Anorexia Nervosa, Bulimia and Other Eating Disorders

Anorexia Nervosa

The earliest written descriptions of anorexia nervosa were written in 1689 by Dr. Morton, an English physician, in his book called “Wasting Disease of Nervous Origins”. Morton considered the condition “nervous consumption” to be caused by “sadness and cares” (Morton, 1689).

In the 1870s, Sir William Gull and a Parisian neurologist, Dr. Charles Lasegue, published papers on a number of cases of self-starvation, now clearly recognizable as anorexia nervosa. Gull coined the term “anorexia nervosa” to distinguish the disorder from tuberculosis, just as Morton had tried to do two centuries previously. Gull felt that the disorder resulted from a “morbid mental state” and a “pervasion of the ego.” Lasegue decided anorexia could be “hysteria,” a common psychiatric grouping of female neurotic disorders at this time (Kirkpatrick & Caldwell, 2001).

Eating disorders, such as anorexia, have their roots at least as far back as the 13th century. They were seen in religious women who were canonized as saints for their fasting practices. These women were referred to as “holy anorexics.” The women of this time seem to value spiritual health, fasting and self-denial much as contemporary times values thinness, self-control and athleticism. Holy anorexia provided women with a highly prized status in both church and society (Kuehnel, 1998; Brumberg, 1988).

Saint Catherine of Siena, a religious devotee who lived in the 14th century, starved herself for very long periods of time as a form of spiritual fulfillment. When she did eat, she stuck twigs down her throat and forced herself to vomit as a punishment for breaking her sacred vow to not eat. She gained notoriety as a result of these practices, enabling her to affect the political and religious government of her time, until she eventually starved to death (Lelwica, 1999).

In the 1980’s, Joan Brumberg (1988), a historian, dispelled beliefs among many who thought that anorexia was simply a fad that would pass with time. She believed that “fasting girls” were medieval martyrs who used starvation to demonstrate religious devotion. Still today, a remarkable number of young women regard their body as the best vehicle for making a statement about their identity and personal dreams. Themes of self-denial, asceticism and abstinence are common to many religions. Purification of the body and soul through rituals involving fasting or avoidance of certain foods is well known. In many faiths, this is still a method used to reach higher and altered states of consciousness and to “purify oneself in the eyes of God” (Brumberg, 1988; Lelwica, 1999).

Bulimia Nervosa

Descriptions of extreme overeating have been recorded for over two millennia. Seneca, a Roman Philosopher and statesman, is quoted as saying “men eat to vomit and vomit to eat.” In the time of Caesar (100 BC), bulimia was evidenced by the presence of “vomitoriums.” “Eat, drink and be merry” included vomiting, which allowed one to return for further eating, drinking and merriment. The ancient Egyptians would consume substances, called emetics, to make them vomit for a few days each month for the purpose of preventing diseases attributed to food (Kuehnel, 1998).

In 1979, Dr. Gerald Russell, a psychiatrist working at the Royal Free Hospital in London, England, was the first person to officially define bulimia nervosa with a specific set of behaviours. One such behaviour was the deliberate or forced vomiting, which dated back to ancient times.

Binge Eating Disorder

BED was first identified in the year 1959. The American Psychological Association officially introduced the phenomena known as binge eating disorder in 1992 at an International Eating Disorder Conference. It was included in the medical diagnostic category in 1994 as distinct from anorexia nervosa and bulimia nervosa. BED is the least recognized and likely the most common eating disorder (Hassink, 2000; Costin, 1999). Compulsive overeaters, emotional eaters, food addicts and “bingers” are terms used to label people who engage in uncontrollable, impulsive and continuous eating well past the point of being full with a desperate, insatiable hunger that drives the binge eater to eat more (Sinton, 2005).

Studies suggest that BED is associated with a much broader demographic distribution in terms of gender, race and age than is the case with bulimia nervosa or anorexia nervosa. It is still however far more frequent in females than males. BED appears to occur at twice the rate of bulimia nervosa and at five times the rate of anorexia nervosa. The mean age of onset of BED occurs in late teens to twenties as compared to anorexia nervosa or bulimia nervosa that is diagnosed in the early to mid teens (Spitzer, Devlin, Walsh, Hasin, Wing, Marcus, Stunkard, Wadden, Agras, Mitchell, & Nonas, 1992; Castonguay, Eldredge, & Agras, 1995).

Binge eating disorder is not well understood although recognized as a significant problem. Individuals with binge eating disorders have a number of differences from both bulimia nervosa and obese non-bingeing (Lacaille, 2002).

A characteristic of BED is the person expressing marked distress about binge eating. They do not engage in regular self-induced purging behaviour, such as vomiting, fasting or the abuse of laxatives. BED is more than an occasional overeating episode that some people may experience over the holidays or family gatherings; it consumes the person’s physical, mental and emotional health. Unlike anorexia or bulimia, BED appears to be equally prevalent among black and white individuals and in those who seek help for weight control. Early binge eating field trials suggest that as many as 30% of people who participate in weight control programs actually have BED and more than 70% of participants in Overeaters Anonymous (Spitzer, Yanovski, Wadden, Wing, Marus, Stunkard, Devlin, Mitchell, & Hasin, 1993; Castonguay et al., 1995).

BED is found both among people of average weight as well as among people who are severely overweight. It is typical for a BED sufferer to have a history of dieting. Dieting behaviour is found to contribute to the development of this disorder (Fairbum & Brownell, 1995). Even as a distinct entity, BED share features from both anorexia and bulimia. For example, individuals share feelings of suffering and shame and have deep conflicts with and obsession towards food.

Eating disorders in general consist of a complex system of beliefs, thoughts, feelings and behaviours developed around self-image and body image that is played out in the sufferer’s relationship with food (Marx, 1989). Anorexia nervosa and bulimia nervosa are potentially fatal due to heart irregularities or the effects of starvation. It is important to remember that not all binge eaters are obese and not all obese people have BED (Costin, 1999).

Many suffer the physical complications of fluctuating weight in additions to psychological and emotional difficulties. After smoking, being overweight is the second leading cause of preventable death and it can increase potential for death from other causes by 60%. BED increases the risk of disease (many are related to being overweight) such as heart disease, high blood pressure, high cholesterol, diabetes, kidney disease or kidney failure, gall bladder disease, various cancers, arthritis and other joint problems, osteoporosis, reproductive system and pregnancy complications and malnutrition (Sinton, 2005; Hassink, 2000; ANRED, 2001).

Binge eaters often engage in “yo-yo dieting” that sets the stage for binge eating (Bloom, Kogel, & Zaphiropoulos, 1994; Sinton, 2005). Sadly the obese population is often ignored, ridiculed or regarded with disdain by an ignorant and fearful public.

The researcher first experienced this phenomenon when she questioned a young girl as to why she was eating her lunch while sitting on the floor next to the toilet stalls in the high school washroom. What would make a person take refuge in such an inappropriate environment as the school bathroom to eat a meal? In seeking an answer to that question the researcher befriended the girl whose only “crime” was to weigh significantly more than the average student. This relationship gave the researcher valuable insight into the experiences of a young girl and her struggles to survive in a “thin” world.

Etiology of Binge Eating Disorder (BED)

A number of people who seek treatment for obesity may also have problems with recurrent binge eating disorder. The causes of these conditions are complex and thought to be environmental, familial, genetic, biochemical, cultural, and psychological (Shuman, 1994). Eating disorders are complex in both cause and cure. It is not uncommon to have a team of medical professionals treating this illness.

Director Ellen Shuman, and licensed psychologist, Dr. Sandy Matthews operate the Acoria Eating Disorders Treatment Center in Cincinnati, a multi-disciplinary treatment team consisting of 12 clinicians: a psychiatrist, psychotherapists, personal coaches, a dietician, and a physical conditioning specialist offering full range of problems associated with overeating; such as depression, anxiety, obsessive-compulsive and impulse control problems, substance abuse, and personality disorders. Patients with BED feel negatively towards their bodies.

They also feel self-conscious about the size of their body as well as having distorted attitudes about eating, shape, and weight. By the time they arrive at the treatment Centre they feel out-of-control and desperate. Most people with BED have a long history of attempting restrictive diets in an effort to “regain control.” Weight however is only a symptom, not the problem. Thus any intervention that involves dieting alone is met with poor success (Shuman, 1994).

BED, as well as anorexia nervosa and bulimia nervosa are a disorder of disconnection; disconnection from one’s feelings and from one’s self. These obsessive “food thoughts” are used to manage intense states. For example, an individual who faces a difficult conversation with his mother may disconnect from the anxiety he is feeling by thinking about the ice cream in his freezer. Another individual, when faced with stress at work or feelings of anger towards her supervisor retreated to the staff lounge and bought candy bars from the vending machines. The moment she started to think obsessively about the food in the vending machines, she successfully disconnected from her life stresses and from her emotions of anger (Shuman, 1994).

Another individual faces an evening of being alone. Tired and hungry, she turns into a drive-through lane and buys enough food to “numb” her transition from work to home. She already knew that she would overeat throughout the evening. People with BED use “food thoughts” in reaction to and as a defence against stressful life situations. Using food thoughts, they “disconnect” from the intensity of feeling. This way of managing their moods becomes a way of life (Shulman, 1994). Gene Roth in “When Food is Love” (1992) described the way people eat as a metaphor for the way they live and love. Many people with BED live in a fantasy world in which food is their friend and protector (Roth, 1992).

Gender Issues and Eating Disorders

“We’ve come along way baby!” is a familiar cliche used by advertisers since the suffragettes’ great advances toward emancipation and self-empowerment in the 1920’s. This was one of the most significant social phenomena of the past century, having universal importance for the achievement of a separate identity for women (Angeloni, 1990). This quest for identity gave women the potential to enjoy both their freedom and independence they perceived men to have had. Or has it?

More than 90% of eating disordered patients are female (Denmark & Paludi, 1993). If the assumptions one makes about the nature of one’s truth and reality shape the way we see the world and our participation in it, then it is important for women to examine their beliefs and the way they think and feel, to understand the impact of these beliefs on their lives.

In the past, social and cultural systems have encouraged the control of appetite in women for different reasons. In the earlier era, control of appetite was linked to piety and belief achieved through fasting. The medieval ascetic wished for perfection in the eyes of her God. In Western culture, the modern female’s control of appetite is embedded in the social structure of family, class and gender. The anorexic today seeks perfection in terms of society’s ideal of physical, rather than spiritual beauty (Lelwica, 1996).

Feminist author and lecturer Sandra Friedman, proposes that in a male-oriented culture (based on competition, independence and detachment), qualities that were once encouraged in females, such as consideration, co-operation, nurturing and politeness are now framed as needy, dependent, hysterical and indecisive (Friedman, 1997). It is not surprising that women are held to be at greater risk for developing depression as compared with men.

In a gender role study by Hart and Thompson (1996) on depressive symptomology, women were found to be depressed slightly more than twice as often as men. Researchers concluded that the most significant factor in depression studies is that women judge themselves more harshly by external standards than men do. They see themselves through the eyes of societal norms to a greater extent (Hart & Thompson, 1996).

It has been found that women are more dissatisfied with their bodies than men are with their bodies. In fact, dissatisfaction with one’s body is so commonplace among women that it has been labelled the “normative discontent” (Bergeron & Senn, 1998; Denmark & Paludi 1993).

However, there is growing evidence that males are becoming increasingly dissatisfied with their weight and body image. Dr. Arnold Andersen, a leading figure and pioneer in identifying eating disorders among males, believes that males are under-represented in most eating disorder statistics due to a lack of professional knowledge, and a reluctance of eating disordered males to seek help (Andersen, Conn, & Holbrook, 2000).

Eating disordered males suffer stigma of shame and embarrassment (Mann, 2000) as eating disorders are seen as a “women’s disease” (i.e., diagnosis of anorexia is the lack of three consecutive menstrual cycles, an impossibility for males) (Andersen et al., 2000). Also, bingeing behaviour and compulsive exercising is considered more acceptable and normal in males than in females (Swan, 2000).

Even though the attitude “we’ve come a long way baby” is theoretically embraced by our society, female gender roles strongly emphasize a young women’s physical appearance over many other possible attributes. Well-intentioned family members, fearing the uncertain future of young women who are not considered “thin” or “attractive” by society’s standards, often perpetuate stereotypical female images (Kirkpatrick & Caldwell, 2001). It is not uncommon to hear adolescent females talk about breast implants and the latest diet fads, perceiving physical attractiveness as having great value and reward.

Eating disorders are a complex interplay of socio-cultural, environmental and individual factors (Thompson, 1996). Eating disorders most often diagnosed in the early teens to late twenties are considered a young woman’s illness. Results of a new area of research finds that it is not uncommon for middle-aged women to also suffer with body image disturbances and eating disorders that are likely under-diagnosed in this population (Hall & Driscoll, 1993; Lewis & Cachelin, 2001).

Why is this? Are they not encouraged to embrace facial wrinkles and sagging breasts as signs of a deeper wisdom earned through years of loving and living? Apparently not as there is more plastic surgery, liposuction and laser treatment to regain youthful appearance (Hesse-Biber, 1998). Media tends to depict older women and the aging processes primarily in negative and critical terms sending a clear message that aging in women leads to a loss of attractiveness, desirability and ultimately love (Zerbe, 2003).

The importance of physical beauty, perfectionist personality traits and high levels of anxiety caused by a multitude of midlife changes, loss of marriage, family, parents, children (empty-nest-syndrome) are implicated in the development of eating disorders in middle-aged women (Streigel-Moore & Marcus, 1995; Allaz, Bernstein, Rouglet, Archinard, & Morabia, 1998; Lewis & Cachelin, 2001).

Goal of Treatment

The American Psychiatric Association’s (APA), based in Washington D.C, and is the pre-eminent scientific and professional organization that represents psychologists in the United States. Their practice guidelines for the treatment of eating disorders states that patients with eating disorders may display a broad range of symptoms that occur along a continuum between those of anorexia nervosa and those of bulimia nervosa and binge eating disorder.

The goal for the treatment of anorexia nervosa is to restore patients to a healthy weight, reduce the threat of physical complications, enhance the patients’ motivation to cooperate (usually administering antidepressants, for example, serotonin reuptake inhibitors) and provide education about healthy nutrition. Other goals of treatment include the correcting of maladaptive thoughts, attitudes and feelings related to the eating disorder, enlisting family support and attempting to prevent a relapse (Miller, 2000).

A multidisciplinary team, consisting of physicians, dieticians, behavioural-cognitive therapists, psychotherapists or nurses may be required, depending on the severity of the disorder. A physician is needed to determine that the patient is not in immediate physical danger. A nutritionist is assigned to help assess and improve the nutritional intake.

The goal of treatment for binge eating disorder is to assist the client in addressing their binge-eating disorder, any associated obesity, and any associated psychopathology through both individual therapy and group therapy.

The primary goals of treatment are to:

  • Reconnect with the body and with feelings
  • Identify cognitive distortions
  • Recognize perfectionism and “all or nothing” thinking
  • Identify physical vs. emotional hunger
  • Increase capacity to tolerate feeling states
  • Learn how to communicate needs and set boundaries
  • Improve body image
  • Learn self-care
  • Recognize recovery as a “process” filled with ups and downs

As treatment continues, clients are encouraged to use other services, such as psychiatrist, psycho-educational programming, support groups and nutritionist (Porzelius &Bolton, 1999).

Psychology plays an important role in the successful treatment of eating disorders. The psychologist identifies issues that need attention and develops a treatment plan. They may help the patient replace destructive thoughts and behaviours with more positive ones. For example, a psychologist and patient might work together to focus on health issues rather than weight, or a patient might keep a food diary as a way of becoming aware of the types of situations that trigger bingeing. Once the patient’s pattern of behaviour has changed, psychologists and patients may explore the psychological issues underlying the eating disorder.

This may improve the patient’s personal relationships and may explore the situation that initially triggered the disorder (Brownell et al., 1998). Many popular treatments for compulsive overeating advise people to give up their focus on losing weight if they are to gain control of their eating patterns. Instead they focus on the individual’s ability to accept their weight addressing their poor body image (Porzelius & Bolton, 1999).

Treatment for Binge Eating Disorder

As binge eating disorder is a relatively new diagnosed eating disorder, the established treatments are thus far quite limited. A few studies have focuses on the recovery of BED through cognitive behaviour therapy (CBT), Interpersonal psychotherapy (IPT) (Fairburn, Cooper, Doll, Norman, & O’Connor, 2000). These are psychological treatments that appear to have a success rate in between one and two thirds of cases (defined as achieving remission) (Wilson & Fairburn, 2000).

Cognitive Behavioral Therapy

Current cognitive behavioral therapy (CBT) of BED resembles treatment developed for bulimia nervosa. It involves keeping a diary of relevant themes (what foods are eaten and what time of day), bingeing behavior (identify feelings and thoughts before and after binge episode). Individuals are taught coping skills to help deal with stressors that are identified as contributor to binge eating pattern (Porzelius & Bolton, 1999). Studies have found that individuals with BED may require treatment that focuses on their binge eating behavior before they try to lose weight. Treatment for BED is well received when administered within a group format (Wilson & Fairburn, 2000).

Interpersonal Psychotherapy

Interpersonal psychotherapy (individually or in groups) has also been used to effectively treat BED. Interpersonal psychotherapy is effective for assisting the client to examine their relationships with friends and family and to make changes in problem areas.

Medications, such as, antidepressants, are prescribed for some individuals. Even though binge eating is the primary diagnosis, many clients have co-morbid conditions, such as depression, which may warrant pharmacological treatment. Anti-depressants that influence the levels of serotonin (SSRI) are often an important component of treatment. Research attempts to determine which method or combination of methods is the most effective in controlling binge eating disorder (International ED, 2005). Many initial studies have had significant shortcomings including the use of weak assessment measures, insufficient controls and lack of follow-up. Most of the research has been restricted to those patients with BED who also meet the criteria for obesity (Wilfley & Cohen, 1997; Wilson & Fairbum, 1998).

Alternative Treatments

The bio-psycho-socio-spiritual model has been widely accepted for several decades in understanding the etiology of mental disorders. It has not been widely applied to the area of eating disorders (Leichner, Brown, Atkinson, Henderson, & Jacek, 2001). The Center for Change, in Orem, Utah, is a treatment Centre that specializes in the treatment of women with eating disorders. Many patients feel a great deal of shame and remorse about their deception and lying, compounded by feelings of guilt for failed promises to give up their eating disorder (Hardman & Berrett, 1999). Results found deep spiritual struggles to be a major focus in their patient’s ability to recover.

Dr. Pierre Leichner, Psychiatrist, and Dr. Ron Manley, Psychologist, at the Children’s Hospital, in Vancouver, British Columbia found several recurring themes working with eating disordered patients. These patients were described as feeling hopeless, undeserving of help, worthless and unable to express their feelings. Eating disorders are a “leveller of experience, reducing life to a small caloric awareness and focus on food” (Leichner & Manley, 2002). According to Dr. Leichner and colleagues, establishing spiritual values can reinforce self-nurturing beliefs and behaviour that is necessary for healthy living.

Eating disorders represent a search for meaning, a desire for recognition and perfection and a hunger for a deeper and larger sense of themselves (Leichner et al., 2001). Can this hunger be satisfied by their personal connection with their mind/body/spirit? Regardless of age, the women in this author’s BED classes are searching for something that will allow them to feel whole, connected and complete in their bodies.

Compared to illnesses such as alcoholism and drug abuse, eating disorders are especially difficult and destructive because they deal with food and nourishment, a part of life that is fundamental to well being. One can give up smoking, taking drugs or drinking “cold turkey,” however food is necessary for the survival of the body thus making this recovery very difficult (Hardman & Berrett, 1999). Women with eating disorders often speak about how fat they feel or of how undeserving of love they are, rather than the deeper, substantive issues of their feelings of pain, loneliness and emptiness (Hardman & Berrett, 1999). One can replace the negative mind with thoughts of hope and inspiration. To see the changes in an individual’s life that come through thinking differently is truly magical.

An intervention used for patients with eating disorders at St. Paul’s Hospital, Vancouver, British Columbia is learning the science of yoga. Inner control through meditation as well as physical control through different breathing method and posture brings together the mind and body in greater harmony. This type of practice supports the mind/body/spirit connection and can create a healthier body image for women.

The results of one study found that spiritual beliefs and practices, such as prayer, meditation and reading spiritual books were an under utilized resource for coping with body image concerns (Jacobs-Pilipski, Winzelberg, Wilfley, Bryson, & Taylor, 2005).

Much has been written about the importance of forgiveness in healing and therapy. According to Richards, Hardman, Frost, Berrett, Clark-Sly, and Anderson (1997), it is one of the most frequently used interventions in psychotherapy. Helping eating disordered patients to forgive parents, abusers, themselves and God is found to be important in the healing process. The idea of forgiveness is explained as a gift or choice rather than a requirement. The patients are encouraged to be open to love and to understand self-forgiveness as a healing process requiring responsibility and accountability rather than self-punishment. True forgiveness is a result of inner understanding and compassion (Richards et al., 1997).

It is not surprising that for thousands of years, long before the advent of modern medicine, people looked to spirituality for cures. Contemplation, meditation, prayer, rituals and other spiritual practices have been known to release the life force in the deepest levels of the human soul. Similarly to the use of spiritual interventions at the Center for Change, Dr. David Elkins cites four ways to begin one’s spiritual journey of healing without placing emphasis on mainstream religious dogma. They include some form of relaxation, meditation, prayer, spiritual readings and being in nature (Elkins, 1999).

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