Eating Disorders

Eating disorders are dangerous psychological (relating to the mind) illnesses that affect millions of people, especially young women and girls. The most widely known eating disorders are anorexia nervosa and bulimia nervosa, which will be discussed further in this chapter.

Officially recognized by the medical community only since 1980, eating disorders were first brought to the public's attention when pop singer Karen Carpenter (1953–83) died from complications resulting from anorexia. People suffering from eating disorders battle life-threatening obsessions with food and unhealthy thoughts about their body weight and shape. If untreated, these disorders can lead to death. Researchers have found many factors that are probable causes of eating disorders. Recovery from an eating disorder is possible, though it is a difficult process that should not be done alone. The first steps toward recovery are for the sufferer to accept that there is a problem and to show a willingness to focus on his or her feelings rather than on food and weight.

This chapter will discuss the types of eating disorders that have been identified, the causes, the consequences of an eating disorder on the mind and body, and the treatment and prevention of eating disorders.

TYPES OF EATING DISORDERS AND THEIR CHARACTERISTICS

Anorexia Nervosa

Anorexia nervosa is a condition in which a person refuses to maintain a healthy body weight (persons whose weight is at least 15 percent below their normal body weight might fall into this category). The term anorexia nervosa means literally "nervous lack of appetite." However, this name is misleading as people with anorexia do not lack an appetite; rather, they battle hunger every day. Anorectics, as people who suffer from anorexia are referred to, are extremely afraid of gaining weight or becoming what they perceive to be fat.

Typically, what accompanies this fear of becoming fat is an anorectic's faulty perception of her body. Some anorectics may realize that they are indeed thin but will still view a particular part of their bodies, such as the stomach or thighs, as being fat and out of proportion. In fact, an anorectic's self-esteem is closely tied to this distorted view of her body. Continued weight loss is considered by anorectics to be a sign of achievement and self-discipline while any weight gain, even if it brings them closer to a healthy body weight, is considered a sign of weakness or a lack of self-control.

Eating Disorders: Words to Know

Adrenaline:

A hormone that is released during times of stress and fear.

Amenorrhea:

The absence of menstrual cycles.

Anorexia nervosa:

A term meaning "lack of appetite"; an eating disorder marked by a person's refusal to maintain a healthy body weight through restricting food intake or other means.

Binge-eating disorder:

An eating disorder that involves repetitive episodes of binge eating in a restricted period of time over several months.

Bingeing:

When an individual eats, in a particular period of time, an abnormally large amount of food.

Body set-point theory:

Theory of weight control that claims that the body will defend a certain weight regardless of factors such as calorie intake and exercise.

Bulimia nervosa:

A term that means literally "ox hunger"; an eating disorder characterized by a repeated cycle of bingeing and purging.

Depression:

Common psychological problem characterized by intense and prolonged feelings of sadness and hopelessness.

Diuretic:

A drug that expels water from the body through urination.

Edema:

Swelling.

Endorphin:

Any of a group of natural proteins in the brain known as natural painkillers that make people feel good after exercising.

Enema:

A process that expels waste from the body by injecting liquid into the anus.

Epidemiology:

The study of disease in a population.

Exercise addiction:

Also known as compulsive exercise, a condition in which participation in exercise activities is taken to an extreme; an individual exercises to the detriment of all other things in his or her life.

Hypertension:

High blood pressure.

Lanugo:

Fine hair that grows all over the body to keep it warm when the body lacks enough fat to accomplish this.

Laxative:

A drug that induces bowel movements.

Obesity:

The condition of being very overweight.

Purging:

When a person gets rid of the food that she has eaten by vomiting, taking an excessive amount of laxatives, diuretics, or enemas or engaging in fasting and/or excessive exercise.

Russell's sign:

Calluses, cuts, and sores on the knuckles from repeated self-induced vomiting.

Anorexia is often difficult to diagnose and treat because of the secretive nature of this illness. Anorectics are usually good at concealing their self-starvation with excuses, or they may even engage in purging (vomiting) if forced to eat. Furthermore, anorectics will often wear heavy clothes that both camouflage (hide) their excessive weight loss from others and keep them warm. (Due to their dangerously low weight and lack of insulating body fat, anorectics are often cold.)

In addition to avoiding eating whenever possible, anorectics will often display high levels of energy that seem at odds with their frail physical conditions. Anorectics may also develop odd oral habits, including chewing gum throughout the day, drinking an excessive amount of coffee or diet soda, and chain-smoking. Finally, many anorectics become obsessed with food, despite their unwillingness to consume any.

Bulimia Nervosa

Bulimia nervosa means literally "ox hunger." This term is appropriate on many levels as bulimia is characterized by a repeated cycle of binge eating and purging. A binge is when an individual eats, in a particular period of time, an abnormally large amount of food. (Of course, this doesn't refer to special occasions, such as holiday meals, when it is acceptable to eat more than usual.)

The binge is then followed by an episode of purging. Purging is when a person gets rid of the food that she has eaten by either making herself vomit, taking an excessive amount of laxatives (drugs that induce bowel movements), diuretics (drugs that expel water from the body through urination), or enemas (a process that expels waste from the body by injecting liquid into the anus), or engaging in fasting and/or excessive exercise. People with bulimia, known as bulimics, engage in such behaviors at least two times a week for a period of six months or more.

A particularly stressful event or depression often triggers an episode of binge eating, intense hunger that follows restricted food intake, or a variety of feelings tied to body weight, body image, and food. The binge eating may temporarily relieve a bulimic's feelings of depression or stress, but often deeper feelings of depression, disappointment, and anxiety may follow. This will then trigger an episode of purging. Many bulimics report feeling out of control when bingeing and use similar terms to describe their need to purge their bodies of the food they just consumed.

Bulimics, like anorectics, are usually ashamed of their behavior and will attempt to hide their illness from others. Because of this and the fact that many bulimics maintain a normal body weight, it is often hard to recognize that a person is, in fact, bulimic.

Many bulimics suffer from low self-esteem and may even have suicidal thoughts. Often they are rigid perfectionists who think in absolutes ("I am bad because I ate that"). Like anorectics, bulimics will make negative statements about their appearance and experience extreme guilt over eating even normal portions of food. They will begin to withdraw from social activities, particularly those that will make it difficult for them to purge without suspicion.

Other Types of Disordered Eating

There are those individuals whose behavior does not fall under the categories of anorexia or bulimia; rather, these people can exhibit a wide range of disordered eating and unhealthy weight management symptoms. Since they cannot be diagnosed as anorexic or bulimic, these individuals will typically receive a diagnosis of an "eating disorder not otherwise specified." An example of disordered eating includes a person of normal weight who eats no fat and occasionally purges. She would not be considered bulimic because she is not bingeing, and she also is not anorectic because she is not dangerously underweight. She would therefore be diagnosed with an eating disorder not otherwise specified.

There are other disorders, such as binge-eating disorder and exercise addiction, that are not yet official psychological diagnoses but which are becoming more and more prevalent. These problems are often diagnosed as "eating disorder not otherwise specified" as well. They often occur in conjunction with anorexia and bulimia. However, they can also occur independently of other disordered eating and may soon have their own official diagnoses.

EATING DISORDERS NAMED

English physician Richard Morton first documented cases of self-starvation in the seventeenth century. The term anorexia nervosa was later coined by French neurologist Charles Lasegue and English physician Sir William Gull in the mid-1870s. The symptoms of bulimia (bingeing and purging) were not recognized as a separate condition from self-starvation until the 1940s. English physician Gerald Russell formally named bulimia nervosa in 1979.

BINGE-EATING DISORDER. Like bulimia, binge-eating disorder involves repetitive episodes of binge eating in a restricted period of time over several months. This illness is different from bulimia, however, because people suffering from binge-eating disorder do not purge after a binge. This disorder has more to do with an absolute lack of control over eating than with the conciliatory acts (purging) that follow a bulimic's binge.

Binge eaters will eat very rapidly, usually until they are uncomfortably full. They will eat big portions of food even if they are not actually hungry. Because of this, many binge eaters engage in binges secretively as they are embarrassed by how much they have eaten and feel guilty and depressed following these episodes. Similar to the binges experienced by bulimics, binge eaters report that depression and anxiety usually trigger their binges. During the binge itself, sufferers often feel out of control or disconnected from their actions.

EATING DISORDER STATISTICS

Eating disorder organizations qualify that eating disorder statistics are estimates because the illnesses are often hidden and difficult to diagnose. It is likely that the actual figures are higher than they appear due to the secretive nature of eating disorders.

• About 8 million people in the United States suffer from an eating disorder. Among young women, it is estimated that 15 percent suffer from some kind of disordered eating behavior.
• Females make up 90 to 95 percent of the people who suffer from anorexia.
• 1 percent of young women between the ages of ten and twenty have anorexia.
• 85 percent of the time, anorexia starts between the ages of thirteen and twenty.
• 10 to 15 percent of anorectics will die from the disease.
• 2 to 5 percent of anorectics will commit suicide.
• About 1,000 women die from anorexia each year.
• 30 to 50 percent of anorectics in treatment show signs of bulimia as well.
• 4 percent of college-aged women have bulimia.
• 10 to 15 percent of people with bulimia are male.
• Of psychological disorders, eating disorders have the highest rate of deaths.
• About 60 percent of eating disorder sufferers recover with treatment.

These statistics are based on information from the following organizations: Anorexia Nervosa and Related Eating Disorders, Inc.; American Anorexia/Bulimia Association, Inc.; and National Depressive and Manic-Depressive Association.

Binge eaters usually suffer from obesity (being very overweight). Furthermore, many have been "yo-yo" dieters (experiencing large fluctuations in weight from a cycle of dieting) their entire lives. Both of these effects can cause binge eaters to feel worse about their inability to control their eating habits. (Not everyone who is obese suffers from binge-eating disorder. Rather, obesity must be paired with certain behaviors for it to be evidence of binge-eating disorder.)

Other signs of binge-eating disorder can include food disappearing from cabinets and cupboards at a rapid rate, or even finding an excessive amount of food wrappers concealed under someone's bed or in her trash. The consumption of odd foodstuffs such as raw cookie dough or condiments can also point to binge-eating disorder.

EXERCISE ADDICTION. Exercise addiction, or compulsive exercise, seems like a strange term as most people consider exercise to be good for their health. Exercise is a fun way to relieve stress and increase energy levels. It releases endorphins (the body's natural painkillers, which make people feel good after exercising). However, when a person's interest and participation in exercise activities are taken to extremes, exercise can turn into an addiction that must be performed each day; the act of exercising provides that person with a temporary high. If an exercise-addicted person cannot exercise, he or she will experience a great deal of guilt and anxiety over the inactivity.

Exercise-addicted individuals will exercise to the detriment of everything else in their lives. Someone who is addicted to exercise will exercise with serious physical injuries, pass up opportunities to spend time with loved ones in favor of exercise, and even miss work or school to spend time exercising. Depression, low self-esteem, and repressed anger are all characteristics of exercise-addicted individuals because no matter how much they exercise or achieve in other areas of their lives, they believe they should do more.

Because some sports demand a certain body type (such as gymnastics or ice skating) or depend on how much a person weighs (such as wrestling or horse racing), exercise addiction often develops in elite athletes like dancers, ice skaters, gymnasts, jockeys, and wrestlers, in their quest to perform the best in their sport. Exercise addiction can also be linked to those suffering from anorexia or bulimia because they feel unsatisfied with their bodies and think excessive exercise can help them get thin. Bulimics will often use compulsive exercise as a method of purging.

CAUSES OF EATING DISORDERS

A number of factors contribute to the development of eating disorders. Some are biological and genetic in nature, while others are a direct result of the cultural and familial environment in which an individual is raised.

MALES WITH EATING DISORDERS

Although eating disorders affect women more than men, a large number of males suffer from anorexia nervosa and bulimia nervosa as well as binge-eating disorder and exercise addiction. In fact, 5 to 10 percent of people suffering from anorexia are male, and approximately 10 to 15 percent of people with bulimia are male. The percentages may even be higher as some experts suspect that few men actually seek help because they are ashamed and embarrassed that they have what has come to be viewed as a "female" problem.

Many male eating-disorder sufferers participate or have participated in a sport that demands a certain body type, such as wrestling and running. Wrestlers are a notoriously high-risk group because many try to lose additional pounds rapidly just prior to a match. This allows the wrestler to compete in a lower weight-class while having developed the skill and strength for a higher weight-class in practice. To accomplish this rapid weight loss, unhealthy weight reduction methods, such as fasting and purging, are often used.

Being overweight in childhood can also influence the development of an eating disorder in males. And dieting, a well-known trigger for eating disorders, can start the development of disordered eating in males.

Biological Factors

There are factors contributing to the development of eating disorders that are biological, or genetic. For example, if a person has a relative in her immediate family with an eating disorder, she is at a higher risk to develop an eating disorder.

Additional biological factors contributing to disordered eating can be triggered by the initial act of starving, binge-eating, or purging. This is because these behaviors can change an individual's chemical balance, particularly brain chemistry. Starvation and overeating lead to the production of brain chemicals that induce feelings of peace and euphoria (happiness). These good feelings mask feelings of anxiety and depression, both of which are commonly experienced by people suffering from eating disorders. This has caused certain researchers to conclude that some people with eating disorders use (or do not use) food as a relief when they are feeling poorly about themselves.

Of note is the fact that certain researchers believe that depression, which is also genetic, can be the cause of an eating disorder. (See section on depression later in this chapter.)

Psychological Factors

People suffering from eating disorders share many of the same personality traits. For example, eating-disordered people lean toward being perfectionists. Furthermore, many of them suffer from feelings of low self-esteem, despite their accomplishments and perfectionist ways. Extremist thinking, too, is present in many people with eating disorders. These individuals assume that if being thin is "good" then being even thinner is better. This leads to the thought that being the thinnest is the absolute best; it is this thinking that pushes some anorectics to plummet to body weights of fifty or sixty pounds.

Often, people who live with eating disorders have no sense of self. They simply do not feel that they know who they are or what their place in the world is. An eating disorder, however, offers a sense of identity to these individuals in that it enables them to say, "I am thin," and "I am dieting." This eventually leads them to define themselves solely on their appearance and their dangerous actions rather than with positive, healthy accomplishments.

Social Factors

Eating disorders, in general, occur primarily in industrialized societies, such as the United States, Australia, Canada, Europe, and Japan. In all of these places, the media (TV, movies, magazines) bombard people with the virtues and importance of being thin. It is endlessly implied in television

shows, movies, and advertisements that thinness will bring a person success, power, approval, popularity, friends, and romantic relationships. Women, in particular, are held to an almost-impossible-to-achieve standard of physical fitness and beauty, the height of which is being slender and thin. (In fact, female fashion models now weigh an average of 25 percent less than an average

woman.) Because of these media messages, and correlating comments from young women about their weight and body shape, a link between eating disorders and social pressures can be established.

Family Factors

People are shaped in part by their experiences with their families. Families contribute to an individual's emotional growth. If someone is raised in a dysfunctional family, she may have feelings of abandonment and loneliness. Certain families have dynamics in which rigidity, overprotectiveness, and emotional distance are commonplace. If parents make all of a child's decisions for her, when she gets to adolescence and needs to make decisions for herself, she may find she doesn't have the tools to do so. All of these dynamics can promote the development of eating disorders in the future.

Families in which unrealistically high expectations are placed on the children can also lead these individuals to develop disordered eating. The disordered eating is used as a way to cope with feelings of inadequacy and as a way to control at least one area of their lives. Children also receive their first messages about their bodies from their families. If parents place too much emphasis on physical appearance, it can lead to low self-esteem in those children, placing them at risk for developing eating disorders when they are older.

Most children learn their eating habits and food preferences from their families. Often times, cleaning one's plate or not eating too much or even parents' close control of what their child eats can lead to disordered eating later in life. Parents' attitudes toward food and their own bodies greatly affect children's attitudes toward food and how they will feel about themselves.

FAMOUS PEOPLE WHO HAVE BATTLED EATING DISORDERS

Paula Abdul, Singer

Justine Bateman, Actor

Karen Carpenter, Singer*

Nadia Comaneci, Gymnast

Susan Dey, Actor

Diana, Princess of Wales

Jane Fonda, Actor/Activist

Zina Garrison, Tennis Player

Tracy Gold, Actor

Heidi Guenther, Ballet Dancer*

Margaux Hemingway, Actor

Christy Henrich, Gymnast*

Daniel Johns, Musician

Kathy Johnson, Gymnast

Gelsey Kirkland, Ballet Dancer

Lucy Lawless, Actor

Gilda Radner, Actor/Comic

Cathy Rigby, Gymnast

Joan Rivers, Comic

Ally Sheedy, Actor

* indicates death resulting from the eating disorder

Triggers

Triggers are items or events that spark the beginning of other events. Eating disorders are often triggered by an event or a circumstance in the life of an individual who is already prone to developing such a condition. A period of adjustment, such as leaving home to attend summer camp, prep school, or college, can easily trigger disordered eating in an individual with such tendencies already in place. A traumatic event in someone's life, such as sexual abuse, can also trigger the development of an eating disorder. Other triggers can seem harmless yet represent large life changes, such as moving, starting a new school or job, graduation, and even marriage. Whatever the trigger is, it is usually closely tied to the end of a valued relationship or a feeling of loneliness.

The most common trigger of an eating disorder, however, is dieting. Very often dieting can lead people to disordered eating of some sort, including anorexia or bulimia.

THE PHYSICAL AND PSYCHOLOGICAL CONSEQUENCES OF EATING DISORDERS

An eating disorder can have serious physical and psychological consequences. How serious these consequences are depends on how early an eating disorder is identified and treated. With help, the effects of an eating disorder can be treated; however, if an eating disorder is left untreated for years, some of the effects are irreversible and life-threatening. For these reasons, early detection and treatment is essential and can save a person's life.

The different types of eating disorders are often connected. In fact, 30 to 50 percent of people with anorexia exhibit signs of bulimia as well. Therefore, the consequences of the disorders are also connected. In other words, bulimia and anorexia often share physical, as well as psychological, consequences.

How Anorexia Nervosa Affects the Body

Anorexia causes many physical problems. For instance, it upsets the normal functions of hormones. For girls, this means the body is unable to produce enough of the female hormone estrogen because it does not have enough fat. This will cause an absence of menstrual cycles, called amenorrhea. For boys, anorexia causes a decrease in the production of the male hormone testosterone, which results in a loss of sexual interest.

An anorectic body lacks the protective layer of fat it needs to stay warm. To compensate for the lack of fat, lanugo (fine hair) will grow all over the body to keep it warm. Another problem anorexia causes is a decrease in bone mass. The body needs calcium for strong bones. Since an anorectic is not eating enough food, which is the source of calcium, the body's bones suffer and weaken. Later in life, this could result in a dangerous bone disease called osteoporosis.

Additionally, without the fuel it needs, an anorectic's body will respond as if it is being assaulted and begins to fight back in order to survive. To survive the body must have energy, but because the body has no food to turn into energy, it seeks out the muscles, and eventually, the organs (heart, kidney, and brain) for sustenance—often causing permanent damage to the organs in the process. This is the most serious consequence of anorexia and can possibly lead to cardiac arrest and/or kidney failure, both of which can result in death.

How Bulimia Nervosa Affects the Body

The frequent purging that occurs with bulimia does serious damage to the body. Self-induced vomiting can severely damage the digestive system. Repeated vomiting also damages the esophagus (throat) and eventually it may tear and bleed. Vomiting brings stomach acids into the mouth, causing the enamel on the teeth to wear away. As a result, the teeth may become weakened and appear ragged. There will also be an increase in cavities from vomiting.

Other consequences include swollen salivary glands, which gives some bulimics the appearance of having chipmunk cheeks, and cuts and sores on the knuckles from repeatedly sticking one's fingers down the throat to induce vomiting (known as "Russell's sign"). Stomach cramps and difficulty in swallowing are also common.

If laxatives (drugs that induce bowel movements) are abused, constipation will result because the body can no longer produce a bowel movement on its own. Abuse of laxatives and diuretics (drugs that expel water from the body through urination) can also cause bloating, water retention, and edema (swelling) of the stomach. Because the body is constantly being denied the nutrients and fluids it needs to survive, the kidneys and heart will also suffer. Specifically, a lack of potassium will result in cardiac abnormalities and possible kidney failure, which can also result in death.

How Binge-Eating Disorder Affects the Body

The physical effects of binge eating are not as severe as with anorexia and bulimia, namely because the body is not denied food or put through the painful process of purging. Nevertheless, there are some potentially serious consequences for binge eaters.

Since binge eaters may suffer from obesity, health complications such as diabetes or heart problems can develop. Health problems from yo-yo dieting can include hypertension (high blood pressure) and long-term damage to major organs, such as the kidney, liver, heart, and other muscles.

How Exercise Addiction Affects the Body

Many anorectics and bulimics exercise compulsively (constantly) in order to lose weight. Compulsive exercise is extremely dangerous and can cause many painful injuries, including stress fractures, damaged bones and joints, as well as torn muscles, ligaments, and tendons. Even worse, the injuries may become more serious as many compulsive exercisers will continue their routines despite their injuries.

When an eating disorder is successfully treated, the body can heal and return to normal. Sometimes, however, the eating disorder has continued for so many years that there is too much damage for a full recovery to occur. A person may have to live with a weak heart or kidney for the rest of her life. A woman may be unable to conceive a child because her reproductive system cannot function properly (due to the absence of menstruation). Also, a person may have to live with the debilitating bone disease osteoporosis.

How Eating Disorders Affect the Mind

The psychological consequences of an eating disorder are complex and difficult to overcome. An eating disorder is often a symptom of a larger problem in a person's life. The disorder is an unhealthy way for that person to cope with the painful emotions tied to the problem. For this reason, the emotional problems that triggered the eating disorder in the first place can worsen as the disorder takes hold.

An eating disorder can also cause more problems to surface in a person's life. Eating disorders make it difficult for people to perceive things normally because certain chemical changes take place when the body is deprived of nutrients. As a result, the body relies on adrenaline (a hormone that is normally released during times of stress and fear) instead of food for energy. Adrenaline naturally makes makes someone excited, which makes it more difficult to deal with painful emotions.

Research has shown that many people suffering from an eating disorder also suffer from other psychological problems. Sometimes the eating disorder causes other problems, and sometimes the problems coexist with the eating disorder. Some of the psychological disorders that can accompany an eating disorder include depression, obsessive-compulsive disorder, and anxiety and panic disorders.

In addition to having other psychological disorders, a person with an eating disorder may also engage in destructive behaviors as a result of low self-esteem. Just as an eating disorder is a negative way to cope with emotional problems, other destructive behaviors, such as self-mutilation, drug addiction, and alcoholism, are similar negative coping mechanisms.

Not everyone who has an eating disorder suffers from additional psychological disorders; however, it is very common. For this reason, psychological counseling is an essential part of recovery (see Chapter 15: Mental Health Therapies).

DEPRESSION. Depression is one of the most common psychological problems related to an eating disorder. It is characterized by intense and prolonged feelings of sadness and hopelessness. In its most serious form, depression may lead to suicide (the taking of one's own life). Considering that an eating disorder is often kept a secret, a person who is suffering feels alienated and alone. A person may feel that it is impossible to openly express her feelings. As a result, feelings of depression will worsen the effects of an eating disorder, making it difficult to break the cycle of disordered eating.

With counseling and support, it is possible to combat these negative feelings and prevent them from progressing over time. Recently, doctors have begun to prescribe antidepressant drugs, such as Prozac, to address the problems of depression resulting from an eating disorder. Prozac can help ease feelings of depression, which in turn gives a person better tools with which to fight an eating disorder. [For more information on depression, see Chapter 12: Mental Illness.]

OBSESSIVE-COMPULSIVE BEHAVIOR. Obsessions are constant thoughts that produce anxiety and stress. Compulsions are irrational behaviors that are repeated to reduce anxiety and stress. People with eating disorders are constantly thinking about food, calories, eating, and weight. As a result, they show signs of obsessive-compulsive behavior. If people with eating disorders also show signs of obsessive-compulsive behavior with things not related to food, they may be diagnosed with Obsessive-Compulsive Disorder (OCD).

Some obsessive-compulsive behaviors practiced by eating disorder sufferers include storing large amounts of food, collecting recipes, weighing themselves several times a day, and thinking constantly about the food they feel they should not eat. These obsessive thoughts and rituals worsen when the body is regularly deprived of food. Being in a state of starvation causes people to become so preoccupied with everything they have denied themselves that they think of little else.

FEELINGS OF ANXIETY, GUILT, AND SHAME. Everyone experiences feelings of anxiety (fear and worry), guilt, and shame at some time; however, these feelings become more intense with the onset of an eating disorder. Eating disorder sufferers fear that others will discover their illness. There is also a tremendous fear of gaining weight.

As the eating disorder progresses, body image becomes more distorted and the eating disorder becomes all-consuming. Some sufferers are often terrified of letting go of the illness, which causes many to protect their secret eating disorder even more.

Eating disorder sufferers have a strong need to control their environment and will avoid social situations where they may have to be around food in front of other people or where they may have to change their behavior. The anxiety that results causes people with eating disorders to be inflexible and rigid with their emotions.

SYMPTOMS OF DEPRESSION

• Extreme mood swings
• Inability to experience pleasure in anything
• Feelings of worthlessness
• Withdrawal from family and friends
• Constant fatigue (exhaustion)
• Insomnia (sleeplessness) or sleeping too much
• Loss of appetite or compulsive eating
• Inability to concentrate or make decisions
• Poor memory
• Unexplained headaches, backaches, or stomachaches

Bulimics and binge eaters, specifically, experience guilt and shame with their disorders. This is mainly because, unlike anorectics, they are not usually in denial and they do realize that there is a problem. Bulimics will feel anxiety before, during, and after a binge and can only relieve this anxiety through purging. Purging, however, brings on overwhelming feelings of guilt and shame.

Binge eaters also feel anxiety during a binge, but because they do not purge, they feel ashamed over their lack of control around food.

EATING DISORDERS AND OTHER DESTRUCTIVE BEHAVIORS

Drug Addiction and Alcoholism

It is common for people with eating disorders also to struggle with drug and alcohol addiction. In fact, research shows that one-third of bulimics have a substance-abuse problem, particularly with stimulants (drugs that excite the nervous system) and alcohol. This may stem from the fact that people with eating disorders have difficulty coping with their emotions and use negative means, such as drugs, to mask their problems. Drugs and alcohol provide temporary escapes from reality but, similar to eating disorders, can progress into serious problems that require treatment to overcome. [For more information on drug addiction and alcoholism, see Chapter 14: Habits and Behaviors.]

Self-Mutilation

Self-mutilation is practiced by many eating disorder sufferers. It is also known as self-inflicted violence (SIV) or "cutting." The most common forms of self-mutilation include cutting, burning, head-banging, hitting, and biting oneself. The reasons people self-mutilate stem from an inability to handle overwhelming feelings or a state of emotional numbness. Many sufferers explain that they hurt themselves in order to distract themselves from emotional pain because it is easier to deal with physical pain than to address uncomfortable emotions, such as fear or anger. They may also hurt themselves in order to feel something which gives them an escape from feelings of loneliness. [For more information on self-mutilation, see Chapter 14: Habits and Behaviors.]

EATING DISORDERS AND SEXUALITY

Eating disorders often develop around puberty, when the body is changing and maturing. This time of change can produce anxiety and confusion for both boys and girls because puberty is the beginning of sexual maturity. Girls develop breasts, start menstruating, grow taller, and develop more body hair. Boys' sexual organs (the penis and testicles) grow. Boys also grow taller, get more body and facial hair, and develop bigger muscles.

The sexual feelings that accompany puberty are new, and what they are feeling or experiencing may embarrass some young people. When someone is suffering from an eating disorder, issues surrounding sexuality can become even more complicated. Some people may seek out sexual relationships to feel close to someone and ease feelings of isolation. Others may avoid sexual relationships altogether because they feel ashamed of their bodies.

In some cases, an eating disorder is triggered by sexual abuse (when a person is forced to engage in sexual activities against his or her will). In these instances, an eating disorder sufferer is usually acting out in response to a painful event. She may gain or lose weight in an attempt to make herself sexually undesirable. She may avoid sexual relations as a way to take control over her body and prevent painful feelings from resurfacing. The anger and distrust felt toward the opposite sex may result in complete rejection of the opposite sex. On the other hand, some eating disorder sufferers may have many sexual partners in an attempt to erase the past and gain acceptance from the opposite sex.

TREATMENT AND RECOVERY FROM EATING DISORDERS

Treatment and recovery go hand in hand. It is very hard to stop an eating disorder without any treatment. Recovery is a long process in which an eating disorder sufferer may have to enter treatment more than once. Some people may even try different kinds of treatment programs during their recovery until they find one that works for them.

There may be obstacles to starting treatment. The fear of becoming fat and losing control, which drives most eating disorders, is very strong and hard to eliminate. Also, an eating disorder sufferer may be in denial about her condition and may be unwilling to consider treatment. These feelings may be based on a fear of letting go of the illness that she feels is part of her identity. The eating disorder sufferer must learn to refocus her thoughts from food and weight to her emotions so that she can deal with what is really bothering her. Since many feelings that need to be addressed have been buried by the disorder, professional counseling is important for a successful recovery.

In order for treatment to work, a person must be ready to be treated. Some sufferers may even say they are ready but really are not. They may pretend to change their attitude about food, but they are still starving themselves or bingeing and purging their food secretively. If a person does not fully commit to a treatment program, she will most likely continue suffering from the deadly illness even after completion of the program.

Treatment Basics

Treatment programs vary in the approach that they take. An eating disorder sufferer needs to find a program that best suits her and her condition. A program may work for one person but be ineffective for another. It is important that the person feels comfortable with and believes in the treatment.

Treatment usually begins with an assessment by a physician or mental health counselor. Depending on the severity of the eating disorder, the sufferer will either enter an inpatient or outpatient program. Inpatient programs, or hospitalization, are for the most severe cases. To be hospitalized, the sufferer is usually at a critical point in her illness where her life is in danger or she may have strong suicidal thoughts. Outpatient programs are conducted at a facility or doctor's office that the patient visits while still living at home.

WORDS OF RECOVERY

Mostly what happened was that my life took over—that is to say, that the impulse for life became stronger in me than the impulse for death. In me, the two impulses coexist in an uneasy balance, but they are balanced enough now that I am alive.

Looking back, I see that what I did then was pretty basic. I took a leap of faith. And I believe that has made all the difference. I hung on to the only thing that seemed real to me, and that was a basic ethical principle; if I was alive, then I had a responsibility to stay alive and do something with the life I had been given. And though I was not at all convinced, when I made that leap of faith, that I had any sensible reason for doing so—though I did not fully believe that there was anything that could possibly make as much sense as an eating disorder—I made it because I began to wonder. I simply began to wonder, in the same way I had wondered what would happen if I began to lose weight, what would happen if I stopped. It was worth it.

It is worth it. It's a fight. It's exhausting, but it is a fight I believe in. I cannot believe, anymore, in the fight between body and soul. If I do, it will kill me. But more importantly, if I do, I have taken the easy way out. I know for a fact that sickness is easier.

But health is more interesting.

Excerpted from Marya Hornbacher, Wasted: A Memoir of Anorexia and Bulimia. New York: HarperFlamingo, 1998, p. 280.

Whether the program is inpatient or outpatient, it will usually include various forms of counseling and medical care to treat the physical effects of the illness. The most common forms of counseling include nutrition, individual, family, and group. Nutrition counseling teaches the patient about healthy eating habits and designs appropriate meals. Its goal is to slowly bring the sufferer's weight back up to a safe level that can be easily maintained without dieting or provoking obsessive behavior about food. The first few months of treatment for anorectics can be very dangerous if the eating disorder has gone on for a long time. This is due to the shock the body experiences from eating food after years of starvation.

Individual counseling is one-on-one counseling in which a therapist helps the sufferer deal with her emotions and take control of her body and life again. Family counseling is when the family of the eating disorder sufferer is involved. This type of counseling helps the family and the sufferer to establish better relationships and change any unhealthy dynamics of the family. In group counseling, a counselor leads meetings of a group of eating disorder sufferers to help them learn how to achieve and maintain strong relationships. It also helps sufferers learn that they are not alone.

In support groups, eating disorder sufferers meet to offer support, understanding, and hope to one another as they battle their disorders. Support groups, like group counseling, help sufferers to not feel so alone in their illnesses and learn from others' experiences.

Some eating disorder sufferers will be prescribed medication to ease depression and anxiety as part of their treatment.

[For more information on types of treatments and therapy, see Chapter 15: Mental Health Therapies.]

The Recovery Process

Recovery is not easy. Most eating disorder sufferers feel that they are not worthy of love or life. It takes time (months, even years) and a lot of support from friends, family, and medical professionals to change the sufferers' self-perceptions. They need to feel worthy again of love from others. However, recovery is not as simple as saying "I love you" to eating disorder sufferers. They need to build their self-esteem so that they can believe that they deserve the love of others. Some people are able to make an initial recovery, but many find recovery to be an ongoing, lifelong process.

An eating disorder sufferer has certain goals, both physical and psychological, that she needs to try to reach in recovery. The physical aims should include the ability to eat a variety of healthful foods (without bingeing and purging) and maintain a healthy weight. Females should start their menstrual periods either for the first time or again without the help of medication.

The psychological aims of recovery should include a noticeable decrease in the fear of food and becoming fat as well as the ability to establish strong relationships with family and friends again. Another goal should be to realize the role society and the media play in furthering disordered thinking about people's weights and body shapes. This realization will help sufferers learn to accept and like their bodies without having to live up to unrealistic standards of beauty and thinness. An eating disorder sufferer should also work to establish new, positive coping skills and engage in activities that do not involve food or weight control.

WHAT TO DO IF YOU THINK SOMEONE HAS AN EATING DISORDER

• First, voice concerns to the person privately.
• Listen carefully to what that person is saying.
• Avoid using judgmental statements.
• Let the person know that you are concerned about her health.
• Be familiar with some resources, such as reading materials, web sites, or community centers, that can be introduced to that person.
• If the person exhibits behaviors that are life-threatening, such as bingeing and purging several times a day, fainting, or expressing suicidal thoughts, tell a trusted adult immediately.

The goals for recovery should start small. Learning to meet modest goals first will provide a sense of accomplishment that will help push a person toward meeting larger goals. It is easy to become overwhelmed and fall back into familiar patterns of living. Eating disorder sufferers have taught themselves how to starve or binge and purge and are familiar with using the disorder to help them cope with life. They need time to relearn healthy eating habits and how to feel good about themselves again at a healthy weight.

PREVENTING EATING DISORDERS

Many eating disorder organizations focus on prevention in their programs. That is, stopping eating disorders before they even start. The belief is that awareness and education can go a long way in preventing the onset of these painful illnesses, which can become lifelong struggles. Many eating disorder experts promote teaching prevention at a young age since eating disorders usually begin in adolescence, although there are reported cases of eating disorders starting in children as young as eight years old.

There are a few main objectives that eating disorder organizations focus on in their prevention programs. These objectives help to provide people with the tools they need to cope with the problems that may contribute to an eating disorder.

Prevention means:

• reordering thoughts on food and weight
• focusing on health
• understanding the dangers of dieting
• developing a positive body image
• rebelling against cultural and media messages that encourage unhealthy behaviors
• explaining why fat is not the enemy
• helping to end fat discrimination

Reordering Thoughts about Food and Weight

Since there is enormous pressure to be thin in many cultures, including the United States, many people are dissatisfied with how they look, believing that they are inadequate and unworthy of affection or love. As a result of a negative body image, many people go on strict diets and believe that food is the enemy. However, the body needs food to survive and going on restrictive diets will only lead to an intense preoccupation with food, calories, and weight.

The first step in preventing the development of eating disorders is to reorder feelings and thoughts about food and weight. Eating disorder experts recommend that people reject unhealthy messages about weight, body shape, and diet. Since body shape and weight are determined mostly from genetics, there is only so much a person can do to control or change weight and body shape. Trying to fight against or change the body's set point (the weight at which one's body naturally falls) is unhealthy and possibly dangerous because it creates a cycle of yo-yo dieting. Research has shown that while not every diet leads to eating disorders, 80 percent of eating disorders are initially triggered by a diet. [See Chapter 1: Nutrition, for more information on body set point.]

DEVELOPING A POSITIVE BODY IMAGE

Developing a positive body image is necessary to the prevention of eating disorders. Many people struggle with this issue and must work hard at accepting their bodies. Eating disorder experts emphasize the importance of exercising for health reasons rather than for burning calories and losing weight. The same experts also recommend becoming politically active in the fight against unhealthy cultural messages because it can be a source of positive feelings and empowerment.

HOW DOES DIETING AFFECT THE BODY AND MIND?

The body needs a certain amount of food to function properly. If caloric intake is restricted and the body falls below its set point, it will respond by lowering its metabolism. Metabolism is the rate at which the body burns energy. When the body doesn't get enough fuel to burn, it must learn to function on less. In response, the body will hold on to any food it gets and store fat more efficiently on fewer calories. Typically, when a person stops dieting, she will gain more weight than what was lost and be more likely to keep the extra weight because the body has made adjustments to compensate for a lack of food from the dieting.

The negative physical effects of dieting can include:

• headaches
• dizziness
• stomach pain
• iron deficiency that causes fatigue
• possible menstrual irregularity
• lack of estrogen
• calcium deficiency
• lack of growth from malnutrition

The negative psychological effects of dieting can include:

• preoccupation with food, eating, and calories
• increased irritability
• increased stress and anxiety from semi-starvation
• inability to determine hunger and fullness
• negative body image that can lead to depression and low self-esteem
• fear of food that can lead to isolation and alienation

Other suggestions include:

• Avoid negative talk about food and weight.
• Avoid referring to foods as "good" or "bad."
• Don't participate in weight-loss programs or experiment with weight-loss products.
• Exercise moderately; don't engage in unhealthy or excessive exercise programs.
• Talk about body-image issues with close friends and family.
• Don't criticize people for gaining weight.
• Don't compliment people for losing weight.
• Encourage family and friends to question cultural attitudes about weight and body shape.

Fat and Fit? The Obesity Question

Many people have been taught to fear fat, which leads to unhealthy dieting and intense struggles to lose weight. This thinking is based on the assumption that being fat is unhealthy and should therefore be avoided at all costs.

Now, however, many researchers are questioning the idea that being fat automatically puts a person at risk for health problems. The New England Journal of Medicine published an article in 1998, edited by Jerome P. Kassirer, M.D. and Marcia Angell, M.D., that confirms what many researchers have already suspected: treatments for obesity do not work, obesity treatments pose serious health risks, and the treatments are not justified because the health risks of obesity are not as high as once thought.

THE NATIONAL ASSOCIATION TO ADVANCE FAT ACCEPTANCE

The National Association to Advance Fat Acceptance (NAAFA) was founded in 1969. Its mission is to work to better the lives of fat people around the world. Through advocacy and education, the organization tries to eliminate the discrimination that fat people face in their lives. NAAFA also works to empower fat people and help them accept their bodies and live more fulfilling lives.

NAAFA's basic message is that a person's worth should not be based on his or her body size. NAAFA uses the word "fat" in the hopes that people will stop using it as an insult and remember it is just an adjective (descriptive word). In this way, the word will not cause shame or embarrassment.

The organization challenges ideas about the connection between obesity and health risks. It promotes research that accurately studies the different aspects of being fat. The goal is to move away from looking for ways to help fat people lose weight and, instead, help fat people be healthy.

NAAFA has more than fifty chapters across the United States that provide support groups for people to share their feelings. Since being fat can be emotionally painful and isolating in many societies, especially in the United States, the organization promotes programs that unite people with similar experiences.

Some researchers claim that obesity is dangerous to one's health when combined with a sedentary (non-active) lifestyle. It is possible to be fat and healthy. In fact, how healthy a person is depends more on how much a person exercises rather than how much a person weighs. Weight alone is not a proper indication of how healthy a person is, and it is more beneficial for a person to concentrate on fitness instead of fatness.

FOR MORE INFORMATION

Books

Bode, Janet. Food Fight: A Guide to Eating Disorders for Pre-Teens and Their Parents. New York: Simon and Schuster, 1997.

Cooke, Kaz. Real Gorgeous: The Truth About Body and Beauty. New York: W.W. Norton, 1996.

Hornbacher, Marya. Wasted: A Memoir of Anorexia and Bulimia. New York: HarperCollins, 1998.

Kolodny, Nancy. When Food's a Foe: How You Can Confront and Conquer Your Eating Disorder. Boston: Little Brown & Co., 1992.

Krasnow, Michael. My Life as a Male Anorexic. New York: Haworth Press, 1996.

Sacker, Ira M. Dying to Be Thin: Understanding and Defeating Anorexia Nervosa and Bulimia—A Practical Lifesaving Guide. Warner Books, 1987.

Web sites

Eating Disorders Information. [Online] http://eatingdisorders.about.com (Accessed November 1, 1999).

Eating disorders

Definition

Description

Demographics

Causes and symptoms

Diagnosis

Treatment

Nutrition/Dietetic concerns

Prognosis

Prevention

Resources

Definition

Eating disorders are psychiatric illnesses that result in abnormal eating patterns that have a negative effect on health.

Description

Eating disorders are mental disorders. They develop when a person has an unrealistic attitude toward or abnormal perception of his or her body. This causes behaviors that lead to destructive eating patterns that have negative physical and emotional consequences. Individuals with eating disorders often hide their symptoms and resist seeking treatment. Depression, anxiety disorders, and other mental illnesses often are present in people who have eating disorders, although it is not clear whether these cause the eating disorder or are a result of it

The two best-known eating disorders, anorexia nervosa and bulimia nervosa , have formal diagnostic criteria and are recognized as psychiatric disorders in the Diagnostic and Statistical Manual for Mental Disorders Fourth Edition (DSM-IV-TR) published by the American Psychiatric Association (APA). Other eating disorders have recognized sets of symptoms, but have not been researched thoroughly enough to be considered separate psychiatric disorders as defined by the APA.

Well-known eating disorders

In the North America and Europe, anorexia nervosa is the most publicized of all eating disorders. It gained widespread public attention with the rise of the ultra-thin fashion model. People who have anorexia nervosa are obsessed with body weight. They constantly monitor their food intake and starve themselves to become thin. No matter how much weight they lose, they continue to restrict their calorie intake in an effort to become ever thinner. Some anorectics exercise to extreme or abuse drugs or herbal remedies that they believe will help them burn calories faster. A few purge their body of the few calories they do eat by abusing laxatives, enemas, and diuretics . In time, they reach a point where their health is seriously, and potentially fatally, impaired.

People with anorexia nervosa have an abnormal perception of their body. They genuinely believe that they are fat, even when the clearly are life-threateningly thin. They will deny that they are too thin, or, if they admit they are thin, deny that their behavior will affect their health. People with anorexia will lie to family, friends, and healthcare provides about how much they eat. Many vigorously resist treatment and accuse the people trying to cure them of wanting to make them fat. Anorexia nervosa is the most difficult eating disorder to recover from.

Bulimia nervosa is the only other eating disorder with specific diagnostic criteria defined by the (DSM-IV-TR). People with bulimia often consume unreasonably large amounts of food in a short time. Afterwards, they purge their body of calories. This is done most often by self-induced vomiting, often accompanied by laxative abuse. A subset of people with bulimia does not vomit after eating, but fast and exercise obsessively to burn calories. Both behaviors result in impaired health.

People with bulimia feel out of control when they are binge eating . Unlike people. with anorexia, they

Symptoms of eating disorders

source: National Institute of Mental Health, National Institutes of Health, U.S. Department of Health and Human Services.

(Illustration by GGS Information Services/Thomson Gale)

recognize that their behavior is abnormal. Often they are ashamed and feel guilty about their behavior and will go to great lengths to hide their binge/purge cycles from their family and friends. People with bulimia are often of normal weight. Although their behavior results in negative health consequences, because they are less likely to be ultra-thin, these consequences are less likely to be life-threatening.

The APA does not formally recognize binge eating as an eating disorder. Binge eating is quite common, but it only rises to the level of a disorder only when bingeing occurs at least twice a week for three months or more. People with binge-eating disorder may eat thousands of calories in an hour or two. While they are eating, they feel out of control and may continue to eat long after they feel full. Binge eaters do not purge or exercise to get rid of the calories they have eaten. As a result, many, but not all, people with binge-eating disorder, are obese, although not all obese people are binge eaters.

Binge eaters are usually ashamed of their behavior and try to hide it by eating in secret and hording food for future binges. After a binge, they usually feel disgusted with themselves and guilty about their eating behavior. They often promise themselves that they will never binge again, but are unable to keep this promise. Binge-eating disorder often takes the form of an endless cycle—rigorous dieting followed by an eating binge followed by guilt and rigorous dieting, followed by another eating binge. The main health consequences of binge eating are the development of obesity-related diseases such as type 2 diabetes, sleep apnea, stroke, and heart attack.

Lesser-known eating disorders

Quite a few eating problems are called disorders even though they do not have formal diagnostic criteria. They fall under the APA definition of eating disorders not otherwise specified. Many have only recently come to the attention of researchers and have been the subject of only a few small studies. Some have been known to the medical community for years but are rare.

Purge disorder is thought by some experts to be a separate disorder from bulimia. It is distinguished from bulimia by the fact that the individual maintains a normal or near normal weight despite purging by vomiting or laxative, enema, or diuretic abuse.

Anorexia athletica is a disorder of compulsive exercising. The individual places exercise above work, school, or relationships and defines his or her self-worth in terms of athletic performance. People with anorexia athletica also tend to be obsessed less with body weight than with maintaining an abnormally low percentage of body fat. This disorder is common among elite athletes.

Muscle dysmorphic disorder is the opposite of anorexia nervosa. Where the anorectic thinks she is always too fat, the person with muscle dysmorphic

KEY TERMS

Fast —a period of at least 24 hours in which a person eats nothing and drinks only water.

Type 2 diabetes —sometime called adult-onset diabetes, this disease prevents the body from properly using glucose (sugar).

disorder believes he is always too small. This believe is maintained even when the person is clearly well muscled. Abnormal eating patterns are less of a problem in people with muscle dysmorphic disorder than damage from compulsive exercising (even when injured) and the abuse of muscle-building drugs such as anabolic steroids.

Orthorexia nervosa is a term coined by Steven Bratman, a Colorado physician, to describe “a pathological fixation on eating ‘proper,’ ‘pure,’ or ‘superior’ foods.” People with orthorexia allow their fixation with eating the correct amount of properly prepared healthy foods at the correct time of day to take over their lives. This obsession interferes with relationships and daily activities. For example, they may be unwilling to eat at restaurants or friends’ homes because the food is impure or improperly prepared. The limitations they put on what they will eat can cause serious vitamin and mineral imbalances. Orthorectics are judgmental about what other people eat to the point where it interferes with personal relationships. They justify their fixation by claiming that their way of eating is healthy. Some experts believe orthorexia may be a variation of obsessive-compulsive disorder.

Rumination syndrome occurs when an individual, either voluntarily or involuntarily, regurgitates food almost immediately after swallowing it, chews it, and then either swallows it or spits it out. Regurgitation syndrome is the human equivalent of a cow chewing its cud. The behavior often lasts up to two hours after eating. It must continue for at least one month to be considered a disorder. Occasionally the behavior simply stops on its own, but it can last for years.

Pica is eating of non-food substances by people developmentally past the stage where this is normal (usually around age 2). Earth and clay are the most common non-foods eaten, although people have been known to eat hair, feces, lead, laundry starch chalk, burnt matches, cigarette butts, light bulbs, and other equally bizarre non-foods. This disorder has been known to the medical community for years, and in some cultures (mainly tribes living in equatorial Africa) is considered normal. Pica is most common among people with mental retardation and developmental delays. It only rises to the level of a disorder when health complications require medical treatment.

Prader-Willi syndrome is a genetic defect that spontaneously arises in chromosome 15. It causes low muscle tone, short stature, incomplete sexual development, mental retardation, and an uncontrollable urge to eat. People with Prader-Willi syndrome never feel full. The only way to stop them from eating themselves to death is to keep them in environments where food is locked up and not available. Prader-Willi syndrome is a rare disease, and although it is caused by a genetic defect, tends not to run in families, but rather is an accident of development. Only 12,000– 15,000 people in the United States have Prader-Willi syndrome.

Demographics

In general, more women have eating disorders than men. About 90% of people with anorexia and bulimia nervosa are female. Almost as many men as women develop binge-eating disorder. Anorexia ath-letica, muscle dysmorphic disorder, and orthorexia nervosa tend to be more common in men. Rumination, pica, and Prader-Willi syndrome affect men and women equally.

Anorexia nervosa begins primarily between the ages of 14 and 18 and affects mainly white girls. Bulimia usually develops slightly later in the late teens and early twenties. Binge-eating disorder is a problem of middle age and affects blacks and whites equally. Prader-Willi syndrome begins in the toddler years. Not enough is known about the other disorders to determine when they are most likely to develop or which races or ethnic groups are most likely to be at risk.

Depression, low self-worth, and anxiety disorders are all common among people with eating disorders. Some disorders have obsessive-compulsive elements. The association between these psychiatric disorders and eating disorders is strong, but the cause and effect relationship is still unclear.

Causes and symptoms

Eating disorders have multiple causes. There appears to be a genetic predisposition in some people toward developing an eating disorder. Biochemistry also seems to play a role. Neurotransmitters in the brain, such as serotonin, play a role in regulating appetite. Abnormalities in the amount of some neurotransmitters are thought to play a role in anorexia, bulimia, and binge-eating disorder. Other disorders have not been studied enough to draw any conclusions. Interestingly, serotonin also helps regulate mood, and low serotonin levels are thought to play a role in causing depression.

Personality type can also put people at risk for developing an eating disorder. Low self-worth is common among all people with eating disorders. Binge eaters and people with bulimia tend to have problems with impulse control and anger management. A tendency toward obsessive-compulsive behavior and black-or-white, all-or-nothing thinking also put people at higher risk.

Social and environmental factors also affect the development and maintenance of eating disorders and may trigger relapses during recovery. Relationship conflict, a disordered, unstructured home life, job or school stress, transition events such as moving or starting a new job all seems to act as triggers for some people to begin disordered eating behaviors. Dieting (nutritional and social stress) is the most common trigger of all. The United States in the early twenty-first century is a culture obsessed with thinness. The media constantly send the message through words and images that being not just thin, but ultra-thin, is fashionable and desirable. Magazines aimed mostly at women devote thousands of words every month to diet and exercise advice that creates a sense of dissatisfaction, unrealistic goals, and a distorted body image .

Diagnosis

Diagnosis involves four components: a health history, a physical examination, laboratory tests, and a mental status evaluation. Health histories tend to be unreliable, because many people with eating disorders lie about their eating behavior, purging habits, and medication abuse. Based on the health history and physical examination, the physician will order appropriate laboratory tests. Mental status can be evaluated using several different scales. The goal is to get an accurate assessment of the individuals’s physical condition and her thinking in relationship to self-worth, body image, and food.

Treatment

Treatment depends on the degree to which the individual’s health is impaired. People with anorexia or bulimia may need to be hospitalized or attend structured day programs for an extended period. Some people are helped with antidepressant medication, but the mainstay of treatment is psychotherapy. An appropriate therapy is selected based on the type of eating disorder and the individual’s psychological profile. Some of the common therapies used in treating eating disorders include:

• Cognitive behavior therapy (CBT) is designed to confront and then change the individual’s thoughts and feelings about his or her body and behaviors toward food, but it does not address why those thoughts or feelings exist. Strategies to maintain self-control may be explored. This therapy is relatively short-term. CBT is often the therapy of choice for people with eating disorders.
• Psychodynamic therapy, also called psychoanalytic therapy, attempts to help the individual gain insight into the cause of the emotions that trigger their dysfunctional behavior. This therapy tends to be more long term than CBT.
• Interpersonal therapy is short-term therapy that helps the individual identify specific issues and problems in relationships. The individual may be asked to look back at his or her family history to try to recognize problem areas or stresses and work toward resolving them.
• Dialectical behavior therapy consists of structured private and group sessions in which the therapist and patient(s) work at reducing behaviors that interfere with quality of life, finding alternate solutions to current problem situations, and learning to regulate emotions.
• Family and couples therapy is helpful in dealing with conflict or disorder that may be a factor in perpetuating the eating disorder. Family therapy is especially useful in helping parents who are anorectics avoid passing on their attitudes and behaviors on to their children.

Nutrition/Dietetic concerns

Eating disorders result in abnormal nutrition that can have life-threatening consequences. A nutritionist or dietitian who can provide nutritional counseling and healthy meal planning is an essential part of the treatment team for any eating disorder. However, nutritional counseling alone will not resolve an eating disorder.

Prognosis

Recovery from eating disorders can be along, difficult process interrupted by relapses. About half of all anorectics recover. Up to 20% die of complications of the disorder. The recovery rate for people with bulimia is slightly higher. Binge eaters experience many relapses and may have trouble controlling their weight even if they stop bingeing. Not enough is known about the other eating disorders to determine recovery rates. All eating disorders have serious social and emotional consequences. All except rumination disorder have serious health consequences. The sooner a person with an eating disorder gets professional help, the better the chance of recovery.

Prevention

Prevention involves both preventing and relieving stresses and enlisting professional help as soon as abnormal eating patterns develop. Some things that may help prevent an eating disorder from developing are listed below:

• Parent should not obsess about their weight, appearance, and diet in front of their children.
• Parents should not put their child on a diet unless instructed to by a pediatrician.
• Do not tease people about their body shapes or compare them to others.
• Make it clear that family members are loved and accepted as they are.
• Try to eat meals together as a family whenever possible; avoid eating alone.
• Avoid using food for comfort in times of stress.
• Monitoring negative self-talk; practice positive self-talk.
• Spend time doing something enjoyable every day.
• Stay busy, but not overly busy; get enough sleep every night.
• Become aware of the situations that are personal triggers for abnormal eating behaviors and look for ways to avoid or defuse them.
• Do not go on extreme diets.
• Be alert to signs of low self-worth, anxiety, depression, and drug or alcohol abuse and seek help as soon as these signs appear.

Resources

BOOKS

Agras, W. Stewart. Overcoming Eating Disorders: A Cognitive-Behavioral Therapy Approach for Bulimia Nervosa and Binge-Eating Disorder 2nd ed. New York: Oxford University Press, 2008.

Carleton, Pamela and Deborah Ashin.Take Charge of Your Child’s Eating Disorder: A Physician’s Step-By-Step Guide to Defeating Anorexia and Bulimia. New York: Marlowe & Co., 2007.

Heaton, Jeanne A. and Claudia J. Strauss. Talking to Eating Disorders: Simple Ways to Support Someone Who Has Anorexia, Bulimia, Binge Eating or Body Image Issues New York, NY: New American Library, 2005.

Kolodny, Nancy J. The Beginner’s Guide to Eating Disorders Recovery. Carlsbad, CA: Gurze Books, 2004.

Liu, Aimee. Gaining: The Truth About Life After Eating Disorders. New York, NY: Warner Books, 2007.

Messinger, Lisa and Merle Goldberg. My Thin Excuse: Understanding, Recognizing, and Overcoming Eating Disorders. Garden City Park, NY: Square One Publishers, 2006.

Rubin, Jerome S., ed. Eating Disorders and Weight Loss Research. Hauppauge, NY: Nova Science Publishers, 2006.

Walsh, B. Timothy. If Your Adolescent Has an Eating Disorder: An Essential Resource for Parents. New York, NY: Oxford University Press, 2005.

PERIODICALS

“Surfing for Thinness: A Pilot Study of Pro-Eating Disorder Web Site Usage in Adolescents With Eating Disorders.” Pediatrics.118, no. 6 (December 2006): e1635-43. http://pediatrics.aappublications.org/cgi/content/full/118/6/e1635>.

ORGANIZATIONS

American Psychological Association. 750 First Street, NE, Washington, DC 20002-4242. Telephone: (800) 374-2721; (202) 336-5500. TDD/TTY: (202)336-6123. Website: <http://www.apa.org>

National Association of Anorexia Nervosa and Associated Disorders (ANAD). P.O. Box 7 Highland Park, IL 60035. Telephone: (847) 831-3438. Website: <http://www.anad.org>

National Eating Disorders Association. 603 Stewart Street, Suite 803, Seattle, WA 98101. Help and Referral Line: (800) 931-2237. Office Telephone: (206) 382-3587. Website: <http://www.edap.org>.

OTHER

Anorexia Nervosa and Related Eating Disorders. “Athletes With Eating Disorders.” October 6, 2006. <http://www.anred.com/ath.html>

Anorexia Nervosa and Related Eating Disorders. “The Better-Known Eating Disorders.” January 16, 2006. <http://www.anred.com/defswk.html>

Anorexia Nervosa and Related Eating Disorders. “Eating Disorders and Pregnancy.” October 18, 2006. <http://www.anred.com/pg.html>

Anorexia Nervosa and Related Eating Disorders. “Males With Eating Disorders.” February 6, 2007. http://www.anred.com/males.html>

Anorexia Nervosa and Related Eating Disorders. “Less-Well-Known Eating Disorders and Related Problems.” January 16, 2006. http://www.anred.com/defslesser.html>

Medline Plus. “Eating Disorders.” U. S. National Library of Medicine, April 2, 2007. <http://www.nlm.nih/gov/medlineplus/eatingdisorders.html>

National Association of Anorexia Nervosa and Associated Disorders “Facts About Eating Disorders.” undated; accessed April 3, 2007. <http://www.anad.org/>

Tish Davidson, A. M.

Eat More, Weigh Less see Dean Ornish’s Eat More, Weigh Less

East African diet see African diet .

Eating Disorders

Anorexia

Bulimia

Obesity

Resources

Eating disorders are psychological conditions that involve either overeating, voluntary starvation, or both. No one is sure what causes eating disorders, but researchers think that family dynamics, biochemical abnormalities, and society’s preoccupation with thinness may all contribute. Eating disorders are virtually unknown in parts of the world where food is scarce and within less affluent socioeconomic groups in developed countries. Although these disorders have been known throughout history, they have gained attention in recent years, in part because some celebrities have died as a result of their eating disorders.

Young people are more likely than older people to develop an eating disorder—the condition usually begins before age 20. Although both men and women can develop the problem, it is more common in women. Only about 5% of people with eating disorders are male. In either sex, eating disorders are considered serious and potentially deadly. Many large hospitals and psychiatric clinics have programs specially designed to treat these conditions.

Anorexia nervosa, anorexic bulimia, and obesity are the most well known types of eating disorders. The word anorexia comes from the Greek word meaning “lack of appetite.” But the problem for people with anorexia is not that they are not hungry. They starve themselves out of fear of gaining weight, even when they are severely underweight. The related condition, anorexic bulimia, literally means being “hungry as an ox.” People with this problem go on eating binges, often gorging on junk food. Then they force their bodies to get rid of the food, either by making themselves vomit or by taking large amounts of laxatives. A third type of eating disorder is obesity caused by uncontrollable overeating. Being slightly overweight is not a serious health risk. But being 25% or more over one’s recommended body weight can lead to many health problems.

Anorexia

People with anorexia starve themselves until they look almost like skeletons. But their self-images are so distorted that they see themselves as fat, even when they are emaciated. Some refuse to eat at all; others nibble only small portions of fruit and vegetables or live on diet drinks. In addition to fasting, they may exercise strenuously to keep their weight abnormally low. No matter how much weight they lose, they always worry about getting fat.

This self-imposed starvation takes a heavy toll on the body. Skin becomes dry and flaky. Muscles begin to waste away. Bones stop growing and may become brittle. The heart weakens. With no body fat for insulation, it’s hard to keep warm. Downy hair starts to grow on the face, back, and arms in response to lower body temperature. In women, menstruation stops and permanent infertility may result. Muscle cramps, dizziness, fatigue, even brain damage, kidney and heart failure are possible. An estimated 10-20% of people with anorexia die, either as a direct result of starvation or by suicide.

Researchers believe anorexia is caused by a combination of biological, psychological and social factors. They are still trying to pinpoint the biological factors, but they have zeroed in on some psychological and social triggers of the disorder. Many people with anorexia come from families in which parents are overprotective and have unrealistically high expectations of their children. The condition seems to run in families, which leads researchers to believe it may have a genetic basis. Anorexia often seems to develop after a young person goes through some stressful experience, such as moving to a new town, changing schools, or going through puberty. Low self-esteem, fear of losing control, and fear of growing up are common characteristics of anorectics (people with anorexia). The need for approval, combined with our culture’s idealization of extreme thinness, also contributes.

The obvious cure for anorexia is eating, but that is the last thing a person with anorexia wants to do. It is unusual for the person himself or herself to seek treatment—usually a friend, family member, or teacher initiates the process. Hospitalization, combined with psychotherapy and family counseling, is often needed to get the condition under control. Force feeding may be necessary if the person’s life is in danger. Some 70% of anorexia patients who are treated for about six months return to normal body weight. About 15–20% can be expected to relapse, however.

Bulimia

Like anorexia, bulimia results in starvation. But there are behavioral, physical and psychological differences between the two conditions. Bulimia is much more difficult to detect because people who have it tend to be of normal weight or overweight, and they hide their habit of binge eating followed by purging, vomiting, or using laxatives. In fact, bulimia was not widely recognized, even among medical and mental health professionals, until the 1980s.

Unlike anorectics, bulimics (people with bulimia) are aware that their eating patterns are abnormal, and they often feel remorse after a binge. For them, overeating offers an irresistible escape from stress. Many suffer from depression, repressed anger, anxiety, and low self esteem, combined with a tendency toward perfectionism. About 20% of bulimics also have problems with alcohol or drug addiction, and they are more likely than other people to commit suicide.

Many people occasionally overeat, but are not considered bulimic. According to the American Psychiatric Association’s definition, a bulimic binges on enormous amounts of food at least twice a week for three months or more.

Bulimics plan their binges carefully, setting aside specific times and places to carry out their secret habit. They may go from restaurant to restaurant, to avoid being seen eating too much in any one place. Or they may pretend to be shopping for a large dinner party, when actually they intend to eat all the food themselves. Because of the expense of consuming so much food, some resort to shoplifting.

During a binge, bulimics favor high carbohydrate foods, such as doughnuts, candy, ice cream, soft drinks, cookies, cereal, cake, popcorn, and bread, consuming many times the amount of calories they normally would consume in one day. No matter what their normal eating habits, they tend to eat quickly and messily during a binge, stuffing the food in their mouths and gulping it down, sometimes without even tasting it. Some say they get a feeling of euphoria during binges, similar to the “runner’s high” that some people get from exercise.

The self-induced vomiting that often follows eating binges can cause all sorts of physical problems, such as damage to the stomach and esophagus, chronic heartburn, burst blood vessels in the eyes, throat irritation, and erosion of tooth enamel from the acid in vomit. Excessive use of laxatives can be hazardous, too. Muscle cramps, stomach pains, digestive problems, dehydration, and even poisoning may result. Over time, bulimia causes vitamin deficiencies and imbalances of critical body fluids, which in turn can lead to seizures and kidney failure.

Some researchers believe that an imbalance in the brain chemical serotonin underlies bulimia, as well as other types of compulsive behavior. The production of serotonin, which influences mood, is affected by both antidepressant drugs and certain foods. But most research on bulimia focuses on its psychological roots.

Bulimia is not as likely as anorexia to reach lifethreatening stages, so hospitalization is not usually necessary. Treatment generally involves psychotherapy and sometimes the use of antidepressant drugs. Unlike anorectics, bulimics usually admit they have a problem and want help overcoming it. Estimates of the rates of recovery from bulimia vary widely, with some studies showing low rates of improvement and others suggesting that treatment is effective. Even after apparently successful treatment, some bulimics relapse.

Obesity

Obesity is an excess of body fat. But the question of what constitutes an excess has no clear answer. Some doctors classify a person as obese whose weight is 20% or more over the recommended weight for his or her height. But other doctors say standard height and weight charts are misleading. They maintain that the proportion of fat to muscle, measured by the skinfold “pinch” test, is a better measure of obesity. A person who is overweight, they point out, is not necessarily obese. A very muscular athlete, for example, might have very little body fat, but still might weigh more than the recommended weight for his or her height.

The causes of obesity are complex and not fully understood. While compulsive overeating certainly can lead to obesity, it is not clear that all obesity results from overindulging. Recent research increasingly points to biological, as well as psychological and environmental factors that influence obesity.

In the United States, people with low incomes are more likely to be obese than are the wealthy. Women are almost twice as likely as men to have the problem, but both menand women tend to gain weight as they age.

In those people whose obesity stems from compulsive eating, psychological factors seem to play a large role. Some studies suggest that obese people are much more likely than others to eat in response to stress, loneliness, or depression. As they are growing up, some people learn to associate food with love,

KEY TERMS

Morbid— From the Latin word for sick, pertaining to or inducing disease.

Risk factor— Any habit, condition, or external force that renders an individual more susceptible to disease. Cigarette smoking, for example, is a significant risk factor for lung cancer and heart disease.

acceptance, and a feeling of belonging. If they feel rejected and unhappy later in life, they may use food to comfort themselves.

Just as emotional pain can lead to obesity, obesity can lead to psychological scars. From childhood on, obese people are taunted and shunned. They may even face discrimination in school and on the job. The low self-esteem and sense of isolation that result may contribute to the person’s eating disorder, setting up an endless cycle of overeating, gaining more weight, feeling even more worthless and isolated, then gorging again to console oneself.

People whose obesity endangers their health are said to be morbidly obese. Obesity is a risk factor in diabetes, high blood pressure, arteriosclerosis, angina pectoralis (chest pains due to inadequate blood flow to the heart), varicose veins, cirrhosis of the liver, and kidney disease. Obesity can cause complications during pregnancy and in surgical procedures. Obese people are about one and one half times more likely to have heart attacks than are other people. Overall, the death rate among people ages 20-64 is 50% higher for the obese than for people of normal weight.

Since compulsive eating patterns often have their beginnings in childhood, they are difficult to break. Some obese people get caught up in a cycle of binging and dieting—sometimes called yo-yo dieting—that never results in permanent weight loss. Research has shown that strict dieting itself may contribute to compulsive eating. Going without their favorite foods for long periods makes people feel deprived. They are more likely, then, to reward themselves by binging when they go off the diet. Other research shows that dieting slows the dieter’s metabolism. When the person goes off the diet, he or she gains weight more easily.

The most successful programs for dealing with overeating teach people to eat more sensibly and to increase their physical activity to lose weight gradually without going on extreme diets. Support groups and therapy can help people deal with the psychological aspects of obesity.

Resources

BOOKS

Epstein, Rachel. Eating Habits and Disorders. New York: Chelsea House Publishers, 1990.

Matthews, John R. Eating Disorders. New York: Facts On File, 1991.

Porterfield, Kay Marie. Focus on Addictions. Santa Barbara: ABC-CLIO, 1992.

PERIODICALS

Berry, Kevin. “Anorexia? That’s a Girls’ Disease.” Times Educational Supplement (16 April 1999): D8.

Dansky, Bonnie S., Timothy D. Brewerton, and Dean G. Kilpatrick. “Comorbidity of bulimia nervosa and alcohol use disorders: results from the National Women’s Study.” The International Journal of Eating Disorders 27, no. 2 (1 March 2000): 180.

OTHER

National Eating Disorders Association. “Eating Disorders Information Index” <http://www.edap.org/p.asp?WebPage_ID=294> (accessed November 20, 2006).

Mirror, Mirror. “Eating Disorders” <http://www.mirror-mirror.org/eatdis.htm> (accessed November 20, 2006).

Nancy Ross-Flanigan

Eating Disorders

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

Diagnosis

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

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

Anorexia nervosa.

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

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

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

Bulimia nervosa.

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

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

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

Binge eating disorder.

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

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

Eating disorder not otherwise specified.

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

Prevalence

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

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

Risk Factors

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

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

Causes

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

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

Treatment Modalities

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

Outpatient therapy.

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

Day treatment programs.

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

Inpatient hospitalization.

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

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

Medication.

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

Outcomes

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

Eating Disorders throughout History

Although eating disorders first came to widespread attention in the 1970s, self-starvation and other pathological eating practices are found throughout recorded history. Bulimia was widely known in both Greek and Roman societies and was recorded in France as early as the eighteenth century. Self-starvation for religious reasons became widespread in Europe during the Renaissance, as hundreds of women starved themselves, often to death, in hopes of attaining communion with Christ. During the nineteenth century, as corpulence stopped being viewed as a symbol of prosperity, self-starvation became common again. The incidence of eating disorders varies widely among cultures and time periods, suggesting that they can be encouraged or inhibited by social and economic factors. Eating disorders have most often been seen in affluent societies and are rarely reported during periods of famine, plague, and warfare.

—Paula Kepos

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

see also Addiction, Food; Anorexia Nervosa; Bulimia Nervosa; Eating Disturbances.

Karen Ansel

Bibliography

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

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

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

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

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

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

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

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

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

Internet Resources

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

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

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

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

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

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

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

Eating Disorders

Eating disorders, particularly anorexia nervosa and bulimia nervosa, are highly gendered phenomena: Approximately 90 percent of known cases occur among girls and young women. In addition, gendered conceptions of the body and personhood shape both people's experiences of these conditions and treatments for them. Research in the social sciences and humanities emphasizes the importance of gender in understanding these complex and perplexing problems.

The cultural and historical specificity of eating disorders underscores the need to analyze the relationship of social categories, including gender, race and ethnicity, and class, to these problems. Anorexia and bulimia appear far more frequently in industrialized societies (American Psychiatric Association 2000). Although some scholars have raised important questions about the assumption of cultural and/or historical particularity for anorexia (Bell 1985, Banks 1992, Lee et al. 2001), most agree that the meanings and manifestations of eating disorders since the 1970s in industrialized settings constitute a uniquely salient focus for attention and research. The role of race and class as well as gender in shaping these disorders is an ever-present and frequently debated concern.

CATEGORIES OF EATING DISORDERS

Anorexia is a form of self-starvation that often is coupled with rigorous exercise, especially since the rise of the fitness movement in the 1970s. It first was identified as a medical disorder in the late nineteenth century (Gull 1874, Lasègue 1873) but occurred extremely rarely until it more than doubled in incidence in the 1970s and 1980s. This increase in incidence represents an actual increase in the number of cases; it is not due simply to greater sensitivity or awareness in identifying the problem (Gordon 2000). Anorexia was recognized officially as a psychiatric disorder in 1980. The typical age of onset is middle to late adolescence. Anorexia is often chronic and lethal; it has the highest mortality rate of any psychiatric illness (approximately 10 percent), and most patients never recover fully.

Bulimia is a binge-purge disorder: Episodes of binge eating are followed by vomiting, the abuse of laxatives or diuretics, fasting, or excessive exercise. First identified in 1979 (Russell 1979), bulimia was recognized as a psychiatric disorder in 1980, and its incidence increased threefold in the 1980s and 1990s. The typical age of onset is late adolescence or early adulthood. Compared with anorexia, little is known about the course or mortality rate of bulimia. Although bulimia can be chronic (most patients have it for at least several years) and also fatal, psychiatrists appear to be more hopeful about the prospects for long-term recovery from bulimia compared with anorexia. However, death caused by electrolyte imbalance from vomiting can occur suddenly among bulimic patients, who can seem healthy on the surface because they are typically within a normal weight range.

Binge eating disorder entails regular episodes of binge eating that ordinarily are not followed by purging or compensatory acts. This disorder was identified in 1994 but is not considered an official eating disorder category in its own right. Individuals with this problem receive a diagnosis of "Eating Disorder Not Otherwise Specified" (American Psychiatric Association 2000). It usually appears in late adolescence or in a person's early twenties and is the most prevalent but least studied eating disorder. It occurs relatively frequently among males, but females are approximately one and one-half times more likely to experience it (American Psychiatric Association 2000).

Officially diagnosed eating disorders are relatively rare; among females, the prevalence of anorexia is about 0.5 percent and that of bulimia is approximately 1 to 3 percent (American Psychiatric Association 2000). However, estimates of significant eating disorder symptoms range from 5 to 10 percent of girls and young women and can run even higher on some college campuses (Boskind-White 2000). Obesity, although common, is not considered an eating disorder "because it has not been established that it is consistently associated with a psychological or behavioral syndrome" (American Psychiatric Association 2000, p. 583).

EATING DISORDERS AS CULTURAL PHENOMENA

Most researchers agree that eating disorders are culturally situated phenomena. It is difficult to explain their rise in incidence in the 1970s and 1980s in industrialized and industrializing social locations without referencing cultural changes during that period. Even so, most psychologists and psychiatrists downplay so-called sociocultural factors such as shifting social ideals of gender in the etiology and treatment of eating disorders. At the same time some proponents of a feminist cultural model "rely on a generic notion of cultural influence and simultaneously medicalize and pathologize all chronic dieting" (Gremillion 2003, p. 27). Simplified representations of nature and nurture are at work in this debate. This problem can be addressed by questioning the status of eating disorders as "pre-given medico-psychological" entities (Malson 1991, p. 31) and by locating eating problems at the intersection of multiple and often contradictory understandings of feminine identity and embodiment (Bordo 1993, Malson 1998). This approach differs from efforts, such as Joan Brumberg's (1989), to integrate biological, psychological, and cultural factors as they currently are understood.

The sociologist Bryan Turner (1984) and the philosopher Susan Bordo (1993) examine developments in Western social contexts that have led to understandings and experiences of the female body as a battleground of gendered conflicts that are specific to consumer culture. Efforts after World War II to promote consumption and the satisfaction of desires coexist with long-standing efforts to control and contain the female body. In this context anorexia is a triumph of control that is wedded to increasingly widespread ideals of slender femininity. Bulimia expresses more directly contradictory cultural imperatives for women and girls in particular to both consume and control the effects of consumption (Bordo 1993).

Bordo's work suggests that a widespread insistence on distinguishing anorexia and bulimia as discrete psychiatric entities conceals the gendered politics of consumer culture that links the two and connects both with a continuum of phenomena that range from chronic dieting to obesity. Significantly, it is not uncommon for patients with anorexia to develop bulimia; also, the prevalence of binge eating disorder is as high as 50 percent (the mean is 30 percent) when samples are drawn from weight-control programs (the prevalence rate is 0.7 to 4 percent in community samples) (American Psychiatric Association 2000).

Mark Nichter and Mimi Nichter (1991) and Robert Crawford (1985) emphasize the importance of class relations in analyzing eating problems. Pressure to manage the contradictions of control and release as well as constraint and freedom at the level of the individual body may influence those who are upwardly mobile most acutely. In this light assessments of obese or seemingly unfit individuals as "lazy" valorize the cultural norms that are implicated in eating disorders. Similarly, representations of bulimia as a "bad" or failed other to anorexia (Burns 2004) arguably scapegoat individual sufferers for problems that are shaped socially and economically.

GENDER AND PSYCHIATRIC TREATMENT

Although treatments for anorexia and bulimia have improved over time, mortality and relapse rates remain high. Difficulties in treatment often are attributed to patients' pathology and tenacity, but a growing number of scholars argue that therapies often unknowingly reproduce problematic sociocultural and gender norms that contribute to patients' struggles. Ideologies of individualism and self-control in the therapeutic management of eating can reinforce the hard-earned sense of self-reliance that is part and parcel of eating problems (Eckerman 1997, Gremillion 2003, MacSween 1993). These ideologies pose irreconcilable dilemmas for women and girls who are taught to sacrifice their own needs for those of others (Boskind-Lodhal 1976, Steiner-Adair 1986, Orbach 1986). In addition, many treatment programs unwittingly perpetuate beliefs about motherhood and feminine "nature" that imply the need for heroic measures to achieve health. A sense of defeat and relapse often follows (Gremillion 2003).

Therapies that do not acknowledge the fact that eating disorders are shaped culturally and historically are likely to perpetuate taken-for-granted understandings of gender that allow these disorders to flourish. The need for a contextual reading of illness and health applies not only to doctor-patient relationships but also to the formulation of treatment protocols and the constitution of gendered relationships within professional treatment teams that often attempt to model health (Sesan 1994, Wooley and Wooley 1985). Formal studies of alternative treatments that acknowledge a politics of gender (White and Epston 1990, Steiner-Adair 1994) are lacking, but anecdotal evidence and pilot study results (Madigan and Goldner 1999) suggest a significant improvement in treatment outcomes.

THE POLITICS OF INCLUSION: GENDER, RACE, CLASS, AND SEXUALITY

Disordered eating affects males as well as females. The effects of consumer culture, particularly as they relate to concerns about body size, shape, and image, are increasingly present in the male body (Nemeroff and associates 1994). Significantly, eating disorders are most prevalent among men and boys who engage in activities that involve weight restrictions, such as bodybuilding, wrestling, dancing, gymnastics, and jockeying (Andersen and colleagues 1995). There is a broad consensus that eating problems are clinically similar between males and females.

However, no clinical or cultural analyst disputes the fact that eating disorders are much more widespread among females. Any attempt to represent eating problems as "equal opportunity" along the axis of gender fails to acknowledge significant gender inequalities that affect the politics of body size and self-control. However, males with eating disorders may be stigmatized as insufficiently "masculine" (Kearney-Cooke and Steichen-Asch 1990) and therefore may be less likely than women and girls to identify these problems openly. It is possible that eating disorders are more prevalent among males than is realized (Hepworth and Griffin 1995). Associations in the literature between eating disorders and homosexuality in males should be evaluated in light of stereotypical views about appropriate masculine behavior.

Scholars who critically analyze representations of eating disorders as white and middle-class phenomena have raised similar questions about whether these disorders are overlooked in particular groups. Eating disorder patient populations are likely to be socioeconomically privileged disproportionately in part because of preconceived ideas about typical patient profiles (Dolan 1991, Gard and Freeman 1996, Gremillion 2003, Thompson 1994a). Evidence is mounting that eating disorders cut across ethnic and class boundaries (Striegel-Moore and Smolak 2000). However, rather than simply attempting to identify eating disorders as they are known among various populations, it is important to ask how these disorders are defined in the first place because official definitions may preclude recognition of significant eating problems.

The sociologist Becky Thompson (1994b) shows that pressures for girls and women to be slim, which can lead to a range of eating problems, are associated with several narratives of privilege, such as whitening, moving up the social ladder, and becoming appropriately heterosexual. At the same time she argues that these powerful narratives do not capture all the meanings of eating difficulties in people's lives. For instance, "dissatisfaction with appearance often serves as a stand-in for topics that are still invisible" (Thompson 1994b, p. 11) such as racism, sexism, poverty, and sexual abuse. According to Thompson, "Doing justice to the social context in which difficulties with food arise requires an integrated analysis—one that accounts for the intersecting influence of gender, race, sexuality, nationality, and class" (Thompson 1994b, p. 360).

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                                        Helen Gremillion