordinarily disqualified from plastic surgery, one study reported that in women whose bulimia was triggered by over-sized breasts, reduction surgery was effective in resolving the eating disorder.

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Eating Disorders: Anorexia and Bulimia

March 1999

WHAT ARE EATING DISORDERS?