Eating disorders and their treatment
Eating disorders (EDs) are widely-differing conditions, defined by distorted thoughts and beliefs, and strange behaviors, around eating, weight, and body image. EDs are typically accompanied by disturbances of self-image, mood, impulses, and social functioning. In this column, I present the defining features of the EDs, provide brief look at how common they are, what may cause them, and how psychologists treat the different forms of them.
The essence of anorexia nervosa (AN) is a relentless pursuit of thinness and a phobia of the consequences of eating. The result, a willful (and often dramatic) restriction of food intake, can lead the affected individual to become underweight or (in the extreme) dangerously emaciated. In AN, weight gain phobia is so intense that actual (or possible) weight gain, in an already thin or emaciated individual, can provoke profound anxiety, irritability, and/or feelings of loss of control. Eating behaviors in people with AN often appear quite bizarre: The individual may eat a restricted range of foods, may avoid social eating situations, may eat in a prescribed order, or in painstakingly metered, low-calorie amounts. In some cases, the individual’s anxiety mounts so intensely after eating that, to appease fears of over eating, he or she may purge through vomiting, misuse of laxatives, or other means. Appetite becomes so over-controlled that over half of individuals with AN eventually develop binge eating—that is, periodic dyscontrol over eating, or incapacity to satiate.
In apparent contrast to the over-controlled eating behavior seen in AN, the main feature of Bulimia Nervosa (BN) is loss of control over eating. BN is diagnosed in relatively normal-weight or overweight individuals (i.e., who do not meet criteria for AN) who display recurrent eating binges (or bulimic episodes), followed by compensation through self-induced vomiting, misuse of laxatives, diuretics, or other substances, or through fasting or intensive exercise. Binge episodes can provoke a terrifying sense of loss of control and are associated with profound feelings of shame, anxiety, or depression. When binge eating, individuals with BN often experience dramatic self-loathing— in some cases, to the point of self-damaging or suicidal feelings. Although the overeating seen in BN may seem to be opposite to the rigid suppression of food intake seen in AN, both An and BN are believed to be causally linked to an over-importance of weight and shape control, an excessive drive for thinness, and resulting compulsive dieting. Many researchers have shown that prolonged dieting and chronically restrictive attitudes around eating increase risk for binge episodes.
How common are Eating Disorders?
Findings of independent studies emanating from various industrialized countries worldwide have led to the impression that strictly defined AN affects just under 1% of adolescent and adult females. Point prevalence obtained for BN in females is around 2%. Although EDs are generally thought to occur far less frequently in men than in women (by a factor of roughly 10), males are certainly observed to develop classical anorexic and bulimic disorders, and there is some evidence that ED prevalence is recently increasing in males. In addition, although it is commonly believed that EDs are disorders of affluent, urban society, data show little systematic linkage to upper socioeconomic status, and unexpectedly high numbers of EDs in rural communities
What causes eating Disorders?
Eating disorders have multiple and (often) shared genetic-biological, psychological, and social risk factors. Psychological traits (like impulsivity, compulsivity, or perfectionism) may be at least as relevant to defining ED syndromes as are any one of a number of superficially more-relevant aspects of ED phenomenology (like presence of body dissatisfaction, binge eating or laxative abuse). Indeed, available data argue that the psychopathological variations may be the stronger predictors of clinical phenomenology, neurobiological substrates, sexual abuse history, treatment outcome, prognosis, and other aspects. If EDs are indeed as multiply determined as available data seem to suggest, pathways to them will likely be immensely heterogeneous, and singularly biological, psychological, or social models will, at best, provide partial explanations. Following from this line of thinking, we propose that what may be of greatest interest about the EDs is, in fact, their tendency to have diverse and interleaved causes.
How do psychologists treat eating disorders?
In severe forms, AN and BN are often treated separately. Individuals with severe AN are usually offered hospitalization to help them gain weight. Individuals with severe BN are often offered intensive outpatient treatments (usually daily) to help interrupt cycles of binge eating and purging. In milder forms (for example, a patient with AN who is not severely underweight, or a patient with BN who binges or purges occasionally) are usually treated with either Cogniitve-Behavioral Therapy (CBT) or with another treatment, called Interpersonal Therapy (IPT). Both therapies are considered equally effective. CBT helps patients to understand what thoughts and situations can trigger their eating disorder symptoms, and to replace eating symptoms with more constructive responses. IPT helps people understand and cope better with difficult changes in life, such as transitioning from adolescence to adulthood. Both CBT and IPT help ED patients to feel less distressed, or be less impaired, by preoccupations relating to weight and shape. IPT can also mean finding other sources of autonomy and self-worth (like family, school, and friends). Hopefully, another benefit of both CBT and IPT is that the underweight patient’s weight normalizes, and binge eating or vomiting (if either are present), will stop. The principle is not to guarantee the patient will be happier with her shape, but rather to make her weight and shape less dominant in the bigger picture of her life. Roughly half of patients will improve after a cycle of therapy, and it can take many cycles before everyone gets better.
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