Eating Disorders (4 hours)
Course Description
Gain important updates to your eating disorders knowledge, as well as an overview. It includes the DSM diagnoses, as well as numerous additional categories of importance in clinical practice, such as orthorexia and nocturnal sleep related eating disorder. New insights into what is proving to be the most populous eating disorder, eating disorder NOS are covered. The course provides incidence rates, course and other valuable information on each disorder. This includes gender issues and demographics. The treatment section covers the needs of the primary eating disorders, and provides a case example. The case demonstrates the conceptualization and flow of eating disorder treatment using EMDR and ego state psychotherapy. The course provides helpful information regarding the psychosocial and sociocultural factors associated with the eating disorders. Current citations and a major metastudy are employed. These include factors such as mood, cognitions, coping and defenses, substance use and abuse, personality factors, and other areas.
Learning Objectives
This course is designed to allow participants to:
Identify and describe the psychological and physical components of eating disorders.
Indicate the prevalence of disordered eating and the primary eating disorders.
Describe the causes of eating disorders from psychological, sociocultural, and biological perspectives.
Describe the risks for relapse and medical complications of eating disorders, including death.
Assess for and recognize the unique features of various eating disorders.
Recognize features that distinguish disordered eating from severe disorders.
Recognize eating disorders in males, and indicate the rates of incidence in males.
Indicate the psychological factors most associated with eating disorders, including mood disorders, trauma, and personality.
Describe key aspects of treatment for eating disorders, including treatment of psychological trauma. Indicate what aspects of treatment are best supported by research. Include level of care as an issue.
Indicate the comorbidities that may require treatment or medical attention.
BIO
Robert A. Yourell, LMFT has experience in the mental health field in roles such as psychotherapist and clinical coordinator for over 30 years.
Disclaimer
The views, opinions, and content of this publication are those of the author and do not necessarily reflect the views, opinions, or policies of the continuing education unit provider or the licensing board.
Copyright Notice
U.S. copyright. All rights reserved, Robert A. Yourell.
Test
1. All persons that engage in disordered eating have eating disorders. F
2. Disordered eating conforms to the following gender pattern:
a. It is exclusively a female problem
b. It is primarily female problem
c. It is primarily a male problem
*d. The answer depends on the type of disordered eating.
3. Obsession with body shape and size can manifest as:
a. Achieving or maintaining thinness
b. Achieving or maintaining muscle mass
c. Achieving or maintaining "sphere-ocity"
*d. a and b
4. Eating disorders can occur
a. In children
b. In teens
c. In adults
*d. All of the above
5. The most deadly eating disorder below is:
a. Binge eating disorder
b. Bulimia nervosa
*c. Anorexia nervosa
d. Nocturnal sleep related eating disorder
6. Excessive attempts to lose weight often involve:
a. Exercise, binging, and purging
b. Smoking, binging, and exercise
*c. Exercise, purging, and laxative use
d. Laxative use, diet pills, and antidepressants
7. Disordered eating and eating disorders are most strongly associated with:
a. Anxiety, depression, irrational cognitions
b. ADHD, substance use and abuse, symptoms of personality disorders
c. Mild intellectual impairment, history of being teased, history of child abuse
*d. a and b
8. Cultural pressure to be thin is associated with anorexia, but not bulimia. F
9. Research shows that a history of child abuse is a major cause of eating disorders. F
10. For treatment:
a. Treat the eating disorder before anxiety or mood disorders.
b. Treat with psychotherapy, but avoid medication because of abuse risk.
*c. Psychotherapy such as CBT and interpersonal therapy can be effective.
d. a and c
11. The best elements of eating disorder treatment can be:
a. Antidepressant medication and bed rest
*b. Nutritional counseling and antidepressant medication
c. Psychotherapy and good-natured chiding regarding body shape
d. Food-aversion conditioning and trauma treatment
12.In anorexia treatment, the first phase of treatment should be:
a. Medication
*b. Reduction of medical symptoms such as unhealthy low weight
c. Control of attention deficit symptoms
d. Specialized psychosocial education
13. Persons with anorexia nervosa are typically most preoccupied with:
a. Social status and its artifacts
*b. Thinness and avoiding weight gain
c. Thinness and avoiding eating
d. Purity and health-promoting aspects of food
14. Anorexia nervosa can involve:
a. Obsessiveness and cutting food into tiny pieces
b. Dental problems and scarring of knuckles
c. Persistent, false belief that the person is overweight, and focusing on hips and thighs
*d. all of the above
15. The continued lack of evidence for a biological basis for anorexia adds to the support for a primary etiology in family dysfunction. F
16. People with bulimia nervosa may have normal weight, even when the condition has persisted for years. T
17. Binging and purging are typically done in secret. T
18. Binge eating disorder differs from bulimia in that it:
a. Involves a loss of control over eating.
*b. Does not involve the compensatory behaviors of bulimia (e.g. excessive exercise)
c. Does not take place in secrecy.
d. Exclusively involves "comfort food."
19. Night eating syndrome is:
*a. A sleep disorder and eating disorder.
b. A sleep disorder and constant hunger.
c. An eating disorder with nighttime cravings.
d. Falling asleep while eating, and sleep walking.
Eating Disorders Overview
Overview, demographics
Eating disorders: According to the National Institute of Mental Health (2011), "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." They have been reported in early psychiatric literature. (Gull, 1873)
These disorders can be life threatening and tend to be chronic. (Attia, 2010; Herzog et al., 1999) They occur in all social strata, and across cultures. The can affect people throughout the lifespan, including childhood; then tend to emerge in early adolescence. (Swanson, Crow, Le Grange, Swendsen, & Merikangas, 2011)
Eating disorders are chronic and, generally, such clients are difficult to manage. Successful treatment usually hinges on cooperation of a variety of clinicians. These include nutritionists, psychologists, psychiatrists, and primary care providers. It is especially important to recognize eating disorders in teens and initiate treatment as early as possible. This is because of the tendency of eating disorders to develop into very serious conditions with medical complications before they are recognized and treated in teens, and the fact that these disorders generally first emerge in adolescence. Over time, people with eating disorders are likely change from one diagnosis to another. (Fairburn, Cooper, Bohn, O’Connor, Doll, & Palmerb, 2007)
Gender: These conditions are found in both genders. Previous research has told us that eating disorders are much more common in females, with approximately 3% of young women having one of the three primary eating disorders: bulimia nervosa, binge-eating disorder, or anorexia nervosa. (Becker et al., 1999). However, research that is more recent tells us that men have many similarities to women in eating disorders, including prevalence, even in anorexia. (Swanson, Crow, Le Grange, Swendsen, & Merikangas, 2011; Gadalla, 2009; Taraldsen, Eriksen, & Götestam, 1996) According to the National Comorbidity Survey Replication, rates of prevalence in women for anorexia nervosa are 0.9%, for bulimia nervosa are 1.5%, and for binge eating disorder are 3.5%. (Hudson, Hiripi, Pope, & Kessler, 2007) Information on incidence in men is not as reliable, as it has not been replicated as much, there is underreporting by men, and the samples are smaller. Much of the underdiagnosis appears to be because of the belief that only women have eating disorders. Also, they can manifest differently in men, as we will discuss. Another reason for the discrepancy with earlier research may be that rates in men are actually rising.
The DSM IV TR provides criteria for two eating disorders: anorexia nervosa and bulimia nervosa, as well as eating disorder NOS (not otherwise specified).
There are less data available regarding eating disorders in men, so the information in this course cannot be applied with as much confidence to men as to women. This imbalance of available data is the result of the much higher prevalence rates of eating disorders in women overall. However, men are receiving more attention concerning eating disorders because of data suggesting significantly increasing rates of eating disorders among men.
Binge-eating disorder involves episodes of uncontrolled eating, but without compensatory behaviors intended to avoid gaining weight, such as laxative use or vomiting. (Devlin, 1996).
Bulimia involves binge eating with attempts to prevent weight gain.
Anorexia nervosa involves low body weight (under 85% of normal), extreme fear of weight gain, and a distorted perception of weight or body shape. Average onset is 17 years of age. (DSM-IV-TR)
Women are especially susceptible to eating disorders during college years, but these disorders appear to be becoming more prevalent at earlier ages. Some groups are especially vulnerable, including females in sports that emphasize appearance such as dance, figure skating, and gymnastics. Track and cross-country athletes also appear to be elevated groups.
NOS: There is also eating disorder NOS (not otherwise specified). Normally, a NOS diagnosis is reserved for a minority of cases that don't fit well-defined criteria. However, in the case of eating disorders, NOS has been found in a number of studies to comprise more than 50% of eating disorder cases.
Disordered eating refers to a broad range of eating patterns. This may rise to the level of Eating Disorder NOS. However, it does not equate to anorexia nervosa or bulimia nervosa. It ranges from relatively mild behaviors to problems that are more serious. It involves an unhealthy relationship with food or with one's body. Disordered eating may include bingeing and going to extremes to lose weight or prevent weight gain. These methods can be harmful. They may include purging, skipping meals, or smoking. Disordered eating may also manifest as extreme reactions to weight gain, and as obsessiveness about food and eating.
A survey by Self Magazine in partnership with the University of North Carolina at Chapel Hill indicates that "Sixty-five percent of American women between the ages of 25 and 45 report having disordered eating behaviors... An additional 10 percent of women report symptoms consistent with eating disorders such as anorexia, bulimia nervosa and binge eating disorder, meaning that a total of 75 percent of American women surveyed endorse some unhealthy thoughts, feelings or behaviors related to food or their bodies." (University of North Carolina at Chapel Hill, 2008) The study revealed a high rate of purging. “What we found most surprising was the unexpectedly high number of women who engage in unhealthy purging activities... More than 31 percent of women in the survey reported that in an attempt to lose weight they had induced vomiting or had taken laxatives, diuretics or diet pills at some point in their life. Among these women, more than 50 percent engaged in purging activities at least a few times a week and many did so every day.”
The survey generated the following statistics:
75% of women report disordered eating behaviors or symptoms consistent with eating disorders; so three out of four have an unhealthy relationship with food or their bodies
67% of women (excluding those with actual eating disorders) are trying to lose weight
53% of dieters are already at a healthy weight and are still trying to lose weight
39% of women say concerns about what they eat or weigh interfere with their happiness
37% regularly skip meals to try to lose weight
27% would be “extremely upset” if they gained just five pounds
26% cut out entire food groups
16% have dieted on 1,000 calories a day or fewer
13% smoke to lose weight
12% often eat when they are not hungry; 49% sometimes eat when they are not hungry.
Since disordered eating is so prevalent, mental health assessments should include questions pertaining to disordered eating, including subclinical behaviors.
Course
Eating disorders usually first become evident during late adolescence to early adulthood. Symptoms are often preceded by a stressful life event. Many cases involve a history of being teased regarding weight or body shape. Weight loss, including loss that is not caused by dieting, can lead to anorexia nervosa.
Social factors reinforce the excessive attempts to control weight. These include comments by others and the feeling of being closer to social ideals for body shape. Eating disorders usually persist for one to fifteen years. As many as 10% die prematurely because of the disorder. Causes include starvation, suicide, and cardiac arrest. Anorexia nervosa is the most deadly of these conditions, with a rate of 0.56% per year. This is twelve times that of the normal female population. (Sullivan, 1995). This rate is higher than nearly all other psychiatric disorders (Herzog, et al., 1996)**update Anorexia nervosa deaths are usually from suicide, starvation, or electrolyte imbalance. (DSM-IV-TR)
Prognosis is greatly improved through early diagnosis and specialized treatment. Unfortunately, treatment does not have a high rate of success.
Causes
Eating disorders are caused by developmental, biological, and cultural factors. (Becker et al., 1999; Kaye et al., 1999) Comorbid psychiatric disorders are very common. These include anxiety disorders, depression, other affective disorders, substance abuse, and personality disorders. (Herzog, et al., 1996)
Environmental factors are believed to trigger epigenetic changes. Anxiety and depression are associated with eating disorders and tend to be elevated in more severe eating disorders. (Vince & Walker, 2008) These states are believed to be heightened in epigenetic changes that stem from stress, especially during childhood development.
Psychosocial Associations
Major metastudy: This section draws from a large metastudy by Vince and Walker (2008) that reviewed 232 studies and 71 metastudies involving 87,878 subjects. The study consolidated data into 12 categories of variables. Most of the studies involved female subjects. However, available data show strong similarities between males and females in various aspects of eating disorders, including behaviors and associated features, so this data should be helpful in understanding eating disorders in men, and guiding future research on men.
Mood: Anxiety and depression are highly associated with disordered eating, especially in anorexia nervosa and bulimia nervosa. (Vince & Walker) A large, prospective study of adolescent girls found that early-onset major depressive disorder increased the risk of an eating disorder 5.9 times, and generalized anxiety disorder by 4.7 times. Depression and anxiety occurring together increased the risk even more. Genetic inheritance does not appear to account for this association, according to studies involving discordant twins (one with and one without the diagnosis). (Sihvola, Keski-Rahkonen, Dick, Hoek, Raevuori, Rose, et al., 2009)
Cognitions: Irrational cognitions "regarding eating, weight and body shape" are associated with eating disorders. The more severe eating disorders, anorexia nervosa and bulimia nervosa, are associated with the most irrational cognition. (Vince & Walker)
Coping and defenses: People with disordered eating tend to have immature defenses and dysfunctional coping styles. (Vince & Walker)
Substance use and abuse: There is some association between eating disorders and illegal drug or nicotine use, but not alcohol use. (Vince & Walker) Persons with eating disorders are more likely to avoid excess alcohol consumption because they are aware that it causes weight gain. Drug abuse may serve as self-medication for comorbid mood and anxiety. Nicotine is used to avoid weight gain.
Attention deficit/hyperactivity disorder: Girls with ADHD have a 3.6 times greater risk for an eating disorder, according to a large study. (Biederman, Ball, Monuteaux, Surman, Johnson, Zeitlin, 2007) A review of the literature supports this, but cautions that the literature (as of 2008)**current was limited. (Nazar, Moreira de Sousa Pinna, Coutinho, Segenreich, Duchesne, Appolinario, et al., 2008)
Personality traits are associated with disordered eating. These include problems with autonomy, shame and guilt, perfectionism, neuroticism, and anger. In actual eating disorders, anger and hostility were further elevated. Additionally, persons with eating disorders had greater levels of borderline and obsessive-compulsive personality disorder traits. Problems with autonomy were especially elevated in persons with bulimia nervosa, but not with anorexia nervosa. (Vince & Walker, 2008)
Persons with disordered eating or eating disorders were not found to have temperament differences, or elevated self-harm or extroversion. (Vince & Walker, 2008)
Abuse History: There is an association between child abuse history and eating disorders or disordered eating, but it is not a simple, causal relationship. (Vince & Walker) The rate of disorder does not increase in a linear way with the amount or intensity of abuse. (Vanderlinden & Vendereycken, 1996) This most prominently exists as a link between post traumatic stress disorder and bulimic disorders, according to Brewerton's (2007) literature review. He concluded that, "The trauma and PTSD or its symptoms must be expressly and satisfactorily addressed in order to facilitate full recovery from the ED and all associated comorbidity." He also pointed out that subclinical PTSD contributes to developing eating disorders. This connection exists regardless of age or gender.
Many clinicians and persons with eating disorders believe that eating disorders can function as a form of insulation against sexual interest from others. This prevents anxiety produced by sexual advances. (Bills, 1996)
Teasing, negative comments, bullying, social pressure: One of the strongest associations revealed by the metastudy was with teasing. (Vince & Walker) Teasing appears to have a lasting impact, and is a common experience of adolescents. This teasing is not just from peers, but takes the form of negative comments from family members. (Taylor, Bryson, Celio Doyle, Luce, Cunning, Abascal, et al., 2006) Bullying is also a factor in eating disorders. (Taylor, Bryson, Celio Doyle, Luce, Cunning, Abascal, et al. 2006). Social pressure regarding thinness is a risk factor. (The McKnight Investigators 2003)
Negative or adverse life events are a risk factor. (The McKnight Investigators 2003)
Attachment, family background: Family dysfunction contributes to eating disorders, especially for younger persons. (Vince & Walker) Persons with disordered attachment styles are at risk for disordered eating, especially anorexia nervosa and bulimia nervosa.
Sociocultural factors are implicated in various ways. The metastudy cited here found only moderate associations (Vince & Walker, 2008), but may not have assessed enough relevant factors such as media exposure.
Eating disorders are more prevalent in industrialized nations. (Goode, 1999) Eating disorders among adolescent girls in Fiji significantly increased within three years of widespread use of television. (Becker, Burwell, Gilman, Herzog, & Hamburg, 2002) The study states, "A growing literature documents the emergence of disordered eating in the setting of cultural transition and globalising political and economic forces," concluding that, "Cultural context appears to be relevant to the development of disordered eating attitudes and behaviours. Western media imagery may have a profoundly negative impact upon body image and disordered eating attitudes and behaviours, even in traditional societies in which eating disorders have been thought to be rare. Social change can rapidly alter mental illness idioms."
Treatment
Eating disorders can respond to psychotherapy and medication. There is much individual variation in treatment needs between the disorders and for individual patients with the same eating disorder. (Surgeon General, 1999) Cognitive behavior therapy and interpersonal therapy have good support as treatments for bulimia and binge eating disorder. (Surgeon General)
Comorbid mental disorders and medical complications must be treated in cases of eating disorders, because they affect the outcome and are disorders in their own right. (Surgeon General)
Binge eating, purging, and bulimia: Fluoxetine and other antidepressants can reduce binge eating and help alleviate the depression that is common to eating disorders, while appetite suppressants can reduce binge eating. (National Institute of Mental Health (2009)
Nutritional counseling provides strategies that help allay fears of weight gain and encourage appropriate eating strategies. (National Institute of Mental Health, 2009)
Individual and group psychotherapy can treat "underlying psychological issues associated with binge-eating." (National Institute of Mental Health)
CBT that is specifically designed to treat bulimia is proving effective as a group or individual approach. It helps with binging and purging behavior as well as attitudes regarding eating.
Anorexia: The first, most crucial goal in anorexia treatment is the reduction of life-threatening symptoms such as low weight. Psychotherapy and medication address the behaviors and thought patterns that contribute to disordered eating and relapse risk. There is some support for antidepressants, antipsychotics, and mood stabilizers in reducing symptoms, including depression and anxiety. However, "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." (National Institute of Mental Health) **current
Males have received less research attention, but this is changing. It is now recognized that there are substantial rates of eating disorders among men and boys. For example, one in four pre-adolescents with anorexia are boys, while binge eating disorder has roughly the same rate in males and females. (National Institute of Mental Health) **current
It appears that treatment needs of males will prove to be similar to those of females. Males binge at rates similar to that of females. There are similarities in the dynamics of social pressures on males and females, even though the content of such pressure has differences. Those differences include the desire for males to bulk up while females feel pressure to be thin. Both males and females with eating disorders have a distorted body image. In males, this often appears an obsessive need to become more muscular (as muscle dysmorphia). This may lead to using dangerous drugs such as steroids. Some are obsessed with losing weight. This is more likely to be stigmatized. Males are even more likely to evade diagnosis than women, because of the widespread belief that only females have eating disorders. Also, the obsession with bulking up is not seen as being as pathological as being obsessed with being thin. Extreme thinness is less socially acceptable than male muscularity, and gives a stronger impression of being unwell. Bear in mind, however, that disturbed eating and early stages of anorexia may not result in obvious body changes.
Prevention: Families can help prevent eating disorders by helping children develop good eating habits. This is best done with affection and attention, while coercion can be harmful.
Treatment of trauma: Research supports the belief that trauma contributes to the development of eating disorders, especially bulimia, and that trauma treatment is important in eating disorders. (Brewerton, 2007; Shapiro & Grand, 2009) In one study, EMDR substantially improved negative body image and related memories compared to the standard treatment condition. (Bloomgarden & Calogero, 2008) **current
An Example of Clinical Process in Outpatient Treatment
This section provides one example of clinical thinking and practice in outpatient eating disorder treatment. Andrew Seubert, MA, NCC, LPC, describes treating a 44 year old woman with eating disorders. Trauma treatment that included EMDR and medication were important elements. Mr. Seubert is an EMDRIA Approved Consultant and Trainer. (Seubert, 2010)
To get initial progress, Seubert reduced the intensity of obsessive thinking. He states, "My first reaction has to do with her obsessive thinking. No amount of mindfulness or cognitive restructuring helped. She was completely 'brain locked.' It was only with the help of some medication to slow down the obsessing that we could move forward."
He described treatment from an ego state perspective. The description may sound like work with multiple personalities, as in dissociative identity disorder. However, ego state therapists are referring to aspects of the personality (ego states), not alters. An ego state is a collection of motives and state-dependent learning and memory. Client motivation and work on therapeutic goals can be enhanced by learning to identify these parts and perform other kinds of ego state work, much as CBT clients learn to manage their thinking patterns.
The resulting improvement in mindfulness is valuable because it helps the client develop a more objective or instrumental approach to their difficulties. This allows the client experience the sense of empowerment that comes from being able to make conscious, healthy choices. It is a welcome alternative to being over-identified with unresourceful states of mind.
"One of the things that also helped to create a healthy separation from the obsessive thinking was mindful awareness, which takes daily practice on the part of the client. Experiencing that I'm not the thoughts, that I can dialogue with the thoughts (ego state) and say, "Thanks for your input, but that's not helpful right now," seemed to help my client as long as she continued the practice. I had to remind her that awareness is not a Band-Aid; it is a way of life."
A challenge to this work is disordered attachment. Attachment issues have been identified in eating disorders in a large metastudy discussed earlier.
"In this case, I needed to do major attachment repair. One of the goals of this work (plus ego state work) is that there is slowly (very slowly) a developing differentiation between an observing/rational/adult Self and the 'part' that is so identified with the eating disorder (ED). The difficulty I encountered was that the ED ego state literally takes over the Self. There is simply a system-wide state of enmeshment or confluence. The fear of fat took over all parts and the Self as well."
In this vein, ego state work attempts to develop the less mature components of the client's personality (or "younger parts"). This assists clients in improving executive functions such as self-soothing and internal nurturance that are impaired in persons with attachment issues.
"In 'reparenting' the younger parts, particularly the ED part(s), the adult Self began to experience compassion and some acceptance AND some separation from the ED consciousness. It is a daily and constant battle for this to happen, and my adult client goes in and out of being alternatively absorbed by, then having some breathing room from, the ED part."
Seubert acknowledges that this can be a time-consuming process. Seubert states that EMDR can be initiated once "targets" (issues, memories, and feelings that are targeted during desensitization and reprocessing) begin responding to treatment. This is evident when a client shows reduced distress and reactivity regarding those targets. At this point, EMDR is used to desensitize and reprocess targets related to trauma and the eating disorder. In addition to early memories, treatment targets feelings related to eating, the body, food, and circumstances in which disordered eating occurs or is primed to occur. Often, a target will be a strong feeling connected to an irrational and dysfunctional cognition. The feeling may help to drive the disordered behavior, or discourage healthy behavior. Reprocessing replaces these feelings with constructive feelings and attitudes. This is illustrated by the following:
"After a year of attachment work and ego state collaboration, we are finally at the place of targeting the memories in which the fear of fat began. It couldn't happen any sooner, because when I tried to target an early (7 year old) memory once before, all other parts, including the adult, ganged up on the 7 year old, blaming that part for what I call the 'common pain.' That's when we backed up and discovered that we had a great deal more attachment work to do. Now her internal system still has powerful reactions to the early event, but all parts are in it together and supportive of each other. This is a major move forward.
"We've just begun again to target that same memory. We have established a key negative cognition (NC): (If I'm fat) 'I'm disgusting'. A positive cognition (PC) of, 'I'm beginning to learn I'm OK as I am' was still off the charts for this client. So we backed up to the level of wanting: 'I want to learn to believe that I'm OK as I am' Although it is slow, progress continues and internal compassion among the parts has been established.
"Seeing the Self as more than merely a "part," Seubert feels that, "One of the tasks is freeing the Self from the trance of the ED."
Anorexia Nervosa
Overview: Anorexia nervosa (AN) is generally thought of as an inability or refusal to eat. This is true, but the primary characteristics of AN is refusal to maintain a healthy weight, an obsessive fear of gaining weight, and distorted body image. (Rosen, Reiter, & Orosan, 1995; Cooper, 2005) This involves cognitive distortions that are highly resistant to treatment. These distortions pertain to nature of the person's body, food, and eating. The DSM-IV-TR distinguishes between restricting and binge eating/purging subtypes. The restricting type refrains from regular binge eating and purging.
Etymology: Anorexia has Greek roots. The letter a serves as a negative, and orexis means appetite. (Costin, 1999)
Additional specific signs, examples: The physical signs of AD can be obvious in advanced stages, but not all individuals exhibit all signs. These signs include lanugo (growth of body and facial hair), dental problems, a distended abdomen, and swollen joints. These result from malnutrition that can lead to serious complications that affect every organ system. (Støving, Hangaard, & Hagen, 2001) A sign of repeated forced vomiting is scars on the knuckles caused while inducing the gag reflex. (Rustin, Foreman, & Dowd, 1990) Purging is not just limited to bulimia; it is one of the behaviors that can occur in anorexia.
The National Institute of Mental Health (2009) provides these additional signs:
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
Behaviors that are indicative of anorexia suggest an obsession or with food. This can be misleading, because it does not appear as an unwillingness to eat. For example, the person may prepare a lavish dinner for guests. However, the individual does not actually eat. He or she may cut food into many, very small pieces, slowing or preventing much eating. Some behaviors exhibit an obsessive fear of gaining weight. They may engage in extreme, excessive exercise and use laxatives, diet pills, ipecac syrup, and water pills. They may go to the bathroom immediately after eating, to secretly induce vomiting.
Distorted cognitions and body image are expressed as the persistent belief that the person is overweight. This often involves focusing on areas that suggest mature body development such as hips and thighs. The individual is likely to insulate themselves from interference or attention on their disorder. These behaviors can include isolation, secretiveness, and even wearing baggy clothes that disguise their weight loss.
Psychological associations: Much more than other eating disorders, AN involves low self-esteem. Bulimia is associated with a history of poor caregiver relationships. (Vince & Walker, 2008)
Environmental associations: Cultural factors contribute to anorexia. The level of exposure to media and other cultural influences that value thinness increase the incidence of anorexia. (Haff, 2009; Lindberg & Hjern, 2003) Sports and professions that involve the expectation of thinness have elevated rates of anorexia.
Biological associations: Anorexia can be triggered by weight loss from dieting or other, non-purposeful factors. In vulnerable individuals, dieting appears to trigger physical and psychological change that somehow causes anorexic behavior. These are referred to as epiphenomena of starvation. This thinking stems from research on people that do not have anorexia, but later exhibit anorexic behaviors under starvation conditions. Changes in the neuroendocrine system have been observed that appear to be responsible for this. (Zandian, Ioakimidis, Bergh, Södersten, 2007; Kaye, 2008; Støving, Hansen-Nord, Hangaard & Hagen, 1996; Brandenburg & Andersen, 2007; Nygaard, 1990)
In order to avoid this chain of events, attempts to achieve weight loss through means that resemble starvation should be avoided. Therapists should refer clients seeking weight loss for nutrition and lifestyle education that emphasizes a gradual and holistic approach.
Anorexia appears to be highly heritable. The concordance rate is estimated to be from 56% to 84%. (Klump, Miller, Keel, McGue, & Iacono, 2001)
Additional biological factors are being identified. These include problems with serotonin regulation and inadequate brain derived neurotrophic factor (BDNF). These factors are also implicated in depression. (Kaye, Bailer, Frank, Wagner, & Henry, 2005; Monteleone, 2005) BDNF is a protein that affects eating behavior and energy homeostasis through the hypothalamus. Although abuse of exercise can be a problem in anorexia, exercise can increase BDNF. Hormones may play a role in AN. Some antibodies may act against neuropeptides that affect the personality in ways that promote eating disorders. Reduced cerebral blood flow in the temporal lobes my be involved. Zinc deficiency appears to worsen anorexia. (Shay & Mangian, 2000)
Another trigger may be obstetric complications. This appears to trigger harm avoidance, a trait associated with anorexia. (Favaro, Tenconi & Santonastaso, 2008; Monteleone, 2005)
Bulimia Nervosa
Bulimia nervosa involves recurring, frequent episodes of eating very large quantities of food (known as binge eating). An incident of binging typically occurs over a short period of time. Many persons with bulimia nervosa report that they feel no control over this pattern of eating. Binging is followed by an effort to compensate for binging, and may include purging (e.g., vomiting or excessive use of diuretics or laxatives), excessive exercise, or fasting.
Persons with bulimia may fall within the normal weight range, unlike persons with anorexia. However, they often experience great fear of gaining weight, as do those with anorexia. They may desperately desire to lose weight, and be extremely unhappy with their size and shape.
The binging and purging are typically done in secret. Persons with bulimia nervosa tend to experience disgust and shame regarding their behavior. The cycle of binging and purging typically occurs several times per week. Coexisting psychological illnesses often include depression, anxiety and substance abuse. Non-purging bulimia is a subtype in which compensatory behaviors do not include purging, instead relying on things such as excessive exercise to control weight. The DSM-IV-TR criteria include a time sensitive one: " The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for three months."
Purging is especially likely to cause medical problems, such as electrolyte imbalances, gastrointestinal disorders, and problems associated with teeth or the oral cavity, such as erosion of teeth resulting from exposure to acidity during vomiting.
According to the National Institute of Mental Health (2009) additional symptoms can 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
Binge Eating Disorder
Binge-eating disorder involves repeated binge eating. Much like bulimia, the individual experiences loss of control over eating. However, this disorder does not involve the compensatory behaviors of bulimia: purging, excessive exercise, and fasting. The result is that persons with binge eating disorder are usually overweight or even obese. The high level of distress they experience in the form of guilt, shame, and concern regarding weight gain can trigger additional binging. Common psychological comorbidities include anxiety, depression, and personality disorders. Obesity is associated with cardiovascular disease and hypertension.
Binge eating often takes the form of a cycle of depression and binging. Persons with bulimia describe using food as a means for dealing with challenging feelings, and refer to "stuffing" their feelings, or relying on "comfort food." As with bulimia, the binging tends to occur in secret and evokes the same feelings as in bulimia, but there is no extreme in compensatory behaviors. Some report that purging is difficult or disgusting. Some state that they don't have the energy to engage in intense compensatory behaviors, perhaps because of comorbid depression.
Eating Disorder NOS
Eating disorder NOS (not otherwise specified) has been shown to have mortality rates as high as anorexia nervosa, long thought to be the most deadly of all psychiatric diagnoses. (Crow, Peterson, Swanson, Raymond, Specker, Eckert, et al., 2009) According to Fairburn, Cooper, Bohn, O’Connor, Doll, and Palmerb (2007), the diagnosis is believed to comprise over 50% of eating disorder cases, making it the most common eating disorder. The authors state that most of these cases appear to be a mixture of anorexia and bulimia features. NOS cases tend to have levels of psychopathology that are comparable to anorexia and bulimia. Most are long-standing. Despite the lack of a clear diagnosis, persons with eating disorder NOS recognize that there is a problem and seek treatment with the same level of perceived need as the other eating disorder categories. The authors feel that the diagnosis cannot simply be reduced by adjusting the criteria for the other eating disorder diagnoses.
Additional Eating Disorders
This section briefly describes additional eating disorders.
Rumination syndrome
Rumination syndrome entails recurring regurgitation of food, with re-chewing, re-swallowing, or discarding. It is a rare diagnosis, especially in adults of normal intelligence.
Diabulimia
Diabulimia involves persons with type 1 diabetes attempting to control their weight by deliberately manipulating their insulin levels. This behavior can result in serious medical consequences.
Food maintenance syndrome
Food maintenance syndrome refers to aberrant eating behaviors by children, typically in foster care, in controlling food. It does not lead to substantial, if any, weight gain. These behaviors can include excessive eating or hoarding food. This appears to be the result of insecurity, stress, and maltreatment.
Female athlete triad
Female athlete triad includes disordered eating, abnormal menstruation (potentially as severe as amenorrhea or oligomenorrhea), and decreased bone density (potentially as severe as osteoporosis and osteoenia). In many cases, only one or two of these conditions are met, but they are still serious. The bone loss may not result in discomfort or complications at first, but this can be a serious problem when bone loss accelerates in menopause. Younger individuals can have delayed menstruation. These conditions may result from a combination of intense athletic training plus disordered eating. This disordered eating is often intended to maintain a body type considered ideal for the sport.
Pica
Pica is a diagnosis for eating non-nutritive objects and substances. These can involve any object that can be swallowed. Persons with this disorder usually have developmental disabilities. The condition can be dangerous, especially when toxic or infected substances are swallowed. The disorder is not well understood, but nutritional deficiencies and obsessive compulsive disorder are implicated. In some cases, the nutritional deficiency may result from a metabolic or digestive disorder. Pregnancy is a pica risk factor.
Orthorexia
Orthorexia nervosa is a fixation on eating foods the person believes to be healthy. However, the beliefs tend to be eccentric and can cause malnutrition. The beliefs tend to be ideological and mystical. In these beliefs, various foods are symbolic of good or bad. Steven Bratman, MD coined the term. Raw food diets are an example this kind of ideology.
The condition often stems from the desire to be pure, spiritual, and natural. People with these ideologies tend to avoid seeking help from physicians, because their beliefs are so different from mainstream medicine, and western medicine is often villainized in these belief systems. Parents that enforce such diets upon their children may place them at great risk. Child protective services has had to remove children from such situations. Although it is not a DSM diagnosis, it has been studied. The behavior appears to be more prevalent in men and individuals with lower education. People who are more socially marginal may be more vulnerable to over-valuing eccentric beliefs such as these.
Nocturnal Sleep Related Eating Disorder
Nocturnal sleep related eating disorder is a combination of parasomnia and an eating disorder. It appears to be sleepwalking that involves directed and eating behavior. The person may eat odd combinations of foods, inappropriate foods, and pica. The odd behavior appears to be the result of the sleepwalking, and can be dangerous or result in obesity. The behavior may involve skill as sophisticated as operating a blender or cooking. Many persons with NSRED do not have histories of distorted body image, other eating disorders, or obsessive attitudes concerning food or diet. Many persons with this diagnosis consume foods high in fat and carbohydrates. These individuals are typically not aware of the behavior until they are informed or see enough evidence.
Night eating syndrome
Night eating syndrome entails late-night binging. It does not involved sleep walking or unconscious eating. It is speculated that aberrations in circadian rhythm may contribute to this behavior. Sufferers experience uncontrollable urges to eat that occur exclusively or predominantly at night. They crave high-carbohydrate foods. This is not just the displacement of eating into the evening, so it causes significant weight gain. For some, this behavior serves to quell anxiety.
Prader-Willi Syndrome
Individuals with Prader-Willi syndrome suffer from nearly constant hunger or desire to eat (polyphagia or hyperphagia). They will go to extremes to find and consume food. The syndrome results from a rare genetic disorder. Andrea Prader, Heinrich Willi and others first described it in 1956.
Persons with the diagnosis typically have mental retardation in the mildly disabled range (from 50 to 70). Other features are obesity, hypotonia (poor muscle tone or strength), short stature, small feet and hands, and hypogonadism (small genitals). They generally have behavior problems, especially obsessive compulsive behaviors. The disorder ranges from mild to severe, and can change in severity or features over the lifespan.
The disorder often goes undetected. It is often mistaken for downs syndrome because of the similar intellectual deficits and facial appearance. Rates of detection are improving through genetic testing and greater awareness on the part of clinicians. **summary
Citations
American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders (4th Ed.) United States of America: American Psychiatric Association.
Attia, E. (2010). Anorexia nervosa: Current status and future directions. Annual Review of Medicine 61, 425–35. doi:10.1146/annurev.med.050208.200745
Bills, E. T. From sexual abuse to empowerment. In, Schwartz, M. F., and Cohn, L. (Eds.) (1996) Sexual Abuse And Eating Disorders, pp. 1-17. New York: Brunner-Routledge.
Biederman, J., Ball, S. W., Monuteaux, M. C., Surman, C. B., Johnson, J. L., and Zeitlin, S. (2007). Are girls with ADHD at risk for eating disorders? Results from a controlled, five-year prospective study. Journal of Developmental and Behavioral Pediatrics, 28(4), 302-7.
Bloomgarden, A. and Calogero, R. M. (2008). A randomized experimental test of the efficacy of EMDR treatment on negative body image in eating disorder inpatients. Eating Disorders, 16(5), 418-427.
Brandenburgi, B. M. and Andersen, A. E. (2007). Unintentional onset of anorexia nervosa. Eating and Weight Disorders, 12(2), 97-100.
Cooper, M. J., (2005). Cognitive theory in anorexia nervosa and bulimia nervosa: progress, development and future directions. Clinical Psychology Review 25(4), 511–31. doi:10.1016/j.cpr.2005.01.003
Costin, C. (1999). The Eating disorder sourcebook. Linconwood: Lowell House.
Favaro, A., Tenconi, E. and Santonastaso, P. (2008). The relationship between obstetric complications and temperament in eating disorders: a mediation hypothesis. Psychosomatic Medicine, 70(3), 372-7.
Crow, S. C., Peterson, C. B., Swanson, S. A., Raymond, N. C., Specker, S., Eckert, E. D., et al. (2009). Increased mortality in bulimia nervosa and other eating disorders. American Journal of Psychiatry, 166, 1342-1346. doi: 10.1176/appi.ajp.2009.09020247
Gadalla, T. M. (2009). Eating disorders in men: A community-based study. International Journal of Men's Health, 8(1), 72-81. doi 10.3149/jmh.0801.72
Goode, E. (1999). Study finds TV alters Fiji girls' view of body. New York Times, 5/20/1999.
Gull, W. W. (1873). Anorexia nervosa (Apepsia Hysterica, Anorexia Hysterica) Clinical Society's Transactions, 7(1874), 2
Haff, D. R. (2009). Racial/ethnic differences in weight perceptions and weight control behaviors among adolescent females. Youth and Society, 41(2), 278 - 301.
Hudson, J. I., Hiripi, E., Pope., H. G., and Kessler, R. C. (2007). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 61(3), 348-59.
Kaye W. (2008). Neurobiology of anorexia and bulimia nervosa. Physiology & Behavior, 94(1), 121-35.
Kaye, W. H., Bailer, U. F., Frank, G. K., Wagner, A., and Henry, S. E. (2005). Brain imaging of serotonin after recovery from anorexia and bulimia nervosa. Physiology & Behavior 86(1-2), 15–7. doi:10.1016/j.physbeh.2005.06.019
Klump, K. L., Miller, K. B., Keel, P. K., McGue, M., and Iacono, W. G. (2001). Genetic and environmental influences on anorexia nervosa syndromes in a population-based twin sample. Psychological Medicine 31(4), 737–40. doi:10.1017/S0033291701003725
Lindberg, L. and Hjern, A. (2003). Risk factors for anorexia nervosa: a national cohort study. The International Journal of Eating Disorders 34(4), 397–408. doi:10.1002/eat.10221
The McKnight Investigators. (2003). Risk factors for the onset of eating disorders in adolescent girls: Results of the McKnight longitudinal risk factor study. American Journal of Psychiatry, 160(2), 248-54.
Monteleone, P. (2005). Circulating brain-derived neurotrophic factor is decreased in women with anorexia and bulimia nervosa but not in women with binge-eating disorder: Relationships to co-morbid depression, psychopathology and hormonal variables. Psychological Medicine, 35(6), 897-905.
National Institute of Mental Health. (2011). Eating Disorders. Accessed at: http://www.nimh.nih.gov/health/publications/eating-disorders/complete-index.shtml
National Institute of Mental Health (2009) Eating disorders. Accessed 4/20/2010: http://www.nimh.nih.gov/health/publications/eating-disorders/complete-index.shtml
Nygaard, J. A. (1990). Anorexia nervosa: Treatment and triggering factors. Acta Psychiatrica Scandinavica Supplement, 361, 44-9.
Rosen, J. C., Reiter, J., and Orosan, P. (1995). Assessment of body image in eating disorders with the body dysmorphic disorder examination. Behaviour Research and Therapy, 33(1), 77–84. doi:10.1016/0005-7967(94)E0030-M
Rustin, M. H., Foreman, J. C., and Dowd, P. M. (1990). Anorexia nervosa associated with acromegaloid features, onset of acrocyanosis and Raynaud's phenomenon and worsening of chilblains. Journal of the Royal Society of Medicine, 83(8), 495-6.
Seubert, A. (2010) Personal correspondence.
Shapiro, R. (Editor) and Grand, C. (Contributor), (2009). EMDR solutions II: For depression, eating disorders, performance, and more. New York: W. W. Norton & Company.
Shay, N. F., and Mangian, H. F. (2000). Neurobiology of zinc-influenced eating behavior. The Journal of Nutrition, 130(5S Suppl), 1493S–9S.
Støving, R. K., Hangaard, J., and Hagen, C. (2001). Update on endocrine disturbances in anorexia nervosa. Journal of Pediatric Endocrinology & Metabolism, 14(5), 459-80.
Støving, R. K., Hansen-Nord, M., Hangaard, J., and Hagen, C. (1996 ). Neuroendocrine disorders in anorexia nervosa--primary or secondary? Ugeskr Laeger, 158(49), 7052-6.
Striegel-Moore, R. H., Dohm, F., Pike, K. M., Wilfley, D. E., and Fairburn, C. G. (2002). Abuse, bullying, and discrimination as risk factors for binge eating disorder. American Journal of Psychiatry 159, 1902-1907.
Surgeon General (1999), Mental health: A report of the Surgeon General. U.S. Public Health Service.
Swanson, S., Crow, S., Le Grange, D., Swendsen, J., Merikangas, K. (2011). Prevalence and correlates of eating disorders in adolescents. Archives of General Psychiatry, Published online March 7, 2011. doi:10.1001/archgenpsychiatry.2011.22
Taraldsen, K. W., Eriksen, L., and Götestam, K. G. (1996). Prevalence of eating disorders among Norwegian women and men in a psychiatric outpatient unit. International Journal of Eating Disorders, 20(2), 185-90.
Taylor, C. B., Bryson, S., Celio Doyle, A. A., Luce, K. H., Cunning, D., Abascal, L. B., et al. (2006). The adverse effect of negative comments about weight and shape from family and siblings on women at high risk for eating disorders. Pediatrics, 118(2), 731 - 738.
University of North Carolina at Chapel Hill. (2008). Three out of four american women have disordered eating, survey suggests. ScienceDaily, April 23. Retrieved April 18, 2010, from http://www.sciencedaily.com/releases/2008/04/080422202514.htm
Vanderlinden, J. and Vendereycken, W. Is sexual abuse a risk factor for developing eating disorders? In, Schwartz, M. F., and Cohn, L. (Eds.) (1996) Sexual Abuse And Eating Disorders, 17-23. New York: Brunner-Routledge.
Vince, E. P., and Walker, I. (2008). A set of meta-analytic studies on the factors associated with disordered eating. The Internet Journal of Mental Health, 5(1).
Zandian, M., Ioakimidis, I., Bergh, C., and Södersten, P. (2007). Cause and treatment of anorexia nervosa. Physiology & Behavior, 92(1-2), 283-90.
