Psychology

Anorexia nervosa and bulimia nervosa may be described as major eating disorders. These may also be described as psychological disorders associated with eating and not eating. The compulsion to eat or to go on diet is extreme, which is gradually increased and gets out of control. These people fear becoming fat or perceive themselves as being fat, when actually they are not. Apart from anorexia and bulimia, the other food related disorders include binge eating disorders, food phobias etc. Although not much is known about what actually causes eating disorders, there are several theories on how people develop them.  Eating disorders are generally evident between the ages of 13 and 17. This is a period associated with adolescent growth and with immense emotional and physical changes. This is also a period where there is academic and peer pressure on an individual, just when he or she struggles with relationships and identity. During puberty, teens get a feeling that they are not in control of their individual freedom, which sometimes include their own bodies (Nemours, 2010). It is normal for girls to put on weight during puberty, which may even be said as being necessary too. However many may see this increase in weight as an adverse development, desperately wanting to get rid of it. Eating disorders can also lead to depression, anxiousness and obsessive compulsive disorder.

Eating disorders are not a recent development. There have been plenty of references to eating disorders in the literatures. During the late 17th century, the English physician Richard Morton described the symptoms as Nervous consumption. Anorexia was formally diagnosed for the first time in 1873.  In 1873 Charles Laseque and William Withey wrote about intentional restriction of food, in which they described symptoms to diagnose anorexia, that were similar to what is followed today. The symptoms however have been observed 300 years early. The number of anorexics has increased tremendously since World War II. Bulimia has also been known for centuries although its prominence and relevance has increased only in the last few decades (Dalkilic, 2004). It has been recorded that people in ancient Rome used to vomit food, they consumed during a feast. There were even specially designated places vomitorium. Physicians in the 18th century perceived bulimia with respect to overeating and vomiting. It was more considered as a gastric dysfunction than an eating disorder with a psychological bearing. It was only in the 20th century that an awareness of anorexia and bulimia came to prominence with a better understanding. In the 1970s, systems of bulimia were identified that were different from anorexia.

Anorexia may be described as a condition associated with dieting that has got out of control. Anorexia often begins with dieting, intended to lose weight. With time however, achieving weight loss is seen as a sign of mastery and control, and the fear and need to control the body becoming important. The urge to become thinner is actually not the primary concern. The individual takes to destructive eating which is often associated with other behaviors like use and overuse of diet medications, over exercising and use of laxatives. It must be noted here that some disorders may be associated with a lack of appetite, but the characteristic feature of anorexia is the deliberate restricting of food. In order to experience a sense of control over the body, these individuals take to extreme limits like even moving close to starvation. The restrictive eating cycles become an obsession, which in many ways is a type of addiction. Women are more prone to anorexia with about 95 of affected population being women although men too can develop the disorder. Anorexia normally manifests in an individual during the early adolescence period. In advanced countries like the US, one in every 100 adolescent girls is expected to have the disorder. It has also been determined that Caucasians are more prone to anorexia compared to people of other backgrounds. Another significant correlation of anorexia is that it is more prevalent among the middle class and upper class sections. According to estimations of the US National Institute of Mental Health, about 0.5 to 3.7 of the women would experience anorexia, sometime in their lives. Individuals belonging to professional groups like sportsmen, dancers, actors etc. who aspire to be thin are especially prone to anorexia.

Bulimia is also an eating disorder associated with excessive or binge eating, only to be followed by inappropriate weight control methods like over exercising, induced vomiting and abuse of laxatives. The condition occurs subsequent to uncontrolled dieting.  The individuals quickly get obsessed with the cycle of over eating and vomiting, similar to drug and substance addiction. The disorder manifests after a sequence of unsuccessful dieting attempts. Bulimia in the US is believed to affect about 3 of all women at some point of their lifetime. About 5 of females in their early twenties and 6 of teenaged girls are expected to suffer from Bulimia. Bulimia is also closely associated with addictions and compulsions. It has been estimated that about 20 to 40 women affected with Bulimia have a history of drug and alcohol abuse, indicating behavioral control problems. Sometimes bulimic behavior is also seen in anorexia. Binge eating is not actually driven by hunger but triggered by depression, stress and other feelings associated with body weight and shape. Generally there is a feeling of satisfaction or happiness after binge eating, but soon there is self-loathing that sinks the short-lived happiness. There is a loss of control during binge eating and the individual resorts to vomiting in an effort to regain control. It should be noted here that all Bulimics do not engage in induced vomiting, use of enema or laxatives. While some resort to fasting for a few days to compensate a binge session, others may resort to excessive exercising. The excessive exercising includes exercising at inappropriate times and places or indulging in it even when sick or injured. Bulimics often experience weight fluctuations, but however their weight loss is not as severe as in anorexia. Also long term prognosis and recovery rate is higher for bulimics compared to anorexics.

Eating disorders can be successfully treated when diagnosed early. Anorexia and bulimia are often overlooked in males, as these are relatively rare in boys and men. Identifying people with such disorders and bringing them under treatment is indeed difficult. The longer the disorders prevail, the greater is the treatment difficulty and its effects on the body. Long term treatment might also be required in some cases. Family and friends can contribute to the success of the treatment by playing a crucial role by offering support and encouragement. Whenever an eating disorder is suspected, a physical examination must first be carried to rule out all other illnesses for the weight loss. Based on the assessment by the clinician, the patient may be hospitalized or treated as an outpatient. Conditions requiring hospitalization include excess and rapid weight loss, extreme binge eating and purging, clinical depression, major metabolic disturbances etc. Given the complex association of psychological and emotional problems in eating disorders, a comprehensive treatment plan involving various experts is necessary. The treatment team should ideally include an internist, a psychotherapist, a nutritionist and a psychopharmacologist, or an expert psychoactive medications. 

Anorexia and bulimia have notable similarities and differences. There is much in common, with both these disorders being associated with people who are unnaturally concerned about becoming obese and begin to diet. They are always preoccupied with weight, food and personal appearance. Wanting to be perfect they struggle with depression and anxiety even taking to substance abuses that probably stated with diet pills. The basic difference between anorexia and bulimia is that while in anorexia people starve themselves or compulsively exercise people with bulimia eat large quantities of food or binge eat only to force it out through vomiting, use of laxatives etc. (Family doctor). Among the other notable differences between the two is that, although both are worried about other peoples opinion, those with bulimia are extremely worried. They are more concerned of pleasing others, wanting to look attractive and get into intimate relationships. They tend to be more sexually active compared to those with anorexia. People with bulimia are driven only by few obsessive qualities that drive anorexics.  However they are likely to get easily frustrated, have long histories of mood swings and find it difficult to control their impulses. Individuals with bulimia are more likely to frequently change friends and relationships and experience strong emotions. One third of those affected by bulimia also exhibit personality disorder characteristics. Another major difference between the two eating disorders is reflected in their medical complications (Susic P, 1999). While almost all women with anorexia are amenorrhic or have irregular menstrual periods, only about half those who suffer bulimia experience it.

The cause of eating disorders is not much known although many are speculated. There is no definite known cause for anorexia despite studies pointing out to genetic links playing a crucial role for an individual becoming susceptible to anorexia. Preliminary studies indicate a gene at chromosome 1p as being responsible for anorexia nervosa (Edwards R. D, 2010). There is also evidence attributed to dysfunction of the hypothalamus of the brain. There has also been evidence of neurotransmitter imbalances in the brain causing anorexia. The risk factors associated with anorexia are, a history of under eating, feeding difficulties during infant stage and depressive symptoms in mother. Negative feelings and an inclination to perfectionism may also predispose an individual to anorexia. It is perceived that people, who have any eating disorders, are likely to have experienced childhood abuse. With a poor self-image, individuals fall under pressure to be attractive and thin, with which the destructive cycle begins. Anorexia cannot be easily diagnosed as individuals often hide their symptoms, through denial and secrecy. The denial is evident when an individual refuses to seek professional help, not willing to accept that there is a problem with him or her. In most cases, diagnosis is established only at the onset of medical complications. Professional help is sought by the family members only when they are alarmed by the weight loss. When sought by the healthcare professional, anorexics would not be able to account for their condition and developments, being unreliable and inaccurate in providing an insight into their problem. Their cooperation is also reflected from their severely malnourished condition. Necessary information for the treatment is therefore sought from parents or other family members. Some important criteria for diagnosing anorexia include

Not wanting to maintain body weight at or above the minimum weight proportionate to height and age. Anorexia is indicated when a bodyweight of less than 85 of this expected weight is maintained.

Despite being underweight, there is an extreme fear of becoming fat

Highly distorted self-perception where weight loss is either not fully acknowledged or is minimized.

Among menstruating women, when three or more consecutive periods are missed or periods occur only after administration of a hormone.

The psychological and behavioral effects associated with anorexia have the potential to devastate an individuals life. It can also affect other family members too. The psychological and behavioral attributes in anorexics are

Depression and withdrawn socially due to extreme underweight.

Gets easily irritated and upset and face difficulties in their interaction with others.

Concentration and attention is reduced.

Most individuals who suffer from anorexia get obsessed with food and thoughts of food. They constantly think of food, prepare meals for other people and stock food

Mood disorders, personality disorders and anxiety disorders are also evident in these individuals.

Anorexia affected individuals complain about everything except food. They normally do well in school and in various activities. Physical appearance being important, excellence in other fields is emphasized too, that they are mostly high achievers.

The medical complications of anorexia include gastrointestinal complications, complications of the heart and the circulatory system. Anorexia is associated with abnormally slow heart rate and low blood pressure. There is also disturbances in the cardiac rhythm, although these may not be life threatening. With regard to gastrointestinal complications, constipation and abdominal pain is common. The process of food absorption into the body is slowed, and enzyme level changes cause liver damage. Adolescent girls with anorexia are particularly prone to disturbed menstrual cycles (Familydoctor.org, 2010).  Although the renal function may look normal, there is an increased or decreased urination. Another important complication of anorexia is osteopenia, a condition related to thinning of bones. There is a rapid bone loss in girls with anorexia. It should be noted here that anorexia is one of the psychiatric conditions with high mortality rates. About 6 of those affected by anorexia succumb to the disease. Cardiac arrest and electrolyte imbalance are the prominent medical complications associated with anorexia leading to death. Under proper treatment, it is possible for half the affected population to make a complete recovery. About 20 of those affected by anorexia remain chronically ill. The treatment for anorexia may stretch for several years and sometimes may require lifetime treatment.

Similarly bulimia too currently has no known cause, but generally perceived to develop with a dislike to ones body. Despite being underweight, an individual looking at a mirror might see a distorted image of being fat, only to start dieting. With the body image continuously perceived as being large, dieting only escalates and induces one to bulimic practices. Studies indicate bulimia to be associated with abnormalities in the levels of neurotransmitters of the brain like serotonin. Studies have also indicated that bulimic individuals have a decreased perception of satiety, altered metabolic rate and abnormal neuroendocrine regulation. Just as in anorexia, bulimia too is associated with secrecy and denial, making diagnosis very complicated (Healthyplace.com). Here too the individuals seek professional help only when the medical or psychological conditions have worsened.  The basic criteria in diagnosing bulimia is

Sequential binge eating within two-hour period, where food consumed is much more than what most people would have.

Uncontrolled eating with a feeling of helplessness to stop.

Compensatory behaviors like vomiting, laxatives abuse, fasting, excessive exercising etc.

While individuals affected by bulimia may be underweight, overweight or normal weight, some symptoms that are likely to indicate bulimia are

Going to bathroom to induce vomiting after every meal.

Swollen cheeks and jaws, damaged tooth enamel, broken blood vessels in the eyes due to excessive vomiting.

Unnecessarily preoccupied with body image or weight.

The medical complications associated with bulimia are mostly due to continued binging and purging. The purging behavior has several effects on the body system. Vomiting can lead to oral complications with the acidic gastric contents eroding the tooth enamel, due to continued exposure. There is an increase in dental cavities and also sensitivity to hot and cold food is developed. Repeated vomiting can also cause the salivary glands to swell and sore. Bulimic behaviors affect esophagus and colon the most. Regular vomiting also cause ulcers and ruptures of the esophagus. When use of laxatives is regularized, the normal elimination process gets impaired. With regard to diuretics misuse, there is an abnormal build up of fluid. The combined abuse of laxatives and diuretics can put a bulimic individual at risk for electrolyte imbalance, which at times can even be life threatening.  A bulimic mother can also cause complications to the fetus or the infant. When untreated psychological problems escalate, the restoration of the normal body functions become difficult.  However these are reversible through treatment. 

Bulimics in serious conditions require to be first brought to a stable physical condition. The treatment of bulimics requires to be directed at meeting both the psychological and physical needs of the patient, so as to restore physical health and normal eating patterns.  An ideal treatment needs to identify and address issues associated with control and self-perception. It is also crucial for the patients to identify the feelings and beliefs that caused the initial disorder. The patient needs to be counseled on nutritional effects, behavior control and best practices in weight control. They need to accept their bodies and strive for a healthy physical and mental life. The recovery process requires immense patience, as the results would be slow.  A positive attitude together with personal efforts on the part of the affected individual is vital for a successful recovery. Several antidepressants have been proved to be beneficial in the treatment of bulimia. Several studies have showed fluoxetine as being effective in treating bulimia. The FDA of the US has also approved fluoxetine in the treatment of bulimia. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI)  type of antidepressant. These are popular than the monoamine oxidase inhibitors (MAOI) due to its reliability, safety and low side effects.

People with eating disorders require their emotional issues to be identified and addressed and therefore psychotherapy is generally used. Mental health professionals provide emotional support and help the patient to understand and cope with the illness. Group therapy has been proved to be successful in the treatment of bulimia. The effectiveness of combined psychotherapy and medications has been studied by scientists of the National Institute of Mental Health. Researchers have recently established that group therapy and antidepressant medications are beneficial to patients, when administered either alone or in combination. Antidepressant medications were also seen to be most beneficial when combined with cognitive-behavioral therapy. The combination has been observed to be very effective in preventing relapse subsequent to the discontinuation of medications. For anorexia, a combination of antidepressant with other forms of treatment is more effective. These antidepressants are also capable of treating co-occurring depression. The metabolic changes associated with eating disorders have made their treatment very difficult. Individuals suffering from anorexia may have to take more calories of food, than required for a similar, normal person, for them to even maintain a stable weight.

Given the increasing prevalence of anorexia and bulimia, todays society has an important role in tackling eating disorders. The food and fashion industry in particular have a responsible role to ensure that people in our society have a perfect physical and mental health. Teenagers watching television fall for the idea that they would only be accepted when they are thin. They are brainwashed into believing that becoming thin is important and aspire to be as thin as their models on the screen. The diet commercials give the implication that losing weight would lead to happiness. Magazines claim to provide the newest and the best diet, each month. Most of these diets are actually unhealthy, depriving the body of the required nutrition and also initiating health problems.  Dieting can be rightfully said to have become obsession with a large section of the population in North America. Today, we see and respect the persona from the outside rather than the inside that actually matters (Thompson C, 2009). We need to accept and love for what we are and not for what we look. Children need to be taught to emphasize on who they are, and to accept others for who they are. They need to be taught healthy eating habits and the irrelevance of being thin.