eating

Eating Disorders

(based on lectures by Dr. Thomas Cummins and also by Dr. Nadine Kaslow)

Eating disorders are very serious, potentially lethal illnesses. They have probably always existed, but are strongly associated with affluent, industrialized societies (although within those societies, there is NO socioeconomic bias in diagnosis - you are as likely to get it if you're poor or rich). Bulimia and anorexia can both occur together. Both involve "control issues" and maybe associated with a childhood history of gastrointestinal problems.

Epidemiology:

0.5-1.0% of population

90-95% of patients are female

M:F ratio is lower in anorexia nervosa than in bulimia, but both are disproportionately diagnosed in women.

Demographics: Affects all ethnic and socioeconomic groups, although most patients are upper SES white females.

History: Probably occurred in 1920s and perhaps in ancient times as well.

40-60% of female high school seniors report dieting within the last year

13% admit to inducing vomiting or using diet pills, diuretics, or laxatives to lose weight

Risk factors:

Biological

1^st degree relatives with eating disorders, depression, anxiety

premorbid obesity

Psychological

Depression

Control issues

obsessive-compulsive disorder

borderling personality disorder

anorexia is a risk factor for bulimia

avoidant once illness occurs

high achievers, perfectionism

low self-esteem

Social

Media influences

Affluence, especially in an affluent Western culture

Low levels of social support

Enmeshed families (particularly with anorexia)

Chaotic and abusive families with bulimia

Public health messages (e.g., that fat is bad)

Gymnasts, wrestlers, runners, dancers, flight attendants (less so now after law suits against airlines).

Etiology:

Multifactorial and not well known; unlikely that any single cause is responsible.

Biological:

? variant of a mood disorder;

? genetic etiology;

Psychological:

Cognitive distortion (distorted body image);

Cultural influences (pressure to be thin).

Family enmeshment, rigidity, abuse, high expressed emotion, or conflict avoidance are associated with the disorder.

Effects of starvation on normals: volunteers developed food hoarding and binging, depression, irritability, and obsessive-compulsive behaviors when forced to lose 25 percent of their body weight.

Symptoms improved 6 to 12 months after regaining prior body weight.

Anorexia Nervosa

Clinical features:

decreased caloric intake
strange dietary rituals
compulsive exercise
compulsions not involving eating

DSM-IV Criteria:

refusal to maintain body weight at or above minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85 percent of that expected…)
intense fear of gaining weight or becoming fat, even though underway.
Disturbance in the way in which once body weight or shape is experienced; undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.
In postmenstrual females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles.

Note that the patients often do not see themselves as having a problem, but are brought in by family members or friends. Therefore the physician must get collateral information from others besides the patient.

Anorexia nervosa has two subtypes:

Restricting type

extreme self-control over food intake
social avoidance, withdrawal and isolation
obsessive cognitive style
ritualistic in other areas that do not involve eating

Binge eating/purging type

unable to refrain from binge/purge cycle
commonly depressed
maybe self-destructive
emotionally dramatic and erratic personalities
alcohol and drug abuse not uncommon, especially in this subtypes

Comorbidity:

50 percent have Major depression

25 percent have Obsessive Compulsive Disorder

50 percent of anorexics also have Bulimia Nervosa

maybe associative with Avoidant Personality Disorder

Prognosis:

full recovery based on medical and nutritional criteria is seen in 30-50% percent of treated patients, but is probably an overestimate

psychological symptoms, on the other hand, tend to persist

to clinical or sub clinical symptoms persist in 30-60 percent of cases

5-10% mortality within ten years of onset, 20 percent within twenty years

12x greater death rate in anorexia than in age-matched and gender-matched controls, making anorexia the deadliest psychiatric disorder by far, according to Dr. Thomas Cummings

major causes of death include chronic malnutrition and cardiac arrhythmias

Suicide does not seem elevated among anorexia patients however. Only 1.4% of a series of 571 anorexia patients committed suicide v. 4.1% for age and sex adjusted control (Coren & Hewitt, 1998; see reference).

good prognostic indicators:

early age of onset

restricting subtypes

Treatment:

Initial evaluation, including comprehensive medical evaluation
weight restoration, the key to initial treatment of anorexia
individual psychotherapy is patient is over 18 years old
behavioral contracting and shaping can be lifesaving, for example: "You can have X privilege if you maintain Y pounds of weight by the end of this month."
Family therapy

- medication, such as selective serotonin re-uptake inhibitors, after weight is restored; note: no double blind placebo controlled studies demonstrate their efficacy (v. in bulimia, in which they are effective)

Bulimia Nervosa

Bulimia involves a recurrent pattern of binging (eating gobs and gobs of food in a compulsive, frantic way) followed by purging (inducing vomiting a la the Romans). Bulimics are less likely to be thin and more likely to be a little overweight.

Bulimia does NOT always have to involve purging behaviors.

A psychodynamic observation regarding anorexics is that their families tend to be perfectionistic, cold, and have taboos against expressing strong emotion. Family secrets and high, unexpressed tension are common.

References:

DSM-IV, pages 539-550.