Anorexia nervosa most commonly starts in the mid-teens. About one in a hundred 16 to 18 years olds has the illness. It is much more common in girls. Bulimia nervosa usually starts when people are a little older, but is again common in girls. Bulimia is more common than anorexia, although people with anorexia in particular do not always ask for treatment. Occasionally men develop eating disorders, but anorexia nervosa is rare. Male development in puberty is very different from that of females. Related bodily concerns are different and less often lead to the extremes of dieting which commonly precede anorexia nervosa.
Mental health professionals need a variety of skills to treat people with eating disorders. A doctor can help diagnose the illness and any associated physical problems resulting from it. In both anorexia nervosa and bulimia, self-help strategies can be very helpful. If this approach does not work, health professionals may suggest a course of psychotherapy. If someone has lost a dangerous amount of weight, the first step will be to help the person start to regain that weight in order to survive. Some people with anorexia may need to be admitted to hospital and the nursing staff has an important role in supporting the patient in the early stages of treatment.
Psychological and psychotherapy skills are also necessary at this acute stage, so that the mental health team can begin to understand why the illness developed and how to help the person to overcome it. In anorexia, this talking treatment will involve the individual with the illness and sometimes-other family members. The long-term aim will be to help that person change their attitude, behavior and ways of thinking, and enable them to cope with the strains of life without the illness as a protection. Shorter-term expert talking treatments and also specific cognitive behavioral treatments are often effective with bulimia nervosa.
What can society do?
We can strive better to understand the distress that underlies and drives these disorders. We can provide access to such information and develop health promotion campaigns aimed at teenagers and young people. Information on how to cope with feelings and fears about growth or about being too fat is useful. We can offer more support in secondary schools and user-friendly services for troubled teenagers. Symptoms are allowed to persist until they become entrenched behaviors, the person may struggle for years before s/he can turn matters around.
The person skips meals, takes only tiny portions, will not eat in front of other people, eats in ritualistic ways, and mixes strange food combinations. May chew mouthfuls of food but spits them out before swallowing. Grocery shops and cooks for the entire household but will not eat the tasty meals. Always has an excuse not to eat: (is not hungry, just ate with a friend, is feeling ill, is upset, and so forth.)
Becomes "disgusted" with former favorite foods like red meat and desserts. Will eat only a few "safe" foods. Boasts about how healthy the meals s/he does consume are. Becomes a "vegetarian" but will not eat the necessary fats, oils, whole grains, and the denser fruits and veggies (such as sweet potatoes and avocados) required by true vegetarianism. Chooses primarily low-fat items with low levels of other nutrients, foods such as lettuce, tomatoes, sprouts, and so forth. Always has a diet soda in hand. Drastically reduces or completely eliminates fat intake. Reads food labels religiously. If s/he breaks self-imposed rigid discipline and eats normal or large portions, excuses self from the table to vomit and get rid of the calories.
Or, in contrast to the above, the person gorges, usually in secret, and empties cupboards and refrigerator. May also buy special binge food. If panicked about weight gain, may purge to get rid of the calories. May leave clues that suggest discovery is desired: empty boxes, cans, and food packages; foul smelling bathrooms; running water To cover sounds of vomiting; excessive use of mouthwash and breath mints; and in some cases, containers of vomit poorly hidden that invite discovery.
Sometimes the person uses laxatives, diet pills, water pills, or "natural" products from health food stores to promote weight loss. May abuse alcohol or street drugs, sometimes to deaden appetite, sometimes to escape emotional pain, and usually in hopes of feeling better, at least temporarily.
Appearance and body image behaviors
The person loses, or tries to lose, weight. Have frantic fears of weight gain and obesity. Wears baggy clothes, sometimes in layers, to hide fat, hide emaciation, and stay warm. Obsesses about clothing size. Complains that s/he is fat even though others truthfully say this is not so. S/he will not believe them. Spends lots of time inspecting self in the mirror and usually finds something to criticize. Detests all or specific parts of the body, especially breasts, belly, thighs, and buttocks. Insists s/he cannot feel good about self unless s/he is thin, and s/he is never thin enough to satisfy her/himself
The person exercises excessively and compulsively. May tire easily, keeping up a harsh regimen only through sheer will power. As time passes, athletic performance suffers. Even so, s/he refuses to change the routine. May develop strange eating patterns, supposedly to enhance athletic performance. May consume sports drinks and supplements, but total calories are less than what an active lifestyle requires.
In spite of average or above-average intelligence, the person thinks in magical and simplistic ways, for example, "If I am thinner, I will feel better about myself." S/he loses the ability to think logically, evaluate reality objectively, and admit and correct undesirable consequences of choices and actions. Becomes irrational, argues with people who try to help, and then withdraws, sulks, or throws a tantrum. Wanting to be special, s/he becomes competitive. Strives to be the best, the smallest, the thinnest, and so forth. Has trouble concentrating. Obsesses about food and weight and holds to rigid, perfectionist standards for self and others.
Has trouble talking about feelings, especially anger. Denies anger, saying something like, "Everything is OK. I am just tired and stressed." Escapes stress by turning to binge food, exercise, or anorexic rituals. Becomes moody, irritable, cross, snappish, and touchy. Responds to confrontation and even low-intensity interactions with tears, tantrums, or withdrawal. Feels s/he does not fit in and therefore avoids friends and activities. Withdraws into self and feelings, becoming socially isolated.
Tries to please everyone and withdraws when this is not possible. Tries to take care of others when s/he is the person who needs care. May present self as needy and dependent or conversely as fiercely independent and rejecting of all attempts to help. Anorexics tend to avoid sexual activity. Bulimic may engage in casual or even promiscuous sex.
Person tries to control what and where the family eats. To the dismay of others, s/he consistently selects low fat, Low-sugar non-threatening - and unappealing - foods and restaurants that in the past have provided these "safe" items. Relationships tend to be either superficial or dependent. Person craves true intimacy but at the same time is terrified of it. As in all other areas of life, anorexics tend to be rigidly controlling while bulimic have problems with lack of impulse control that can lead to rash and regrettable decisions about sex, money, stealing, commitments, careers, and all forms of social risk taking.
Who is at risk?
These disorders usually appear in bright, attractive young women between twelve and twenty-five, although there are both older and younger exceptions. At least five to ten percent (5-10%) are male, possibly more. Researchers and statisticians are just now beginning to determine how widespread eating disorders are in men and boys.
What kinds of things trigger eating disorders?
Problems often begin when a person is dealing with a difficult transition, shock, or loss: puberty, marriage, divorce, family problems, death, new job, new school, breakup of an important relationship, sexual or physical abuse, critical comments from a respected authority figure, and so forth. These situations sometimes overwhelm a person's ability to handle them. S/he feels helpless and out of control. People vulnerable to eating disorders also, in most cases, are experiencing relationship problems, loneliness in particular. Some may be withdrawn with only superficial or conflicted connections to other people. Others may seem to be living exciting lives filled with friends and social activities, but later they will confess that they did not feel they really fit in, that no one seemed to really understand them, and that they had no true friends or confidants with whom they could share their innermost thoughts, feelings, doubts, insecurities, fears, hopes, ambitions, and so forth. Often they desperately want healthy connections to others but fear criticism and rejection if their perceived flaws and shortcomings become known. Wanting to take control and fix things, but not really knowing how, and under the influence of a culture that equates success and happiness with thinness, the person tackles her/his body instead of the problem at hand. Dieting, bingeing, purging, exercising, and other strange behaviors are not random craziness. They are heroic, but misguided and ineffective, attempts to take charge in a world that seems overwhelming.
Note: Dieting and the resulting hungers, both physical and emotional, caused by deprivation are two of the strongest triggers of binge eating we know of. It is a bit simplistic, but nonetheless true, that if no one dieted, there would be no anorexia nervosa. Neither would there be the bulimia that results from prolonged restricted eating, the hunger that follows, and the overwhelming cravings for lots of calorie-laden food that naturally accompany strict self-denial. About 50% of people who have starved themselves into anorexia become bulimic when they lose control of urges to make up for lost time, and calories, by eating lots of food very rapidly.
What are people with anorexia like?
People who become anorexic often were good children: conscientious, hard working and good students. They may be people pleasers who seek approval and avoid conflict. They may take care of other people and strive for perfection, but underneath they feel defective and inadequate. They want to be special, to stand out from the mediocre masses. They try to achieve that goal by losing weight and being thin. People who develop anorexia may feel anxious when faced with new situations. Many have low tolerance for change, feeling that it represents chaos and loss of control. Although they have great trouble admitting it, many fear growing up, taking on adult responsibilities, and meeting the demands of adulthood. Many are overly engaged with parents to the exclusion of peer relationships. They use dieting and weight preoccupations to avoid, or ineffectively cope with, the demands of a new life stage such as adolescence or a new milestone such as expectations of adult sexuality.
What are people with bulimia like?
People who become bulimic often have problems with anxiety, depression, and impulse control (shoplifting, casual sexual activity, binge shopping, alcohol and drug abuse, and so forth. They may be dependent on their families even though they fiercely profess independence. Many have problems trusting other people. They have few or no truly satisfying friendships or romantic relationships.
Are some people at special risk?
Because of intense demands for thinness, some people are at high risk for eating disorders: wrestlers, jockeys, cheerleaders, sorority members, socialites, dancers, gymnasts, runners, models, actresses, entertainers, and male homosexuals.
Eating disorders and physical or sexual abuse
Some clinicians find that a high percentage of their clients with eating disorders also have histories of physical or sexual abuse. Research, however, suggests that people who have been abused have about the same incidence of eating disorders as those who have not been mistreated. Nevertheless, the subject arises often enough to warrant discussion here. People who have survived abuse often do not know what to do with the strong feelings and overwhelming memories that remain, sometimes even many years later. Some try to escape those feelings and memories by numbing themselves with binge food or through starvation. Some try to symbolically cleanse themselves by vomiting or abusing laxatives. Some starve themselves because they believe they feel they are "bad" and do not deserve the comfort of food and the nurture it represents. As with all eating disorders, the starving and stuffing that follow abuse are coping behaviors. The key to recovery is finding out what the person is trying to achieve, or avoid, with the behaviors. S/he then needs to find, and use, healthier and more effective behaviors to feel better and make life happier. Almost always professional counseling is necessary to complete the process.
What causes eating disorders?
There are many theories and no one simple answer that covers everyone. For any particular person, some or all of the following factors will be woven together to produce starving, stuffing, and purging.
Temperament seems to be, at least in part, genetically determined. Some personality types (obsessive-compulsive and sensitive avoiding, for example) are more vulnerable to eating disorders than others. New research suggests that abnormal levels of brain chemicals predispose some people to anxiety, perfectionism, and obsessive-compulsive thoughts and behaviors. These people seem to have more than their share of eating disorders. Also, once a person begins to starve, stuff, or purge, those behaviors in and of themselves can alter brain chemistry and prolong the disorder. For example, both under-eating and overeating can activate brain chemicals that produce feelings of peace and euphoria, thus temporarily dispelling anxiety and depression. In fact some researchers believe that eating disordered folks may be using food to self-medicate painful feelings and distressing moods.
People with eating disorders tend to be perfectionist. They may have unrealistic expectations of themselves and others. In spite of their many achievements, they feel inadequate, defective, and worthless. In addition, they see the world as black and white, no shades of gray. Everything is either good or bad, a success or a failure, fat or thin. If fat is bad and thin is good, then thinner is better, and thinnest is best - even if thinnest is sixty-eight pounds in a hospital bed on life support. Some people with eating disorders use the behaviors to avoid sexuality. Others use them to try to take control of themselves and their lives. They are strong, usually winning the power struggles they find themselves in, but inside they feel weak, powerless, victimized, defeated, and resentful. People with eating disorders often lack a sense of identity. They try to define themselves by manufacturing a socially approved and admired exterior. They have answered the existential question, "Who am I?" by symbolically saying "I am, or I am trying to be, thin. Therefore, I matter."
People with eating disorders often are legitimately angry, but because they seek approval and fear criticism, they do not know how to express their anger in healthy ways. They turn it against themselves by starving or stuffing.
Some people with eating disorders say they feel smothered in overprotective families. Others feel abandoned, misunderstood, and alone. Parents who overvalue physical appearance can unwittingly contribute to an eating disorder. So can those who make critical comments, even in jest, about their children's bodies. These families tend to be overprotective, rigid, and ineffective at solving conflict. Sometimes they are emotionally cold. There are often high expectations of achievement and success. The children learn not to disclose doubts, fears, anxieties, and imperfections. Instead they try to resolve their problems by manipulating weight and food. In addition, research suggests that daughters of mothers with histories of eating disorders may be at higher risk of eating disorders themselves than are children of mothers with few food and weight issues. According to a report published in the April 1999 issue of the International Journal of Eating Disorders, mothers who have anorexia, bulimia, or binge eating disorder handle food issues and weight concerns differently than mothers who have never had eating disorders.
Patterns are observable even in infancy. They include odd feeding schedules, using food for rewards, punishments, comfort, or other non-nutritive purposes, and concerns about their daughters weight. Still to be determined is whether or not daughters of mothers with eating disorders will themselves become eating disordered when they reach adolescence?
TV, movies, and magazines are three examples of media that flood people with messages about the "advantages" of being thin. The actors tell impressionable readers and viewers, sometimes directly, sometimes indirectly and models that are chosen for display, that goodness, success, power, approval, popularity, admiration, intelligence, friends, and romantic relationships all require physical beauty in general and thinness in particular. The corollary is also promoted: People who are not thin and beautiful are represented as failures: bad, morally lax, weak, out of control, stupid, laughable, lonely, disapproved of, and rejected.
Girls and women are disproportional affected by eating disorders and cultural demands for thinness. Never before in recorded history have females been exhorted to be as thin as is currently fashionable. Men, by contrast, are encouraged to be strong and powerful. As they work to develop their power in the gym and workplace, they equate "thin" with "skinny" and "weak." Even though today's female models often look frail, wounded, and vulnerable (characteristics men abhor in themselves), female thinness is not rejected as "skinny." Instead is coveted and defined as glamorous, sexy, and evidence of the with-it woman. Perhaps this explains, at least in part, why only five to ten percent of people with eating disorders are male.