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Anorexia and bulimia are the two psychiatric disorders that have the most significant degree of significant physical dysfunction because of the aberrant eating patterns and the problems that occur relative to nutrition. It is a disorder that occurs primarily in white, middle to upper class individuals. We are seeing anorexia gradually extend down into the lower socioeconomic classes. It primarily affects females between the ages of 12 and 20. The instance has increased from about 1:250 twenty years ago, to about 1:100 at the present time. There has indeed been a marked increase in the last 15 -18 years for this disorder. It is commonly seen in individuals who are involved in appearance-related sporting activities or in activities where appearance is a primary determinant of scoring; such as gymnastics, dance, modeling and acting. There’s a significant female predisposition to this with a female to male ratio of eating disorder, anorexia nervosa and bulimia.
The mortality rate early on was 5% to 10%, and that was primarily because of starvation. The two most likely ways in which an anorexic individual will subsequently lose her life, are from suicide or from organ failure, particularly cardiac dysfunction and cardiac arrhythmias. Anorexia nervosa generally begins in adolescence and oftentimes it begins just with the individual feeling a little fat and overweight and wanting to trim down and wanting to lose a little weight. She then begins a diet but that dieting evolves in to a tremendous preoccupation with food. Anorexia is really not a disorder of dieting, it’s a disorder of food. It’s a tremendous preoccupation with limiting their caloric intake and trying to eliminate fat from the diet as much as possible. Almost uniformly, in an attempt to enhance the weight loss further, these individuals will pick up and increase their exercise activity.
We don't know all there is to know, obviously, about the pathogenesis of this disorder. We do know that there are a number of factors involved, as depicted here. There are social/culture factors which are very strong and very prominent. You can’t look at television these days without getting a message about dieting.
There are familiar problems which are more characteristic in families from which anorexic individuals will come. They are families often described as being significantly meshed with a lot of rigidity. There are developmental problems within the individual, per se, particularly with ego development.
There is a complex interplay between the factors which are currently being looked at, as far as perpetrating anorexia nervosa is concerned. First of all, there are a lot of adolescent conflicts going on in these individuals. Not the least of course is weight, the concerns about weight, how they look. "Am I attractive?" There are a lot of interpersonal problems and the insecurity. There’s a lot of stress and failure. They then tend to try to separate out one aspect of their life that they can control. So many of the other aspects it seems that they are uncomfortable with, that they have very little control over. They are dissatisfied with life.
There are four major criteria for anorexia nervosa. The first one is that they have to have lost weight, or never gained weight, to where they are now 85% or less than what they ought to be. So they have a refusal to maintain body weight over a minimal normal weight for age, or they’ve never gained that. So that they are at that 85% expected. So that’s an important number to remember. Secondly, they have an intense fear of gaining weight or becoming fat.
As far as body image is concerned, and again they will have anywhere from 5% to 20% distortion. They’re thin, continuing to get thinner and thinner and thinner, but their perception of themselves of course is that they are still overweight, they are still fat, they still need to trim quite a bit.
This is the kind of image that they uniformly get portrayed, or uniformly get presented to them as the goal for their acquisition. Very thin, asthenic sort of individual and you can see again, this individual is obviously proud, successful and quite pleased with all aspects of her life. Let’s look then at what society has portrayed as being body image or healthy body image over the course of a number of centuries. I think this particular statue depicts for us a far more reasonable appearance of
You can play a role in the treatment of these, although I would caution all physicians not to ever try to assume the care of an anorexic all by themselves. You simply don’t have the time. You don’t have the wherewithal to go through all the mental help and therapy that these individuals need. But you can continue to follow their nutrition. You can continue to follow their metabolism as they go through psychotherapy and nutritional counseling, either as an outpatient or as an inpatient. You need a team. These individuals are second only to the individuals with addictive disorders as far as their ability to play off one team member against another and try to get what they want. So you need a good strong team alliance with primary focus of the team being the physician, the psychotherapist and the dietitian.
The outpatient goal is to get them to slowly achieve weight. We start them off with a caloric intake about 250 calories above where they were when they came in. Every three or four days we increase their caloric intake by about 250 calories. An interesting thing happens. They lower their metabolism during the process of
They need a steady weight gain up to 90% of ideal body weight if they are over 18. If they are still an adolescent - particularly if they are 10, 11, 12, 13 years of
Psychotherapy, nutritional counseling, and again a strong team alliance, because they are going to try to play one of you against the other and try to limit their caloric intake. They’ll hide food. They’ll water load before their weight scales in the morning so that they look like they’ve gained weight but they haven’t gained
Bulimia nervosa most commonly affects white middle and upper class individuals. Again, females aged 15 to 20. A little bit older. Anorexia we start seeing at 11, 10, 12 years of age. Bulimia oftentimes not until they are 14 or 15 years of age. Incidence is much higher than anorexia nervosa, 2% to 5% in the general
These individuals begin dieting, but they can’t control the diet to the extent that the anorexic individual ultimately is able to. They get frustrated with the diet. Continue to want to lose weight and try to devise some shortcut by which they can get the weight loss to begin. So they being experimenting with purging
They then develop progressive escalation of purging behaviors. They are extremely secretive about their behaviors. Even more so than the anorexic. I have had some individuals who have been able, for over 15 years, to hide this from their husband, to hide it from other family members, to hide their bulimic purging behaviors from other individuals. We had a secretary once who worked with about 15 other secretaries, she know to the minute when all those other individuals
Again, there are a number of factors which are more commonly present in families of individuals with bulimia nervosa. These are families that are disengaged. They have high conflict difficulties, low expressivity and high achievement goals. There are biogenetic factors which appear to be more commonly present in individuals who are developing bulimia nervosa - and we’ll talk about those in a minute - and of course there are tremendous social-cultural factors; pursuit of thinness and a particular stigma against obesity. As far as their biogenetic underpinning or association with this disorder, there is an association - anywhere from 20% to 70% - of families will have affective disorders; depression, dysthymia, chronic low self esteem, chronic low grade dysphoria, just not feeling well. So there’s a strong association of depression. In fact, in individuals with bulimia about 50% have significant levels of clinical depression and that’s why medications like Zoloft, Luvox or Prozac are very helpful in the treatment of bulimia nervosa, because of the strong association with affective disorders.
There are endocrine abnormalities that occur more commonly in these individuals than in the general population, so there is some supposition that these patients also have subtle endocrinologic abnormalities. They have a failure to suppress to the extent that you would expect on dexamethasone suppression test and a more prominent response on a TRH stimulation test. They have similar EEG patterns with decreased REM latency and that’s again why they respond to antidepressive drugs. There is also a high association of alcoholism and drug dependency; addictive sort of behaviors, kleptomania, in these individuals with bulimia nervosa. The family, we’ve already talked about. They are
Social-culture particular emphasis on thinness, and a significant … I mean the degree, we don’t appreciate the degree to which there is a social stigma now associated with being obese in our country. They have done psychological surveys on children. In children, they attach a more negative concept to people that are obese than they attach to people with multiple handicaps. There is a significant stigma against obesity. They are teased, they are ridiculed. It’s merciless because
The characteristic personality style for individuals who are at risk for developing bulimia nervosa includes affective instability and they have low self esteem. Affective instability means that they are impulsive, they have low frustration tolerance, low moods, highly variable moods and high anxiety levels. If you have an