INTRODUCTION:
Eating Disorders
Eating disorders are life-threatening mental illnesses characterized by an obsession with food and weight. Anorexia, bulimia, binge eating disorder and related eating disorders are more common in women than men and typically start in adolescence, though their effects can be seen across all ages, races and genders.
Genetics and emotional and psychological issues are at the root of many eating disorders. In addition, our society’s thirst for thinness and unrealistic ideals of beauty, which are communicated in various forms of media, lead many to develop low self-esteem and a negative body image.
Eating disorders are so common in America that 1 or 2 out of every 100 students will struggle with one. Each year, thousands of teens develop eating disorders, or problems with weight, eating, or body image.
Eating disorders are more than just going on a diet to lose weight or trying to exercise every day. They're extremes in eating behavior — the diet that never ends and gradually gets more restrictive, for example. Or the person who can't go out with friends because he or she thinks it's more important to go running to work off a snack eaten earlier.
The most common eating disorders are
anorexia nervosa and
bulimia nervosa (usually called simply "anorexia" and "bulimia"). But other food-related disorders, like binge eating, body image disorders, and food phobias, are becoming more and more common.
Anorexia
People with anorexia have a real fear of weight gain and a distorted view of their body size and shape. As a result, they can't maintain a normal body weight. Many teens with anorexia restrict their food intake by dieting, fasting, or excessive exercise. They hardly eat at all — and the small amount of food they do eat becomes an obsession.
Others with anorexia may start binge eating and purging — eating a lot of food and then trying to get rid of the calories by forcing themselves to vomit, using laxatives, or exercising excessively, or some combination of these.
Bulimia
Bulimia is similar to anorexia. With bulimia, someone might binge eat (eat to excess) and then try to compensate in extreme ways, such as forced vomiting or excessive exercise, to prevent weight gain. Over time, these steps can be dangerous — both physically and emotionally. They can also lead to compulsive behaviors (ones that are hard to stop).
To be diagnosed with bulimia, a person must be binging and purging regularly, at least twice a week for a couple of months. Binge eating is different from going to a party and "pigging out" on pizza, then deciding to go to the gym the next day and eat more healthfully.
People with bulimia eat a large amount of food (often junk food) at once, usually in secret. Sometimes they eat food that is not cooked or might be still frozen, or retrieve food from the trash. They typically feel powerless to stop the eating and can only stop once they're too full to eat any more. Most people with bulimia then purge by vomiting, but may also use laxatives or excessive exercise.
What Are Eating Disorders?
An eating disorder is marked by extremes. It is present when a person experiences severe disturbances in eating behavior, such as extreme reduction of food intake or extreme overeating, or feelings of extreme distress or concern about body weight or shape.
A person with an eating disorder may have started out just eating smaller or larger amounts of food than usual, but at some point, the urge to eat less or more spirals out of control. Eating disorders are very complex, and despite scientific research to understand them, the biological, behavioral and social underpinnings of these illnesses remain elusive.
The two main types of eating disorders are anorexia nervosa and bulimia nervosa. A third category is "eating disorders not otherwise specified (EDNOS)," which includes several variations of eating disorders. Most of these disorders are similar to anorexia or bulimia but with slightly different characteristics. Binge-eating disorder, which has received increasing research and media attention in recent years, is one type of EDNOS.
Eating disorders frequently appear during adolescence or young adulthood, but some reports indicate that they can develop during childhood or later in adulthood. Women and girls are much more likely than males to develop an eating disorder. Men and boys account for an estimated 5 to 15 percent of patients with anorexia or bulimia and an estimated 35 percent of those with binge-eating disorder. Eating disorders are real, treatable medical illnesses with complex underlying psychological and biological causes. They frequently co-exist with other psychiatric disorders such as depression, substance abuse, or anxiety disorders. People with eating disorders also can suffer from numerous other physical health complications, such as heart conditions or kidney failure, which can lead to death.
Eating disorders are treatable diseases
Psychological and medicinal treatments are effective for many eating disorders. However, in more chronic cases, specific treatments have not yet been identified.
In these cases, treatment plans often are tailored to the patient's individual needs that may include medical care and monitoring; medications; nutritional counseling; and individual, group and/or family psychotherapy. Some patients may also need to be hospitalized to treat malnutrition or to gain weight, or for other reasons.
Anorexia Nervosa
Anorexia nervosa is characterized by emaciation, a relentless pursuit of thinness and unwillingness to maintain a normal or healthy weight, a distortion of body image and intense fear of gaining weight, a lack of menstruation among girls and women, and extremely disturbed eating behavior. Some people with anorexia lose weight by dieting and exercising excessively; others lose weight by self-induced vomiting, or misusing laxatives, diuretics or enemas.
Many people with anorexia see themselves as overweight, even when they are starved or are clearly malnourished. Eating, food and weight control become obsessions. A person with anorexia typically weighs herself or himself repeatedly, portions food carefully, and eats only very small quantities of only certain foods. Some who have anorexia recover with treatment after only one episode. Others get well but have relapses. Still others have a more chronic form of anorexia, in which their health deteriorates over many years as they battle the illness.
According to some studies, people with anorexia are up to ten times more likely to die as a result of their illness compared to those without the disorder. The most common complications that lead to death are cardiac arrest, and electrolyte and fluid imbalances. Suicide also can result.
Many people with anorexia also have coexisting psychiatric and physical illnesses, including depression, anxiety, obsessive behavior, substance abuse, cardiovascular and neurological complications, and impaired physical development.
Other symptoms may develop over time, including:
- thinning of the bones (osteopenia or osteoporosis)
- brittle hair and nails
- dry and yellowish skin
- growth of fine hair over body (e.g., lanugo)
- mild anemia, and muscle weakness and loss
- severe constipation
- low blood pressure, slowed breathing and pulse
- drop in internal body temperature, causing a person to feel cold all the time
- lethargy
TREATING ANOREXIA involves three components:
- restoring the person to a healthy weight;
- treating the psychological issues related to the eating disorder; and
- reducing or eliminating behaviors or thoughts that lead to disordered eating, and preventing relapse.
Some research suggests that the use of medications, such as antidepressants, antipsychotics or mood stabilizers, may be modestly effective in treating patients with anorexia by helping to resolve mood and anxiety symptoms that often co-exist with anorexia. Recent studies, however, have suggested that antidepressants may not be effective in preventing some patients with anorexia from relapsing. In addition, no medication has shown to be effective during the critical first phase of restoring a patient to healthy weight. Overall, it is unclear if and how medications can help patients conquer anorexia, but research is ongoing.
Different forms of psychotherapy, including individual, group and family-based, can help address the psychological reasons for the illness. Some studies suggest that family-based therapies in which parents assume responsibility for feeding their afflicted adolescent are the most effective in helping a person with anorexia gain weight and improve eating habits and moods.
Shown to be effective in case studies and clinical trials, this particular approach is discussed in some guidelines and studies for treating eating disorders in younger, nonchronic patients.
Others have noted that a combined approach of medical attention and supportive psychotherapy designed spe-cifically for anorexia patients is more effective than just psychotherapy. But the effectiveness of a treatment depends on the person involved and his or her situation. Unfortunately, no specific psychotherapy appears to be consistently effective for treating adults with anorexia. However, research into novel treatment and prevention approaches is showing some promise. One study suggests that an online intervention program may prevent some at-risk women from developing an eating disorder.
Bulimia Nervosa
Bulimia nervosa is characterized by recurrent and frequent episodes of eating unusually large amounts of food (e.g., binge-eating), and feeling a lack of control over the eating. This binge-eating is followed by a type of behavior that compensates for the binge, such as purging (e.g., vomiting, excessive use of laxatives or diuretics), fasting and/or excessive exercise.
Unlike anorexia, people with bulimia can fall within the normal range for their age and weight. But like people with anorexia, they often fear gaining weight, want desperately to lose weight, and are intensely unhappy with their body size and shape. Usually, bulimic behavior is done secretly, because it is often accompanied by feelings of disgust or shame. The binging and purging cycle usually repeats several times a week. Similar to anorexia, people with bulimia often have coexisting psychological illnesses, such as depression, anxiety and/or substance abuse problems. Many physical conditions result from the purging aspect of the illness, including electrolyte imbalances, gastrointestinal problems, and oral and tooth-related problems.
Other symptoms include:
- chronically inflamed and sore throat
- swollen glands in the neck and below the jaw
- worn tooth enamel and increasingly sensitive and decaying teeth as a result of exposure to stomach acids
- gastroesophageal reflux disorder
- intestinal distress and irritation from laxative abuse
- kidney problems from diuretic abuse
- severe dehydration from purging of fluids
As with anorexia, TREATMENT FOR BULIMIA often involves a combination of options and depends on the needs of the individual.
To reduce or eliminate binge and purge behavior, a patient may undergo nutritional counseling and psychotherapy, especially cognitive behavioral therapy (CBT), or be prescribed medication. Some antidepressants, such as fluoxetine (Prozac), which is the only medication approved by the U.S. Food and Drug Administration for treating bulimia, may help patients who also have depression and/or anxiety. It also appears to help reduce binge-eating and purging behavior, reduces the chance of relapse, and improves eating attitudes.
CBT that has been tailored to treat bulimia also has shown to be effective in changing binging and purging behavior, and eating attitudes. Therapy may be individually oriented or group-based.
Binge-Eating Disorder
Binge-eating disorder is characterized by recurrent binge-eating episodes during which a person feels a loss of control over his or her eating. Unlike bulimia, binge-eating episodes are not followed by purging, excessive exercise or fasting. As a result, people with binge-eating disorder often are overweight or obese. They also experience guilt, shame and/or distress about the binge-eating, which can lead to more binge-eating.
Obese people with binge-eating disorder often have coexisting psychological illnesses including anxiety, depression, and personality disorders. In addition, links between obesity and cardiovascular disease and hypertension are well documented.
TREATMENT OPTIONS FOR BINGE-EATING DISORDER
Are similar to those used to treat bulimia. Fluoxetine and other antidepressants may reduce binge-eating episodes and help alleviate depression in some patients.
Patients with binge-eating disorder also may be prescribed appetite suppressants. Psychotherapy, especially CBT, is also used to treat the underlying psychological issues associated with binge-eating, in an individual or group environment.
FDA Warnings On Antidepressants
Despite the relative safety and popularity of SSRIs and other antidepressants, some studies have suggested that they may have unintentional effects on some people, especially adolescents and young adults. In 2004, the Food and Drug Administration (FDA) conducted a thorough review of published and unpublished controlled clinical trials of antidepressants that involved nearly 4,400 children and adolescents. The review revealed that 4% of those taking antidepressants thought about or attempted suicide (although no suicides occurred), compared to 2% of those receiving placebos.
This information prompted the FDA, in 2005, to adopt a "black box" warning label on all antidepressant medications to alert the public about the potential increased risk of suicidal thinking or attempts in children and adolescents taking antidepressants. In 2007, the FDA proposed that makers of all antidepressant medications extend the warning to include young adults up through age 24. A "black box" warning is the most serious type of warning on prescription drug labeling.
The warning emphasizes that patients of all ages taking antidepressants should be closely monitored, especially during the initial weeks of treatment. Possible side effects to look for are worsening depression, suicidal thinking or behavior, or any unusual changes in behavior such as sleeplessness, agitation, or withdrawal from normal social situations. The warning adds that families and caregivers should also be told of the need for close monitoring and report any changes to the physician. The latest information from the FDA can be found on their Web site at www.fda.gov.
Results of a comprehensive review of pediatric trials conducted between 1988 and 2006 suggested that the benefits of antidepressant medications likely outweigh their risks to children and adolescents with major depression and anxiety disorders.
28 The study was funded in part by the National Institute of Mental Health.
How Are Men And Boys Affected?
Although eating disorders primarily affect women and girls, boys and men are also vulnerable. One in four preadolescent cases of anorexia occurs in boys, and binge-eating disorder affects females and males about equally.
Like females who have eating disorders, males with the illness have a warped sense of body image and often have muscle dysmorphia, a type of disorder that is characterized by an extreme concern with becoming more muscular. Some boys with the disorder want to lose weight, while others want to gain weight or "bulk up." Boys who think they are too small are at a greater risk for using steroids or other dangerous drugs to increase muscle mass.
Boys with eating disorders exhibit the same types of emotional, physical and behavioral signs and symptoms as girls, but for a variety of reasons, boys are less likely to be diagnosed with what is often considered a stereotypically "female" disorder.
How Are We Working To Better Understand And Treat Eating Disorders?
Researchers are unsure of the underlying causes and nature of eating disorders. Unlike a neurological disorder, which generally can be pinpointed to a specific lesion on the brain, an eating disorder likely involves abnormal activity distributed across brain systems. With increased recognition that mental disorders are brain disorders, more researchers are using tools from both modern neuroscience and modern psychology to better understand eating disorders.
One approach involves the study of the human genes. With the publication of the human genome sequence in 2003, mental health researchers are studying the various combinations of genes to determine if any DNA variations are associated with the risk of developing a mental disorder. Neuroimaging, such as the use of magnetic resonance imaging (MRI), may also lead to a better understanding of eating disorders.
Neuroimaging already is used to identify abnormal brain activity in patients with schizophrenia, obsessive-compulsive disorder and depression. It may also help researchers better understand how people with eating disorders process information, regardless of whether they have recovered or are still in the throes of their illness.
Conducting behavioral or psychological research on eating disorders is even more complex and challenging. As a result, few studies of treatments for eating disorders have been conducted in the past. New studies currently underway, however, are aiming to remedy the lack of information available about treatment.
Researchers also are working to define the basic processes of the disorders, which should help identify better treatments. For example, is anorexia the result of skewed body image, self esteem problems, obsessive thoughts, compulsive behavior, or a combination of these? Can it be predicted or identified as a risk factor before drastic weight loss occurs, and therefore avoided?
These and other questions may be answered in the future as scientists and doctors think of eating disorders as medical illnesses with certain biological causes. Researchers are studying behavioral questions, along with genetic and brain systems information, to understand risk factors, identify biological markers and develop medications that can target specific pathways that control eating behavior. Finally, neuroimaging and genetic studies may also provide clues for how each person may respond to specific treatments.
BE AWARE: A sufferer DOES NOT need to appear underweight or even "average" to suffer ANY of these signs and symptoms. Many men and women with Eating Disorders appear NOT to be underweight... it does not mean they suffer less or are in any less danger.
Anorexia/Bulimia
- Dramatic weight loss in a relatively short period of time.
- Wearing big or baggy clothes or dressing in layers to hide body shape and/or weight loss.
- Obsession with weight and complaining of weight problems (even if "average" weight or thin).
- Obsession with calories and fat content of foods.
- Obsession with continuous exercise.
- Frequent trips to the bathroom immediately following meals (sometimes accompanied with water running in the bathroom for a long period of time to hide the sound of vomiting).
- Visible food restriction and self-starvation.
- Visible bingeing and/or purging.
- Use or hiding use of diet pills, laxatives, ipecac syrup (can cause immediate death!) or enemas.
- Isolation. Fear of eating around and with others.
- Unusual Food rituals such as shifting the food around on the plate to look eaten; cutting food into tiny pieces; making sure the fork avoids contact with the lips (using teeth to scrap food off the fork or spoon); chewing food and spitting it out, but not swallowing; dropping food into napkin on lap to later throw away.
- Hiding food in strange places (closets, cabinets, suitcases, under the bed) to avoid eating (Anorexia) or to eat at a later time (Bulimia).
- Flushing uneaten food down the toilet (can cause sewage problems).
- Vague or secretive eating patterns.
- Keeping a "food diary" or lists that consists of food and/or behaviors (ie., purging, restricting, calories consumed, exercise, etc.)
- Pre-occupied thoughts of food, weight and cooking.
- Reading books about weight loss and eating disorders.
- Self-defeating statements after food consumption.
- Hair loss. Pale or "grey" appearance to the skin.
- Dizziness and headaches.
- Frequent soar throats and/or swollen glands.
- Low self-esteem. Feeling worthless. Often putting themselves down and complaining of being "too stupid" or "too fat" and saying they don't matter. Need for acceptance and approval from others.
- Complaints of often feeling cold.
- Low blood pressure.
- Loss of menstrual cycle.
- Constipation or incontinence.
- Bruised or calluses knuckles; bloodshot or bleeding in the eyes; light bruising under the eyes and on the cheeks.
- Perfectionistic personality.
- Loss of sexual desire or promiscuous relations.
- Mood swings. Depression. Fatigue.
- Insomnia. Poor sleeping habits
Compulsive Overeating/Binge Eating Disorder
- Fear of not being able to control eating, and while eating, not being able to stop.
- Isolation. Fear of eating around and with others.
- Chronic dieting on a variety of popular diet plans.
- Holding the belief that life will be better if they can lose weight.
- Hiding food in strange places (closets, cabinets, suitcases, under the bed) to eat at a later time.
- Vague or secretive eating patterns.
- Self-defeating statements after food consumption.
- Blames failure in social and professional community on weight.
- Holding the belief that food is their only friend.
- Frequently out of breath after relatively light activities.
- Excessive sweating and shortness of breath.
- High blood pressure and/or cholesterol.
- Leg and joint pain.
- Weight gain.
- Decreased mobility due to weight gain.
- Loss of sexual desire or promiscuous relations.
- Mood swings. Depression. Fatigue.
- Insomnia. Poor Sleeping Habits.
Treatments
Eating disorders can affect functioning in every system of the body, especially the heart and kidneys, and may cause lasting damage and even death. Because of the urgency of the risks associated with eating disorders, getting high-quality eating disorder treatment early on is the best way to combat the mental and physical consequences of these devastating mental illnesses.
Because eating disorders impact the whole person – mind, body and spirit – treatment must be comprehensive and individualized. The best eating disorder treatment programs combine medical care, individual, group and family therapy, nutrition education, and other interventions tailored to the specific needs of each individual.
Art Therapy Sometimes individuals with eating disorders have difficulty identifying or describing their thoughts and feelings. Art therapy allows people with eating disorders to express themselves in non-verbal ways, without the perceived pressure of one-on-one therapy. Art therapy can also be an outlet to explore body image and media messages, giving people with eating disorders a new perspective on their distorted self-image.
Art therapists use various materials and activities to appeal to patients' creative side, including:
- Paint
- Collage
- Sculpting
- Colored Markers/Pencils
- Pastels
- Mask-Making
The artwork patients create becomes a journal of their journey toward eating disorder recovery, which they can look back on and see their progress.
Cognitive-Behavioral Therapy
Cognitive-behavioral therapy (CBT) is widely used in counseling for eating disorders to change the way patients think about their bodies and their relationship with food. Unlike some forms of therapy that focus on the past, CBT is an active and practical approach for solving problems and changing self-defeating thought patterns. With new skills, patients are able to reduce eating disorder symptoms, recognize triggers and avoid relapse.
Culinary Therapy
Day-to-day life in recovery is likely going to involve preparing and eating meals, yet many patients feel uncomfortable in the kitchen or grocery store. In culinary therapy, patients may take cooking classes with a chef, plant crops in a garden, or go on grocery store and restaurant outings to help change their relationship with food. As patients begin to view food as a tool for achieving optimal health, they see mealtime as an opportunity rather than a threat.
Dialectical Behavior Therapy
One of the most effective therapies used to treat eating disorders is Dialectical Behavior Therapy, or DBT. This approach, originally developed by Marsha Linehan, Ph.D., is designed to teach patients new coping strategies to more effectively handle difficult emotions. Rather than turning to eating disorder behaviors, patients develop a set of life skills they can draw from for lasting recovery.
The four DBT skill sets are:
- Mindfulness – Staying present in the moment with a deep awareness of one’s thoughts, feelings and actions. Rather than judging a thought or feeling, mindfulness practice helps patients learn to accept whatever they are experiencing in a given moment. With greater awareness, patients are better able to regulate their thoughts and feelings and shift their attention in another direction when their thought pattern is becoming unproductive or unhealthy.
- Distress Tolerance – Learning to accept distress and other difficult emotions that are an inevitable part of life, rather than resorting to eating disorder behaviors. Part of distress tolerance is delaying gratification and avoiding impulsive behaviors, and finding healthier ways to cope such as self-soothing, distracting, and assessing pros and cons.
- Emotion Regulation – Identifying emotions and working to let go of painful feelings to make room for positive ones.
- Interpersonal Effectiveness – Improving interpersonal relationships by increasing assertiveness and communication skills. Some of the skills patients learn include asking for what they need, setting healthy boundaries, and coping with conflict effectively without hurting others or jeopardizing their self-respect.
Family Therapy
Eating disorders affect the entire family, causing frustration and concern and drawing attention away from siblings. Recovery isn’t an isolated event – it is a process that unfolds each day, in the presence of family and friends.
Studies show that family involvement is essential for successful eating disorder recovery, particularly for teens. In family therapy, patients have the opportunity to discuss underlying issues and conflicts with their family in the presence of an objective therapist.
The goals of family therapy are to:
- Educate family members about eating disorders and the recovery process
- Instill new conflict resolution skills and communication strategies
- Prepare family members for the patient’s return home (if applicable)
- Help family members learn how to support their loved one’s recovery
- Connect with other families to share stories and support (multi-family therapy)
- Ensure that family members have a support network of their own and a healthy sense of self
With guidance, families can take care of their own needs while offering support and encouragement for their loved one.
Group Therapy
Group therapy is a critical aspect of eating disorder treatment. For many people, hearing about the experiences of others and receiving honest feedback from people who are facing similar struggles is one of the most beneficial aspects of treatment.
In a safe, nurturing setting, patients share their pain and in doing so, realize that they are not alone. The camaraderie that develops in the group can build self-esteem and serve as a model for trusting, supportive relationships. The group setting is also a safe place to practice new communication skills and the art of acceptance of both self and others.
In group therapy, patients help one another identify and resolve problems with the guidance and expertise of a professional therapist. With a spirit of caring, they can question each other's distorted thoughts and destructive behaviors and facilitate the process of change. They also learn about nutrition, the process of recovery, relapse prevention, assertiveness techniques, coping skills and other important topics.
Individual Therapy
Although recovery happens while surrounded by family, friends and professionals, eating disorder treatment is essentially a journey of self-discovery. In individual therapy, patients have an opportunity to explore sensitive personal issues with feedback from a therapist. Common topics for discussion include childhood experiences, difficult emotions and relationship issues.
Depending on the patient's needs and preferences, therapists utilize a variety of approaches in individual therapy, including psychoanalysis, cognitive-behavioral therapy and an eclectic approach that combines a number of theories. Ultimately, one-on-one therapy creates an opportunity for healing by directly addressing the specific issues facing the individual patient.
Medical Care
Eating disorders exact a heavy toll on the body. The longer eating disorder behaviors take place, the more likely the patient is to experience serious, and sometimes life-threatening, health consequences.
Some of the medical complications that arise as a result of anorexia, bulimia and related eating disorders are:
- Heart Disease
- Depression
- Irregular Menstrual Periods
- Bone Loss
- Seizures
- Digestive Problems
- Kidney Damage
- Diabetes
- High or Low Blood Pressure
- Dental Damage
Movement Therapy
Some eating disorder treatment programs offer some form of movement therapy. While exercise can trigger or exacerbate eating disorder behaviors, movement therapy helps patients become more aware of their bodies and more comfortable in their own skin.
Some of the benefits of movement therapy include:
- A healthier body image and greater appreciation for one’s physical health
- A positive outlook brought on by the combination of movement and music
- Relaxation through breathing exercises
- Acceptance of self and others
Nutrition Therapy
Nutrition education and counseling is sometimes offered as part of a well-rounded eating disorder treatment program. Nutrition therapy is typically led by a registered dietitian who works with patients to normalize their food intake and develop a healthy relationship with food. The dietitian may begin with an assessment of the patient's eating patterns, weight, exercise habits, medical concerns and body image.
In a nutrition counseling session, patients may learn about:
- The different types of food, including carbohydrates, proteins and fats, and why the body needs foods from each category
- Portion sizes and eating a variety of foods in moderation
- The consequences of eating disorder behaviors
- Recognizing the body's hunger cues
- Creating balanced meal plans
- Eating in social settings
- Overcoming fears around certain foods
- Healthy exercise routines
- Nutritional supplements
Together, the dietitian and patient create achievable goals and begin working toward those goals with support, encouragement and understanding. Once the patient's basic nutritional needs are being met, they often find that they have more energy, sleep better, and feel happier and more grounded.
Psychiatric Care
Psychiatrists work with patients to assess, diagnose and treat eating disorders. Other mental health issues, such as depression and anxiety, often accompany eating disorders and require dual diagnosis treatment from a team of nurses, doctors and therapists. When appropriate, psychiatrists may prescribe medications to aid in weight maintenance or to treat symptoms of co-occurring mental health issues.
Move over Weight Watchers 
Despite the recent frenzy surrounding African Mango and its weight-loss benefits, the fruit has actually been used as a diet aid for centuries in Cameroon, Africa—the only place in the world where African Mango is grown.
