Eating Disorders
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Eating is controlled by many factors, including
appetite, food availability, family, peer, and cultural
practices, and attempts at voluntary control. Dieting to a
body weight leaner than needed for health is highly promoted
by current fashion trends, sales campaigns for special foods,
and in some activities and professions. Eating
disorders involve serious disturbances in eating behavior,
such as extreme and unhealthy reduction of food intake or
severe overeating, as well as feelings of distress or extreme
concern about body shape or weight. Researchers are
investigating how and why initially voluntary behaviors, such
as eating smaller or larger amounts of food than usual, at
some point move beyond control in some people and develop into
an eating disorder. Studies on the basic biology of appetite
control and its alteration by prolonged overeating or
starvation have uncovered enormous complexity, but in the long
run have the potential to lead to new pharmacologic treatments
for eating disorders.
Eating disorders are not due to a failure of will or
behavior; rather, they are real, treatable medical illnesses
in which certain maladaptive patterns of eating take on a life
of their own. The main types of eating disorders are anorexia
nervosa and bulimia nervosa.
A third type, binge-eating disorder, has been suggested but
has not yet been approved as a formal psychiatric
diagnosis.
Eating disorders frequently develop during adolescence or
early adulthood, but some reports indicate their onset can
occur during childhood or later in adulthood.
Eating disorders frequently co-occur with other psychiatric
disorders such as depression,
substance abuse, and anxiety
disorders.
In addition, people who suffer from eating disorders can
experience a wide range of physical health complications,
including serious heart conditions and kidney failure which
may lead to death. Recognition of eating disorders as real and
treatable diseases, therefore, is critically important.
Females are much more likely than males to develop an
eating disorder. Only an estimated 5 to 15 percent of people
with anorexia or bulimia
and an estimated 35 percent of those with binge-eating
disorder
are male.
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An estimated 0.5 to 3.7 percent of females suffer from
anorexia nervosa in their lifetime.
Symptoms of anorexia nervosa include:
- Resistance to maintaining body weight at or above a
minimally normal weight for age and height
- Intense fear of gaining weight or becoming fat, even
though 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
- Infrequent or absent menstrual periods (in females who
have reached puberty)
People with this disorder see themselves as overweight even
though they are dangerously thin. The process of eating
becomes an obsession. Unusual eating habits develop, such as
avoiding food and meals, picking out a few foods and eating
these in small quantities, or carefully weighing and
portioning food. People with anorexia may repeatedly check
their body weight, and many engage in other techniques to
control their weight, such as intense and compulsive exercise,
or purging by means of vomiting and abuse of laxatives,
enemas, and diuretics. Girls with anorexia often experience a
delayed onset of their first menstrual period.
The course and outcome of anorexia nervosa vary across
individuals: some fully recover after a single episode; some
have a fluctuating pattern of weight gain and relapse; and
others experience a chronically deteriorating course of
illness over many years. The mortality rate among people with
anorexia has been estimated at 0.56 percent per year, or
approximately 5.6 percent per decade, which is about 12 times
higher than the annual death rate due to all causes of death
among females ages 15-24 in the general population.
The most common causes of death are complications of the
disorder, such as cardiac arrest or electrolyte imbalance, and
suicide.
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An estimated 1.1 percent to 4.2 percent of females have
bulimia nervosa in their lifetime.
Symptoms of bulimia nervosa include:
- Recurrent episodes of binge eating, characterized by
eating an excessive amount of food within a discrete period
of time and by a sense of lack of control over eating during
the episode
- Recurrent inappropriate compensatory behavior in order
to prevent weight gain, such as self-induced vomiting or
misuse of laxatives, diuretics, enemas, or other medications
(purging); fasting; or excessive exercise
- The binge eating and inappropriate compensatory
behaviors both occur, on average, at least twice a week for
3 months
- Self-evaluation is unduly influenced by body shape and
weight
Because purging or other compensatory behavior follows the
binge-eating episodes, people with bulimia usually weigh
within the normal range for their age and height. However,
like individuals with anorexia, they may fear gaining weight,
desire to lose weight, and feel intensely dissatisfied with
their bodies. People with bulimia often perform the behaviors
in secrecy, feeling disgusted and ashamed when they binge, yet
relieved once they purge.
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Community surveys have estimated that between 2 percent and
5 percent of Americans experience binge-eating disorder in a
6-month period.
Symptoms of binge-eating disorder include:
- Recurrent episodes of binge eating, characterized by
eating an excessive amount of food within a discrete period
of time and by a sense of lack of control over eating during
the episode
- The binge-eating episodes are associated with at least 3
of the following: eating much more rapidly than normal;
eating until feeling uncomfortably full; eating large
amounts of food when not feeling physically hungry; eating
alone because of being embarrassed by how much one is
eating; feeling disgusted with oneself, depressed, or very
guilty after overeating
- Marked distress about the binge-eating behavior
- The binge eating occurs, on average, at least 2 days a
week for 6 months
- The binge eating is not associated with the regular use
of inappropriate compensatory behaviors (e.g., purging,
fasting, excessive exercise)
People with binge-eating disorder experience frequent
episodes of out-of-control eating, with the same binge-eating
symptoms as those with bulimia. The main difference is that
individuals with binge-eating disorder do not purge their
bodies of excess calories. Therefore, many with the disorder
are overweight for their age and height. Feelings of
self-disgust and shame associated with this illness can lead
to bingeing again, creating a cycle of binge eating.
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Eating disorders can be treated and a healthy weight
restored. The sooner these disorders are diagnosed and
treated, the better the outcomes are likely to be. Because of
their complexity, eating disorders require a comprehensive
treatment plan involving medical care and monitoring,
psychosocial interventions, nutritional counseling and, when
appropriate, medication management. At the time of diagnosis,
the clinician must determine whether the person is in
immediate danger and requires hospitalization.
Treatment of anorexia calls for a specific program that
involves three main phases: (1) restoring weight lost to
severe dieting and purging; (2) treating psychological
disturbances such as distortion of body image, low
self-esteem, and interpersonal conflicts; and (3) achieving
long-term remission and rehabilitation, or full recovery.
Early diagnosis and treatment increases the treatment success
rate. Use of psychotropic medication in people with anorexia
should be considered only after weight gain has been
established. Certain selective serotonin reuptake inhibitors
(SSRIs) have been shown to be helpful for weight maintenance
and for resolving mood and anxiety symptoms associated with
anorexia.
The acute management of severe weight loss is usually
provided in an inpatient hospital setting, where feeding plans
address the person's medical and nutritional needs. In some
cases, intravenous feeding is recommended. Once malnutrition
has been corrected and weight gain has begun, psychotherapy
(often cognitive-behavioral or interpersonal psychotherapy)
can help people with anorexia overcome low self-esteem and
address distorted thought and behavior patterns. Families are
sometimes included in the therapeutic process.
The primary goal of treatment for bulimia is to reduce or
eliminate binge eating and purging behavior. To this end,
nutritional rehabilitation, psychosocial intervention, and
medication management strategies are often employed.
Establishment of a pattern of regular, non-binge meals,
improvement of attitudes related to the eating disorder,
encouragement of healthy but not excessive exercise, and
resolution of co-occurring conditions such as mood or anxiety
disorders are among the specific aims of these strategies.
Individual psychotherapy (especially cognitive-behavioral or
interpersonal psychotherapy), group psychotherapy that uses a
cognitive-behavioral approach, and family or marital therapy
have been reported to be effective. Psychotropic medications,
primarily antidepressants such as the selective serotonin
reuptake inhibitors (SSRIs), have been found helpful for
people with bulimia, particularly those with significant
symptoms of depression or anxiety, or those who have not
responded adequately to psychosocial treatment alone. These
medications also may help prevent relapse. The treatment goals
and strategies for binge-eating disorder are similar to those
for bulimia, and studies are currently evaluating the
effectiveness of various interventions.
People with eating disorders often do not recognize or
admit that they are ill. As a result, they may strongly resist
getting and staying in treatment. Family members or other
trusted individuals can be helpful in ensuring that the person
with an eating disorder receives needed care and
rehabilitation. For some people, treatment may be long
term.
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Anorexia
