The University of Pittsburgh School of Medicine

University of Pittsburgh Student Affair School of Medicine

ANOREXIA NERVOSA AND BULIMIA NERVOSA

Approximately two thirds of patients with eating disorders present with one of two syndromes: Anorexia Nervosa and Bulimia Nervosa. Individuals with these disorders are overly concerned about being fat and make attempts to restrict eating. When a disturbance of eating becomes persistent it can severely impair physical health and psychosocial functioning. While there are some similarities between the two syndromes, there are enough differences to describe them separately. ANOREXIA NERVOSA

Who is affected:
Anorexia nervosa affects approximately 1% of adolescent girls and young women. While females predominate, 5%-10% of patients are male. Anorexia nervosa has been recognized as an illness for over 100 years and it tends to be found mainly in affluent societies associated with Western culture. Within these societies, it occurs at all socioeconomic levels.

Clinical manifestations:
The illness begins with a desire to lose weight, and soon turns into a preoccupation with weight loss. Patients seem genuinely terrified at being overweight, and will feel themselves to be obese even when they are emaciated. In addition to wilful starvation, they will use compulsive exercise to burn off calories. The anorectic will avoid most foods, especially carbohydrates and fats. Most eat meals alone and cut foods into small pieces to control intake. It is not uncommon for anorectics to be highly interested in food and cooking and prepare elaborate meals for others which they themselves will not eat. Some take laxatives and diuretics and others resort to vomiting, which may lead to bulimia.

The anorectic patient often has a history of being perfectionistic, introverted, having poor peer relations and suffering with low self-esteem. It is not uncommon for this individual to have been a "perfect child", compliant and helpful. In the early stage of the illness, the anorectic becomes increasingly preoccupied with dieting, tends to isolates herself, and focusses on work and study with great intensity. When family and friends call attention to the symptoms of the illness, they are greatly surprised by the response they receive. The usually compliant individual may become extremely angry, deceptive and manipulative.

According to the DSM-IV, diagnostic criteria for Anorexia Nervosa include the following:

  1.  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).
  2. Intense fear of gaining weight or becoming fat, even though underweight.
  3. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.
  4. In postmenarchal females, amenorrhea, i.e., the absence of three consecutive menstrual cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen administration).

Specify type:

Restricting Type: during the current episode of Anorexia Nervosa, the person has not regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas)

Binge-Eating/Purging Type: during current episode of Anorexia Nervosa, the person has regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas)

It should be noted that diagnostic criteria for males are similar to those of females with regard to starvation and fear of fat but different in the specific reproductive hormone abnormality involved.

Psychological and physical consequences:
There are severe psychological and physical symptoms associated with anorexia which tend to be the consequences of starvation. These include depressed mood, social withdrawal, preoccupation with food and diets, insomnia, irritability, decreased libido, obsessional ruminations and rituals and eventually reduced alertness and concentration. Patients experience a variety of symptoms such as hair loss, dry, scaly skin, vitamin deficiency and altered thyroid metabolism. Starvation can lead to death, and the vomiting and laxative abuse can cause cardiac arrest by disturbing the body's electrolyte balance.

Treatment:
Initially, the patient with anorexia tends to resist treatment, insisting that here is no problem. This is often frustrating to family and friends. Though the patient may show surprise at the concern of others, she is likely be aware that she has a serious problem. Treatment, inpatient or outpatient, involves several strategies:
 

  1.  Weight Gain: Because of the devastating effects of starvation, it is critically important for family, friends and the health care team to encourage the patient to gain and maintain weight. Nutritional counseling on how to eat regular and balanced meals is very important. When starvation has been severe, hospitalization may be necessary to carefully monitor food intake.
  1.  Psychotherapy: Allows the patient to examine some of the complex psychosocial issues thought to be associated with anorexia. One of the most important factors appears to be the individual's dissatisfaction with body image. Patients may be so dissatisfied with their bodies that they worry about being unattractive, repulsive or deviant looking. The cognitive-behavioral approach to treatment helps patients to recognize maladaptive thoughts and to correct these beliefs. Improving self-esteem and strengthening the patient's relationships with family members and friends are essential to recovery.
  1. Medication: particular antidepressants have been used to help the patient control her preoccupation with body shape and weight.

  BULIMIA NERVOSA  
Who is affected:
Bulimia Nervosa has clinical features similar to Anorexia Nervosa but differs in that bulimic patients tend to maintain a normal body weight. It is more common than anorexia. Approximately 5% of females in Western countries between the ages of 15 to 35 suffer from bulimia. Studies have shown that 19% of female students report bulimic symptoms.

Clinical manifestations:
As observed among anorectics, bulimic patients are preoccupied with feeling fat and begin to diet. It is not unusual for bulimics to have first been anorectic (approximately 40%). With prolonged dieting, patients can experience an intense hunger and craving for food (often junk food). These patients report that once they begin to eat they find it difficult to stop. They may eat for as much as several hours and then feel guilty and very uncomfortable. What follows usually involves self-induced vomiting, laxative or diuretic abuse or self-starvation. Patients repeat this cycle anywhere from several times a week to several times a day. They may see binging and purging as a way to eat without associated weight gain but soon realize that they are powerless to stop the behavior. Over time, this pattern of behavior can become a coping mechanism in reducing tensions associated with feelings of depression, anger, anxiety or stress. It can also be a way of dealing with happy times such as celebrations. In most cases, patients are very secretive about their illness.

According to the DSM-IV, diagnostic criteria for Bulimia Nervosa include the following:

  1.  Recurrent episodes of binge eating. An episode of binge eating is characterized by the following:
    1. (a) eating, in discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances
      (b) a sense of lack of control over eating during this episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)

  1.  Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise.
  1. The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months.
  1. Self-evaluation is unduly influenced by body shape and weight.
  1. The disturbance does not occur exclusively during episodes of Anorexia Nervosa.

Specify type:
Purging Type: during current episode of Bulimia Nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas

Nonpurging Type: during the current episode of Bulimia Nervosa, the person has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self induced vomiting or the misuse of laxatives, diuretics, or enemas

Psychological and physical consequences:
Depression and low self-esteem are very common among bulimic patients. The anxiety and secretiveness surrounding the bulimic cycle of behavior often leads to social isolation. Patients can become dependent on the various chemicals used in the binge-purge cycle such as laxatives, diuretics and diet pills. Some are also dependent on alcohol. These psychological effects can eventually severely interfere with the patient's ability to study, work or maintain healthy relationships.

There are potentially life threatening consequences when prolonged purging leads to significant potassium loss. Sudden death can occur when a severe depletion of potassium causes the heart to stop. Other symptoms associated with the disorder include damage to the throat, the esophagus and stomach, amenorrhea, dry skin, loss of hair, dental decay, constipation and back pain. It has also been observed that over time, the methods of purging become less effective in controlling weight.

Treatment:
As with Anorexia Nervosa, many bulimic patients resist treatment because they fear weight gain. However, what such patients do not realize is that the longer they practice this behavior, the less effective it is in maintaining body weight. There are several treatment strategies for bulimic patients.
 

  1. Nutritional counseling: is essential in prescribing the patient a nutritional diet and in teaching the patient how to eat healthy meals to maintain body weight.
  1. Psychotherapy: the bulimic cycle becomes a habitual way of coping with feelings both pleasant and painful. Learning alternative ways of dealing with these feelings is an important goal of psychotherapy. As with anorexia, bulimic patients struggle with low self esteem, isolation, perfectionism, and the drive to be thin. Psychotherapy helps the patient to understand the destructive nature of these symptoms and to develop healthier thoughts and behaviors.
  1. Medication: particular antidepressants are used to help control both depressive symptoms and the urge to binge. They are safe and effective when used in conjunction with nutritional counseling and psychotherapy.

TREATMENT RESOURCES
Students that become aware of an eating disorder are urged to seek treatment as soon as possible. Eventually, the untreated illness will interfere with almost every aspect of physical, emotional and social functioning. It can cause irreversible damage and possibly death. Recovery is quicker and more effective the sooner the illness is brought to treatment. The Eating Disorders Clinic at UPMC, under the direction of Dr. Marsha Marcus, is an excellent resource for treatment. They provide comprehensive treatment including nutritional counseling, psychotherapy and medication, all essential to recovery. This program can be contacted directly by the student by calling 624-5420 or by first contacting either Dr. Penkower at 624-1041 or a member of the SHARP committee.
 
Adapted from:

1. "Treatment of Anorexia Nervosa" and "Treatment of Bulimia Nervosa" authored by Dr. Marsh Marcus, Ph.D., Director, Eating Disorders Clinic, WPIC.

2. Brownell KD, Fairburn CG. (Eds). (1995) Eating disorders and obesity: A comprehensive handbook, New York, Guilford Press.
 

Western Psychiatric Institute & Clinic
 

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SHARP / Clinical Depression / Alcohol Abuse and Dependency /
Anorexia Nervosa and Bulimia Nervosa