Many people have heard the term “Eating Disorder” but don’t have a good idea of exactly what that means. The diagnostic manual that physicians and other mental health providers use to diagnose eating disorders define them as being “characterized by a persistent disturbance of eating or eating-related behaviors that results in the altered consumption or absorption of food and that significantly impairs physical health or psychosocial functioning.” In everyday language, that means an abnormal pattern of eating or eating-related behaviors (like excessive exercising, or purging behaviors such as vomiting after meals or abusing laxatives for weight loss) that leads to damages in physical, emotional and social well-being.
Although eating disorders are the most deadly mental illness (with the exception of Addictive Disorders), fewer than 1 in 10 people with eating disorders get treatment.
There are eight different diagnoses that fall into the Feeding and Eating Disorders category in the diagnostic manual. In this article, we will focus on the three most common disorders: Anorexia Nervosa, Bulimia Nervosa and Binge Eating Disorder.
Anorexia Nervosa is defined by an abnormal, irrationally intense fear of gaining weight or becoming overweight. Individuals with Anorexia Nervosa have a distorted view of their bodies which leads to food restriction, excessive exercise and denial of the seriousness of the current low body weight. There are two types of Anorexia Nervosa, both of which are always associated with being significantly underweight:
- Restricting Type which is associated with severe food restriction and excessive exercising, but not with bingeing or purging.
- Binge-eating/Purging Type which is associated with recurrent episodes of bingeing and purging.
Isolated symptoms of food restriction, bingeing and purging are much more common than the full Anorexia Disorder. When those symptoms are combined with a significantly low body weight, intense fear of gaining weight, and inability to appreciate that the low weight is abnormal, a diagnosis of Anorexia Nervosa is made.
The severity of Anorexia Nervosa is defined by how underweight the individual is, using the Body Mass Index (BMI) as the measure. Severity is measured by body weight because the more underweight an individual is, the more health consequences there are. Every major organ system in the body is affected by Anorexia Disorder including cardiac, hormonal, digestive etc. Severe malnutrition results in the body’s inability to maintain normal acid-base status, normal electrolyte balance and nearly all other processes are damaged as well. For these reasons, it is critical that when we recognize symptoms of Anorexia Nervosa in ourselves, friends, families or others, we speak up immediately and help them get involved in treatment.
BINGE EATING DISORDER
Binge Eating Disorder was added to the diagnostic manual just a short two years ago. Unlike Anorexia Nervosa which requires being underweight in order for the diagnosis to be made, Binge Eating Disorder occurs in individuals who are normal weight, overweight and obese. While up to 40% of Americans binge eat in response to stress, it is estimated that only about 1 in 100 women and 1 in 50 men have a binge eating pattern and consequences that are severe enough to justify a diagnosis of Binge Eating Disorder. So while it is a common misperception that most or all individuals who are obese must also have Binge Eating Disorder, this is not correct. The diagnosis of Binge Eating Disorder requires recurrent episodes of binge eating that happen at least once a week for three months. The binge eating episodes are associated with eating much more rapidly than normal, eating much more rapidly than normal, eating until feeling uncomfortably full , eating large amounts of food when not feeling physically hungry, eating alone because of feeling embarrassed by how much one is eating and/or feeling disgusted with oneself, depressed, or very guilty afterwards. Very importantly, the binges are not associated with other eating behaviors like restricting food intake or purging (i.e. vomiting after meals), as those behaviors would lead to a different diagnosis.
The severity of Binge Eating Disorder is defined by the number of binges per week with an average of 1-3 binge-eating episodes per week being mild, an average of 8-13 binge-eating episodes per week being moderate and an average of 14 or more binge-eating episodes per week being severe. The more binge episodes a person is having each week, the more severe health consequences will be.
Studies have shown that individuals with Binge Eating Disorder have higher rates of depressive and anxiety disorders, lower quality of life, higher levels of distress and poorer functioning in life. For these reasons, it is extremely important to recognize the symptoms of Binge Eating Disorder and help those who are experiencing them get connected to treatment.
Bulimia Nervosa is the third of the most common eating disorders, and is defined by recurrent episodes of binge eating alternating with inappropriate behaviors to prevent weight gain. These behaviors can include forced oneself to vomit, abusing laxatives, diuretics and other medications, fasting and/or excessive exercise. Again, there are individuals who have symptoms of Bulimia Nervosa, but don’t meet criteria for the full disorder which requires that binge episodes and inappropriate behaviors both occur on average at least once a week for 3 months. Like Binge Eating Disorder, which is defined by the number of binge episodes per week, the severity of Bulimia Nervosa is defined by the number of inappropriate compensatory behaviors each week, with more frequent behaviors representing a higher severity of illness.
The symptoms of Bulimia Nervosa can cause hormonal abnormalities, fluid and electrolyte imbalances, tears in the esophagus or stomach from vomiting, chronic constipation, abnormal heart rhythms and other have life-threatening complications.
WHY DO PEOPLE DEVELOP EATING DISORDERS?
Like all medical illness, eating disorders develop for biological, psychological and social reasons. Biologically, risk for eating disorders can be inherited. It is known that individuals who have a first-degree relative (mother, father, sister, brother) with anorexia nervosa or bulimia nervosa, themselves have an increased risk of developing the disorder.
Additionally, it appears eating disorders share some biological mechanisms with depressive and anxiety disorders as individuals with anxiety disorders or obsessive traits in childhood are more likely to develop an eating disorder during adolescence or early adulthood.
Psychological and environmental factors can also contribute to the development of eating disorders. Children who are overweight, anxious, depressed and/or have low self-esteem are at increased risk of developing eating disorders. Individuals who participate in activities that require certain body types such as dancers, actors and athletes with weight checks also have a higher risk of developing eating disorders when compared with the general public.
WHAT CAN WE DO?
Because we know that eating disorders have biological, psychological and environmental factors and because we know that eating disorders can be deadly not just because of the medical abnormalities they cause but also because of higher suicide rates among individuals with eating disorders, treatment focuses on safety while concentrating interventions in those same areas (biological, psychological and environmental).
The three main goals of treatment for eating disorders are:
Restore a healthy nutritional state by restoring weight to normal range and ensuring metabolic balance.
Change and correct abnormal eating behaviors such as bingeing, vomiting and excessive exercising.
Change and correct distorted beliefs about the benefits of weight loss.
Depending on the severity of the disorder, treatment can happen as an outpatient, in a day program, in a residential program or in a hospital on the inpatient unit. While the intensity of interventions varies depending on the setting, the following types of interventions are standard:
- Biological interventions include high calorie meals, monitoring with blood work and EKGs and medications for any additional symptoms such as depression, anxiety and vitamin deficiencies.
- Psychological and environmental interventions include education, behavioral modification, behavioral contracts and psychotherapy for the individual and family, daily weights and observation after all meals to prevent abnormal behaviors.
WHY SHOULD WE ENCOURAGE TREATMENT OF EATING DISORDERS?
The outcome of eating disorders can range from full recovery to malignant weight loss and death. Studies have shown that up to 11% of individuals with eating disorders die within 12 years of receiving the diagnosis. However, studies also show that as many as 40% of individuals with eating disorders have a good outcome. Those factors associated with having a good outcome are shorter duration of illness and earlier access to treatment. This means, we have the ability to prevent deaths from eating disorders, by supporting adequate access to treatment.