Eating disorders are characterized by extreme attitudes and behaviors surrounding weight and food issues. Included in this class of disorders are anorexia nervosa and bulimia nervosa. Although each of these disorders is manifested in distinct ways, they both have the potential to result in extreme harm to physical and psychological health and can have life-threatening consequences. Clinical and scientific interest in eating disorders has increased greatly in the past 20 years. As a result of this growing interest, advances have been made in how these disorders are conceptualized. The abundance of studies in this area has led to an increased understanding of the warning signs, possible causes, and treatments related to eating disorders.
Definition And Identification
Anorexia Nervosa
Anorexia nervosa is an eating disorder that is characterized by self-starvation and excessive weight loss. In order for a health care professional to diagnose an individual with anorexia nervosa, certain criteria must be met. These criteria are outlined in the DSM-IV-TR, or the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, published by the American Psychiatric Association. One of these criteria is a person’s refusal to maintain body weight at or above a minimally normal weight for an individual’s age and height. Specifically, an individual must weigh less than 85% of expected body weight. In children, there may be a failure to make expected weight gain during periods of growth, which would lead to a body weight that is less than 85% of that expected. Additional criteria necessary to diagnose anorexia nervosa include intense fear of gaining weight or becoming fat, even though the individual is underweight; disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight; and amenorrhea, the absence of at least three consecutive menstrual cycles in females.
Body image refers to the way people see themselves when looking in the mirror or when picturing themselves in their minds. Individuals with anorexia nervosa have a distorted body image. That is, they perceive parts of their bodies unlike they really are, which leads them to feel uncomfortable and awkward in their bodies and to feel ashamed, self-conscious, and anxious about their bodies. Individuals with anorexia tend to overestimate their body size. Some individuals may perceive that their entire body is overweight, while others will recognize that they are thin but perceive specific parts of their bodies to be fat. The word anorexia actually means loss of appetite. This definition is misleading, however, because individuals with anorexia nervosa rarely experience loss of appetite. Rather, they intentionally try to lose weight through restricted dieting, purging, or excessive exercise. Anorexia nervosa can be classified in one of two ways, based on the manner in which an individual attempts to limit caloric intake. In anorexia nervosa restricting type, individuals try to lose weight by strict dieting, fasting, or exercise. In anorexia nervosa binge eating/purging type, individuals engage in regular binge eating (consuming large quantities of food in a relatively brief period of time, accompanied by a perceived lack of control) or purging, or both.
Intervening during the early stages of anorexia nervosa can significantly improve the likelihood of recovery. Therefore, it is important to be aware of some of the warning signs of this disorder. Common warning signs include dramatic weight loss over short periods of time; preoccupation with weight, food, calories, fat grams, and dieting; dieting despite extreme thinness; comments about feeling fat or overweight despite weight loss; development of food rituals or eating very small quantities of food; repeated excuses to avoid mealtimes or situations involving food; excessive, rigid exercise regimens; anxiety about gaining weight or being fat; denial of hunger; withdrawal from usual friends and/or activities or other depressive symptoms; and any behaviors and attitudes indicating that weight loss and dieting have become primary concerns. It is important to note that, by themselves, each of these signs is not definitively diagnostic of anorexia.
Bulimia Nervosa
Bulimia nervosa is characterized by a secretive style of binge eating followed by behaviors such as self-induced vomiting to compensate for the effects of binge eating. In order to diagnose bulimia nervosa, certain symptoms or criteria must be present, as set forth in the DSM-IV-TR. These criteria include recurrent episodes of binge eating; recurrent, inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting or use of laxatives, diuretics, excessive exercise, or strict dieting; binge eating and compensatory behaviors occurring on average of at least twice a week for 3 months; and self-evaluation that is overly influenced by body shape and weight.
Individuals with bulimia nervosa may overestimate their body size to the same extent as individuals with anorexia nervosa. While persons with bulimia or anorexia share some characteristics, such as overestimation of body size, there are also major differences between the two groups. Both diagnostic categories show significant concern about their weight and make attempts at controlling it. Most persons with bulimia, however, maintain weight within the average range for their age and height, while those with anorexia experience dramatic weight loss. Fluctuations in weight may occur in bulimia as a result of alternating cycles of bingeing and fasting or dieting, but dramatic weight loss will generally not occur in these individuals.
Bulimia nervosa can also be classified in one of two ways: purging type and nonpurging type. Individuals who have bulimia nervosa purging type engage in regular self-induced vomiting or regular misuse of laxatives or diuretics. Those who are diagnosed as having bulimia nervosa nonpurging type use other forms of compensation for their overeating, such as fasting or excessive exercise. It has been estimated that as many as two thirds of individuals with bulimia engage in purging, with self-induced vomiting being the most frequently reported method of purging among individuals who seek treatment for this disorder.
Similar to anorexia nervosa, the chance for recovery from bulimia nervosa increases the earlier the disorder is detected. Thus, awareness of the following warning signs can be instrumental in successful recovery: evidence of binge eating, such as disappearance of large amounts of food over short periods of time or the presence of empty wrappers or containers indicating the consumption of large food quantities; evidence of purging behaviors, such as frequent trips to the bathroom after meals, empty packages for laxatives or diuretics, or vomit-like odors; excessive, rigid exercise regimens; swelling of cheeks or jaw area; calluses on hands or knuckles from self-induced vomiting; staining or discoloration of teeth; withdrawal from usual friends and/or activities; and any behaviors or attitudes indicating that weight loss and dieting are primary concerns. As with the warning signs of anorexia, each of these signs by themselves is not absolutely diagnostic of bulimia nervosa.
Prevalence
Most estimates indicate that the risk for developing anorexia nervosa is highest during adolescence and early adulthood. Occasionally, however, this disorder is seen in prepubescent children as young as 7 or 8 years old. Anorexia nervosa primarily occurs in females, with only 10% of reported cases being male. Estimates regarding the frequency of cases in the population vary. According to the DSM-IV-TR, prevalence estimates, or estimates of the actual number of cases in the population at a certain point in time, suggest rates of 0.5% for anorexia nervosa among females.
The number of cases of anorexia nervosa has increased in the past two decades. This increase is likely due to greater awareness of this disorder among the public and among health care professionals. The secretiveness and shame associated with eating disorders, however, is likely to prevent many cases from being reported. Therefore, rates obtained from self-reports in doctor’s offices may be underestimates of the true number of cases in the population.
Similar to anorexia nervosa, bulimia nervosa primarily occurs in young females and typically develops in late adolescence or early adulthood. The prevalence of bulimia nervosa, as stated in the DSM-IV-TR, is approximately 1.0% to 3.0% among females, while the occurrence of this disorder in males is approximately one tenth that of females. As with anorexia nervosa, bulimia nervosa may be increasing in the population.
Health Consequences
Individuals who have anorexia nervosa subject their bodies to a cycle of self-starvation, which denies the body the essential nutrients it needs to work properly. This causes the body’s normal functions to slow down, resulting in serious medical consequences. Among these consequences are abnormally slow heart rate and low blood pressure; increased risk for heart failure; reduction of bone density or osteoporosis; muscle loss and weakness; severe dehydration, which can result in kidney failure; fainting, fatigue, and overall weakness; dry hair and skin; and hair loss.
The recurrent binge-and-purge cycles that are characteristic of bulimia can also have serious health consequences. These cycles can affect the entire digestive system and can lead to electrolyte and chemical imbalances in the body, which influence heart and other main bodily functions. Specifically, these imbalances can lead to irregular heartbeats and possibly heart death. Additional health consequences that may result from bulimia nervosa include inflammation and rupture of the esophagus from recurrent vomiting, tooth decay and staining from stomach acids released during vomiting, and irregular bowel movements as a result of laxative use.
Underlying Causes
Several theories have been proposed in an effort to explain why eating disorders originate, but no single factor has been labeled as the major cause of any type of eating disorder. Most modern theorists believe that biological, social, cultural, and psychological characteristics interact to contribute to the development and maintenance of eating disorders.
Biological
Research suggests that a person’s genetic makeup might increase the likelihood that he or she will develop an eating disorder, although this biological role is thought to be minimal. Eating disorders have been found to run in families. Relatives of patients with anorexia or bulimia nervosa, particularly female relatives, are more likely to develop an eating disorder themselves. Additional evidence for a genetic contribution to the development of eating disorders comes from twin studies indicating that the likelihood of identical twins having an eating disorder may be greater than 50%.
Familial
Family structure and family functioning have also been identified as possible contributors to the development of eating disorders. Some theorists have argued that anorexia nervosa and bulimia nervosa develop when mother-child relationships are impaired. Negative interaction patterns among family members may also play a role in the development of these disorders. Families of eating-disordered children are likely to lack the ability to manage conflicts appropriately. Children are more likely to develop eating disorders if they are raised in families in which family members are overprotective of one another, overinvolved in one another’s affairs, or resistant to family change. It has also been suggested that children develop eating disorders as a means of diverting attention away from family problems, such as marital discord, and toward themselves.
Family processes can lead to an overemphasis on weight and dietary control. Mothers who are critical of their daughters’ body weight or who engage in frequent dieting themselves, for example, may unintentionally foster the development of an eating disorder. Parents who are frequently absent, uninvolved, or have unusually high expectations are also thought by family processing theorists to contribute to eating disorders in their children. Families of adolescents with eating disorders are more likely to be characterized by negative communication patterns and mistrust and to engage in fewer helping behaviors.
The connection between early childhood sexual abuse and eating disorders remains unclear. Some studies of the general population indicate that women with bulimia nervosa are more likely to have been sexually abused as children than women without the disorder. Other studies, however, have not found similar results among individuals with eating disorders. In addition to sexual abuse, other forms of stress or trauma, including physical abuse, being bullied, parental divorce, or concerns over being homosexual have been implicated in the development of eating disorders.
Social and Cultural
Historically, it was thought that eating disorders occurred only in White, middle-class women. Recently, however, studies have shown that eating disorders exist in minority populations as well. Research has indicated that, in the United States, eating disorders seem to occur as frequently in Hispanic females as in Caucasian females and to be most common among Native Americans. The occurrence of these disorders is less frequent among Black and Asian females.
Anorexia nervosa and bulimia nervosa tend to occur more frequently in industrialized societies. According to the DSM-IV-TR, these disorders may be most common in the United States, Canada, Europe, Australia, Japan, New Zealand, and South Africa. It is widely believed that certain features of contemporary Western culture heavily influence eating disorders. In American society, a thin body type is preferred and is considered ideal. This ideal is abundantly portrayed through magazine ads, television shows, and other forms of media. Young girls and women compare themselves to an idealized body image that hardly resembles what most women in our population look like. Alarming numbers of women report being dissatisfied with their bodies and feeling guilty about eating normal quantities of food. At an early age, American girls adopt the cultural focus on dieting and thinness, which is likely to play a role in the onset of eating disorders.
While eating disorders can occur in individuals from any socioeconomic group, females from higher socioeconomic status groups tend to be more concerned with becoming thin than females from lower socioeconomic status groups. White females from middle and upper-class societies tend to base evaluations of self-worth and success on outward physical appearance. Thus, eating disorders among individuals in this group serve to restore a sense of satisfaction with physical appearance and self-control.
The fact that eating disorders are far more common in females than in males has been attributed to societal assumptions about what it is to be feminine and what it means to be masculine. Specifically, the focus here is on the belief that girls receive positive attention and reinforcement for being attractive, while boys receive attention and praise for their achievements. Young women tend to base their self-perceptions and identity on the status of their relationships, and these relationships are often heavily influenced by body image and physical appearance.
Subgroups in which there are increased pressures to diet or maintain a thin shape may be particularly susceptible to eating disorders. For example, research suggests that there is a high occurrence of eating disorders among athletes and performing artists. Particular subgroups in which high incidences of eating disorders have been reported are ballet dancers, professional dancers, wrestlers, swimmers, and gymnasts.
Psychological
The biological, social, and cultural forces mentioned above are thought to contribute to and interact with psychological processes in the development and maintenance of eating disorders. The risk of developing an eating disorder is increased when outside pressures to be thin and attractive interact with internal psychological factors, particularly during times of developmental growth and change. For example, as a result of family or societal influences, a young girl may begin to think she is fat and unattractive as her body develops into a more adult form. In order to avoid the unwanted growth that accompanies the transition into adulthood, this young girl may develop an eating disorder.
Individuals with anorexia nervosa may be described as obsessive, emotionally restricted, approval-seeking, and resistant to change. These characteristics can lead to vulnerability during developmental transitions that involve rapid and notable change, such as puberty. Many persons who seek treatment for anorexia also meet the criteria for one or more personality disorders. Depression and anxiety are common among individuals with eating disorders and are usually manifested near the onset of the disorder. The personality of an adolescent with bulimia is likely to be characterized by frequent mood swings and lack of impulse control. Abuse of alcohol or stimulants occurs in at least one third of adolescents who seek treatment for bulimia.
Perfectionism may account for the high frequency of depression among individuals with eating disorders. A high need for perfectionism in combination with a high level of daily stress is likely to lead to depression. The likelihood of developing an eating disorder is greater among individuals who have a high need for perfectionism and also think of themselves as being fat or unattractive. In other words, individuals with eating disorders perceive their actual self to be different from their ideal self, so they develop symptoms of an eating disorder in an effort to reach their perceived ideal self.
Adolescents with bulimia or anorexia may believe that limiting food intake and losing weight are means by which to gain control over their lives and to become better people. They may start out with a moderate diet, which will gradually develop into the rigid eating patterns characteristic of anorexia or bulimia. Teenagers may unintentionally initiate a dangerous eating cycle because they are dissatisfied with the way their bodies look, following which their efforts are rewarded by weight loss and a sense of greater self-control. Extra attention from peers may serve to reward dieting behavior and lead to a transition from dieting to a full-blown eating disorder.
Treatment Methods
Treatment methods for anorexia and bulimia have changed significantly over the past 20 years. Early treatment focused on the need for patients to use insight into emotional traumas to uncover fears surrounding food consumption. The recognition that treatment must involve more than just insight led to the evolution of more sophisticated and comprehensive approaches. Modern treatment approaches, particularly psychological interventions, are leading to more effective outcomes for adolescents and adults with eating disorders. In addition to changes in specific treatment approaches, changes have occurred regarding who treats individuals with eating disorders. The discovery of anorexia nervosa and bulimia nervosa in pediatric populations has led to increased involvement of pediatric psychologists in the treatment of these disorders.
Anorexia Nervosa
Although anorexia is typically less responsive to treatment than bulimia, progress has been made in the treatment of this disorder. The treatment of anorexia typically consists of two stages: weight restoration and psychotherapy. The goal of the first stage is for anorexics to restore body weight while under the supervision of a medical professional. This stage may require inpatient hospitalization, either in a general medical unit or a psychiatric unit. During the weight restoration stage, individuals with anorexia are gradually reintroduced to increasing quantities of food until they are able to reach a daily intake of approximately 2500 calories.
Many patients will successfully gain weight while in the hospital, but may return to maladaptive patterns of weight loss and distorted beliefs about food and body image once they are released from the hospital. For this reason, it is important that the second phase of treatment, psychotherapy, be implemented. Through psychotherapy, patients achieve an understanding of their experience with anorexia nervosa, the factors that led to the development of the disorder, how the disorder was maintained, and how to prevent relapse.
Psychotherapy for anorexia nervosa may include behavioral, cognitive-behavioral, and family components. Behavioral techniques can be implemented both during and after the weight restoration stage. Specifically, interventions involve rewarding individuals for positive behaviors. During the weight restoration phase, for example, patients may be rewarded for weight gain by being allowed to participate in hospital activities and privileges. Similarly, patients may be rewarded for weight maintenance once they have left the hospital. These types of behavioral approaches have been shown to lead to short-term success.
The use of cognitive-behavioral therapy to treat anorexia nervosa evolved out of the belief that anorexics have distorted ways of thinking, distorted beliefs, and distorted perceptions. For example, as mentioned earlier, individuals with anorexia nervosa have the faulty belief that they are evaluated based on their weight or body shape. Another example of distorted thinking in anorexia is the tendency to overestimate body size and to believe that eating will lead to loss of control and obesity. Cognitive-behavioral therapies lead to changes in eating behaviors by rewarding or modeling appropriate behaviors and helping patients change distorted or rigid thinking patterns. Although cognitive-behavioral therapy is a popular choice among professionals who treat individuals with anorexia nervosa, few research studies have proven that it is more effective than other therapies in treating this disorder.
For individuals who are younger and still living at home, family therapy is a treatment of choice for anorexia. Family therapy is important because parents are responsible for their children’s well-being and can help bring about change by providing assistance in reaching treatment goals while being present in the child’s physical environment. Additionally, family therapy serves to restore healthy communication among family members, while eliminating the unhealthy communication patterns that led to the eating disorder in the first place. By involving the entire family, therapists can look at family members’ attitudes toward body shape and body image, which may have been interpreted by the child with anorexia as critical judgments.
Group therapy is generally not an effective method of treatment for individuals with anorexia nervosa. These individuals typically have difficulty with social interactions and, due to their preoccupation with weight and negative views of their body, do not welcome group interaction of this sort. Regardless of the type of treatment applied, patients with anorexia have a tendency to deny their illness or to minimize the severity of their symptoms. This denial can stand in the way of progress, regardless of which treatment modality is chosen.
Bulimia Nervosa
Most patients with bulimia nervosa can be treated as outpatients, as they do not typically require the same degree of medical supervision that is required by individuals with anorexia nervosa. Some estimates indicate that approximately 10% of individuals with bulimia nervosa will require inpatient treatment. Inpatient treatment is usually considered when patients have severe medical complications as a result of their eating disorder, are suicidal, or have failed to improve after outpatient treatment. Persons with bulimia also differ from persons with anorexia in that they often seek treatment on their own and are able to acknowledge that they have a problem. Persons with anorexia, on the other hand, tend to be brought in for treatment by their family members and typically deny the severity of their problem.
As with anorexia nervosa, cognitive-behavioral therapy has been used to treat bulimia nervosa by addressing distorted thoughts about eating, weight, and body shape. In treating bulimia, the goals of cognitive-behavioral therapy are to establish more normal eating patterns, change distorted thoughts underlying the disorder, discuss physical and psychological problems related to the disorder, and prevent the disorder from emerging again in the future. Patients learn to identify circumstances that trigger binge eating and avoid such circumstances. Research has shown significant support for the effectiveness of cognitive-behavioral approaches in treating bulimia.
A type of cognitive-behavioral therapy, exposure plus response prevention, is used to prevent self-induced vomiting in patients with bulimia nervosa. This method involves having a patient eat what they would normally eat during a binge episode. The patient is then guided by a therapist in learning how to resist vomiting and how to deal with anxiety that might result from not being able to purge. A related approach involves having a patient consume small amounts of food, which would typically lead to loss of control and a binge episode. In this situation, the therapist teaches the patient how to avoid or prevent a subsequent binge. After time, the patient will no longer experience anxiety after eating and will no longer feel the need to purge to relieve that anxiety.
Research supports the effectiveness of cognitive behavioral and behavioral approaches in treating patients with bulimia nervosa. These approaches have resulted in significant reductions in both binge eating and self-induced vomiting. Additionally, these effects appear to remain stable over time, with some studies reporting the absence of binge/purge behaviors for 7 to 10 years following the termination of treatment.
Drug Treatment
Due to the strong association between eating disorders and emotional states like depression and anxiety, attempts have been made to treat these disorders with various medications. Antidepressants and antianxiety medications are among the drugs that have been used with eating-disordered patients. Antianxiety medications have been used to help patients cope with the anxiety they encounter as a result of having to eat during the refeeding phase. Antidepressants have been used to help patients with bulimia decrease the number of bingeing and purging behaviors in which they engage. Another class of medications, called opiate blockers, is believed to prevent persons with anorexia from feeling euphoric during periods of starvation. The prevention of this euphoric feeling is expected to make starvation less of a rewarding experience for the patient with anorexia and, therefore, may lead the patient to start eating again.
Generally speaking, a number of medications for bulimia nervosa and anorexia nervosa have produced positive short-term effects. The long-term effectiveness of these medications, however, is unclear. High relapse rates occur once these medications are discontinued. Furthermore, numerous changes in medication are often required over time, and patients tend to discontinue taking medications before they are advised to do so, often to avoid their negative side effects. Thus, while drug treatment does have a place in the treatment of eating disorders, psychotherapy appears to be the preferred method of treatment.
Summary
Eating disorders are primarily disorders of young females, with those in adolescence or early adulthood being at greatest risk for developing these disorders. Bulimia nervosa and anorexia nervosa, though distinct in certain ways, can both result in serious harm to physical and emotional well-being. Increased attention to these disorders over the past 20 years has led to an increased awareness and understanding of their underlying causes. Most modern theorists believe that biological, familial, social, and cultural factors interact with one another, leading to the devilment of anorexia nervosa or bulimia nervosa in an individual.
Treatments for these disorders have shifted from a focus on insight to more comprehensive approaches, involving behavioral, cognitive-behavioral, and family therapies, as well as drug treatment in some cases. As mentioned previously, the chance of recovery from anorexia nervosa or bulimia nervosa increases when these disorders are detected early and treated promptly. Thus, it is important to be aware of the warning signs associated with these disorders.
Fortunately, social and cultural patterns may be shifting toward healthier norms of eating. This may be due to increasing public advertisements, talk shows, and television shows devoted to discussions of eating disorders and healthier decision making. Nonetheless, many people continue to suffer from the physical and emotional effects of eating disorders, and these disorders can result in mortality if professional help is not sought out.
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