"The reason eating disorders are on the increase is because of media and cultural pressure." Discuss this statement with reference to other possible explanations for the development of anorexia and bulimia.

"By the power of will I will make myself the impossible spite who lives on air, on water, on purity"
Katherine Harrison, The Kiss

"Vomunt et edant, edunt et vomant"
(They vomit to eat and eat to vomit)
Seneca, Ad Marnan, xix

Eating disorders (ED) were a curiosity and rarity in both clinical and societal spheres prior to 1970. However the last three decades of the 20th century have seen sharp increases in ED, mostly in Euro-America. One study of an area in N. E. Scotland (population of 550,000) between 1965 and 1992 reveals an average increase of 5% in the number of cases per year.

While cases of anorexia nervosa had been documented as early as the 19th century, bulimia nervosa was hardly heard of before 1970s as a clinically presenting disorder. By mid-70s the syndrome was becoming common on college campuses. A bulimia diagnosis first appeared in DSM-III in 1980, yet by the mid-80s the prevalence of bulimia had out-stripped anorexia. As Craig Johnson (a noted ED researcher, US) stated - " we went out to study anorexics but we found bulimics."

Media complicity in the development of ED is suspected because there is a highly disputed relationship between the incidence of anorexia and media treatment of the female form over the years. Silverstein's findings are much quoted. Looking at photographs in Vogue and Ladies Home Journal magazines, he measured the bust-to-waist ratio of female models from the beginning of 20th century to 1980. In Vogue, the ratio was 1.95 (highly curvaceous) in 1909, but fell to 1.25 (highly tubular) in 1925. It had risen to 1.7 by 1949, only to fall to 1.2 in 1970. It remained 1.2 until 1980.

Another well-known study that documents the increasing stringency of the 'thin ideal' was by Garner and Garfinkel and colleagues (1980). They looked at two standards of attractiveness: Miss America and Playmate of the month. For 20 years since 1960, they measured the weight and waist-to-hip ratio of the models. They found a gradual decrease in weight and curvaceousness, to the point where preferred shape became tubular and boyish by 1980. Crucially, as model bodies weights decreased, the average body weight of the population increased.

It is very hard to demonstrate the direct role of media imagery in onset of eating disorders. However there is strong evidence that a history of weight consciousness is a predisposing factor for bulimia (Fairburn et al, 1997). Kalodner (1997) found that media thinness imagery made non-ED college students feel self-conscious and inadequate. Murray et al (1993) found that exposure to thinness imagery led a group of ED patients to significantly overestimate their body size more than the non-ED control group. So ED patients are likely to be even more susceptible to media images of thinness.

There are some controversial media practices that blatantly promote and glamorise extreme thinness. Graphic distortion e.g. airbrushing cellulite, making thighs thinner than calves, are troublesome because these false forms become accepted as ideal reflections of the female form. Further, the popularisation of the idea that thin models are the ideal clothes-horse and the use of thin females to promote a ubiquitous range of products results in the 'thin ideal' being relentlessly disseminated.

Probably no psychiatric disorder has received as much media attention as ED has. Anecdotal reports of people who developing anorexia after watching a televised piece and deciding to 'try it out' are documented (Martin, 1983). Obesity experts S and O.W. Wooley criticised the best-selling diet book The Beverly Hills Diet as the first time one disorder (ED) was offered as a cure for another (obesity). They suggest that it represents " a form of direct training in anorexic behaviour", " the mass marketing of anorexia nervosa".

Perhaps the media merely reflects social appetites. Some would even argue that the thin ideal is a reflection of male preferences and the wish of women to fulfil them. A seminal study by Fallon and Rozin (1985) aimed to measure if male and female standards for female shape differed. The sample group comprised male and female college students at the University of Pennsylvania. They were asked to view sketches of male and female figures (of varying size but same height) and rank them according to:

1. The figure that looks most like their own
2. The figure they would most like to look like
3. The figure they thought would be most attractive to the opposite sex
4. The opposite-sex figure they found most attractive.

The subjects were also asked to estimate what percentage of other students was heavier than they were. Female students overestimated their current weight (1). This overestimation tended to be even heavier than the figure they thought would be most attractive to men (3). Most interestingly, their ideal figure (2) was consistently smaller than that chosen by men as the most attractive (4)! This suggests that women's standards rather than men's drive the thin ideal. Men, however, showed no discrepancies between 1,2 and 3. Interestingly, their choice of 3 was heavier than women's choice of 4!

The culpability of the media in the development of ED has not been universally embraced. Some contend that greater sensitivity to the disorder by health professionals and the general public could have led to more cases being diagnosed. The counter-argument would be that physicians have been aware of anorexia nervosa (but not bulimia) since the late nineteenth century and its symptoms are difficult to misattribute. In fact, the trend for anorexia is probably underestimated because only treated cases of anorexia- often the most severe- are accounted for in most surveys. Bulimia is also likely to be missed during examinations because bulimics often present with normal weight. While some would argue that bulimia 'came out of the closet' following increased media attention, publicity in major press rather than preceded the first influx of sufferers.

Williams and King (1987) analysed demographic figures and rates of admission to psychiatric hospitals in England, between 1972-81. They did confirm a sharp rise in admissions for ED over that period. However they also found that this could be accounted for entirely by an 11 % increase in the population of females between the ages of 15-24 over that decade. Contemporary influences (changing fashion norms) were not found to play a role. Hence increased incidence was due to a larger at-risk population group.

While this may be true between 1972-81, there is evidence suggesting that sociocultural factors are more important in the 1980s and onwards. Since the 1970s there has been a sharp increase in dieting behaviours, which other research has shown to be a clear precursor of ED . Among college student populations studied, some sociocultural causes advanced include increasing focus on thinness among college women and anxiety about identity and sexuality in the wake of social upheaval of the 60's.

Data on whether ED has continued to increase since the 1970s and 1980's is mixed. Confounding factors, e.g. the aura of shame surrounding vomiting behaviour, the prevalence of stringent dieting and body-image preoccupation and binge eating among people who do not fulfil all criteria for clinical eating disorder, make inference of trends difficult. This has led to the inclusion of a new diagnosis in the DSM: Eating disorder- not otherwise specified (EDNOS).

If one were to accept that the unrelenting, media-driven progression towards a rigid, extreme thin ideal were a major factor in the development of ED, then the relative incidence of ED is suprisingly low. This discrepancy suggests that there must be other more important factors in the aetiology of ED.

"Don't go crazy, but if you do you must behave as follows."
George Devereux, Basic Problems of Ethnopsychiatry

George Devereux, a psychiatrist and anthropologist, was interested in the relationship between culture and psychopathology. In 1955, he introduced the concept of ethnic disorders. The phrase encapsulates the relationship between psychological disorders in the individual and the core conflicts in society. He applied this concept to schizophrenia, though increasing evidence for biological causes has discounted his ideas. The concept has been re-visited by Richard Gordon in relevance to eating disorders.
Devereux suggested that phenomena like hysteria and amok typified ethnic disorders. Hysteria, a nervous disease' occurring in women, was prevalent in the 19th century. The symptoms of paralysis, fainting and seizures seemed contagious, yet no biological reason accounted for this characteristic. Though the disordered behaviour was an exaggeration of feminine passivity and delicacy, the hysteric exercised passive power over the helpless husband and ineffectual physician. The decline of hysteria at the turn of the century coincided with societal changes in status of women and increased sophistication in appreciation of psychosomatic disorders.

Amok (from which we take the phrase running amok) was characterised by highly patterned homicidal violence. Among men in Malaysia, Indonesia and New Guinea it was a response to an insult or accumulation of stress. After brooding, the injured party would emerge and strikes out indiscriminately. After such an attack they would lapse into exhaustion and amnesia. It seems socially sanctioned because it was considered the final veto of a man against oppressive rulers.

Gordon argues that ED, like hysteria and amok, can be seen as a societal adaptive response to a repressive status quo.

ED appears to fulfil many of the criteria stipulated for ethnic disorders. It occurs with frequency in relation to other psychiatric disorders . It expresses a cultural conflict: the idealisation of thinness in a bountiful economic environment, whilst the less fortunate starve. It is also an exaggeration of contemporary concerns about weight management. Because it draws on valued behaviours (will power, healthy eating, exercising, bon viveurisim) but involves deviance (vomiting, starvation) it elicits ambivalent societal responses, just as amok would. Some argue that it is a final common pathway for idiosyncratic problems, since clinical studies show that underlying triggers among patients do vary greatly. It is suspected that the rise in ED is a reflection of its contagious nature rather than any underlying pathology. The most likely contagion for its spread is the media, through innocent information programmes and less-innocent glamorisation of the thin ideal.

The idea that ED is a socially sanctioned expression of deviance and psychological stress is echoed in cognitive explanations of the development of ED. Cognitive accounts propose that the underlying drive is the need for self-control. The expression of this need as ED is due to an increasing tendency to judge self-worth in term of shape and weight in Western culture. This tendency has been driven by a number of factors e.g. consciousness about the relationship between heart disease and diet and increasing public roles of women.

The cognitive behavioural theory of ED has been developed since the 1970's. Fairburn's main contribution has been a theory of development and treatment of anorexia nervosa . The central feature, he argues, is an extreme need to control eating, arising out of a need for self-control. At first, people who develop anorexia try to control other aspects of their lives e.g. work and sport. Controlling of eating, shape and weight becomes dominant because this area is little influenced by others. Also, it provides immediate and direct evidence of self-control. Strober (1991) emphasises that ED provides a means of potentially arresting or even reversing puberty, a potential threat to self-control. Further there is constant reinforcement from the value placed on controlling shape and weight in Western societies.

The rewards of controlling food intake weight and shape appeal to a certain character. Bruch (1973) and Fairburn (1998) have found that anorexic individuals have longstanding low self-esteem, a sense of ineffectiveness and perfectionism. Fairburn suggests three main self-perpetuating feedback mechanisms that maintain the disordered behaviour. Firstly, the dietary restriction itself, rather than the weight-loss consequences, restores a sense of control. Vitousek and Ewald (1993) describe starving patients as feeling ""delighted, inspired, triumphant, proud and powerful". These feelings are reinforcing because as the disorder progresses, interests narrow. Hence the patient succeeds in controlling the most important thing in their lives. The ED becomes the index of self-control and self-worth. Gradually the patient associates with 'being anorexic' and this contributes to the disorder's egosyntonic character. Anorexics are much harder to engage in treatment than bulimics because they see their behaviour as an achievement. Bulimia, however, is egodystonic in the sense that both the bingeing and purging provide little reward as neither is conducive to weight-loss.

Secondly, aspects of starvation further encourage dietary restriction. Intense hunger threatens the sense of control. This promotes more restrictive behaviour. A sense of fullness becomes a signal of failure of self-control. The rate of weight loss declines after a while: this is perceived as a failure of dietary control, which may induce even more extreme dieting behaviour. In advanced stages of illness, the euphoria that accompanies the stress response to starvation is a further maintaining factor.
Lastly, extreme concerns about shape and weight encourage dietary restrictions. Frequent weighing creates sensitivity to small fluctuations and maintains distorted beliefs about weight. Repeated checking to gain 'objective' measure of body shape is subject to negative mood (Taylor and Cooper, 1992), consumption of food that is highly calorific (Thompson et al, 1993) and seeing media images of thin women (Hamilton and Waller, 1993). Hypervigilant checking in turn increases arousal and self-focused attention and anxiety, leading to further monitoring and anxiety. This vicious cycle is sometimes broken when individuals are no longer able to tolerate their own image. They avoid monitoring, thus losing a potential means of disconfirmation.

Indirect support for cognitive accounts of ED comes from findings by Cooper and Fairburn (1993) . In a previous study they had found that interference in a colour-naming Strop task in bulimics (where the target card had words like cakes, thighs, fat) was related to frequency of purging, the score on Eating Attitudes Test and general psychopathology. To separate which factor was most important in predicting interference, they repeated the task using a bigger sample and multiple regression analysis. Interference was best predicted by frequency of purging, as would be predicted by cognitive theory. Purging is an indication of severity of disorder hence level of interference. More importantly weight and shape concern measures were not predictive of interference. This is direct evidence that purging and weight concerns reflect two different aspects of the cognitive disturbance in ED. The central feature in bulimia is likely to be the need to restore control through purging. The concerns about weight are an extraneous substrate.
The successful application of cognitive behavioural therapy (CBT) to ED bolsters support for cognitive accounts. CBT has been found superior to all to other treatments (including antidepressants) except Interpersonal Therapy (IPT). Changes achieved with CBT appear well maintained. Fairburn et al (1995) found that 5.8 (+/- 2) years after treatment, 63% patients had no ED. 37% received more treatment but this group correlated with a higher chronicity of ED on presentation.

IPT seems as effective as CBT (Kleinman et al 1984) although it ignores ED and focuses on modifying personal problems and depression. This supports the notion that ED is an adaptive expression of underlying psychological stresses. In fact, a number of studies (e.g. Fernandez et al., 1994) have had difficulty in distinguishing anorexics from non-ED subjects based on overestimation of body size. Obsession about body weight is common: a study of 33,000 women of varying age and class revealed that 75% felt they were too fat, while only 25% were actually overweight .

However, Fairburn et al (1993b) found that bulimic patients most concerned with weight and shape were most likely to relapse (75% rate). Those less concerned had a relapse rate of (9%). This is contrast to the finding by Cooper and Fairburn (1993): interference in a Stroop test did not correlate with weight and shape concern scores in bulimics. Perhaps this reveals that there is gradual change in the importance of maladaptive cognitive states in the course of the disease. Cognitive processes surrounding control and the need to purge may be more important in the onset and maintenance of the disorder. In determining the risk of relapse, cognitive beliefs about shape and weight may be the more important factor.

The implications for treatment is that while BT to reduce bingeing and purging is effective, attempts must be made to modify beliefs about shape and weight to reduce risk of relapse. Fairburn et al (1993a) found that dismantling treatment by removing procedures for causing cognitive change attenuated the effects of CBT and made bulimic patients more prone to relapse. Negative self-evaluation needs to be addressed as well. Fairburn et al (1987, 1993b) also found that the degree of self-esteem at presentation was related to the degree of response to treatment.

CBT of ED, however, does not fully account for development of ED. Bingeing is hard to fit into the scheme for maintenance. Why would one binge if they were worried about weight? Fairburn suggests that this is a consequence of adopting stringent dietary rules. Once a dietary stricture is lapsed, the whole diet exercise is seen as 'broken' (perfectionism/ dichotomous thinking) and a binge ensues. The binges are reinforcing on the periods of starvation and vice versa. Some have suggested that bulimia is developed by 'failed' anorexics/ psuedoarorexics . Those who lack the anorexic temperament of pathological perfectionism are unable to maintain their own stringent dietary rules. Instead they are develop and an impulse-driven binge-purge cycle.

Mandy McCarthy also holds the view that underlying psychological stresses lead to development of ED. She argues that the increased stringency of the thin ideal has led to increased occurrence of depression in women which leads to the development of eating disorders in some of these women. One must stress that the link between depression and ED has yet to be directly tested and her ideas so far are only based on the following correlations.

Firstly, twice as many women as men are likely to be depressed. This gender bias in depression may be because women's self-esteem is more closely tied to their appearance (Davies and Furnham, 1986) and for women there is an increasing discrepancy between cultural ideal and reality. In fact, the incidence of ED has risen over the past 20 years (Silverstein et al, 1986), as has the incidence of depression. Also, dieting itself can lead to depression. Most diets cause initial unsustainable weight-loss because physiological mechanisms counter initial weight-loss. Ironically many dieters end up fatter due to the after-effects of dieting. When dieting leads to constant failure, this may cause depression. According to Seligman's (1975) learned helplessness model of depression, lack of control and the expectation that this will continue in the future can lead to depression. Dykens and Gerrard (1986) found that repeated dieters have lower self-esteem than non-dieters do, and Rierdan et al (1988) found that depression leads to negative body image. Polivy and Herman (1983) found that food is often used to assuage depression. This suggests that there is a vicious cycle established between low self-esteem and dieting behaviours. The gender bias in depression may contribute to the statistic that majority (95%) of ED patients are female (DSM III R, 1987).

Secondly, the gender bias in depression emerges at puberty. A number of studies record a rise in depression for both boys and girls at entry to puberty. However Rutter et al (1986) found that depression is twice as common in boys before puberty and twice as common in girls after puberty. Girgus et al (1989) found that negative body image correlates well with depression in both adolescent boys and girls, and that dissatisfied girls are more likely to become depressed when faced with negative life events than satisfied girls. McCarthy suggests that the thin ideal may cause increased depression in women at puberty because this is when the discrepancy between the thin ideal and reality grows , and sexual attractiveness becomes important. She argues further that this accounts for the emergence of most cases of ED at puberty (DSM III R, 1987).

Thirdly, this gender bias in depression is only found in western countries. Nolen-Hoeksema (1987) reviewed the sex ratio in depression in a number of countries. In rural, non-modern societies there is no sex difference in depression. But in western industrialised countries, the sex ratio is biased against women. Sobal and Stunkard (1987) reviewed 137 studies from developed and under-developed countries. They found that on the whole obesity is a lower class phenomenon in women in developed countries. In the under-developed world, the inverse is true. McCarthy argues that Sobal and Stunkard's findings demonstrate the presence of the thin ideal in the western world. She brings these data together to show simple correlation between presence of thin ideal and increased depression among women in western countries. The higher incidence of the thin ideal and depression in women to the Western world appears to run parallel with the increased prevalence of ED in western countries.

Lastly, the average onset for depression is now younger than in the past. McCarthy attributes this to exposure of girls to thin ideal at an ever-younger age. McCarthy concludes that a replacement of thin ideal with a plumper one would decrease depression and also ED in women since they are associated through a cohort effect. However, while it is documented that depression can occur before onset of ED, this is not seen in most cases. Hence depression caused by failure to reach the thin ideal is not a full explanation for the development of ED.

If we accept that the underlying cause of ED is a dystonic cognitive state (or even depression) that drives the subject to restore equilibrium by exercising stringent control over eating, shape and weight, the next question would be why these particular substrates are chosen with such frequency. Why does ED become the final common pathway for various idiosyncratic pressures?

As mentioned before, people who develop anorexia also try and control other aspects of their lives. However controlling food is often more successful because it is less under the influence of others. Also it provides immediate and direct evidence of self-control.

Epidemiological studies in various countries show the dominant prevalence of ED in Western Europe and America . The low prevalence of ED outside the Euro-American sphere of influence (e.g. Japan and most of Africa) was often attributed to economic factors . It is unlikely that a disorder, whose chief symptom is starvation, that requires squandering of food, would develop where food supplies were limited. However they're increasing reports of anorexia and bulimia in non-traditional environments. This has been associated with the 'globalisation of culture'. The distribution of clothes, cosmetics, magazines etc is ever more global in scale. The correlation between exposure to Euro-American lifestyle values and the rise of ED in cultures previously ED-free is receiving much attention.

Sing Lee, working in Hong Kong, reports an increased incidence of ED cases in the 1980's. He is unsure whether this was a genuine rise in ED or an artefact of heightened awareness especially among Western-trained psychiatrists. However, his findings are interesting because most of his patients interpret inability to eat as caused by fear of 'bloating'/ gastric distress, rather than fear of being fat. Further, they do not report any body image distortions. Lee argues for a re-evaluation of 'universal' criteria of diagnosis and suggests that ED may a typical adolescent reaction to psychological stress. However its particular expression in the West (stringent dieting or purging) may be culturally determined. He argues persuasively that since obesity is not a real problem in Hong Kong, and plumpness is seen as a sign of health, anorexia there is probably about rejection of familial control by rejecting nourishment.

However Lee's findings are contradicted by later studies in the mid 1990's (by himself and colleagues), that found increasing preoccupation with weight among high school students. So Lee's concept of non-fat phobic anorexia may have been born of the patients' reluctance to voice untraditional/ 'westernised' views about body size to their psychiatrist.

Anorexia has shown substantial prevalence among the Caucasian population in S. Africa and among the upper economic classes in Santiago, Chile. These groups are more exposed to Euro-American culture than other people in those countries. Furnham and Alibhai (1983) published a study comparing attitudes to body shapes in three groups: Kenyans in Kenya, Kenyans in Britain and British Caucasians. They found that Kenyans in Kenya preferred a larger body shape than British Caucasians. However, Kenyans who had immigrated to Britain preferred an even thinner body image than did the British Caucasians. Hence exposure of immigrant Kenyans to Euro-American cultural values led to assimilation, with a vengeance.

Accounts of ED discussed so far have broadly agreed that the control of eating, shape and weight in ED is not a central motivation but merely a substrate over which control can be expressed. This approach is useful because it leaves room for explanations of ED in males, which do not involve the 'thin ideal'.

Research findings suggest that about 10% of patients with ED are men. Despite this, most research has been conducted in women. Others suggest that ED are seriously misdiagnosed and underreported in men. Even the diagnostic criteria are gynaecentric since amenorrhea is something no anorexic male could ever achieve.

However the common explanations for the origin of ED in men are decidedly body-centric and practical. Approximately 20% of all men diagnosed with ED in the UK self-declare as gay . This figure is double the proportion of gay men in the general population. Some suggest that this is because in the gay scene the male body is subjected to similar scrutiny, as is the female body. Childhood bullying for being overweight is also given as a factor for ED in males. Some men involved in occupations where weight is a e.g. wrestling, athletics, dance, horse racing also have higher rates of ED.

It seems suprising that popular accounts of ED in males do not seek 'underlying factors' (e.g. perfectionism, feelings of inadequacy, a need to diminish or perfect one's emptiness) as causal. Undoubtedly more work is needed in this area. At present there is even doubt as to whether anorexia in men and women is attributable to similar mechanisms. The disorder of reverse anorexia/ bigorexia is seen as more related to female anorexia because of the emphasis of the body beautiful.

Any model of ED needs to account for ED in both males and females if it is to be acceptable as a final common pathway. A single model of ED is needed for the establishment of a universally applicable standard of treatment.

Conclusion
Walters and Kendler (1995) had 35 patients with narrowly defined anorexia and 80 with broadly defined anorexia. The narrow studies were not reported. However MZ concordance was found to be 10% and DZ was found to be 22% among broadly defined anorexics. Kendel et al (1991) found that in narrowly defined bulimic sample (n=60) the MZ concordance was 23% and the DZ was 16%. This was reiterated in broadly defined bulimia (n=123) where rate was 26% and DZ rate was 16%.

These suprising findings broadly suggest a familial component in ED. This is further supported by evidence of elevated eating pathology in relatives of ED diagnosed subjects. As well as ED, there is an increased incidence of substance abuse, mood, anxiety and personality disorders in relatives of ED patients. Though familial components are suspected in ED, the nature of transmission and vulnerability still to be determined.

Stress and eating behaviour are known to be under neuroendocrine controlled. The onset of anorexia and bulimia nervosa is often preceded by a severe stressful event. This might put a strain on coping resources especially if the subject has underdeveloped coping strategies. There have been suggestions of genetic vulnerability factors that reduce ones ability to cope with stress e.g. an elevated cortisol set point . Stress impacting on such individuals results in maladaptive physiological and hence psychological responses.
Any genetic or neurochemical involvement in ED needs investigation, as does the relationship between ED and addiction .

However, genetic and molecular factors could not account for the sudden rise in ED in the last thirty years. If the cause of ED is depression of maladaptive cognitive states, then one must account for the rise in these two causal factors over the last thirty years. Various changes in consciousness of society over this period may be the cause of discontent. Hence eating disorders may be an societal adaptive response to this content. The media has played a role in both shaping and disseminating these sociocultural changes.

Eating Disorders
by James T Webb and Diane Latimer

Research conducted and supported by the National Institute of Mental Health (NIMH) brings hope to millions of people who suffer from mental illness and to their families and friends. In many years of work with animals as well as human subjects, researchers have advanced our understanding of the brain and vastly expanded the capability of mental health professionals to diagnose, treat, and prevent mental and brain disorders.

Now, in the 1990s, which the President and Congress have declared the "Decade of the Brain," we stand at the threshold of a new era in brain and behavioral sciences. Through research in animals and humans, we will learn even more about mental disorders such as depression, manic-depressive illness, schizophrenia, panic disorder, and obsessive-compulsive disorder. And we will be able to use this knowledge to develop new therapies that can help more people overcome mental illness.

The National Institute of Mental Health is a part of the National Institutes of Health (NIH), the Federal Government's primary agency for biomedical and behavioral research. NIH is a component of the U.S. Department of Health and Human Services.

Each year millions of people in the United States develop serious and sometimes life-threatening eating disorders. The vast majority--more than 90 percent--of those afflicted with eating disorders are adolescent and young adult women. One reason that women in this age group are particularly vulnerable to eating disorders is their tendency to go on strict diets to achieve an "ideal" figure. Researchers have found that such stringent dieting can play a key role in triggering eating disorders.

Approximately 1 percent of adolescent girls develop anorexia nervosa, a dangerous condition in which they can literally starve themselves to death. Another 2 to 3 percent of young women develop bulimia nervosa, a destructive pattern of excessive overeating followed by vomiting or other "purging" behaviors to control their weight. These eating disorders also occur in men and older women, but much less frequently. The consequences of eating disorders can be severe, with 1 in 10 cases leading to death from starvation, cardiac arrest, or suicide. Fortunately, increasing awareness of the dangers of eating disorders--sparked by medical studies and extensive media coverage of the illness--has led many people to seek help. Nevertheless, some people with eating disorders refuse to admit that they have a problem and do not get treatment. Family members and friends can help recognize the problem and encourage the person to seek treatment.

This brochure provides valuable information to individuals suffering from eating disorders, as well as to family members and friends trying to help someone cope with the illness. The publication describes the symptoms of eating disorders, possible causes, treatment options, and how to take the first steps toward recovery.

Scientists funded by the National Institute of Mental Health (NIMH) are actively studying ways to treat and understand eating disorders. In NIMH-supported research, scientists have found that people with eating disorders who get early treatment have a better chance of full recovery than those who wait years before getting help.

Anorexia Nervosa
People who intentionally starve themselves suffer from an eating disorder called anorexia nervosa. The disorder, which usually begins in young people around the time of puberty, involves extreme weight loss--at least 15 percent below the individual's normal body weight. Many people with the disorder look emaciated but are convinced they are overweight. Sometimes they must be hospitalized to prevent starvation.

Deborah developed anorexia nervosa when she was 16. A rather shy, studious teenager, she tried hard to please everyone. She had an attractive appearance, but was slightly overweight. Like many teenage girls, she was interested in boys but concerned that she wasn't pretty enough to get their attention. When her father jokingly remarked that she would never get a date if she didn't take off some weight, she took him seriously and began to diet relentlessly--never believing she was thin enough even when she became extremely underweight.

Soon after the pounds started dropping off, Deborah's menstrual periods stopped. As anorexia tightened its grip, she became obsessed with dieting and food, and developed strange eating rituals. Every day she weighed all the food she would eat on a kitchen scale, curing solids into minuscule pieces and precisely measuring liquids. She would then put her daily ration in small containers, lining them up in neat rows. She also exercised compulsively, even after she weakened and became faint. She never took an elevator if she could walk up steps.

No one was able to convince Deborah that she was in danger. Finally, her doctor insisted that she be hospitalized and carefully monitored for treatment of her illness. While in the hospital, she secretly continued her exercise regimen in the bathroom, doing strenuous routines of situps and knee-bends. It took several hospitalizations and a good deal of individual and family outpatient therapy for Deborah to face and solve her problems.

Deborah's case in not unusual. People with anorexia typically starve themselves, even though they suffer terribly from hunger pains. One of the most frightening aspects of the disorder is that people with anorexia continue to think they are overweight even when they are bone-thin. For reasons not yet understood, they become terrified of gaining any weight.

Food and weight become obsessions. For some, the compulsiveness shows up in strange eating rituals or the refusal to eat in front of others. It is not uncommon for people with anorexia to collect recipes and prepare gourmet feasts for family and friends, but not partake in the meals themselves. Like Deborah, they may adhere to strict exercise routines to keep off weight. Loss of monthly menstrual periods is typical in women with the disorder. Men with anorexia often become impotent.

Bulimia Nervosa
People with bulimia nervosa consume large amounts of food and then rid their bodies of the excess calories by vomiting, abusing laxatives or diuretics, taking enemas, or exercising obsessively. Some use a combination of all these forms of purging. Because many individuals with bulimia "binge and purge" in secret and maintain normal or above normal body weight, they can often successfully hide their problem from others for years.

Lisa developed bulimia nervosa at 18. Like Deborah, her strange eating behavior began when she started to diet. She too dieted and exercised to lose weight, but unlike Deborah, she regularly ate huge amounts of food and maintained her normal weight by forcing herself to vomit. Lisa often felt like an emotional powder keg--angry, frightened, and depressed.

Unable to understand her own behavior, she thought no one else would either. She felt isolated and lonely. Typically, when things were not going well, she would be overcome with an uncontrollable desire for sweets. She would eat pounds of candy and cake at a time, and often not stop until she was exhausted or in severe pain. Then, overwhelmed with guilt and disgust, she would make herself vomit.

Her eating habits so embarrassed her that she kept them secret until, depressed by her mounting problems, she attempted suicide. Fortunately, she didn't succeed. While recuperating in the hospital, she was referred to an eating disorders clinic where she became involved in group therapy. There she received medications to treat the illness and the understanding and help she so desperately needed from others who had the same problem.

Family, friends, and physicians may have difficulty detecting bulimia in someone they know. Many individuals with the disorder remain at normal body weight or above because of their frequent binges an purges, which can range from once or twice a week to several times a day. Dieting heavily between episodes of binging and purging is also common. Eventually, half of those with anorexia will develop bulimia.

As with anorexia, bulimia typically begins during adolescence. The condition occurs most often in women but is also found in men. Many individuals with bulimia, ashamed of their strange habits, do not seek help until they reach their thirties or forties. By this time, their eating behavior is deeply ingrained and more difficult to change.

Binge Eating Disorder
An illness that resembles bulimia nervosa is binge eating disorder. Like bulimia, the disorder is characterized by episodes of uncontrolled eating or binging. However, binge eating disorder differs from bulimia because its sufferers do not purge their bodies of excess food.

Individuals with binge eating disorder feel that they lose control of themselves when eating. They eat large quantities of food and do not stop until they are uncomfortably full. Usually, they have more difficulty losing weight and keeping it off than do people with other serious weight problems. Most people with the disorder are obese and have a history of weight fluctuations. Binge eating disorder is found in about 2 percent of the general population--more often in women than men. Recent research shows that binge eating disorder occurs in about 30 percent of people participating in medically supervised weight control programs.

Medical Complications
Eating disorders have among the highest mortality rates of all mental disorders, killing up to 10 percent of their victims. Individuals with eating disorders who use drugs to stimulate vomiting, bowel movement, or urination are in the most danger, as this practice increases the risk of heart failure.

In patients with anorexia, starvation can damage vital organs such as the heart and brain. To protect itself, the body shifts into "slow gear": monthly menstrual periods stop, breathing, pulse, and blood pressure rates drop, and thyroid function slows. Nails and hair become brittle; the skin dries, yellows, and becomes covered with soft hair called lanugo. Excessive thirst and frequent urination may occur. Dehydration contributes to constipation, and reduced body fat leads to lowered body temperature and the inability to withstand cold.

Mild anemia, swollen joints, reduced muscle mass, and light-headedness also commonly occur in anorexia. If the disorder becomes severe, patients may lose calcium from their bones, making them brittle and prone to breakage. They may also experience irregular heart rhythms and heart failure. In some patients, the brain shrinks, causing personality changes. Fortunately, this condition can be reversed when normal weight is reestablished.

In NIMH-supported research, scientists have found that many patients with anorexia also suffer from other psychiatric illnesses. While the majority have co-occurring clinical depression, others suffer from anxiety, personality or substance abuse disorders, and many are at risk for suicide. Obsessive-compulsive disorder (OCD), an illness characterized by repetitive thoughts and behaviors, can also accompany anorexia. Individuals with anorexia are typically compliant in personality but may have sudden outbursts of hostility and anger or become socially withdrawn.

Bulimia nervosa patients--even those of normal weight--can severely damage their bodies by frequent binge eating and purging. In rare instances, binge eating causes the stomach to rupture; purging may result in heart failure due to loss of vital minerals, such as potassium. Vomiting causes other less deadly, but serious problems--the acid in vomit wears down the outer layer of the teeth and can cause scarring on the backs of the hands when fingers are pushed down the throat to induce vomiting. Further, the esophagus becomes inflamed and the glands near the cheeks become swollen. As in anorexia, bulimia may lead to irregular menstrual periods. Interest in sex may also diminish.

Some individuals with bulimia struggle with addictions, including abuse of drugs and alcohol, and compulsive stealing. Like individuals with anorexia, many people with bulimia suffer from clinical depression, anxiety, OCD, and other psychiatric illnesses. These problems, combined with their impulsive tendencies place them at increased risk for suicidal behavior.

People with binge eating disorder are usually overweight, so they are prone to the serious medical problems associated with obesity, such as high cholesterol, high blood pressure, and diabetes. Obese individuals also have a higher risk for gallbladder disease, heart disease, and some types of cancer. Research at NIMH and elsewhere has shown that individuals with binge eating disorder have high rates of co-occurring psychiatric illnesses--especially depression.

Causes of Eating Disorders
In trying to understand the causes of eating disorders, scientists have studied the personalities, genetics, environments, and biochemistry of people with these illnesses. As is often the case, the more that is learned, the more complex the roots of eating disorders appear.

Personalities
Most people with eating disorders share certain personality traits: low self-esteem, feelings of helplessness, and a fear of becoming fat. In anorexia, bulimia, and binge eating disorder, eating behaviors seem to develop as a way of handling stress and anxieties.

People with anorexia tend to be "too good to be true." They rarely disobey, keep their feelings to themselves, and tend to be perfectionists, good students, and excellent athletes. Some researchers believe that people with anorexia restrict food--particularly carbohydrates--to gain a sense of control in some area of their lives. Having followed the wishes of others for the most part they have not learned how to cope with the problems typical of adolescence, growing up, and becoming independent. Controlling their weight appears to offer two advantages, at least initially: they can take control of their bodies and gain approval from others. However, it eventually becomes clear to others that they are out-of-control and dangerously thin.

People who develop bulimia and binge eating disorder typically consume huge amounts of food--often junk food--to reduce stress and relieve anxiety. With binge eating, however, comes guilt and depression. Purging can bring relief, but it is only temporary. Individuals with bulimia are also impulsive and more likely to engage in risky behavior such as abuse of alcohol and drugs.

Genetic and Environmental Factors
Eating disorders appear to run in families--with female relatives most often affected. This finding suggests that genetic factors may predispose some people to eating disorders, however, other influences--both behavioral and environmental--may also play a role. One recent study found that mothers who are overly concerned about their daughters' weight and physical attractiveness may put the girls at increased risk of developing an eating disorder. In addition, girls with eating disorders often have fathers and brothers who are overly critical of their weight.

Although most victims of anorexia and bulimia are adolescent and young adult women, these illnesses can also strike men and older women. Anorexia and bulimia are found most often in Caucasians, but these illnesses also affect African Americans and other racial ethnic groups. People pursuing professions or activities that emphasize thinness--like modeling, dancing, gymnastics, wrestling, and long-distance running--are more susceptible to the problem. In contrast to other eating disorders, one-third to one-fourth of all patients with binge eating disorder are men. Preliminary studies also show that the condition occurs equally among African Americans and Caucasians.

Biochemistry
In an attempt to understand eating disorders, scientists have studied the biochemical functions of people with the illnesses. They have focused recently on the neuroendocrine system--a combination of the central nervous and hormonal systems. Through complex but carefully balanced feedback mechanisms, the neuroendocrine system regulates sexual function, physical growth and development, appetite and digestion, sleep, heart and kidney function, emotions, thinking, and memory--in other words, multiple functions of the mind and body. Many of these regulatory mechanisms are seriously disturbed in people with eating disorders.

In the central nervous system--particularly the brain--key chemical messengers known as neurotransmitters control hormone production. Scientists have found that the neurotransmitters serotonin and norepinephrine function abnormally in people affected by depression. Recently, researchers funded by NIMH have learned that these neurotransmitters are also decreased in acutely ill anorexia and bulimia patients and long-term recovered anorexia patients. Because many people with eating disorders also appear to suffer from depression, some scientists believe that there may be a link between these two disorders. This link is supported by studies showing that antidepressants can be used successfully to treat some people with eating disorders. In fact, new research has suggested that some patients with anorexia may respond well to the antidepressant medication fluoxetine, which affects serotonin function in the body.

People with either anorexia or certain forms of depression also tend to have higher than normal levels of cortisol a brain hormone released in response to stress. Scientists have been able to show that the excess levels of cortisol in both anorexia and depression are caused by a problem that occurs in or near a region of the brain called the hypothalamus.

In addition to connections between depression and eating disorders, scientists have found biochemical similarities between people with eating disorders and obsessive-compulsive disorder (OCD). Just as serotonin levels are known to be abnormal in people with depression and eating disorders, they are also abnormal in patients with OCD. Recently, NIMH researchers have found that many patients with bulimia have obsessive-compulsive behavior as severe as that seen in patients actually diagnosed with OCD. Conversely, patients with OCD frequently have abnormal eating behaviors.

The hormone vasopressin is another brain chemical found to be abnormal in people with eating disorders and OCD. NIMH researchers have shown that levels of this hormone are elevated in patients with OCD, anorexia, and bulimia. Normally released in response to physical and possibly emotional stress, vasopressin may contribute to the obsessive behavior seen in some patients with eating disorders.

NIMH-supported investigators are also exploring the role of other brain chemicals in eating behavior. Many are conducting studies in animals to shed some light on human disorders. For example, scientists have found that levels of neuropeptide Y and peptide YY recently shown to be elevated in patients with anorexia and bulimia, stimulate eating behavior in laboratory animals. Other investigators have found that cholecystokinin (CCK), a hormone known to be low in some women with bulimia, causes laboratory animals to feel full and stop eating. This finding may possibly explain why women with bulimia do not feel satisfied after eating and continue to binge.

Treatment
Eating disorders are most successfully treated when diagnosed early. Unfortunately, even when family members confront the ill person about his or her behavior, or physicians make a diagnosis, individuals with eating disorders may deny that they have a problem. Thus, people with anorexia may not receive medical or psychological attention until they have already become dangerously thin and malnourished. People with bulimia are often normal weight and are able to hide their illness from others for years. Eating disorders in males may be overlooked because anorexia and bulimia are relatively rare in boys and men. Consequently, getting--and keeping--people with these disorders into treatment can be extremely difficult.

In any case, it cannot be overemphasized how important treatment is--the sooner, the better. The longer abnormal eating behaviors persist, the more difficult it is to overcome the disorder and its effects on the body. In some cases, long-term treatment may be requested. Families and friends offering support and encouragement can play an important role in the success of the treatment program.

If an eating disorder is suspected, particularly if it involves weight loss, the first step is a complete physical examination to rule out any other illnesses. Once an eating disorder is diagnosed, the clinician must determine whether the patient is in immediate medical danger and requires hospitalization. While most patients can be treated as outpatients, some need hospital care. Conditions warranting hospitalization include excessive and rapid weight loss, serious metabolic disturbances, clinical depression or risk of suicide, severe binge eating and purging, or psychosis.

The complex interaction of emotional and physiological problems in eating disorders calls for a comprehensive treatment plan, involving a variety of experts and approaches. Ideally, the treatment team includes an internist, a nutritionist, an individual psychotherapist, a group and family psychotherapist, and a psychopharmacologist--someone who is knowledgeable about psychoactive medications useful in treating these disorders.

To help those with eating disorders deal with their illness and underlying emotional issues, some form of psychotherapy is usually needed. A psychiatrist, psychologist, or other mental health professional meets with the patient individually and provides ongoing emotional support, while the patient begins to understand and cope with the illness. Group therapy, in which people share their experiences with others who have similar problems, has been especially effective for individuals with bulimia.

Use of individual psychotherapy, family therapy, and cognitive-behavioral therapy--a form of psychotherapy that teaches patients how to change abnormal thoughts and behavior--is often the most productive. Cognitive-behavior therapists focus on changing eating behaviors, usually by rewarding or modeling wanted behavior. These therapists also help patients work to change the distorted and rigid thinking patterns associated with eating disorders.

NIMH-supported scientists have examined the effectiveness of combining psychotherapy and medications. In a recent study of bulimia, researchers found that both intensive group therapy and antidepressant medications, combined or alone, benefitted patients. In another study of bulimia, the combined use of cognitive-behavioral therapy and antidepressant medications was most beneficial. The combination treatment was particularly effective in preventing relapse once medications were discontinued. For patients with binge eating disorder, cognitive-behavioral therapy and antidepressant medications may also prove to be useful.

Antidepressant medications commonly used to treat bulimia include desipramine, imipramine, and fluoxetine. For anorexia, preliminary evidence shows that some antidepressant medications may be effective when combined with other forms of treatment. Fluoxetine has also been useful in treating some patients with binge eating disorder. These antidepressants may also treat any co-occurring depression.

The efforts of mental health professionals need to be combined with those of other health professionals to obtain the best treatment. Physicians treat any medical complications, and nutritionists advise on diet and eating regimens. The challenge of treating eating disorders is made more difficult by the metabolic changes associated with them. Just to maintain a stable weight, individuals with anorexia may actually have to consume more calories than someone of similar weight and age without an eating disorder.

This information is important for patients and the clinicians who treat them. Consuming calories is exactly what the person with anorexia wishes to avoid, yet must do to regain the weight necessary for recovery. In contrast, some normal weight people with bulimia may gain excess weight if they consume the number of calories required to maintain normal weight in others of similar size and age.