Anorexia Nervosa and Bulimia Nervosa

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Eating disorders are chronic and severe illnesses with some of the highest rates of morbidity and mortality of all psychiatric disorders. Although eating disorders can develop in males and females at any age, they are most common among adolescent girls and young women, with average prevalence rates of 0.3% for anorexia nervosa and 1% for bulimia nervosa in young females (Hoek HW, Curr Opin Psychiatry 2006;19(4):389–394).

Despite their severity, eating disorders are often trivialized and minimized in popular culture. The influence of the media on the pursuit of thinness has prevailed, which may contribute to both onset and severity of illness (Herpertz-Dahlmann B, Child Adolesc Psychiatr Clin N Am 2009;18(1):31–47).

In a meta-analysis done in 2001, data from 25 studies were collected to look at the “effect of experimental manipulations of the thin body ideal, as portrayed in the mass media” (Groesz LM et al, Int J Eat Disord 2002;31(1):1–16). Results showed that body image was negatively affected when people saw images of thin people versus when they viewed average size models, plus size models, or inanimate objects. The conclusion drawn was that mass media creates the ideal of a thin body that makes people feel bad about the bodies that they have.

Contrary to popular belief, eating disorders are not a lifestyle choice, but rather the end result of a combination of genes, environment, and psychosocial influences (Costin C. The Eating Disorder Sourcebook: A Comprehensive Guide to the Causes, Treatments, and Prevention of Eating Disorders, 3rd edition. New York:McGraw-Hill;2006). What often starts as a simple diet can quickly become a life-threatening disorder, with limited likelihood of treatment and recovery. Criteria for official DSM-IV-TR diagnosis are stringent, and many people suffering from disordered eating do not fit neatly into any of the diagnoses in the manual. What remains clear and consistent, however, is the “morbid preoccupation with weight and shape,” ultimately controlling the individual’s life (Herpertz-Dahlmann op cit).

In the upcoming DSM-5, scheduled for release in May, the chapter on feeding and eating disorders includes “several changes to better represent the symptoms and behaviors of patients dealing with these conditions across the lifespan,” according to a fact sheet released by the American Psychiatric Association (APA).

Changes include recognition of binge eating disorder (see “DSM-5 to Include Binge Eating Disorder” sidebar) and revised diagnostic criteria for anorexia nervosa and bulimia nervosa. Also included are pica, rumination, and avoidant/restrictive food intake disorder. These three disorders had been listed in the DSM-IV chapter for “disorders usually first diagnosed in infancy, childhood, or adolescence,” a chapter eliminated in DSM-5.

“In recent years, clinicians and researchers have realized that a significant number of individuals with eating disorders did not fit into the DSM-IV categories of anorexia nervosa and bulimia nervosa. By default, many received a diagnosis of ‘eating disorder not otherwise specified,’ ” according to the APA fact sheet. However, studies suggest that a significant number of those individuals may actually have binge eating disorder, according to the fact sheet.

This article will discuss two of the most common eating disorders, specifically anorexia nervosa and bulimia nervosa, and will include diagnostic criteria, common symptoms, and influences of gender.

A Look at Anorexia Nervosa

The word “anorexia” means “lack of appetite,” and was originally used to describe the lack of appetite associated with various ailments or medical illnesses (Costin op cit). The term anorexia nervosa is recognized as a separate entity, meaning “lack of desire to eat due to a mental condition,” which has become part of the criteria necessary for the DSM-IV-TR diagnosis.

Though not formally diagnosed and accepted until years later, the first documented case was recorded in 1686 (Costin op cit). While people with anorexia due to medical causes simply lose their appetite and have little desire to eat, people suffering from anorexia nervosa may actually yearn for food, but develop “an intense fear of gaining weight or becoming fat, even though underweight,” according to the DSM-IV-TR. The following four criteria must be met to formally diagnose a patient with anorexia nervosa (criteria that undergo “several minor but important changes” in DSM-5):

  1. Refusal to maintain minimal body weight expected for age and height (less than 85% of expected body weight). (DSM-5 “no longer includes the word ‘refusal’ in terms of weight maintenance since that implies intention on the part of the patient and can be difficult to assess,” according to the APA fact sheet.)
  2. Intense fear of gaining weight or becoming fat (even though underweight).
  3. Disturbance in the way in which one’s body weight or shape is experienced (too much impact of body weight or shape on self-evaluation, or denial of seriousness of current low body weight).
  4. Amenorrhea (in postmenarcheal females). (Eliminated in DSM-5, because it does not apply to males, pre-menarchal females, females taking oral contraceptives, and post-menopausal females, according to the APA fact sheet. “In some cases, individuals exhibit all other symptoms and signs of anorexia nervosa but still report some menstrual activity,” the APA noted.)

Two subtypes of anorexia nervosa also exist, namely: the restricting type (does not regularly binge eat or purge) and the binge eating/purging type. (Purging is defined as self-induced vomiting, or the misuse of laxatives, diuretics, or enemas.)

The disorder is marked by the maintenance of low body weight. Interestingly, while this may initially be voluntary, by exercising and food restriction, later on it becomes a consequence of “starvation-induced biological changes” that result in unintentional weight loss perpetuated by continued restriction and excessive activity (Herpertz-Dahlmann op cit; Keys A et al. The biology of human starvation. Minneapolis (MN):University of Minneapolis Press;1950).

Those suffering from anorexia often exhibit various personality traits, most commonly, perfectionism, rigidity, and obsessiveness. These traits are evident during the illness, but also persist when a patient is in remission (Herpertz-Dahlmann op cit). Author Carolyn Costin notes, “what often (but not always) begins as a determination to lose weight, progresses and transforms into a morbid fear of gaining any weight—even when it is necessary to maintain life. Of the eating disorders, anorexia nervosa is the most tenacious, the most deadly, and the most rare.”

A Look at Bulimia Nervosa

The word bulimia derives from a Greek word that means “hunger of an ox.” The condition that we now call bulimia nervosa was first described by psychiatrist Pierre Janet, in 1903, when a woman was observed “compulsively binging in secret” (Costin op cit). According to the DSM-IV-TR criteria, individuals suffering from bulimia nervosa demonstrate recurrent episodes of binge eating, with a frequency of at least twice a week for three months; recurrent attempts to compensate and avoid gaining weight through self-induced vomiting, laxative abuse, or fasting; and self-worth based on shape and weight, not occurring in the context of anorexia nervosa.

Note that in DSM-5, the criteria reduces the frequency of binge eating and compensatory behaviors that people must exhibit, to once a week rather than twice a week.

There are two subtypes of this disorder, specifically the purging and non-purging types. Bulimic patients differ from anorectic patients in that their weight is mostly within the normal range (some slightly lower, some slightly above). In this disorder, however, periods of dieting/fasting are interrupted by out-of -control binge eating episodes. Attempts to compensate or get rid of the food include purging or nonpurging behaviors, such as fasting or excessive exercise, and are practiced mostly in secret (Herpertz-Dahlmann op cit; Costin op cit). Patients shy away from seeking treatment out of shame and embarrassment, in contrast to anorectics, who more typically maintain a lack of insight into the severity and implications of their disorder. Both are difficult to diagnose and treat.

An Equal Opportunity Disorder

Psychiatric comorbidities are common among patients with anorexia and bulimia nervosa. Both are associated with major depressive disorder, anxiety, obsessive-compulsive disorder, substance use disorders, and personality disorders (Herpertz-Dahlmann op cit; Costin op cit). Because many of these conditions are exacerbated by starvation and the abnormal eating patterns characteristic of eating disorders, clinicians should carefully consider the relationship between eating disorders and coexisting disorders prior to diagnosis or treatment.

Statistics indicate that 90%–95% of eating disorder cases are female as compared with 5%–10% male; however, a large proportion (~40%) of those diagnosed with binge eating disorder are male (Costin op cit). According to the National Institute of Mental Health, recent data suggest that approximately 25% of all college students have eating disorders, and although the “problem is more widespread among women,” 10%–15% of eating disordered patients are male (Ammenheuser M. Eating disorders boom as kids enter college. The Tennessean. December 27, 2012).

Of all the psychiatric disorders, eating disorders have been most commonly associated with women (Gordon RA. Anorexia and Bulimia: Anatomy of a Social Epidemic. New York: Blackwell; 2000), and thus eating disorders in males have been “overlooked, understudied, and underreported” (Costin op cit; Sterling op cit). Perhaps eating disorders are more recognized in women because of the female tendency to worry about dieting, thinness, and appearance, which have been identified as risk factors for developing eating disorders. Males, however are also subject to unrealistic media standards based on appearance and weight. Until there is more recognition and acknowledgment of the disorder in males, prevention and treatment remain suboptimal.

TCRBH’s Take: Eating disorders are complex, chronic, and potentially fatal. Although a significant amount of research has been done, many questions remain. There is much yet to be learned about the causes of eating disorders, and the treatment options are still limited.