Eating disorders are severe disturbances in eating behavior that result from the sufferer’s obsessive fear of gaining weight. The DSM-IV-TR lists two major types of eating disorders: anorexia nervosa and bulimia nervosa. The most obvious characteristic of anorexia nervosa is extreme emaciation, thinness. The term anorexia literally means loss of appetite.

Bulimia nervosa is characterized by repeated episodes of binge eating, followed by inappropriate compensatory behaviors such as self-induced vomiting, misuse of laxatives, or excessive exercise. According to the National Centers for Disease Control and Prevention, at any point in time 44% of high school females are attempting to lose weight compared with 15% of males.

Anorexia Nervosa Symptoms

The most obvious and most dangerous symptom of anorexia nervosa is a refusal to maintain a minimally normal body weight. DSM-IV-TR contains no formal cutoff as to how thin is too thin but suggests 85 percent of expected body weight as a rough guideline. The average individual with anorexia loses 25 to 30% of normal body weight. A second defining symptom of anorexia nervosa is a perceptual, cognitive, or affective disturbance in evaluating one’s weight and shape. Individuals with anorexia have an inaccurate perception of body size and shape. They can be extremely skinny and still believe they are overweight or look fat. They also have an intense fear of becoming fat is a third defining characteristic of anorexia. It’s this fear that makes treatment so difficult. Females with anorexia stop menstruating with the absence of at least three consecutive menstrual cycles. The body is reacting to the loss of body fat and associated physiological changes.

Medical Complications

Individuals with anorexia often experience constipation, abdominal pain, intolerance to cold, and overall lethargy. They often develop lanugo – a fine hair on face or trunk. There bodies often begin deteriorating resulting in anemia, impaired kidney functioning, cardiovascular difficulties, dental erosion, etc. This deterioration leads to extreme electrolyte imbalance. It is a constant battle for control over their bodies.

Comorbid Psychological Disorders

Anorexia is associated with other psychological problems, particularly obsessive–compulsive disorder, obsessive–compulsive personality disorder and depression. However, comorbid psychological problems may be reactions to anorexia, not the cause of it. For instance, depression is a common secondary reaction to starvation. Anorexia often co-occurs with symptoms of bulimia.

Bulimia Symptoms

Binge eating is one key symptom of bulimia. It’s when an individual eats an amount of food (usually high in fat and carbohydrates) that is clearly larger than most people would eat under similar circumstances in a fixed period of time. Binge eating can be planned or spontaneous, but it is often triggered by unhappy mood. To make up for these binges, individuals with bulimia often purge. Purging is designed to eliminate consumed food from the body through self-induced vomiting, misuse of laxative, diuretics, or exercise. However, purging has only limited effectiveness in reducing caloric intake. Individuals suffering from bulimia place excessive emphasis on weight and body shape. It is the defining feature of their lives. Their self-esteem and much of the daily routine is centered around weight and diet.

Comorbid Psychological Disorders

Depression is common. Like anorexia, it may precede or follow the eating disorder. Nonetheless, eating disturbances are more severe and social impairment greater when the two problems are comorbid.

Medical Complications

Bulimia is rough on the body. Repeated vomiting can erode dental enamel and can also produce a gag reflex that is triggered too easily and perhaps unintentionally. These unintentional gag reflexes sometimes force rumination – regurgitation and re-chewing of food. Bulimic individuals often experience enlargement of the salivary glands.

Diagnoses

Anorexia nervosa coined in 1874 by Sir William Withey Gull, a British physician. References to eating disorders were rare in the literature prior to 1960. The diagnoses of anorexia nervosa and bulimia nervosa first appeared in DSM in 1980 (DSM-III).

Contemporary Classification

Anorexia Nervosa

Includes two subtypes

Restricting type

Binge eating/purging type

Bulimia Nervosa

Divided into two subtypes in DSM-IV-TR.

Purging type: regularly uses self-induced vomiting, laxatives, diuretics, or enemas.

Nonpurging type: attempts to compensate for binge eating only with fasting or excessive exercise.

Frequency

Anorexia nervosa is rare in the general population. However, it is far more common among certain segments of the population, particularly among young women.

Why is this the case?

Popular attitudes about women in the United States tell us that “looks are everything,” and thinness is essential to good looks. Magazine covers are notorious for talking about weight loss techniques. It’s all relative though. Parents and general community can help foster a healthier standard of beauty.

Eating disorders typically begin in late adolescence or early adulthood.

The onset of eating disorders has provoked much speculation about their etiology, including hormonal changes, autonomy struggles and various sexual problems.

Causes

Social Factors

Girls want to “feel” pretty and want the attention from guys. Because of this, eating disorders are far more common among young women than young men. The prevalence of eating disorders in the U.S. has risen, as the image of the ideal woman has increasingly emphasized extreme thinness. Eating disorders are even more common among young women working in fields that emphasize weight and appearance, such as models, ballet dancers, and gymnasts. Not too surprising. It’s the same reason baseball players take steroids.

Adolescent boys often want to be bigger and stronger, not slimmer.“Reverse anorexia” or the “Adonis complex,” is characterized by excessive emphasis on extreme muscularity and often accompanied by the abuse of anabolic steroids.

Men with anorexia or bulimia deviate far from male norms, and this can lead to rejection and stigmatization by other men, therapists, and even females with eating disorders.

Troubled Family Relationships

Young people with bulimia nervosa report considerable conflict and rejection in their families, difficulties that also may contribute to their depression. In contrast, young people with anorexia generally perceive their families as cohesive and nonconflictual.

Psychological Factors

A struggle for perfection and control. In the teenage years, girls do not have much control over their lives. What they eat is one thing they can.

Hilde Brush, a German physician, viewed struggle for control as the central psychological issue in the development of eating disorders.

Perfectionists tend to set unrealistically high standards, are self-critical, and demand flawless performance from themselves. This personality often leads to eating disorders.

Depression, Low Self Esteem, and Dysphoria

Depression is often comorbid, but it is not always clinical depression. The Low self-esteem likely related with women being preoccupied with their social self. Dsyphoria simply means there mood is generally negative.

Negative Body Image

A highly critical evaluation of one’s weight and shape. Current research focuses on dissatisfaction with body image, a negative evaluation of one’s body that includes cognitive and affective elements.

Dietary Restraint

Inappropriate dieting can contribute directly to subsequent binge eating. “Quick-fix” diets rarely work, and dieters are likely to be left with a sense of failure, disappointment, and self-criticism. Dietary restraint also may directly cause some of the symptoms of anorexia nervosa.

Biological Factors

Weight set points – fixed weights or small ranges of weight.

Genetic factors also contribute to eating disorders. Genetics may influence some personality characteristic that, in turn, increases the risk for bulimia nervosa such as anxiety.

Treatment

The treatments for anorexia nervosa and bulimia nervosa differ in approach and effectiveness.

Treatment focuses on two goals:

Help the patient gain at least a minimal amount of weight.
Address the broader eating and personal difficulties.

There is some evidence that family therapy is more effective than individual therapy.

Antidepressants

Medication alone is not the treatment of choice. Relapse is common once medication is stopped.

Psychotherapy

Psychotherapy, such as cognitive behavioral therapy,  is an important component of treatment.

Christopher Fairburn developed three treatment stages:

Education and behavioral strategies
Address the client’s broader, dsyfunctional beliefs about self.
Attempt to consolidate gains and prepare the client for expected relapses in the future.

Can eating disorders be prevented?

More successful prevention efforts do not directly focus on body image or disordered eating. Instead, they attack the thinness ideal indirectly, or focus on promoting healthy eating rather than eliminating unhealthy habits.

Cognitive dissonance intervention is used.Participants complete tasks inconsistent with the thinness ideal. Over time, their beliefs will conform with how they are behaving.

Course and Outcome of Anorexia Nervosa

Evidence on the course and outcome of anorexia nervosa further shows the limited effectiveness of contemporary treatments. Perhaps 10% of patients starve themselves to death or die of related complications, including suicide. Of all mental illnesses, eating disorders are the most deadly.

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