Eating disorder

Classification

Bulimia nervosa is a disorder characterized by binge eating and purging, as well as excessive evaluation of one's self-worth in terms of body weight or shape. Purging can include self-induced vomiting, over-exercising, and the use of diuretics, enemas, and laxatives. Anorexia nervosa is characterized by extreme food restriction and excessive weight loss, accompanied by the fear of being fat. The extreme weight loss often causes women and girls who have begun menstruating to stop having menstrual periods, a condition known as amenorrhea. Although amenorrhea was once a required criterion for the disorder, it is no longer required to meet criteria for anorexia nervosa due to its exclusive nature for sufferers who are male, post-menopause, or who do not menstruate for other reasons. The DSM-5 specifies two subtypes of anorexia nervosa—the restricting type and the binge/purge type. Those who suffer from the restricting type of anorexia nervosa restrict food intake and do not engage in binge eating, whereas those suffering from the binge/purge type lose control over their eating at least occasionally and may compensate for these binge episodes. The most notable difference between anorexia nervosa binge/purge type and bulimia nervosa is the body weight of the person. Those diagnosed with anorexia nervosa binge/purge type are underweight, while those with bulimia nervosa may have a body weight that falls within the range from normal to obese.

ICD and DSM

These eating disorders are specified as mental disorders in standard medical manuals, such as in the ICD-10, the DSM-5, or both.

Other

Signs and symptoms

Symptoms and complications vary according to the nature and severity of the eating disorder:

Some physical symptoms of eating disorders are weakness, fatigue, sensitivity to cold, reduced beard growth in men, reduction in waking erections, reduced libido, weight loss and failure of growth. Unexplained hoarseness may be a symptom of an underlying eating disorder, as the result of acid reflux, or entry of acidic gastric material into the laryngoesophageal tract. Patients who induce vomiting, such as those with anorexia nervosa, binge eating-purging type or those with purging-type bulimia nervosa are at risk for acid reflux. Polycystic ovary syndrome (PCOS) is the most common endocrine disorder to affect women. Though often associated with obesity it can occur in normal weight individuals. PCOS has been associated with binge eating and bulimic behavior. Other possible manifestations are dry lips, burning tongue, parotid gland swelling, and temporomandibular disorders.

Pro-Ana subculture

Pro-ana refers to the promotion of behaviors related to the eating disorder anorexia nervosa. Several websites promote eating disorders, and can provide a means for individuals to communicate in order to maintain eating disorders. Members of these websites typically feel that their eating disorder is the only aspect of a chaotic life that they can control. These websites are often interactive and have discussion boards where individuals can share strategies, ideas, and experiences, such as diet and exercise plans that achieve extremely low weights. A study comparing the personal web-blogs that were pro-eating disorder with those focused on recovery found that the pro-eating disorder blogs contained language reflecting lower cognitive processing, used a more closed-minded writing style, contained less emotional expression and fewer social references, and focused more on eating-related contents than did the recovery blogs.

Psychopathology

The psychopathology of eating disorders centers around body image disturbance, such as concerns with weight and shape; self-worth being too dependent on weight and shape; fear of gaining weight even when underweight; denial of how severe the symptoms are and a distortion in the way the body is experienced.

Causes

The cause of eating disorder is not clear.

Many people with eating disorders suffer also from body dysmorphic disorder, altering the way a person sees themself. Studies have found that a high proportion of individuals diagnosed with body dysmorphic disorder also had some type of eating disorder, with 15% of individuals having either anorexia nervosa or bulimia nervosa. This link between body dysmorphic disorder and anorexia stems from the fact that both BDD and anorexia nervosa are characterized by a preoccupation with physical appearance and a distortion of body image. There are also many other possibilities such as environmental, social and interpersonal issues that could promote and sustain these illnesses.} Also, the media are oftentimes blamed for the rise in the incidence of eating disorders due to the fact that media images of idealized slim physical shape of people such as models and celebrities motivate or even force people to attempt to achieve slimness themselves. The media are accused of distorting reality, in the sense that people portrayed in the media are either naturally thin and thus unrepresentative of normality or unnaturally thin by forcing their bodies to look like the ideal image by putting excessive pressure on themselves to look a certain way. While past findings have described the causes of eating disorders as primarily psychological, environmental, and sociocultural, new studies have uncovered evidence that there is a prevalent genetic/heritable aspect of the causes of eating disorders.

Genetics

Psychological

Eating disorders are classified as Axis I disorders in the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-IV) published by the American Psychiatric Association. There are various other psychological issues that may factor into eating disorders, some fulfill the criteria for a separate Axis I diagnosis or a personality disorder which is coded Axis II and thus are considered comorbid to the diagnosed eating disorder. Axis II disorders are subtyped into 3 "clusters": A, B and C. The causality between personality disorders and eating disorders has yet to be fully established. Some people have a previous disorder which may increase their vulnerability to developing an eating disorder. Some develop them afterwards. The severity and type of eating disorder symptoms have been shown to affect comorbidity. The DSM-IV should not be used by laypersons to diagnose themselves, even when used by professionals there has been considerable controversy over the diagnostic criteria used for various diagnoses, including eating disorders. There has been controversy over various editions of the DSM including the latest edition, DSM-V, due in May 2013.

Cognitive attentional bias issues

Attentional bias may have an effect on eating disorders. Many studies have been performed to test this theory.

Personality traits

There are various childhood personality traits associated with the development of eating disorders. During adolescence these traits may become intensified due to a variety of physiological and cultural influences such as the hormonal changes associated with puberty, stress related to the approaching demands of maturity and socio-cultural influences and perceived expectations, especially in areas that concern body image. Eating disorders have been associated with a fragile sense of self and with disordered mentalization. Many personality traits have a genetic component and are highly heritable. Maladaptive levels of certain traits may be acquired as a result of anoxic or traumatic brain injury, neurodegenerative diseases such as Parkinson's disease, neurotoxicity such as lead exposure, bacterial infection such as Lyme disease or viral infection such as Toxoplasma gondii as well as hormonal influences. While studies are still continuing via the use of various imaging techniques such as fMRI; these traits have been shown to originate in various regions of the brain such as the amygdala and the prefrontal cortex. Disorders in the prefrontal cortex and the executive functioning system have been shown to affect eating behavior.

Celiac disease

People with gastrointestinal disorders may be more risk of developing disordered eating practices than the general population, principally restrictive eating disturbances. An association of anorexia nervosa with celiac disease has been found. The role that gastrointestinal symptoms play in the development of eating disorders seems rather complex. Some authors report that unresolved symptoms prior to gastrointestinal disease diagnosis may create a food aversion in these persons, causing alterations to their eating patterns. Other authors report that greater symptoms throughout their diagnosis led to greater risk. It has been documented that some people with celiac disease, irritable bowel syndrome or inflammatory bowel disease who are not conscious about the importance of strictly following their diet, choose to consume their trigger foods to promote weight loss. On the other hand, individuals with good dietary management may develop anxiety, food aversion and eating disorders because of concerns around cross contamination of their foods. Some authors suggest that medical professionals should evaluate the presence of an unrecognized celiac disease in all people with eating disorder, especially if they present any gastrointestinal symptom (such as decreased appetite, abdominal pain, bloating, distension, vomiting, diarrhea or constipation), weight loss, or growth failure; and also routinely ask celiac patients about weight or body shape concerns, dieting or vomiting for weight control, to evaluate the possible presence of eating disorders, specially in women.

Child maltreatment

Child abuse which encompasses physical, psychological and sexual abuse, as well as neglect has been shown to approximately triple the risk of an eating disorder. Sexual abuse appears to about double the risk of bulimia; however, the association is less clear for anorexia.

Social isolation

Social isolation has been shown to have a deleterious effect on an individual's physical and emotional well-being. Those that are socially isolated have a higher mortality rate in general as compared to individuals that have established social relationships. This effect on mortality is markedly increased in those with pre-existing medical or psychiatric conditions, and has been especially noted in cases of coronary heart disease. "The magnitude of risk associated with social isolation is comparable with that of cigarette smoking and other major biomedical and psychosocial risk factors." (Brummett et al.)

Social isolation can be inherently stressful, depressing and anxiety-provoking. In an attempt to ameliorate these distressful feelings an individual may engage in emotional eating in which food serves as a source of comfort. The loneliness of social isolation and the inherent stressors thus associated have been implicated as triggering factors in binge eating as well.

Waller, Kennerley and Ohanian (2007) argued that both bingeing–vomiting and restriction are emotion suppression strategies, but they are just utilized at different times. For example, restriction is used to pre-empt any emotion activation, while bingeing–vomiting is used after an emotion has been activated.

Parental influence

Parental influence has been shown to be an intrinsic component in the development of eating behaviors of children. This influence is manifested and shaped by a variety of diverse factors such as familial genetic predisposition, dietary choices as dictated by cultural or ethnic preferences, the parents' own body shape and eating patterns, the degree of involvement and expectations of their children's eating behavior as well as the interpersonal relationship of parent and child. This is in addition to the general psychosocial climate of the home and the presence or absence of a nurturing stable environment. It has been shown that maladaptive parental behavior has an important role in the development of eating disorders. As to the more subtle aspects of parental influence, it has been shown that eating patterns are established in early childhood and that children should be allowed to decide when their appetite is satisfied as early as the age of two. A direct link has been shown between obesity and parental pressure to eat more.

Coercive tactics in regard to diet have not been proven to be efficacious in controlling a child's eating behavior. Affection and attention have been shown to affect the degree of a child's finickiness and their acceptance of a more varied diet.

Hilde Bruch, a pioneer in the field of studying eating disorders, asserts that anorexia nervosa often occurs in girls who are high achievers, obedient, and always trying to please their parents. Their parents have a tendency to be over-controlling and fail to encourage the expression of emotions, inhibiting daughters from accepting their own feelings and desires. Adolescent females in these overbearing families lack the ability to be independent from their families, yet realize the need to, often resulting in rebellion. Controlling their food intake may make them feel better, as it provides them with a sense of control.

Peer pressure

In various studies such as one conducted by The McKnight Investigators, peer pressure was shown to be a significant contributor to body image concerns and attitudes toward eating among subjects in their teens and early twenties.

Eleanor Mackey and co-author, Annette M. La Greca of the University of Miami, studied 236 teen girls from public high schools in southeast Florida. "Teen girls' concerns about their own weight, about how they appear to others and their perceptions that their peers want them to be thin are significantly related to weight-control behavior", says psychologist Eleanor Mackey of the Children's National Medical Center in Washington and lead author of the study. "Those are really important."

According to one study, 40% of 9- and 10-year-old girls are already trying to lose weight. Such dieting is reported to be influenced by peer behavior, with many of those individuals on a diet reporting that their friends also were dieting. The number of friends dieting and the number of friends who pressured them to diet also played a significant role in their own choices.

Elite athletes have a significantly higher rate in eating disorders. Female athletes in sports such as gymnastics, ballet, diving, etc. are found to be at the highest risk among all athletes. Women are more likely than men to acquire an eating disorder between the ages of 13–30. 0–15% of those with bulimia and anorexia are men.

Cultural pressure

There is a cultural emphasis on thinness which is especially pervasive in western society. There is an unrealistic stereotype of what constitutes beauty and the ideal body type as portrayed by the media, fashion and entertainment industries. "The cultural pressure on men and women to be 'perfect' is an important predisposing factor for the development of eating disorders". Further, when women of all races base their evaluation of their self upon what is considered the culturally ideal body, the incidence of eating disorders increases. Eating disorders are becoming more prevalent in non-Western countries where thinness is not seen as the ideal, showing that social and cultural pressures are not the only causes of eating disorders. For example, observations of anorexia in all of the non-Western regions of the world point to the disorder not being "culture-bound" as once thought. However, studies on rates of bulimia suggest that it might be culturally bound. In non-Western countries, bulimia is less prevalent than anorexia, but these non-Western countries where it is observed can be said to have probably or definitely been influenced or exposed to Western culture and ideology.

Socioeconomic status (SES) has been viewed as a risk factor for eating disorders, presuming that possessing more resources allows for an individual to actively choose to diet and reduce body weight. Some studies have also shown a relationship between increasing body dissatisfaction with increasing SES. However, once high socioeconomic status has been achieved, this relationship weakens and, in some cases, no longer exists.

The media plays a major role in the way in which people view themselves. Countless magazine ads and commercials depict thin celebrities like Lindsay Lohan, Nicole Richie, Victoria Beckham and Mary Kate Olsen, who appear to gain nothing but attention from their looks. Society has taught people that being accepted by others is necessary at all costs. Unfortunately this has led to the belief that in order to fit in one must look a certain way. Televised beauty competitions such as the Miss America Competition contribute to the idea of what it means to be beautiful because competitors are evaluated on the basis of their opinion.

In addition to socioeconomic status being considered a cultural risk factor so is the world of sports. Athletes and eating disorders tend to go hand in hand, especially the sports where weight is a competitive factor. Gymnastics, horse back riding, wrestling, body building, and dancing are just a few that fall into this category of weight dependent sports. Eating disorders among individuals that participate in competitive activities, especially women, often lead to having physical and biological changes related to their weight that often mimic prepubescent stages. Oftentimes as women's bodies change they lose their competitive edge which leads them to taking extreme measures to maintain their younger body shape. Men often struggle with binge eating followed by excessive exercise while focusing on building muscle rather than losing fat, but this goal of gaining muscle is just as much an eating disorder as obsessing over thinness. The following statistics taken from Susan Nolen-Hoeksema's book, (ab)normal psychology, shows the estimated percentage of athletes that struggle with eating disorders based on the category of sport.

Although most of these athletes develop eating disorders to keep their competitive edge, others use exercise as a way to maintain their weight and figure. This is just as serious as regulating food intake for competition. Even though there is mixed evidence showing at what point athletes are challenged with eating disorders, studies show that regardless of competition level all athletes are at higher risk for developing eating disorders that non-athletes, especially those that participate in sports where thinness is a factor.

Pressure from society is also seen within the homosexual community. Homosexual men are at greater risk of eating disorder symptoms than heterosexual men. Within the gay culture, muscularity gives the advantages of both social and sexual desirability and also power. These pressures and ideas that another homosexual male may desire a mate who is thinner or muscular can possibly lead to eating disorders. The higher eating disorder symptom score reported, the more concern about how others perceive them and the more frequent and excessive exercise sessions occur. High levels of body dissatisfaction are also linked to external motivation to working out and old age; however, having a thin and muscular body occurs within younger homosexual males than older.

It is important to realize some of the limitations and challenges of many studies that try to examine the roles of culture, ethnicity, and SES. For starters, most of the cross-cultural studies use definitions from the DSM-IV-TR, which has been criticized as reflecting a Western cultural bias. Thus, assessments and questionnaires may not be constructed to detect some of the cultural differences associated with different disorders. Also, when looking at individuals in areas potentially influenced by Western culture, few studies have attempted to measure how much an individual has adopted the mainstream culture or retained the traditional cultural values of the area. Lastly, the majority of the cross-cultural studies on eating disorders and body image disturbances occurred in Western nations and not in the countries or regions being examined.

While there are many influences to how an individual processes their body image, the media does play a major role. Along with the media, parental influence, peer influence, and self-efficacy beliefs also play a large role in an individual's view of themselves. The way the media presents images can have a lasting effect on an individual's perception of their body image. Eating disorders are a worldwide issue and while women are more likely to be affected by an eating disorder it still affects both genders (Schwitzer 2012). The media influences eating disorders whether shown in a positive or negative light, it then has a responsibility to use caution when promoting images that projects an ideal that many turn to eating disorders to attain.

To try to address unhealthy body image in the fashion world, in 2015, France passed a law requiring models to be declared healthy by a doctor to participate in fashion shows. It also requires re-touched images to be marked as such in magazines.

There is a relationship between “thin ideal” social media content and body dissatisfaction and eating disorders among young adult women, especially in the Western hemisphere. New research points to an “internalization” of distorted images online, as well as negative comparisons among young adult women. Most studies have been based in the U.S, the U.K, and Australia, these are places where the thin ideal is strong among women, as well as the strive for the “perfect” body.

In addition to mere media exposure, there is an online “pro-eating disorder” community. Through personal blogs and Twitter, this community promotes eating disorders as a “lifestyle”, and continuously posts pictures of emaciated bodies, and tips on how to stay thin. The hashtag “#proana” (pro-anorexia), is a product of this community, as well as images promoting weight loss, tagged with the term “thinspiration”. According to social comparison theory, young women have a tendency to compare their appearance to others, which can result in a negative view of their own bodies and altering of eating behaviors, that in turn can develop disordered eating behaviors.

When body parts are isolated and displayed in the media as objects to be looked at, it is called objectification, and women are affected most by this phenomenon. Objectification increases self-objectification, where women judge their own body parts as a mean of praise and pleasure for others. There is a significant link between self-objectification, body dissatisfaction, and disordered eating, as the beauty ideal is altered through social media.

Mechanisms

Diagnosis

The initial diagnosis should be made by a competent medical professional. "The medical history is the most powerful tool for diagnosing eating disorders"(American Family Physician). There are many medical disorders that mimic eating disorders and comorbid psychiatric disorders. All organic causes should be ruled out prior to a diagnosis of an eating disorder or any other psychiatric disorder. In the past 30 years eating disorders have become increasingly conspicuous and it is uncertain whether the changes in presentation reflect a true increase. Anorexia nervosa and bulimia nervosa are the most clearly defined subgroups of a wider range of eating disorders. Many patients present with subthreshold expressions of the two main diagnoses: others with different patterns and symptoms.

Medical

The diagnostic workup typically includes complete medical and psychosocial history and follows a rational and formulaic approach to the diagnosis. Neuroimaging using fMRI, MRI, PET and SPECT scans have been used to detect cases in which a lesion, tumor or other organic condition has been either the sole causative or contributory factor in an eating disorder. "Right frontal intracerebral lesions with their close relationship to the limbic system could be causative for eating disorders, we therefore recommend performing a cranial MRI in all patients with suspected eating disorders" (Trummer M et al. 2002), "intracranial pathology should also be considered however certain is the diagnosis of early-onset anorexia nervosa. Second, neuroimaging plays an important part in diagnosing early-onset anorexia nervosa, both from a clinical and a research prospective".(O'Brien et al. 2001).

Psychological

After ruling out organic causes and the initial diagnosis of an eating disorder being made by a medical professional, a trained mental health professional aids in the assessment and treatment of the underlying psychological components of the eating disorder and any comorbid psychological conditions. The clinician conducts a clinical interview and may employ various psychometric tests. Some are general in nature while others were devised specifically for use in the assessment of eating disorders. Some of the general tests that may be used are the Hamilton Depression Rating Scale and the Beck Depression Inventory. longitudinal research showed that there is an increase in chance that a young adult female would develop bulimia due to their current psychological pressure and as the person ages and matures, their emotional problems change or are resolved and then the symptoms decline.

Differential diagnoses

There are multiple medical conditions which may be misdiagnosed as a primary psychiatric disorder, complicating or delaying treatment. These may have a synergistic effect on conditions which mimic an eating disorder or on a properly diagnosed eating disorder.

Psychological disorders which may be confused with an eating disorder, or be co-morbid with one:

Prevention

Prevention aims to promote a healthy development before the occurrence of eating disorders. It also intends early identification of an eating disorder before it is too late to treat. Children as young as ages 5–7 are aware of the cultural messages regarding body image and dieting. Prevention comes in bringing these issues to the light. The following topics can be discussed with young children (as well as teens and young adults).

Internet and modern technologies provide new opportunities for prevention. On-line programs have the potential to increase the use of prevention programs. The development and practice of prevention programs via on-line sources make it possible to reach a wide range of people at minimal cost. Such an approach can also make prevention programs to be sustainable.

Treatment

Treatment varies according to type and severity of eating disorder, and usually more than one treatment option is utilized. There is no well-established treatment for eating disorders, meaning that current views about treatment are based mainly on clinical experience. Family doctors play an important role in early treatment of people with eating disorders by encouraging those who are also reluctant to see a psychiatrist. Treatment can take place in a variety of different settings such as community programs, hospitals, day programs, and groups. That said, some treatment methods are:

There are few studies on the cost-effectiveness of the various treatments. Treatment can be expensive; due to limitations in health care coverage, people hospitalized with anorexia nervosa may be discharged while still underweight, resulting in relapse and rehospitalization.

For children with anorexia, the only well-established treatment is the family treatment-behavior. For other eating disorders in children, however, there is no well-established treatments, though family treatment-behavior has been used in treating bulimia.

Outcomes

Outcome estimates are complicated by non-uniform criteria used by various studies, but for anorexia nervosa, bulimia nervosa, and binge eating disorder, there seems to be general agreement that full recovery rates are in the 50% to 85% range, with larger proportions of people experiencing at least partial remission. The outcomes of eating disorders (ED) vary among the cases. For many, it can be a lifelong struggle or it can be overcome within months. In the United States, twenty million women and ten million men have an eating disorders at least once in their lifetime. The mortality rate for those with anorexia nervosa is 5.4 per 1000 individuals per year. Roughly 1.3 deaths were due to suicide. A person who is or had been in an inpatient setting had a rate of 4.6 deaths per 1000. Of individuals with bulimia nervosa about 2 persons per 1000 persons die per year and among those with EDNOS about 3.3 per 1000 people die per year.

Anorexia Nervosa symptoms include the increasing chance of getting osteoporosis. This disease causes the bones of an individual to become brittle, weak, and low in density. Thinning of the hair as well as dry hair and skin is also very common. The muscles of the heart will also start to change if no treatment is inflicted on the patient. This causes the heart to have an abnormally slow heart rate along with low blood pressure. Heart failure becomes a major consideration when this begins to occur. Muscles throughout the body begin to lose their strength. This will cause the individual to begin feeling faint, drowsy, and weak. Along with these symptoms, the body will begin to grow a layer of hair called lanugo. The human body does this in response to the lack of heat and insulation due to the low percentage of body fat.

Bulimia nervosa symptoms include heart problems like an irregular heartbeat that can lead to heart failure and death may occur. This occurs because of the electrolyte imbalance that is a result of the constant binge and purge process. The probability of a gastric rupture increases. A gastric rupture is when there is a sudden rupture of the stomach lining that can be fatal.The acids that are contained in the vomit can cause a rupture in the esophagus as well as tooth decay. As a result, to laxative abuse, irregular bowel movements may occur along with constipation. Sores along the lining of the stomach called peptic ulcers begin to appear and the chance of developing pancreatitis increases.

Binge eating symptoms include high blood pressure, which can cause heart disease if it is not treated. Many patients recognize an increase in the levels of cholesterol. The chance of being diagnosed with gallbladder disease increases, which affects an individual’s digestive tract.

Epidemiology

Eating disorders result in about 7,000 deaths a year as of 2010, making them the mental illnesses with the highest mortality rate.

One study in the United States found a higher rate in college students who are transgender.

Economics