Introduction

Chapter 1: Defining Eating Disorders

Chapter 2: Soical Precipitants

Chapter 3: Psychological Precipitants

CHAPTER ONE: DEFINING EATING DISORDERS    

Eating disorders are divided into two classifications, anorexia nervosa and bulimia.  Bulimia is also referred to as bulimia nervosa or bulimarexia.  Vary often, however, patients will demonstrate behaviors from both classifications intermittently.  It is difficult at times to define a patient as anorexic or bulimic because of the overlapping of symptoms and behaviors.  The anorexic patient who starves herself for several weeks will often eventually  break down and binge and purge for several days before beginning her fast again.  Binge-purge behavior has been observed in approximately 50% of anorexia patients (Garner et al, 1985).  Likewise, the patient who binges and purges on a regular basis will more than likely go through days of trying a starvation diet to pay for what she considers to be disgusting, out of control behavior.  Both disorders are viewed as a perpetual cycle of self-defeating behavior built upon distortion and/or dissatisfaction with body image.

The individual will generally display a more predominant behavior pattern which serves to identify the patient as either anorexic or bulimic.  Both disorders have characteristic behaviors, symptoms and psychological issues.  The diagnostic criteria for eating disorders according to the American Psychiatric Association in the DSM-III-R provide definitions for both disorders.

Anorexia Nervosa

1. Refusal to maintain body weight over a minimal normal weight for age and height, e.g., weight loss leading to maintenance of body weight 15% below that expected; or failure to make expected weight gain during period of growth, leading to body weight 15% below 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, size or shape is experienced, e.g., the person claims to “feel fat” even when emaciated, believes that one area of the body is “too fat” even when obviously underweight.
4. In females, absence of at least three consecutive menstrual cycles when otherwise expected to occur (primary or secondary amenorrhea).  (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen administration.)

The age at onset for anorexia is usually early to late adolescence.  Although it can also begin in adulthood, especially when the onset is related to a stressful life event, such as death of a loved one, geographic relocation, marriage, birth of a child.  It occurs predominately in females (95%) (DSM-III-R).  Prevalence studies show a range of from 1 in 800 to 1 in 100 females between the ages of 12 and 18 (DSM-III-R).  Mortality rates are from 5% to 18% due to complications of starvation.

There appears to be a familial pattern.  Anorexia has commonly been found among sisters and mothers of those with the disorder, much more than among the general population.  Studies also indicate a higher than expected frequency of major depression and bipolar disorder among first-degree biologic relatives of patients with anorexia nervosa (DSM-III-R).

Bulimia Nervosa

1. Recurrent episodes of binge eating (rapid consumption of a large amount of food in a discrete period of time).
2. A feeling of lack of control over eating behavior during the eating binges.
3. The person regularly engages in either self-induced vomiting, use of laxatives or diuretics, strict dieting or fasting, or vigorous exercise in order to prevent weight gain.
4. A minimum average of two binge eating episodes a week for at least three months.
5. Persistent over-concern with body shape and weight.

The age at onset is usually adolescence or early adulthood.  A study of college freshman indicated that 4.5% of the females and 0.4% of the males had a history of bulimia (DSM-III-R).  Studies have reported that the parents of these individuals are obese and there is a higher than expected frequency of major depression in first-degree biologic relatives of people with bulimia (DSM-III-R).

The addition to the diagnostic criteria, both bulimics and anorexics display characteristic behaviors which further help to identify the existence of an eating disorder.  Cases of bulimia are less easily detected than anorexia.  Bulimics usually appear to be of normal weight and their behavior is almost always conducted in private.  Their binges usually involve copious amounts of easily ingested, high caloric foods, with little nutritional value.  Their purge behavior is excessive, such as vomiting up to 20 or more times daily or taking 50 doses of a laxative per day.  Although the anorexic will occasionally binge and purge, it is not the same as the bulimic who’s binge-purge behavior is a ritual that controls her life.

Contrary to the anorexic who wears her thinness proudly, the bulimic lives in the constant fear she will be found out.  Her behavior is punctuated by a constant need for secrecy and compulsively destroying any evidence of her binging and purging. Bulimics often succumb to stealing and lying in order to support their habit.  The amount of money spent on food can lead to financial difficulties.  Bulimic wives will go to great lengths to destroy food bills and cover up for funds spent on groceries.  Bulimics live in a constant state of anxiety, feeling enslaved to their behavior and hating themselves for it.

Anorexics, on the other hand, feel proud of their ability to exert such extreme control over their bodies.  Though the term anorexia literally means “lack of appetite”, just the opposite is true of the illness.  Afflicted individuals do not suffer from disinterest in food or poor appetite.  They are actually obsessed with food and eating, but consider self-denial and discipline of such high virtue that hey condemn the satisfaction of their needs and desires as weak and indulgent, something to be ashamed of.  This complete preoccupation with food is evidenced by such behaviors as recipe collecting, cooking large amounts of food for others and actually forcing food on others.  They will cut food into tiny pieces and take an inordinate amount of time to eat one item.  So hyper vigilant in their abstinence from calories, they may even refuse to like a postage stamp for fear of the calories that could exist (Burch, 1978).

Anorexics, much more than bulimics, are obsessive about exercise.  They will engage in vigorous exercise for prolonged periods and several times per day.  Their normal gait is brisk and they can often be seen running from one point to another.  There is a case reported of a high-school girl who would arise in the morning hours before the rest of the household to do an hour of calisthenics, then pretend to her parents that she would take the bus to school, while in fact she would run the 3.5 miles to get there, engage in after school sports, run home, then do another hour of calisthenics after the household had gone to bed.   Anorexics can appear so strong and vital that an onlooker would have difficulty perceiving the existence of a life-threatening illness.

In America, many men and women diet and exercise in an effort to obtain a certain desired physique.  However, an individual with an eating disorder has attitudes towards body image and food which are quite distorted and excessive, beyond a typical dieting mentality.  Someone with an eating disorder is not only concerned about gaining weight, but absolutely terrified by the idea.  Eating disorder victims typically overestimate their body size by 25-50%.  Their behavior around food and/or exercise becomes the focal point of their lives, and indeed each day their self-esteem is predicated on how well they are able to control themselves in regards to food.  The anorexic’s perfect day of abstinence can give her a feeling of power and accomplishment, while the bulimic’s constant out of control behavior fills her with debilitating low self-esteem, shame and depression.  If the anorexic goes beyond the limits of her restricted diet, her sense of failure will prompt self-castigating activities such as over-exercise and even stricter rules around intake.

Both anorexia and bulimia are disorders with food-related behavior.  In anorexia, the individual restricts her intake, or avoids food in an effort to deal with emotional issues.  In bulimia, the patient turns to food and abuses it as a result of emotional conflict.

An eating disorder is a major health concern in America.  In addition, there are many people with concerns about food, weight and body image who would not necessarily fit the criteria for an eating disorder, but who live with very unhealthy attitudes and practices around food and exercise.  These attitudes are borne out of, and supported by, a culture consumed with thinness as a model for physical beauty.  Our society’s discrimination towards fat will now be explored as a precipitant to eating disorders.

 Next: CHAPTER TWO: SOCIAL PRECIPITANTS