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Frequently Asked Questions
back to Help/Resources
(provided by Craig Johnson, Ph.D. Laureate Psychiatric
Clinic and Hospital, Tulsa, Oklahoma)
What are Eating Disorders?
What Causes an Eating Disorder?
Who Is Most at Risk for Developing an Eating
Disorder?
What Are the Long-Term Medical and Emotional
Consequences of these Disorders?
What Is the Treatment for Eating Disorders?
How Do You Help Someone You Suspect Might Have an
Eating Disorder?
What are Eating Disorders?
An eating disorder is a collection of interrelated eating
habits, weight management practices, attitudes about food,
weight and body shape that have become disordered. Some
common features of eating disorders include an irrational
fear of fat, dissatisfaction with one's body often coupled
with a distorted perception of body shape, unhealthy weight
management, or extreme food intake. This disordered eating
behavior is usually an effort to solve a variety of
emotional difficulties in which the individual feels out of
control. Anyone can develop an eating disorder—males
and females of all social and economic classes, races and
intelligence levels.
There are three primary eating disorders. They
are Anorexia Nervosa, Bulimia Nervosa and Binge Eating
Disorder.
Anorexia Nervosa
Anorexia nervosa is an emotional "weight loss" disorder
characterized by physical, social and psychological
symptoms. Weight loss is achieved by a variety of obsessive
behaviors. Most individuals with this disorder strongly deny
it. A feeling of control is gained by severely restricting
the amount of food eaten. The ability to do without food is
viewed as success in attempting to cope with life's
stresses. Because early detection is important to successful
recovery, it is important to recognize the common warning
signs of Anorexia nervosa.
Major characteristics:
- An intense drive for thinness.
-
An intense fear of gaining weight or becoming fat.
- A disturbance in body image.
Important facts:
-
It typically develops in early to mid-adolescents.
- It affects about 1 in 2400 adolescents.
-
90-95 percent of individuals with anorexia nervosa are
female.
-
It is usually preceded by dieting behavior.
-
Psychological problems are displaced onto food.
- Unusual food behaviors are practiced.
-
Need to vicariously enjoy food by cooking it, serving,
it or being around it, is common.
- Preoccupation with body weight and image.
- Dieting becomes increasingly important.
- Denial of the condition can be extreme.
-
Body image disturbance (misperception of body size and
shape) is common.
- Pronounced emotional changes are common.
-
Between one third and one half of anorexics subsequently
develop Bulimia nervosa.
Anorexia nervosa should be considered when a normal-weight
person frequently:
-
Experiences significant or extreme weight loss with no
known medical illness.
- Reduces food intake.
-
Performs ritualistic eating habits (cutting meat into
very small pieces or excessive chewing )
- Denies hunger.
- Is critical and intolerant of others.
- Exercises excessively.
-
Chooses low-to-no-fat and low-calorie foods.
-
Says he/she is too fat, even when this is not true.
- Practices highly self-controlled behavior.
- Hides feelings.
Bulimia Nervosa
Bulimia is an emotional "weight control" disorder
characterized by episodes of binge eating followed by some
form of purging or restriction. Binges are the secretive
periods of rapid consumption of high-caloric foods over a
discrete period of time. Most bulimics follow bingeing with
self-induced vomiting. However, the purging may take the
form of laxative, emetic or diuretic abuse, excessive
exercise, or fasting. The binge-purge cycle is normally
accompanied by self-deprecating thoughts, depression, and an
awareness that the eating disorder is abnormal and out of
control. Because most bulimics are within a normal weight
range, the illness may go undetected by others for years.
Common purging behaviors include:
- Self-induced vomiting
- Emetic abuse
- Laxative abuse
- Diuretic abuse
- Fasting
- Excessive exercise
Important facts:
-
There are two types of bulimia nervosa; purging and
non-purging.
-
It occurs in 0.5 percent to 2.0 percent of adolescents
and young adult women.
-
It appears to be relatively uncommon in men.
-
It typically develops in early-to-mid-adolescents.
-
It is usually preceded by dieting behavior.
-
Bulimics are usually of average or above-average weight.
-
Self-evaluation is unduly influenced by size and weight.
-
A complex lifestyle develops to accommodate
eating-disorder behaviors.
-
There are ongoing feelings of isolation,
self-deprecating thoughts, depression, and low
self-esteem.
-
There is full recognition of the behavior as abnormal.
Bulimia should be considered when a normal-weight person
frequently:
-
Makes excuses to go to the bathroom after meals.
- Shows mood swings.
-
Buys large amounts of food that suddenly disappears.
- Has unusual swelling around the jaw.
-
Eats large amounts of food on the spur of the moment.
-
Laxative or diuretic wrappers frequently found in
trashcan.
-
If there is unexplained disappearance of food where the
person lives.
Binge-Eating Disorder
Binge eating is the consumption of unusually large amounts
of food in a discrete time period. Individuals with Bulimia
nervosa and Binge-eating disorder practice binge eating.
Those with Bulimia nervosa follow binge eating with some
type of purging behavior (i.e. self-induced vomiting,
laxatives, etc.). Those with Binge-eating disorder do not
practice purging, but have feelings of lost control and
marked distress over their eating behavior. Normal or
overweight individuals who meet the criteria for Bulimia
nervosa, but who do not practice purging or other
compensating behaviors, are diagnosed with Binge-eating
disorder.
The prevalence of Binge-eating disorder in the general
population is unknown, but studies suggest that
approximately 25-50 percent of obese individuals binge eat.
Studies also suggest that those suffering from Binge-eating
disorder have difficulties with impulse control in other
areas of their lives.
Binge-eating should be considered when a person frequently:
-
Eats an abnormal amount of food in a discrete period of
time.
- Eats rapidly.
-
Eats to the point of being uncontrollably full.
- Eats alone.
-
Shows irritation and disgust with self after
over-eating.
- Does not use methods to purge.
What Causes an Eating Disorder?
Anorexia nervosa and Bulimia are very complicated disorders
and the reasons for developing them can be different from
one person to the next. Although many view these behaviors
as self-destructive acts, most individuals who develop
eating disorders do not perceive their behaviors as
self-harmful. To the contrary, most patients feel that they
begin the behaviors to try to fix problems they are
experiencing in their lives.
The most common reason that we hear from people about why
they develop anorexia or bulimia is that at one point in
time they felt terribly out of control. This loss of control
could be something they were feeling inside themselves or
something that was happening to them from their outside
environment. The experience of being out of control directly
affects their feelings about themselves and usually results
in low self-esteem. The following are some of the most
common causes of eating disorders.
Major Life Transitions
Most eating disorders patients have difficulty with change.
Anorexics, in particular, prefer that things be predictable,
orderly and familiar. Consequently, transitions such as the
onset of puberty, entering high school or college, major
illness, or death of a significant other can overwhelm these
individuals and result in their feeling out of control.
The onset of puberty is arrested in many females with eating
disorders because their body weight and/or body fat is
lowered to the point where they lose their menstrual cycle.
Those whose body weight is below a menstrual threshold
essentially return to a more childlike state both physically
and psychologically. They neither feel nor look like
adolescent or young adult women, and therefore, postpone
making the transition to adolescence or young adulthood.
Family Problems
Some individuals with eating disorders come from disordered
families. The families of anorexic patients are often
characterized by extremely controlling parents and poor
boundaries between the parents and the child. For many of
these individuals, the Anorexia nervosa is a misguided, but
understandable, attempt at differentiating from their
parents. Put another way, some anorexics are very protective
of their illness because they feel it is the first thing in
their lives that they have done that was truly "their own
idea."
In contrast, individuals who struggle with Bulimia often
come from families where there is disconnection among the
family members. For these individuals the Bulimia can be a
desperate attempt to draw attention to themselves, or an
effort to fill up, numb, or distract themselves from the
feelings of emptiness related to the disconnection.
Social/Romantic Problems
Most people who develop eating disorders report painfully
low self-esteem prior to the onset of their eating problems.
Many patients report going through a painful experience,
such as being teased about their appearance, being shunned,
or going through a difficult break-up of a romantic
relationship. They begin to believe that these things
happened because they were fat and that if they become thin,
it will protect them from these experiences happening
again.
Failure at School, Work, or Competitive Events
Eating-disorder patients can be perfectionists with very
high achievement expectations. If their self-esteem is
disproportionately tied to being successful then any failure
can produce devastating feelings of shame, guilt, or
self-worthlessness. For these individuals, losing weight can
be seen as the first step to improving themselves. Binge
eating and purging can serve the purpose of proving their
worthlessness or it can provide an escape from these
feelings.
Traumatic Event
Evidence continues to accumulate that between one-third and
two-thirds of patients who present at treatment centers for
eating disorders have histories of sexual or physical abuse.
It appears, however, that the prevalence of sexual abuse in
eating disorders is about the same as that for other
psychiatric disorders.
There is, however, a subgroup of patients whose
eating-disordered symptoms are a direct consequence of, or
an attempt to cope with, their sexual or physical abuse.
Such individuals may try to consciously or unconsciously
avoid further sexual attention by losing enough weight to
lose their secondary sexual characteristics (e.g. breasts).
Similarly, the consistency or type of some foods can
directly trigger flashbacks of abuse, resulting in an
individual avoiding certain foods altogether.
Major illness or injury can also result in an individual
feeling extremely vulnerable or out of control. Anorexia and
Bulimia can be attempts to control or distract themselves
from the trauma.
Biological Vulnerability to other Psychiatric
Illnesses
We have also learned that some individuals develop an eating
disorder in response to other psychiatric symptoms that
develop before the onset of the eating-related problems. The
onset of these other psychiatric symptoms appear to be
triggered biologically and may or may not be related to
events that were occurring in the individual's environment.
Between one-third and one-half of eating-disorders patients
report struggling with significant depression or anxiety
prior to the onset of their eating disorder. These episodes
of depression and/or anxiety appear to be severe enough that
the individual felt extremely out of control and fearful
that they were falling apart. Once again, restrictive
eating, excessive exercise, and/or binge/purge behavior can
be attempts to contain or manage the depression and
anxiety.
Furthermore, approximately one-third of eating-disorder
patients report struggling with obsessive-compulsive
symptoms before they developed their eating disorder. For
these individuals the obsessional fear of fat and compulsive
behaviors to control this fear are simply the outward
symptoms of the more central problem of obsessive-compulsive
disorder.
These are just some of the reasons people develop eating
disorders. It is important to reiterate that while many
individuals with eating disorders think and act in very
similar ways, the reasons they have developed these thoughts
and actions can be quite different.
Who Is Most at Risk for Developing an Eating Disorder?
The following are the most common risk factors that have
been identified:
-
Adolescent or young adult females from a
middle-to-upper-socioeconomic group in westernized
cultures.
-
Working or aspiring to work in a field that places high
emphasis on thinness, such as acting, modeling, ballet.
or gymnastics.
-
Previous history of being overweight or teased about
weight that results in dieting behavior.
-
Family history of eating disorders, weight
consciousness, alcoholism, depression or
obsessive-compulsive disorder.
-
Low self-esteem, high achievement expectations,
perfectionism, social insecurity and difficulty
identifying and expressing feelings.
-
Personality characteristics of an anorectic individual
may include being overly cautious, fearful of change,
hypersensitive and orderly.
-
Personality characteristics of a bulimic may include
being impulsive, disorganized, a risk-taker, easily
bored and having a preference for novel situations.
-
Families that lean too much in the direction of being
either over-protective and controlling, or too
disengaged and uninvolved.
-
History of physical, sexual or significant relational
trauma.
-
Large discrepancy between how an individual presents
themselves to others and how they actually feel about
themselves.
-
Difficulty identifying and/or verbalizing feelings,
particularly anger.
What Are the Long-Term Medical and Emotional
Consequences of these Disorders?
The longer these illnesses persist, the greater the
impairment to the individual's ability to work, love, and
play. The course of these illnesses is very similar to other
psychiatric difficulties such as drug and alcohol abuse,
depression, anxiety, phobia, and obsessive-compulsive
disorder. The illnesses dramatically interfere with being
able to consistently work or go to school. They ruin
relationships and make it very difficult to experience
pleasure in life.
In addition to being emotionally devastating, the illnesses
can create serious medical problems. Adolescence is a time
of rapid growth and development. The average weight gain for
girls between the ages of 11 and 14 is 40 pounds.
Approximately 90 percent of adult bone mass will be
established during adolescence. Osteoporosis ("porous bones"
that break easily) can begin early in both girls and boys
who are dieting or suffering from Anorexia nervosa. An
extended period of semi-starvation stunts growth, can delay
the onset of menstruation, and can damage vital organs such
as the heart and brain. Listed below are some of the most
common medical problems.
Medical Consequences of Anorexia Nervosa:
-
Starvation deprives the body of protein and prevents the
normal metabolism of fat. In an effort to protect
itself, the body slows down.
-
The heart muscle changes and its beat becomes irregular.
The ultimate result can be heart failure that results in
death.
-
Menstruation often stops, even before extensive weight
loss. This is called amenorrhea.
-
Dehydration, kidney stones and kidney failure may
result.
-
A fine body hair, called lanugo, develops on the arms
and can even cover the face.
-
Muscles atrophy or waste away, resulting in weakness and
lost muscle function.
-
Delayed gastric emptying caused by a lack of energy and
slowed body function results in bowel irritation and
constipation.
-
Loss of bone calcium leads to osteoporosis.
Medical Consequences of Bulimia Nervosa:
-
Vomiting, laxatives and diuretics flush sodium and
potassium from the body resulting in an electrolyte
imbalance. Arrhythmia (irregular heartbeat) can result,
which can ultimately lead to heart failure and death.
-
The stomach acids in vomit can erode tooth enamel,
resulting in damage such as cavities and discoloration.
-
Self-induced vomiting can result in irritation and tears
in the lining of the throat, esophagus and stomach.
-
Laxative abuse can create dependency and result in an
inability to have normal bowel movements.
-
Abuse of emetics to induce vomiting can result in
toxicity, heart failure and death.
Medical Consequences of Binge-Eating Disorder:
-
High blood pressure, elevated cholesterol levels, and
elevated triglyceride levels cause hardening of the
arteries, heart disease and heart attacks.
-
Over-eating simple carbohydrates—sweets and junk
food—places stress on the pancreas. At first there
is an abnormally low amount of glucose in the blood.
Later in life, secondary diabetes can result.
What Is the Treatment for Eating Disorders?
Tragically, eating disorders are quite lethal. The death
rate is about 12 times higher than for other women of
similar ages. One in ten will die from the illness. Anorexia
nervosa ranks as the third most common chronic illness among
adolescent females in the United States.
There is hope and help for eating disorders. Early
intervention is the key. A team of professionals,
specifically trained in eating disorders, will be able to
evaluate and set up an individualized treatment plan. This
should include a comprehensive multi-dimensional assessment
and a coordinated care plan.
Comprehensive Multi-Dimensional Assessment
A comprehensive, multi-dimensional assessment will include a
full physical exam and laboratory studies to determine the
patient's physical status and risk of death. The assessment
should also include a meeting with a nutritionist to help
re-establish a safe diet plan and provide ongoing
nutritional counseling.
In addition, the assessment should include a complete mental
health evaluation. This psychiatric evaluation should
include a review of the patient's symptoms, current life
situation, treatment history, personal and family history,
and a thorough examination of the patient's thoughts,
feelings and behaviors. The mental health evaluation is
extremely important because a proper diagnosis is essential.
Research shows that nearly 50% of individuals with eating
disorders suffer from at least one other psychiatric
disorder. It is important that these co-occurring disorders
be identified and treated.
Coordinated Care Plan
After the assessment, a coordinated Care Plan will be
established. A team of experienced eating disorders
professionals will work together to assist the patient in
recovery. Treatment is tailored to the individual and may
include an internist, nutritionist, individual or group
therapist, psycho-pharmacologist, and family therapist.
Treatment interventions are first aimed at nutritional
rehabilitation and the restoration of normal eating patterns
to correct the biological and psychological effects of
malnutrition. The long-term goals are to diagnose and help
resolve the associated psychological, family, social and
behavioral problems so that relapse does not occur.
Psychotherapy
There are many types of psychotherapy or "talking therapy"
used in the treatment of eating disorders. We can only touch
on a few here. Two types of psychotherapy, cognitive
behavioral therapy, and interpersonal therapy are now
proving to be very effective in the treatment of eating
disorders. Cognitive behavioral therapy is designed to help
the patient gain control of unhealthy eating behaviors and
to alter the distorted and rigid thinking that perpetuates
the syndrome. The treatment uses a combination of behavioral
and cognitive procedures to change the patient's behavior,
their attitudes about shape and weight, and where relevant,
other cognitive distortions such as low self-esteem and
extreme perfectionism. In interpersonal therapy, the focus
is on the patient's current circumstances and relationships.
The initial sessions are typically devoted to a detailed
analysis of the interpersonal context in which the eating
disorder has developed and been maintained.
These types of therapy can take place in individual, family,
or group sessions and it is likely that a combination of the
three will be recommended. The goals of individual
psychotherapy are to help the patient regain physical
health, reduce symptoms, increase self-esteem and proceed
with personal and social development. Family therapy
attempts to establish more appropriate eating patterns,
facilitate communication and permit family members to feel
more connected to one another. Group therapy allows the
patient to feel less alone with his or her symptoms, to get
feedback from his or her peers, and to enhance social
skills.
Typically, therapy takes place on an outpatient basis.
However, hospitalization may be necessary when an eating
disorder has led to physical problems that may be
life-threatening or when associated with severe emotional
distress.
Medication
In addition to therapy, medication may be helpful in the
treatment of eating disorders. Patients with severe eating
disorders appear to have abnormalities in brain
neurotransmitter systems, as do patients with depressive
disorder, obsessive-compulsive disorders, and anxiety
disorders. Because these illnesses are thought to have
biological roots, they respond well to medications that work
by affecting brain chemistry.
Although the use of medication is more common for patients
with Bulimia than with Anorexia, there is evidence that some
medications do assist with recovery in both illnesses.
Anti-depressants are helpful for patients with significant
symptoms of depression, anxiety, or obsessions. They may
also have a specific role in reducing the binge purge cycle
in Bulimia nervosa. In Anorexia nervosa, use of medication
is usually best assessed following weight gain, when the
psychological effects of starvation are resolving, although
some anti-depressants appear to help stabilize weight
recovery. In addition to anti-depressants, a variety of
other psychotropic agents are sometimes used.
Medication is generally used in conjunction with
psychotherapy and a coordinated treatment plan. Before
medication is prescribed, a psychiatrist or family physician
will discuss any co-existing medical problems, review
current medications being taken, and assess the patient's
physical health in order to ensure proper dosage and
minimize potential negative interactions or side effects.
Several medication trials are sometimes necessary to
establish the proper dosage. It is important for the patient
to continue seeing a psychiatrist or family physician to
monitor these medications.
Whether with therapy, medication, or a combination of both,
eating disorders can be successfully treated. Seventy to 80
percent of people respond to treatment. Relapses can occur,
but the sooner treatment begins, the better the chances for
recovery and a return to a healthy life.
How Do You Help Someone You Suspect Might Have an
Eating Disorder?
If you are concerned about your friend, don't keep your
suspicions to yourself. Being healthy means accepting and
nourishing your body. Someone who is not eating, or is
eating too much, may need help. In a calm and caring way,
tell your friend what you saw or heard. Use "I" statements
and let your friend know that you are concerned. Here are
some suggestions:
"I'm worried about you because you haven't eaten lunch
this week."
"I heard you talking about taking laxatives...(or diet
pills) and that scares me."
"Are you OK? Were you vomiting after lunch? I am concerned
about you."
Listen carefully to what your friend says. Think about how
your friend might feel. Your friend might feel ashamed or
scared. Your friend may feel unimportant or think that
life doesn't matter. Feeling out of control is also
common. Not eating, or eating too much, may be your
friend's way of coping with problems at home or at school.
What if they get mad or deny it? It is very common for
people with problems to say that there is nothing wrong.
They might beg you not to tell. Or they may promise they
won't do it anymore. Your friend may get angry because of
fear, shame or other strong emotions.
What your friend is doing is scary and unhealthy. Tell your
friend that you care and that you want her or him to get
help. Encourage your friend to talk to a grown-up. Say you
would be willing to go along to provide support.
Tell your friend that you want to help and don't want to
keep your concern a secret. Your friend's health might be in
danger. You may decide to tell your friend that you want to
talk to a grown-up about it.
Being worried about your friend and wanting to help is a
good thing. Consider telling your parents or your friend's
parents, a teacher, or the school nurse or counselor, what
you know. Tell someone who will understand and can get help
for your friend. It is not "tattling" or "ratting" on your
friend if you are worried about her or his health.
Here are some suggestions of what to say:
"I'm worried about ______ because I saw her (him) throw up
on purpose/take a laxative/talk about taking diet
pills/throw away her (his) lunch."
"I'm concerned about ______ because she (he) always
complains about being too fat/seems so sad/says she (he)
never can do anything right."
Knowing what your friend is doing and telling someone about
it might be stressful for you. You might decide to talk to
someone, such as a counselor, about your experience with
trying to help your friend. You are doing the right thing.
Others will be glad to know and want to help you as well.
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