Eating Disorders: Bulimia and Anorexia Nervosa

Eating disorders are very common in our population. It is important to understand the dynamics of two most common types of eating disorders:  Anorexia Nervosa, and Bulimia.

Anorexia Nervosa:

Anorexia Nervosa in Greek and Latin roots means “lack of appetite of nervous origin”. It generally appears in early or middle adolescence. The girl begins to starve herself and sometimes exercises compulsively. She loses weight but she remains in denial that her behavior is dangerous. She sometimes begins to wear baggy clothes to hide her weight loss from parents. She may also begin to  discard food instead of eating it.

According to the diagnostic manual of the Psychiatric Association (DSM -!V-TR), one of the main symptom of Anorexia nervosa is refusal to maintain body weight at or above a minimally normal weight for age and height ( e.g. , weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected) In addition, the person has intense fear of  gaining weight, even though she is underweight. A woman is suffering from clinical Anorexia when her weight has fallen to 15 % below the normal range and she has not menstruated for at least 3 months. Other symptoms include dry skin, brittle nails and hair, constipation, anemia, and swollen joints. The level of female hormones in the blood of an anorectic woman is reduced significantly. Moreover, her sexual development may be delayed. Her heart rate and blood pressure can become remarkably low and loss of potassium in the blood may cause irregular heart rhythms. Cardiac failure, infections, osteoporosis and kidney damage could also be long term dangers of this disease.


Bulimia Nervosa (“ox like hunger of nervous origin”) is defined as two or more episodes of binge eating (rapid consumption of a large amount of food, about 5,000 calories) every week for at least 3 months. The binges are sometimes followed by vomiting or purging and may alternate with compulsive exercise and fasting. The symptoms can develop at any age from early adolescence to age 40, but usually become clinically serious in late adolescence. Bulimia can have two subtypes: the purging type and non purging type.

Bulimia is not as dangerous to health as anorexia, but it has many unpleasant side effects, including fatigue, weakness, constipation, fluid retention, swollen salivary glands, erosion of dental enamel, sore throat from vomiting, and scars on the hand from inducing vomiting. Over use of laxatives can lead to digestive problems. In addition, the person can also suffer from dehydration, loss of potassium, and tearing of the esophagus. It has been found that about 40 % of the most bulimic patients have a history of anorexia.

Both anorexia and bulimia are genetic. The rate of anorexia among mothers and sisters of anorectic women is 2% to 10%. In one study, it was found that 20 % of anorectic patients had a family member with an eating disorder.

One cause of eating disorders could be abnormalities in the activity of hormones and neurotransmitters that preserve the balance between energy output and food intake. Serotonin activity is low in starving anorectic patients. According to one study, bulimic patients respond weakly to serotonin and to cholecystokinin, a hormone that induces fullness. Their response improves when they take antidepressant drugs that enhance the effects of serotonin.

Eating disorders can also be regarded as a cultural phenomenon and a social problem. More than half of American women say they are on a diet. There is so much social pressure for slimness created by the media and it directly influences the young woman. As a result, she is more likely to become obsessed with thoughts of being slim like the models in the commercials or TV and movie stars, she develops an eating disorder. Sometimes the girl begins to believe that having a slim body is the way to win praise and approval. Additionally, she also begins to believe that a slim figure is a symbol of success. This belief system makes her control her food intake to the point that she becomes anorectic.

Treatment of Eating Disorder

In order to treat anorexia, the most important goal is to help the patient gain weight. Treatment generally requires team effort of physicians, psychiatrists and dietitians. An anorectic woman is hospitalized in the most severe cases in which her weight has been more than 20% below normal for several months and is in extreme danger, health wise. Occasionally tube feeding may be needed to keep the patient alive. Behavior therapy is used to encourage her to eat. Laxatives are forbidden, and rules like she must clean up if she vomits, are enforced in the hospital setting.  These behavioral contingencies are implemented to prevent vomiting behavior.  Anorectic patients sometimes tend to relapse as they are in denial and they resume their old behaviors once they are discharged from the hospital. Drugs which are responsible for weight gain are not especially useful as anorectic patients are hesitant to take them and they also have severe side effects which can be uncomfortable to their weak bodies.

Behavior and Cognitive Therapies

These therapies can be extremely useful once the patient has regained her weight. Systematic desensitization, progressive muscle relaxation with visual imagery or direct exposure to a graded series of situations that involve food and eating are some of the examples of clinical interventions to treat eating disorders.

Cognitive techniques are also used to correct patient’s set of beliefs about eating. The therapists aim to increase awareness of the cognitive distortions that they might have in their thinking and thus develop an insight to perceive things differently. It is also important to challenge their irrational beliefs about self criticism, perfectionism, and exaggerated fear of separation from parents. People with eating disorders worry obsessively about gaining weight and are afraid that their weight will become noticeable if they gain few pounds. The therapist has to explore the patient’s automatic thoughts which govern her life and then present a healthier perspective of looking at things.

Insight oriented approach is also used by some therapists at a later stage. Therapists with interpersonal orientation will examine the patient’s current situation and her recent and future relations with others. Psychodynamic therapists also try to explore and resolve conflicts of childhood that may have created the need for anorectic behaviors. It is also equally important to include the family members in treatment and provide them psycho education and counseling. Since they live with the patient and have a very crucial role in handling the behaviors of anorectic family member, they need to be active participant of the interventions needed to help the anorectic patient.

Bulimia and Obesity:

Treatment of bulimia is relatively easier than anorexia as bulimic patients usually have the motivation to change. Antidepressant drugs relieve the symptoms, usually more quickly than they relieve depression. Selective serotonin reuptake inhibitors (SSRI) are probably helpful in alleviating the symptoms of bulimia.

Cognitive behavior therapy is also used to treat bulimia in which the therapist tries to explore the irrational beliefs and thought patterns and give insight into correcting these beliefs and automatic self talk. Progressive muscle relaxation, systematic desensitization, and visualization with guided imagery exercises are taught for stress management and patients are encouraged to monitor their food intake and set realistic goals to achieve weight loss. Their conflicts are resolved in therapeutic sessions and they are offered therapeutic tools to work on self esteem, become more assertive in their interpersonal styles, and manage their anger and other negative feelings like hostility, jealousy, resentment and grudges. People tend to overeat when they harbor negative feelings and have difficulty managing their feelings and emotions. There are many mental health centers which offer group therapy to treat eating disorders and they take the comprehensive approach to recovery. There are groups offered on self esteem, nutrition, assertiveness, and anger management in these day programs. It will be useful to join one of these treatment programs to address eating disorder.

Eating disorders should not be ignored and they must be treated to prevent health hazards they might impose if left untreated.

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