Eating Disorders: Anorexia and Bulimia
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Anorexia Nervosa is a disruption in normal eating habits characterized by an all consuming fear of becoming "fat." It typically starts in teenage women as a normal attempt to diet but gradually leads to more and more weight loss, often more than 25% of original body weight. There is an intense preoccupation with food and body size, which may involve compulsive exercising. Anorexics intentionally starve themselves, for although they are emaciated, they are convinced that they are overweight. As the eating disorder progresses, many normal activities may stop. Menstruation ceases in women and there are a number of physical symptoms of malnutrition such as lowered heart rate, low blood pressure, decreased metabolic rate and sensations of coldness particularly in the extremities.
People with anorexia nervosa are obsessed with food and deny that they have a problem or that they are too thin. They may be able to work or study and have some social life but usually function far below their potential. Frequently they are also depressed. Sometimes anorexics must be hospitalized to prevent starvation. Other anorexics are able to check the downward spiral of weight loss and maintain a steady but seriously underweight condition. In all cases, even severe weight loss does not diminish the perception of being "fat."
Consider the following case of Deborah, a young woman suffering from anorexia nervosa:
-- Deborah developed anorexia nervosa when she was 16. A rather shy, studious teenager, she tried hard to please everyone. She had an attractive appearance, but was slightly overweight. Like many teenager girls, she was interested in boys but concerned that she wasn't pretty enough to get their attention. When her father jokingly remarked that she would never get a date if she didn't take off some weight, she took him seriously and began to diet relentlessly --never believing she was thin enough even when she became extremely underweight.
-- Soon after the pounds started dropping off, Deborah's menstrual periods stopped. As anorexia tightened its grip, she became obsessed with dieting and food and developed strange eating rituals. Every day she weighed all the food she would eat on a kitchen scale, cutting solids into minuscule pieces and precisely measuring liquids. She would then put her daily ration in small containers, lining them up in neat rows. She also exercised compulsively, even after she weakened and became faint. She never took an elevator if she could walk up steps.
-- No one was able to convince Deborah that she was in danger. Finally, her doctor insisted that she be hospitalized and carefully monitored for treatment of her illness. While in the hospital, she secretly continued her exercise regimen in the bathroom, doing strenuous routines of sit-ups and knee-bends. It took several hospitalizations and a good deal of individual and family outpatient therapy for Deborah to face and solve her problems.
Deborah's case is not unusual. People with anorexia typically starve themselves, even though they suffer terribly from hunger pains. One of the most frightening aspects of the disorder is that people with anorexia continue to think they are overweight even when they are bone-thin. For reasons not yet understood, they become terrified of gaining any weight.
Food and weight become obsessions. For some, the compulsiveness shows up in strange eating rituals or the refusal to eat in front of others. It is not uncommon for people with anorexia to collect recipes and prepare gourmet feasts for family and friends, but not partake in the meals themselves. Like Deborah, they may adhere to strict exercise routines to keep off weight.
Loss of monthly menstrual periods is typical in women with the disorder. Men with anorexia often become impotent.
In patients with anorexia, starvation can damage vital organs such as the heart and brain. Excessive thirst and frequent urination may occur. Dehydration contributes to constipation, and reduced body fat leads to lowered body temperature and the inability to withstand cold. Mild anemia, swollen joints, reduced muscle mass, and light-headedness also commonly occur in anorexia. If the disorder becomes severe, patients may lose calcium from their bones, making them brittle and prone to breakage. They may also experience irregular heart rhythms and heart failure. In some patients, the brain shrinks, causing personality changes. Fortunately, this condition can be reversed when normal weight is reestablished.
Scientists have found that many patients with anorexia also suffer from other psychiatric illnesses. While the majority have co-occurring clinical depression, others suffer from anxiety, personality or substance abuse disorders, and many are at risk for suicide. Obsessive-compulsive disorder (OCD), an illness characterized by repetitive thoughts and behaviors, can also accompany anorexia. Individuals with anorexia are typically compliant in personality but may have sudden outbursts of hostility and anger or become socially withdrawn.
Bulimia is a cycle of uncontrolled binge eating following by purging. People with bulimia nervosa consume large amounts of food and then rid their bodies of the excess calories by vomiting, abusing laxatives or diuretics, taking enemas, or exercising obsessively. Some use a combination of all these forms of purging. Because many individuals with bulimia "binge and purge" in secret and maintain normal or above normal body weight, they can often successfully hide their problem from others for years.
Bulimia can range from a mild and relatively infrequent response to stress to an extremely debilitating pattern that absorbs nearly all of a person's time, energy, and money. In its most severe forms, binge eating and purging may occur ten or more times a day.
Bulimia usually begins innocuously as an attempt to control weight. Purging may seem to be a convenient means for a person to overeat without gaining weight. It can quickly become a destructive process that cannot be controlled. Persons with bulimia are often aware that their eating patterns are abnormal and out of control and that their lives are dominated by their eating habits. They may feel quilty and depressed after a binge. Over time, the cycle becomes more and more dominant in the person's thoughts and behavior. It may impair personal relationships and interfere with other activities, leading to depression, isolation, and lowered self-esteem. Once caught in this pattern, the resulting shame and sense of helplessness may make it difficult for the person to seek the help that is needed.
Physical effects can also be serious. Frequent vomiting can cause permanent tooth damage from erosion of tooth enamel as well as damage to the tissues of the throat and esophagus. Kidney problems and seizures are also possible. Electrolyte imbalance with consequent risk of serious cardiac problems is also a significant danger.
Consider the case of Lisa, a young woman suffering from bulimia.
-- Lisa developed bulimia nervosa at 18. Her strange eating behavior began when she started to diet. She too dieted and exercised to lose weight, she regularly ate huge amounts of food and maintained her normal weight by forcing herself to vomit. Lisa often felt like an emotional powder keg--angry, frightened, and depressed.
-- Unable to understand her own behavior, she thought no one else would either. She felt isolated and lonely. Typically, when things were not going well, she would be overcome with an uncontrollable desire for sweets. She would eat pounds of candy and cake at a time, and often not stop until she was exhausted or in severe pain. Then, overwhelmed with guilt and disgust, she would make herself vomit.
-- Her eating habits so embarrassed her that she kept them secret until, depressed by her mounting problems, she attempted suicide. Fortunately, she didn't succeed. While recuperating in the hospital, she was referred to an eating disorders clinic where she became involved in group therapy. There she received medications to treat the illness and the understanding and help she so desperately needed from others who had the same problem.
Family, friends, and physicians may have difficulty detecting bulimia in someone they know. Many individuals with the disorder remain at normal body weight or above because of their frequent binges and purges, which can range from once or twice a week to several times a day. Dieting heavily between episodes of binging and purging is also common. Eventually, half of those with anorexia will develop bulimia.
As with anorexia, bulimia typically begins during adolescence. The condition occurs most often in women but is also found in men. Many individuals with bulimia, ashamed of their strange habits, do not seek help until they reach their thirties or forties. By this time, their eating behavior is deeply ingrained and more difficult to change.
Bulimia nervosa patients--even those of normal weight--can severely damage their bodies by frequent binge eating and purging. In rare instances, binge eating causes the stomach to rupture; purging may result in heart failure due to loss of vital minerals, such as potassium. Vomiting causes other less deadly, but serious, problems--the acid in vomit wears down the outer layer of the teeth and can cause scarring on the backs of hands when fingers are pushed down the throat to induce vomiting. Further, the esophagus becomes inflamed and glands near the cheeks become swollen. As in anorexia, bulimia may lead to irregular menstrual periods. Interest in sex may also diminish.
Some individuals with bulimia struggle with addictions, including abuse of drugs and alcohol, and compulsive stealing. Like individuals with anorexia, many people with bulimia suffer from clinical depression, anxiety, OCD, and other psychiatric illnesses. These problems, combined with their impulsive tendencies, place them at increased risk for suicidal behavior.
Causes of Eating Disorders
Anorexia nervosa has been known for over a century but it is only since the early 1970's that bulimia, not associated with anorexia, has been known to professionals. One out of every one hundred women may become anorexic. Estimates of the frequency of bulimia vary from five out of a hundred to twenty out of a hundred in college age women. Men also develop anorexia nervosa and bulmia but in far smaller numbers. Both disorders appear to be on the increase. Experts do not know the causes of these disorders nor why they are increasing, but most agree that biological, psychological, and social factors all play a part.
Least is known about biological factors. Some evidence suggests that eating disorders may develop as a response to inherited predispositions to mood swings and depression. Other evidence reveals an increased incidence of major depression and alcoholism in blood relatives of persons with bulimia or bulimic variations of anorexia nervosa. Antidepressant medication under the supervision of a physician has been found helpful to some individuals in controlling the binge-purge cycle.
More attention has been paid to the psychological development of persons with eating disorders. It is speculated that anorexia may function as an attempt to gain control over life or life circumstances when a person has felt little control in the past. It may also serve as an avoidance of the bewildering complexities of physical and emotional maturation. Individuals with anorexia are often compliant "model children" who tend to be intelligent, perfectionistic, and have high personal standards. They often want to please others but have low self-esteem and problems with assertion. They will also frequently be depressed. High expectations within their families may be another contributing factor.
Persons with bulimia also suffer from low self-esteem but tend to be less passive than persons with anorexia nervosa. Individuals with bulimia tend to be more socially active, are more likely to date, and may use alcohol and drugs. Research suggests that persons with bulimia have a higher general level of anxiety than others. Thus the binge-purge cycle may function as a mechanism for relieving anxiety and emotional stress.
Social factors also seem to contribute to eating disorders. Excessive emphasis within our culture on slim, boyish figures for women makes it increasingly hard for the adolescent girl, already worried about herself and her body, to feel acceptable. Increasing numbers of teenage girls resort to extreme diets or purging in attempts to make their maturing bodies conform to the expectations of society. Some of these individuals will be trapped in the destructive pattern of eating disorders. Females have traditionally felt more pressure than males to conform to physical stereotypes of what is acceptable. This may explain why so many more females than males develop eating disorders.
Treatment of Eating Disorders
An important first step in overcoming an eating disorder is for the person to acknowledge to him or herself and to helping professionals that an eating disorder is a problem. Medical and psychological help should be sought from individuals experienced in the treatment of such disorders. A complete physical examination including lab tests will often be necessary.
Psychotherapy is also usually necessary. It may include individual and/or group therapy. One immediate benefit of such therapy is the feeling of relief at no longer having to keep such an important part of one's life a secret. Psychotherapy will often focus on improving self-esteem. It may be supplemented by nutrition education, discussions of eating habits, and food selection.
This combination of medical, psychological, and educational treatments can be effective on an outpatient basis. In extreme cases, e.g., a person with anorexia nervosa whose weight is extremely low or a person with bulimia who is completely out of control, temporary hospitalization may be required. What is most important is that professional treatment be sought as quickly as possible. Attempts at self-help are rarely successful, and the longer the disorder remains unchecked the harder it may be to overcome.