Eating Disorders

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1. Introduction to the Eating Disorders

  • Eating disorders are becoming increasingly common but are nothing new to society; they have been around for centuries. Many people often feel the need to be skinny in order to fit into society. A person with an eating disorder is diagnosed when their condition becomes clinically significant and they "suffer from extreme disturbances in their eating behavior that is caused by obsessive or irrational fear of gaining weight." Although, psychological factors and social variables play an important role in the development of this type of disorder. Eating disorders can be a serious type of behavioral problems that can greatly interfere with the well being of an individual, not only can their health be greatly affected, but also their emotional and psychological well being.
  • Eating disorders are characterized by severe disturbances in an individual's eating behavior. A person with an eating disorder can use eating, purging or food restricting to attempt to cope with problems they may be experiencing. Some underlying issues that could be associated with eating disorders could include low self-esteem, depression, feelings of loss of control, feelings of worthlessness, identity concerns, family communication problems, and an inability to deal with emotions.
  • Young girls from Western Societies are at a great risk for developing an eating disorder. Society portrays a perfect image to young girls that is unrealistic and fake. Magazines and movies show women to be airbrushed, perfect, and without blemish. Young girls see this image and strive to be like these women. This is an unrealistic view of themselves which often leads to body dismorphic disorder which leads to eating disorders. Eating disorders cause physical problems along with emotional problems. An eating disorder can actually result in death. Many people who have an eating disorder go away to clinics to try and reverse the bad body image they have.
  • In the DSM-V, some of the proposed changes include the addition of purging disorder (recurrent purging in the absence of binge eating) and night eating syndrome.

2. Statistics

  • Nearly 50% of people with eating disorders meet the criteria for depression.
  • 95% of those who have eating disorders are between the ages of 12 and 25.
  • 25% of college aged women binge and purge as a weight-management technique.
  • Men are less likely to seek help for eating disorders because of the false perception that it is a "woman's disease".
  • Nearly 14% of gay men suffer from bulimia and over 20% of them suffer from anorexia.
  • 20% of people suffering from anorexia will prematurely die from complications related to their eating disorder, including suicide and heart problems.

3. Anorexia Nervosa (307.1)

  • DSM-IV-TR criteria
    • A. Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected).
    • B. Intense fear of gaining weight or becoming fat, even though underweight.
    • C. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body shape on self-evaluation, or denial of the seriousness of the current low body weight.
    • D. In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen, administration).
    • Specify type: Restricting Type: The person describes presentations in which weight loss is accomplished by dieting, fasting, or excessive exercise and has not regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or misuse of laxatives, diuretics, or enemas).
    • Binge-Eating/Purging Type: During the current of Anorexia Nervosa, the person has regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas).(The binge-eating/purging type used to be called bulimiarexia. That term is now archaic.). Some in this subtype do not binge, but do purge after consuming small amounts of food.
  • Associated features
    • People that suffer from Anorexia Nervosa typically view themselves as overweight. The term anorexia means "loss of appetite"; however, individuals that have anorexia constantly feel hungry since they constantly deprive their body of adequate nutrition. Often time's individuals with anorexia refuse to eat in order to lose weight. If they feel they have gained weight, they may use extreme measurements to become thin, such as using laxatives, induce vomiting, excessive exercise, consuming diet or diuretic pills, and obsessing all caloric intake of everything they eat.
    • Some anorexic women consider amenorrhea as a milestone in weight loss; if they are menstruating they often think they are too fat.
    • Many people that have anorexia often deny how severley underweight they are; they think they are still too fat and need to continuously lose weight. In young girls, obsession with wieght typically begins at the onset of puberty. Girls who mature early are at a greater risk of developing an eating disorder than girls that mature at a normal rate. Other people are worried about their health but not in such an extensive way as anorexic people. However, anorexic individuals rarely believe that their current weight is acceptable and do not seem to find a point at which it is unhealthy to lose additional weight. Therefore, they end up losing more weight than necessary which can cause serious health problems.
    • The signs and symptoms of anorexia can include: low body temperature, coldness in the extremities, and constipation for some time. The individuals with anorexia nervosa are unable to tolerate cold temperatures; they also often report fatigue or tiredness, episodes of dizziness, constipation, periodic vomiting, and shortness of breath. Individuals also tend to develop irregular menstrual cycles or actually lose their periods for long stages of time due to malnutrition and being underweight. Anorexia can also effect a woman's fertility. In females, there are low levels of serum estrogen, and there are low levels of serum testosterone in men. Thinning of the hair, sunken eyes like low in eyelids, and puffy cheeks are some of the most observable signs that one may be anorexic. The individuals, however, are unable to tell that these characteristics are seen as abnormal towards others. Anorexia nervosa is commonly co-morbid with mood disorders. Many individuals with the eating disorder also report anxiety disorders such as obsessive-compulsive disorder (OCD) and social phobia disorders. People who suffer from anorexia also tend to have a harder time with concentration due to the fact that they are constantly reminded by their body of its nutritional needs.
    • The behaviors expressed tend to be more introverted like social withdrawal in particular situations and decreased interest in sex over time. An individual who views themselves as excessively thin may feel sexually undesirable resulting in a reduction of sexual interest. Recovery rates are low for anorexia nervosa. Although 50% achieve partial recovery, only 10% fully recover from the disorder. Within the first five years of the diagnosis, many individuals with the restricting subtype of anorexia nervosa will develop an eating pattern that is more typical of the binge-eating/purging subtypes. If unchecked, chronic starvation and weight loss can result in severe dehydration and electrolyte imbalance that may require hospitalization if not cared for or attended to soon.
    • These individuals put extreme amounts of emphasis on their weight that they may actually measure everything that comes in and out by the ounce.
  • Child vs. adult presentation
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  • Recovered: Twelve year old Bryony with her mom Jacqui (above) and in the grip of anorexia (below)
    • Anorexia nervosa normally begins in mid to late adolescence (age 14-18 years). It is not likely to see children under the age of 13 with anorexia because of their lack of concern with social acceptance and appearance. Seventeen is the average age of onset of anorexia nervosa. Rare cases of older adults being diagnosed with the disorder do exist, however, it is highly unlikely that an individual over 40 years of age will be diagnosed. Most individuals in the age group of 14-18 are very social, seek relationships and social acceptance much of the time. These individuals may become very self-conscious about their physical appearance, predisposing them to the development of anorexia nervosa.
  • Gender and cultural differences in presentation
    • Anorexia nervosa is more common in females than in males. This may be the result females being more concerned about their appearance than males. It is a common stereotype that many females are more willing to go to extremes to look better. Among the amount of people with the disorder, about 95% are female compared to 5% of whom are male. Most of these come from high-achieving families and believe they have to be presentable, which is viewed as thin and beautiful opposed to big and bulky. There has also been an associated link found between Anorexia and authoritarian parenting styles, many say the child can feel too much pressure from their parents, and thus develop disorders such as anorexia. Anorexia nervosa is most prevalent in the U.S. and other countries with high economic status. It is estimated that about one out of every 100 adolescent girls has the disorder. Caucasians are more often affected than people of other racial backgrounds, but currently there has been an increase in the number of African American females who are being diagnosed with this disorder. Anorexia is also more common in middle and upper socioeconomic groups. According to the U.S. National Institute of Mental Health (NIMH), an estimated 0.5% to 3.7% of women will suffer from this disorder at some point in their lives.Approximately half of anorexic females are predicted to develop bulimia, which is also considered a psychological eating disorder, and is defined as excessively overeating and then different improper methods are used to get rid of the food just ingested, such as throwing up.
  • Epidemiology
    • In women, anorexia nervosa can occur between a percentage rate of 0.5% to 3%. The lifetime prevalence rate of this disorder is around 0.5%. Approximately 1% of the population will be diagnosed with anorexia nervosa in a lifetime, and there is some concern that this rate is increasing. Since the 1930s, there has been an increasing number of anorexia nervosa cases. This may be due to the increase in the prevalence of industrialized societies, as well as the constant pressure to be thin as implicated by the mass media (characteristics of personality and the cultural approval of thinness). Television shows constantly portray favorable bias toward thin, better looking people as opposed to those who are considered to be overweight individuals.
    • Anorexia Nervosa usually begins in mid to late adolescence. The rarely occurs in females over 40 years of age. The onset may be associated with a strssful life event. The course and outcome are highly variable. Some never fully recover after a single episode; some exhibit a pattern of weight gain and loss, and others experience a chronic course over many years. With time, a significant of the Restricting Type develop binge eating, changing to the Binge Eating/Purging Subtype. The long term mortality is over 10%, most commonly from starvation, suicide, or electrolyte imbalance.
  • Etiology
    • Socio-cultural factors: Industrialized societies place great value on women who are thin. Evidence of this can be seen in the entertainment industry, (such as movies, TV shows, advertising and catalogs), where nearly all of the women featured are thin. Being thin is considered better than being bigger. Through this media, young women are conditioned to believe that only "thin" is beautiful, and they may become obsessed with attaining this image, such as an hour glass figure (big in the hips and thin in the waist). Inner beauty is not a factor in the real-world which helps one achieve success; it is physical appearance and social capital. Furthermore, being thin in these industrialized societies is culturally reinforced by what the favorable definitions are for popularity. Since men are also conditioned to believe that "thin" is beautiful, the attention that petite women receive from the opposite sex acts to reinforce women's attitudes that they look good being thin and that is the body image men desire. Anorexia Nervosa is far more prevalent in industrial societies such as the United States, Canada, Europe, Australia, Japan, New Zealand, and South Africa. Moreover, eating disorders are less prevalent in societies where women have fewer decision-making responsibilities.
    • Psychological Factors: Individuals with anorexia nervosa tend to be perfectionists, a person who places very high standards on everything and is displeased with things if they fall short of the expected standard, which affects the way they look at their body. They become so obsessed with achieving the image of the "ideal woman" that they will push themselves to dangerous extremes and begin possessing obsessive or narcissistic qualities. They also engage in compulsive behavior, which includes frequently checking their appearance and weight, like combing their hair, shaving, brushing teeth, or even repetitive flossing. These individuals crave control, especially over their eating habits, by engaging in restrictive diets and always eating the same thing because nothing else is satisfying. They in return learn to ignore the resulting internal cues of hunger. Psychological symptoms of anorexia consist of those characteristics that are related to the development of the disorder and those that are secondary to the disorder.
    • Biological factors: Twin studies in anorexia have found concordance rates for mono-zygotic (identical) twins to be significantly higher than concordance rates for dy-zygotic (nonidentical or fraternal) twins. This finding suggests that there may be genetic factors involved in predisposing individuals to anorexia nervosa, such as gene combination with parental sequences, passed down. There is also an increased risk of anorexia nervosa developing in the first-degree biological relatives of anorexic individuals. They have a greater chance of acquiring the odd sequences that cause these problems in anatomy and dietary functions. There also can be a weak genetic component more developmental than mental so other factors should be considered like family history of eating, perfectionist and their personality.
  • Empirically supported treatments
    • Anorexia nervosa is difficult to treat and relapse is common among the patients with the disorder. Most anorexic individuals do not see a problem with themselves and, consequently, are not admitted to treatment by their own accord. Often, a friend of the troubled individual has to intervene and recommend that he or she seek help to further their daily functioning. Help may be gained either through medication or behavioral therapies. Denial, coupled with an individual's unwillingness to participate in treatment, can make changing a patient's attitude very challenging.
    • There are two major goals for treating patients with this disorder:
      1. Getting the patient to gain weight is not an easy task. It is important that the patient gradually begins to eat more during each meal time and not forcibly trying to eat larger amounts of food at one time. If adequate nutrients are not obtained in food, normal functioning is inhibited. It is crucial for underweight individuals to gain more weight, at least to the point where health and nutritional concerns are no longer a factor. Underweight individuals possess less ability to fight off pathogenic diseases because their immune systems are not prepared to provide proper circulation to crucial areas of the muscles, glands, and other areas due to a lack of nutrition. Also, the body needs the right amount of nutrition to be able to function to its normal capacity. However, the patient needs to be aware of the importance of gaining weight gradually because the body will encounter problems attempting to adjust to rapid increases in weight. If this occurs, it can cause complications in the individual's digestive system and a person may become overstuffed and burst.
      2. Addressing other psychological, social, and environmental issues is a vital part of one's treatment. During treatment, clinicians try to change the way the patient views his or her self. Clinicians goals are to address the issues that potentially caused the disorder, change the patient’s perspectives on body image, maintain a healthy diet, and help the patient classify a healthy weight. The clinicians let the patients know what is socially acceptable or popular and emphasize the vitality of maintaining healthy food choices. The clinicians also inform the patient of a respectable weight he or she should maintain.
    • When treating the young women and men who are suffering from anorexia nervosa, the most common technique is through family therapy. In family therapy, the clinician usually tries to change the patient's attitude about their body image. They also try to increase the patient’s self-esteem by teaching him or her to accept the way his or her body looks and becoming satisfied with it. The family attends these counseling sessions with the patient and will gain control over the patient's eating habits until the patient can maintain healthy habits oneself. They also reinforce what the clinician says. For example, the family members may stress that the patient's body is fine and satisfying to the public eye. Families may also be asked to monitor exercise habits. If the patient exercises excessively, they will need to improve the workout by designating only a certain amount of time a day for exercise. However, this technique usually only lasts for a short period of time and the patient becomes bored with the activities. This is due to the fact that many patients are in denial and tend to get into a relapse or think that they are really fine, that everyone is jealous around them because they are better.
    • Another technique for treating people diagnosed with anorexia nervosa is attending self-help groups. The American Anorexia Bulimia Association is one organization that provides support groups for those who are suffering from eating disorders that need to talk it out with others experiencing the same problems. The more "experienced," affected individuals with anorexia nervosa are very good when telling the "newbies" how to deal with certain problems they already have experienced. The same techniques do not work for everyone but can help ignorant patients that do not know where to turn for help. People can gather and give each other support to help them recover from this disorder and prevent them from going into denial or put in a relapse.
    • Medication is not recommended for treating people with anorexia nervosa. The main reason is because these individuals are often very thin. Because they are thin, their bodies have a harder time with the chemicals found in the drugs. Those with low body weight can overdose much quicker than others, and their immune system is very weak. They could become dependent on drugs such as Xanax or Valium, both are CNS depressants, which could cause a number of health, and maybe even legal problems that need to be avoided if at all possible. Psychotropic drugs can decrease the patient's suffering, but also allow a degree of stabilization in the patient's chaotic life. Some psychiatrists prefer to use SSRIs because of their efficacy. This could cause negative side effects and complications, sometimes even death. Estrogen may also be prescribed as part of treatment. Women with anorexia are at risk of fractures as a result of osteoporosis, which usually occurs during menopause; however, the lack of mensturation due to their low body weight puts them in a state like early menopause. There is some suggestion that taking estrogen can help some women have the ability to regain some of their bone funcitoning and stability that has been lost and prevent other fractures from possibly happening.
    • Parenting classes have been a new and upcoming technique that helps parents learn how to build self-esteem in their kids. This treatment helps the teen to value themselves as a person and learn to trust their abilities and feelings while working toward their goals.

  • -- Individuals who suffer from Anorexia Nervosa believe that they are improving their appearance while often harming themselves by abstaining from food. See video
  • A girl discusses her life with Anorexia. Note: Some of the images in this video may be disturbing. See Video
  • The following link is from Morning Edition on NPR. It is a short recount of a young girl's experience with anorexia.
  • The following link is from New and Notes on NPR. Farai Chideya interviews different people on eating disorders and anorexia specifically for African-Americans.

To view images of anorexia visit: Anorexia in Males and Anorexia in Females
Explanation of Anorexia Nervosa Impact of Eating Disorder
Story of 12yr old Bryony above:
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4. Bulimia Nervosa (307.51)

  • DSM-IV-TR criteria
    • A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
      1. eating in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances; it is common for more than 10,000 calories to be consumed per binge
      2. an abnormal constant craving for food; a sense of a lack of control of eating during an episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)
      3. eating is usually done in secret
    • B. Recurrent inappropriate, compensatory behavior in order to prevent weight gain. Such as self-induced vomiting, misuse of laxatives, diuretics, enemas, or other medications, fasting, or excessive exercise.
    • C. The binge eating and inappropriate compensatory behaviors both occur on average at least twice a week for three months.
    • D. Self-evaluation is unduly influenced by body shape and weight.
    • E. The disturbance does not occur exclusively during episodes of Anorexia Nervosa.
    • Specify type:
      • Purging Type: during a current episode of Bulimia Nervosa, the person regularly engages in self-induced vomiting or the misuse of laxatives, diuretics, enemas or ipeac, as means of rapidly extricating the contents consumed.
      • Non-purging Type: during a current episode of Bulimia Nervosa, the person uses other inappropriate compensatory behaviors, such as fasting or excessive exercise, but does not regularly engage in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.
      • The following six criteria should be met for a patient to be diagnosed with bulimia
        • 1.The patient feels incapable of controlling the urge to binge, even during the binge itself, and consumes a larger amount of food than an average healthy person would normally consume at one sitting.
        • 2.The patient purges him or herself of the recent intake, resorting to vomiting, laxatives, diuretics, exercising, etc.
        • 3. The patient engages in such secretive behavior at least twice per week for three months.
        • 4. The patient is focused upon body image and possesses a desperate desire to appear thin.
        • 5. The patient does not meet the diagnostic criteria for anorexia nervosa
        • 6.The patient is of normal weight or overweight, contrasting with characteristics of anorexia nervosa.
  • Associated features/ effects
    • A person with Bulimia Nervosa suffers from "body image disturbance", which makes them unable to perceive their body size accurately. By having these distorted thoughts about their body, they avoid looking into a mirror. People suffering from bulimia nervosa are usually not noticed right away. They seem normal in appearance and are not noticed as easily as anorexics are in public settings. This is because they engage in binge eating activities privately as a solitary activity. People with bulimia nervosa consume their food at a rapid pace, and this may be present along with depression feelings, environmental influential factors, irritability, and tension in some parts of their life. After a binge episode, feelings of guilt and depression follow, forcing the bulimic into purging behaviors which allows them to regain control of the situation. The actual word, bulimia, is translated as "hunger like an ox."
    • They experience fluctuating weight loss, but unlike anorexia nervosa, people with bulimia nervosa are still able to maintain the average weight with respect to their height, so they appear relatively normal. Bulimia nervosa is more of a mental aspect than a physical one such as private eating activities. Compared to the rest of the population or those with regular eating habits, people with bulimia nervosa are still considered to be the thinner individuals. Them also wear loose-fitting clothes in order to hide their bodies.
    • Research has shown that, if caught in early stages enough and treated in the right way, 80% of people with bulimia nervosa can fully recover. This is because the habits are not formed completely in the mind's everyday activities schedule. If it is not so branded into the behaviors, one can change the eating habits to normal functioning abilities. Most patients can control the behavior with psychotherapy, counseling, biofeedback training and inindividual or group psychotherapy. Without treatment complications can be fatal.
    • These individuals may have scabs or nicks on their knuckles from constantly trying to make themselves vomit. Their teeth and esophagus suffer from the constant presence of acid. The recurrent vomiting can lead to loss of dental enamel, and their teeth may appear chipped and ragged. Excessive vomiting also leads to scratched and discolored fingernails due to the patient sticking them down the throat. Sometimes, the salivary glands become permanently enlarged. Also, a person suffering from bulimia will usually display the often recognized "chipmunk cheeks" because they are inflamed due to repeated vomiting. Amenorrhea and chronic bowel problems are also associated with this eating disorder.
    • Although it is stereotyped that individuals suffering from anorexia nervosa fear the scale, it is actually bulimics that seem to show the most fear of stepping onto a scale. Because bulimia nervosa sufferers have an exaggerated fear of gaining weight, they tend to avoid weighing themselves.
  • New findings of associated features
    • Professors and researchers at the University of Pittsburg Medical Center have found evidence supporting that Nervosa Bulimia may be linked by a biological factor. The researchers suggest that an alteration of brain chemistry contributes to a persons development of bulimia nervosa. Dr. Walter H. Kaye, a professor of psychiatry, states in his journal article that, "Women with bulimia nervosa, when bingeing and purging, are known to have alterations of brain serotonin activity and mood as well as obsessions with perfectionism" (Kaye, et al., 1998). An alteration in seratonin levels could cause one to portray anxious and obsessive behaviors.
    • Symptoms
    • 1. The patient's laboratory blood studies, including measurement of electrolyte levels are abnormal
    • 2. Patient suffers from recurrent mood swings or depression. 3. Problems with stomach, esophagus, colon and throat.
      4. Patient has no satisfaction with their body shape and is preoccupied with becoming thin.
      5. Excessive exercising to control weight gain.
      6. Unable to stop binge/purge cycle without intervention.
      7. Dental problems
      8. Frequent weight fluctuation
      9. Fear of weight gain
      10. Build up of fluid with swelling of the parotid galnds.
  • Child vs. adult presentation
    • Onset is later in both children and adults for anorexia nervosa, and bulimia usually begins in late adolescence or early adulthood. It is usually 15 to 21 years of age that onset is diagnosed or becomes possible to diagnose. It is vital that a clinician has time to evaluate the behaviors of the individuals and the environments they inhabit.
    • The age of onset for children has recently lowered to 9-12 years. This could be related to the pressures from the media and television. Television shows for kids show the same favorable societal definitions that adult shows provide. The decrease in the age of onset could also be related to the onset of puberty decreasing as well. Because children are beginning to experience puberty sooner, their bodies are also developing at a earlier age. For girls, this means more fat tissue is formed which may possibly cause unhealthy self images to exist at earlier ages. Because these children are so young, the abnormal diet and lack of nutrition can lead to the absence of nutritional essentials for their development.
  • Gender and cultural differences in presentation
    • Females are much more likely to suffer from Bulimia Nervosa than males. About 1 male for every 10 females suffers from Bulimia Nervosa. This is because women tend to care more about their appearance than males. There are no cultural differences among patients with Bulimia Nervosa regarding their symptoms.
    • Cultural differences: In Eastern Asian countries, weight is concidered to be an indifferent topic; however, their body structure and diet may reduce the chances of staying thin.
  • Epidemiology
    • About 1% to 3% of people have reported or been diagnosed with Bulimia Nervosa during their lifetime, and most are female. The male to female ratio is 1 male to 10 females.
    • There are also new studies being conducted that compare the environmental factors of binging and purging habits on the individuals who have Bulimia Nervosa. One of the studies show that there is a 46% binging variance and a 72% vomiting variance. Showing that because of environmental factors, binging can only occur during certain periods while vomiting can happen more frequently. Also, another study in the UK has shown that Bulimia Nervosa is increasing at high rates, almost doubling in occurrence every year, with a lower frequency of occurrence for Anorexia Nervosa.
    • Bulimia Nervosa usually begins in late adolescence or early adult life. The binge eating often begins during or after a dieting episode. Distrubed eating behavior lasts for at least several years in clinical samples. The course may be chronic or intermittant, with remission altering with relapses into binge eating. over long term, the symptoms of many seem to diminish. Remission longer than one year is associated with better long-term outcome.
    • Studies show that only 6% of people suffering from Bulimia Nervosa recieve mental health care. Statistics show that there has been a dramatic increase of Bulimia in recent years among women between the ages of 15 and 24.
  • Etiology
    • The cause for this disorder is believed to be less from the desire for food, and more from an interaction between biological, environmental, and psychological factors. Common personality characteristics found in people with this disorder are that they are outgoing, sociable, impulsive, and more sexually active. However, a decrease in sex drive or a person's libido is also reported along with an increase in suicidal behavior.
    • There is strong evidence of genetic heritability for people with Bulimia Nervosa. A person is six times more likely to develop the disorder if they have a relative with the disorder. Low levels of serotonin have also been found to have a connection with development of Bulimia Nervosa. There is more familial prevalance of obesity in Bulimia Nervosa, compared to that of Anorexia Nervosa.
    • Psychological Factors: Bulimia includes an obsession with thinness, a diminished perception of self-worth, and an impaired sense of self-confidence. People with bulimia also associate thinness with success, attractiveness, and happiness.
  • Comorbid Conditions
    • Depression, anxiety, phobias or intense fears, and personality disorders such as Histrionic Personality Disorder, Borderline Personality Disorder, and Obsessive Compulsive Personality Disorder, are often associated with Bulimia Nervosa along with other types of eating disorders. Also, insomnia is sometimes coexistent with Bulimia Nervosa due to malnutrition. It is not uncommon for people with Bulimia Nervosa to develop certain addictions like gambling, shoplifting, or alcohol and drug usage. In fact, research shows 9% of the general population use alcohol and drugs, whereas 30-50% of people with eating disorders use them.
  • Empirically supported treatments
    • Some medications, such as fluoxetine (Prozac) are used to treat mood symptoms (depressive symptoms, mood elevations, binge eating desires) for people who are suffering from Bulimia Nervosa. The most common medications are Tricyclic antidepressants such as Selective Serotonon Re-Uptake Inhibitors (SSRI's). Medication to treat acid reflux caused by bulimia may also be perscribed. Vitamin and mineral supplements are necessary until signs of deficiency disappear and normal eating patterns are established.
    • Cognitive Behavioral Therapy methods are also conducted to change the mindset of people with Bulimia Nervosa. This method focuses on changing the way patients think about their body image, and can sometimes be done in groups. In addition, restriction to binge-type foods is also used to control people who engage in binge-eating.
    • Family therapy involving communication exercises, conflict resolution, and re-establishing boundaries is used more often than other treatments of Bulimia Nervosa.
    • Individual psychotherapy helps the patient develop self-esteem and assertiveness. This therapy also teaches the patient streamlining social skills and pressure-coping strategies.
    • Hospitilisation is helpful for bulimia patients who have extreme eating binges which have caused severe medical problems and health hazards. Patients may also have to be hospitalized if they show signs of being suicidal.


5. Eating Disorder Not Otherwise Specified (307.50)

  • DSM-IV-TR Criteria
    • The Eating Disorder Not Otherwise Specified category is for disorders of eating that do not meet the criteria for any specific Eating Disorder. Examples include
      • 1. For females, all of the criteria for Anorexia Nervosa are met except that the individual has regular menses.
      • 2. All of the criteria for Anorexia Nervosa are met except that, despite significant weight loss, the individual's current weight is in the normal range.
      • 3. All of the criteria for Bulimia Nervosa are met except that the binge eating and inappropriate compensatory mechanisms occur at a frequency of less than twice a week or for a duration of less than 3 months.
      • 4. The regular use of inappropriate compensatory behavior by an individual of normal body weight after eating small amounts of food (e.g., self-induced committing after the consumption of two cookies).
      • 5. Repeatedly chewing and spitting out, but not swallowing, large amounts of food.
      • 6. Binge-eating disorder: recurrent episodes of binge eating in the absence of the regular use of inappropriate compensatory behaviors characteristic of Bulimia Nervosa.


6. Binge-Eating Disorder

  • DSM-IV-TR criteria
    • A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
      • (1) eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances
      • (2) a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)
    • B. The binge-eating episodes are associated with three (or more) of the following:
      • (1) eating much more rapidly than normal
      • (2) eating until feeling uncomfortably full
      • (3) eating large amounts of food when not feeling physically hungry
      • (4) eating alone because of being embarrassed by how much one is eating
      • (5) feeling disgusted with oneself, depressed, or very guilty after overeating
    • C. Marked distress regarding binge eating is present.
    • D. The binge eating occurs, on average, at least 2 days a week for 6 months.
      Note: The method of determining frequency differs from that used for Bulimia Nervosa; future research should address whether the preferred method of setting a frequency threshold is counting the number of days on which binge eating occur or counting the number of episodes of binge eating.
    • E. The binge eating is not associated with the regular use of inappropriate compensatory behaviors (e.g., purging, fasting, excessive exercise) and does not occur exclusively during the course of Anorexia Nervosa or Bulimia Nervosa.
    • F. About 2 percent of all adults in the United States (as many as 4 million Americans) have binge eating disorder. About 10 to 15 percent of people who are mildly obese and who try to lose weight on their own or through commercial weight-loss programs have binge eating disorder. The disorder is even more common in people who are severely obese.
  • Associated Feature
    • Some individuals report that binge eating is triggered by dysphoric moods, such as depression and anxiety. Others are unable to identify specific precipitants but may report a nonspecific feeling of tension that is relieved by the binge eating. Some individuals describe a dissociative quality to the binge episodes (feeling "numb" or "spaced out"). Many individuals eat throughout the day with no planned meal times.
    • These individuals are seen in clinical setting have varying degrees of obesity. Most have a long history of repeated efforts to diet and feel desperate about their difficulty in controlling food intake. Some continue to make attempts to restrict caloric intake, whereas others have given up on all efforts to diet because of repeated failures. In weight-control clinics, individuals with this eating pattern are, on average, more obese and have a history of more marked weight fluctuations than individuals without this pattern. In non-patient community samples, most individuals without this eating pattern are overweight (although some have never been overweight).
    • These Individuals may report that their eating or weight interferes with their relationships with other people, with their work, and with their self-esteem. In comparison with individuals of equal weight without this pattern of eating, they report higher rates of self-loathing, disgust about body size, depression, anxiety, somatic concern, and interpersonal sensitivity. There may be higher lifetime prevalence of Major Depressive Disorder, Substance-Related Disorders, and Personality Disorders. Individuals suffering from this disorder also report a lower sexual drive and level of self-satisfaction and higher levels of embarrassment and guilt.
    • Individuals who develop BED often come from families who put an unnatural emphasis on the importance of food. For example, these families may use food as a source of comfort in times of emotional distress. As children, BED patients may have been taught to clean their plates regardless of their appetite, or to be a good girl or boy and finish all of the meal. Cultural attitudes towards beauty and thinness may also be a factor in BED.
  • Etiology
    • The causes of binge eating disorder is still unknown. BED patients are also more likely to have an additional diagnosis of impulsive behaviors (for example, compulsive shopping), post-traumatic stress disorder (PTSD), panic disorder, or personality disorders. Due to the high rates of depression seen in patients who compulsively eat, the two disorders are suspected to be linked. Whether binge eating disorder causes depression or if depression causes the disorder is still unknown. Risk increases with depression, anorexia nervosa, stress caused by lifestyle changes, such as moving or starting a new job, or a neurotic preoccupation with being physically attractive.
  • Epidemiology
    • In samples drawn from weight-control programs, the overall prevalence varies from approximately 15% to 50% (with a mean of 30%), with females approximately 1.5 times more likely to have this eating pattern than males. In non-patient community samples, a prevalence rate of 0.7% - 4% has been reported.
  • Empirically supported treatment
    • The onset of binge eating is in the late adolescence or in the early 20’s, often coming soon after significant weight loss from dieting. Among individuals presenting for treatment, the course appears to be chronic.
    • Psychotherapy
      • Cognitive behavioral therapy: Some studies show that cognitive behavioral therapy may help you cope better with issues that may trigger binge-eating episodes, such as negative feelings about your body or a depressed mood. It may also give you a better sense of control over your behavior and eating patterns. However, cognitive behavioral therapy hasn't been shown helpful in reducing weight. So if you're overweight, you may need additional treatment.
      • Interpersonal therapy: Interpersonal therapy focuses on your current relationships with other people. This may help reduce binge eating that's triggered by poor relationships and unhealthy communication skills. The goal is to improve your interpersonal skills — how patients relate to others, including family, friends, and colleagues. The patients learn how to evaluate the way they interact with others and develop strategies for dealing with relationship and communication problems.
      • Dialectical behavior therapy: This form of therapy can help patients learn behavioral skills to help their tolerate stress, regulate their emotions and improve their relationships with others, all of which can reduce the desire to binge eat.
      • Allopathic Treatment: Antidepressants may be prescribed for BED patients. SSRI's, such as Prozac, are usually preferred because they offer fewer side effects. However, clinical studies don't show much effectiveness for use of antidepressants in treating BED. Psychotherapy have produced better results. Once the binge eating behavior is curbed and depressive symptoms are controlled, the physical symptoms of the disorder can be addressed.
    • Medications
      • Antidepressants: Antidepressants, known as selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs) may be helpful for binge eating. It's not clear how these can reduce binge eating, but it may be related to how they affect certain brain chemicals associated with mood.
      • The anticonvulsant topiramate (Topamax): Normally used to control seizures, topiramate has also been found in some studies to reduce binge-eating episodes. However, it can cause serious side effects, including blurred vision, double vision, clumsiness or unsteadiness, dizziness, drowsiness, and trouble in thinking.
      • The anti-obesity medication sibutramine (Meridia): Officially included in the group of antidepressants known as serotonin and norepinephrine reuptake inhibitors (SNRIs), sibutramine has been FDA approved for long-term obesity treatment. Sibutramine may be most helpful if you have binge-eating disorder and are obese. It's been found to suppress hunger and make you feel full, leading to weight loss. However, it can cause dangerous changes in your blood pressure and other side effects.
  • Links


7. Rumination Syndrome (307.53)

    • DSM-IV-TR criteria
      • A. Repeated regurgitation and re-chewing of food for a period of at least 1 month that follows a normal functioning period
      • B. The behavior does not occur exclusively during the course of Anorexia Nervosa or Bulimia Nervosa.
        • If the symptoms occur exclusively during the course of Mental Retardation or a Pervasive Developmental Disorder, they are sufficient to warrant independent attention.
      • C. The behavior is not due to an associated gastrointestinal or other general medical condition.
        • Esophogeal reflux, GI tract problems, etc.
    • Associated Features
      • Rumination Syndrome may be diagnosed when a person deliberately brings food back into the mouth after being swallowed, and either re-chews and re-swallows it or removes it from the mouth.
      • Rumination Syndrome is also referred to as Merycism.
      • This disorder is most commonly found in cases of Mental Retardation and is usually found in infants.
      • The regurgitation is not caused by a medical condition.
    • Etiology
      • Rumination Syndrome is most common in infants and mentally handicapped persons, but also occurs in children, adolescents and adults of normal intelligence. In infants, it is thought to be caused by a lack of physical contact or nurturing. It also might be done in an effort to self-soothe.
      • Studies show there is a correlation to heredity, in most cases the parents of the patient had this disorder.
      • It can be brought on by a previous serious illness or through the transition of drugs.
      • In adults and adolescents the disorder can be split into two categories, habit-induced or trauma-induced.
        • Habit-induced usually stems when a person has a history of regurgitation, such as Bulimia Nervosa or Professional Regurgitation. The act can manifest itself to a state beyond the person's realm of control.
        • Trauma-induced might stem from emotional or physical injury, usually one that involves excessive vomiting.
    • Epidemiology
      • This disorder has a low prevalence and is often misdiagnosed as Bulimia Nervosa, Anorexia Nervosa, or Gastroesophageal Reflux disease (GERD).
      • It is more predominantly female
      • It is found more quickly in males than in females, the average for males is 11 whereas in females it's 13.8 making the average age 12.9.
      • In infants the prevalence rate is 6-10% of the population and 8-10% of institutionalized adults.
      • It's been shown that up to 20% of people with Bulimia Nervosa ruminate.
    • Treatments
      • Treatment for infants with Rumination Syndrome may be as simple as being fed by someone other than the primary caregiver; this is most effective if the parent is the cause of the disorder, for example, if they aren't caring or nurturing as they should be. Counseling for parents is also strongly recommended. Therapy to increase the parent-child bond can be done to deplete rumination.
      • In adults, often giving gum to appease an oral fixation may be helpful. Some of the same treatments for Anorexia Nervosa and Bulimia Nervosa have been shown to be helpful. Behavior Modification has also been successful in treating this disorder. Treatment also depends on the age and cognitive ability of the patient.
      • Diaphragmatic breathing has shown good results, by teaching to breathe with the diaphragm the muscles used to ruminate are occupied by breathing.
      • Children that are in serious life-threatening danger due to rumination may need to be hospitalized until their condition can be stabilized.
      • The Mayo Clinic has been one of the leaders in treating Rumination Syndrome and they have a high success rate. For the most successful outcome, the Mayo Clinic uses a collaboration of pediatricians, psychologists and gastroenterologists.
      • Medical treatment such as proton pump inhibitors or H2 receptor antagonists may be offered to help the patient protect the lining of the esophogus due to severe regergitation.
  • Additional links: