Eating Disorders

People with an eating disorder feel compelled to repeat certain behaviors, such as overeating or eating too little. For this reason, eating disorders are placed in the category "behavioral disorder." Like substance abuse, another behavioral disorder, eating disorders can be very difficult to interrupt since the problem lies in what the individual does—her or his behavior and its consequences. These compelling behaviors gradually come to dominate the affected sufferers' lives, often disturbing the functioning of their bodies, their minds, and their everyday social lives. People with behavioral disorders sometimes also have other compulsions . For example, they may be unable to control the impulse to spend money (compulsive spending) or to gamble (compulsive gambling).

The eating disorders discussed below include anorexia nervosa, bulimia nervosa, and binge eating disorder. Compulsive eating can be a symptom of anorexia nervosa, bulimia, or binge eating, but it is not considered a separate disorder.

Anorexia Nervosa

Anorexia nervosa is a potentially life-threatening syndrome of self- starvation. The Greek term anorexia means "loss of appetite." This is actually an inappropriate name for the condition. Individuals with anorexia nervosa are starved and think constantly and obsessively about food. They refuse to eat not because they have lost their appetite but because they have an irrational fear of being fat.

Anorexia nervosa affects from 0.5 to 1 percent of female adolescents and young women and occasionally occurs in males. In extreme cases, girls and women can undergo weight loss to less than 60 percent of normal weight. At these very low weights, individuals usually admit that they are too thin, yet they still feel as though some part of their body, typically their stomach or thighs, remains fat. Alternatively, they describe being unable to eat normally because they fear that they will lose control, go on an eating binge , and become overweight.

Anorectic behavior includes dieting by skipping meals or severely limiting the amount of fat consumed. Eating behavior may include rituals, such as eating only certain foods and preparing foods in complicated ways. It is also common for anorexics to exercise excessively with the goal of burning calories. Individuals who lose weight solely by extreme dieting and exercising have the restricting type of anorexia nervosa.

Some people with anorexia nervosa occasionally lose control of their rigid eating pattern and binge on the high-fat, high-calorie foods they have forbidden themselves to eat. After the binge, they may purge by making themselves vomit, or by taking higher than recommended doses of laxatives , diuretics , or diet pills. Individuals who binge and/or purge in addition to dieting and exercise to lose weight have the binge/purge type of anorexia nervosa.

Bulimia Nervosa

The Greek word bulimia means "hunger of an ox." People with bulimia try to prevent weight gain through a cycle of dieting, binge eating, and purging behavior. In bulimia, binge eating occurs at least twice a week for three months or more. As with anorexia nervosa, bulimia nervosa mostly affects young women, although 10 percent of cases occur in men. While 1 to 3 percent of young women and adolescents have the full syndrome of bulimia nervosa, as many as 20 percent of college-age women experiment with bulimic behaviors and experience a limited range of symptoms.

Bulimics, like anorexics, place extreme value on thinness. The main difference between the two diagnoses is one of weight. Anorexics have starved themselves to a low body weight, while bulimics are at least normal weight. Underweight patients who binge and purge are usually diagnosed with the binge/purge type of anorexia nervosa rather than with bulimia. But the dividing line between anorexia nervosa and bulimia is not always clear. It is common for an eating disorder to start as anorexia nervosa and progress to bulimia over time, since dieting is the biggest risk factor that contributes to binge eating.

As with anorexia nervosa, there are two types of bulimia: (1) purging type and (2) nonpurging type. In purging-type bulimia, individuals use some kind of purging behavior after a binge to get rid of the extra calories they have consumed. The most common method of purging is by self-induced vomiting, although some bulimics may abuse laxatives, diuretics, or diet pills. In nonpurging bulimia, individuals go through episodes of binge eating alternating with episodes of restricting their diet, fasting, or excessive exercise routines.

Medical Complications

Anorexia nervosa has the highest death rate of any psychiatric condition. Occasionally, bulimia nervosa can also result in life-threatening complications. Both disorders seriously damage the body, and most medical complications are the result of starvation or purging behaviors. Individuals with purging-type anorexia nervosa are at highest risk, since they are both starved and regular purgers. Complications of starvation include:

• slow heart rate (bradycardia)
• low blood pressure and fainting or dizzy spells
• intolerance to cold
• thinning hair
• constipation
• weakness and fatigue
• loss of a monthly menstrual period (amenorrhea)

Amenorrhea causes rapid bone loss and thinning of the bones, or osteoporosis. This process cannot be reversed, and may lead to hip and spinal fractures. Purging by vomiting often results in tooth decay, a swelling of the salivary glands in the cheeks that distorts the person's face, and a risk of ulcers in the esophagus. The most dangerous risk of regular vomiting is developing electrolyte imbalances. Electrolytes are salts in the blood, such as potassium, that are necessary for the heart to function properly. Changes in electrolyte levels can result in fatally abnormal heart rhythms. Laxative abuse can cause similar electrolyte abnormalities as well as laxative dependence and dehydration . In extreme cases, kidney failure can follow severe laxative or diuretic abuse.

Psychiatric Problems and Eating Disorders

Individuals with eating disorders are more likely than the rest of the population to have a second, simultaneous psychiatric problem. The most common illness that goes along with eating disorders is a mood disorder, such as depression or anxiety . Studies have found that 50 percent or more of patients with anorexia nervosa or bulimia also have depression. However, starvation alone causes a syndrome identical to major depression. As a result, it is often difficult to determine whether a patient has depression in addition to anorexia nervosa, or depressive symptoms caused by the starved state that accompanies anorexia nervosa. If the patient has a close relative with depression, it is more likely that the patient has true depression.

Anorexics are also more likely to have obsessive-compulsive disorder than the rest of the population. In bulimia, as many as 30 percent of patients also have alcohol abuse problems. A small proportion of individuals with bulimia have other impulse-control problems such as substance abuse, compulsive spending or shoplifting, promiscuity , self-harm , and other risk-taking behaviors.

The Risk Factors for Eating Disorders

Rates of anorexia nervosa and bulimia are much higher in Western countries, such as the United States, than in developing countries, such as those in Africa and Asia. Young women in Western cultures are exposed to strong social pressures that encourage dieting and value thinness as an ideal of female beauty. For example, 90 percent of models photographed in young women's magazines have a body type that naturally occurs in only 10 percent of the female population.

Another factor that contributes to eating disorders in the United States is the increasing average weight of Americans. Obesity has reached epidemic proportions as a result of a decrease in physical exercise and an increase in the availability of high-calorie, oversized, and cheap fast food. As the population grows heavier, dieting tends to be viewed as a normal, healthy activity, even though evidence suggests that dieting behaviors often backfire. Adolescent girls grow up dieting, yet many become overweight adults. This is thought to be because dieting increases the risk of future binge eating. The best way to prevent both obesity and eating problems is to exercise regularly and eat three normal-sized, balanced meals daily.

The pressure to be thin and actual widespread obesity contribute to the increasing rates of eating disorders in the United States. Yet these factors alone cannot explain the development of the full syndrome of bulimia or anorexia nervosa in only 3 to 4 percent of young women. Experts believe that other risk factors make some girls vulnerable to these disorders once they start dieting. Genes may play a role, since eating disorders run in families. Recent evidence indicates that individuals who develop bulimia nervosa have different levels of the neurotransmitter serotonin in their brains than do other individuals. Serotonin plays a role in both eating behaviors and moods. Certain personality traits are more common in individuals with eating disorders. These include: perfectionism, sensitivity to criticism, dis- liking change, and a tendency to be self-critical. Finally, in over 50 percent of cases a stressful life situation (such as the loss of a relationship, parental divorce, or a physical illness) occurred in the year before the eating disorder began.

Efforts at preventing eating disorders have focused on educating young people about the disorders and their dangers. Yet many young girls say that they first considered vomiting as a way to prevent weight gain after a health-class lecture or reading an educational article on bulimia. Many girls believe they can control this behavior, only to discover, often very rapidly, that they have lost control of it and feel a compulsive need to continue dieting and/or bingeing.

The Treatment of Eating Disorders

Both anorexia nervosa and bulimia can be treated. About 50 percent of individuals who receive treatment will eventually recover, although in many cases symptoms continue for years. The symptoms may fluctuate over time, often worsening when the person is under stress. As with all behavioral disorders, the first step in treatment is to block, or stop, the behavior. In the treatment of most kinds of substance abuse, the aim is to help the person stop using drugs, whereas in the treatment of eating disorders, the aim is to help the person reestablish a normal, nondieting eating pattern and to abstain from, or give up, the behaviors of the eating disorder.

For underweight patients, treatment goals include weight gain to counteract starvation, since starvation increases these patients' obsessive focus on food, eating rituals, and exercise. Very low-weight patients may require admission to a treatment program for eating disorders, where a team of professionals helps patients relearn healthy eating. Treatment includes behavioral therapy to help patients get over their fears of food, observation by nurses to make sure the patient is not purging, group and family therapy, and medication for other psychiatric disorders, such as depression, that a patient may have. Although sometimes used, forced tube feeding is not necessary for the treatment of anorexia nervosa in the presence of an expert behavioral program. Group therapy, led by an experienced therapist, can generate healthy peer pressure. Unfortunately, unsupervised self-help groups such as those available on the Internet may be dangerous. These groups create an atmosphere in which patients compete in telling "war stories" of their eating disorders and can actually worsen symptoms.

Treatment for bulimia nervosa usually begins with cognitive- behavioral therapy as an outpatient . Cognitive-behavioral therapy includes keeping a food log, identifying situations that trigger bulimic behavior, and challenging irrational thoughts that sustain these behaviors. The therapist helps the patient develop healthier eating behaviors, avoid trigger situations, and correct irrational thinking. Patients learn to eat all foods in moderation and to have regular meals. Antidepressant medications can be helpful in decreasing urges to binge or vomit, but the combination of behavioral therapy and medication is more effective than medication alone.

Most patients want to know why they developed an eating disorder. However, it is important to realize that exploring the reasons behind the disorder does not lead to recovery from that disorder. An eating disorder is like other addictions: Once a person has it, it takes on a life of its own. Knowing what led to the eating disorder does not help the individual stop dieting or bingeing.

Binge Eating Disorder

Binge eating disorder affects about 2 percent of adults in the United States and is slightly more common in women than in men. A person with this disorder binges frequently and feels out of control and distressed over the amount he or she has eaten. However, unlike bulimia nervosa, binge eaters do not purge. Other possible symptoms include eating rapidly, eating till uncomfortably full, eating large amounts when not hungry, feeling embarrassed about the quantity of food consumed, and feeling disgusted or guilty about bingeing. Most people with binge eating disorder are obese, that is, more than 20 percent above normal weight. Depression is more common in binge eaters than in obese individuals who do not binge. The main complications of binge eating are those of obesity, including diabetes, high blood pressure, heart disease, and arthritis. As with bulimia, strict dieting may worsen binge eating. Treatment consists of cognitive- behavioral therapy aimed at stopping all bingeing behavior, increasing exercise, and returning to normal eating patterns, rather than immediate weight loss.

Eating Disorders, Substance Abuse, and the Brain

The study of substance abuse has revealed that drugs of abuse, such as cocaine or amphetamines, increase levels of dopamine, a neurotransmitter , in brain areas known as the reward circuit (such as the nucleus accumbens). Higher levels of dopamine may lead to drug tolerance, meaning that a person needs increasing doses of a drug to produce the same effect achieved from the initial dose, and drug dependence, when a person can no longer function normally without the drug.

Recent research into eating disorders indicates that food may act on brain reward systems in the same way that drugs of abuse do. For example, in one research studies monkeys deprived of food increased their intake of any drug of abuse. This suggests that the rewarding effects of food and drugs of abuse operate in similar ways in the brain, involving the reward pathway and neurotransmitters such as dopamine. Changes in these brain systems may predispose a person to an eating disorder, or contribute to it once it has begun.

Results of another recent study suggest that overeating may increase dopamine levels in the brain, leading to a decrease in the number of dopamine receptors . This change may contribute to increased cravings for food in obese individuals. Current research is studying whether weight loss corrects these changes in dopamine receptor numbers.

Conclusion

Occasionally an eating disorder may not fit neatly into one of the diagnostic categories discussed here and yet may seriously affect an individual's well-being. These atypical eating disorders may be quite severe and require treatment. Anorexia nervosa, bulimia nervosa, and other eating disorders are behavioral disorders that become consuming passions interfering with normal functioning. Treatment is necessary to help the person recover from the disorder and learn how to lead a normal, healthy life free of these harmful behaviors.

see also Addiction: Concepts and Definitions; Gender and Substance Abuse; Risk Factors for Substance Abuse; Research.

RECOVERING FROM ANOREXIA

One day I was walking to the mail box in front of my house and I passed out. I woke up in the hospital and that's when the doctor told me that I was too thin. Too thin! I couldn t believe what he was telling me. Did everyone want me to be fat?

I was so angry that I had to gain weight. . . . I was required to eat 6 times a day. I had only stayed in the hospital for about 8 days when I was released. I still had to go to the hospital every morning and they monitored my weight.

I joined group therapy, because my doctor told me that it would be helpful. It was very difficult at first, trying to find the motivation to go, but once I started to connect with the other people in the group, I was starting to feel like I was a part of something. I was no longer alone.

Renee, 19-year-old recovering anorexic

FICTION SPEAKS VOLUMES

Isabelle Holland, in her novel, Heads You Win, Tails I Lose (1982), describes Melissa's battle with her body image, which leads her to take diet pills in the hopes that she will become thin, popular, and loved.