The term "eating disorders" encompasses a group of problems that fall into two broad categories—overeating (binging), and undereating (anorexia)—sometimes referred to as "starving or stuffing." Eating disorders are most commonly found in young females during early adolescence. However, eating disorders affect both males and females at many stages in the life cycle. Although the conditions create physical problems, the causes are usually psychological.
Eating disorders have been recognized by health experts for many years. Bulimia symptoms were described by the Egyptians, Hebrews, and Greeks; and anorexia nervosa was first described in the 1600s. However, it was not until 1980 that these conditions were categorized as psychiatric disturbances.
Eating disorders are marked by extreme dissatisfaction and preoccupation with body size and shape. People with these disorders may see themselves as overweight when their weight is actually lower than normal, or they may measure their self-worth by their weight. Emotional disturbance accompanies disordered eating, including self-loathing over amounts eaten or panic about possible weight gain. In addition to overeating or undereating, individuals with eating disorders engage in "compensatory behaviors," such as purging (self-induced vomiting or inappropriate use of laxatives, enemas, or diuretics), fasting, excessive exercise, and restricting (overly strict limiting of calories or food types).
Eating disorders can be distinguished from dieting by the psychological distress that accompanies the concern about weight; by the interference with everyday responsibilities and pleasures; and by the danger of causing medical problems, possibly even death.
Shame and secrecy often accompany eating disorders, and the problem may go undetected for years. Recognition of these disorders is necessary to begin the long process of treatment. Unlike other addictive or habit problems, food cannot be avoided, and recovery requires developing a healthier relationship to food and to one's own body, as well as improved coping skills.
Mental health professionals recognize three main types of eating disorders, anorexia nervosa, bulimia nervosa, and binge eating.
Anorexia. Although the word "anorexia" literally means "without appetite," the condition is better described as "restricted eating" or "self-starvation." The person with anorexia has an appetite, and food tastes good; however, food is seen as "the enemy." One authority terms anorexia "food phobia." The disorder is characterized by a refusal to maintain a minimal normal body weight, an intense fear of gaining weight, a disturbance in the self-perception of body size and shape, and (in women) an absence of menstrual periods for three or more consecutive months. Anorexia may be further classified as a restricting type or binge-eating/purging type.
Bulimia. Bulimia (Greek for "ox hunger") is characterized by recurrent episodes of binge eating. Binging (eating an extreme amount of food) is accompanied by a sense of lack of control over amounts eaten, and a feeling of being unable to stop. The disorder is further classified as either purging or nonpurging bulimia depending on whether the individual uses fasting or exercise instead of purging to "compensate" for binging.
Binge Eating. Binge eating is sometimes termed "stress eating" or "emotional overeating." It is characterized by compulsive overeating, usually in secret and without purging, followed by guilt or remorse for the episode. It has been estimated that up to 40 percent of people with obesity may be binge eaters. The term "binge eating disorder" was officially introduced in 1992. Unlike nonpurging bulimia, there is no attempt to "compensate" for the binge by fasting or overexercising.
Eating disorders can be considered biologically based alterations filtered through cultural pressures and individual psychology. The psychological aspects of anorexia are frequently thought to include conflicts between mothers and adolescent daughters over perfection. Bulimia is often thought to involve conflicts over dependence and loneliness. Binging may share causal factors with obsessive-compulsive behavior.
Since people commonly deny or try to hide their disordered eating behaviors, it is difficult to accurately estimate the number of people affected by these problems. Nonetheless, experts report approximately 1.2 million women in the United States are affected by anorexia or bulimia.
Anorexia is more present in developed societies, especially in societies where being attractive is linked to being thin. The prevalence of anorexia has been estimated to be 0.5 to 1 percent of the population, and rates appear to be increasing. The condition usually begins in early adolescence (13–18 years) and 90 percent of the cases are female. Occasionally, but rarely, the disorder may begin in someone over age forty. Stressful life events (e.g., leaving home for college) occasionally trigger the onset of the problem. Long-term death rates from anorexia approach 10 percent, with death usually resulting from starvation, suicide, or electrolyte imbalance.
The chances of developing an eating disorder are higher among females (female cases outnumber male cases 10 to 1), among those pressured by society or family to be thin, and among athletes. Athletes for whom weight control and/or thinness provides an advantage (e.g., gymnastics, wrestling) are particularly susceptible to eating disorders. Psychological factors that put a person at risk for disordered eating include low self-esteem, poor coping ability, perfectionism, and body image distortion. Genetics may also play a role. Risk increases among those with a close relative (a parent or sibling) with an eating disorder, especially with binging/purging.
Eating disorders cause an array of medical problems ranging from fatigue to illness, and occasionally death. Even when eating disorders do not reach this level of severity they can be significant sources of suffering for the patient and family members. Mild complications include lack of energy, cavities, cold intolerance, irregular periods, constipation and diarrhea, and difficulty with concentration. Serious complications include electrolyte instability, irregular heartbeat, suicidal tendencies, and death. Between 5 to 18 percent of those with anorexia or bulimia will die from complications of the disorder.
Malnourishment and self-starvation affect the heart, thyroid, and the digestive and reproductive systems, as well as seriously decreasing bone density. Specific problems seen in athletes with eating disorders include impaired athletic performance and an increased risk of injuries and stress fractures. Female athletes with an eating disorder may be considered to have the "female athlete triad" if they manifest symptoms of: (1) disordered eating (which leads to decreased body fat causing a lower estrogen level); (2) amenorrhea (not having a period for three consecutive cycles because of low estrogen); and (3) osteoporosis (fragile bones because of low estrogen).
Although eating disorders are not contagious, the culture in which the person lives can contribute to the spread of an eating disorder, particularly in cultures that glorify thinness. Although obesity may be a consequence of binge eating, it does not typically result from the major eating disorders. Prevention efforts may help, and early detection efforts are essential as patients do not typically request treatment for themselves. Psychological consequences of semistarvation include depressed mood, social withdrawal, insomnia, irritability, and loss of libido, as well as obsessive thoughts about food.
The most important factor in treating people with eating disorders is the recognition of the disorder. Disordered eating is usually not self-diagnosed because of associated denial and embarrassment. Anorexics usually do not even realize there is a problem with their behavior, and bulimics usually realize the problem but try to hide their behavior. Family, friends, or health care professionals are often the people who recognize the problem. A team treatment approach is frequently employed, consisting of a physician, a nutritionist, and a psychologist. Medically, antidepressants may be needed, and complications may require treatment or hospitalization if the situation is severe enough. Nutritionally, people with disordered eating need to learn how to eat in a healthful way. Psychologically, modification of inappropriate food-related behavior and development of improved coping mechanisms are necessary. In addition, changes in body image and ideal body image may be necessary.
Treatment, especially for anorexia, can be a long drawn-out affair, and it can take a big toll on family resources and on the social productivity of the person. Recovery from these disorders is difficult, and estimates of 50 percent relapse rates for anorexia and 33 percent for bulimia are common. A difficulty in the control of disordered eating behaviors is the need to continue to eat. This it is in contrast to other disorders of habit or addiction in which treatment involves total avoidance of the abused substance.
The Academy of Eating Disorders (http://www.acadeatdis.org) is a multidisciplinary professional group devoted to the improved detection and treatment of these conditions. Efforts to expand screening are promoted through eating disorders awareness week on U.S. college campuses, and this has now been expanded to high school and the general public (http://www.nmisp.org/eat.htm).
Other valuable resources include the following:
LEONARD J. HAAS
(SEE ALSO: Anorexia; Menstrual Cycle; Mental Health; Nutrition; Social Determinants)
American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders. 4th edition. Washington, DC: Author.
American Psychiatric Association (2000). "Practice Guideline for the Treatment of Patients with Eating Disorders (Revision)." American Journal of Psychiatry 157 (January Supp.):1.
Browell, K. D., and Fairburn, C. G., eds. (1995). Eating Disorders and Obesity. New York: Guilford Press.
Christensen, L. (1996). Diet-Behavior Relationships: Focus on Depression. Washington, DC: American Psychological Association Books.
Danowski, D., and Lazora, P. (2000). Why Can't I Stop Eating? Recognizing, Understanding, and Overcoming Food Addiction. Center City, MN: Hazelden Information Education Services.
Fairburn, C. G. (1995). Overcoming Binge Eating. New York: Guilford Press.
Natenshon, A. H. (1999). When Your Child has an Eating Disorder: A Step-by-step Workbook for Parents and Other Caregivers. San Francisco: Jossey Bass Publishers.
Siegel, M.; Brisman, J.; and Weinshel, M. (1997). Surviving an Eating Disorder: New Perspectives and Strategies for Family and Friends. New York: Harper Collins.
Stunkard, A. J., and Wadden, T. (ed.) 1993. Obesity: Theory and Therapy. Lancaster, CA: Raven Press.
Thompson, A. K., ed. (1996). Body Image, Eating Disorders and Obesity: An Integrated Guide to Assessment and Treatment. Washington, DC: American Psychological Association Books.