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What Are Eating Disorders	Who develops Eating Disorders	What causes Eating Disorders	How Serious is Bulimia w/ out Anorexia
How Serious is Anorexia	What Are the symptoms of Eating Disorders	What will confirm a diagnosis of an Eating Disorder	Statistics
Symtoms of Anorexia	Signs of Anorexia	Symptoms of Bulimia	Signs of Bulimia

WHAT ARE EATING DISORDERS?

Eating disorders are devastating behavioral maladies brought on by a complex interplay of factors, which may include emotional and personality disorders, family pressures, a possible genetic or biologic susceptibility, and a culture in which there is an overabundance of food and an obsession with thinness. There are four general categories of eating disorders:

Bulimia nervosa.
Anorexia nervosa.
Binge eating.
Eating disorders not otherwise specified.

These are not new disorders. Although anorexia nervosa was first defined as a medical problem in the late 1800s, descriptions of self-starvation have been found even in medieval writings.

Bulimia nervosa

It is characterized by cycles of bingeing and purging, and typically takes the following pattern: Bulimia is often triggered when young women attempt restrictive diets, fail, and react by binge eating. (Binge eating involves consuming amounts of food that are larger than average portions within a two-hour period.) In response to the binges, patients compensate, usually by purging, by vomiting, by using enemas, or by taking laxatives, diet pills, or drugs to reduce fluids.
Patients then revert to severe dieting, excessive exercise, or both. (Some patients with bulimia follow bingeing only with fasting and exercise. They are then considered to have non-purging bulimia.)

The cycle then swings back to bingeing and then to purging again.

Some studies have reported that patients with bulimia average about 14 episodes of binge-purging per week. To be diagnosed with bulimia, however, a patient must binge and purge at least twice a week for three months. (Some experts believe that going through the cycle only once a week is sufficient for a diagnosis.)

In some cases, the condition progresses to anorexia. Most people with bulimia, however, have a normal to high-normal body weight, although it may fluctuate by more than 10 pounds because of the binge-purge cycle.

It should be noted that young people who occasionally force vomiting after eating too much are not considered bulimic, and most of the time this occasional unhealthy behavior does not continue beyond youth.

Anorexia Nervosa

At least 15% to as much as 60% of normal body weight is lost.

The patient with anorexia nervosa has an intense fear of gaining weight, even when he or she is severely underweight. Individuals with anorexia nervosa have a distorted image of their own weight or shape and deny the serious health consequences of their low weight. Women with anorexia nervosa miss at best three consecutive periods. (It should be noted that some experts believe women can be anorexic without this occurrence.) Patients with the condition are often characterized as anorexia restrictors or anorexic bulimic patients. Each type is about equally prevalent.

Anorexia restrictors reduce their weight by severe dieting. Anorexic bulimic patients maintain emaciation by purging. Although both types are serious, the bulimic type, which imposes additional stress on an undernourished body, is the more damaging.

It should be noted that the term "anorexia" literally means absence of appetite. For example, severe anorexia is common in the elderly, who may experience weight loss because of social isolation, impaired gastrointestinal function, or loss of certain chemicals related to the feeding drive. Such anorexia, however, is not synonymous with anorexia nervosa, which is a psychologic disorder.

Binge-Eating (Binge-Eating Disorder)

Known as compulsively overeating (binge eating) without other bulimic behaviors, such as vomiting or laxative abuse, used to eliminate calories. Binge-eating usually leads to becoming overweight.

To be diagnosed as a binge eater, a person typically has the following characteristics: Bingeing at least twice a week for six months. Consuming 5,000 to 15,000 calories in one sitting. Eating three meals a day plus frequent snacks. Overeating continually throughout the day, rather than consuming large amounts of food during binges. Since binge-eating disorder is generally associated with weight gain, it will not be further discussed in this report.

Eating Disorders Not Otherwise Specified

Infrequent binge-purge episodes (occurring less than twice a week or having such behavior for less than three months). Repeated chewing and spitting without swallowing large amounts of food. Normal weight and anorexic behavior.

WHO DEVELOPS EATING DISORDERS?

The approach to food in Western Countries is extremely problematic. Enough food is produced in the US to supply 3,800 calories every day to each man, woman, and child, far more than any single person needs to sustain life. Obesity is a global epidemic, and few people living in this over-fed and sedentary culture eat a meal guiltlessly. One can nearly make the sweeping generalization that everyone who lives in a developed nation is at risk for either obesity or some eating disorder.

Age

In general, eating disorders occur in adolescents and young adults, although one study reported that 5% of cases occurred in children under 12 years old.

Age of Onset for Bulimia

A 1997 survey by the Centers for Disease Control of high school students reported that 4.5% induced vomiting after meals or used laxatives to lose weight. Estimates of the prevalence of bulimia nervosa among young women range from about 3% in adolescents to 10% in college women. Some experts claim that even these percentages grossly underestimate the problem because many people with bulimia are able to conceal their purging and do not become noticeably underweight. For example, a European study detected bulimic behavior in 14.4% of adolescents 14 to 16 years old, with full-blown bulimia observed in 1.8% of girls and 0.3% of boys.

Age of Onset for Anorexia

Anorexia nervosa is the third most common chronic illness in adolescent women, and is estimated to occur in 0.5% to 3% of all teenagers. Anorexia usually first occurs in adolescence with peaks at 13 to 14 years of age and at 17 to 18 years of age. Over the past 40 years, however, the incidence has been steady in teenagers, but it has increased threefold in young adult women.

Gender

Studies typically report that 90% of eating disorder cases are in females. However, the rate in males appears to be increasing. For example, a 2000 study of teenagers in Minnesota reported that 13% of girls and 7% of boys reported disordered eating behavior.

When eating disorders occurs in young adults, men are more apt to conceal them, so the incidence among males may be underreported. One study of Navy men, for example, reported a prevalence of 2.5% for anorexia, 6.8% of bulimia, and 40% for binge eating. A 2001 study reported that the psychiatric and social profiles of men and women with eating disorders were very similar to each other, although profiles between men with eating disorders and men without were quite different. Sexual preference may affect the risk of specific eating disorders in men. One study reported that 42% of male civilians with bulimia reported that they were homosexual or bisexual while 58% of the men with anorexia were asexual.

Ethnic Factors

Most studies of individuals with eating disorders have been conducted using Caucasian middle-class females. Studies are now reporting, however, that minority populations, including Hispanic- and African-American, are significantly affected. There is some indication that African-American girls and young women may be at particular risk for eating disorders because of poor body images caused by cultural attitudes that denigrate the physical characteristics of minorities. In one study, bulimia was equally common among both Caucasian and African American women, although the latter were more likely to binge recurrently, to fast, and to use laxatives and diuretics to control weight. Binge eating may be an even more severe a problem in Hispanic Americans. A 2000 study on Asian women also reported rates of dieting and body dissatisfaction that were similar to those in other cultures, but Asian women had much lower percentages of actual eating disorders.

Socioconomic Factors

Living in any economically developed nation on any continent appears to pose more of a risk for eating disorders than belonging to a particular population group. Symptoms remain strikingly similar across high-risk countries.

Income Levels

Oddly enough, within developed countries there appears to be no difference in risk between the rich and the poor. Some studies suggest that those in lower economic groups may be at higher risk for bulimia.

Urban Life

City living is a risk factor for bulimia but it has no effect on risk for anorexia.

Intelligence

In one sample, people with eating disorders scored significantly higher than average on IQ tests. People with bulimia, but not anorexia, had higher nonverbal than verbal scores.

Excessively Physically Active People

Highly competitive athletes are often perfectionists, a trait common among people with eating disorders.

Women Athletes and Dancers

Women in "appearance" sports, including gymnastics and figure skating, and in endurance sports, such as track and cross-country, are at particular risk for anorexia. Success in ballet also depends on the development of a wiry and extremely slim body. Estimates for episodes of eating disorders among such athletes and performers range from 15% to over 60%.

Male Athletes

Male wrestlers and light-weight rowers are also at risk for excessive dieting. One-third of high school wrestlers use a method called weight-cutting for rapid weight loss. This process involves food restriction and fluid depletion using steam rooms, saunas, laxatives, and diuretics. Although male athletes are more apt to resume normal eating patterns once competition ends, studies are showing that the body fat levels of many wrestlers are still well below their peers during off-season and are often as low as 3% during wrestling season. Of concern is a recently recognized body-image disorder, referred to as muscle dysmorphia, that occurs mostly in men who are preoccupied with weight lifting and perceive themselves as puny.

Men and Women in the Military

Studies are also showing a higher-than-average risk for eating disorders in men and women in the military. A study of eating behavior on one Army base reported that 8% of the women had an eating disorder, compared to 1% to 3% in the civilian female population.

Vegetarians

Studies report that vegetarianism in adolescence is a risk factor for eating disorder in both males and females. In one study, while these teens appear to eat more fruits and vegetables, they are also twice as likely to diet frequently, four times as likely to intensively diet, and eight times as likely to use laxatives as their non-vegetarian peers. This study does not mean that being a vegetarian equals having an eating disorder. It does suggest, however, that parents with children who suddenly become vegetarian, should be sure their children are eating a balanced meal with sufficient calories. Anorexic behavior in vegetarians should be suspected under certain conditions:

If the person has stopped eating meat only to avoid fat rather than from other motives, such as love of animals. If vegetarian diet coincides with rapid weight loss.

If the person is avoiding certain foods, such as tofu, nuts, and dairy products, that contain oils or fats.

Young People with Diabetes or Other Chronic Diseases

According to one survey, 10.3% of teenage girls and 6.9% of boys with chronic illness, such as diabetes or asthma, had an eating disorder.

Diabetes. Eating disorders are particularly serious problems in people with either type 1 or type 2 diabetes. Binge eating (without purging) is most common in type 2 diabetes and, in fact, the obesity it causes may even trigger this diabetes in some people.
Both bulimia and anorexia are common in type 1 diabetes. Some experts report that one-third of insulin-dependent patients have an eating disorder, most often because diabetic women omit or underuse insulin in order to control weight. If such patients develop anorexia, their extremely low weight may appear to control the diabetes for a while. Eventually, however, if they fail to take insulin and continue to lose weight, these patients develop life-threatening complications.

Early Puberty

There is a greater risk for eating disorders and other emotional problems in girls who undergo early puberty, when the pressures experienced by all adolescents are intensified by experiencing, possibly alone, these early physical changes, including normal increased body fat. One interesting study reported the following:

Before puberty, girls ate quantities of food appropriate to their body weight, were satisfied with their bodies, and noted their depression increased with lower f ood intake. After puberty, girls ate about three-quarters of the recommended calorie intake, had a worse body self-image, and noted their depression increased with higher food intake.

This study was reporting on girls without eating disorders, but it certainly suggests patterns that can lead to eating problems, particularly in girls who go through puberty early.

WHAT CAUSES EATING DISORDERS?

There is no single cause for eating disorders. Although concerns about weight and body shape underlie all eating disorders, the actual cause of these disorders appear to result from a convergence of many factors, including cultural and family pressures and emotional and personality disorders. Genetics and biologic factors may also play a role.

Personality Disorders

A 2000 study reported that people with eating disorders tended to share similar personality traits, including low self-esteem, dependency, and problems with self-direction. Researchers have been attempting to determine specific personality disorders or behavioral characteristics that might put people at higher risk for one or both of the eating disorders. Some studies have reported the following personality disorders linked to particular eating disorders:

Avoidant personalities, mostly in anorexia. Such people are generally high functioning, persistent, and perfectionists. Dependent personalities, mostly seen in anorexia. (This group is usually overcontrolled and withdrawn.) Borderline and histrionic personalities, mostly seen in bulimia. (Such individuals are emotionally uncontrolled and impulsive.) Narcissism in both anorexia and bulimia. Should be noted that any of these personality traits can appear in either patients with bulimia or anorexia; some experts believe that the patient's specific personality disorders, rather than whether they are anorexic or bulimic, may be the more important factor in determining treatment choices.

Avoidant Personalities

Some studies indicate that as many as a third of anorexia restrictors have avoidant personalities. This personality disorder is characterized by the following: Being a perfectionist.
Being emotionally and sexually inhibited.
Having less of a fantasy life than people with bulimia or without an eating disorder.
Not being rebellious, or usually perceived as always being "good." Being terrified of being ridiculed or criticized or of feeling humiliated. People with anorexia are extremely sensitive to failure, and any criticism, no matter how slight, reinforces their own belief that they are "no good." The person with both anorexia and avoidant personality disorder may hypothetically develop a behavioral and eating pattern as follows:

For such individuals, achieving perfection, with all that that involves, is the only way to obtain love.

Part of the drive for perfection and love is being trouble-free and attaining some ideal image of thinness. The individual is driven to demand nothing, including food.

Failure is inevitable, since being loved by another person rarely has anything to do with being perfect. (In fact, people who are always seeking perfection can alienate others around them.)

Failure to achieve love is followed by a sense of being even more imperfect (which is equivalent to being fat) and a renewed sense of striving for perfection (ie, becoming even thinner).

Although people with eating disorders are not typically suicidal, one expert described her anorexic patients as having a total lack of self, well beyond having low self-esteem. The process of not-eating, then, becomes an act of passive revenge on those whose love is always out of reach: "See? I am slowly disappearing, and you will be very sad when I am gone."

Borderline Personalities

Studies indicate that almost 40% of people who are diagnosed with bulimic anorexia (who lose weight by bingeing and purging) may have borderline personalities. Such people tend to have the following characteristics:

Having unstable moods, thought patterns, behavior, and self-images. People with borderline personalities have been described as causing chaos around them by using emotional weapons such as temper tantrums, suicide threats, and hypochondriasis. Being frantically fearful of being abandoned. Being unable to be alone. Having difficulty controlling their anger and impulses. (In fact, between one-quarter and one-third of people with bulimia have impulsive symptoms.) Being prone to idealize other people. Frequently this is followed by rejection and by disappointment.

Some research has suggested that the severity of this personality disorder predicts difficulty in treating bulimia, and it might be more important than the presence of psychological problems, such as depression.

Narcissism

Studies have also found that people with bulimia or anorexia are often highly narcissistic and manifest the following personality traits:

Having an inability to soothe oneself.

Having an inability to empathize with others.

Having a need for admiration. Being hypersensitive to criticism or defeat.

Accompanying Emotional Disorders Between 40% and 96% of all eating-disordered patients experience depression and anxiety disorders. Depression, anxiety, or both is also common in families of patients with eating disorders. It is not clear if emotional disorders, particularly obsessive-compulsive disorder (OCD), are actual causes of the eating disorders, increase susceptibility to them, or share common biologic cause.

Obsessive-Compulsive Disorder (OCD)

Obsessive-compulsive disorder is an anxiety disorder that occurs in up to 69% of patients with anorexia and up to 33% of patients with bulimia. In fact, some experts believe that eating disorders are just variants of OCD. Obsessions are recurrent or persistent mental images, thoughts, or ideas, which may result in compulsive behavior, repetitive, rigid, and self-prescribed routines that are intended to prevent the manifestation of the obsession. Women with anorexia and OCD may become obsessed with exercise, dieting, and food. They often develop compulsive rituals, eg, weighing every bit of food, cutting it into tiny pieces, or putting it into tiny containers. The presence of OCD with either anorexia or bulimia does not, however, appear to have any effect on whether a patient improves or not.

Other Anxiety Disorders

A number of other anxiety disorders have been associated with both bulimia and anorexia. Phobias. Phobias often precede the onset of the eating disorder. Social phobias, in which a person is fearful about being humiliated in public, are common in both eating disorders.
Panic Disorder. Panic disorder often follows the onset of an eating disorder. It is characterized by periodic attacks of anxiety or terror ( panic attacks ). Post-Traumatic Stress Disorder. One study of 294 women with serious eating disorders reported that 74% of them recalled a traumatic event and more than half exhibited symptoms of post-traumatic stress disorder (PTSD), which is an anxiety disorder that occurs in response to violent circumstances.

Depression

Depression is common in people with eating disorders, particularly anorexia. Depression and eating disorders are also linked to a similar seasonal pattern, as indicated by the following observations:

In many people, depression is more severe in darker winter months. Similarly, a subgroup of bulimic patients suffers from a specific form of bulimia that worsens in winter and fall. Such patients are more apt to have started bingeing at an earlier age and to binge more frequently than those whose bulimia is more consistent year round. Onset of anorexia appears to peak in May, which is also the peak month for suicide.

Major depression is unlikely to be a cause of eating disorders, however, because treating and relieving depression rarely cures an eating disorder. The severity of the eating disorder is also not correlated with the severity of any existing depression. In addition, depression often improves after anorexic patients begin to gain weight.

Dysmorphic Disorder

Body dysmorphic disorder involves a distorted view of one's body that is caused by social, psychologic, or possibly biologic factors. It is often associated with anorexia or bulimia, but it can also occur without any eating disorder. People with this disorder also commonly suffer from emotional disorders, including obsessive-compulsive disorder and depression.

Muscle Dysmorphia

Experts are also increasingly reporting a disorder in which people have distorted body images involving their muscles. It tends to occur in men who perceive themselves as being "puny" and results in excessive body building, preoccupation with diet, and social problems.

Negative Family Influence

Negative influences within the family play a major role in triggering and perpetuating eating disorders. Some studies have produced the following observations and theories regarding family influence.

Insecure Infancy

Some experts theorize that parents who fail to provide a safe and secure foundation in infancy may foster eating disorders. In such cases, children experience so-called insecure attachments . They are more likely to have greater weight concerns and lower self-esteem than are those with secure attachments.

Parental Personalities

One study found that 40% of nine to 10 year-old girls try to lose weight generally with the urging of their mothers. Some studies have found that mothers of anorexics tend to be over-involved in their child's life, while mothers of people with bulimia are critical and detached. Some research strongly implicates overly critical fathers, brothers, or both in the development of anorexia in both girls and boys.

Family History of Addictions or Emotional Disorders

Studies report that people with either eating disorder are more likely to have parents with alcoholism or substance abuse than are those in the general population. Parents of people with bulimia appear to be more likely to have psychiatric disorders than parents of patients with anorexia.

History of Abuse

Women with eating disorders, particularly bulimia, appear to have a higher incidence of sexual abuse; studies have reported sexual abuse rates as high as 35% in women with bulimia.

Family History of Obesity

People with bulimia are more likely than average to have an obese parent or to have been overweight themselves during childhood.

At least one study has reported that the most positive way for parents to influence their children's eating habits and prevent weight problems and eating disorders is to have healthy eating habits themselves.

Problems Surrounding Birth
In some studies people with anorexia have reported a higher than average incidence of problems during the mother's pregnancy or after birth. These problems include the following:

Infection.
Physical trauma.
Seizures.
Low birth weight.
Older maternal age.

Some experts believe, then, that such patients experienced some injury to the brain while in the womb that predisposed them to eating problems in infancy and subsequent eating disorders later in life. Studies have suggested that people with anorexia often had stomach and intestinal problems in infancy.

Genetic Factors

Anorexia is eight times more common in people who have relatives with the disorder, and some experts estimate that genetic factors may influence more than half of the variances in eating disorders. For example, a 2000 study reported that twins had a tendency to share specific eating disorders (anorexia nervosa, bulimia nervosa, and obesity). Some evidence has reported an association with genetic factors responsible for serotonin, the brain chemical involved with both well-being and appetite. Some inherited traits that might make someone susceptible to eating disorders include the following:

A genetic propensity toward thinness caused by a faster metabolism and reinforced by cultural approval could predispose some people to develop anorexia. An inherited propensity for obesity could also trigger eating disorders to compensate.
Inherited personality traits also play some causal role.

Cultural Pressures

One interesting anthropologic study reported the following observations:

During historical periods or in cultures where women are financially dependent and marital ties are stronger, the standard is toward being curvaceous, possibly reflecting a cultural or economic need for greater reproduction.
During periods or in cultures where female independence has been possible, the standard of female attractiveness tends toward thinness.

hether or not the current Western cultural pressure is for fewer children, the response of the media to both the cultural drive for thinness and overproduction of food play major roles in triggering obesity and eating disorders. On the one hand, advertisers heavily market weight-reduction programs and present anorexic young models as the paradigm of sexual desirability. Clothes are designed and displayed for thin bodies in spite of the fact that few women could wear them successfully.

One study reported that teenage boys and girls who made strong efforts to look like celebrities of the same sex were more likely to be constant dieters. On the other hand, food is overproduced, and the media floods the public, and particularly women and children, with attractive ads for consuming foods, both at home and out of the home. And, the emphasis is on junk foods. In a country where obesity is epidemic, young women who achieve thinness believe they have accomplished a major cultural and personal victory; they have overcome the temptations of junk food and, at the same time, created body images idealized by the media. Weight loss brings a feeling of triumph over helplessness. This sense of accomplishment is often reinforced by the envy of heavier companions who perceive the anorexic friend as being emotionally stronger and more sexually attractive than they are.

Excessive Athleticism and the Female Athlete Triad. The cultural attitude toward physical activity is a fitting companion to the general disordered attitude regarding eating. Americans are encouraged to admire physical activity only as an intense competitive effort that few can attain, leaving most people in their armchairs as spectators.

In the small community of athletes, excessive exercise plays a major role in many cases of anorexia (and, to a lesser degree, bulimia). In young female athletes, anorexia postpones puberty, allowing them to retain a muscular boyish shape without the normal accumulation of fatty tissues in breasts and hips that may blunt their competitive edge. Many coaches and teachers compound the problem by overstressing calorie counting and loss of body fat. Some over-control the athletes' lives and are even abusive to an athlete that goes over the weight limit. (Male athletes are also vulnerable to their coaches' influence and anorexia is also a problem among this group.)

In response, people who are vulnerable to such criticism may lose excessive weight, which has been known to be deadly even for famous athletes. The term "female athlete triad" in fact, is now a common and serious disorder facing young female athletes and dancers and describes the combined presence of the following problems:

Eating disorders. Amenorrhea (absence or irregular menstruation). Evidence is mounting that overly restricting calories may be more important than low weight in causing menstrual problems. Studies suggest that amenorrhea occurs even in women with normal weight if they severely diet. Osteoporosis. Bone loss, on the other hand, appears to be related to low weight. The more severe the weight loss, the more bone is lost.

In one study, female athletes who consumed a high-fat diet (35% of daily calories) performed longer and with greater intensity than those with a standard athletic low-fat diet (27% of daily calories). And such a diet appeared to be more estrogen-protective.

Hormonal Abnormalities. Hormonal problems are rampant in eating disorders and include chemical abnormalities in the thyroid, the reproductive regions, and areas related to stress, well-being, and appetite. Many of these chemical changes are certainly a result of malnutrition or other aspects of eating disorders, but they also may play a role in perpetuating or even creating susceptibility to the disorders.

The primary setting of many of these abnormalities originate in a small area of the brain called the limbic system. A specific system called hypothalamic-pituitary-adrenal axis (HPA) may be particularly important in eating disorders. It originates in the following regions in the brain:

Hypothalamus. The hypothalamus is a small structure that plays a role in controlling our behavior, such as eating, sexual behavior and sleeping, and regulates body temperature, emotions, secretion of hormones, and movement.

The Pituitary Gland. The pituitary gland develops from an extension of the hypothalamus downwards. It is involved in controlling thyroid functions, the adrenal glands, growth and sexual maturation.

Amygdala. This small almond-like structure lies deep in the brain and is associated with regulation and control of major emotional activities, including anxiety, depression, aggression, and affection. Stress Hormones. The HPA systems trigger the production and release of stress hormones called glucocorticoids, including the primary stress hormone cortisol. Chronically elevated levels of stress chemicals have been observed in patients with anorexia and bulimia. Cortisol is very important in marshaling systems throughout the body (including the heart, lungs, circulation, metabolism, immune systems, and skin) to deal quickly with any threat. Among the specific effects is inhibition of neuropeptide Y (NPY), a powerful appetite stimulant that also has anti-anxiety properties. This process may serve as a biologic link between extreme stressful conditions in a young person's life and the later development of anorexia, although some imaging studies indicate that stress-hormone related changes occur after anorexia has developed. More work is needed to determine if changes in stress hormones are a cause or result of eating disorders.

Release of Neurotransmitters. The HPA system also releases certain neurotransmitters (chemical messengers) that regulate stress, mood, and appetite and are being heavily investigated for a possible role in eating disorders. Abnormalities in the activities of three of them, serotonin, norepinephrine, and dopamine, are of particular interest. Serotonin is involved with both well-being and appetite (among other traits), and norepinephrine is a stress hormone. Abnormalities in both have been observed in patients who binge and in those with anorexia or bulimia. Dopamine is involved in reward-seeking behavior, so deficiencies might create a more intense need for rewards, such as carbohydrates. Studies on dopamine abnormalities have been mixed, however.

Low-Leptin Levels. Leptin is a hormone that appears to trigger the hypothalamus to stimulate appetite, and low levels have been observed in people with anorexia and bulimia.

Low Reproductive HormonesThe hypothalamic-pituitary system is also responsible for the production of important reproductive hormones that are severely depleted in anorexics. Although most experts believe that these reproductive abnormalities are a result of anorexia, others have reported that in 30% to 50% of people with anorexia, menstrual disturbances occurred before severe malnutrition set in and remained a problem long after weight gain, indicating that hypothalamic-pituitary abnormalities precede the eating disorder itself.

Compensating for Mood Swings during Binge-Purging Cycles

Serotonin Imbalances. Low levels of serotonin have been observed not only in eating disorders but also in depression. One theory for the persistence of the binge-purge cycle in bulimia involves restoring serotonin imbalances and so improving mood. It involves the following:

Bingeing elevates tryptophan, a compound found in food, particularly carbohydrates, that is essential to the production of serotonin in the brain. People may binge then in order to produce serotonin and improve mood.An initial increase in tryptophan, however, produces depression in some people. Both events are consistent with a study on young people with bulimia who reported negative moods before and even worse moods right after bingeing. Such depression may become associated with guilt over bingeing and therefore the need to purge. Right before and after a purge cycle, however, studies report an improvement in mood, which might indicate the delayed increase in serotonin triggered by the tryptophan. The heightened mood after the purge cycle may be due to stimulation of natural opioids that occur during this process.
The binge-purge cycle then might be stimulated by chemical changes and perpetuated by feelings of guilt and depression after bingeing and release from guilt and euphoria during and after purging. Infections In some cases, infection has been associated with anorexia. Immune factors released to fight these infections may cause inflammation and injury in the areas of the brain that affect appetite and behavior. Streptococcal Infection. Research has found a link between anorexia and group A beta-hemolytic streptococcal (GABHS) bacteria, the cause of strep throat. GABHS has already been identified as a trigger of a rare form of obsessive-compulsive disorder (OCD) in children, which often accompanies eating disorders. Epstein Barr. Epstein Barr, the virus that causes mononucleosis has also been associated with the development of anorexia.

Chances for Recovery

Some studies have suggested that between 60% and 80% of patients are in remission within three months of treatment. However, relapse is common and up to half of women with bulimia continue to battle disordered eating habits for years, with bulimia itself persisting in 10% to 25% of patients. Medical

Consequences

In general, there are few major health problems for bulimic people who maintain normal weight and do not go on to become anorexic. For example, one study comparing adolescents with anorexia and bulimia reported abnormal heart rhythms in patients with anorexia but not in those with bulimia. It should be noted, however, that in one study of bulimic patients undergoing therapy, after six years the mortality rate was 1%. Those who have both bulimia and anorexia, however, are in great danger.

And, the disorder, even without anorexia, is not without health problems and serious risks. The following are medical problems associated with bulimia:

Teeth erosion, cavities, and gum problems. Water retention, swelling, and abdominal bloating.

Occasionally, fluid loss with low potassium levels. This occurs from excessive vomiting or laxative use. In severe cases it can cause extreme weakness, near paralysis, or lethal heart rhythms.

Acute stomach distress.

Problems in swallowing. This is an area of possible concern because of repetitive assaults on the esophagus (the food pipe) from forced vomiting. It is not clear, however, if this problem is common.

Rupture of the esophagus, or food pipe. (Cases have been reported with forced vomiting but are not common.) Weakened rectal walls. In rare cases, walls may weaken to the extent that they protrude through the anus. This is a serious condition that requires surgery. Most pregnant women with a history of eating disorder have healthy pregnancies, although they face higher risks for a number of complications, including cesarean sections, postpartum depression, miscarriages, and complicated deliveries. Their babies may also have a higher risk for low birth weight, prematurity, and malformation. Irregular periods. (It should be noted that menstrual irregularities in patients with bulimia do not have the serious effects, particularly bone loss, as they do in patients with anorexia.)

Self-Destructive Behavior

A number of self-destructive behaviors occur with bulimia:

Smoking. Many teenage girls with eating disorders smoke because it is thought to help prevent weight gain. Impulsive Behaviors . Women with bulimia are at higher-than-average risk for dangerous impulsive behaviors, such as sexual promiscuity, self-cutting, and kleptomania. Some studies have reported such behaviors in half of those with bulimia.

Alcohol and Substance Abuse. An estimated 30% to 70% of patients with bulimia abuse alcohol, drugs or both. This rate is higher than for the general population and in people with anorexia. It should be noted, however, that this higher rate of substance abuse may be a distortion, because studies are conducted only on diagnosed patients. Bulimia tends not to get diagnosed. And, reports of bulimia in the community (where the incidence of the eating disorder is higher than statistics suggest) indicate that substance abuse is actually lower than in people with anorexia.

Abuse of Over the Counter Medications. Women with bulimia frequently abuse over-the-counter medications, such as laxatives, appetite suppressants, diuretics, and drugs (e.g., ipecac) that induce vomiting. None of these drugs is without risk. For example, ipecac poisonings have been reported, and some people become dependent on laxatives for normal bowel functioning. Diet pills, even herbal and over-the-counter medications, can be hazardous, particularly if they are abused.

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HOW SERIOUS IS ANOREXIA NERVOSA?

Chances for Recovery

At this time no treatment program for anorexia nervosa is completely effective, and about 50% of patients never achieve a normal weight. Many still display traits characteristic of the disorder, including perfectionism and a drive for thinness, that could keep them at risk for recurrence of the eating disorder. Even in those who recover, one study indicated that recovery took between four and nearly seven years. Risk

Factors for Early Mortality

Studies of anorexic patients have reported death rates ranging from 4% to 25%. According to different studies, the risk for early death is higher in the people with the following conditions or characteristics:

Being younger. Having bulimia anorexia. (The mortality rate is twice as high in this group than in the anorexic-restrictor types.) Being severely low in weight at the time of treatment. Being sick for more than six years. Having been previously obese. Having personality disorders. Having an accompanying severe psychological disorder. Having a dysfunctional marriage. Being male. (The higher risk for life-threatening medical problems in males may be due their tendency to be diagnosed with anorexia later than women are.)

Suicide

Suicide has been estimated in some studies to account for as many as half the deaths in anorexia. In one study, suicide rates occurred in 1.4% of women with anorexia. The study, however, only looked at female death records. Such records may not have always recorded anorexia as an accompanying condition, so the incidence of suicide in anorexia may be much higher.

Heart Disease

Heart disease is the most common medical cause of death in people with severe anorexia. The effects of anorexia on the heart are as follows:

Dangerous heart rhythms, including slow rhythms known as bradycardia, may develop. Such abnormalities can show up even in teenagers with anorexia. Blood flow is reduced. Blood pressure may drop. The heart muscles starve, losing size. Cholesterol levels tend to rise.

A primary danger to the heart is from abnormalities in the balance of minerals, such as potassium, calcium, magnesium, and phosphate, which are normally dissolved in the body's fluid. The dehydration and starvation that occurs with anorexia can reduce fluid and mineral levels and produce a condition known as electrolyte imbalance . Electrolytes of calcium and potassium are critical for maintaining the electric currents necessary for a normal heart beat. An imbalance in these electrolytes, then, can be very serious and even life-threatening unless fluids and minerals are replaced. Heart problems are a particular risk when anorexia is compounded by bulimia and the use of ipecac, a drug that causes vomiting.

Medical Consequences of Hormonal Changes
Anorexia has a number of hormonal effects that can have severe health consequences:

Reproductive hormones are lower.
Thyroid hormones are lower.
Stress hormones are higher.

Growth hormones are lower. Children and adolescents with anorexia may experience retarded growth.

The result of many of these hormonal abnormalities in women is long-term, irregular or absent menstruation (amenorrhea). This can occur early on in anorexia, even before severe weight loss. Over time this causes infertility and bone loss. Low weight alone may not be sufficient to cause amenorrhea. Extreme fasting and purging behaviors may play an even stronger role in hormonal disturbance.

Long-Term Outlook on Fertility

After treatment and weight increase, estrogen levels are usually restored and periods resume. In severe anorexia, however, even after treatment, normal menstruation never returns in 25% of such patients. If a woman with anorexia becomes pregnant before regaining normal weight, she faces a higher risk for miscarriage, cesarean section, and for having an infant with low birth weight or birth defects. She is also at higher risk for post partum depression. Women with anorexia who seek fertility treatments have lower chances for success.

Long-Term Effect on Bones

Loss of bone minerals (osteopenia) and loss of bone density (osteoporosis) is a common result of low estrogen levels in women with anorexia. Bone loss in such women may also be worsened by low calcium levels and by higher levels of stress hormones (which impair bone growth). Up to two-thirds of children and adolescent girls with anorexia fail to develop strong bones during their critical growing period. The less the patient weighs, the more severe the bone loss. Women with anorexia who also binge-purge face an even higher risk for bone loss.

Weight gain, unfortunately, does not restore bone. Only achieving regular menstruation as soon as possible can protect against permanent bone loss. The longer the eating disorder persists the more likely the bone loss will be permanent.

Neurological Problems People with severe anorexia may suffer nerve damage that affects the brain and other parts of the body. The following nerve-related conditions have been reported:

Seizures. Disordered thinking. Numbness or odd nerve sensations in the hands or feet (a condition called peripheral neuropathy).

Brains scans indicate that parts of the brain undergo structural changes and abnormal activity during anorexic states. Some of these changes return to normal after weight gain, but there is evidence that some damage may be permanent. Still, the extent of the neurologic problems is unclear, and some studies have been unable to determine specific mental problems associated with anorexia.

Blood Problems Anemia is a common result of anorexia and starvation. A particularly serious blood problem is pernicious anemia, which can be caused by severely low levels of vitamin B12. If anorexia becomes extreme, the bone marrow dramatically reduces its production of blood cells, a life-threatening condition called pancytopenia.

Gastrointestinal Problems

Bloating and constipation are both very common problems in people with anorexia.

Multiorgan Failure

In very late anorexia, the organs simply fail. The main signal for this is elevated levels of liver enzymes, which require immediate administration of calories.

Diabetic Adolescents

Eating disorders are very serious in young people with type 1 diabetes. The complications of anorexia that affect all patients are even more dangerous in this group of patients. Hypoglycemia, or low blood sugar, for example, is a danger in anyone with anorexia, but it is a particularly dangerous risk in those with diabetes. One study found that 85% of young women with diabetes and eating disorders had retinopathy, damage to the retina in the eye, which can lead to blindness.

Drug and Alcohol Abuse

Some studies estimate that between 12% and 18% of people who are anorexic also abuse alcohol or drugs.

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WHAT ARE THE SYMPTOMS OF EATING DISORDERs

Distorted Body Image

Possibly the most bewildering symptom of both eating disorders is the distorted body image ( body dysmorphia ). Although people typically associate distorted body image with severe anorexia, one study indicated that distortion may be more prevalent in people with bulimia. People with bulimia were more likely than those with anorexia to overestimate their size. There was also a greater disparity between what they wanted to look like and what they believed they looked like. In another study, people with anorexia tended to have an accurate perception of their upper body, but overestimated the size of their abdominal and pelvic area. Symptoms

Specific to Bulimia without Anorexia

People with bulimia nearly always practice it in secret, and, although they may be underweight, they are not always anorexic. Symptoms or signs of bulimia, then, may be very subtle and go unnoticed. They may include the following:

Evidence, such as discarded packaging, of laxatives, diet pills, emetics (drugs that induce vomiting), or diuretics (medications that reduce fluids). Regularly going to the bathroom right after meals. Suddenly eating large amounts of food or buying large quantities that disappear right away. Compulsive exercising. Broken blood vessels in the eyes (from the strain of vomiting). Swollen salivary glands. These occur within days of vomiting in about 8% of people with bulimia. They often give a pouch-like appearance to areas below the corners of the mouth.

Dry mouth

Teeth develop cavities, diseased gums, and irreversible enamel erosion from excessive acid. (Gargling with baking soda after purging rather than using toothpaste may help neutralize the acid.)

Rashes and pimples.

Small cuts and calluses across the tops of finger joints. (These cuts can occur from repeated self-induced vomiting, in which a person thrusts the hand down the throat past the front teeth.)

Symptoms Specific to Anorexia

Weight Loss

The primary symptom of anorexia is major weight loss from excessive and continuous dieting, which may either be restrictive dieting or binge-eating and purging. Note. Young women who have both diabetes and eating disorders may have normal weight or even be overweight from the effects of insulin. However, they still are at high risk from the medical consequences of anorexia.

Other Symptoms

Other symptoms may include the following:

In women, menstruation may be infrequent or absent. Often, compulsive exercising coupled with emaciation leads to orthopedic problems, particularly in dancers and athletes. Such problems, in fact, may be the first sign of trouble that forces such patients to seek medical help. Refusal to eat in front of others. Ritualistic eating, including cutting food into small pieces. Hypersensitivity to cold. (In fact, some women wear several layers of clothing to both keep warm and hide their thinness.) Yellowish skin, especially on the palms of the hands and soles of the feet. (This occurs in people eating too many vitamin A-rich vegetables, such as carrots.) The skin may be dry and covered with fine hair. Normal scalp hair may be thin. The feet and hands may be cold or sometimes swollen. The stomach is often distressed and bloated after eating. Thinking may be confused or slowed, and an anorexic patient may have poor memory and lack judgment.

Admitting the Problem

The first step toward a diagnosis is to admit the existence of an eating disorder. Often, the patient needs to be compelled by a parent or others to see a doctor because the patient may deny and resist the problem. Some patients may even self-diagnose their condition as an allergy to carbohydrates, because after being on a restricted diet, eating carbohydrates can produce gastrointestinal problems, dizziness, weakness, and palpitations. This may lead such people to restrict carbohydrates even more severely.

It is often extremely difficult for parents as well as the patient to admit that a problem is present. For example, because food is such an intrinsic part of the mother/child relationship, a child's eating disorder might seem like a terrible parental failure. Parents themselves may have their own emotional issues with weight gain and loss and perceive no problem in having a "thin" child.

Interview Tests

It is recommended that a supportive companion be present during part of the initial medical interview to offer additional information on the patient's eating history and to help offset any resistance or denial the patient may express.

Various questionnaires are available for assessing patients. For example, a brief British test called the SCOFF questionnaire is proving to be very reliable in accurately identifying people who are at high risk for either eating disorder.

SCOFF Questionnaire

S Do you feel Sick because you feel full?

C Do you lose Control over how much you eat?

O Have you lost more than One stone (about 13 pounds) recently?

F Do you believe yourself to be Fat when others say you are thin?

F Does Food dominate your life?

Answering yes to two of these questions is a strong indicator of an eating disorder.

Diagnosing Bulimia Nervosa

In spite of the prevalence of bulimia, in one study only 30% of Midwest family physicians had ever diagnosed bulimia in a patient. Younger and female physicians are more likely to detect bulimia. A physician should make a diagnosis of bulimia if there are at least two bulimic episodes per week for three months. Because people with bulimia tend to have complications with their teeth and gums, dentists could play a crucial role in identifying and diagnosing bulimia.

Diagnosing Anorexia Nervosa

Generally, an observation of physical symptoms and a personal history will quickly confirm the diagnosis of anorexia. The standard criteria for diagnosing anorexia nervosa are:

The patient's refusal to maintain a body weight normal for age and height. Intense fear of becoming fat even though underweight. A distorted self-image that results in diminished self-confidence. Denial of the seriousness of emaciation and starvation. In women, the loss of menstrual function for at least three months.

The physician then categorizes the anorexia further:

Restricting (severe dieting only). Anorexia bulimia (binge purge behavior).

Because the disorder rarely shows up in men, physicians may not be on the look out for it in male patients, even if they show classic symptoms of anorexia. Physicians should be very aware of these symptoms in anyone, particularly in athletes and dancers.

Diagnosing Complications of Eating Disorder Once a diagnosis is made, physicians should immediately check for any serious complications of starvation. They should also rule out other medical disorders that might be causing the anorexia. Tests should include the following:

A complete blood count.

Tests for electrolyte imbalances. Low potassium levels indicate that the disorder is more likely to be accompanied by the binge-purge syndrome.

Test for protein levels.

An electrocardiogram and a chest x-ray.

Tests for liver, kidney, and thyroid problems.

A bone density test.

In the United States, conservative estimates indicate that after puberty, 5-10 million girls and women and 1 million boys and men are struggling with eating disorders including anorexia, bulimia, binge eating disorder, or borderline conditions.

The Prevalence of Eating Disorders

Because of the secretiveness and shame associated with eating disorders, many cases are probably not reported. In addition, many individuals struggle with body dissatisfaction and sub-clinical disordered eating attitudes and behaviors. For example, 80% of American women are dissatisfied with their appearance (Smolak, 1996). The Drive for Thinness
42% of 1st-3rd grade girls want to be thinner (Collins, 1991). 81% of 10 year olds are afraid of being fat (Mellin et al., 1991). The average American woman is 5�4" tall and weighs 140 pounds. The average American model is 5�11" tall and weighs 117 pounds. Most fashion models are thinner than 98% of American women (Smolak, 1996).

Dieting

51% of 9 and 10 year-old girls feel better about themselves if they are on a diet (Mellin et al., 1991). 46% of 9-11 year-olds are "sometimes" or "very often" on diets, and 82% of their families are "sometimes" or "very often" on diets (Gustafson-Larson & Terry, 1992). 91% of women recently surveyed on a college campus had attempted to control their weight through dieting, 22% dieted "often" or "always" (Kurth et al., 1995). 95% of all dieters will regain their lost weight in 1-5 years (Grodstein, 1996). 35% of "normal dieters" progress to pathological dieting. Of those, 20-25% progress to partial or full-syndrome eating disorders (Shisslak & Crago, 1995).

25% of American men and 45% of American women are on a diet on any given day (Smolak, 1996).

Americans spend over $40 billion on dieting and diet-related products each year (Smolak, 1996).

Distorted Body Image
Intense fear of gaining weight
Feelings of guilt after eating
Is already thin and weight is still dropping
Cessation of a period for three consecutive cycles
Counts every calorie and fat gram that is eaten
Paleness, dizziness, or fainting spells
Intense, dramatic mood swings
Excessively and compulsively exercises
Complaints of being cold
Hair loss
A high need for control
Wearing loose clothing
Exhaustion and Fatigue
Hiding food in napkins, under beds, in drawers, etc.
Abuse of laxatives, diet pills, or diuretics Very poor self-esteem
Never eats around others

The individual is constantly complaining about being "fat," "obese" or "huge."
The individual is very preoccupied with weight, counting calories and fat grams, and dieting.
The individual is drained and has little energy.
The individual has begun wearing extremely loose fitting clothing.
The individual comes up with new found excuses not to eat such as, "I already ate and I have an upset stomach."
The individual is extremely defensive about his/her weight.
The individual is often cold.
The individual often cooks or bakes food for other people, but refuses to eat the food themselves.
The individual has started growing fine facial and body hair-a type of fur (lanugo).
The individual is extremely irritable and has dramatic mood swings.
The individual tends to isolate in social situations or avoid social gathering.
The individual consumes a lot of non-caloric foods such as diet soda, gum, etc.
The individual's hair is falling out and/or becoming extremely dry and brittle.
The individual often withdraws from touching others
The individual avoids restaurants and eating in front of others.
The individual's complexion has become pale and his/her skin is extremely dry.
When the individual looks in the mirror, his/her reflection is like a "funhouse" mirror. (Distorted)
Meal times have become extremely ritualistic- e.g. the individual will insist on eating in the same bowl, he/she will cut their food into tiny pieces, he/she will not let the articles of food on the plate touch one another, he/she will keep on moving food around the plate to make it appear as if something has been eaten, etc.
The individual uses excessive laxatives, diuretics, or diet pills to control weight.

Bingeing and Purging
Secretive Eating- Missing Food
Severe self-criticism
Feelings of guilt after eating
Visits to the bathroom after meals
Weight fluctuations (10-20 lbs.)
Tooth decay
Avoids eating in public, in front of others
Swollen glands in neck & puffiness in cheeks
Excessive and compulsive exercise regimes
Constant sore throat
Increased promiscuous attitude
Feels like he/she has no control over food
Wearing tight clothing
Broken blood vessels in eyes
Poor impulse control- i.e. drugs, alcohol, spending,mood, etc.
Abuse of laxatives, diet pills, ipecac, and/or diuretics
Very poor self-esteem

The individual often goes to the restroom right after meals and remains for an extended period of time.
The individual feels like he/she does not have control over food.
The individual hides food in secret locations for use during binges.
The individual eats a great deal but does not seem to gain or lose a lot of weight.
The individual takes laxatives and gives himself/herself enemas more than once a week. The individual constantly complains about being "fat," "obese," or "huge."
The individual has blood shot eyes.
The individual eats nothing or very little in front of others, and then binges in private. Quantities of food seem to mysteriously disappear from their refrigerator and/or pantry.
The individual tends to have swollen glands in his/her neck and/or face.
The individual has scrape wounds on the back of her/his knuckles (due to the contact between knuckles and teeth to induce vomiting).
The individual abuses Ipecac Syrup, laxatives, diuretics, and/or diet pills.
The individual has started to excessively drink, smoke, abuse drugs, or spend money.
The individual is extremely defensive when questioned about his/her weight.
The individual's tooth enamel is eroding and has increased cavities.
The individual has begun to wear extremely tight fitting, figure revealing clothes.
The individual will go through times of dramatic weight fluctuations of ten pounds or more within a short period of time.
The individual tends to be sexually overactive, even quite promiscuous.
The individual takes numerous trips to grocery stores, convenience stores, etc. in a single day.
The individual has an enormous preoccupation with body weight and food.
The individual is constantly complaining of a sore throat.
The individual alternates between eating massive quantities of food and periods of self-starvation.