Chapter 1

2. Describe the causes of eating disorders in terms of personal, genetic and environmental, biological, psychological, family, social, and trigger factors.

3. Describe the behavioral patterns of someone with an eating disorder in terms of food, appearance, exercise, thinking and emotions.

4. Describe the medical complications of eating disorders.

Each year millions of people in the United States develop serious and sometimes life-threatening eating disorders. The vast majority—more than 90 percent—of those afflicted with eating disorders are adolescent and young adult women. One reason that women in this age group are particularly vulnerable to eating disorders is their tendency to go on strict diets to achieve an "ideal" figure. Researchers have found that such stringent dieting can play a key role in triggering eating disorders.

Approximately 1 percent of adolescent girls develop anorexia nervosa, a dangerous condition in which they can literally starve themselves to death. Another 2 to 3 percent of young women develop bulimia nervosa, a destructive pattern of excessive overeating followed by vomiting or other "purging" behaviors to control their weight. These eating disorders also occur in men and older women, but much less frequently.

The consequences of eating disorders can be severe, with 1 in 10 cases leading to death from starvation, cardiac arrest, or suicide. Fortunately, increasing awareness of the dangers of eating disorders—sparked by medical studies and extensive media coverage of the illness—has led many people to seek help. Nevertheless, some people with eating disorders refuse to admit that they have a problem and do not get treatment. Family members and friends can help recognize the problem and encourage the person to seek treatment. Scientists have found that people with eating disorders who get early treatment have a better chance of full recovery than those who wait years before getting help.

How Many People Have Eating Disorders?

Research suggests that about 1% of female adolescents have anorexia nervosa and another 4% have bulimia. Perhaps as many as 20% of college-aged women have eating disorders, primarily bulimia. About 10% of people with eating disorders are boys and men. About one-third of adult Americans, both male and female, are overweight or obese. Many of these people have binge eating disorder.

Since physicians do not have to report these disorders to a health agency, and since people who have them tend to be secretive, denying they have problems, we have no way of knowing how many people in this country are affected. Percentages extrapolated from research are as close as we can get.

Who Gets Eating Disorders?

Eating disorders usually appear between 12 and 25, although there are exceptions in both directions. They tend to 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 respect authority figure, and so forth. These situations demand more of a person than she believes she can deliver. She feels helpless and out of control.

Wanting to take control but not really knowing how, she seizes control of the one thing readily available to her: body. Her dieting, bingeing, purging, exercising, and other strange behaviors are not random craziness. They are heroic, but misguided and ineffective, attempts to take charge of herself in a world that feels overwhelming.

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 become bulimic often have problems with anxiety, depression and impulsivity (shoplifting, casual sexual activity, alcohol and drug abuse, etc.) They may be dependent on their families, even though they profess independence. Many have problems trusting other people and have few or no satisfying friendships and romantic relationships.

Danger Signs

Since everyone today seems concerned about weight, and since most people diet at least once in a while, how can one tell what is "normal" behavior and what is a problem that may escalate to threaten life and happiness? No one person will manifest all of the characteristics listed below, but people with eating disorders will demonstrate several.

Food behaviors: Skips meals, takes only tiny portions, won't eat in front of other people, eats in ritualistic ways, mixes strange food combinations. Always has a reason why she isn't hungry, becomes "disgusted" with favorite foods like red meat and desserts, eats only a few "safe" foods, boasts of how healthy she eats, always has a diet soda in hand, drastically reduces or completely eliminates fat intake, reads food labels religiously. If she breaks her rigid discipline and eats normal or large portions, she excuses herself from the table to vomit and get rid of the calories. She sometimes uses laxatives, diet pills, water pills, or "natural" products from the health food store to promote weight loss.

Appearance and body image behaviors: Loses, or tries to lose, weight. Frantic fears of weight gain and obesity. Wears baggy clothes, sometimes in layers, to hide fat, hide emaciation, and stay warm. Obsesses about clothing sizes, complains that she is fat even though others reassure her she is not, spends lots of time inspecting herself in the mirror, and usually finds more to criticize than to be pleased about. Detests all or specific parts of her body, especially breasts, belly, thighs, and buttocks. Insists that she cannot feel good about herself unless she is thin, and she never gets thin enough to satisfy herself.

Exercise behaviors: She exercises excessively and compulsively. She may tire easily, keeping up her regimen only through sheer will power. As time passes, her athletic performance suffers. She complains of being cold even when other people are too warm.

Thinking behaviors: In spite of her average or above-average intelligence, she thinks in magical, simplistic ways: e.g., "If I'm thinner, I'll feel better." She loses the ability to think logically, evaluate reality objectively, and admit and correct undesirable consequences of her choices and actions. She argues, becomes irrational, and then withdraws or throws a tantrum. She becomes competitive, wanting to be special: the best, the smallest, the thinnest, etc. She has trouble concentrating, obsesses about food and weight, and holds to rigid, perfectionistic standards for herself and others.

Emotional behaviors: Has trouble talking about her feelings, especially anger; denies she is angry: e.g., "Everything is OK. I'm just tired." Escapes stress by turning to binge food, exercise, or anorexic rituals, Becomes moody, irritable, cross, and snappish. Touchy: responds to confrontation and even low-intensity interactions with tears, tantrums or withdrawal. Feels she does not fit in; avoids friends and activities; withdraws and becomes socially isolated.

Medical Complications

If not stopped, starving, stuffing, and purging can lead to irreversible physical damage and even death. Eating disorders can affect every cell, tissue, and organ in the body.

Eating disorders have among the highest mortality rates of all mental disorders, killing up to 10 percent of their victims. Individuals with eating disorders who use drugs to stimulate vomiting, bowel movements, or urination are in the most danger, as this practice increases the risk of heart failure.

In patients with anorexia, starvation can damage vital organs such as the heart and brain. To protect itself, the body shifts into "slow gear": monthly menstrual periods stop, breathing, pulse, and blood pressure rates drop, and thyroid function slows. Nails and hair become brittle; the skin dries, yellows, and becomes covered with soft hair called lanugo.

Excessive thirst and frequent urination may occur. Dehydration contributes to constipation, and reduced body fat leads to lowered body temperature and the inability to withstand cold.

Mild anemia, swollen joints, reduced muscle mass, and light-headedness also commonly occur in anorexia. If the disorder becomes severe, patients may lose calcium from their bones, making them brittle and prone to breakage. They may also experience irregular heart rhythms and heart failure. In some patients, the brain shrinks, causing personality changes. Fortunately, this condition can be reversed when normal weight is reestablished.

In National Institutes of Mental Health (NIMH)-supported research, scientists have found that many patients with anorexia also suffer from other psychiatric illnesses. While the majority have co-occurring clinical depression, others suffer from anxiety, personality or substance abuse disorders, and many are at risk for suicide. Obsessive-compulsive disorder (OCD), an illness characterized by repetitive thoughts and behaviors, can also accompany anorexia. Individuals with anorexia are typically compliant in personality but may have sudden outbursts of hostility and anger or become socially withdrawn.

Bulimia nervosa patients_even those of normal weight—can severely damage their bodies by frequent binge eating and purging. In rare instances, binge eating causes the stomach to rupture; purging may result in heart failure due to loss of vital minerals, such as potassium. Vomiting causes other less deadly, but serious, problems— the acid in vomit wears down the outer layer of the teeth and can cause scarring on the backs of hands when fingers are pushed down the throat to induce vomiting. Further, the esophagus becomes inflamed and the glands near the cheeks become swollen. As in anorexia, bulimia may lead to irregular menstrual periods. Interest in sex may also diminish.

Some individuals with bulimia struggle with addictions, including abuse of drugs and alcohol, and compulsive stealing. Like individuals with anorexia, many people with bulimia suffer from clinical depression, anxiety, OCD, and other psychiatric illnesses. These problems, combined with their impulsive tendencies, place them at increased risk for suicidal behavior.

People with binge eating disorder are usually overweight, so they are prone to the serious medical problems associated with obesity, such as high cholesterol, high blood pressure, and diabetes. Obese individuals also have a higher risk for gallbladder disease, heart disease, and some types of cancer. Research at NIMH and elsewhere has shown that individuals with binge eating disorder have high rates of co-occurring psychiatric illnesses, especially depression.

Causes of Eating Disorders

In trying to understand the causes of eating disorders, scientists have studied the personalities, genetics, environments, and biochemistry of people with these illnesses. As is often the case, the more that is learned, the more complex the roots of eating disorders appear.

There are many theories. For any particular person, some or all of the following factors may be woven together to produce the final problem.

Personalities

Most people with eating disorders share certain personality traits: low self-esteem, feelings of helplessness, and a fear of becoming fat. In anorexia, bulimia, and binge eating disorders, eating behaviors seem to develop as a way of handling stress and anxieties.

People with anorexia tend to be "too good to be true." They rarely disobey, keep their feelings to themselves, and tend to be perfectionists, good students, and excellent athletes. Some researchers believe that people with anorexia restrict food— particularly carbohydrates—to gain a sense of control in some area of their lives. Having followed the wishes of others for the most part, they have not learned how to cope with the problems typical of adolescence, growing up, and becoming independent. Controlling their weight appears to offer two advantages, at least initially: they can take control of their bodies and gain approval from others. However, it eventually becomes clear to others that they are out-of-control and dangerously thin.

People who develop bulimia and binge eating disorder typically consume huge amounts of food—often junk food—to reduce stress and relieve anxiety. With binge eating, however, comes guilt and depression. Purging can bring relief, but it is only temporary. Individuals with bulimia are also impulsive and more likely to engage in risky behavior such as abuse of alcohol and drugs.

Genetic and Environmental Factors

Eating disorders appear to run in families—with female relatives most often affected. This finding suggests that genetic factors may predispose some people to eating disorders; however, other influences—both behavioral and environmental— may also play a role. One recent study found that mothers who are overly concerned about their daughters' weight and physical attractiveness may put the girls at increased risk of developing an eating disorder. In addition, girls with eating disorders often have fathers and brothers who are overly critical of their weight.

Although most victims of anorexia and bulimia are adolescent and young adult women, these illnesses can also strike men and older women. Anorexia and bulimia are found most often in Caucasians, but these illnesses also affect African Americans and other racial ethnic groups. People pursuing professions or activities that emphasize thinness—like modeling, dancing, gymnastics, wrestling, and long-distance running—are more susceptible to the problem. In contrast to other eating disorders, one-third to one-fourth of all patients with binge eating disorder are men. Preliminary studies also show that the condition occurs equally among African Americans and Caucasians.

Biological Factors

Temperament seems to be, at least in part, genetically determined, and some temperaments are more vulnerable to eating disorders than others. Also, once a person begins to starve, stuff, or purge, those behaviors can alter brain chemistry and prolong the problem. For example, both starving and stuffing can activate brain chemicals that produce feelings of peace and euphoria that temporarily dispel anxiety and depression.

In an attempt to understand eating disorders, scientists have studied the biochemical functions of people with the illnesses. They have focused recently on the neuroendocrine system— a combination of the central nervous and hormonal systems. Through complex but carefully balanced feedback mechanisms, the neuroendocrine system regulates sexual function, physical growth and development, appetite and digestion, sleep, heart and kidney function, emotions, thinking, and memory—in other words, multiple functions of the mind and body. Many of these regulatory mechanisms are seriously disturbed in people with eating disorders.

In the central nervous system—particularly the brain—key chemical messengers known as neurotransmitters control hormone production. Scientists have found that the neurotransmitters serotonin and norepinephrine function abnormally in people affected by depression. Recently, researchers funded by NIMH have learned that these neurotransmitters are also decreased in acutely ill anorexia and bulimia patients and long-term recovered anorexia patients. Because many people with eating disorders also appear to suffer from depression, some scientists believe that there may be a link between these two disorders. This link is supported by studies showing that antidepressants can be used successfully to treat some people with eating disorders. In fact, new research has suggested that some patients with anorexia may respond well to the antidepressant medication fluoxetine, which affects serotonin function in the body.

People with either anorexia or certain forms of depression also tend to have higher than normal levels of cortisol, a brain hormone released in response to stress. Scientists have been able to show that the excess levels of cortisol in both anorexia and depression are caused by a problem that occurs in or near a region of the brain called the hypothalamus.

In addition to connections between depression and eating disorders, scientists have found biochemical similarities between people with eating disorders and obsessive-compulsive disorder (OCD). Just as serotonin levels are known to be abnormal in people with depression and eating disorders, they are also abnormal in patients with OCD. Recently, NIMH researchers have found that many patients with bulimia have obsessive-compulsive behavior as severe as that seen in patients actually diagnosed with OCD. Conversely, patients with OCD frequently have abnormal eating behaviors.

The hormone vasopressin is another brain chemical found to be abnormal in people with eating disorders and OCD. NIMH researchers have shown that levels of this hormone are elevated in patients with OCD, anorexia, and bulimia. Normally released in response to physical and possibly emotional stress, vasopressin may contribute to the obsessive behavior seen in some patients with eating disorders.

NIMH-supported investigators are also exploring the role of other brain chemicals in eating behavior. Many are conducting studies in animals to shed some light on human disorders.

For example, scientists have found that levels of neuropeptide Y and peptide YY, recently shown to be elevated in patients with anorexia and bulimia, stimulate eating behavior in laboratory animals. Other investigators have found that cholecystokin in (CCK), a hormone known to be low in some women with bulimia, causes laboratory animals to feel full and stop eating. This finding may possibly explain why women with bulimia do not feel satisfied after eating and continue to binge.

Psychological Factors

People with eating disorders tend to be perfectionistic. They may have unrealistic expectations of themselves and others. In spite of their many achievements, they feel inadequate, defective, and worthless. In addition, they do not see shades of gray in themselves or in the world. Everything is either good or bad, a success or a failure, fat or thin. If thin is good, then thinner is better, and thinnest is best—even if thinnest is 68 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 powerless, defeated, and resentful.

People with eating disorders often lack a sense of identity. They try to create one by creating a socially acceptable appearance. They have answered the existential question, "Who am I?" with "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.

Family Factors

Some people with eating disorders say they feel smothered in their families. Others feel abandoned, misunderstood, and alone. Parents who overvalue physical appearance can unwittingly contribute to anorexia or bulimia. 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. There are often high expectations of achievement and success. Children learn not to disclose self-doubts, fears, anxieties, and imperfections. Instead they try to resolve their problems by manipulating weight and food.

Social Factors

TV, movies, and magazines are but three examples of media that flood girls and women with messages about the "advantages" of being thin Impressionable readers and viewers are told, sometimes directly, sometimes more subtly by the actresses and models that are chosen for display, that thinness is a requirement for goodness, success, power, approval, popularity, intelligence, friends, and romantic relationships. The corollary is that non-thin means badness, moral laxity, weakness, lack of control, failure, stupidity, loneliness, rejection, and disapproval. Never before in recorded history have females been exhorted to be as thin as is current fashion. Men, by contrast, are encouraged to be strong and powerful. As they work to develop their power in the gym and in the workplace, they equate "thin" with "skinny and weak." Perhaps that explains, at least in part, why only 10% of people with eating disorders are male. 

Trigger Factors

If a person is vulnerable to an eating disorder, sometimes all it takes to put the ball in motion is a trigger event that the person does not know how to handle. A trigger could be something as innocuous as teasing or as devastating as rape or incest. Triggers often involve the breakup of a valued relationship. They meet expectations: new school, new job, death, divorce, family problems, and so forth.

Continue to the next chapter.