Anorexia Nervosa and Bulimia Nervosa

Anorexia and Bulimia have become widely recognized by health professionals and mainstream society. While this recognition has increased prevention and intervention, it may have also intensified the secretiveness of these eating disorders among those suffering from them. Prevalence has been increasing and over 8 million people are estimated to have either anorexia, bulimia or a combination of both.

What Are They?

Eating disorders are characterized by significant disturbances in eating behavior. ANOREXIA is diagnosed when a person refuses to maintain a normal body weight or is unable to stop losing weight; is intensely fearful of gaining any weight even if underweight; sees oneself as fat even when underweight; and in women, when menstrual periods stop occurring.

Extreme weight loss occurs because one "feels fat," so strictly reduces food intake and usually exercises excessively in order to burn off "extra" calories. Often times, people with anorexia cannot maintain the caloric restriction they believe they "should" in order to prevent weight gain so will turn to laxatives, diet pills and/or diuretics.

BULIMIA is similar to anorexia in that people with bulimia also have an extreme fear of fat and an excessive concern with body shape and weight. The difference between the two disorders is that bulimics engage in bingeing and purging. A "binge" is defined as the rapid consumption of large amounts of food within a short period of time. During the binge there is the distinct feeling of being out of control and unable to stop the eating episode. Because a binge creates such physical discomfort, some form of "purging" usually follows to relieve that discomfort and prevent weight gain. Vomiting is the most commonly known form of purging. Less recognized, but equally as prevalent forms of purging include laxative abuse, diuretic abuse, excessive exercise and strict dieting. For the bulimic, the purpose of purging is to get rid of all the calories consumed during the binge in order to prevent weight gain.

Why Do They Happen?

Those with eating disorders believe their only problem is that they are fat and need to lose weight. Working from that frame of reference, their thoughts become totally consumed with dieting, calories, the number on the scale, how much they can exercise, how to hide their very thin bodies or their shameful bingeing and purging behaviors so others do not find out, etc.

Why would someone become so consumed with their weight? When the majority of time is spent obsessing about food, weight and exercise, there is no time to think about problems or feelings. Many people with eating disorders have low self-esteem even though they are high achievers, may have experienced some form of sexual or other trauma during their lifetime, suffer from other emotional problems such as depression or anxiety, may come from dysfunctional families and generally feel out of control in various aspects of their lives.

Because feelings associated with the above problems are often times debilitating and create the sense of being out of control, body weight is focused on as something that can be controlled. People with eating disorders believe that if they could just lose 5 more pounds they would he happier, more successful, accepted by others, etc. Everything in their lives eventually becomes contingent on what they weigh. The ironic aspect about eating disorders is that in the attempt to gain control by manipulating food and exercise, the more out of control the rest of their life becomes.

In 2009, the Academy for Eating Disorders (AED) determined that there was a reasonable degree of medical or scientific certainty (meaning, it is more likely than not) that eating disorders are biologically based, serious mental illnesses. The AED is the largest international organization of eating disorder scientists and clinical specialists in the world. It has affirmed that emerging science shows that eating disorders have a significant genetic influence; are affected by changes in brain function (related to malnourishment); greatly impair thinking, judgment and emotional stability; and restrict the life activities of those affected by these illnesses.

AED's position supports that anorexia nervosa, bulimia nervosa and variants of these disorders are the result of genetic, biological and personality vulnerabilities that interact with environmental stressors and increase a person's risk for developing an eating disorder. As biologically based mental illnesses, eating disorders warrant the same level and breadth of health care coverage afforded to other conditions currently defined this way, including depression, bipolar disorder, obsessive compulsive disorder and schizophrenia. The AED position paper entitled "Eating Disorders Are Serious Mental Illnesses" can be found in the March 2009 issue of the International Journal of Eating Disorders.

The Effects of Starvation

For those who are truly overweight, the typical diet prescription is to decrease caloric intake and increase energy expenditure; in other words, eat less and exercise more. When this prescription is taken to the extreme by one who is of normal weight or underweight, the opposite effect of what is expected eventually occurs. It is expected that by eating fewer calories and by exercising to burn calories, body fat will be eliminated. However, when the body is malnourished or in a state of starvation, the first thing to be metabolized is muscle tissue and the last thing metabolized is fat. This means that excessive diet, exercise and/or purging forces the body to literally metabolize, or eat, itself because it is not receiving any fuel or food. Anorexics and bulimics often state that all they see on their bodies is fat. While this perception is primarily due to body image distortion, there is some truth to it because muscle mass will deteriorate and there will be less muscle tone to give their bodies shape.

Eating disordered behaviors are further reinforced when an attempt is made to eat normally again. Because the body is in a state of starvation, the metabolic rate drops, the body stores whatever fuel it is given, and weight gain occurs. This is interpreted as "If I eat I will keep gaining weight and never stop, so I just won't eat." In reality, it is actually very difficult to gain weight when a person is underweight. When a person with anorexia increases their dietary intake, the metabolism speeds up, uses the calories to repair the body and keeps burning. In the process of recovery, a person often has to eat more than normal to stay ahead of their metabolism and prevent weight loss. When the body recognizes it is receiving regular and consistent nutrition, the metabolic rate will even out and weight gain will stabilize when the normal weight range is reached.

Medical and Physical Problems

In addition to the physical changes are the physiological consequences of eating disorders, many of which are life threatening. Because the heart is a muscle, it too deteriorates when the body is starved, thereby increasing the risk of cardiac arrhythmias and arrest. Other common problems include dehydration, dizziness, fainting, muscle weakness, abdominal pain, swollen glands, liver and kidney failure and always feeling cold no matter what the temperature.

The malnutrition caused by eating disorders intensifies irritability, mood swings and the inability to concentrate as well as depression and anxiety. This can create problems at work and in other relationships, thereby impeding the happiness and success the thin body is expected to attract. This cycle sets the eating disordered person to strive for more weight loss. They believe they are having difficulties because they just have not lost enough weight and are still too fat. They do not recognize they are having difficulties because they have lost too much weight and are barely functioning physically or mentally.

Getting Help For Anorexia and Bulimia

The treatment of eating disorders is very challenging. It is usually long-term because treatment is often not sought until the condition has been in existence for several years. Additionally, one must relearn how to deal with food in an adaptive manner, overcome the notion that food is the enemy and increase their eating in a culture that constantly screams "diet."

In addition to focusing on normal eating, underlying emotional issues must also be addressed. The typical phrase "Nothing is wrong with me, I just feel fat" is challenged because "fat" is not a feeling. "Feeling fat" comes to be a more tolerable way of avoiding the intolerable feelings of depression, guilt, anger, fear, shame, loneliness, powerlessness, self-loathing, etc.

While the attempt is to avoid these kinds of emotions, ironically, the secretiveness of eating disordered behaviors exacerbates them and the anorexic or bulimic unknowingly intensifies all the feelings they are seeking to escape. Clearly, controlling food is not the underlying problem, but rather the way internal conflicts are manifested.

If you recognize eating disordered behaviors in someone you know, do not ignore the problem -- it will not go away, it will only get worse. Talk to the person about the specific behaviors and changes you have seen. Help the person find a psychologist or therapist who specializes in treating eating disorders -- ask about their specific training, credentials, experience and treatment methods. Many therapists will claim they treat eating disorders, but often have no training and are not qualified to treat these complex and difficult disorders.

Warning Signs:

• Rapid or extreme weight loss
• Continued dieting even though under normal weight
• Preoccupation with food, weight, calories, exercise
• Excessive concern about appearance and body image
• Distorted eating patterns: Skipping meals, eating in secret, ritualistic eating behaviors, strict dieting
• Excessive exercising
• Disappearing to the restroom after every meat
• Feeling sick or bloated after eating a normal meal
• Perfectionism; rigid, inflexible routines
• Withdrawal from friends and activities
• Low self-esteem
• Change in personality
• Mood swings
• Manipulative, sneaky behaviors
• Wearing baggy clothes to hide the body
• Overeating with no weight gain
• Loss of menstrual periods
• Refusal to eat with others or attend social events