The eating disorders are characterized by severe disturbances in eating behavior. The 2 specific diagnoses of this disorder are “Anorexia Nervosa” and “Bulimia Nervosa.” Anorexia is characterized by a refusal to maintain a minimally normal body weight. Bulimia Nervosa is characterized by repeated episodes of binge(episodes of uncontrollable overeating) eating followed by inappropriate compensatory behaviors such as self-induced vomiting; misuse of laxatives; fasting; or excessive exercise.
A disturbance in perception of body shape and weight is an essential feature of both Anorexia Nervosa and Bulimia Nervosa.
Eating disorders appeared in the DSM for the first time in 1980 as a subcategory of disorders beginning in childhood or adolescence. With the publication of DSM-IV the eating disorders became a distinct category reflecting the increased attention they have received from clinicians and researchers over the past 3 decades
a) Diagnostic features - The term “anorexia” refers to loss of appetite, and “nervosa” indicates for emotional reasons. The term is a misnomer because most patients with anorexia nervosa do not lose their appetite or interest in food. In fact, while starving themselves, they’re often preoccupied with thoughts of food and may even go to the extent of cooking gourmet meals for their families.
There are 4 features of anorexia nervosa that are required for diagnosis:
- The person must refuse to maintain a normal body weight. This is usually taken to mean that the person weighs less than 85% of what is considered normal for that person’s age and height. Weight loss is typically achieved through dieting, although purging (self-induced vomiting, heavy use of laxatives or diuretics) and excessive exercise can also be a part of the picture.
- The person has an intense fear of gaining weight, and the fear is not reduced by weight loss. They can never be thin enough
- Patients with anorexia nervosa have a distorted sense of their body shape. Even when emaciated they maintain that they are overweight or that certain parts of their bodies, particularly their abdomen, buttocks, and thighs, are too fat. To check their body size, they typically weight themselves frequently, measure the size of different parts of the body, and gaze critically at their reflections in mirrors. Their self-esteem is closely linked to maintaining thinness.
- In females, the extreme emaciation causes amenorrhea, the loss of the menstrual period. Of the four diagnostic criteria, amenorrhea seems least important; few differences have been found between women who meet all four criteria and those who meet the other three but not amenorrhea (Garfinkel et al., 1996)
b) Associated features- DSM-IV distinguishes two types of anorexia nervosa. In the restricting type, weight loss is achieved by severely limiting food intake; in the binge-eating-purging type, the person has to regularly engage in binge eating and purging. Numerous differences between these two subtypes support the validity of this distinction. The binge-purging subtype appears to be a more psychopathological; patients exhibit more personality disorders, impulsive behavior, stealing, alcohol and drug abuse, social withdrawal, and suicide attempts than do patients with the restricting type of anorexia. (Pryor, Wiederman, & McGilley, 1996)
c) Course and Prevalence - Anorexia typically begins in the early to middle teenage years, often after an episode of dieting and the occurrence of a life stress. It is about ten times more frequent in women than in men, with a lifetime prevalence of a little less than 1 percent (Hsu, 1990; Walters & kindler, 1994). When anorexia nervosa does occur in men, symptomatology and other characteristics, such as reports of family conflicts, are generally similar to those reported by women with the disorder (Olivardia et al., 1995).
d) Associated disorders (co morbidities)- Patients with anorexia nervosa are frequently diagnosed with depression, obsessive-compulsive disorder, phobias, panic disorder, alcoholism and various personality disorders (Kennedy & Garfinkel, 1992; Walters & Kendler, 1994).
Women with anorexia nervosa are also likely to have sexual disturbances.
e) Anorexia and Depression – The strong correlation between anorexia nervosa and depression has prompted some researchers to consider the possibility that anorexia nervosa cause depression (e.g., through the biochemical changes produced by starvation or the feelings of guilt and shame that accompany it). Anorexia Nervosa does not always precede depression, however. (Pope & Hudson, 1988).
The two disorders could also share a common diathesis or common environmental causes, such as a disturbed family environment or other life stress. Supporting the possibility of a genetic diathesis, studies have shown that the relatives of patients with anorexia are at high risk for depression (e.g., Hudson et al., 1987). On the psychological side, research has also found that women with anorexia who are depressed have a depressive attributional style. When they experience a stressful life event, they tend to explain the event in ways that create negative emotional states (Metalsky et al., 1997)
It has also been proposed that depression causes anorexia nervosa or that anorexia is a variant of depression, as symptoms of depression and anorexia are similar. Weight loss, for example, is a symptom of depression. There are biological similarities as well. For example, both people who are depressed and people with anorexia have low levels of the neurotransmitter serotonin.
All three hypotheses remain plausible explanations of the high co morbidity between anorexia and depression.
f) Physical Changes in Anorexia Nervosa – Self starvation and use of laxatives produce numerous undesirable biological consequences in patients with anorexia nervosa. Blood pressure often falls, heart rate slows, kidney and gastrointestinal problems develop, bone mass declines, the skin dries out, nail become brittle, hormone levels change, and mild anemia may occur. Some patients lose hair from the scalp, and they may develop laguna, a fine, soft hair, on their bodies. Levels of electrolytes, such as potassium and sodium, are altered. These ionized salts, present in various bodily fluids, are essential for the process of neural transmission, and lowered levels can lead to tiredness, weakness, cardiac arrthymias, and even sudden death. Brain size declines in patients with anorexia, and EEG abnormalities and neurological impairments are frequent (Garner, 1997; Lambe et al., 1997).
g) Prognosis – About 70% of patients with anorexia eventually recover. However, recovery often takes six or seven years, and relapses are common before a stable pattern of eating and maintenance of weight is achieved (Strober, Freeman & Morrel, 1997).
Anorexia is a life-threatening illness; death rates are ten times higher among patients with the disorder among the general population and twice as high as among patients with other psychological disorders. Death most often results from physical complications of the illness – for example, congestive heart failure – and from suicide (Crisp et al., 1992; Sullivan, 1995)
a) Diagnostic criteria – “Bulimia” stems from the Greek word meaning “ox hunger.” This disorder involves episodes of rapid consumption of a large amount of food, followed by compensatory behaviors, such as vomiting, fasting, or excessive exercise, to prevent weight gain. The DSM defines a binge as eating an excessive amount of food within less than two hours. Bulimia Nervosa is not diagnosed if the binging and purging occur only in the context of anorexia nervosa and its extreme weight loss; the diagnosis in such a case is anorexia nervosa: binge eating purging type.
Binges typically occur in secret, may be triggered by stress and the negative emotions it arouses, and continue until the person is uncomfortably full (Grilo, Shiffman & Carter-Campbell, 1994). During a binge the person feels that he or she cannot control the amount of food that is being consumed. Foods that can be rapidly consumed, especially sweets such as ice cream or cake, are usually a part of a binge.
Although research suggests that patients with bulimia nervosa sometimes ingest an enormous quantity of food during a binge, often more than what a normal person eats in an entire day, binges are not always as large as the DSM implies and there is a wide variation in the caloric content consumed by individuals with Bulimia Nervosa during binges (e.g., Rossiter & Agras).
Patients are usually ashamed of their binge and try to conceal them. They report that they lose control during a binge, even to the point of experiencing something akin to a dissociative state, perhaps losing awareness of what they are doing or feeling that it is not really they who are binging.
After the binge is over, disgust, feelings of discomfort and fear of weight gain lead to purging to undo the caloric effects of the binge. Patients most often stick fingers down their throats to cause gagging, but after a time many can induce vomiting at will without gagging themselves. Laxative and diuretic abuse (which do little to reduce body weight) as well as fasting and excessive exercise also are used to prevent weight gain.
Although many people binge occasionally and some people also experiment with purging occur at least twice a week for three months. Few differences are found between patients who binge twice a week and those who do so less frequently, suggesting that it is more about the continuum of severity rather than a sharp distinction (Garfinkel et al., 1995). Like patients with anorexia nervosa, patients with bulimia nervosa are afraid of gaining weight and their self esteem depends heavily on maintaining normal weight. People without eating disorders typically underreport their weight and say they are taller than they actually are; patients with bulimia nervosa are more accurate in their reports (Doll & Fairburn, 1998)
b) Associated Features - As with anorexia, two subtypes of bulimia nervosa are distinguished; purging type and non purging type, in which the compensatory behaviors are fasting or excessive exercise. In some studies, people diagnosed with non purging bulimia were heavier, binged less frequently, and showed less psychopathology than did people with purging type bulimia. (e.g., Mitchell, 1992).
c) Course and Prevalence – Bulimia Nervosa typically begins in late adolescence or early adulthood. About 90% of cases are women and prevalence among women is thought to be 1-2% of the population (e.g., Tobias, Griffing, & Griffing, 1997). Many patients with bulimia were somewhat overweight before the onset of the disorder and the binge eating started during an episode of dieting.
d) Associated Disorders (Co morbidities) – Bulimia Nervosa is associated with numerous other diagnoses most notably depression, personality disorders (especially borderline personality disorder), anxiety disorder, substance abuse, and conduct disorder (Ames-Frankel et al., 1992; Carroll, Touyz, & Beumont, 1996; Kennedy & Garfinkel, 1992; Lilenfeld et al., 1997). Suicide rates are much higher among people with bulimia nervosa than in the general population (Favaro & Santonastaso, 1998). A twin study has found that bulimia and depression are genetically related (Walters et al., 1992). Bulimia can also be associated with stealing. Patients with bulimia who steal tend also to be illicit drug users and to be promiscuous (Rowston & Lacey, 1992). This combination of behaviors may reflect impulsivity or lack of self control, characteristics that may be relevant to the behavior of binge eating.
e) Physical changes in Bulimia Nervosa – Frequent purging can cause potassium depletion. Heavy use of laxatives induces diarrhea, which can also lead to changes in electrolytes and cause irregularities in the heart beat. Recurrent vomiting may lead to tearing of tissue in the stomach and throat and to the loss of dental enamel as stomach acids eat away at the teeth, which become ragged. The salivary glands may become swollen. Mortality rates appear to be much less in bulimia nervosa than in anorexia nervosa (Keel and Mitchell, 1997)
f) Prognosis - Long term follow ups of patients with bulimia nervosa reveal that about 70% recover, although about 10% remain fully symptomatic (Keel et al., 1999)
Binge Eating Disorder
a) Diagnostic Features- DSM-IV includes binge eating as a diagnosis in need of further study rather than as a formal diagnosis. This disorder includes recurrent binges (two times per week for six months), lack of control during the binging episode, and distress about binging, as well as other characteristics, such as rapid eating and eating alone. It is distinguished from anorexia nervosa by the absence of weight loss and from bulimia by the absence of compensatory behaviors (purging, fasting, or excessive exercise).
b) Prevalence – Binge eating disorder appears to be more prevalent than either anorexia or bulimia. In a community sample, it was found in 6% of successful dieters (those who had kept their weight off for more than one year) and in 19% of unsuccessful dieters (Ferguson & Spitzer, 1995). One advantage of including this disorder as a diagnosis is that it would apply to many patients who are now given the vague diagnosis of “Eating disorder not otherwise specified” because they do not meet criteria for anorexia or bulimia (Spitzer et al.,1995)
It occurs more frequently in women than in men and is associated with obesity and a history of dieting (Kinzl et al., 1999)
c) Associated Features – It is linked to impaired work and social functioning, depression, low self esteem, substance abuse and dissatisfaction with body shape (Spitzer et al.,1993; Striegel-Moore et al., 1998)
d) Risk factors of developing Binge Eating Disorder- Childhood obesity, critical comments regarding being overweight, low self concept, depression, and childhood physical or sexual abuse (Fairburn et al., 1998)
Nevertheless, some researchers do not view binge eating disorder as a discrete diagnostic category but rather as a less severe version of bulimia nervosa. The reason is that few differences are found between patients with binge eating disorder and the non purging form of bulimia nervosa (Hay & Fairburn, 1998; Santonastaso, Ferrara, & Favaro, 1999).
Etiology of Eating Disorders
A single factor is unlikely to cause an eating disorder. Several areas of current research- genetics, the role of the brain, sociocultural pressures to be thin, the role of the family, and the role of environmental stress – suggest that eating disorders result when several influences converge in a person’s life.
a) Genetics – Both anorexia and bulimia nervosa run in families. First degree relatives of young women with anorexia nervosa are about four times more likely than average to have the disorder themselves (e.g., Strober et al., 1990). Similar results have been found for bulimia nervosa (e.g., Kassett et al., 1987). Furthermore, relatives of patients with eating disorders are more likely than average to have symptoms of eating disorders that do not meet the complete criteria for a diagnosis (Lilenfeld et al., 1998). Twin studies of eating disorders also suggest a genetic influence. Most studies of both anorexia and bulimia report higher MZ than DZ concordance rates (Fichter & Naegel, 1990).
Research has also shown that key features of the eating disorders, such as dissatisfaction with one’s body and a strong desire to be thin, appear to be heritable (Rutherford et al., 1993)
b) Eating Disorders and the Brain – The hypothalamus is a key brain centre in regulating hunger and eating. Research on animals with lesions to the lateral hypothalamus indicate that they lose weight and have no appetite (Hoebel & Teitelbaum, 1996); thus it is not surprising that the hypothalamus has been proposed to play a role in anorexia. The levels of some hormones regulated by the hypothalamus, such as cortisol, are indeed abnormal in patients with anorexia; rather than causing the disorder, however, these hormonal abnormalities occur as a result of self starvation and levels return to normal following weight gain (Doerr et al., 1980) The hypothalamus does not account for body image disturbance or fear of becoming fat. A dysfunctional hypothalamus thus does not seem highly likely as a factor in anorexia nervosa.
Endogenous opioids are substances produced by the body that reduce pain sensations, enhance mood, and suppress appetite, at least among those with low body weight. Opioids are released during starvation and have been viewed as playing a role in both anorexia and bulimia. Starvation among patients with anorexia may increase the levels of endogenous opioids, resulting in a positively reinforcing euphoric state (Marrazzi & Luby, 1986). Furthermore, the excessive exercise seen among some patients with eating disorders would increase opioids and thus be reinforcing (Davis, 1996; Epling & Pierce, 1992). Hardy and Waller (1988) hypothesized that bulimia is mediated by low levels of endogenous opioids, which are thought to promote craving; a euphoric state is then produced by the ingestion of food, thus reinforcing binging.
Some research has focused on several neurotransmitters related to eating and satiety (feeling full). Animal research has shown that serotonin promotes satiety; therefore, it could be that the binges of patients with bulimia result from a serotonin deficit that causes them not to feel satiated as they eat.
In American culture, there has been a steady progression to thinness. Starting from Beauty Pageant contestants to Fashion Models, the fad of being thin started from the 1970’s and since then has progressed to quite a degree. Size Zero is considered the ideal size, nowadays.
The percentage of obese people is has become double in the past 10 years, which has resulted in extreme behavior especially from teenage girls, who view themselves as a product of what they look like.
Women are typically more valued for their appearance whereas men are valued more for their wealth and social status. It is due to this reason that most women feel that it is of utmost importance that they be looking their best at all times. Society makes the rules about what defines good looks and based on this, women try to alter their appearance.
Women are more likely to diet which makes them more susceptible to eating disorders.
The risk for eating disorders among groups of women who might be expected to be concerned with their weight appear to be especially high. (Garner et al.,1980)
The concept of being thin varies not only among
cultures but among races as well. For example, white women in
This is also true in third world countries, where there is less pressure to be thin. It is considered more attractive to be “healthy” as it shows that the person is well fed.
White teenage girls diet more frequently than do African American teenage girls and are more likely to be more likely to be dissatisfied with their bodies (Story et al.,1995)
Cross Cultural Studies
Eating Disorders appear to be far more common in
industrialized societies, such as
In one study of 369 adolescent girls in
a) Disturbed Parent-Child Relationship: According to the psychodynamic view, eating disorders are caused by disturbed parent-child relationship. This is possibly the core cause for eating disorders. A child has an unsatisfied relationship with parent/s, this causes him/her to feel that he/she is not good enough. Child feels unfulfilled and unwanted.
According to Goodsitt (1997) bulimia in females stems from a failure to develop an adequate sense of self because of a conflict ridden mother-daughter relationship.
According to Hilde Bruch (1980) anorexia is an attempt by children who have been raised to feel ineffectual to gain competence and respect and to ward off feelings of helplessness.
b) Personality Traits – Core personality traits such as low self esteem and perfectionism are found in individuals with eating disorders
Treatment of Eating Disorders
Research on the treatment of eating disorders is exploring how different treatments can be helpful for different types of eating disorders. The American Psychiatric Association has published a set of practice guidelines for the treatment of patients with eating disorders (American Psychiatric Association, Practice Guidelines for Eating Disorders, American Journal of Psychiatry, 2000).
a) Hospitalization: In cases where a patient is severely ill and has a relapse from baseline weight, or is below 15 percent of appropriate body weight; OR the patient has other medical problems, inpatient hospitalization may be necessary. Patients are encouraged to eat regular meals with liquid supplements, but those who refuse feedings are given feedings through a nasogastric tube (plastic tube passed through nose, down esophagus, into stomach). Group and individual therapy supplement dietary and medical therapies. At one time inpatient treatment lasted many weeks, if not months, but in todayÆs climate the goals of hospitalization are weight gain and medical stabilization. The patient is moved to outpatient therapy when it is considered safe to do so.
Cognitive -Behavioral Therapy includes standard elements of behavioral treatment with a focus on identifying and altering dysfunctional thought patterns, attitudes and beliefs, which may trigger and perpetuate binge behavior or restrictive eating. Monitoring intake of food is an important component, along with identifying triggers and developing alternative reactions to them
Interpersonal Psychotherapy: IPT focuses on relationship difficulties, self-esteem, assertiveness, social skills and coping strategies.
Family Therapy: There is no one unified form of family therapy. The goal of the family therapist is to help members of the family change behaviors that may have contributed to the development of some of the anorexicÆs pathologic thoughts and activities. Blame is not placed on one individual.
Group Psychotherapy: When anorexics are recovering, group therapy can be very helpful. The group format allows people the opportunity for a sharing of information, survival skills, feedback about one with others, and it is a chance to enhance a personÆs self esteem by helping others. A trained leader or two directs the group.
c) Medications: Unlike depression or panic disorder there are no specific medications that are used to treat anorexia nervosa. First and foremost, the doctor will prescribe medication that will treat any medical problems, like electrolyte abnormalities or abnormal heart rhythms.
Antidepressants: Many patients also have depression, and their symptoms may respond to antidepressants . There is no data, however, that shows that antidepressants are effective in the acute treatment of Anorexia Nervosa, and actually since people with Anorexia Nervosa may be more at risk of suffering from side effects. Research has shown that people respond to medication much better after they are restored to a more normal weight. The antidepressants like Fluoxetine ( Prozac ), Sertraline (Zoloft ), Paroxetine (Paxil) - which are approved for depression and obsessive compulsive disorder may help the anorexic have fewer depressed feelings, as well as be less obsessed with food and their weight.
Tranquilizers: Short-term use of medicines called benzodiazepines may help anorexics deal with some of their anxiety. These medicines are highly addictive, so they should not be used in individuals who have had problems with drugs or alcohol.
a) Psychotherapy:: Psychotherapy can be very helpful in addressing disordered eating, but also overall emotional health and happiness.
Cognitive-behavioral therapy includes standard elements of behavioral treatment with a focus on identifying and altering dysfunctional thought patterns, attitudes and beliefs that may trigger and perpetuate binge behavior or restrictive eating.
Interpersonal psychotherapy focuses on relationship difficulties, self-esteem, assertiveness, social skills and coping strategies.
When a person with bulimia is recovering, group therapy can be very helpful. The group format allows people the opportunity for sharing information, survival skills and feedback about how one interacts with others. It is also a chance to enhance a person’s self-esteem by helping others. A trained leader directs the group.
b) Medications: Many people with bulimia also have depression and their symptoms may respond to antidepressants. As of now, only Fluoxetine Prozac is approved by the Food and Drug Administration for the treatment of bulimia nervosa. This medication has been found to decrease the number of binges as well the desire to vomit in people with moderate to severe bulimia nervosa.
Medications such as Fluoxetine (Prozac), Sertraline (Zoloft), Paroxetine (Paxil), which are approved for depression and obsessive compulsive disorder may help the person with bulimia have less depressed feelings, as well as be less obsessed with food and their weight. At appropriate doses (similar to those used for OCD treatment), antidepressants, which act on the serotonin system in the brain (e.g., Prozac), have been found to decrease the strength of urges to binge for some individuals. Individuals with a positive response to these medications have reported a lessening of their carbohydrate cravings, which prevents bingeing. Others have experienced a less dramatic relief/pleasure associated with binge/purge behaviors. This response makes the binge/purge cycle less enticing as a means of stress release.
How would you consider a conversion disorder related to stress and how would you treat such disorder?
In conversion disorder, physical symptoms resemble those of a neurologic disorder develop. The symptoms are triggered by mental factors such as conflicts or other stresses.
Conversion disorder once referred to as hysteria, is thought to be caused by mental factors such as stress and conflict, which people with this disorder experience as convert into physical symptoms. The critical psychological conflict or stress may not be apparent initially, but it becomes evident in the course of obtaining a patient’s history, ideally it is a psychological factor related symbolically and temporally to symptom onset. Conversion symptoms are presumed to resume from an unconscious process. Although conversion disorder tends to develop during late childhood to early adulthood, it may appear at any age. The disorder appears to be more common among women.
Conversion disorder is classified as one of the somatoform disorder in the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association DSM-IV TR. Conversion symptoms are not considered to be under voluntary control and should not be explained by any physical disorder after appropriate medical evaluation.
Clinical description of conversion disorder date to almost 4000 years ago,the Egyptians attributed symptoms to a wandering uterus.In the 19th century,Paul Briquet described the disorder as a dysfunction of the CNS ( central nervous system).Freud first used the term conversion to refer to the development of a somatic symptom to help bind anxiety around a repressed conflict.
Symptoms begin after some distressing social or psychological event.Other symptoms may include paralysis of an arm or leg or loss of sensation in a part of the body__ suggest nervous system dysfunction__ loss one of the special senses such as vision or hearing.
A supportive,trustful doctor-patient relationship is essential.The most helpful may involve collaboration with a psychiatrist or a psychologist.As the doctor evaluates a possible physical disorder and reassures the person that the symptoms do not indicate a serious underlying disease.
The following treatment may help:
Hypnosis may help by enabling people to control how stress and other mental states affect their bodily functions.
Psychotherapy,including cognitive-behavioural therapy,is effective for some people.
NLT ( no lift therapy).In this therapy person is completely screened out,it is a more sort of time out concept.A person is given no attention and is completely left alone and is only given food.