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Anorexia nervosa and bulimia nervosa are two of the most commonly recognized eating disorders. The term “eating disorder” encompasses a variety of psychological/psychiatric disorders involving disturbed eating patterns and attitudes toward food and body image. Unhealthy weight control practices and intense body image distortion or disparagement are central features of eating disorders.
I. Overview of Eating Disorder Terms
II. Continuum of Health Related to Eating Disorders
III. Diagnostic Criteria
A. Anorexia Nervosa
B. Bulimia Nervosa
C. Eating Disorders Not Otherwise Specified
V. Psychological and Social Impairment
VI. Medical Complications
VII. Detection and Assessment
C. Nutritional Counseling
I. Overview of Eating Disorder Terms
The word “nervosa” indicates that each of these conditions is a “nervous disorder.” Psychological difficulties are likely to be involved in the development of these disorders, and also are likely to be exacerbated by the eating-disordered behavior. “Anorexia” means “lack of appetite.” The hallmark feature of anorexia nervosa (AN) is failure to maintain a minimally normal body weight. The meaning of the term “bulimia” is “ox hunger,” or “hungry as an ox.” Bulimia nervosa (BN) is characterized by recurrent episodes of binge eating (i.e., eating large amounts of food accompanied by a sense of loss of control) and compensatory behaviors (e.g., purging, fasting, or excessive exercise). Overlap between the symptoms of these disorders occurs in some individuals. Furthermore, individuals may engage in disturbed eating behaviors and/or indicate intense body image disparagement, but not meet full criteria for anorexia nervosa or bulimia nervosa. Detailed information about diagnostic criteria are provided later in this research paper. It is important to note that eating-related behaviors may be best conceptualized as existing along a continuum ranging from “healthy” to “unhealthy” eating-related behaviors and body image.
II. Continuum of Health Related to Eating Disorders
The pursuit of and preoccupation with beauty represent a central feature of the female sex-role stereotype. Therefore, it is possible that attractiveness, and specifically body image, have a greater influence on self-concept for women than for men. Although standards of beauty have varied widely across time and cultures, the mass media have contributed to the development of a more uniform standard of beauty.
Unfortunately, the current images of women that are portrayed in the media often represent unrealistic weights and shapes for most women. In a classic study, Garner and colleagues demonstrated a consistent decrease in body weights and measurements of two (albeit arguable) standards of beauty (e.g., Miss America pageant winners, and Playboy centerfolds) over two decades (1950s to 1970s). Fashion models are now 23 % thinner than average women, compared to 8% thinner than average woman three decades ago. Indeed, models who depict the in-vogue “waif” look are likely to have a body weight consistent with criteria for anorexia nervosa.
Given the preponderance of images of thinness as the ideal for beauty that are depicted in the media, it is not surprising that many females would perceive their bodies as inadequate. Because women naturally have more body fat than men, even those who are of normal body weight may judge themselves as overweight. In a recent national survey, over 40% of females reported having a negative body image. Although almost one half of young girls reported wanting to lose weight in one survey, only 4% actually were found to be overweight. Women are far more likely to rate their ideal figure to be significantly thinner than actual size than are men.
Therefore, perceptions that one is overweight may be potentially more distressing for women and may lead to attempts to control body weight and shape through methods such as dieting. Female college students report dieting at much higher rates than their male counterparts. In a recent large-scale national survey data from the Centers for Disease Control and Prevention, containing a sample of over 60,000 adults, 38% of female and 24% of male adults reported to be trying to lose weight, and 44% of females versus 15 % of males in high school sample of over 11,000 students reported to be trying to lose weight.
The high prevalence rates of negative body image attitudes and dietary behaviors found among females has been referred to as “normative discontent.” Therefore, although not necessarily “healthy,” it may in fact be “normal” for women in Western cultures to hold disparaging views toward their bodies and to engage in activities aimed at modifying their weight and shape. However, body image disparagement and dieting behaviors may pose as risk factors for the development of an eating disorder. Initial degree of body image dissatisfaction has been found to predict increased eating disturbance in longitudinal studies of adolescent girls and to predict eating disordered behavior in adults. Similarly, the interaction between body image and other risk factors (e.g., pressure for thinness) increased probability of reporting eating disturbance in female athletes. In a study of adult ballet students, body dissatisfaction and dietary restriction were found to predict eating-disordered symptoms.
Therefore, individuals who derive self-esteem primarily or exclusively based on the perception of body image may be at increased risk for development of an eating disorder. It has been argued that individuals who develop eating disorders unquestionably accept and internalize societal messages about thinness as the ideal for female attractiveness. Excessive dietary restraint, often used as a means to modify body weight and shape in an attempt to more closely correspond to a thin ideal of beauty, has been posited to increase the potential for development of binge eating. Secondary symptoms of semi-starvation resulting from prolonged dietary restriction or fasting, such as increases in preoccupation with food, urges to binge eat, and depressed mood, may lead to further exacerbation of body image disparagement and disturbed eating. Although body image concerns and dieting practices are commonplace for many women, when body image disparagement and eating disturbances become extreme and begin to interfere with functioning or to compromise health, an eating disorder may be diagnosed.
III. Diagnostic Criteria
Although the symptoms of the various eating disorder syndromes overlap considerably and often are characterized as along a continuum, classification of specific eating disorders is based on criteria as outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).
A. Anorexia Nervosa
The primary distinguishing feature of anorexia nervosa (AN) is the refusal to maintain a minimally normal body weight (i.e., at least 85% of expected body weight considering age and height). Despite their excessively low-weight status, individuals with AN exhibit intense fear of gaining weight. Such individuals experience their body weight or shape in a distorted manner (e.g., size distortion) and often indicate intense distress regarding body image. Body weight or shape unduly influences self-evaluation, often being the primary determinant of self-esteem. Absence of three or more consecutive menstrual cycles (i.e., amenorrhea) is also required to make a diagnosis of AN. Perhaps the feature that presents the greatest challenge in accurately assessing and effectively treating this disorder is the adamant denial of the seriousness of maintaining an excessively low body weight. Individuals with anorexia nervosa may also engage in recurrent binge eating and purging (i.e., self-induced vomiting, abuse of laxatives, or diuretics), which is classified as the binge eating/purging subtype of AN. Absence of recurrent binge eating and purging characterizes the restricting type of AN.
B. Bulimia Nervosa
Within the past two decades bulimia nervosa (BN) only has been recognized as a distinct clinical disorder. The primary feature of BN is recurrent binge eating (i.e., eating large amounts of food in a short time period accompanied by a sense of loss of control) followed by methods of inappropriate compensation. Compensatory methods include purging (i.e., self-induced vomiting, or abuse of laxatives, or diuretics), fasting, or excessive exercise. Symptom frequency for a diagnosis of bulimia nervosa entails binge eating and compensatory behavior(s) occurring on average at least twice a week for a 3-month period. Perception of body shape and weight unduly influencing self-evaluation also is required for the diagnosis of BN. A diagnosis of BN is not given to individuals who receive a diagnosis of AN, because that diagnosis takes precedence. Subclassification of BN is based on type of recurrent compensatory methods, referred to as purging and nonpurging types.
C. Eating Disorders Not Otherwise Specified
A large number of individuals engage in disturbed eating behaviors, but do not meet strict diagnostic criteria for anorexia nervosa or bulimia nervosa, in which case a diagnosis of eating disorder not otherwise specified (ED-NOS) may be appropriate. Examples of symptom constellations that might meet the criteria for ED-NOS include bulimic behavior occuring less frequently than two times per week or purging in the absence of binge eating behavior. Another example of ED-NOS, binge eating disorder (BED), which is characterized by recurrent binge eating in the absence of compensatory behaviors, has been listed in the appendix of DSM-IV as a diagnosis warranting further research.
IV. Epidemiology of Eating Disorders
Although increasing prevalence combined with increased recognition of eating disorder problems for women has contributed to the perception that eating disorders have become an “epidemic,” this is not supported by epidemiological research. However, the high prevalence of eating disorders is well documented, with women representing the majority of those afflicted. Although these disorders are most commonly seen in women, approximately 5% to 10% of individuals who develop anorexia nervosa or bulimia nervosa are men. Research on AN and BN indicate that these disorders are most often found among Caucasian adolescent and young adult females in industrialized countries espousing the ideology of Western culture. The most recent figures indicate that from .10% to 1.0% of young females have AN. Prevalence rates are higher for BN, ranging from 1% to 3% of young women when using stringent diagnostic criteria.
Increased rates of anorexia nervosa and bulimia nervosa have been associated with certain professions (e.g., fashion models, ballet dancers) that emphasize thinness. Elevated rates of eating disorders have also been found among individuals involved in competitive athletics, particularly those in which maintenance of a low body weight is competitively advantageous (e.g., gymnastics, running, wrestling). It is possible that participation in such activities poses as a risk factor in the development of an eating disorder. Alternatively, some individuals with established eating disorders (or body image disparagement) may be drawn to such activities, in order to use compulsive exercise as a socially condoned form of dietary compensation in efforts to maintain or achieve a low body weight.
- Psychological and Social Impairment
Body image disturbance is a central feature of anorexia nervosa and bulimia nervosa. Body size overestimation among individuals with AN and BN has been empirically documented. Among individuals with AN and BN, marked fluctuations of body image disparagement frequently occur, which may precipitate and/or result from intensified eating disordered behavior.
Increased psychological distress often is found among individuals with an eating disorder. Relatively high rates of comorbid psychopathology (especially affective disorders) have been reported for samples of individuals with anorexia nervosa. In addition, problems with past or present substance abuse are not uncommon among eating disordered samples. Individuals with eating disorders also display a pattern of cognitive abnormalities, such as a dichotomous thinking style. Low self-esteem and difficulties in interpersonal relationships are often reported by individuals seeking treatment for eating disorders.
The extent to which these psychological and social difficulties may be involved in the development of eating disorders remains unclear and could be clarified by prospective, longitudinal studies. However, it is important to note that many of these symptoms are ameliorated with treatment that results in reduction or cessation of eating disordered behaviors.
VI. Medical Complications
Several thorough reviews are available providing detailed accounts of adverse medical sequale of eating disorders. Although prevalence rates for anorexia nervosa (AN) are relatively low, the medical consequences can be grave. Mortality rates for AN at long-term follow-up range from 6% to 20% and up to one-fourth of anorectic individuals develop severe, chronic disabilities resulting from the disorder. The results of prolonged malnutrition found in AN include certain visibly recognizable symptoms, including obvious weight loss, dry hair and skin, alopecia (i.e., hair loss), and excessive lanugo hair (e.g., fine, downy body hair). Cold intolerance, sleep disturbances, headaches, and fatigue are common among individuals with AN. Prolonged protein depletion resulting from chronic malnutrition results in additional symptoms, detectable through laboratory examinations. Abdominal pain and bloating, and constipation are often reported by individuals with AN, which may be due to delayed gastric emptying. Constipation also may result from laxative abuse and starvation. Among the most serious consequences of AN are osteoporosis, growth stunting, and cardiac complications.
Although mortality rates for bulimia nervosa are low, fatalities have been documented as a result of gastric rupture after binge eating, esophageal perforations (i.e., Boerhooves syndrome), and cardiomyopathy due to chronic ingestion of Ipecac. Fluid loss due to recurrent purging can result in dehydration and electrolyte imbalance, potentially leading to cardiovascular disturbances. Recurrent vomiting may result in esophageal erosion. Constipation and abdominal bloating and pain may result from binge eating.
VII. Detection and Assessment
Several factors contribute to the secretive nature of eating disorders, including denial of the seriousness of symptoms, embarrassment regarding the symptoms, and/or fear of the consequences of relinquishing the disturbed behaviors (i.e., potential weight gain or increased anxiety). Consequently, eating disorders often go unnoticed and can be challenging to assess, although warning signs are often present. Secretive eating, refusal to eat in public, and frequent dieting may be indicative that an individual is struggling with some form of an eating disorder; these symptoms are usually found in individuals with either anorexia nervosa or bulimia nervosa. Behavioral indications of purging behavior include spending excessive amounts of time in bathrooms or frequently going to a bathroom immediately following eating. Excessive or compulsive physical activity may also indicate the use of exercising as a form of dietary compensation. The use of stringent diets or fasting for extended periods of time may signal the presence of an eating disorder. Substantial changes in body weight, including weight fluctuations, or continued weight gain or loss may also be indicative of an eating disorder.
Emaciation is usually the primary physical indication of anorexia nervosa. Measurements of body weight obviously aids in determining if an individual is below 85% of expected weight; however, individuals with AN may drink excessive amounts of fluid or wear concealed weights in an attempt to manipulate assessment of body weight. Overactivity (e.g., continuous body movement or pacing) is often observed among individuals with AN. As described above, some of the additional detectable signs of AN include dry skin and hair, lanugo, and alopecia. Ammenorhea may also indicate the possibility of AN, although the use of oral contraceptives may complicate the detection of this symptom.
Although frequent weight fluctuations may signal the presence of bulimia nervosa (BN), many individuals with BN are of normal weight and appear relatively healthy. Although BN is usually less easily detected than anorexia nervosa, certain signs may aid in its detection. One indication of recurrent self-induced vomiting, sometimes referred to as a “Russell’s sign,” is the development of callouses or scarring on the back of the hand resulting from abrasion during self-induced vomiting. This symptom may not be present in those individuals who primarily use alternative forms of purging (i.e., laxative, diuretic, or enema abuse), who have nonpurging BN, or who after prolonged vomiting have come to do so reflexively. Self-induced vomiting may also contribute to hypertrophy of the salivary glands, creating a swollen appearance of the neck and face (i.e., “puffy cheeks”). Although this symptom may be fairly pronounced in some women, it is not detectable in the majority of individuals with BN. Additional signs include the presence of small skin hemorrhages (i.e., facial petechiae) or conjunctival hemorrhages that may result from forceful vomiting. Dental enamel erosion, most pronounced on the inside surface of the upper teeth, is another indication of purging that may produce protrusion of dental fillings or discoloration (i.e., darkening) of the teeth. This symptom, which is easily detected during dental examinations, may be overlooked during routine physical examinations unless specifically assessed. Edema may be present for those who abuse laxatives or diuretics. Individuals with BN often present with complaints of “bloating,” constipation, or lethargy. Laboratory tests may be used to detect electrolyte imbalance, although such abnormalities are detected in only approximately 40% of individuals with BN.
Psychotherapy is commonly used in the treatment of eating disorders. One form of psychotherapeutic intervention, cognitive behavioral therapy (CBT) has been the most extensively studied. Based on the work of Beck for the treatment of depression, CBT is a time-limited, present-focused, solution-oriented form of therapy. This approach is based on “collaborative empiricism” in which the client and therapist actively work together using an experimental approach to resolve a specified problem. As applied to eating disorders, the primary focus is on modifying disordered eating behaviors and distorted cognitions about food, weight, and shape. A combination of behavioral techniques, cognitive interventions, and emphasis on relapse prevention are integrated in this approach. The efficacy of CBT has been demonstrated in several studies of BN. Favorable reduction rates of binge eating (ranging from 77% to 93%) and purging (74% to 94 %) have been reported for five of the most recent, large studies. Methods used in behavior therapy (BT) also are commonly integrated in CBT treatment for individuals with eating disorders. Studies comparing BT with CBT have generally demonstrated that the addition of cognitive interventions to behavioral methods are associated with similar or greater clinical gains.
The efficacy of an alternative type of psychotherapy, Interpersonal Psychotherapy (IPT), recently has been demonstrated in treating individuals with BN, as well as BED. IPT is time-limited, present-focused, and solution-oriented. IPT differs from CBT in that the emphasis of treatment is on modification of interpersonal interactions, rather than eating disordered behavior or cognitions.
Another therapeutic approach that has been investigated is supportive-expressive therapy, a short-term, nondirective, dynamically informed modality that conceptualizes core conflicts in terms of interpersonal issues. Although supportive-expressive therapy was found to be effective in reducing binge eating in this study, CBT was found to be associated with greater improvements in many aspects of eating disturbance and psychopathology, and a higher rate of remission in bulimic symptoms.
Alternative psychotherapeutic approaches to treating individuals with eating disorders recently have been well articulated, although no controlled outcome studies have yet to be conducted. The relative efficacy of psychodynamic therapy is unclear given the absence of empirical data. However, this approach may be beneficial for clients who have not derived benefit from less intensive interventions, such as CBT. Feminist therapists have convincingly argued for the importance of considering sociocultural and political issues in designing interventions for individuals with eating disorders. The potential efficacy of psychotherapeutic interventions incorporating feminist perspectives warrant future empirical investigation.
Although favorable results have been reported using psychotherapy, particularly CBT and IPT, several limitations of this body of research warrant discussion. Despite the substantial rates of symptom reduction and remission reported in these studies, it is important to note that approximately one-third to one-half of participants remained symptomatic at the end of treatment. Furthermore, strict inclusion criteria utilized in research studies such as these limit the generalizability of the findings, which may not be representative of the majority of individuals seeking treatment for bulimia nervosa. Data are not available regarding the relative efficacy of individual versus group administration of CBT or IPT. Additional research comparing the relative efficacy of alternative psychotherapeutic approaches is warranted. However, this body of literature provides support for the efficacy of using solution-focused psychotherapeutic interventions such as CBT and IPT in treating individuals with BN.
Despite the fact that anorexia nervosa (AN) has received attention from clinical researchers for several decades, little empirical data are available regarding efficacy of psychotherapy for this disorder. To a large extent, the paucity of AN treatment research is attributable to the logistical difficulties involved in implementing controlled studies with this population. Only four outpatient psychotherapy studies of AN have been reported to date, with some suggestions of effectiveness. The potential benefits of using behavioral modification programs (which overlap to a certain extent with CBT interventions) during inpatient hospitalization has received support in several studies. Although limited empirical data are available regarding the relative efficacy of individual versus family therapy in treating individuals with eating disorders, some therapists have convincingly articulated the potential benefits of using family approaches in working with eating disordered individuals. Some empirical support exists for using family therapy for younger individuals with AN. Additional research is needed to investigate various psychotherapeutic interventions for treating individuals with AN, and relapse prevention strategies, given the substantial rate of relapse in those who initially respond to treatment.
Antidepressant medications have been found to effectively reduce binge eating and purging symptoms in several bulimia nervosa studies. Four controlled trials involving outpatient samples have demonstrated the superiority of serotonin-reuptake inhibitors (SRIs) in comparison to placebo in reducing bulimic symptoms, although one impatient trial failed to support added benefit for the drug. These medications generally have been found to be well-tolerated. Therefore, fluoxetine hydrochloride (Prozac) administered at daily doses of 60 mg (higher than the recommended dose of 20 mg used to treat individuals with major depressive disorder) is considered by some the first choice for pharmacotherapy for BN. The use of tricyclic antidepressants or monoamine oxidase inhibitors also is supported by research. Although the side effects of these classes of medications may be more problematic for many individuals than the SRIs, they may be beneficial treatment strategies for those individuals who do not respond to the use of SRIs. In addition, some clinicians prefer the second generation tricyclics, such as despiramine, as the initial intervention owing to the lower cost of the medication.
Despite the relative efficacy of antidepressant medications compared to placebo in reducing bulimic symptoms, it is important to note that rates of bulimic symptom remission at end of treatment range from 4 % to 20% in most studies. These rates of symptom remission are lower than those reported in psychotherapy outcome studies. Augmenting psychotherapy with pharmacotherapy may seem indicated in some cases, although results from research on this are mixed. Three studies have reported no benefit to adding antidepressant treatment regimen to psychotherapy on outcome in eating variables, and the results are equivocal in one study. There is some suggestion that certain other symptoms, such as those of depression, may benefit from the combination of interventions.
Little empirical data are available from investigations of the benefits of pharmacotherapy in promoting weight restoration in individuals with anorexia nervosa. Approximately a dozen controlled trials have been conducted on variety of medications, yielding often ambiguous results. Benefits have been demonstrated for the use of amitriptyline in one study and for cyproheptadine in two studies. However, the majority of placebo-controlled studies, investigiating the efficacy of these and other medications (e.g., antipsychotics, clonidine, cisapride, lithium, and tetrahydrocannabinol) have not demonstrated efficacy in promoting weight restoration.
C. Nutritional Counseling
Nutritional counseling is often regarded as a necessary therapeutic component for treatment of individuals with eating disorders. Healthy meal planning is the cornerstone of this approach, which involves providing objective nutritional information about the types and amounts of food necessary to achieve or maintain adequate nutrition and healthy weight. Behavioral strategies are also employed to increase the likelihood of successfully adhering to nutritional recommendations. Nutritional counseling is essential for the treatment of anorexia nervosa, which requires an increase in caloric intake to promote gradual weight restoration at a rate of I to 3 pounds per week. Nutritional counseling is also useful for treating BN to help stabilize the dietary chaos that often promotes binge eating.
At times sufficient medical danger exists (e.g., dehydration, severe electrolyte imbalance, gastrointestinal bleeding, severe emaciation, suicidal ideation) to require inpatient hospitalization. Goals of hospitalization include interruption of weight loss (usually if less than 70 to 75% of ideal body weight), progress toward restoration of healthy body weight, cessation of binge eating or vomiting, treatment of medical complications, and treatment of comorbid conditions (e.g., depression or substance abuse). Hospitalization also may be indicated if clinical benefits are not obtained from adequate outpatient therapy. This may be required for severely underweight individuals who, evidence starvation-induced impaired cognitive functioning.
Day treatment, or partial hospitalization, may be recommended following inpatient discharge or as an alternative to hospitalization. This type of treatment allows patients to receive therapy during the day without requiring an overnight stay. This type of treatment is more economical than inpatient hospitalization and is less socially disruptive. Additional benefits of this type of treatment include allowing the patient to pursue work or education while obtaining intensive treatment, and providing a structured atmosphere during meal times.
IX. Prevention of Eating Disorders
Given the prevalence of these disorders and the seriousness of the psychological and medical sequelae, the prevention of eating disorders is an important area that requires increased attention. Such efforts often involve providing psychoeducational information in school-based settings aimed at reducing unhealthy dieting behavior and enhancing body acceptance, often involving critical analysis of messages conveyed through mass media. A number of eating disorder studies have been conducted to investigate the effectiveness of primary prevention programs. However, an unfortunately consistent finding across such studies is that although knowledge about eating disorders often increases, behavioral changes (i.e., reductions in unhealthy dietary practices) have not been detected among participants. Failure to observe the desired behavioral outcomes of primary prevention programs may be attributable, in part, to a variety of methodological challenges, including the validity of self-report assessments and the relatively low baseline frequency of eating disordered behaviors (e.g., self-induced vomiting) among the general adolescent population. However, it is also possible that, in order to have a significant impact, prevention efforts may need to be delivered to individuals at a younger age (i.e., elementary school). Increased understanding of the complex etiology of anorexia nervosa and bulimia nervosa may be required in order to develop more comprehensive and effective prevention strategies. In addition, relatively little attention has been devoted to investigating the effectiveness of secondary prevention of eating disorders. As such, effective strategies to assist in identifying individuals who are experiencing initial symptoms of an eating disorder and facilitating appropriate treatment remain an important area to be developed.
Stringent diagnostic criteria show that the prevalence for any single eating disorder is rather low. However, combining prevalence rates across various types of disorders reveals that up to 5 to 10% of women may be afflicted with a diagnosable eating disorder (i.e., AN, BN, or ED-NOS). Serious medical, psychological, and social consequences are associated with these disorders.
The treatment of individuals with eating disorders often requires a multifaceted approach (e.g., psychotherapy, pharmacotherapy, nutritional counseling, medical management) involving members of several professional disciplines (e.g., dieticians, psychologists, psychiatrists, internists) and various settings (e.g., inpatient, outpatient, day treatment, residential).
Literature on the treatment of these disorders indicates that substantial progress has been made in the last few decades. However, a sizable subgroup of individuals with either anorexia nervosa or bulimia nervosa do not adequately respond to established therapies, or do respond but subsequently relapse. Much additional work is needed in predicting treatment response, matching individuals to treatments, and developing relapse prevention strategies. Furthermore, effective primary and secondary prevention strategies remain to be established.
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