What are anorexia nervosa and bulimia nervosa?

Introduction

Anorexia nervosa and bulimia nervosa are two types of eating disorders. They are illnesses with a biological basis modified by emotional and cultural factors. Anorexia literally means a severe loss of appetite, while nervosa means nervousness. Actually, the word anorexia is somewhat of a misnomer, given that most people with anorexia nervosa have not lost their appetites.

History of the Disorders

Anorexia is a disorder that can be traced as far back as the twelfth century, when it was associated with religion—saints refused food to get closer to God. The disorder was specifically named as a diagnosis in 1874, when Sir William Gull published an article giving the disorder its present name.

The binge/purge behavior of bulimia has been around for centuries, and bulimia nervosa was identified as a disorder in the 1930s but was thought to be a form of anorexia. Bulimia nervosa was not named as a disorder separate from anorexia until the late 1970s, when both disorders began receiving media attention with stories of girls and women refusing to eat and dying from the behavior. Probably the most famous case at that time was that of Karen Carpenter, a singer who died at age thirty-two of heart failure caused by anorexia. There is evidence to suggest that the incidence of both disorders in the United States has increased since the 1970s. The increased emphasis on thinness within American society is a likely explanation for the increase in eating disorders.

Symptoms

The disorder of anorexia nervosa consists of three prominent symptoms, according to the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The first symptom is an abnormally low weight for one’s age, height, and physical condition due to significant restriction of energy intake. Because many people with anorexia nervosa (known as anorectics or anorexics) are secretive about their eating behaviors and cover their weight loss with clothing, they are not diagnosed until they have already lost significant amounts of weight. The second symptom of anorexia nervosa can take the form either of an intense fear of gaining weight or being fat or of behavior that prevents weight gain. This second symptom has been labeled weight phobia
by some researchers because of the anorectic’s anxiety toward food and the desperate attempts the person makes to avoid food. The third major symptom of the syndrome is distorted body image. Distorted body image, which sometimes takes the form of body dysmorphic disorder, involves the anorectic seeing herself or himself as obese when in reality she or he is extremely underweight. Because of this, during treatment, anorectics are not allowed to know their weight. Premenopausal women with anorexia nervosa also often experience the absence of at least three menstrual cycles in a condition known as amenorrhea, which is caused by being severely undernourished. The lack of nutrients affects the hypothalamic, pituitary, gonadal axis, causing the lack of hormones that result in amenorrhea.

Bulimia nervosa refers to the recurring cycle of binge eating, a short period of excessive overeating, followed by purging or other compensatory behaviors as drastic efforts to lose the weight gained by binge eating. For the bulimic, binging has two components: eating large amounts in a limited amount of time and feeling a lack of control while eating. Purging may be accomplished through several means, including vomiting (done either by gagging oneself or through the consumption of certain drugs) and the use of laxatives, diuretics, or enemas; other inappropriate compensatory behaviors include fasting or strict dieting and excessive exercising. To be diagnosed with bulimia, according to the DSM-5, a person must engage in the cycle of binge eating and compensatory behaviors at least once per week, on average, for three months. It is likely that the number of bulimics reported would be higher without this strict criterion. However, bulimia should not be confused with binge eating disorder, which, according to the DSM-5, is characterized by binge eating that is not followed by inappropriate compensatory behaviors such as purging.

Health Problems

Numerous health problems may occur as a result of anorexia or bulimia. The health problems of anorectics include an abnormally low heart rate and low blood pressure as well as irregular heart functioning, often resulting in heart failure. Fatigue is common, and bone thinning (osteopenia) may lead to osteoporotic fractures if left untreated. Dehydration can lead to kidney failure, and lack of body fat combined with the change in hormones makes it difficult to regulate body temperature. Anorectics may develop lanugo hair over their bodies, including the face, to help with temperature regulation. The death rate for anorexia nervosa is one of the highest for any mental health condition, and generally, the longer the condition lasts, the higher the death rate.

Most of the health complications of bulimia are related to the purging behaviors. Electrolyte imbalances, particularly potassium reduction, can occur from all purging behaviors and can lead to irregular heartbeats and possibly heart failure and death. Vomiting leads to the erosion of tooth enamel and a variety of disorders affecting digestive organs. A significantly lower number of people are thought to die from bulimia as compared with anorexia. Those with binge eating disorder exhibit the same health consequences as anyone with obesity, so heart disease and type 2 diabetes are common.

When compared with obesity, which in some cases can be the result of an eating disorder, anorexia and bulimia are rare. According to a 2012 report by the Centers for Disease Control and Prevention, approximately 35.7 percent of American adults and 16.9 percent of American children are obese. In contrast, an estimated 0.6 percent of American adults will have anorexia during their life, according to 2007 statistics compiled by the National Institute of Mental Health. The incidence of anorexia among adolescents, especially female adolescents, however, is significantly higher than in the general population. Bulimia is likewise estimated to occur in 0.6 percent of American adults, and again, the incidence of bulimia among adolescents is estimated to be significantly higher. A subpopulation in which the incidence of eating disorders is higher is athletes. The type of eating disorder seems to correlate with the sport. In individual sports, in which lower weight is an advantage or looks are a factor, anorexia is more common, and in team sports, bulimia is more common. Male and female athletes show similar rates of eating disorders because the disorders are related to the sport and athletic performance.

Causes and Explanations

The proposed causes of anorexia and bulimia can be grouped into four categories: biological, sociocultural, familial, and psychological. The notion of biological causes of anorexia and bulimia involves the idea that anorectics and bulimics have specific brain or biochemical disturbances that lead to their inability to maintain a normal weight or eating pattern. One biological explanation researched for the occurrence of anorexia and bulimia is the existence of an abnormal amount of certain brain neurotransmitters, especially norepinephrine and serotonin. Neurotransmitters are chemical messengers within the brain that transmit nerve impulses between nerve cells.

In contrast to biological explanations, sociocultural causes are factors that are thought to exist within a society that lead certain individuals to develop anorexia or bulimia. Joan Brumberg, a historian of anorexia, has outlined the sociocultural forces of the late nineteenth and twentieth centuries that many believe promoted the increased incidence of eating disorders among women. These societal forces included an emphasis on weight reduction and aesthetic self-control and the treatment of women as sexual objects. The most prominent of these suggested cultural factors is the heightened importance placed on being thin.

Some researchers believe that particular family types cause certain of their members to develop anorexia and bulimia. For example, family investigators believe that a family whose members are emotionally too close to one another may lead one or more family members to strive for independence by refusing to eat, according to Salvador Minuchin, Bernice Rosman, and Lester Baker. Other researchers believe that families whose members are controlling and express an excessive amount of hostility toward one another promote the occurrence of bulimia. Some research also shows genetic tendencies; that is, if a parent had an eating disorder, it is more likely that one or more of his or her children will also be diagnosed with one, even if the parent is no longer exhibiting symptoms.

The most prominent of the suggested psychological causes for anorexia and bulimia are those expressed by researchers who take psychoanalytic or cognitive behavioral perspectives. For example, cognitive behavioral theorists emphasize the role of distorted beliefs in the development and continuation of anorexia and bulimia. These distorted beliefs include that the person is attractive only if she or he weighs a certain number of pounds, usually a number well below normal weight, or that consuming certain types of foods (such as carbohydrate-rich foods) will automatically make a person fat.

Treatments

Numerous treatments have been used for individuals who have anorexia or bulimia, but they can be broadly grouped into the categories of medical and psychological therapies. If symptoms are life threatening, these disorders are treated in a hospital, and if they are more manageable, these disorders can be treated on an outpatient basis.

Before the 1960s, medical therapies for anorexia included such radical approaches as lobotomies and electroconvulsive therapy (ECT). The first goal for the treatment of anorexia is to ensure the person’s physical health, which involves restoring the person to a healthy weight. Reaching this goal may require hospitalization. Although a controversial treatment, various types of tube feeding continue to be used when a patient’s malnutrition from anorexia poses an imminent risk of death. Tube feeding can be accomplished either intravenously or by inserting a tube via a patient’s nasal cavity into the patient’s stomach.

Once a person’s physical condition is stable, treatment usually involves individual psychotherapy and family therapy, during which parents help their children learn to eat again and maintain healthful eating habits on their own.
Behavioral therapy also has been effective for helping anorectics return to healthful eating habits. Supportive group therapy may follow, and self-help groups within communities may provide ongoing support. There are a number of in-patient treatment facilities that specialize in anorexia throughout the United States. The most effective treatment no matter the location is team treatment addressing all three areas of concern. A physician treats the medical conditions and potentially the mental aspects if drugs are required, a counselor manages the behavioral aspect, and a dietician manages the dietary component.

When treating bulimia, unless malnutrition is severe, any substance abuse problems that may be present at the time the eating disorder is diagnosed are usually treated first. The next goal of treatment is to reduce or eliminate the person’s binge eating and purging behavior. Behavioral therapy has proven effective in achieving this goal. Psychotherapy has proven effective in helping prevent the eating disorder from recurring and in addressing issues that led to the disorder. Studies have also found that fluoxetine (Prozac), an antidepressant, may help people who do not respond to psychotherapy. Some bulimics also exhibit obsessive-compulsive disorder (OCD), and drugs appropriate for OCD also help reduce the bulimic behaviors. As with anorexia, family therapy is also recommended.

The family treatment of anorectics involves the therapist seeking to change the interactions among family members that serve to maintain the self-starvation of the patient. In attempting to change family interactions, the family therapist might address the parents’ overprotectiveness or the way family members manipulate one another’s behavior. For bulimics, the family therapist would seek to lower the amount of family conflict or to redirect conflict between the parents away from the bulimic.

Another frequently employed method of treatment for bulimia is group therapy. Group treatment initially involves educating bulimics about their disorder, including its negative health consequences. The group experience provides members with the opportunity to share with fellow bulimics regarding their eating problems and to find support from one another in overcoming bulimia. In addition, the therapist or therapists initiate discussions regarding healthful eating and exercise habits as well as specific ways to end the cycle.

A final issue involved in surveying the different interventions for anorexia and bulimia is the effectiveness of these treatments. A meta-analysis of one hundred studies of anorectics in 1988 found only small differences between the various types of treatment in the amount of weight gained during therapy, although behavioral treatments appeared to work faster. A negative impact of changes in health insurance coverage for anorectics has been shorter treatment times and poorer outcomes. Definitive research shows that the closer anorectics are to their ideal weight on discharge, the less likely they are to be readmitted, even if that requires a longer treatment initially. Managed care generally allows a certain amount of time or certain number of treatment sessions rather than basing coverage on return to normal weight.

Less research has been conducted investigating the effectiveness of different therapies for bulimia. No single therapy for bulimia, however, whether medical or psychological, has shown clear superiority in its effectiveness as compared with other interventions. More important was when treatment began. Patients with bulimia nervosa demonstrated a better recovery rate if they received treatment early in their illness.

Prevention and Remaining Questions

Research has begun to focus on the prevention of eating disorders. Catherine Shisslak and colleagues have suggested that preventive efforts should be targeted at female adolescents, given that they are at increased risk for developing an eating disorder. One of the most important ideas that has come out of research on eating disorders is that outcomes are much better when treatment begins early. Research also suggests that if the disordered eating behaviors are caught when they begin and before they have reached diagnostic criteria, development of the eating disorder may be prevented. These preventive efforts should focus on issues such as the physical, emotional, and social changes that occur in maturation. Also, information regarding diet and exercise should be provided, and the connection between emotions and eating should be discussed, as should ways to resist the pressure to conform to peers’ and societal expectations regarding appearance.

With evidence of the increasing prevalence of anorexia and bulimia and binge eating disorder, it is important to learn more regarding the causes and effective treatment methods of these disorders. Some of the questions that remain to be definitively answered are why certain groups have a greater likelihood of developing anorexia and bulimia (notably, white female adolescents), whether the underlying causes of anorexia are different from those of bulimia, and whether a more effective treatment can be developed for those with anorexia or bulimia.

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