Eating disorders like anorexia nervosa and bulimia are serious eating behavior disturbances and involve either a reduction of food intake or severe overeating. This is usually accompanied by feelings of distress or extreme concern about body shape or weight. Eating disorders are mostly seen in adolescent females. The etiology is varied. Treatment is mainly psychotherapy and counseling.
Classification of eating disorders
The current diagnostic classification of eating disorders includes anorexia nervosa (AN), bulimia nervosa (BN), and eating disorders not otherwise specified (ED NOS). Binge eating disorder (BED) is still classified as ED NOS. (Nutrition Research Newsletter, 2002.)
Eating disorders are seen most frequently in adolescents and young adults, and more common in females than in males (Pritts & Susman, 2003). In adolescents, the disease is observed almost exclusively among females (90%-95%). The peak age of onset is between 13- 20 years of age (George, 2000). There is no ethnic predisposition but it is more common in whites of industrialized nations (Pritts & Susman, 2003).
It has been observed that taking part in activities (which promote thinness) like ballet dancing, modeling, and athletics are possible risk factors for developing an eating disorder (Pritts & Susman, 2003). Other possible risk factors are having “certain personality traits like low self-esteem, difficulty expressing negative emotions, difficulty resolving conflict and being a perfectionist” (Pritts & Susman, 2003).
Anorexia nervosa (AN) and bulimia could be inherited disorders, and there is evidence of a disordered hypothalamic-pituitary-adrenal axis in AN (George, 2000). Another contributory factor in the development of AN could be psychological trauma, especially sexual abuse (George, 2000).
Anorexia Nervosa (AN)
This disorder is characterized by abnormal eating behavior, a morbid concern about body weight, and a distorted perception of body size.
There are 2 types of AN:
- Restricting type – where there is no regular binge eating or purging.
- Binge eating/purging type-where there is regular binge eating or purging (George, 2000).
According to the 1994 American Psychiatric Association (DSM-IV), the criteria for the diagnosis of anorexia nervosa includes the refusal to maintain minimal normal weight with bodyweight less than 85% of that expected for age and height, fear of becoming fat or gaining weight, disturbance in body weight and shape perceptions, absence of at least three normal non-drug induced consecutive menstrual cycles.
The signs of anorexia nervosa include signs of lowered metabolism (bradyarrhythmia, bradypnea), hypotension (systolic blood pressure < 90 mm Hg), hypothermia, lanugo hair on arms and face with loss of scalp and pubic hair; edema of the legs, muscle atrophy, emaciation, carotenemia, dry skin with desquamation, and small uterus/cervix and pink, dry vaginal mucosa (George, 2000). Osteoporosis is a serious complication of AN due to estrogen deficiency.
Anorectics also might have other associated psychological disorders like major depression, bipolar disorder, obsessive-compulsive disorder, substance abuse disorder, and borderline personality disorder.
Several studies have indicated that treatment with psychotropic medication is not very useful in AN; however, antidepressants may be useful in preventing relapse (Casper, 2002). Renutrition, cognitive and interpersonal psychotherapy, and family therapy are the core of treatment in AN (Casper, 2002). Hospitalization might be required in case of severe malnutrition (more than 30% loss of ideal weight for height), rapid loss of more than 30% weight in less than 3 months, presence of cardiac arrhythmia, intractable hypokalemia, hypothermia, altered mental status, suicidal ideation or acute psychotic reaction (George, 2000).
The prognosis in AN is good in 50%, moderately good in 30 %, and poor in 20 % (Pritts & Susman, 2003.)
Bulimia Nervosa (BN)
This condition is “characterized by repeated bouts of overeating that lead the patient to engage in vomiting, fasting, excessive exercising, and the misuse of diuretics, laxatives, and enemas”. About 30% to 80% of patients might alternate between the two extremes of AN and BN, this is known as bulimarexia (George, 2000).
There are two specific types:
- Purging type: where there is self-induced vomiting or the misuse of laxatives, diuretics, and enemas.
- Nonpurging type: there is no regular self-induced vomiting or misuse of laxatives, diuretics, and enemas but the presence of fasting or excessive exercise (George, 2000).
The signs of BN include caries, pyorrhoea, and gum disorders (due to gastric acid erosion of the tooth enamel, mostly on the lingual surfaces of the upper teeth), and Russell’s sign, which is bleeding, scarred, or callused knuckles (due to repeated contact with the front teeth). Parotid hypertrophy occurs in 80 % of cases and the cause is not known. Common serum abnormalities include hypochloremic metabolic alkalosis and hypokalemia, due to vomiting (George, 2000).
Fluoxetine is the drug of choice for the treatment of BN. In addition, cognitive-behavioral therapy (CBT) and bright light therapy (for seasonal bulimia) are recommended (George, 2000). The prognosis of bulimia is good in 45%, moderately good in 18%, and poor in 21% (Pritts & Susman, 2003.)
Binge-eating disorder (BED)
Binge-eating disorder is characterized by recurrent episodes of binge eating (eating excessively within a short time, without any control). The binge-eating is associated with some of the following: eating faster than normal; eating till feeling uncomfortably full; eating large amounts when not hungry; eating alone due to embarrassment of the amount of food eaten, and feeling disgusted, depressed, or very guilty after overeating. Binge eating occurs for at least 2 days a week for 6 months, on average. There are no associated inappropriate compensatory behaviors (e.g., purging, fasting, excessive exercise). The main difference from bulimia is that there is no attempt to purge; because of this, many with BED are overweight for their age and height.
Generated feelings of self-disgust and shame can lead to bingeing again, creating a cycle. The treatment is similar to bulimia (National Institute of Mental Health, n.d.)
The Female Athlete Triad
This condition is seen in female athletes and is characterized by eating disorders, amenorrhoea, and osteoporosis. The treatment is cognitive behavior therapy, and exercise restriction (George, 2000).
Male Eating Disorders
Eating disorders are not confined to females alone.
Gay or bisexual men engaged in modeling or acting jobs might also suffer from eating disorders. Most of these men have a history of premorbid obesity and have a history of substance use and a family history of alcoholism or affective disorders. The prognosis is usually poorer than other eating disorders (George, 2000).
Pica is an eating disorder of childhood and is sometimes seen in mentally disabled people, and pregnant women. Patients might ingest mud, ice, starch, ropes, wood, or other products (Padilla & De la Torre, 2006.)
Differential Diagnosis of eating disorders
Before making a diagnosis of an eating disorder, the following conditions must be considered in the differential diagnosis: hyperthyroidism, malignancy, inflammatory bowel disease, immunodeficiency, malabsorption, chronic infections, Addison’s disease, and diabetes.
Eating disorders include anorexia nervosa, bulimia, binge eating disorder, and other types like a male eating disorder, pica, and the female athlete triad.
Eating disorder is usually accompanied by feelings of distress or extreme concern about body shape or weight.
Although frequently seen in female adolescents, eating disorders are not uncommon in men. Etiology is varied, and includes genetic factors, having certain personality traits, psychological trauma, and social factors. The mainstay of therapy in eating disorders includes various types of psychotherapy.
Casper, RC (2002). How Useful are Pharmacological Treatments in Eating Disorders? Psychopharmacol Bull. 36:88-104.
George, ED (2000). Managing Eating Disorders. American College of Physicians-American Society of Internal Medicine Annual Session. Web.
National Institute of Mental Health (n.d). Eating Disorders Facts About Eating Disorders and the Search for Solutions. Web.
Nutrition Research Newsletter (2002). Full syndromal versus subthreshold eating Disorders. Web.
Pritts, SD, Susman, J (2003). Diagnosis of eating disorders in primary care-Cover article: problem-oriented diagnosis-Brief Article. American Family Physician. Web.
Viguria Padilla, F, Mijan de la Torre, A (2006). Pica: the portrait of a little known clinical entity. Nutr Hosp. 21(5): 557-66.