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• Highlights
• Introduction
• Risk Factors
• Causes
• Complications of Bulimia
• Complications of Anorexia
• Symptoms
• Diagnosis
• Treatment
• Treatment for Bulimia
• Treatment for Anorexia
• Therapy
• Resources
• References

Eating disorders

Description

An in-depth report on the treatment and prevention of eating disorders.

Alternative Names

Anorexia; Bulimia; Binge eating

Risk Factors

Many factors contribute to the risk of developing an eating disorder.

Age

Dating disorders occur most often in adolescents and young adults. However, new research finds that they are increasingly prevalent among young children. Eating disorders are more difficult to identify in young children because they are rarely suspected.

Age of Onset for Bulimia. A 2004 study of high school students in the United States found that about 25% of girls and 10% of boys followed abnormal eating and weight control practices. Another study found that 2% of adolescent girls and 0.3% of adolescent boys fulfilled the criteria for bulimia. The average age of onset was 17 years. According to estimates, as many as 10% of college-aged women have bulimia. Some experts claim that even these percentages grossly underestimate the problem because many people with bulimia are able to conceal their purging and do not become noticeably underweight.

Age of Onset for Anorexia Nervosa. After asthma and obesity, anorexia nervosa is the third most common chronic illness in adolescent women. It is estimated to occur in 0.5 - 3% of all teenagers. Anorexia usually first occurs in adolescence with peaks at 13 - 14 years of age and at 17 - 18 years of age. Over the past 40 years, however, the incidence has been steady in teenagers, but has increased threefold in young adult women.

Gender

Studies typically report that 90% of those with eating disorders are females. However, the prevalence in males appears to be increasing. For example, a 2003 Canadian health survey reported that 20% of the patients were male. A 2000 study of teenagers in Minnesota reported that 13% of girls and 7% of boys reported disordered eating behavior.

When eating disorders occur in young adults, men are more apt to conceal them, so the incidence among males may be underreported. One study of Navy men, for example, reported a prevalence of 2.5% for anorexia, 6.8% of bulimia, and 40% for binge eating.

Studies suggest that the psychiatric and behavioral profiles of men and women with eating disorders are very similar to each other, although there are some differences. Excessive physical activity is more prevalent in males with anorexia. Anorexics tend to have very low sexual interest, although there is a higher rate of homosexuality among young men with anorexia than women. Sexual preference for men may tend to differ, however, by the specific eating disorders. One study reported that 42% of male civilians with bulimia were homosexual or bisexual while 58% of the men with anorexia were asexual.

Ethnic Factors

Most studies of individuals with eating disorders have been conducted using Caucasian middle-class females. Studies now indicate, however, that minority populations, (including Hispanic Americans and African-Americans), are significantly affected. There is some indication that African-American girls and young women may be at particular risk for eating disorders because of poor body images caused by cultural attitudes that denigrate the physical characteristics of minorities. A 2004 study found that about the same percentage of Caucasian women 72.0%), African-American women (68.3%), and Hispanic women (69.4%) wanted to weigh less, and about half of the women in each group were actively trying to lose weight. In one study, bulimia was equally common among both Caucasian and African-American women, although the latter were more likely to binge recurrently, to fast, and to use laxatives and diuretics to control weight. Binge eating may be an even more severe problem in Hispanic Americans. A 2000 study on Asian women also reported rates of dieting and body dissatisfaction that were similar to those in other cultures, but Asian women had much lower percentages of actual eating disorders.

Socioeconomic Factors

Living in any economically developed nation on any continent appears to pose more of a risk for eating disorders than belonging to a particular population group. Symptoms remain strikingly similar across high-risk countries.

Income Levels. Oddly enough, within developed countries there appears to be no difference in risk between the rich and the poor. Some studies suggest that those in lower economic groups may be at higher risk for bulimia. But a 2005 study of Latina adolescents found that the risk of eating disorders was actually higher among girls of higher socioeconomic status.

Urban Life. City living is a risk factor for bulimia, but it has no effect on the risk for anorexia.

Intelligence. In one sample, people with eating disorders scored significantly higher than average on IQ tests. People with bulimia, but not anorexia, had higher nonverbal than verbal scores.

Personality Disorders

A 2000 study reported that people with eating disorders tended to share similar personality traits, including low self-esteem, dependency, and problems with self-direction. Researchers have been attempting to determine specific personality disorders or behavioral characteristics that might put people at higher risk for one or both of the eating disorders. Some studies have reported the following personality disorders linked to particular eating disorders:

• Avoidant personalities, mostly seen in anorexia. Such people are generally high functioning, persistent, and perfectionists.
• Dependent personalities, mostly seen in anorexia. This group is usually over-controlled and withdrawn.
• Borderline and histrionic personalities, mostly seen in bulimia. Such individuals are emotionally uncontrolled and impulsive.
• Narcissism is seen in both anorexia and bulimia.

Any of these personality traits can appear in patients with either bulimia or anorexia. Some experts believe that the patient's specific personality disorder, rather than whether they are anorexic or bulimic, may be the more important factor in determining treatment choice.

Avoidant Personalities. Some studies indicate that as many as a third of anorexic restrictors have avoidant personalities. This personality disorder is characterized by:

• Being a perfectionist
• Being emotionally and sexually inhibited
• Having less of a fantasy life than people with bulimia or those without an eating disorder
• Not being rebellious, or being perceived as always being "good”
• Being terrified of being ridiculed or criticized or of feeling humiliated

People with anorexia are extremely sensitive to failure, and any criticism, no matter how slight, reinforces their own belief that they are "no good.”

The person with both anorexia and an avoidant personality disorder may develop a behavioral and eating pattern as follows:

• For such individuals, achieving perfection is the only way they believe they can obtain love.
• Part of the drive for perfection and love is being trouble-free and attaining some ideal image of thinness. Eating is also associated with lower animal drives, so fasting has been linked historically to saintliness. The individual is driven to demand nothing, including food.
• Failure is inevitable, since being loved has nothing to do with being perfect. (In fact, people who are always seeking perfection often alienate others around them.)
• This failure to achieve love is followed by a sense of being even more imperfect (which is equivalent to being fat) and a renewed sense of striving for perfection -- becoming even thinner.

In keeping with the avoidant personality, one expert described her anorexic patients as having a total lack of self, well beyond having low self-esteem. In support of this, a 2002 study reported that women with eating disorders were less likely to attend to their own needs and to care for themselves. In other words, they felt "self-less" and experienced guilt if they felt they were promoting their own self-interest.

The process of not eating may become an act of passive revenge on those whose love is always out of reach: "See? I am slowly disappearing, and you will be very sad when I am gone."

Obsessive-Compulsive Personality. Obsessive-compulsive personality defines certain character traits (being a perfectionist, morally rigid, or preoccupied with rules and order). This personality disorder has been strongly associated with a higher risk for anorexia. These traits should not be confused with the anxiety disorder called obsessive-compulsive disorder (OCD), although they may increase the risk for this disorder.

Borderline Personalities. Studies indicate that almost 40% of people who are diagnosed with bulimic anorexia (losing weight by bingeing and purging) may have borderline personalities. People with borderline personalities have been described as causing chaos around them by using emotional weapons, such as temper tantrums, suicide threats, and hypochondriasis. Such people tend to:

• Have unstable moods, thought patterns, behavior, and self-images
• Be frantically fearful of being abandoned
• Be unable to be alone
• Have difficulty controlling their anger and impulses -- moreover, between one-quarter and one-third of people with bulimia have impulsive symptoms.
• Be prone to idealize other people (frequently followed by rejection and disappointment)

Some research has suggested that the severity of this personality disorder predicts difficulty in treating bulimia, and it might be more important than the presence of psychological problems, such as depression.

Narcissism. Studies have also found that people with bulimia or anorexia are often highly narcissistic and tend to:

• Have an inability to soothe oneself
• Have an inability to empathize with others
• Have a need for admiration
• Be hypersensitive to criticism or defeat

Accompanying Emotional Disorders

Between 40 - 96% of all eating-disordered patients experience depression and anxiety disorders. Depression, anxiety, or both is also common in families of patients with eating disorders. It is not clear if emotional disorders, particularly obsessive-compulsive disorder (OCD), cause the eating disorders, increase susceptibility to them, or share common biologic cause.

Obsessive-Compulsive Disorder (OCD). Obsessive-compulsive disorder is an anxiety disorder that occurs in up to 69% of patients with anorexia and up to 33% of patients with bulimia. In fact, some experts believe that eating disorders are variants of OCD. Obsessions are recurrent or persistent mental images, thoughts, or ideas, which may result in compulsive behaviors (repetitive, rigid, and self-prescribed routines) that are intended to prevent the manifestation of the obsession. Women with anorexia and OCD may become obsessed with exercise, dieting, and food. They often develop compulsive rituals (weighing every bit of food, cutting it into tiny pieces, or putting it into tiny containers). The presence of OCD with either anorexia or bulimia does not, however, appear to have any influence on whether a patient improves or not.

Other Anxiety Disorders. A number of other anxiety disorders have been associated with both bulimia and anorexia, including:

• Phobias. Phobias often precede the onset of the eating disorder. Social phobias, in which a person is fearful about being humiliated in public, are common in both types of eating disorders.
• Panic Disorder. Panic disorder often follows the onset of an eating disorder. It is characterized by periodic attacks of anxiety or terror ( panic attacks ).
• Post-Traumatic Stress Disorder. One study of 294 women with serious eating disorders reported that 74% of them recalled a traumatic event, and more than half exhibited symptoms of post-traumatic stress disorder (PTSD) -- an anxiety disorder that occurs in response to life-threatening circumstances.

Depression. Depression is common in people with eating disorders, particularly anorexia. Depression and eating disorders are also linked to a similar seasonal pattern, as indicated by the following observations:

• For many people, depression is more severe in darker winter months. Similarly, a subgroup of bulimic patients suffers from a specific form of bulimia that worsens in winter and fall. Such patients are more apt to have started bingeing at an earlier age and binge more frequently than those whose bulimia is more consistent year round.
• Onset of anorexia appears to peak in May, which is also the peak month for suicide.

Major depression is unlikely to be a cause of eating disorders, however, because treating and relieving depression rarely cures an eating disorder. The severity of the eating disorder is also not correlated with the severity of any existing depression. In addition, depression often improves after anorexic patients begin to gain weight.

Being Overweight

A 2002 study reported that among American teenagers 18% of overweight girls and 6% of overweight boys reported extreme eating disorder behaviors, including use of diet pills, laxatives, diuretics, and vomiting. Researchers are working on strategies for preventing the development of eating disorders among overweight adolescents. A 2006 study that targeted overweight college-age women reported success with an Internet-based cognitive behavioral therapy program that helped these women become more comfortable with their body weight and shape. The program also included information on the risks of eating disorders, and education on healthy eating and weight maintenance.

Body Image Disorders

Body Dysmorphic Disorder. Body dysmorphic disorder (BDD) involves a distorted view of one’s body that is caused by social, psychologic, or possibly biologic factors. It is often associated with anorexia or bulimia, but it can also occur without any eating disorder. People with this disorder commonly suffer from emotional disorders, including obsessive-compulsive disorder and depression. As part of obsessive thinking, some people with BDD may obsess about a perceived deformity in one area of their body, and may repeatedly seek cosmetic surgery to “correct” it. People with BDD are also at higher risk for suicidal thinking and attempts. Some evidence suggests that treatment with fluoxetine (Prozac), a common antidepressant known as an SSRI helps reduce this problem, even in people without an eating disorder.

Muscle Dysmorphia. Experts are also increasingly reporting a disorder in which people have distorted body images involving their muscles. It tends to occur in men who perceive themselves as being "puny,” which results in excessive body building, preoccupation with diet, and social problems. Such individuals are prone to eating disorders and other unhealthy behaviors, including the use of anabolic steroids.

Excessive Physical Activity

Highly competitive athletes are often perfectionists, a trait common among people with eating disorders.

Female Athletes and Dancers. Women in "appearance" sports, including gymnastics and figure skating, and in endurance sports, such as track and cross-country, are at particular risk for anorexia. Success in ballet also depends on the development of a wiry and extremely slim body. Estimates for episodes of eating disorders among such athletes and performers range from 15 - 60%.

Male Athletes. Male wrestlers and lightweight rowers are also at risk for excessive dieting. One-third of high school wrestlers use a method called weight-cutting for rapid weight loss. This process involves food restriction and fluid depletion by using steam rooms, saunas, laxatives, and diuretics. Although male athletes are more apt to resume normal eating patterns once competition ends, studies show that the body fat levels of many wrestlers are still well below their peers during off-season and are often as low as 3% during wrestling season. Of concern is a recently recognized body-image disorder, referred to as muscle dysmorphia, which occurs mostly in men who are preoccupied with weight lifting and who perceive themselves as puny.

Men and Women in the Military. Studies also show a higher-than-average risk for eating disorders in men and women in the military. A study of eating behavior on one Army base reported that 8% of the women had an eating disorder, compared to 1 - 3% in the civilian female population.

Vegetarianism

In general, vegetarianism, with careful planning, is a healthy practice for both adults and adolescents. Studies report, however, that vegetarianism in adolescence may be a risk factor for eating disorders in both males and females. In one study, while vegetarian teens ate more fruits and vegetables, they were also twice as likely to diet frequently, four times as likely to intensively diet, and eight times as likely to use laxatives as their non-vegetarian peers. Another study indicated that college-aged vegetarian women were significantly more likely to have eating disorder-like attitudes and behaviors than women who were not vegetarians.

These studies do not mean that being a vegetarian equates with having an eating disorder. They do suggest, however, that parents with children who suddenly become vegetarians should be sure that their children are eating a balanced meal with sufficient protein, calories, and important minerals, such as calcium. Parents also might suspect anorexic behavior in their child under certain conditions:

• If the child has stopped eating meat only to avoid fat rather than from other motives, such as love of animals or to improve health.
• If the vegetarian diet coincides with rapid weight loss.
• If the child avoids important vegetable products because of calories (such as whole grains) or because of fats and oils (such as tofu, nuts, and dairy products).

Diabetes or Other Chronic Diseases

According to one survey, 10.3% of teenage girls and 6.9% of boys with chronic illness, such as diabetes or asthma, had an eating disorder. Some recent research suggests an endocrinological link between obesity, diabetes, and eating disorders.

Diabetes. Eating disorders are particularly serious problems for people with either type 1 or type 2 diabetes.

• Binge eating (without purging) is most common in type 2 diabetes and, in fact, the obesity it causes may even trigger this diabetes in some people.
• Both bulimia and anorexia are common in type 1 diabetes. A 2005 study indicated that as many as 25% of young women with type 1 diabetes may develop abnormal eating habits, and that the combination of diabetes and an eating disorder can have serious health consequences in the women’s future. Diabetic women often omit or underuse insulin in order to control weight. If such patients develop anorexia, their extremely low weight may appear to control the diabetes for a while. Eventually, however, if they fail to take insulin and continue to lose weight, these patients develop life-threatening complications.

Early Puberty

There is a greater risk for eating disorders and other emotional problems for girls who undergo early puberty, when the pressures experienced by all adolescents are intensified by experiencing, possibly alone, these early physical changes, including normal increased body fat. One interesting study reported that:

• Before puberty, girls ate quantities of food appropriate to their body weight, were satisfied with their bodies, and noted their depression increased with lower f ood intake.
• After puberty, girls ate about three-quarters of the recommended calorie intake, had a worse body self-image, and noted their depression increased with higher food intake.

This study reported on girls without eating disorders, but it certainly suggests patterns that can lead to eating problems, particularly in girls who go through puberty early. Other studies also indicate that girls who start menstruating at a younger age are more likely to develop eating disorders.

• Review Date: 12/13/2006
• Reviewed By: Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

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