Preteens, teens, and college-age women are at special risk for eating disorders. In fact, most of those who develop an eating disorder are young women. However, between 5% and 15% of people with anorexia or bulimia and about 35% of those with binge-eating disorder are male, according to the NIMH. No one knows exactly how many men and teenage boys are afflicted. Until recently, there has been a lack of awareness that eating disorders can be a problem for males, perhaps because men are more likely to mask the symptoms of eating disorders with excuses and rationales such as preventing heart disease or diabetes or trying to build a more muscular physique. Studies suggest that for every ten women with an eating disorder, one male is afflicted.
Anorexia Nervosa
Anorexia nervosa involves severe weight loss—a minimum of 15% below normal body weight. People with anorexia literally starve themselves, although they may be very hungry. For reasons that researchers do not yet fully understand, people with anorexia become terrified of gaining weight. Both food and weight become obsessions. They often develop strange eating habits, refuse to eat with other people, and exercise strenuously to burn calories and prevent weight gain. Individuals with anorexia continue to believe they are overweight even when they are dangerously thin.
The medical complications of anorexia are similar to starvation. When the body attempts to protect its most vital organs—the heart and the brain—it goes into "slow gear." Monthly menstrual periods stop, and breathing, pulse, blood pressure, and thyroid function slow down. The nails and hair become brittle, and the skin dries. Water imbalance causes constipation, and the lack of body fat causes an inability to withstand cold temperatures. Depression, weakness, and a constant obsession with food are also symptoms of the disease. In addition, personality changes may occur. The person suffering from anorexia may have outbursts of anger and hostility or may withdraw socially. In the most serious cases, death can result.
Bulimia
The person who has bulimia eats compulsively and then purges (gets rid of the food) through self-induced vomiting; use of laxatives, diuretics, strict diets, fasts, or exercise; or a combination of several of these compensatory behaviors. In 2002 the NIMH reported that based on community surveys, between 2% and 5% of Americans engage in binge eating, and about half of those with anorexia will turn to bulimia. Bulimia often begins when a young person is disgusted with the excessive amount of "bad" food consumed and vomits to rid the body of the calories.
Many people with bulimia are at a normal body weight or higher because of their frequent binge-purge behavior, which can occur from once or twice a week to several times a day. Those people with bulimia who maintain normal weights may manage to keep their eating disorders secret for years. As with anorexia, binge-eating disorder usually begins during adolescence, but many people with bulimia do not seek help until they are in their thirties or forties.
Binge eating and purging is dangerous. In rare cases, bingeing can cause stomach ruptures, and purging can result in heart failure because the body loses vital minerals. The acid in vomit wears down tooth enamel and the stomach lining and can cause scarring on the hands when fingers are pushed down the throat to induce vomiting. The esophagus may become inflamed, and glands in the neck may become swollen.
People with bulimia often talk of being "hooked" on certain foods and needing to feed their "habits." This addictive behavior carries over into other areas of their lives, including substance (alcohol and drug) abuse. Many people with bulimia suffer from comorbidities such as severe depression, which increases their risk for suicide.
Causes of Eating Disorders
Evidence suggests a genetic component to susceptibility to eating disorders. For example, in the general population the chance of developing anorexia is about one in two hundred, but when a family member has the disorder, the risk increases to one in thirty. Twin studies demonstrate that when one twin is affected there is about a 50% chance the other will develop anorexia (Arline Kaplan, "Exploring the Gene-Environment Nexus in Anorexia, Bulimia," Psychiatric Times, vol. 29, no. 9, August 2004).
People with bulimia and anorexia seem to have different personalities. Those with bulimia are likely to be impulsive (acting without considering the consequences) and are more likely to abuse alcohol and drugs. People with anorexia tend to be perfectionists, good students, and competitive athletes. They usually keep their feelings to themselves and rarely disobey their parents. People with bulimia and anorexia share certain traits: they lack self-esteem, have feelings of helplessness, and fear gaining weight. In both disorders, the eating problems appear to develop as a way of handling stress and anxiety.
The person with bulimia consumes huge amounts of food (often junk food) in a search for comfort and stress relief. Yet the bingeing brings only guilt and depression. However, persons with anorexia restrict food to gain a sense of control and mastery over some aspect of their lives. Controlling their body weight seems to offer two advantages—the victims can take control of their bodies and can gain approval from others.
Demographics and Prevalence of Eating Disorders
Individuals with eating disorders usually come from white, middle- or upper-class families. The NIMH noted that while eating disorders have increased substantially in industrialized countries during the past twenty years, they are almost unheard of in developing countries. Thinness is not necessarily admired among all people throughout the world, especially in countries where hunger is not a matter of choice.
Estimates of the prevalence of eating disorders vary in part because secretiveness and shame prevent many cases from being reported. The NIMH in "Eating Disorders: Facts about Eating Disorders and the Search for Solutions" (2001, http://www.nimh.nih.gov/Publicat/eatingdisorders.cfm) estimates that throughout their lifetimes, from .5% to 3.7% of females suffer from anorexia and from 1.1% to 4.2% suffer from bulimia. The lifetime prevalence of binge eating was estimated as 2-5% for males and females. The National Women's Health Information Center names eating disorders as a key health issue affecting from 1% to 4% of young women in the United States. The center also observes that eating disorders often coexist with other high-risk health behaviors such as tobacco, alcohol and drug use, delinquency, unprotected sexual activity, and suicide attempts.
Dean D. Krahn et al in "Pathological Dieting and Alcohol Use in College Women—A Continuum of Behaviors" (Eating Behaviors, January 2005) examined the relationship between dieting, binge eating disorder, and alcohol use in female college students. The University of Wisconsin researchers found a relationship between dieting and bingeing severity and the frequency, intensity, and negative consequences of alcohol use in the students. In fact, dieting and bingeing was more closely associated with alcohol use than depression, the subjects' parents' drinking history, or their ages when they had their first alcoholic drinks. Further, the severity of the disordered eating behavior was linked to the occurrence of negative consequences of alcohol use such as blackouts and unintended sexual activity. The researchers concluded that destructive eating behaviors are often associated with harmful alcohol use.
According to the National Eating Disorders Association, conservative estimates of the prevalence of eating disorders in the United States project that as many as ten million women and one million men are affected. An estimated 35% of normal dieters progress to the dangerous extreme dieting that is a precursor of eating disorders. The Eating Disorders Coalition for Research, Policy, and Action reports that the incidence of eating disorders has doubled since the 1960s and that mortality attributable to eating disorders is as high as 20%—the highest mortality rate of any mental illness.
Treatment of Eating Disorders
Generally a physician treats the medical complications of the disorder, while a nutritionist advises the affected individual about specific diet and eating plans. To help the person with an eating disorder face his or her underlying problems and emotional issues, psychotherapy is usually necessary. Persons with eating disorders, whether they are normal weight, overweight, or obese, should seek help from a mental health professional such as a psychiatrist, psychologist, or clinical social worker for their eating behavior. Sometimes the challenge is to convince people with eating disorders to seek and obtain treatment; other times it is difficult to gain their adherence to treatment. Many anorexics deny their illness, and getting and keeping anorexic patients in treatment can be difficult. Treating bulimia is similarly difficult. Many bulimics are easily frustrated and want to leave treatment if their symptoms are not quickly relieved.
Several approaches are used to treat eating disorders. Cognitive behavioral therapy (CBT) teaches people how to monitor their eating and change unhealthy eating habits. It also teaches them how to change the way they respond in stressful situations. CBT is based on the premise that thinking influences emotions and behavior—that feelings and actions originate with thoughts. CBT posits that it is possible to change the way people feel and act even if their circumstances do not change. It teaches the advantages of feeling calm when faced with undesirable situations. CBT clients learn that they will confront undesirable events and circumstances whether they become troubled about them or not. When they are troubled about events or circumstances, they have two problems—the troubling event or circumstance, and the troubling feelings about the event or circumstance. Clients learn that when they do not become troubled about trying events and circumstances they can reduce the number of problems they face by half.
Interpersonal psychotherapy (IPT) helps people look at their relationships with friends and family and make changes to resolve problems. Interpersonal psychotherapy is short-term therapy that has demonstrated effectiveness for the treatment of depression. According to the International Society for Interpersonal Psychotherapy, IPT does not assume that mental illness arises exclusively from problematical interpersonal relationships. It does emphasize, however, that mental health and emotional problems occur within an interpersonal context. For this reason, the therapy aims to intervene specifically in social functioning to relieve symptoms.
Like other forms of psychotherapy, IPT may be used in conjunction with medications. Because eating disorders frequently recur, it is recommended that successful short-term treatment be combined with ongoing maintenance therapy, such as monthly sessions following completion of the short-term phase.
Group therapy has been found helpful for bulimics, who are relieved to find that they are not alone or unique in their binge-eating behaviors. A combination of behavioral therapy and family systems therapy is often the most effective with anorexics. Family systems therapy considers the family as the unit of treatment and focuses on relationships and communication patterns within the family rather than the personality traits or symptoms displayed by individual family members. Family systems therapy considers the family as an entity that is more than the sum of its individual members and uses "systems theory" to determine family members' roles within the system as a whole. Problems are addressed by modifying the system rather than trying to change an individual family member. Persons with eating disorders who also suffer from depression may benefit from antidepressant and antianxiety medications to help relieve coexisting mental health problems.
A long-term study (approximately 11.5 years) of 173 young women diagnosed with bulimia reiterated the strong hold eating disorders have on their victims (P. K. Keel et al, "Long-Term Outcome of Bulimia Nervosa," Archives of General Psychiatry, vol. 56, January 1999). At the final follow-up, 30% of the patients still showed symptoms of eating disorders. Eighteen percent were diagnosed with an "eating disorder not otherwise specified," 11% with bulimia, and .6% with anorexia nervosa.
Of the 70% in remission, one-third had achieved only partial remission. Patients who had longer periods of symptoms before beginning treatment and those who had a history of substance abuse were less likely to be successful. The results of this study underscore the observation that the earlier the eating disorder is diagnosed and treated, the more likely the patient will recover to a healthy weight.
Recovery from eating disorders is uneven. The Eating Disorders Coalition for Research, Policy, and Action characterized recovery as a process that frequently entails multiple rehospitalizations, limited ability to work or attend school, and limited capacity for interpersonal relationships. About one-third of sufferers recover after an initial episode and treatment, another third fluctuate between recovery and relapse, and the remaining one-third suffer chronic decline and deterioration.
In part, eating disorders are difficult to treat effectively because many sufferers resist entering treatment and/or fail to complete treatment programs. Katherine Halmi et al. in "Predictors of Treatment Acceptance and Completion in Anorexia Nervosa: Implications for Future Study Designs" (Archives of Psychiatry, July 2005) examined the factors leading to nonacceptance and noncompletion (dropping out) of treatment of a specific treatment plan—cognitive behavioral therapy, fluoxetine hydro-chloride, or their combination for one year to treat anorexia nervosa. Of the 122 subjects with diagnosed anorexia nervosa, almost half (46%) dropped out of treatment. More than two-thirds (68%) of those who dropped out cited "dissatisfaction with some aspect of the treatment" as their reason for noncompletion. While the researchers did not pinpoint the reasons for nonacceptance and noncompletion, their study offered some clues and direction for further investigation. For example, the study found that subjects with high self-esteem were more likely than those with low self-esteem to complete treatment. As a result, the researchers opined that remedies must be identified to "improve acceptance of treatment and reduce dropout in those patients with low obsessive preoccupation and low self-esteem."
Robin Sysko et al in "Eating Behavior among Women with Anorexia Nervosa" (American Journal of Clinical Nutrition, August 2005) reconfirmed the finding that while hospital treatment of persons with anorexia is often successful, 30% to 70% of patients suffer relapses when they are discharged back into the community. The researchers wanted to find out whether current treatment for anorexia successfully addresses severe caloric restriction and other characteristic features of anorexia nervosa. To do this, they scrutinized eating behavior among persons with anorexia nervosa before and immediately after treatment that restored their weight and compared these behaviors to those of control subjects.
They observed twelve anorexic patients and twelve individuals without eating disorders who were asked to consume a strawberry yogurt shake, which they were told would be their lunch for the day. They were also told to consume as much as they wanted. The yogurt shake was in an opaque container and was drunk with a straw so that the subjects could not see the shake. They were also not told the contents of the shake or how many calories it contained. The anorexic patients were tested when they were admitted for treatment, and re-tested after they had reached 90% of their ideal body weight.
Before treatment, anorexic patients consumed an average 103.97 grams of the shake, which increased to an average of 178.03 grams after treatment. However, in both instances, control subjects consumed significantly more than anorexic patients, at an average of 489.58 grams. The researchers observed that subjects with anorexia found the experiment difficult and anxiety provoking because they were unable to see the shake and control their calorie intake. This was despite the fact that subjects treated for anorexia displayed significant decreases in psychological and eating-disordered symptoms after they had regained weight. The researchers felt their findings underscored the need for interventions for people with anorexia once they leave an intensive treatment program. They hope to devise strategies to help normalize patients' eating behavior outside the hospital, for example by helping reduce their anxiety and fear about eating unknown quantities of food.
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