eating disorder

n.
Any of various psychological disorders, such as anorexia nervosa or bulimia, that involve insufficient or excessive food intake.

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Disorders characterized by abnormal eating behaviors and beliefs about eating, weight, and shape. The three major diagnoses are anorexia nervosa, bulimia nervosa, and binge eating disorder. In addition, there are many cases of abnormal eating that have only some of the features required for an eating disorder diagnosis; these cases are classified as eating disorders not otherwise specified. Obesity is classified as a general medical condition and not as an eating disorder (a psychiatric condition) because it is not consistently associated with psychological or behavioral problems.

There are also three childhood eating disorders: (1) Pica is a persistent pattern of eating nonnutritive substances in infants or young children. (2) Rumination disorder involves repeated regurgitation and rechewing of food. This behavior is not the result of a gastrointestinal or medical condition; the partially digested food comes back into the mouth without any observable nausea, disgust, or attempt to vomit. (3) Feeding disorder of infancy or early childhood is the persistent failure to eat adequately, as reflected in insufficient weight gain for age. Pica and rumination disorder are thought to be uncommon and frequently associated with developmental delays and mental retardation. Perhaps half of the pediatric hospitalizations for inadequate weight gain (which constitute 1–5% of all pediatric hospitalizations) may be due to feeding disorder of infancy or early childhood.

Anorexia nervosa

Anorexia nervosa is characterized by a refusal to maintain a minimal normal body weight (defined as 15% below average weight for height), an intense fear of becoming fat, and, if female, amenorrhea for at least 3 months. The majority of cases of anorexia nervosa are classified as restricting type; these individuals achieve abnormally low weight by severely dieting, fasting, and often by exercising compulsively. In severe cases, patients refuse to eat and can die of starvation or severe medical complications. Another subtype of anorexia nervosa is binge eating/purging type. Despite being emaciated or dangerously thin, persons with anorexia nervosa perceive themselves as overweight (distorted body image), deny the seriousness of their condition, and have an intense fear of becoming fat.

Anorexia nervosa occurs in roughly 1% of adolescent and young adult females. Most cases (90%) are female, and the majority are Caucasian and come from middle-class or higher socioeconomic groups. Anorexia nervosa is more prevalent in industrialized countries that share western views regarding thinness as an ideal. It develops most frequently during adolescence.

Persons with anorexia nervosa frequently manifest symptoms of depression and anxiety. The restricting type of anorexia nervosa is associated with obsessionality, rigidity, perfectionism, and overcontrol, whereas the binge/purge subtype is associated with greater mood instability and impulsivity across a wide range of areas, including substance abuse.

Although some cases of anorexia nervosa show no evidence of medical problems, prolonged starvation affects most organ systems, and a wide array of medical problems tend to be present. Long-term mortality from anorexia nervosa is estimated at 5–10% with most deaths resulting from starvation, cardiac events, or suicide.

The causes of anorexia nervosa are not yet understood but are likely to involve a complex combination of genetic, familial, psychological, and sociocultural factors. The onset of anorexia nervosa tends to follow a period of dieting and is frequently triggered by a stressful life events or transitions.

Since the starvation and weight loss can be life-threatening, initial treatment efforts need to focus on weight gain and the reestablishment of regular eating patterns. Inpatient hospitalization is frequently necessary. Although significant psychological issues tend to be present, it is generally ineffective to address these until weight has been stabilized. Once weight gain is achieved, psychotherapies can become useful. Relapse rates are high. See also Anorexia nervosa; Psychotherapy.

Bulimia nervosa

Bulimia nervosa is characterized by recurrent episodes of binge eating (eating large amounts of food while experiencing a subjective sense of lack of control over the eating), the regular use of extreme weight compensatory methods (for example, self-induced vomiting), and dysfunctional beliefs about weight and shape that unduly influence self-evaluation or self-worth.

Bulimia nervosa occurs in roughly 2% of adolescents and adults. It is most common in females (90% of cases), Caucasians, and middle-class or higher socioeconomic groups. The prevalence of bulimia has increased over the past few decades, and is also becoming more common in non-Caucasian groups.

Persons with bulimia nervosa have high rates of depression, anxiety, and substance abuse problems. Although this condition is less dangerous than anorexia nervosa, medical complications can occur. Dental erosion and periodontal problems are common. Electrolyte imbalance and dehydration can result in serious medical complications, including cardiac arrhythmias. In rare cases, esophageal bleeding and gastric ruptures occur.

Bulimia nervosa is likely to result from a combination of genetic, familial, psychological, and sociocultural factors. Although many persons have weight and diet concerns, the development of bulimia is thought to arise only in vulnerable individuals and usually after a stressful event. Bulimia nervosa is a self-maintaining vicious cycle.

Bulimia nervosa can often be treated successfully with outpatient therapies. Cognitive behavioral therapy and interpersonal psychotherapy have been found to be most effective for reducing binge eating and vomiting and improving associated concerns such as depression, self-esteem, and body image. These two therapies also have the best results over the long term. Certain types of pharmacotherapy, notably antidepressant medications, are also effective.

Binge eating disorder

Binge eating disorder is characterized by recurrent episodes of binge eating but, unlike bulimia nervosa, no extreme weight control behaviors (purging, laxatives, fasting) are present. Persons with binge eating disorder have chaotic eating patterns and frequently overeat as well as binge.

Although obesity is not required for the diagnosis, many people with binge eating disorder are overweight. Binge eating disorder is estimated to occur in 3% of the general population but in roughly 30% of obese persons. Binge eating disorder occurs most frequently in adulthood, affects men nearly as often as women, and occurs across different ethnic groups.

Obese binge eaters are characterized by higher levels of psychiatric problems (depression, anxiety, substance abuse) and psychological problems (poor self-esteem, body image dissatisfaction) than non-binge eaters and closely resemble persons with bulimia nervosa. Overweight persons with binge eating disorder are at high risk for further weight gain and weight fluctuations and associated medical complications. The etiology of binge eating disorder is unknown.

Cognitive behavioral therapy is effective for reducing binge eating and improving associated concerns such as depression, self-esteem, and body image, but does not seem to result in weight loss. There is some evidence that behavioral weight control treatment can reduce binge eating and facilitate weight loss. Antidepressant medications appear to reduce binge eating but do not produce weight loss; relapse is rapid after discontinuation of the medication. See also Affective disorders.

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A potentially dangerous disturbance in the pattern of eating. It usually has an underlying psychological basis, but is sometimes caused by a malfunction of the appetite centre in the hypothalamus at the base of the brain. Eating disorders are usually classified into two main groups: anorexia nervosa and bulimia nervosa. In reality there is a spectrum of disorders and it is not always easy to assign a particular disorder neatly into either of the two main groups. Patients who do not meet all the criteria for either anorexia nervosa or bulimia nervosa are said to suffer an ‘eating disorder not otherwise specified’ (NOS).

Eating disorders of any type are more prevalent among females than males. More than 90 per cent of those with eating disorders are women, mostly adolescents. Many sociologists and psychiatrists blame the disorders on the preoccupation of Western culture with slimness and the negative stereotyping of women who are plump. Women are continually bombarded with images from the media reinforcing the notion that they have to be slim to be beautiful, successful, healthy, and happy.

There now appears to be a significant change in cultural expectations for men, with a greater emphasis on good looks and a muscular physique. This has resulted in many young men becoming compulsive exercisers and resorting to the use of anabolic steroids and special body-building diets. The obsession of men with physical appearance may parallel that of women; both can result in psychological disorders, but of different types. See also anorexia nervosa; bulimia nervosa; and eating disorder not otherwise specified.

The modern term that covers all forms of the conditions known as anorexia nervosa and bulimia nervosa. It also sometimes includes obesity. The recorded prevalence of all three has increased during the past 40 years.

Anorexia nervosa, a form of food refusal, is mostly found in young girls, though 1 in 20 cases is a boy. Sometimes it improves spontaneously and sometimes it continues throughout life. The sufferers are usually intelligent high achievers and are often ambitious, and come from families who have ample food. Some have markedly ‘hysterical’ personalities, tending to be dramatic, to overreact, and to manipulate those in their environment. Others are more obsessional, ruminate constantly about food, and develop rituals connected with it. Anorexia means a lack of appetite, but the condition is misnamed because sufferers control rather than lose their appetite. It has been called ‘the relentless pursuit of thinness’. Sufferers rigorously suppress their desire for food in order to be thinner, avoiding all food that they think contains more than the minimum of calories. They often tell lies about the food they do or do not eat, perhaps hiding it or disposing of it secretly to give the impression that it has been eaten. They think about food constantly, weigh themselves several times a day, and have distorted ideas about their bodies, believing that they look fat when they are actually dangerously thin. They tend to wear many layers of loose clothes, partly to hide their condition and partly because they suffer from the cold. Many exercise obsessively and constantly in an attempt to lose further weight. Some, like sufferers from bulimia, have episodes of binge-eating, after which they make themselves vomit to get rid of the food. The most severe cases are medical emergencies and require the most skilled care of a physician in hospital to avoid death. The underlying condition, and the full care of less severe cases, is usually managed by psychiatrists.

Bulimics, who are usually of normal weight, gorge food, but then induce vomiting, sometimes several times a day. They deliberately vomit, at least initially, in order to become thinner. However, it frequently becomes a habit that is hard to break and their whole lives may be concentrated on bingeing and vomiting. Frequent vomiting leads to unpleasant mouth odour and can promote tooth decay, so sufferers tend to be secretive, to avoid close contact with other people, and to clean their teeth several times during the day. Famous bulimics have included Princess Diana and Audrey Hepburn.

Anorexia nervosa and bulimia nervosa are sometimes regarded clinically as different forms of the same illness.

A number of ‘causes’ are believed to underlie these conditions. Those most discussed are disturbed family relationships and social pressures to be thin. Some sufferers also use their obsession with food as a means of controlling their families, perhaps by creating parental anxiety or by insisting that they do all the family cooking and preventing their parents going away because they are doing this. Some have very dominant mothers and feel that the only way in which they can gain power themselves is by controlling their intake of food.

A theory has arisen that anorexia and bulimia are ‘caused’ by sexual abuse in childhood. Sometimes there is an association between the two. However, therapists of doubtful training and repute have suggested that those with eating disorders have invariably been abused in childhood. In pursuit of this belief they may have used persuasive techniques to elicit many apparent ‘memories’ of sexual abuse of which the patient was previously unaware. This has given rise to what has been labelled ‘false memory syndrome’, which has disrupted many otherwise intact families. The current view among most psychiatrists is that true memories of sexual abuse in childhood are seldom if ever repressed and that ‘memories’ which emerge for the first time during treatment, especially with a therapist who believes that they must be there, should be treated with great caution.

Anorexia nervosa was identified by William Gull in the nineteenth century. It has certainly existed for much longer, perhaps throughout the history of civilization, wherever there was ample food. It used to be regarded as a rare condition, partly because doctors tended to believe what their patients told them, and to look for physical disease. Many cases in the past were probably misdiagnosed as tuberculosis, endocrine disease (such as Simmond's disease, a failure of the pituitary gland), or loss of weight from unknown cause. The secretiveness and deceptiveness of the patients made the diagnosis difficult for those who were unaware of this tendency. Since then doctors have realized that anorexia nervosa is usually not difficult to identify and that bulimia is much more common than was supposed.

The recorded incidence of anorexia nervosa increased greatly during the 1950s and 1960s, and it became a worrisome epidemic, especially in girls' boarding schools. This rise was undoubtedly partly due to the increasing recognition of the condition by doctors, but partly because of the fashion for thinness, which became popular and was accompanied by hostility to plumpness and fear of gaining weight. Those responsible for the care of young girls have shown hostility towards the fashion trade's flaunting of skeletal models to display and advertise clothes, but the custom persists, as does the epidemic of anorexia, which is found at ever younger ages, even as young as 6 or 7. Some of the youngest sufferers are the children of anorexics and bulimics, many of whom raise their families with bizarre attitudes towards food. Doctors have expressed anxiety about the threat to health in children who are fed on skimmed milk and high fibre food, virtually free of sugar and fat. Such a diet is unsuitable for growing bodies and can cause long-term damage. The fact that eating disorders tend to run in families may not be entirely due to parental feeding practices: it seems likely that there is a genuine genetic factor in their causation.

The ‘epidemic’ of anorexia may now have peaked as the incidence seems no longer to be rising. According to figures from the Eating Disorders Unit in the University of London, during 1988-93 the incidence of anorexia remained stable at about 20 cases per 100 000 of the population, whereas the incidence of bulimia rose from 15 to 50 cases per 100 000. This apparent dramatic rise in bulimia can be at least partly explained by the fact that the disease was first described in 1979: doctors and the public have only gradually become aware of it. Probably it was common before it was identified. Since the sufferer usually looks normal, the condition is unlikely to be diagnosed unless the sufferer admits to having the problem or their behaviour is noticed by others.

Some people with these conditions recover spontaneously but many need help, which they are often reluctant to seek. Various treatments have been tried, including incarceration with ‘rewards’ (such as having visitors) for weight gain, sedatives (to suppress activity), and various forms of psychotherapy. Antidepressant drugs are often quite effective and many clinicians believe that there is considerable overlap between eating disorders and depression.

Obesity represents the other end of the eating disorders spectrum. Classically, it is a problem of middle age, but its incidence has been rising, even among young children, especially in the developed world. It affects women more than men and lower social classes more than upper. It is associated with higher than average morbidity and mortality. Heart disease, high blood pressure, diabetes, and even accidents are much more common in overweight people than in those of normal weight. Obesity is commonest where food is ample but protein is expensive and it is particularly likely to develop in people whose diet is high in processed foods, since these often contain many ‘hidden’ calories in the form of fat and sugar. The recent increase in obesity is thought to be related to the sedentary and labour-saving characteristics of modern life in the developed world. People drive cars rather than walk, guide the vacuum cleaner rather than scrub the floor, and spend much time watching television. A sedentary lifestyle makes it difficult to lose weight. Many people control any tendency to gain weight by deliberately taking exercise, perhaps joining a gym or playing an energetic game regularly, but others dislike taking exercise. It is often harder to persuade a patient to take exercise than to keep to a slimming diet.

— Ann Dally

See also dieting; development and growth; obesity.

The term "eating disorders" encompasses a group of problems that fall into two broad categories—overeating (binging), and undereating (anorexia)—sometimes referred to as "starving or stuffing." Eating disorders are most commonly found in young females during early adolescence. However, eating disorders affect both males and females at many stages in the life cycle. Although the conditions create physical problems, the causes are usually psychological.

Eating disorders have been recognized by health experts for many years. Bulimia symptoms were described by the Egyptians, Hebrews, and Greeks; and anorexia nervosa was first described in the 1600s. However, it was not until 1980 that these conditions were categorized as psychiatric disturbances.

Eating disorders are marked by extreme dissatisfaction and preoccupation with body size and shape. People with these disorders may see themselves as overweight when their weight is actually lower than normal, or they may measure their self-worth by their weight. Emotional disturbance accompanies disordered eating, including self-loathing over amounts eaten or panic about possible weight gain. In addition to overeating or undereating, individuals with eating disorders engage in "compensatory behaviors," such as purging (self-induced vomiting or inappropriate use of laxatives, enemas, or diuretics), fasting, excessive exercise, and restricting (overly strict limiting of calories or food types).

Eating disorders can be distinguished from dieting by the psychological distress that accompanies the concern about weight; by the interference with everyday responsibilities and pleasures; and by the danger of causing medical problems, possibly even death.

Shame and secrecy often accompany eating disorders, and the problem may go undetected for years. Recognition of these disorders is necessary to begin the long process of treatment. Unlike other addictive or habit problems, food cannot be avoided, and recovery requires developing a healthier relationship to food and to one's own body, as well as improved coping skills.

Types of Eating Disorders

Mental health professionals recognize three main types of eating disorders, anorexia nervosa, bulimia nervosa, and binge eating.

Anorexia. Although the word "anorexia" literally means "without appetite," the condition is better described as "restricted eating" or "self-starvation." The person with anorexia has an appetite, and food tastes good; however, food is seen as "the enemy." One authority terms anorexia "food phobia." The disorder is characterized by a refusal to maintain a minimal normal body weight, an intense fear of gaining weight, a disturbance in the self-perception of body size and shape, and (in women) an absence of menstrual periods for three or more consecutive months. Anorexia may be further classified as a restricting type or binge-eating/purging type.

Bulimia. Bulimia (Greek for "ox hunger") is characterized by recurrent episodes of binge eating. Binging (eating an extreme amount of food) is accompanied by a sense of lack of control over amounts eaten, and a feeling of being unable to stop. The disorder is further classified as either purging or nonpurging bulimia depending on whether the individual uses fasting or exercise instead of purging to "compensate" for binging.

Binge Eating. Binge eating is sometimes termed "stress eating" or "emotional overeating." It is characterized by compulsive overeating, usually in secret and without purging, followed by guilt or remorse for the episode. It has been estimated that up to 40 percent of people with obesity may be binge eaters. The term "binge eating disorder" was officially introduced in 1992. Unlike nonpurging bulimia, there is no attempt to "compensate" for the binge by fasting or overexercising.

Causation

Eating disorders can be considered biologically based alterations filtered through cultural pressures and individual psychology. The psychological aspects of anorexia are frequently thought to include conflicts between mothers and adolescent daughters over perfection. Bulimia is often thought to involve conflicts over dependence and loneliness. Binging may share causal factors with obsessive-compulsive behavior.

Prevalence and Risk Factors

Since people commonly deny or try to hide their disordered eating behaviors, it is difficult to accurately estimate the number of people affected by these problems. Nonetheless, experts report approximately 1.2 million women in the United States are affected by anorexia or bulimia.

Anorexia is more present in developed societies, especially in societies where being attractive is linked to being thin. The prevalence of anorexia has been estimated to be 0.5 to 1 percent of the population, and rates appear to be increasing. The condition usually begins in early adolescence (13–18 years) and 90 percent of the cases are female. Occasionally, but rarely, the disorder may begin in someone over age forty. Stressful life events (e.g., leaving home for college) occasionally trigger the onset of the problem. Long-term death rates from anorexia approach 10 percent, with death usually resulting from starvation, suicide, or electrolyte imbalance.

The chances of developing an eating disorder are higher among females (female cases outnumber male cases 10 to 1), among those pressured by society or family to be thin, and among athletes. Athletes for whom weight control and/or thinness provides an advantage (e.g., gymnastics, wrestling) are particularly susceptible to eating disorders. Psychological factors that put a person at risk for disordered eating include low self-esteem, poor coping ability, perfectionism, and body image distortion. Genetics may also play a role. Risk increases among those with a close relative (a parent or sibling) with an eating disorder, especially with binging/purging.

Impact

Eating disorders cause an array of medical problems ranging from fatigue to illness, and occasionally death. Even when eating disorders do not reach this level of severity they can be significant sources of suffering for the patient and family members. Mild complications include lack of energy, cavities, cold intolerance, irregular periods, constipation and diarrhea, and difficulty with concentration. Serious complications include electrolyte instability, irregular heartbeat, suicidal tendencies, and death. Between 5 to 18 percent of those with anorexia or bulimia will die from complications of the disorder.

Malnourishment and self-starvation affect the heart, thyroid, and the digestive and reproductive systems, as well as seriously decreasing bone density. Specific problems seen in athletes with eating disorders include impaired athletic performance and an increased risk of injuries and stress fractures. Female athletes with an eating disorder may be considered to have the "female athlete triad" if they manifest symptoms of: (1) disordered eating (which leads to decreased body fat causing a lower estrogen level); (2) amenorrhea (not having a period for three consecutive cycles because of low estrogen); and (3) osteoporosis (fragile bones because of low estrogen).

Although eating disorders are not contagious, the culture in which the person lives can contribute to the spread of an eating disorder, particularly in cultures that glorify thinness. Although obesity may be a consequence of binge eating, it does not typically result from the major eating disorders. Prevention efforts may help, and early detection efforts are essential as patients do not typically request treatment for themselves. Psychological consequences of semistarvation include depressed mood, social withdrawal, insomnia, irritability, and loss of libido, as well as obsessive thoughts about food.

Treatment

The most important factor in treating people with eating disorders is the recognition of the disorder. Disordered eating is usually not self-diagnosed because of associated denial and embarrassment. Anorexics usually do not even realize there is a problem with their behavior, and bulimics usually realize the problem but try to hide their behavior. Family, friends, or health care professionals are often the people who recognize the problem. A team treatment approach is frequently employed, consisting of a physician, a nutritionist, and a psychologist. Medically, antidepressants may be needed, and complications may require treatment or hospitalization if the situation is severe enough. Nutritionally, people with disordered eating need to learn how to eat in a healthful way. Psychologically, modification of inappropriate food-related behavior and development of improved coping mechanisms are necessary. In addition, changes in body image and ideal body image may be necessary.

Treatment, especially for anorexia, can be a long drawn-out affair, and it can take a big toll on family resources and on the social productivity of the person. Recovery from these disorders is difficult, and estimates of 50 percent relapse rates for anorexia and 33 percent for bulimia are common. A difficulty in the control of disordered eating behaviors is the need to continue to eat. This it is in contrast to other disorders of habit or addiction in which treatment involves total avoidance of the abused substance.

Resources

The Academy of Eating Disorders (http://www.acadeatdis.org) is a multidisciplinary professional group devoted to the improved detection and treatment of these conditions. Efforts to expand screening are promoted through eating disorders awareness week on U.S. college campuses, and this has now been expanded to high school and the general public (http://www.nmisp.org/eat.htm).

Other valuable resources include the following:

• American Anorexia/Bulimia Association, 165 West 46th Street #1108, New York, New York 10036; (212) 575–6200, http://www.aabainc.org/
• National Eating Disorders Organization (formerly the National Anorexic Aid Society), 6655 South Yale Avenue, Tulsa, Oklahoma 74136; (918) 481–4044, http://www.kidsource.com/nedo/
• Overeaters Anonymous Headquarters, World Service Office, 6075 Zenith Court NE, Rio Rancho, New Mexico 87124;(505) 891–2664, http://www.overeatersanonymous.org/

(SEE ALSO: Anorexia; Menstrual Cycle; Mental Health; Nutrition; Social Determinants)

Bibliography

American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders. 4th edition. Washington, DC: Author.

American Psychiatric Association (2000). "Practice Guideline for the Treatment of Patients with Eating Disorders (Revision)." American Journal of Psychiatry 157 (January Supp.):1.

Browell, K. D., and Fairburn, C. G., eds. (1995). Eating Disorders and Obesity. New York: Guilford Press.

Christensen, L. (1996). Diet-Behavior Relationships: Focus on Depression. Washington, DC: American Psychological Association Books.

Danowski, D., and Lazora, P. (2000). Why Can't I Stop Eating? Recognizing, Understanding, and Overcoming Food Addiction. Center City, MN: Hazelden Information Education Services.

Fairburn, C. G. (1995). Overcoming Binge Eating. New York: Guilford Press.

Natenshon, A. H. (1999). When Your Child has an Eating Disorder: A Step-by-step Workbook for Parents and Other Caregivers. San Francisco: Jossey Bass Publishers.

Siegel, M.; Brisman, J.; and Weinshel, M. (1997). Surviving an Eating Disorder: New Perspectives and Strategies for Family and Friends. New York: Harper Collins.

Stunkard, A. J., and Wadden, T. (ed.) 1993. Obesity: Theory and Therapy. Lancaster, CA: Raven Press.

Thompson, A. K., ed. (1996). Body Image, Eating Disorders and Obesity: An Integrated Guide to Assessment and Treatment. Washington, DC: American Psychological Association Books.

— LEONARD J. HAAS; TRISHA PALMER

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A continuum ranging from abnormal eating behaviours to clinical eating disorders Included in the continuum are norexia nervosa, bulimia nervosa, and eating orders not otherwise specified, as well as subclinical (subtheshold) eating problems that do not meet the clinical criteria for a disorder. Eating disorders are much more prevalent among women (especially adolescents) than men. Many sociologists blame the disorders on the preoccupation of Western culture with slimness. Eating disorders are of major concern in female athletes. Some estimates suggest that as many as 50% of elite athletes in certain sports may have an eating disorder. High-risk-sports include appearance sports (e.g. diving, figure skating, and gymnastics), endurance sports (e.g. distance running and swimming), and weight-classification ports (e.g. judo). A mild eating disorder (loss of appetite and weight) is one of the symptoms of overtraining.

Eating Disorders are a group of psychological ailments characterized by intense fear of becoming obese, distorted body image, and prolonged food refusal (anorexia nervosa) and/or binge eating followed by purging through induced vomiting, heavy exercise, or use of laxatives (bulimia). The first American description of eating disorders appeared in 1859, when the asylum physician William Stout Chipley published a paper on "sitomania," a type of insanity consisting of an intense dread or loathing of food. Clinical research in Great Britain and France during the 1860s and 1870s replaced sitomania with the term "anorexia nervosa" and distinguished the disorder from other mental illnesses in which appetite loss was a secondary symptom and from physical "wasting" diseases, such as tuberculosis, diabetes, and cancer.

Eating disorders were extremely rare until the late twentieth century. Publication of Hilde Bruch's The Golden Cage (1978) led to increased awareness of anorexia nervosa, bulimia, and other eating disorders. At the same time, a large market for products related to dieting and exercise emerged, and popular culture and the mass media celebrated youthful, thin, muscular bodies as signs of status and popularity. These developments corresponded with an alarming increase in the incidence of eating disorders. Historically, most patients diagnosed with eating disorders have been white, adolescent females from middle-and upper-class backgrounds. This phenomenon suggests that eating disorders are closely linked with cultural expectations about young women in early twenty-first century American society.

Bibliography

Brumberg, Joan Jacobs. Fasting Girls: The Emergence of Anorexia Nervosa as a Modern Disease. Cambridge, Mass: Harvard University Press, 1988.

Vandereycken, Walter, and Ron van Deth. From Fasting Saints to Anorexic Girls: The History of Self-Starvation. Washington Square: New York University Press, 1994.

—Heather Munro Prescott/C. W.

Eating Disorders throughout History Although eating disorders first came to widespread attention in the 1970s, self-starvation and other pathological eating practices are found throughout recorded history. Bulimia was widely known in both Greek and Roman societies and was recorded in France as early as the eighteenth century. Self-starvation for religious reasons became widespread in Europe during the Renaissance, as hundreds of women starved themselves, often to death, in hopes of attaining communion with Christ. During the nineteenth century, as corpulence stopped being viewed as a symbol of prosperity, self-starvation became common again. The incidence of eating disorders varies widely among cultures and time periods, suggesting that they can be encouraged or inhibited by social and economic factors. Eating disorders have most often been seen in affluent societies and are rarely reported during periods of famine, plague, and warfare.

Eating disorders affect both the mind and the body. Although deviant eating patterns have been reported throughout history, eating disorders were first identified as medical conditions by the British physician William Gull in 1873. The incidence of eating disorders increased substantially throughout the twentieth century, and in 1980 the American Psychiatric Association formally classified these conditions as mental illnesses.

Diagnosis
Individuals with eating disorders are obsessed with food, body image, and weight loss. They may have severely limited food choices, employ bizarre eating rituals, excessively drink fluids and chew gum, and avoid eating with others. Depending on the severity and duration of their illness, they may display physical symptoms such as weight loss; amenorrhea; loss of interest in sex; low blood pressure; depressed body temperature; chronic, unexplained vomiting; and the growth of soft, fine hair on the body and face.

There are various types of eating disorders, each with its own physical, psychological, and behavioral manifestations. They are classified into four distinct diagnostic categories by the American Psychiatric Association: anorexia nervosa, bulimia nervosa, binge eating disorder, and eating disorder not otherwise specified.

Anorexia nervosa. Clinically, anorexia nervosa is diagnosed as intentional weight loss of 15 percent or more of normal body weight. The anorexic displays an inordinate fear of weight gain or becoming fat, even though he or she may be extremely thin. Food intake is strictly limited, often to the point of life-threatening starvation. Sufferers may be unaware of or in denial of their weight loss, and may therefore resist treatment.

Peak ages of onset are between 12 and 13 and at age 17. Among women of menstruating age, menstruation ceases due to weight-related declines in female hormones.

This illness has two subtypes: the restricting type, in which weight loss is achieved solely via reduction in food intake, and the binge eating/purging type, in which anorexic behavior is accompanied by recurrent episodes of binge eating or purging.

Bulimia nervosa. Bulimia nervosa is characterized by repeated episodes of bingeing followed by compensatory behaviors to prevent weight gain. Compensatory behaviors include vomiting, diuretic and laxative abuse, fasting, or excessive exercise. Like the anorexic, the typical bulimic has an unusual concern about body weight and weight loss. Unlike the anorexic, he or she is acutely aware of this condition and has a greater sense of guilt and loss of self control.

Bulimia typically develops during the late teens and early twenties. In contrast to the typically emaciated anorexic, most bulimics are of normal body weight, although weight may fluctuate frequently. Physically, the bulimic may have symptoms such as erosion of tooth enamel, swollen salivary glands, potassium depletion, bruised knuckles, and irritation of the esophagus.

To qualify for a clinical diagnosis of bulimia nervosa, binge eating and related compensatory behaviors must take place at least two times a week for a minimum of three months. Sufferers are classified into one of two subtypes: the purging type, which employs laxatives, diuretics, or self-induced vomiting to compensate for bingeing, or the nonpurging type, which relies on behaviors such as excessive exercising or fasting to offset binges.

Binge eating disorder. Binge eating disorder is characterized by eating binges that are not followed by compensatory methods. This condition, which frequently appears in late adolescence or the early twenties, affects between 15 and 50 percent of individuals participating in diet programs and often develops after substantial diet-related weight loss. Of those affected, 50 percent are male.

Binge eating disorder is diagnosed when an individual recurrently (at least twice a week for a six month period) indulges in bingeing behavior. A clinical diagnosis also requires three or more of the following behaviors: (1) eating at an unusually rapid pace, (2) eating until uncomfortably full, (3) eating large quantities of food in the absence of physical hunger, (4) eating alone out of shame, and (5) feelings of self-disgust, guilt, or depression subsequent to bingeing episodes.

Eating disorder not otherwise specified. The category eating disorder not otherwise specified (EDNOS) is used to diagnose individuals whose eating disorders are equally as serious as anorexia nervosa, bulimia nervosa, or binge eating disorder, but do not meet all of the diagnostic criteria for these illnesses. An example of EDNOS might be a female who fulfills all of the criteria for anorexia but is still having regular menstrual periods, or an individual with all of the signs of bulimia who binges and purges less than twice a week.

Prevalence
Originally considered to be a disease targeting affluent white women and adolescents, eating disorders are now prevalent among both males and females, affecting people of all ages and from many ethnic and cultural groups. As many as 70 million people worldwide are estimated to suffer from these conditions, with one in five women displaying pathological eating patterns.

Most eating-disorder research focuses on females, who represent 90 percent of all cases. The additional 10 percent are males, a group that is often underdiagnosed due a widespread misperception that this disease only affects females. This belief also makes males less likely to seek treatment, frequently resulting in poor recovery. Among males, body image is a driving factor in the development of eating problems. Gender identity may also play a role in the evolution of eating disorders, with homosexual males more prone to this disorder than the overall male population.

Risk Factors
Environmental, social, biological, and psychological factors all contribute to eating-disorder risk. Early childhood environment and parenting may have a substantial impact. Many sufferers report dysfunctional family histories, with parents who were either emotionally absent or overly involved in their upbringing. As a result, these children may not tolerate stress well, they may have low self-esteem, and they may have difficulty in interpersonal relationships. Children who have been abused either physically, sexually, or psychologically are also highly vulnerable to eating disorders, particularly bulimia. Those raised by eating-disordered parents may be at heightened risk due to repeated exposure to maladaptive food-related behaviors.

Professions, activities, and dietary regimens that emphasize food or thinness may also encourage eating disorders. For example, athletes, ballet dancers, models, actors, diabetics, vegetarians, and food industry and nutrition professionals may have higher rates of disordered eating than the general population. In addition to environmental and social influences, biological and psychological factors may also increase risk for eating disorders in some people. Low levels of serotonin, a neurotransmitter involved in appetite regulation and satiety, may be indicative of a predisposition to pathological eating behaviors. Similarly, as many as 50 to 75 percent of those who are diagnosed with eating disorders suffer from depression, a mental illness also associated with abnormalities in serotonin balance. Other psychiatric disturbances, such as bipolar depression, obsessive-compulsive disorder, seasonal affective disorder, post-traumatic stress disorder, attention-deficit–hyperactivity disorder, and addictive behaviors, are also common in people with eating disorders.

Causes
Societal influences also contribute to this illness. Increasingly, Westernized culture portrays thinness as a coveted physical ideal associated with happiness, vitality, and well-being, while obesity is perceived as unhealthy and unattractive. This has encouraged a growing sentiment of body dissatisfaction, particularly among young women. Endless images of unrealistically thin models and actors in all forms of media further promote body dissatisfaction—one of the strongest risk factors for the development of disordered eating.

Abnormal eating patterns are most likely to develop during the mid- to late teens, a period of considerable physical, psychological, and social change. While the exact events that lead to the evolution of these disorders are unknown, there are two common milestones that can trigger disordered eating, especially in those with a biological predisposition. The first is the occurrence of a traumatic event, such as the death of a loved one or a divorce. The other is the adoption of a strict diet, which may be even more pivotal than a personal trauma. In fact, rigorous dieting has been identified again and again as the most common initiating factor in the establishment of an uncontrollable pattern of disordered eating.

Treatment Modalities
Treatment is based on a combination of psychotherapy, medication, and nutritional counseling. Goals include restoration of healthy body weight, correction of medical complications, adoption of healthful eating habits and treatment of maladaptive food-related thought processes, treatment of coexisting psychiatric conditions, and prevention of relapse. Depending on the severity of the illness, therapy may be conducted on an outpatient, day treatment, or inpatient basis.

Outpatient therapy. Outpatient therapy provided by practitioners specializing in eating disorders is appropriate for highly motivated patients within 20 percent of their normal body weight and whose illness is mild or just developing. Treatment consists of cognitive-behavioral therapy, intensive nutritional counseling, support-group referrals, and medical monitoring. At the outset of treatment, a contract is established, outlining an anticipated rate of weight gain (usually between 0.5 and 2 pounds per week), target goal weight, and consequences if weight gain is not achieved. Vitamin and mineral supplementation and the use of liquid supplements to facilitate weight gain may also be indicated.

Day treatment programs. Day treatment programs are being used with increasing frequency in place of inpatient hospitalization. This form of therapy provides an intermediate level of care for patients who require frequent monitoring but do not require treatment twenty-four hours a day. It may be used for patients who are not responding to outpatient therapy or who are stepping down from inpatient hospitalization. Treatment, which may take place four or five days per week from morning until evening, is similar in structure to outpatient therapy, but is provided on a more intensive level.


Inpatient hospitalization. Inpatient hospitalization is indicated for patients whose eating disorder has reached life-threatening status. Criteria for admission to such programs are weight loss of 25 percent or more of ideal body weight or the presence of an eating disorder in a child or adolescent. It may also be necessary for individuals who are medically unstable. Usually, participants in inpatient programs are anorexic, although hospitalization for bulimia may be necessary if there is serious deterioration of vital signs, uncontrollable vomiting, or concurrent psychiatric illness.

The immediate goals of inpatient treatment are weight gain and stabilization of vital signs. In many cases, the patient is so fragile that complete bed rest is required. Eating is gently encouraged. In extreme medical situations refusal may be met with tube feeding or, in rare instances, intravenously.

Medication. Medication is increasingly becoming a routine part of treatment for eating disorders. Antidepressants, particularly the selective serotonin reuptake inhibitors (SSRIs), are the most effective and most commonly used medication in treating this spectrum of illnesses. They are found to be of greatest benefit when used in combination with therapy, and are of little value if offered on their own. In the case of anorexia, these medications are most effective if employed after successful weight restoration is achieved, at which time they can be useful for relapse prevention and the treatment of coexisting psychiatric conditions. SSRIs are also used in preventing binge relapses among bulimics, although their effectiveness ceases once the medication is discontinued. Although antidepressants have also been employed in the treatment of binge eating disorder, outcomes have not been sufficiently positive to warrant recommendations for their use.

Outcomes
Individuals are usually considered to be ready to terminate therapy once they have achieved a healthy body weight and can eat all foods free of guilt or anxiety. For a complete recovery, extensive treatment may be required from six months to two years, and for as long as three to five years in cases where other psychiatric conditions are present. For some, eating disorders will be a lifelong struggle, with stressful or traumatic events triggering relapses that may require occasional check-in therapy to restore healthful eating patterns.

Of individuals with anorexia nervosa, 50 percent will have favorable outcomes, 30 percent will have intermediate results, and 20 percent will have poor outcomes. The prognosis for bulimics is slightly less favorable, with 45 percent achieving favorable outcomes, 18 percent having intermediate results, and 21 percent with poor results. Among both anorexics and bulimics, 5.6 percent will die of complications related to their illness. Those who receive treatment early in the course of their disease have a greater chance of full recovery on both a physical and an emotional level. A favorable prognosis is also likely with an early age at diagnosis, healthy parent-child relationships, and close supportive relationships with friends or therapists. With early identification and treatment, eating disorders can be prevented from becoming chronic and potentially lethal.

See also Addiction, food; Anorexia nervosa; Bulimia nervosa; Eating disturbances.

Bibliography
American Academy of Pediatrics (2003). "Policy Statement: Identifying and Treating Eating Disorders." Pediatrics 111(1):204–211.
American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, 4th edition. Washington, DC: Author.
Berkow, Robert M., ed. (1997). The Merck Manual of Medical Information Home Edition. Whitehouse Station, NJ: Merck Research Laboratories.
Cassell, Dana, and Gleaves, David (2000). The Encyclopedia of Eating Disorders, 2nd edition. New York: Facts on File.
Costin, Carolyn (1996). The Eating Disorder Sourcebook. Los Angeles: Lowell House.
Pritts, Sarah D., and Susman, Jeffrey (2003). "Diagnosis of Eating Disorders in Primary Care." American Family Physician January 15.
Rome, Ellen S., et al. (2003). "Children and Adolescents with Eating Disorders: The State of the Art." Pediatrics 111:e98–e108.
Stice, Eric; Maxfield, Jennifer; and Wells, Tony (2003). "Adverse Effects of Social Pressure to Be Thin on Young Women: An Experimental Investigation of the Effects of 'Fat Talk.'" International Journal of Eating Disorders 34:108–117.
Woolsey, Monika M. (2002). Eating Disorders: A Clinical Guide to Counseling and Treatment. Chicago: American Dietetic Association.


Internet Resources
American Psychiatric Association (2001). "Men Less Likely to Seek Help for Eating Disorders." Available from http://www.nlm.nih.gov/medlineplus
American Psychiatric Association. "Practice Guideline for the Treatment of Patients with Eating Disorders." Available from http://www.psych.org
Anorexia Nervosa and Related Eating Disorders, Inc. (2002). "Males with Eating Disorders." Available from http://www.anred.com/males.html
Devlin, Michael J., and Walsh, Timothy B. (2000) "Psychopharmacology of Anorexia Nervosa, Bulimia Nervosa, and Binge Eating." American College of Neuropsychopharmacology. Available from http://www.acnp.org/g
National Eating Disorders Association (2002). "Males and Eating Disorders." Available from http://www.nationaleatingdisorders.org
National Eating Disorders Association (2002). "What Causes Eating Disorders?" Available from http://www.nationaleatingdisorders.org
Renfrew Center Foundation (2002). "Eating Disorders: A Summary of Issues, Statistics and Resources." Available from http://www.renfrew.org

. KEY TERMS Fast—a period of at least 24 hours in which a person eats nothing and drinks only water. Type 2 diabetes—sometime called adult-onset diabetes, this disease prevents the body from properly using glucose (sugar).

    Demographics
    Causes and symptoms
    Diagnosis
    Treatment
    Nutrition concerns
    Prognosis
    Prevention
    Resources

What are Eating disorders?

Eating disorders are psychiatric illnesses that result in abnormal eating patterns that have a negative effect on health.

Description of Eating disorders

Eating disorders are mental disorders. They develop when a person has an unrealistic attitude toward or abnormal perception of his or her body. This causes behaviors that lead to destructive eating patterns that have negative physical and emotional consequences. Individuals with eating disorders often hide their symptoms and resist seeking treatment. Depression, anxiety disorders, and other mental illnesses often are present in people who have eating disorders, although it is not clear whether these cause the eating disorder or are a result of it

The two best-known eating disorders, anorexia nervosa and bulimia nervosa, have formal diagnostic criteria and are recognized as psychiatric disorders in the Diagnostic and Statistical Manual for Mental Disorders Fourth Edition (DSM-IV-TR) published by the American Psychiatric Association (APA). Other eating disorders have recognized sets of symptoms, but have not been researched thoroughly enough to be considered separate psychiatric disorders as defined by the APA.

Well-known eating disorders
In the North America and Europe, anorexia nervosa is the most publicized of all eating disorders. It gained widespread public attention with the rise of the ultra-thin fashion model. People who have anorexia nervosa are obsessed with body weight. They constantly monitor their food intake and starve themselves to become thin. No matter how much weight they lose, they continue to restrict their calorie intake in an effort to become ever thinner. Some anorectics exercise to extreme or abuse drugs or herbal remedies that they believe will help them burn calories faster. A few purge their body of the few calories they do eat by abusing laxatives, enemas, and diuretics. In time, they reach a point where their health is seriously, and potentially fatally, impaired.

People with anorexia nervosa have an abnormal perception of their body. They genuinely believe that they are fat, even when the clearly are life-threateningly thin. They will deny that they are too thin, or, if they admit they are thin, deny that their behavior will affect their health. People with anorexia will lie to family, friends, and healthcare provides about how much they eat. Many vigorously resist treatment and accuse the people trying to cure them of wanting to make them fat. Anorexia nervosa is the most difficult eating disorder to recover from.

Bulimia nervosa is the only other eating disorder with specific diagnostic criteria defined by the (DSM-IV-TR). People with bulimia often consume unreasonably large amounts of food in a short time. Afterwards, they purge their body of calories. This is done most often by self-induced vomiting, often accompanied by laxative abuse. A subset of people with bulimia does not vomit after eating, but fast and exercise obsessively to burn calories. Both behaviors result in impaired health.

People with bulimia feel out of control when they are binge eating. Unlike people. with anorexia, they

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recognize that their behavior is abnormal. Often they are ashamed and feel guilty about their behavior and will go to great lengths to hide their binge/purge cycles from their family and friends. People with bulimia are often of normal weight. Although their behavior results in negative health consequences, because they are less likely to be ultra-thin, these consequences are less likely to be life-threatening.

The APA does not formally recognize binge eating as an eating disorder. Binge eating is quite common, but it only rises to the level of a disorder only when bingeing occurs at least twice a week for three months or more. People with binge-eating disorder may eat thousands of calories in an hour or two. While they are eating, they feel out of control and may continue to eat long after they feel full. Binge eaters do not purge or exercise to get rid of the calories they have eaten. As a result, many, but not all, people with binge-eating disorder, are obese, although not all obese people are binge eaters.

Binge eaters are usually ashamed of their behavior and try to hide it by eating in secret and hording food for future binges. After a binge, they usually feel disgusted with themselves and guilty about their eating behavior. They often promise themselves that they will never binge again, but are unable to keep this promise. Binge-eating disorder often takes the form of an endless cycle—rigorous dieting followed by an eating binge followed by guilt and rigorous dieting, followed by another eating binge. The main health consequences of binge eating are the development of obesity-related diseases such as type 2 diabetes, sleep apnea, stroke, and heart attack.

Lesser-known eating disorders
Quite a few eating problems are called disorders even though they do not have formal diagnostic criteria. They fall under the APA definition of eating disorders not otherwise specified. Many have only recently come to the attention of researchers and have been the subject of only a few small studies. Some have been known to the medical community for years but are rare.

Purge disorder is thought by some experts to be a separate disorder from bulimia. It is distinguished from bulimia by the fact that the individual maintains a normal or near normal weight despite purging by vomiting or laxative, enema, or diuretic abuse.

Anorexia athletica is a disorder of compulsive exercising. The individual places exercise above work, school, or relationships and defines his or her self-worth in terms of athletic performance. People with anorexia athletica also tend to be obsessed less with body weight than with maintaining an abnormally low percentage of body fat. This disorder is common among elite athletes.

Muscle dysmorphic disorder is the opposite of anorexia nervosa. Where the anorectic thinks she is always too fat, the person with muscle dysmorphic

disorder believes he is always too small. This believe is maintained even when the person is clearly well muscled. Abnormal eating patterns are less of a problem in people with muscle dysmorphic disorder than damage from compulsive exercising (even when injured) and the abuse of muscle-building drugs such as anabolic steroids.

Orthorexia nervosa is a term coined by Steven Bratman, a Colorado physician, to describe “a pathological fixation on eating ‘proper,’ ‘pure,’ or ‘superior’ foods.” People with orthorexia allow their fixation with eating the correct amount of properly prepared healthy foods at the correct time of day to take over their lives. This obsession interferes with relationships and daily activities. For example, they may be unwilling to eat at restaurants or friends’ homes because the food is impure or improperly prepared. The limitations they put on what they will eat can cause serious vitamin and mineral imbalances. Orthorectics are judgmental about what other people eat to the point where it interferes with personal relationships. They justify their fixation by claiming that their way of eating is healthy. Some experts believe orthorexia may be a variation of obsessive-compulsive disorder.

Rumination syndrome occurs when an individual, either voluntarily or involuntarily, regurgitates food almost immediately after swallowing it, chews it, and then either swallows it or spits it out. Regurgitation syndrome is the human equivalent of a cow chewing its cud. The behavior often lasts up to two hours after eating. It must continue for at least one month to be considered a disorder. Occasionally the behavior simply stops on its own, but it can last for years.

Pica is eating of non-food substances by people developmentally past the stage where this is normal (usually around age 2). Earth and clay are the most common non-foods eaten, although people have been known to eat hair, feces, lead, laundry starch chalk, burnt matches, cigarette butts, light bulbs, and other equally bizarre non-foods. This disorder has been known to the medical community for years, and in some cultures (mainly tribes living in equatorial Africa) is considered normal. Pica is most common among people with mental retardation and developmental delays. It only rises to the level of a disorder when health complications require medical treatment.

Prader-Willi syndrome is a genetic defect that spontaneously arises in chromosome 15. It causes low muscle tone, short stature, incomplete sexual development, mental retardation, and an uncontrollable urge to eat. People with Prader-Willi syndrome never feel full. The only way to stop them from eating themselves to death is to keep them in environments where food is locked up and not available. Prader-Willi syndrome is a rare disease, and although it is caused by a genetic defect, tends not to run in families, but rather is an accident of development. Only 12,000– 15,000 people in the United States have Prader-Willi syndrome.

Symptoms of eating disorders

Anorexia nervosa	Bulimia nervosa	Binge-eating disorder
Resistance to maintaining body weight at or above a minimally normal weight for age and height	Recurrent episodes of binge eating, characterized by eating an excerssive amount of food within a discrete period of time and by a sense of lack of control over eating during the episode	Recurrent episodes of binge eating, characterized by eating an excessive amount of food within a discrete period of time and by a sense of lack of control over eating during the episode
Intense fear of gaining weight or becoming fat, even though underweight	Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting or misuse of laxatives, diuretics, enemas, or other medications (purging); fasting; or excessive exercise	The binge-eating episodes are associated with at least 3 of the following: eating much more rapidly than normal; eating until feeling uncomfortably full; eating large amounts of food when not feeling physically hungry; eating alone because of being embarrassed by how much one is eating; feeling disgusted with oneself, depressed, or very guilty after overeating
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	The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice week for 3 months	Marked distress about the binge-eating behavior
Infrequent or absent menstrual periods (in females who have reached puberty)	Self-evaluation is unduly influenced by body shape and weight	The binge eating occurs, on average, at least 2 days a week for 6 months
	Self-evaluation is unduly influenced by body shape and weight	The binge eating is not associated with the regular use of inappropriate compensatory behaviors (e.g., purging, fasting, excessive exercise)

National Institute of Mental Health, National Institutes of Health, U.S. Department of Health and Human Services.

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Eating disorders are medical illnesses in which patients become obsessed with food and their body weight. Research indicates that more than 90 percent of those who have eating disorders are women between the ages of 12 and 25. The main types of eating disorders are anorexia nervosa and bulimia nervosa. A third disorder, binge eating disorder, is still being investigated by researchers.

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Eating disorders are psychological, or mental, ailments that involve an obsession with food and with being thin. Eating disorders strike about one percent of teenagers in the United States, and girls are affected far more often than boys. People with eating disorders frequently feel depressed and anxious, and they often have a low opinion of themselves. They develop an obsession with food and sometimes devote many hours a day to an intense exercise routine. They frequently withdraw from friends and family, finding excuses to avoid social situations, particularly those that involve food.

The two most common eating disorders are anorexia and bulimia. People suffering from anorexia avoid eating whenever possible. What little food they do eat causes anxiety and fear that it will make them fat. Anorexic people usually lose weight rapidly, but even after they've become alarmingly skinny they still look in the mirror and see themselves as overweight. Anorexia can cause a severe drop in energy and ability to concentrate; it can also result in damage to internal organs, loss of hair, and weakening of bones. If it goes untreated, anorexia can become quite serious and even deadly. Bulimia is characterized by behavior known as binge and purge: people suffering from this disorder eat large quantities of food, but as soon as they've finished eating they make themselves throw up or take laxatives, which stimulates the colon to produce a bowel movement. Bulimia can cause damage to the kidneys and stomach, and the frequent vomiting sometimes causes the person's tooth enamel to decay. People with anorexia often appear dramatically thinner, but bulimia can be harder to recognize as a bulimic person does not actually lose much weight.

Doctors aren't exactly sure what causes eating disorders. Some believe they are a result of the tremendous pressure society places on young girls to be thin-models in magazines and celebrities on television reinforce the idea that being beautiful equals being thin. Some research has suggested that eating disorders may be the result of a chemical imbalance in the brain, and that the tendency to develop such a disorder can run in families. Regardless of the cause, it's vitally important that people with eating disorders seek treatment. Eating disorders can be very serious, and the longer they go on, the harder it becomes to treat them.

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n.pl

A group of dysfunctional behaviors of nutrition, including anorexia, bulimia, or cravings for such nonfood items as ice, clay, or starch.

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