Introduction
The recent Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition-Text Revision (DSM-IV-TR) (American Psychiatric Association [APA], 2000) distinguishes two eating disorders, anorexia nervosa (AN) and bulimia nervosa (BN). Whereas these two diagnoses share some common characteristics, they are distinct disorders. The key variables that assist differentiate the disorders are (1) body weight, (2) the presence or absence of binge eating, as well as (3) the presence or absence of compensatory behaviours for example vomiting.
Definitions
Anorexia nervosa is a name with Greek and Latin roots, first used in 1873 by Sir William Gull, an English physician, to denote loss of appetite because of nervous symptoms. Gull used it to explain a “want of appetite” attributable to a “morbid mental state”. (J. Treasure, U. Schmidt, & E. van Furth, 2002) The main symptom is important weight loss, ensuing from severely limited eating or starvation, which may be accompanied by extreme exercising and purging. Weight is at least fifteen percent below what is measured to be normal, and it may fall to a level that is life-threatening, even though persons with this disorder are inclined to refute the grave medical risks. They experience an extreme fear of gaining weight and a distorted body image. DSM-IV includes in its criteria amenorrhea, the absence of a minimum of three successive menstrual cycles. Most persons with anorexia nervosa are of normal weight before the start of the disorder and become underweight through a combination of dieting and exercising. About fifty percent of people with anorexia nervosa will use starvation and purging for weight control, therefore incorporating symptoms of both anorexia nervosa and bulimia nervosa.
Bulimia nervosa, described as oxlike hunger of nervous origin, was measured to be an unusual symptom of anorexia nervosa until 1979, when it was recognized as a disorder that shares some symptoms with anorexia however is characterized by binge-purge cycles. Some people with anorexia nervosa binge and a small group of people with bulimia nervosa build up anorexia nervosa. The majority people who suffer from bulimia are within ten percent of normal weight. Some are overweight, and some are underweight, although like people with anorexia nervosa, they have a morbid preoccupation with body shape and weight. The most outstanding feature is a binge-purge cycle characterized by a compulsion to eat, at least twice a week, large quantities of calorie rich food over a short period of time, generally about two hours, followed by vomiting, abuse of laxatives, diuretics, or amphetamines, or a period of rigorous fasting. DSM-IV requires that this pattern persist for three months or longer so as to warrant the diagnosis of bulimia nervosa.
Clinical Course
The line between dieting as well as suffering from an eating disorder is not always obvious, and if a clinician simply follows the DSM-IV criteria, recognition of the extent of the problem may be delayed. A person may be losing noteworthy weight however continue to menstruate; some people suffering from obesity may binge without purging; people may have a binge-purge cycle that is not as common as twice a week. Knowledge of any of these behaviours must alert the clinician to the possibility of an eating disorder. Twenty-five percent of people with anorexia nervosa and 40 percent of those with bulimia nervosa were in fact overweight before the onset of these disorders. Therefore overweight have to be measured a possible risk factor.
People suffering from anorexia nervosa or bulimia nervosa see themselves as overweight despite evidence to the contrary; initially they may try to control their weight by increasing their exercise, avoiding snacks between meals, or visiting “fat farms,” efforts that may be praised by family and peers at first. These behaviours, though, are then followed by extreme dieting, fasting, and in some cases vomiting or abusing laxatives and diuretics.
Anorexia Nervosa
Anorexia nervosa generally begins to develop in the early teens. People suffering from anorexia usually start restricting foods that are high in carbohydrates, then fatty foods, and eventually all foods, as they move further toward self-starvation. Frequent weight loss is viewed as success, and maintaining a consistent weight without loss may cause the person to experience panic and despair. Though as many as forty percent of people with anorexia nervosa will, in time, binge-eat, most people with bulimia nervosa will not develop anorexia nervosa. The most common disorder suffered by people whose symptoms propose recovery from anorexia nervosa is bulimia nervosa.
Anorexia nervosa is a psychosomatic disorder whose physical symptoms, in addition to dehydration, vitamin deficiencies, as well as electrolyte imbalance, may comprise slow heart rate, low blood pressure, dry skin, brittle nails and hair, constipation, edema, loss of bone, swollen joints, drop in hormone levels, as well as the presence of a layer of soft, downy hair on arms, back, and face. Twenty percent of persons suffering from anorexia nervosa will die from a combination of dehydration, malnutrition, and starvation. (Morgan, J. F., & Lacey, J. H, 2000).
Bulimia Nervosa
Bulimia nervosa generally develops after age 18, with initial concern regarding appearance and being overweight. Several people with this disorder try fad diets or starve themselves, do not feel content, and turn to binge eating. Following the start of a binge, they will then feel full, have had their binge interrupted by others, or turn out to be anxious regarding the calories they have consumed, will induce vomiting during or at the end of the binge, and as well use laxatives between or after binges. As the disorder becomes more severe, patterns of behaviour develop. The person may secretly prepare for a binge by hoarding food or, on the contrary, will keep very little food in the house and then frantically go shopping for “forbidden foods,” for example ice cream, cake, cookies, peanuts, or chocolate, which are consumed right away upon returning home. The amount of food eaten when bingeing can symbolize up to thirty times the person’s usual intake, even though most do not eat all of the food they have assembled for the binge. Some will gulp the food frantically, others will savor it gradually. Frequently there is a specific time, usually evenings or weekends, when bingeing is probably to occur. Most people binge in private, even if some binge to induce guilt in others with whom they are in conflict. Individual patterns differ with 50 percent bingeing as a minimum once a day, some bingeing several times a day, some several times a week, and others going on extended periods of bingeing that may last days or even weeks. For some, a cycle develops during which they initially may feel anxious, depressed, empty, angry, rejected, or lonely; will binge to feel better; and will after that feels guilty or anxious regarding possible weight gain. These feelings of tension and uneasiness will induce another binge.
People suffering from bulimia nervosa will frequently abuse laxatives, diet pills, or diuretics, causing physical problems for instance dehydration, electrolyte imbalances, seizures, and renal damage. Vomiting will as well cause dehydration, dental problems, plus damage to the esophagus. Other medical complications can comprise menstrual and endocrine disorders and risk of stomach rupture. Twenty percent of people suffering from bulimia nervosa as well abuse alcohol or other chemical substances, further rising the risk of health problems. Studies have revealed that people with bulimia nervosa who have had a history of anorexia nervosa have a poorer prognosis than those who have never had anorexia. Other factors unenthusiastically affecting the prognosis are long duration of the disorder, assessment of a coexisting personality disorder, and a family history of emotional disorders. Review of result studies with five- and ten-year follow-ups illustrated a decline in bingeing and purging in direct relation to the duration of the follow-up. At the end of ten years 70 percent were in remission, 11 percent still met most criteria for bulimia nervosa, and 0.6 percent met the criteria for anorexia nervosa. Thirty percent recognized some bingeing-purging activity, and 18 percent met the criteria for eating disorder not otherwise specific. The same study illustrated that substance abuse was associated to a poorer prognosis.
When women suffering from anorexia nervosa or bulimia nervosa become pregnant, symptoms frequently remit for the reason that they are afraid of producing a damaged infant. Some will express hope that the pregnancy will make them “well” and are capable to distinguish the positive changes in their appearance. Good eating habits are more probable to be established all through the pregnancy and whereas the woman is nursing, however relapse is a risk when the woman no longer feels that her eating habits affect the baby and she reverts to viewing herself as fat, despite evidence to the contrary. (J. Treasure, U. Schmidt, & E. van Furth, 2002)
Differential Diagnosis
Since the symptoms of anorexia nervosa and bulimia nervosa are so characteristic, there is usually not a problem with differential diagnoses. Weight changes, though, may specify medical problems. To rule these out, it is necessary that any person thought to have an eating disorder have a very detailed physical examination, together with a review of any medications he or she may be taking. AIDS, cancer, and tuberculosis may have an effect on appetite and cause noteworthy weight loss, whereas brain tumors or endocrine problems can cause obesity. Some medications, for instance neuroleptics and some antidepressants, as well affect weight. A physical examination is always necessary to find out what kinds of physical damage may have occurred from what may have been years of poor nutrition. (J. Treasure, U. Schmidt, & E. van Furth, 2002)
Depression can as well account for changes in eating patterns and therefore in weight. Conversely, depression may be a response to the eating disorder, particularly in people suffering from bulimia, who may experience intense dysphoria after a binge-purge cycle. Questions need to be asked regarding feelings of sadness, despair, thoughts about suicide, loss of interest and motivation, lessening of sense of self-worth, and changes in sleep patterns. If, upon assessment, the person usually does not appear to feel depressed and is functioning well in other areas, then the primary problem is most likely one of abnormal eating rather than depression and the depression will reduce when normal eating is re-established. Other problems frequently experienced by people with eating disorders comprise anxiety, personality disorders, obsessive compulsive disorder, family problems, and substance abuse. There is a high comorbidity of eating disorders and personality disorders, particularly the cluster B disorders, borderline or histrionic; or the cluster C disorders, avoidant, obsessive-compulsive, and dependent. If the person fails to get better after seeking intervention for an eating disorder, the primary disorder may be one more problem rather than the eating disorder. If so, the focus of intervention needs to change. If a person suffering from bulimia nervosa as well has a noteworthy problem with substance abuse, the latter have to be the initial focus of intervention, since binges may occur when the person is under the influence and out of control. (J. Treasure, U. Schmidt, & E. van Furth, 2002)
Bulimia nervosa in some cases responds to antidepressant medication, even if the person has not reported feeling depressed. Some people, though, do identify depression, and if there is family history of depression, comorbidity is suggested. The start of depression following treatment for bulimia nervosa proposes that it is the consequence of having the disorder rather than the cause. Diagnosis is made easier by the fact that when a physical or emotional disorder is the primary cause of weight changes, the person generally is practical about weight and body image.
Intervention
Even though eating disorders are potentially serious, people with these disorders usually do not seek out mental health professionals for intervention unless they have been urged to do so by their internists or concerned family and friends, or if they are experiencing associated problems of anxiety, depression, or low self-esteem. Most people with eating disorders like food, and the problem is one of control of eating: rigid over control by those suffering from anorexia nervosa, lack of control by those suffering from bulimia nervosa or obesity.
In order for intervention to be successful, the person have to perceive an eating problem as affecting lifestyle, perhaps affecting physical health, and as possibly serving to avoid other problem areas. People with bulimia nervosa more frequently seek intervention as they experience their symptoms as egodystonic, whereas people with anorexia nervosa often do not recognize a problem; for an intervention to be successful, they need to become motivated. Several people diagnosed as obese may be unhappy and at first want to look better however later decide not to considerably alter their weight since failure to do so, after several attempts, may merely augment their already susceptible sense of self-esteem. Working with people looking for intervention for eating disorders generally involves prolonged and intense interaction. The clinician needs to be supportive and understanding, accepting of relapse, and capable to maintain a positive attitude toward the likelihood of change, presenting the problem as soluble whereas simultaneously being aware that feelings of hopelessness, anger, frustration, and being manipulated may appear in the course of the intervention. Good prognostic indicators for intervention with people who have anorexia nervosa comprise early age of onset and weight gain within two years after the start of the intervention. Poorer prognosis is pointed out with later onset, comorbidity with personality disorders, a history of psychiatric hospitalizations, and poor family relationships.
Hospitalization
Hospitalization, if probable on a unit specializing in eating disorders, is specified when the person with the eating disorder is in danger of dying from starvation, is at risk from several medical problems related to or stemming from the disorder, is a suicide risk, has not responded to outpatient intervention, or cannot control weight loss or break the cycle of bingeing without supervision. As control is a major factor in these disorders, though, outpatient intervention, which gives the person more accountability for progress, would be the intervention of choice. In the hospital, these people require close supervision, as they are inclined to store food in their mouths, napkins, or under the table to avoid eating it; those who are probable to binge need controlled portions of food, to make bingeing impossible. Food consumption plus use of the bathroom are supervised, at least initially. Weighing is generally done daily, at the same time, and safety measures are taken to see that the person does not drink water, avoid emptying the bladder, or wear clothing or jewellery that might wrongly yield a higher weight. Several inpatient programs use cognitive positive reinforcement by permitting the person greater privileges if weight is gained and requiring bed rest or even tube feeding if weight is lost in the hospital. A team approach is used, together with family education and involvement, individual psychotherapy, and educational groups frequently involving a dietician. Intervention is intended at beginning the process of stabilizing the person’s weight, improving the general physical condition, understanding the need to alter eating habits, correcting distortions regarding weight and body shape, and helping to identify problems that may obstruct recovery. Good discharge planning have to determine the outpatient interventions needed to prevent relapse. Since the temptation to resume former eating habits, or to discontinue intervention, will be great, the person must be connected with outpatient resources before leaving the hospital.
Managed care has resulted in more day programs or partial hospitalization, which is supposed to be more cost-effective than inpatient hospitalization. The person is provided with structure, particularly at mealtime, at the same time as continuing to face the challenges, triggers, and problems with social supports in their home environment.
Psychotherapy
As with several psychological disorders, the development of anorexia and bulimia reflect the interaction of physical, psychological and social influences. Compared with the affective disorders, anxiety and schizophrenia, there has been comparatively little aetiological research in this area, and it is therefore more suitable to consider factors which may influence susceptibility to eating disorders, rather than those that directly cause them. It is as well valuable considering how eating disorders, once established, are perpetuated.
Perpetuating Factors
The changes in diet and exercise that show the way to weight loss in anorexia appear to be sustained by a range of psychological and physical mechanisms. Socially, the disruption of relationships with family and peers may continue the disorder and obviously makes restoration of a normal lifestyle more of a challenge.
Additionally, the patient may value the sense of control that comes with strict dieting. Initially at least there may be approval from others about weight loss and body shape. Therefore a form of conditioning may come to operate, in which weight loss is reinforced by the dual mechanisms of self- and peer-approval. Why then does the weight loss continue past normal levels of thinness? If one sees the attention gained through approval as the reinforcer, rather than the approval itself, then conditioning could elucidate the continued weight loss. Becoming growingly ill would continue to attract attention and thus maintain the reinforcement.
Cognitive explanations of eating disorders focus on the central idea of an over-valued and unhealthy concern with the importance of body weight and shape. These core beliefs as well determine and perpetuate many other aspects of the full clinical picture. Therefore self-worth comes to be measured in terms of how effectively control of body weight and shape is achieved. The person comes to think of fatness as extremely undesirable, whereas being slim is attractive and desirable.
Self-control, attained through constant weighing, calorie-counting, purging and so on, as well comes to assume central importance in the quest for ideal body physique. To some extent these beliefs are no more than exaggerations of the views common to many people. It is the sense of personal significance, coupled with the dysfunctional reasoning and behaviour that differentiates someone with an eating disorder from the person who simply wishes to keep in shape.
Even though this argument explains the maintenance of anorexia, it is less satisfactory in accounting for the enduring features of bulimia. For instance, if control of body weight was the essential issue, we might expect that fear of weight gain would simply show the way to constant dieting and that restoration of normal weight might be followed by even more severe dieting. In actual fact neither of these things happens in bulimia. Sufferers with bulimia are not very good at sticking to diets in the first place and having transgressed; they may then go to the other extreme and overeat.
Physical factors may have the effect of perpetuating anorexia nervosa, once it has become recognized. Starvation, even in otherwise healthy people, is recognized to lead to increased concern with food and to reduce interest in the outside world. Prolonged food deprivation as well affects the working of the digestive system in order that eating even small quantities of food results in an exaggerated sense of fullness: something which would, certainly, perpetuate the disorder.
Disturbances in neurotransmitter function have also been examined in relation to the maintenance of eating disorders. The evidence is strongest for bulimia nervosa. The neurotransmitter 5-HT (serotonin) is involved in the regulation of appetite and it has been recommended that bingeing may reflect dysfunction of these systems. This suggestion is supported by the observation that SSRI drugs, which are known to influence brain serotonin systems, can show the way to remarkable reductions in the incidence of bingeing.
Thus both anorexia nervosa and bulimia nervosa are frequently explained exclusively on the basis of psychological, social or family factors, however, as we have seen, somatogenic influences may be equally significant and a full understanding will involve the integration of all of these approaches. Longitudinal research on eating disorders is lacking and there is a real need for inclusive evaluations of the effects of different interventions on long-term outcome. (Wonderlich, S., Crosby, R., Mitchell, J. E., Thompson, K. M., Redlin, J., DeMuth, G., Smyth, J., & Haseltine, B, 2001).
Medication
Medication is not frequently used for people with anorexia nervosa, while low doses of neuroleptics have been used to alleviate marked obsessional, anxious, or psychotic thoughts. Some reasons not to use medications when a person has a very low weight are the danger due to metabolic and biological changes caused by the weight loss, heightened sensitivity to side effects because of augmented sensitivity to changes in body or feelings, and danger of noncompliance if taking medication is equated with loss of control and autonomy or results in weight gain as a side effect. If there is comorbid depression, antidepressant medications must be considered. Trials of fluoxetine (Prozac) have also reported weight gain. Antidepressant medications such as imipramine (Tofranil), desipramine (Norpramine), trazodone (Desyrel), and fluoxetine (Prozac) have helped to reduce the binge-purge cycle of bulimia nervosa as well as the binges of people suffering from obesity. The efficiency of high doses of fluoxetine suggests that an augment in serotonin may result in feelings of satiation and that it has an antibulimic property independent of its mood-stabilizing effects. Fluoxetine appears as well to help with obsessional thinking and compulsive behaviours related with eating disorders. Fenfluramine (Pondimin), a serotonin antagonist, is sometimes used as an appetite suppressant to produce satiety in people with bulimia nervosa or obesity. (Sansone, R. A., Wiederman, M. W., & Shrader, J. A, 2000).
Conclusion
Intervention outcomes for people with eating disorders are better for people with anorexia nervosa than for people with bulimia nervosa or obesity. Less than 50 percent of people with anorexia nervosa have a full recovery; 70 percent show important improvement, even though they will most likely always be thin, however the death rate on follow-up was 15–20 percent. Merely 40 percent of people with bulimia nervosa have what is regarded as a good outcome, and relapse is not uncommon when the person is under stress. Some degree of chronic bulimia nervosa or obesity appears to be more the rule than the exception in those with a history of these disorders. Positive outcome appears in part to depend on motivation, capability to feel autonomous, self-awareness, optimism, self acceptance, and high self-esteem. Hindrances appear to be strong use of denial, pessimistic thinking, impulsivity, unrealistic expectations, poor self-esteem, plus a tendency to view any weight gain as a disaster. (Nagata, T., Kawarada, Y., Kiriike, N., & Iketani, T, 2000).
Research into the etiology, epidemiology, and intervention outcome has been marred by underdiagnosis, high dropout rate after intervention begins, insufficient follow-up that most likely underestimates relapse, and the fact that clinicians and clients may differ on what constitutes a favourable outcome. Research is as well needed into the comorbidity of personality and eating disorders and the implications for intervention.
Social workers, particularly those working with young women, must be alert to appearance and ask questions about eating habits. Education is needed regarding nutrition to correct false beliefs about food, to discourage rigid dieting, and to encourage eating with others rather than alone. Exercise must be put in perspective, stressing the general health benefits while as well representing that it is maladaptive if used merely out of fear of “fatness.” This educational approach might serve as prevention against the media’s influential preoccupation with thinness and the seductiveness of “fast food.”
References:
American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
J. Treasure, U. Schmidt, & E. van Furth. (Eds.) (2002). Handbook of eating disorders, 2nd ed. (pp. 271-277). Chichester, England: Wiley.
Morgan, J. F., & Lacey, J. H. (2000). Bloodletting in anorexia nervosa: A case study. International Journal of Eating Disorders, 27, pp. 483-500.
Nagata, T., Kawarada, Y., Kiriike, N., & Iketani, T. (2000). Multi-impulsivity of Japanese patients with eating disorders: Primary and secondary impulsivity. Psychiatry Research, 94, 239-250.
Nasser M., & DiNicola, V. (2001). Eating disorders and cultures in transition (pp. 171-187). London: Brunner & Routledge.
Sansone, R. A., Wiederman, M. W., & Shrader, J. A. (2000). Naturalistic study of the weight effects of amitriptyline, fluoxetine, and sertraline in an outpatient medical setting. Journal of Clinical Psychopharmacology, 20, 272-274.
Wonderlich, S., Crosby, R., Mitchell, J. E., Thompson, K. M., Redlin, J., DeMuth, G., Smyth, J., & Haseltine, B. (2001). Eating disturbance and sexual trauma in childhood and adulthood. International Journal of Eating Disorders, 30, 401-412.