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(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.

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.

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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