Dieting and concern about body image are an American pastime. At any given moment, some 50 million Americans are on a weight-loss regimen. Although few of those who wish they were thinner suffer from a true psychiatric eating disorder, the number of individuals who have either of the two major forms of eating disorders - anorexia nervosa and bulimia - has risen dramatically in recent decades.
Obesity is sometimes considered a third eating disorder. Technically, it is not viewed as a true psychiatric problem, unless attempts to lose weight become abnormally obsessive or concern about body image becomes so severe that it interferes with normal functioning and good mental health. These emotional problems frequently accompany obesity.
Anorexia nervosa (severe self-starvation) and bulimia (binge-eating and purging) have striking, sometimes life-threatening physical features that must be treated medically. The roots of these disorders are emotional and psychological and treatment approaches are primarily psychological. While investigators do not agree on the causes of these disorders, numerous factors that contribute to their development have been identified.
Ordinarily, bulimia begins between the ages of 17 and 25, however, because many bulimics are deeply ashamed of their bingeing and purging and keep these activities a secret, an actual diagnosis may not be made until a patient is well into her 30s or 40s.
Bulimia usually begins in conjunction with a diet, but once the binge-purge cycle becomes established, it can get out of control. Some bulimics may be somewhat underweight and a few may be obese, but most tend to keep a normal weight. In many, the menstrual cycle becomes irregular. Sexual interest may diminish. Bulimics may exhibit impulsive behaviors, such as shoplifting, alcohol and drug abuse. Many appear to be healthy and successful perfectionists at whatever they do. Actually, most bulimics have very low self-esteem and are often depressed.
To lose the gained weight, the bulimic begins purging, which may include using laxatives or diuretics (drugs to increase urination), self-induced vomiting caused by gagging, using an emetic (a chemical substance that causes vomiting) or simply mentally willing the action. Between binges, the person may fast or exercise excessively.
The bulimia binge-purge cycle can be devastating to health in a number of ways. It can upset the balance of electrolytes - sodium, magnesium, potassium and calcium - which can cause fatigue, seizures, muscle cramps, irregular heartbeat and decreased bone density (leading to osteoporosis). Repeated vomiting can damage the esophagus and stomach, cause the salivary glands to swell, make gums recede and erode tooth enamel. In some cases, all teeth must be pulled prematurely because of the constant wash by gastric acid. Other effects may be rashes, broken blood vessels in the cheeks, and swelling around the eyes, ankles and feet. For diabetics, bingeing on high-carbohydrate foods and sweets is particularly hazardous since their bodies cannot properly metabolize the starches and sugars.
The individual with anorexia nervosa is usually someone of normal or slightly above normal weight who starts on an "innocent" diet and eventually begins suppressing hunger sensations (to the point of self-starvation). There is frequently a history of someone in the family who is a dieter, overweight or focused on staying slim and fit.
Although the illness is most common among teenage or young adult women, it can also affect males, preadolescents, older adults and individuals from different ethnic and cultural backgrounds. Classic anorectics starve themselves to skeletal thinness, losing more than 15 percent (frequently 25 to 35 percent) of their original body weight. This dramatic weight loss is usually accompanied by an intense fear of gaining weight or becoming obese that does not diminish as weight loss progresses. Other characteristics of the disorder include a distorted body-image (indicated by the individual's claims of being fat, even when emaciated), a refusal to maintain body weight over minimum normal weight for age and height, and the loss of menstrual periods.
The causes of anorexia nervosa are unknown. The widespread emphasis on diets and the desire for thinness in our society contribute to its high incidence, and psychological factors play an important role in its development.
A person who has several of the following signs may be developing or has already developed an eating disorder:
- has lost a great deal of weight in a short period of time
- continues to diet, although bone-thin.
- reaches diet goal and immediately sets another goal for further weight loss
- remains dissatisfied with appearance, claiming to feel fat, even after reaching weight-loss goal
- prefers dieting in isolation to joining a diet group
- loses monthly menstrual periods
- develops an unusual interest in food
- develops strange eating rituals and eats small amounts of food, e.g., cuts food into tiny pieces or measures everything before eating into extremely small amounts
- becomes a secret eater
- becomes obsessive about exercising
- appears depressed much of the time
- begins to binge and purge
- binges regularly (eats large amounts of food over a short period of time) and purges regularly (forces vomiting and/or uses drugs to stimulate vomiting, bowel movements or urination)
- diets and exercises often, but maintains or regains weight
- becomes a secret eater
- eats enormous amounts of food at one sitting, but does not gain weight
- disappears into the bathroom for long periods of time to induce vomiting
- abuses drugs or alcohol, or steals regularly
- appears depressed much of the time
- has swollen neck glands
- has scars on the back of hands from forced vomiting
Anorexia Nervosa (AN) and Bulimia (BN) require a multidimensional approach to treatment, addressing all contributing factors. The initial step is to return eating to a more normal pattern. For bulimic patients, this stage involves cessation of bingeing, purging and dieting behaviors. For patients with AN, it involves reducing the fears of a normal body weight by a process of gradual weight restoration.
Strategies include encouragement and support, the use of psychoeducational groups and materials and medication to reduce the anxiety associated with eating. Some form of nutritional supplementation may be required, which may range from food or nutrient supplements to nasogastric or intravenous feeding of AN patients in extreme low-weight states. While nutritional rehabilitation alone is insufficient, treatments that do not address the effects of disordered eating and weight, or which collude with dieting behaviors by giving permission to eat minimal quantities of food by avoiding certain food groups, are unlikely to be effective.
Efforts to address significant psychological factors in the illness must proceed hand-in-hand with the return of good physical health. Assisting the patient to identify alternative coping mechanisms for stress is ultimately helpful. Family involvement may be beneficial, especially in the younger age group. Such involvement should be aimed at encouraging the family to become more knowledgeable about the disease and to feel less helpless, rather than engaging in family therapy (at least initially).
A stepped approach to therapy has been found valuable for some patients with BN. A significant minority of bulimic patients will respond well to a minimal intervention, such as a few group sessions of a psychoeducational nature, providing basic information about the illness, consultation with a dietitian-nutritionist and support to cope with any weight change that may occur.
Patients who do not respond to such an approach may benefit from outpatient group therapy (focusing on abnormal eating) or outpatient individual psychotherapeutic treatment of a multidimensional nature. Patients who continue to be symptomatic may then be referred for more intensive treatment, either in a day hospital or an inpatient unit. The most resistant patients can be referred to a center dedicated to the treatment of these illnesses.
Several controlled studies have found that cognitive-behavioral therapy is the most effective treatment for bulimia, compared with other kinds of psychotherapy or drugs. An essential element in the cognitive-behavioral treatment is "self-monitoring" - getting the patient to pay close attention to the physical signals of the emotional triggers that lead to bingeing. Estimates are this approach can help approximately 65 percent of those with eating disorders.
Treatment for eating disorders increasingly includes antidepressants because depression commonly accompanies the problem. This area changes rapidly, depending upon what researchers discover. Discuss this with your doctor.
Is my problem anorexia or bulimia?
How is a "binge cycle" harmful to my health?
What are the treatment options?
Is psychotherapy a consideration?
What about medication?
Would nutritional supplements help?