About Eating Disorders
Today we know a great deal about eating disorders. They are common, can become chronic and are potentially life-threatening conditions primarily affecting young women. Anorexia nervosa is estimated to be the third most common chronic medical illness in girls aged 15-19 years and bulimia nervosa is even more common. The death rates for anorexia nervosa are twice as high as seen in any other psychiatric disorder and more than 12 fold the number of deaths expected from all causes among women 15-24 years of age; mortality rates for bulimia nervosa are lower but not insignificant.
Medical complications are typical during the acute phase of an eating disorder and persist among those not successfully treated leading to a wide range of physical and emotional disorders into early adulthood. This is the bad news. The good news is that effective treatment dramatically reduces medical complications and mortality. Recovery is not only possible but also the most likely outcome with the right kind of care. Learn more about eating disorders in the section below.
The Following Information is an Overview of Eating Disorder Topics
How common are eating disorders and what are the risks?
Eating disorders have been part of the psychiatric literature for many years; however, only in the past two decades have they commanded widespread interest in psychology, psychiatry, and allied professions. Part of the reason for this interest has been the recognition of the severe health consequences of the disorders; anorexia nervosa (AN) has a long and established history of high mortality, having an estimated mortality that is 12 times higher than expected and mortality rates are consistently ranked the highest of any other psychiatric disorder. Mortality rates for bulimia nervosa (BN) are much lower, but still notable. The prevalence rates of eating disorders in Western cultures are the topic of some debate; however, most epidemiological studies point to prevalence of 0.3% for AN and 1% for BN among young women.
The diagnostic system in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5]; American Psychiatric Association, 2013) classifies eating disorders into four basic diagnostic categories: anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED) and Other Specified Feeding or Eating Disorder (OSFED). AN individuals have further been classified into subtypes of those who simply restrict caloric intake (AN-R) and those who have symptoms of bingeing and/or purging (AN-B/P). The most notable change in the DSM-5 over the previous edition DSM-IV-R was the recognition of binge eating disorder as separate eating disorder category. Eating disorders such as AN, BN, and BED, include extreme emotions, attitudes, and behaviors surrounding weight and food issues. Eating disorders are serious emotional and physical problems that can have life-threatening consequences for females and males. Overview of major eating disorders:
- Inadequate food intake leading to a weight that is clearly too low.
- Intense fear of weight gain, obsession with weight and persistent behavior to prevent weight gain.
- Self-esteem overly related to body image.
- Inability to appreciate the severity of the situation.
- Binge-Eating/Purging Type involves binge eating and/or purging behaviors during the last three months.
- Restricting Type does not involve binge eating or purging.
- Frequent episodes of consuming very large amount of food followed by behaviors to prevent weight gain, such as self-induced vomiting.
- A feeling of being out of control during the binge-eating episodes.
- Self-esteem overly related to body image
Binge Eating Disorder
- Frequent episodes of consuming very large amounts of food but without behaviors to prevent weight gain, such as self-induced vomiting.
- A feeling of being out of control during the binge eating episodes.
- Feelings of strong shame or guilt regarding the binge eating.
- Indications that the binge eating is out of control, such as eating when not hungry, eating to the point of discomfort, or eating alone because of shame about the behavior.
Other Specified Feeding or Eating Disorder (OSFED)
- A feeding or eating disorder that causes significant distress or impairment, but does not meet the criteria for another feeding or eating disorder.
- Examples include:
- Atypical anorexia nervosa (weight is not below normal)
- Bulimia nervosa (with less frequent behaviors)
- Binge-eating disorder (with less frequent occurrences)
- Purging disorder (purging without binge eating)
- Night eating syndrome (excessive nighttime food consumption)
Despite merits of diagnostic classifications, the clinical stability of eating disorder diagnoses have been questioned in the long-term due to significant crossover between both diagnostic categories and subtypes. While there is some distinctiveness between the categories of AN and BN diagnoses, the remarkable heterogeneity in psychological features within diagnostic subgroups underscores the clinical utility of evaluating patients on a broad spectrum of meaningful psychosocial variables. For clinical purposes, there is far greater conceptual value indirectly assessing psychological domains that are conceptually relevant across all eating disorder subgroups rather than simply drawing inferences from DSM-5 diagnostic categories.
Are the medical complications a serious concern?
Medical complications are typical during the acute phase of an eating disorder and persist among those not successfully treated. Eating disorders additionally are associated with a wide range of physical and emotional disorders through early adulthood, including major depression, OCD, substance abuse and anxiety. The complex interplay between psychological and physical symptoms argues against defining eating disorders as exclusively “psychiatric” or “medical” since effective treatment must target both domains.
Risk and Maintaining Factors
The understanding of factors that cause and maintain eating disorders has advanced substantially in recent decades. Most models assume that eating disorders have multiple causes and vary tremendously in their presentation. It is believed that the variations represent the interplay of three broad classes of predisposing or risk factors: cultural, individual, and familial. More recent scientific evidence, however, has begun to specify in greater detail the respective roles of these categories.
Excessive restrictive dieting can prompt eating disorders in people who do not have an underlying personality or family disturbances. It has been increasingly recognized that dieting can play a direct role in causing serious symptoms such as depression and binge-eating. Why do many women and an increasing number of men try to reduce their overall food intake?
For decades now, women have been bombarded with the message that they must diet in order to meet standards for beauty represented by ultra-thin fashion models. Thinness in women has become a symbol for beauty, success, happiness and self-control in our culture. Unfortunately, the idealized body shape for women is almost impossible for most people to achieve because it is completely contrary to biological and inherited factors that determine body weight. This conflict between fashion industry ideals and biological reality has led to a disturbing situation where most young women are incredibly dissatisfied with their body and feel they are too fat.
There have also been theories suggesting that the family may play a role in the development and maintenance of anorexia nervosa. Some have suggested that families of those with the disorder tend to be overprotective, rigid, and suffocating in their closeness. In these cases, anorexia nervosa develops as a struggle for independence, autonomy, and individuality. It is likely to surface in adolescence when the individual, her parents, or the entire family are forced to deal with the new demands for independence and mature functioning. It must be emphasized that most of the descriptions of families have been based on observations made after anorexia nervosa has developed and, thus, they may reflect a response to a serious illness rather than an underlying cause of the disorder. The reason why this issue is so important is that parents often experience overwhelming feelings of guilt once they recognize that one of their children has an eating disorder.
While in some cases, family relationships may contribute to an anorexia nervosa, in other instances, it occurs in families that appear to be functioning well before the eating disorder has developed. Regardless, it is important to remember that an eating disorder is tremendously disruptive to the family and distress by all family members can be expected. Even when serious family dysfunction is present, it would be a serious error for either sufferers or their families to blame themselves for the eating disorder since it virtually never reflects some sort of deliberate wrongdoing on anyone’s part.
There is some evidence that other family factors may increase the vulnerability to anorexia nervosa. For example, if one member of the family has the eating disorder, it is more likely to occur in other family members. It has also been suggested that a family history of depression or alcohol abuse may increase the likelihood of anorexia nervosa. Finally, there is evidence indicating that sexual abuse may increase the chance of an eating disorder developing.
In sum, the family can play a role in the development or the maintenance of an anorexia nervosa but it is also possible for an eating disorder to develop in families that were functioning well prior to the development of the eating disorder. In either case, blaming the sufferer or the family is inappropriate. As will be described later, the family can play a very important role in recovery.
People may be vulnerable to eating disorders either because of their psychological makeup or biological susceptibility. There have been many theories regarding psychological or personality attributes that may increase the risk of eating disorders. It has been suggested that those who develop the disorder may have difficulties in adapting to the host of sexual and social demands associated with adolescence. According to this view, self-starvation becomes a mechanism for avoiding maturity because it results in a return to pre-pubertal appearance and hormonal status. This regression is thought to provide relief from adolescent turmoil and conflicts for sufferers and their families. This explanation of anorexia nervosa should not be generalized to all cases since it only applies to a subgroup of sufferers.
Other factors that have been identified as leading to eating disorders are low self-esteem, feelings of ineffectiveness, poor body image, depression, emotional instability, rigid thinking patterns, and perfectionism. Particularly within the context of overall a poor self-image, the experience of self-control, virtue, and even power derived from success in weight control may lead a person to persist in weight loss efforts, even when it becomes obvious to others that this behavior is inappropriate. Those with anorexia nervosa often appear emotionally “driven” not only toward weight loss, but also in other areas of their life such as schoolwork, physical fitness, or career.
Unfortunately, a problem in determining which traits may cause eating disorders is that weight loss itself causes certain psychological disturbances to develop. Thus, some traits that have been observed in anorexia nervosa may be a consequence, rather than a cause, of the disorder.
It has been suggested that eating disorders may represent a form of “addictive” disorder and that certain foods should thus be avoided. Although there are parallels between anorexia nervosa and chemical dependency, there is little evidence that eating disorders are actually related to “addiction.” Of greatest importance is that many of the treatment recommendations that come from the “addiction model” of eating disorders are ineffective and others may even be harmful.
There is some evidence indicating that genetics may play a role in eating disorders. For example, it is more likely that an eating disorder will develop in one identical twin if the other twin has the disorder. This is in contrast to fraternal twins (not identical) who have about the same risk of developing anorexia nervosa as do same-sex siblings. This may reflect some underlying biological vulnerability to eating disorders or it may indicate that being an identical twin presents particular psychological challenges that raise the likelihood of the observed association (e.g., competitiveness, difficulties in developing a separate identity). There have been other speculations regarding biological vulnerability to eating disorders but the evidence for this is not compelling at this time.