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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 selective serotonin reuptake inhibitors
(SSRIs) and other antidepressants, some studies have suggested
that they may have unintentional effects on some people,
especially adolescents and young adults. In 2004, after
a thorough review of data, the Food and Drug Administration
(FDA) adopted 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 children, adolescents and young
adults taking antidepressants should be closely monitored,
especially during the initial weeks of treatment, for any
worsening depression, suicidal thinking or behavior, or any
unusual changes in behavior such as sleeplessness, agitation,
or withdrawal from normal social situations. However, 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. The study was
partially funded 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.
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