Reading Corner - Eating Disorders

EATING DISORDERS

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The modern day culture often places an overemphasis on thinness and personal appearance, without appropriate regard for genuine health, nutrition and fitness. Young adults and teens are not properly educated about diet and nutrition, and they often engage in harmful habits and eating patterns in order to achieve the "perfect figure". The conflicting feelings about food and eating that trouble these victims take an especially demoralizing and debilitating form in the eating disorders, anorexia and bulimia.

It is an excellent achievement to look and feel great, but this can only be accomplished through proper knowledge and regard for health as the first priority. If there is a risk to bodily wellness, all other dreams for beauty, youthfulness, and slenderness has to wait. In addition to the "beauty" and "slenderness" issues, there are also emotional issues that should be addressed in order to understand the true nature of eating disorders. The physiological, psychological and sociological causes need to be analyzed along with appropriate treatment and intervention.

DIAGNOSIS OF EATING DISORDERS

The accurate diagnosis of an eating disorder is needed so that the individual is offered proper intervention and help, before the disease harms the body and proves fatal. It is important to know the signs and symptoms so that the eating disorder will not go ignored and untreated. Eating disorders are caused by emotional imbalances in which the patient maintains unhealthy attitudes and behaviors toward food, eating and body image. They include anorexia nervosa, bulimia nervosa and compulsive overeating.

Anorexia Nervosa

 The term, anorexia nervosa, means "lack of appetite of nervous origin" according to its Greek and Latin root meanings. It usually appears in early or middle adolescence, with the victims being mainly all females. It is interesting that the German word for anorexia is Pubertätsmagersucht or pubertal addiction to thinness. Individuals with anorexia nervosa typically display a noticeable weight loss during and following periods of severe restriction in food intake. They have an extreme fear of gaining weight or becoming "fat".

The symptoms are sudden drop in weight along with the deterioration of health, but the individual persists in denying that the behavior is abnormal or dangerous.  These patients may have very distorted body images, believing themselves to be overweight and fat even when they appear thin or even emaciated. They will try to conceal weight loss from parents, family, friends and others. The individual may wear baggy clothes and may also secretly pocket and discard food instead of eating it. Despite refusal to eat, the appetite is usually normal, at least at first.

According to the current diagnostic manual of the American Psychiatric Association (DSM-IV), the subject suffers from clinical anorexia and not just dieting or fasting, when the weight has fallen to 15% below the normal range. For females, this is coupled with not menstruating for at least three months. The level of female hormones in the blood of an anorexic woman also falls drastically, and sexual development may be delayed. Her heart rate and blood pressure can become dangerously low, and the loss of potassium in the blood may cause irregular heart rhythms. Over a 10-year period, about 5% of women diagnosed with anorexia will die, mainly from infections or cardiac failure. Other serious long-term dangers are osteoporosis and kidney damage.

Despite low food intake, the individual may be very active and energetic. Some may exercise excessively in an effort to maintain and speed up weight loss. Physical symptoms that may accompany anorexia include dry skin, dry hair, brittle hair, hair loss, lanugo (fine downy hair on the limbs), brittle nails, constipation, anemia, swollen joints, decrease in body fat, and quick and noticeable weight loss.

The damage that the anorexic teen does is detrimental to their present and future health because during this time, the body goes through many changes in growth and development. Nutrient intake should be at its prime. In fact, teenagers need extra nutrients to support the adolescent growth spurt, which begins in girls at ages 10 or 11, reaches its peak at age 12 and is completed at about 15. In boys, it begins at 12 or 13 years of age, peaks at 14 and ends at about 19. This intensive growth period brings dramatic increases in height as well as hormonal changes affecting every body organ, including the brain.

Iron is especially important with the onset of menstruation in girls and the increase in lean body mass in boys. The recommended daily allowance for iron is 12 to 15 milligrams a day. The increase in skeletal mass also boosts teens' requirements for calcium to about 1,200 mg a day. Approximately half of adult bone structure is deposited during adolescence. Calcium is important even for young adults who have completed their linear growth spurt, since the mineral continues to be deposited in their bones for another decade.

Teens' caloric needs vary depending on their growth rate, degree of physical maturation or body composition, and activity level. Males generally have higher energy requirements than females due to their larger proportion of lean body mass to adipose tissue. But individual growth spurts also must be considered. For example, a rapidly-growing athletic 15-year-old boy may need 4,000 calories a day just to maintain his weight. And an inactive girl the same age, whose growth is nearly completed, may need 2,000 calories a day.

Bulimia

 The term, bulimia, means ox-like hunger of nervous origin according to its Greek and Latin root meanings. It was not recognized as a distinct psychiatric disorder until the 1970's, and it did not appear in the diagnostic manual of the American Psychiatric Association until 1980. Bulimia is defined as two or more episodes of binge eating, the rapid consumption of a large amount of food (up to 5,000 calories), every week for at least three months. The binges are usually followed with self-induced vomiting or purging with laxatives and diuretics. These individuals do so in an effort to avoid weight gain.

Patients suffering from bulimia are over-concerned and show preoccupation with weight control and body shape and size, although they may or may not demonstrate a significant weight loss. Some bulimics are sometimes even obese. However, they obsessively and compulsively weigh themselves, exercise and fast. The symptoms can develop at any age from early adolescence to the forties, but it usually becomes clinically serious during late adolescence.

Bulimia is not as dangerous to health as anorexia, but it has many unpleasant physical effects, including fatigue, weakness, constipation, fluid retention (bloating), swollen salivary glands, erosion of dental enamel, sore throat from vomiting, and scars on the hand from inducing vomiting. Overuse of laxatives can cause stomach upset and other digestive disorders. Other dangers are dehydration, loss of potassium, tearing of the esophagus, and cancer.  Patients with diabetes coupled with bulimia often lose weight after an eating binge by reducing insulin dosages. According to recent research, this practice damages eye tissue and raises the risk of diabetic retinopathy, which can lead to blindness.

Anorexia and Bulimia

Anorexic individuals also indulge in occasional eating binges, with about half of them make the transition to bulimia. About 40% of the most severely bulimic patients have a history of anorexia. It is debatable whether the combination of anorexia with bulimia is more physically and emotionally debilitating than just anorexia alone. According to one research, anorexic patients who binge and purge are less stable emotionally and more likely to commit suicide. However, another recent study suggests that, on the contrary, they are more likely to recover.

Compulsive Eating

Compulsive overeaters are also preoccupied with food and may feel powerless to control their eating. These individuals may, but do not necessarily, display a weight gain or obesity. Compulsive overeaters usually center most daily activities around food, meals and snacks. Food may obsessively occupy their thoughts, and they may eat excessively either when hungry or not. They may eat in response to sadness, loneliness, distress or other "negative" emotions, and they may eat or binge secretly and when alone.

Obesity is linked with major health problems including heart disease, high blood pressure and diabetes. But for those who are just somewhat overweight, the risks are less. To be sure, weight gain is associated with an increased risk of death, largely from heart disease, but the additional amount of risk appears to be modest and declines with age. According to a 12-year study of more than 62,000 men and 262,000 women, the dangers of being overweight are greatest for younger people. Overweight is one of the most serious nutrition problems of adolescents, particularly among Native Americans, Hispanics and low-income African Americans.

A study released last fall by Dr. Aviva Must, Ph.D., of the U.S. Department of Agriculture's Human Nutrition Research Center in Boston, shows being overweight as a teenager is associated with serious health problems later in life, regardless of whether the teen becomes overweight as an adult. The study, reported in the New England Journal of Medicine, was based on 508 adults who participated in the Harvard Growth Study some 55 years ago.

Overweight teenage boys were twice as likely as thin adolescents to die by age 70, primarily from heart disease. They also were about five times more likely to develop colon cancer and twice as likely to develop gout than the lean counterparts. Overweight girls were 60% more likely to have arthritis and twice as likely to suffer heart disease in their 70's than girls who were not overweight. Dr. Must said the findings underscore the importance of preventing overweight in youth by monitoring diet as well as exercise.

Scientists calculate weight category by a complicated formula called the body-mass index, or BMI. To derive this number, divide body weight in kilograms by the square of body height in meters. For example, the "ideal weight" for a 5'4" generic woman is about 123 pounds, or a BMI of 21. Every additional six pounds translates into another point on the BMI and a healthy BMI can range up to 25. To see an effect on health, the BMI has to get up to at least 27 or 28. That means the 5'4" woman would have to weigh almost 165 pounds to be in obesity trouble.

Related Physical Disorders

1)  The rate of alcoholism in bulimic patients and their parents measure higher than the general public.

2)  Bulimia has been associated to personality disorders, such as borderline personality.

3)  In a recent Swedish study, researchers found that one-third of anorexic women had mild autistic symptoms as well as personality disorders of the avoidant, dependent, or obsessive type.

4)  According to one estimate, women suffering from depression have 2 times the average lifetime rate of bulimia and 8 times the average rate of anorexia. Major depression was found in the families of 28% of bulimic patients and only 9% of the controls. 40% of anorexic patients have been or are seriously depressed. Physiological changes caused by abnormal eating and exercise habits may result in depressive symptoms.

5)  In an often-cited experiment, 36 young male conscientious objectors volunteered to undergo starvation. Over a period of six months, as their weight fell to 75% of its original level, they developed many symptoms typical of anorexia, including a preoccupation with food, depression, irritability, and anxiety. Even their responses to a personality questionnaire changed.

PREVALENCE OF EATING DISORDERS

Anorexia is rare compared to most other serious psychiatric disorders. The prevalence of anorexia in the United States is between 0.1% to 0.6% in the general population and several times higher in adolescent girls. An astounding 90% of the sufferers are women. Among the few young men and boys with anorexia, there is evidence that homosexuality and concerns about sexual identity are common.

People suffering from bulimia are at least 2-3 times more than anorexia. A survey based on interviews with more than 2,000 bulimics in the early 1990's found a prevalence of 1% in the general population and 4% among women ages 18 to 30. As many as 10% of all women may suffer from bulimia at some time in their lives.

An estimated two-thirds of college women indulge in an eating binge once a year, 40% at least once a month, and 20% once a week. As many as 4% of all adults (60% of them women) and 30% of the seriously overweight are thought to be binge eaters. Binge eating without attempts to compensate by vomiting or using laxatives is one of the conditions included in the current APA diagnostic manual under the label "eating disorders not otherwise specified."

However, drawing a line between eating disorders and "normal" socially approved dieting is not easy. There is a fine line, and who should determine where the line is at to classify a person as anorexic or bulimic? Many women have symptoms that resemble anorexia or bulimia in milder forms. They may be losing too much weight but still menstruating, or binge eating without vomiting or using laxatives, or bingeing less often than twice a week. And what categories do these individuals fit under?

BIOLOGICAL CAUSES OF EATING DISORDERS

Hormones and Neurotransmitters

Abnormalities in the activity of hormones and neurotransmitters that preserve the balance between energy output and food intake may also be a cause of eating disorders. This regulation is a complex process involving several regions of the brain and several organ systems. Nerve pathways descending from the hypothalamus to the base of the brain control levels of sex hormones, thyroid hormones, and the adrenal hormone cortisol. These endocrines influence appetite, body weight, mood and responses to stress.

The neurotransmitters, serotonin and norepinephrine, are found in these hypothalamic pathways. Serotonin activity is low in starving anorexic patients but higher than average when their weight returns to normal. According to some reports, bulimic patients respond weakly to serotonin and to cholecystokinin, a hormone that induces fullness. Their response improves when they take antidepressant drugs that enhance the effects of serotonin.

Endorphines

Another speculation is that enkephalins and endorphins influence eating disorders. They are the opiate-like substances produced in the body. Some studies have found that the spinal fluid of anorexic patients contains higher levels of these endogenous opioids, and some of the patients gain weight when given naloxone, which inhibits opioid activity.

Excess Physical Activity

An unusual and not widely accepted but interesting theory is that in some cases anorexia results from excessive physical activity. Evidence for this theory comes from experiments in which rats are allowed to exercise on a wheel at will but fed only a single daily meal, which is adequate for survival. They are given only a brief time to eat it. When put on this regime, they start to run more and more and eat less and less. Eventually they may die of starvation.

According to the theory, these conditions are equivalent to self-imposed diet and exercise regimens. Normally people eat more when physical activity rises. But if food intake is restricted at the same time, a self-perpetuating cycle may develop in which restricted food intake heightens the urge to move, and constantly increasing exercise depresses interest in eating.

Heredity and Lifestyle

Like most psychiatric disorders, anorexia and bulimia has a tendency to run in families. There is a genetic link as well as a lifestyle pattern and way of thinking that is connected between family members. The rate of anorexia among mothers and sisters of anorexic women is between 2% to 10%.  In one study, researchers found that 20% of anorexic patients and only 6% of people with other psychiatric disorders had a family member with an eating disorder.

Several twin studies suggest that this family susceptibility is largely hereditary. In one comparison, anorexia was found in 9 of 16 identical twins of anorexic patients but only 1 of 14 fraternal twins. In another study, researchers found that if one of a pair of identical twins has bulimia, the chance that the other would also have it is 23%, which is eight times higher than the rate in the general population. For fraternal twins, the rate is 9%, or three times higher than the general population.

PSYCHOLOGICAL CAUSES OF EATING DISORDERS

In the vast psychological and sociological literature on eating disorders, wide varieties of influences and causes have been suggested, ranging from peer pressure to sexual anxieties. Definitely, emotional constitution and characteristics play an important part in physiological action, the key is to determine which ones cause eating disorders. Due to the nature and prevalence, most theories pertain to young women when discussing the eating disorders of anorexia and bulimia.

Sexuality

The personality characteristics of most anorexic individuals, before, during, and after the illness are serious, well-behaved, orderly, perfectionist, hypersensitive to rejection, inclined to irrational guilt, and prone to obsessively worry. Anorexia has been described as the method a young girl with this type of personality may respond to the notion of adult sexuality and independence. One common theme is that starvation is a self-punishment with the purpose to please an "internal parent" who imposes harsh restrictions.

This individual wants to be strong and successful, but is afraid of being assertive and separating from the family. Being a good girl and pleasing her parents and teachers is no longer enough. She is unable to acknowledge her sexual desires and may regard the developing body as an "alien invasion". Her fear of adult femininity may also be a fear of becoming like her mother. According to this theory, fasting restores a sense of order by allowing control over herself and others. She is proud of her ability to lose weight, and self-imposed rules about food are a substitute for genuine independence.  

Suppress Emotional Emptiness

Some experts believe that anorexic girls starve themselves to suppress or control feelings of emotional emptiness. They struggle for perfection to prove that they need not depend on others to tell them who they are and what they are worth. According to some psychodynamic theories, a young woman has come to this desperate pass because her parents have never responded adequately to her initiatives or recognized her individuality. Now that she is an adolescent, they are making conflicting demands, such as "show adult independence, but do not separate from the family".

According to this theory, the anorexic girl has trouble distinguishing her own wants from those of other people, and she fears abandonment if she takes any action on her own. Denying her needs is the only way she knows how to show that she will not permit anyone else to control her. She will not allow outside influences, including food, invade her.

The Family

Since young girls with anorexia usually live with their parents, psychotherapists have often found it helpful to work with the whole family. The resulting discoveries and speculations are an important source of "family systems theory", in which the family is conceived as a social unit with internal structures and processes. Family systems theorists speak of family rules, roles and rituals. They analyze the distribution of power within a family and the workings of subsystems of various combinations of parents and children.

The anorexic child who refuses to eat may be seen as trying to keep the family together by providing an object of common concern for parents who would otherwise be drifting apart. Or the individual may be trying to restore balance to the family by siding with one parent in a conflict with the other.

Theories about the influence of parents raise similar questions of cause and effect. The mother and father of a child who is starving herself are under great strain, and the family is bound to be in turmoil. In any case, an unhappy woman with an eating disorder will naturally be dissatisfied with her family. A parent who tries to intervene may be regarded as intrusive, one who tries to avoid conflict as uninvolved. Researchers have found that anorexic women are likely to describe their fathers as distant or their mothers as over-controlling, but their brothers and sisters do not necessarily agree.

The responsibilities of each person and the boundaries between them are indistinct. Everyone in the household is said to be over-responsive to and overprotective of everyone else. Conventional social roles are maintained, but individual needs are not met, feelings are not honestly acknowledged, and conflicts are not openly resolved. When the daughter reaches puberty, her parents are reluctant to make necessary changes in the family rules and roles. In this view, anorexia is a symptom of a rigid family system's need and inability to adapt to a new stage of development.

Bulimia has been recognized for a much shorter time than anorexia, and there is less research on its origins. One theory is that bulimic women lack all the parental affection and involvement they need and soothe themselves with food as compensation. The overeating subdues feelings of which they are barely conscious, at the price of later shame and self-hatred. One recent study found that bulimic women differed from depressed and anxious women in several ways: 1) These individuals were more likely to be overweight. 2) They were more inclined to have overweight parents. 3) They usually began menstruation at an earlier age. 4) They were also more likely to say that their parents had high expectations for them but gave limited contact and affection.

Sexual Abuse

In some families of women with anorexia and bulimia, the problem may be more serious than just rigidity, being over-protective, or giving inadequate nurturing. Child sexual abuse, an increasingly common explanation for psychiatric disorders in women, has been proposed as a cause of eating disorders.

SOCIOLOGICAL CAUSES OF EATING DISORDERS

Eating disorders may be regarded as a cultural phenomenon and a social problem. It is certainly important to understand the role the general public plays in psychological and physiological conditions, and how the society's values affect the individual. By addressing these issues, changes can be made to improve attitudes and treat one another better. Anorexia nervosa may illuminate the influence of culture on psychopathology better than any other disorder. The main social causes of eating disorders are slenderness, high discipline, wealth and social status, saintliness, and some unknown reasons.

Slenderness

In the United States, women are becoming heavier with each generation, while the body presented as ideal for health or beauty becomes slimmer. As a result, more than half of American women wants to go on a diet. In a recent survey of 5^th to 8^th grade girls, 31% said they were dieting, 9% said they sometimes fasted, and 5% had deliberately induced vomiting. In a 1950 survey, 7% of men and 14% of women said they were trying to lose weight. By the early 1990s, 37% of men and 52% of women thought they were overweight; 24% of men and 40% of women said they were dieting.

The more intense the social pressure for slenderness, the more likely it seems that a troubled young woman will develop an eating disorder in addition to other psychiatric symptoms, especially if she believes that control over one's appetite is the way to win admiration and attain social success. A wish to mold one's body is also consistent with cultural ideals of achievement and self-sufficiency.

Cultural comparisons and historical studies confirm evidence from the American society that eating habits and preoccupations with similar effects may have different causes in different circumstances. For example, the culture values slenderness, and this encourages a woman to diet. Even though she is predisposed to depression and anxiety and suffers from family troubles and a neurochemical imbalance, she still wants to lose weight. The weight loss causes physical and emotional changes that make it even more difficult to eat normally. The resulting hunger may lead to eating binges followed by vomiting and purging with laxatives. These episodes cause anxiety and depression that lead to further bingeing and further dieting.

High Discipline

Anorexia and bulimia are especially common among girls committed to the demanding disciplines of ballet, competitive swimming, and gymnastics. According to one survey, 15% of female medical students have had an eating disorder at some time. But the common belief that high social status raises the risk for eating disorders are no longer correct, at least not for American women. In a 1996 review of 13 surveys, researchers found that eating disorders were equally common among Anglo-Americans and African-Americans and in all social classes.

Wealth and Social Status

Wealth and social status may be more important in underdeveloped countries, where eating disorders are generally thought to be rare. Certainly, self-starvation cannot be a form of self-discipline unless the supply of food is abundant and reliable, as it usually is for the vast majority in Western industrial societies. For most women at most places and times, food has not been so easy to come by. But that does not mean eating disorders are uniquely a product of modern social conditions and the ideal of body shape promoted by contemporary Western culture. Rules about food have carried many other meanings.

Saintliness

Prolonged fasting, a recognized religious discipline, is usually practiced by men but was also used by certain noblewomen of medieval Europe to demonstrate their moral strength and spiritual purity. The most famous of these women was Catherine of Siena, born in 1347. At age 15, she decided to preserve her virginity and devote her life to helping the poor. She died at 33, presumably from the effects of starvation. Saint Catherine wrote: "Make a supreme effort to root out that self-love from your heart and to plant in its place this holy self-hatred. This is the royal road by which we turn our back on mediocrity and which leads us without fail to the summit of perfection." The choice of words may seem peculiar to most anorexic patients, but the sentiment is not alien.

Historians have suggested that female saints of the Middle Ages wanted to liberate themselves from subordinate social roles, including marriage and childbearing, to which they considered unsuited. Catherine of Siena is said to have begun fasting soon after a customary aristocratic marriage had been arranged for her. What Saint Catherine had in common with the fasting male ascetics of India or early Christianity was a socially accepted way to satisfy her unusual needs and ambitions.

In more completely male-dominated cultures, like parts of the Moslem world today, eating disorders among women are practically unknown. In these societies women have no alternatives to subordination and no opportunities to gain recognition as exceptional. The prestige of female religious fasting eventually declined in Europe, and by the 17th century the attitude of the Church had changed. Women like Catherine of Siena were no longer considered candidates for sainthood. It was during this time that physicians made the first known clinical observations of anorexia as a disorder of the mind.

Unknown Causes

Presumably neither Saint Catherine nor male religious ascetics were worried about being slim or beautiful. In a recent study of anorexic Chinese women in Hong Kong, researchers found that they too deny concern about their weight and their looks. They say only that they have family problems, lack appetite, or cannot explain their behavior. Whether they seek slenderness or saintliness or simply "don't know", women who starve themselves may be rejecting unacceptable biological and social demands, a woman's body and a woman's place.

If this idea is right, some women with eating disorders are making an inarticulate social protest, a hunger strike without a conscious political purpose. Fear of gaining weight may be just one cultural expression of the illness rather than its central feature. As if acknowledging this, the American Psychiatric Association now includes in its diagnostic manual, among eating disorders not otherwise specified, a condition with all the symptoms of anorexia nervosa except an obsession with body shape.

TREATMENT OF EATING DISORDERS

Consult A Qualified Doctor and Nutritionist

            It is essential to receive the proper health care for the treatment of eating disorders. Acupuncture, herbal medicine, and food therapy are very beneficial. It is highly recommended for patients to seek the help and advice of a healthcare provider who has achieved proven methods of success in the area. Also it is necessary to be properly educated about the right attitudes and importance of food.

Our clinic offers food and nutrition consultations and seminars to help patients with eating disorders. There are essential nutrients needed by the body to achieve proper recovery and healing.

Weight Gain

In the treatment of eating disorders, several therapeutic techniques are used in different combinations with different patients. The services of psychiatrists, physicians, and dietitians may be needed. An anorexic patient must first eat until the weight is in normal range. In most severe cases, the individual is hospitalized. This is usually done when weight has dropped more than 20% below normal for several months, serious physical symptoms are developing, or when there is mortal danger.

At times, tube feeding may be needed just to keep the patient alive. Simple forms of operant conditioning are used to encourage food intake. The individual may be started on a liquid diet or frequent small meals and told every day how much food has been consumed and how the weight is doing. Nurses may have to remain present during meals to provide moral support, make sure the patient eats, and prevent vomiting.

The reward for gaining weight is greater freedom of movement and more visitors. If the anorexic patient does not eat, he or she may be confined to the bed. Laxatives are forbidden, and the patient must clean up if vomiting occurs. Recent research suggests that strict regimes with detailed schedules, graduated privileges, and careful recording of food consumption may be less effective than more limited programs that use only the threat of bed-rest for not eating. In the looser arrangements, the patient is more likely to cooperate and hospital staff members have less need to compromise their therapeutic function by acting as a police force.

Gaining weight while hospitalized does not guarantee long-term success. Anorexic patients sometimes "eat their way out of the hospital" and then stop. Their emotional condition may improve when their weight is closer to normal, but preventing relapse is difficult, partly because of the tendency to deny the illness. Drugs, even those that tend to cause weight gain, are not especially useful. Anorexic patients are predictably reluctant to take them, and the side effects can be uncomfortable or dangerous to feeble bodies.

Cognitive Therapies

When the patient's health is not in immediate danger, various behavioral and cognitive techniques can be used to preserve and promote weight gain. One of these is systematic desensitization, or muscle relaxation with visual imagery or direct exposure to a graded series of situations that involve food and eating. Cognitive techniques are used to correct the patient's false beliefs about food and about body image. Issues, such as harsh self-criticism, perfectionism, and exaggerated fears of separation from parents are dealt with. The therapist and patient explore superstitions about food and exercise, and unjustified interpretations of other people's behavior.

1)  The patient may be told to take a look from another point of view. For example, the individual feels fat, but says that others of the same height and weight are too thin,

2)  The patient may be told to make vague fears explicit. For example, what would be the worst thing that could happen if you ate more?

3)  The patient may be asked to test the hypotheses. For example, what will other people think if you eat dessert?"

4)  The patient may be asked to achieve a more accurate impression of the size of his or her body and the amount of food being consumed.

Some therapists move on to an insight-oriented approach at a later stage, when the patient must learn to do without the comforting discipline that has given life a meaning and goal. Interpersonal therapists examine the patient's present situation and both recent and future relationships. Psychodynamic therapists also try to explore and resolve emotional problems that may have created the need for self-starvation. Some speak of providing an experience that serves as a symbolic equivalent of the relationship between a mother and a child. If child sexual abuse is part of the story, treatment for post-traumatic stress may be needed.

Most families of anorexic patients can use help, if only education and counseling. Parents may be asked to record family conversations and listen to them. They may be told to answer their child's requests in new ways, spend time with the child in unfamiliar settings, or communicate in writing to make it clear what everyone in the family wants. Parents are usually instructed not to beg, plead, or scold, and told to avoid discussing food while eating with their child. The individual should not be told that weight gain has made improvements in the appearance, since he or she may be convinced that people care only about what is on the outside. Food and eating should be discussed only in connection with health. Therapists influenced by family systems theory also try to change what they see as the family's over-protectiveness, inability to admit conflicts, and uncertainty about the roles of parents and children.

Bulimia and Obesity

Bulimia is often treated more successfully than anorexia, partly because bulimic patients usually want to be treated. The problem of bulimia is closely related to the problem of obesity, since most bulimic women either are or think they are overweight. According to a widely accepted theory, each person's body weight has a biological setpoint that is strongly influenced by heredity. Studies in several countries have found that mothers and their biological daughters have a similar weight-height ratio, while the correlation between adoptive parents and adoptive children is low. According to the setpoint theory, metabolism during a diet slows to counteract the effect of reduced intake until it settles at a lower level consistent with the new weight. A person who continues the same diet will eventually regain weight until the setpoint is reached.

The setpoint may be determined by a brain center in the hypothalamus that regulates the amount of fatty tissue stored by the body. A substance called leptin is produced by fat cells and circulates in the blood until it reaches the brain. When this hypothalamic region detects sufficient leptin, it tells the body to stop storing fat. Neuron in this region use serotonin, and enhancement of serotonin activity is the main effect of the harmful FDA approved diet drug, dexienfluramine (Redux).

Some bulimic patients seem to be emotionally stable individuals whose concern about weight is more or less realistic given their social circumstances and cultural expectations. If a patient is bingeing and purging to circumvent the fat storage and wishes to pursue a body shape incompatible with the biological setpoint, weight-reducing drugs are often prescribed. However, the risks of these medications are high and include possible heart valve damage and pulmonary hypertension (dangerously high blood pressure in the arteries carrying blood to the lungs). Exercise may be a better way, since, apart from the expenditure of energy involved, it seems to reduce fat storage by altering the leptin mechanism.

Group Therapies

More often bulimic patients are given behavior therapy. One behavioral treatment for self-induced vomiting is exposure and response prevention. The patient is allowed to eat until nauseated and then asked to concentrate on the discomfort and write down all thoughts and feelings. Bathrooms are locked so that the individual will be ashamed to vomit, and he or she has to just tolerate the anxiety. The effectiveness of this method is disputed. Bulimic patients are also asked to examine self-defeating beliefs, such as the fear that any momentary lapse must precipitate a binge, the conviction that a slight weight gain is obvious to everyone, or the illusion that their worth depends on looks. Insight-oriented or exploratory psychotherapy may be especially useful for the many bulimic women patients who have other emotional problems or psychiatric disorders. If they are living with their families, family therapy may also help.

Group therapy is popular with both bulimic and anorexic patients. Groups are an efficient setting in which to present information and advice on eating habits. They are also used to apply a variety of therapeutic techniques, with cognitive and behavioral methods dominant. Apart from any specific therapeutic procedures, groups provide a sense of belonging and a source of friendship. The members learn from one another, teach, comfort, and are comforted. They watch one another for signs of relapse. They feel less ashamed when they realize that they are not alone, and they can correct distorted notions about themselves by watching and imitating others. Self-help groups are available as well as professional group therapy; Overeaters Anonymous, an organization modeled after Alcoholics Anonymous, provides support and advice for these groups.

Recovery

Treatment of anorexia can be frustrating, and recovery is usually prolonged and difficult. Even women whose most serious symptoms are relieved often relapse or suffer from various residual effects and chronic troubles. In long-term studies covering periods from 4 to 30 years, 50% to 70% are found to be no longer clinically anorexic: they are menstruating and maintaining a weight in the normal range. About 25% show some menstrual irregularities, and their weight is sometimes low. The outcome is poor for another 25%; they are not menstruating and their weight is far below normal. Whether they recover or not, many of these women are still preoccupied with weight and dieting. Bulimia is the most frequent diagnosis, and depression and anxiety disorders are also common. Individuals with personality disorders and those who have symptoms for a long time before seeking treatment are least likely to recover.

Full recovery from bulimia is more common. In a 1997 meta-analysis of studies on the outcome of treatment, researchers found an average recovery rate of 50% after periods of 6 months to 5 years. Relapse was common (about 30% in 6 years), but so was a second recovery. In a recent meta-analysis examining the effectiveness of various treatments, researchers found no differences between group and individual therapy. The best treatments concentrated on emotional problems and family relations, without reference to therapeutic theory or persuasion.

In one recent study with a 6-year follow-up, both cognitive-behavioral and interpersonal therapies were effective even when eating habits and weight were not made the center of interest. Simple behavior therapy was less successful, with a high dropout rate. Patients are least likely to recover if they have other disorders, such as alcoholism and borderline personality. In one recent study, the lowest recovery rate was found among women who were seriously overweight or whose fathers were overweight. In the long run, symptoms of bulimia often fade even without treatment, and the disorder is uncommon in women over 40.

Researchers are calling for further cross-cultural research and more studies in which individuals are interviewed for the first time before developing symptoms. Researchers must examine more closely the relationship between eating problems and other psychiatric disorders, including addictions and compulsive behavior, partly so that treatments can be modified for different combinations of symptoms. An especially important goal of research is to find ways to prevent eating disorders and recognize and treat them at an early stage

What is portrayed in the media often sets the social norm and sends people chasing after fantasies and unrealistic goals. Thin female models strutting the catwalk in small bikinis and male models showing of perfect "wash-board" stomachs ignite the craving for young men and women to lust after and imitate. Therefore, many people, especially young women, tend to get obsessed with weight control, being slim and having a perfect-ten figure. Although their current weight is normal, many adolescents feel pressured to be "ideally" thin like models in movies or magazines. Some girls embark on their first diet before even leaving elementary school.

It is important to know that not everyone who watches their weight, exercises regularly, or overeats food has an eating disorder. However, people who display symptoms or are suspected of eating disorders should never be ignored. The condition could be caused by sociological, physiological and psychological factors, and the behaviors associated with eating disorders can lead to serious health problems and in extreme cases, even death.

Detection and treatment is often further complicated by the fact that individuals with the disorders often deny the problem or attempt to conceal their symptoms. Diagnosis and treatment of eating disorders should be undertaken by a mental health professional in conjunction with a physician and a nutritionist in order to treat the psychological disorder along with the physiological.