Eating disorders are actually quite rare, however due to their mortality rate they received a lot of attention in media. Eating disorders are characterised by disordered eating habits and irrational fear of getting fat.
In this post I will discuss Anorexia and Bulimia Nervosa, which are the most common EDs in the UK - however, other types also include binge eating disorder and EDNOS (eating disorders not otherwise specified).
In this post I will discuss Anorexia and Bulimia Nervosa, which are the most common EDs in the UK - however, other types also include binge eating disorder and EDNOS (eating disorders not otherwise specified).
Anorexia Nervosa
Lifetime prevalence of Anorexia Nervosa is 0.6%, and it is 3 times as common in women than in men. Typically, onset is in the age of 16-22 years old.
The criteria for Anorexia Nervosa (according to the DSM-IV-TR) is as follows:
- Refusal to maintain body weight (typically going down to about 85% of expected weight, BMI<18.5)
- Irrational fear of gaining weight and becoming fat, even when underweight
- Distorted perception of body shape and size
- Absence of at least 3 consecutive menstruations in women
Anorexia is subdivided in two types:
1) Restrictive type is characterised with dramatic restriction in food intake. Patients are typically perfectionists and are very competitive; they often have problems with self-esteem. They typically:
- don't binge/purge
- secretly dispose of food
- avoid eating in others' presence
- eat as little as possible, count calories
- divide food into 'good' and 'bad' categories
- cut food in little pieces, squeeze it etc., eat slowly
2) Binge/purge type is characterised by restricting food intake for as long as possible and then engage in binge eating, purging or both. About 30-50% of restrictive anorexics eventually switch to this type.
Medical complications of AN
-Thinning hair; loss of hair
- Feeling cold
- Feeling weak, loss of energy
- Kidney failure
- Lanugo
- Heart arrhythmia (often lethal)
Individual risk factors
- High scores on perfectionism
- Association with long-term depression
- Some association (perhaps indirect) to history of sexual abuse
- Thinking of being thin as of being attractive, happy
- Perceptual biases and dissatisfaction with their body
- History of dieting
Biological risk factors
Twin studies suggest AN is heritable; family studies showed that risk of developing AN is 11.5 times greater in AN relatives than in healthy controls
Serotonin levels are typically lower in AN patients than those in healthy controls, however it is hard to determine the direction of causation: either low serotonin levels provoke ED to develop or presence of the disorder affects the serotonin levels. Sometimes, antidepressants which increase serotonin levels help to alleviate ED. It has been found that the serotonin levels increase once anorexics are recovered.
Familial risk factors
More than 1/3 of AN patients reported some kind of family disfunction. Mostly it is excessive overprotectiveness, control; parents' dissatisfaction with a child's body, achievements etc.
Sociocultural factors
AN is more common among middle class white women, and is less common in black women. However, AN is not limited to Western societies. Anorexics also typically have a lot of exposure to images of thinner women; for instance, AN is much more common among the dancers, models etc., as they are constantly surrounded by slim women. However, the causality is not always clear-cut: it is unclear whether those who read lots of fashion magazines develop AN due to this, or if they read those magazines because they are obsessed with thinness in the first place.
Treatment
Treatment of anorexia may be very difficult for many reasons. Firstly, anorexics do not believe that there is anything wrong with them, and perceive their eating habits simply as a lifestyle choice. When anyone tries to intervene and make them eat, anorexics perceive it as an attempt to make them fat and jeopardise the way they look. The mortality rate is quite high, because patients often refuse to engage in treatment till the very end. In some cases, even when presented with factual evidence of serious health consequences - such as kidney/heart failure, etc. - they think that it is fake, created to persuade them to eat.
1) Family therapy
This is a preferred and the most effective type of treatment. During the therapy, parents and close relatives are taught how to become one 'team' with a patient where eating is concerned. It is extremely important for a patient to stop seeing the family as an enemy, but understand that they are on the same side with her/him. The treatment is quite efective, with 70-90% patients fully recovering after about 5 year of therapy. The therapy is more effective if the patients are adolescents (rather than mature people) and if they had been ill for short period of time with no bulimia.
2) Pharmacological treatment
Medications have been proven to be ineffective in treating AN; however, AN is often comorbid for mood disorders, therefore antidepressants may help indirectly, by tackling patient's depression. They are normally used in addition to other therapies.
3) Cognitive behavioural therapy
This therapy aims to tackle disturbed thinking of patients and to correct their eating habits. However, it is much less effective than family therapy, as AN patients continue to see the therapists as enemies who try to change their lifestyle choice (which they still see as normal). It is extremely important for the therapists not to sound patronising or disrespectful; if a patients, distrustful from the beginning, feels that (s)he is being considered shallow/stupid/not worthy etc., they are very likely to completely shut the therapist off.
The criteria for Anorexia Nervosa (according to the DSM-IV-TR) is as follows:
- Refusal to maintain body weight (typically going down to about 85% of expected weight, BMI<18.5)
- Irrational fear of gaining weight and becoming fat, even when underweight
- Distorted perception of body shape and size
- Absence of at least 3 consecutive menstruations in women
Anorexia is subdivided in two types:
1) Restrictive type is characterised with dramatic restriction in food intake. Patients are typically perfectionists and are very competitive; they often have problems with self-esteem. They typically:
- don't binge/purge
- secretly dispose of food
- avoid eating in others' presence
- eat as little as possible, count calories
- divide food into 'good' and 'bad' categories
- cut food in little pieces, squeeze it etc., eat slowly
2) Binge/purge type is characterised by restricting food intake for as long as possible and then engage in binge eating, purging or both. About 30-50% of restrictive anorexics eventually switch to this type.
Medical complications of AN
-Thinning hair; loss of hair
- Feeling cold
- Feeling weak, loss of energy
- Kidney failure
- Lanugo
- Heart arrhythmia (often lethal)
Individual risk factors
- High scores on perfectionism
- Association with long-term depression
- Some association (perhaps indirect) to history of sexual abuse
- Thinking of being thin as of being attractive, happy
- Perceptual biases and dissatisfaction with their body
- History of dieting
Biological risk factors
Twin studies suggest AN is heritable; family studies showed that risk of developing AN is 11.5 times greater in AN relatives than in healthy controls
Serotonin levels are typically lower in AN patients than those in healthy controls, however it is hard to determine the direction of causation: either low serotonin levels provoke ED to develop or presence of the disorder affects the serotonin levels. Sometimes, antidepressants which increase serotonin levels help to alleviate ED. It has been found that the serotonin levels increase once anorexics are recovered.
Familial risk factors
More than 1/3 of AN patients reported some kind of family disfunction. Mostly it is excessive overprotectiveness, control; parents' dissatisfaction with a child's body, achievements etc.
Sociocultural factors
AN is more common among middle class white women, and is less common in black women. However, AN is not limited to Western societies. Anorexics also typically have a lot of exposure to images of thinner women; for instance, AN is much more common among the dancers, models etc., as they are constantly surrounded by slim women. However, the causality is not always clear-cut: it is unclear whether those who read lots of fashion magazines develop AN due to this, or if they read those magazines because they are obsessed with thinness in the first place.
Treatment
Treatment of anorexia may be very difficult for many reasons. Firstly, anorexics do not believe that there is anything wrong with them, and perceive their eating habits simply as a lifestyle choice. When anyone tries to intervene and make them eat, anorexics perceive it as an attempt to make them fat and jeopardise the way they look. The mortality rate is quite high, because patients often refuse to engage in treatment till the very end. In some cases, even when presented with factual evidence of serious health consequences - such as kidney/heart failure, etc. - they think that it is fake, created to persuade them to eat.
1) Family therapy
This is a preferred and the most effective type of treatment. During the therapy, parents and close relatives are taught how to become one 'team' with a patient where eating is concerned. It is extremely important for a patient to stop seeing the family as an enemy, but understand that they are on the same side with her/him. The treatment is quite efective, with 70-90% patients fully recovering after about 5 year of therapy. The therapy is more effective if the patients are adolescents (rather than mature people) and if they had been ill for short period of time with no bulimia.
2) Pharmacological treatment
Medications have been proven to be ineffective in treating AN; however, AN is often comorbid for mood disorders, therefore antidepressants may help indirectly, by tackling patient's depression. They are normally used in addition to other therapies.
3) Cognitive behavioural therapy
This therapy aims to tackle disturbed thinking of patients and to correct their eating habits. However, it is much less effective than family therapy, as AN patients continue to see the therapists as enemies who try to change their lifestyle choice (which they still see as normal). It is extremely important for the therapists not to sound patronising or disrespectful; if a patients, distrustful from the beginning, feels that (s)he is being considered shallow/stupid/not worthy etc., they are very likely to completely shut the therapist off.
Bulimia Nervosa
Bulimia Nervosa is also quite rare, with a lifelong prevalence of 1% (1 year prevalence of 0.3%), and it is three times more common in women than in men. Age of onset is similar to that of AN: 15-22 years. It usually persists for about 2 - 15 years; it is much longer than that of AN, because the mortality risk is not as high.
The DSM-IV-TR criteria for BN is:
- Recurrent binge eating episodes. These episodes are characterised by eating a much bigger amount of food in a discreet time period than people usually would under similar circumstances. It is usually 'bad' foods - such as sweets, chocolate, take away pizzas and fries; basically, what we students call 'revision' food. The episodes are typically accompanied by strong sense of lack of control over eating.
- After the binge episodes, bulimics feel a need to compensate for the effects of bingeing (i.e. gaining weight) and a strong feeling of guilt and shame for what they see as being greedy.
- Their self-esteem is very much based on their body shape and weight.
Bulimics normally start from restrictive eating, dieting etc. Then they lose control and binge on the foods they consider to be 'forbidden' - and try to compensate for loss of control by purging/exercising. The compensating behaviours reduce the fear of gaining weight, and eventually become compulsive, similar to the OCD disorders. Many bulimics describe purging as something they 'must' do after eating, as if the choice does not belong to them.
Bulimia can be subdivided in two types: purging and non-purging. Purging types represent about 80% of cases. They often use laxatives to cause vomiting. Non-purging bulimics compensate by fasting and excessive exercises.
Medical complications of BN
Complications are mostly associated with purging, and are not as severe or lethal as those of AN. It is important to remember that most bulimics are not underweight, but are average weight or even overweight; unlike anorexics, they still do take in some food, even if purging some/most of it. Complications include decayed teeth due to exposure to acid from stomach; mouth ulcers and throat scratches, swollen salivary glands.
Differences between AN and BN
An intense and irrational fear of gaining weight and preoccupation with self image, body shape and weight are in the core of both disorders. However, they are very different otherwise - both psychologically and in relation to physical effects.
AN patients are almost always underweight, and suffer from a variety of medical complications of this. Bulimics, on the contrary, maintain average body weight or are overweight; sometimes even obese. Thus, anorexia has a much higher mortality rate.
Psychologically, anorexics tend to deny there is a problem, while bulimics know their behaviour isn't normal, and feel ashamed of it. Anorexics tend to be perfectionists; restricting themselves from eating gives them feeling of strength and control. Bulimics, however, tend to have a low self-esteem and have a strong feeling of lack of control.
Risk factors to develop BN are very similar to those of AN: it also has been shown to be familial and heritable, has been associated with lower serotonin levels and comorbid with mood disorders such as depression.
Treatment
1) Pharmacotherapy
Antidepressants are widely used to treat BN, as they decrease patient's preoccupation with body image and reduce the bingeing episodes.
2) Cognitive Behavioural therapy
This therapy concentrates on normalising eating habits by creating meal plans, teaching patients about nutrition etc. Eating smaller portions regularly is a good tactic for bulimics. Therapists also aim to change the distorted cognition of bulimics, which involves getting rid of 'all or nothing' biases, of dividing food into 'good' and 'bad', improving self esteem, learning to enjoy food etc. The therapy is quite effective in reducing the severity of symptoms, however full recovery is unlikely, and patients often remain being concerned with their body shape and weight.
Below is a BBC documentary about bulimia and anorexia; second part can be found on YouTube.
The DSM-IV-TR criteria for BN is:
- Recurrent binge eating episodes. These episodes are characterised by eating a much bigger amount of food in a discreet time period than people usually would under similar circumstances. It is usually 'bad' foods - such as sweets, chocolate, take away pizzas and fries; basically, what we students call 'revision' food. The episodes are typically accompanied by strong sense of lack of control over eating.
- After the binge episodes, bulimics feel a need to compensate for the effects of bingeing (i.e. gaining weight) and a strong feeling of guilt and shame for what they see as being greedy.
- Their self-esteem is very much based on their body shape and weight.
Bulimics normally start from restrictive eating, dieting etc. Then they lose control and binge on the foods they consider to be 'forbidden' - and try to compensate for loss of control by purging/exercising. The compensating behaviours reduce the fear of gaining weight, and eventually become compulsive, similar to the OCD disorders. Many bulimics describe purging as something they 'must' do after eating, as if the choice does not belong to them.
Bulimia can be subdivided in two types: purging and non-purging. Purging types represent about 80% of cases. They often use laxatives to cause vomiting. Non-purging bulimics compensate by fasting and excessive exercises.
Medical complications of BN
Complications are mostly associated with purging, and are not as severe or lethal as those of AN. It is important to remember that most bulimics are not underweight, but are average weight or even overweight; unlike anorexics, they still do take in some food, even if purging some/most of it. Complications include decayed teeth due to exposure to acid from stomach; mouth ulcers and throat scratches, swollen salivary glands.
Differences between AN and BN
An intense and irrational fear of gaining weight and preoccupation with self image, body shape and weight are in the core of both disorders. However, they are very different otherwise - both psychologically and in relation to physical effects.
AN patients are almost always underweight, and suffer from a variety of medical complications of this. Bulimics, on the contrary, maintain average body weight or are overweight; sometimes even obese. Thus, anorexia has a much higher mortality rate.
Psychologically, anorexics tend to deny there is a problem, while bulimics know their behaviour isn't normal, and feel ashamed of it. Anorexics tend to be perfectionists; restricting themselves from eating gives them feeling of strength and control. Bulimics, however, tend to have a low self-esteem and have a strong feeling of lack of control.
Risk factors to develop BN are very similar to those of AN: it also has been shown to be familial and heritable, has been associated with lower serotonin levels and comorbid with mood disorders such as depression.
Treatment
1) Pharmacotherapy
Antidepressants are widely used to treat BN, as they decrease patient's preoccupation with body image and reduce the bingeing episodes.
2) Cognitive Behavioural therapy
This therapy concentrates on normalising eating habits by creating meal plans, teaching patients about nutrition etc. Eating smaller portions regularly is a good tactic for bulimics. Therapists also aim to change the distorted cognition of bulimics, which involves getting rid of 'all or nothing' biases, of dividing food into 'good' and 'bad', improving self esteem, learning to enjoy food etc. The therapy is quite effective in reducing the severity of symptoms, however full recovery is unlikely, and patients often remain being concerned with their body shape and weight.
Below is a BBC documentary about bulimia and anorexia; second part can be found on YouTube.