WHAT IS IT?
Eating disorders are psychological disturbances related to body image and eating habits.
Anorexia nervosa and bulimia nervosa are the two primary eating disorders recognized today.
Anorexia nervosa is a potentially life threatening condition characterized by an obsessive level of concern over one's body weight, specifically the fear of appearing fat.
As a result, people with this disorder will rigidly restrict their dietary intake, are markedly underweight and often suffer from malnutrition.
Frequently, the individual will abuse laxatives or deliberately cause vomiting in an effort to avoid what are seen as excess calories.
They may exercise excessively. Regardless of how thin they actually are, their self-image is greatly distorted.
So, even though these individuals may appear emaciated to others, in their mind's eye, they see themselves or parts of their body as grossly overweight.
Even when the condition is brought to their attention, there is little or no change in eating habits until failing health finally forces medical attention.
In other words, a major feature of eating disorders is denial; while the problem is painfully evident to those around them, the afflicted individual is blind to it.
Bulimia nervosa is a closely related condition that is characterized by "binge" eating episodes followed by compensatory measures to avoid weight gain.
Usual measures include dieting, purging (self-induced vomiting), laxative and diuretic abuse, or in some cases, excessive exercise.
Unlike anorexia nervosa, most individuals are of normal or near normal weight and, in some cases, may even be or have been somewhat overweight.
Again, body image is distorted and there is a preoccupation with physical appearance.
There are also a number of potentially serious health hazards including malnutrition, blood salt (electrolyte) imbalances, esophageal ulcers or rupture, and rampant dental decay.
In general, both of these conditions predominantly afflict adolescent and younger adult females.
It is about ten times more common in women than in men. These are serious, life threatening conditions that are difficult to treat.
HOW IS IT DIAGNOSED?
History: The diagnosis is based largely on history, but laboratory and physical examination data may be used to support the diagnosis, particularly when the individual is believed to be trying to hide the disorder from others. This is not so rare as it might seem; these illnesses most frequently affect individuals with poor self-esteem who may also be in denial of their illness. The critical elements under DSM-IV necessary to make the diagnosis of anorexia nervosa are: body weight is less than 85% of what is normal for age, sex, and height; an intense fear of becoming fat or gaining weight; disturbed body image and/or denial of the problem, and in women of childbearing age, loss of menstrual cycling due to malnutrition. Binge eating and purging (or similar compensatory measures) may be present. Bulimia nervosa is diagnosed when the following symptoms are present: repeated episodes of excessive eating and loss of control over what is consumed, repeated compensatory efforts to prevent weight gain from these food binges, both of the above occur at least twice a week for three months, self-esteem is too dependent on perceived body shape, and anorexia nervosa is not the only problem.
An unspecified eating disorder refers to any condition similar to the above, but which fails to meet all of the criteria. Examples would include anorexia nervosa where menstrual cycling still occurs, or purging after even small meals.
Physical exam: In these conditions, there may be prominent physical signs that point to the diagnosis. Because both of these conditions are potentially life threatening, good medical care including frequent physical exams, is important.
Tests: Not only is laboratory testing useful in making the diagnosis, but the presence of complications such as blood salt imbalances, hormonal disturbances, heart problems, and dehydration can also be monitored with frequent laboratory testing. Another useful aspect of testing is to monitor compliance with treatment recommendations and relapse. Blood bicarbonate and amylase levels are particularly useful here.
HOW IS IT TREATED?
Any number of treatment approaches have been tried with moderate success. The more successful treatments involve multiple disciplines and include behavioral modification, psychotherapy, and careful medical attention. Occasionally, medications are helpful. Typically, treatment is carried out over months to years. In severe cases, inpatient treatment may be necessary. Medical complications may require hospitalization.
WHAT MIGHT COMPLICATE IT?
There are any number of severe complications, many of them serious. Those seen more commonly in anorexia are absence of menstrual cycling and other glandular problems, malnutrition, and severe imbalances in blood chemistry, which can cause irregular heartbeat, seizures, coma, and death. Muscle wasting, kidney failure, problems due to poor liver function and superior mesenteric artery syndrome are other possible complications, as well as significant weight loss to less than 75% of normal, which is a very dangerous condition and can lead to medical hospitalization. Bulimics also run the risk of severe blood chemistry imbalances and the associated complications as well as rupture of the stomach or esophagus and advanced dental decay.
Depression, irritability,
insomnia, and generally poor mental functioning are some of the more common psychological complications. These disorders share in common many features of drug and
alcohol abuse, so it is not surprising that these illnesses often co-occur in these individuals. This vastly complicates treatment as the individual "trades" addictions.
PREDICTED OUTCOME
Over a five-year span, approximately one-third of individuals will have a complete or near complete remission of their symptoms, one-third will show significant improvement, while the remaining one-third either fail to improve or deteriorate. Mortality is significant. Anorexia nervosa has a mortality rate of four or five percent, but some studies place it as high as twenty percent. Because these disorders are usually quite complicated, it is difficult to predict the outcome. Generally, the younger the age at which the symptoms appear, the poorer the prognosis.
ALTERNATIVES
Two of the more common psychiatric syndromes that may be mistaken for these eating disorder are depression and
schizophrenia. Another psychiatric illness often present, as well, is that of
obsessive-compulsive disorder.
Borderline personality disorder may have many of the same behaviors. Generally, a good history taken by a trained psychiatrist is sufficient to exclude these other conditions. Physical causes such as brain tumors and other types of cancer, infections, and glandular problems need to be excluded through physical and laboratory tests.
APPROPRIATE SPECIALISTS
Psychiatrist, psychologist, or other licensed mental health worker, registered dietitian, nurse practitioner, and internist.