Eating Disorders: Disordered Eating Past And Present

Anorexia nervosa and bulimia nervosa have become familiar household words. As recently as the 1980s, it was difficult to find anybody who knew the true meaning of these terms, much less to know someone truly suffering from one of these syndromes. Today disordered eating is alarmingly common, and having an eating disorder is almost seen as a trendy problem. Starving and purging have become the acceptable weight loss methods for 80 percent of our eighth-grade girls. Binge eating disorder, a newly named syndrome, goes beyond overeating to an out-of-control illness ruining the person's life. Eating disorders are becoming so common that the question seems to be not "Why do so many people develop eating disorders?" but, rather, "How is it that anyone, particularly if female, does not?"

The first hint that eating disorders might become a serious problem was introduced in 1973 in a book by Hilde Bruch called Eating Disorders: Obesity, Anorexia Nervosa, and the Person Within. It was the first major work on eating disorders but was geared to professionals and was not readily available to the public. Then, in 1978, Hilde Bruch gave us her pioneer work, The Golden Cage, which continues to provide a compelling, passionate, and empathetic understanding of the nature of eating disorders, particularly anorexia nervosa, and of those who develop them. Finally, the public, for better or worse, began to be educated.

With the book and the television movie The Best Little Girl in the World, Steven Levenkron brought the knowledge of anorexia nervosa into the average home. And in 1985, when Karen Carpenter died from heart failure due to anorexia nervosa, eating disorders made the headlines as the emaciated picture of the famous and talented singer haunted the public from the cover of People magazine and in the national news. Since then, women's magazines began and have not ceased to run feature articles on eating disorders, and we learned that people who we thought had everything - beauty, success, power, and control - were lacking something else, as many began admitting that they, too, had eating disorders. Jane Fonda told us she had bulimia and had been purging food for years. Olympic Gold medalist gymnast Kathy Rigby revealed a struggle with anorexia and bulimia that almost took her life, and several others followed suit: Gilda Radner, Princess Di, Sally Field, Elton John, Tracy Gold, Paula Abdul, and the late gymnast Christy Heinrich, to name just a few.

Characters with eating disorders started appearing in books, plays, and television series. Hospital treatment programs sprang up across the country, marketing to those afflicted with phrases such as "It's not what you're eating, it's what's eating you," "It's not your fault," and "Are you losing it?" Eating disorders finally made it to top billing when Henry Jaglom produced and directed a major motion picture titled simply but provocatively Eating. The scenes in this film, many of which are unrehearsed excerpts of monologues or dialogues happening between women at a party, are revealing, compelling, sad, and disturbing. The film and this book are in part about the war in which females in our society are engaged, the war between the natural desire to eat and the biological reality that doing so deprives them of attaining the standard of appearance held up for them to achieve. Talk shows on eating disorders are at an all-time high, featuring every possible eating disorder angle one can imagine: "Anorexics and Their Moms," "Pregnant Women with Bulimia," "Males with Eating Disorders," "Eating Disordered Twins," "Eating Disorders and Sexual Abuse."

When people ask, "Are eating disorders really more common now or have they just been in hiding?" the answer is, "Both." First, the numbers of individuals with eating disorders do seem to be continually increasing, paralleling society's increasing obsession with thinness and losing weight. Feelings that may have been brought out in other ways in the past now find expression through the pursuit of thinness. Second, it is easier to admit that a problem exists when that problem is better understood by society and there is help available to treat it. Even though individuals suffering from eating disorders are reluctant to admit it, they do so more now than in the past because they and their significant others are more likely to know that they have an illness, the possible consequences of that illness, and that they can get help for it. The trouble is, they often wait too long. Knowing when problem eating has become an eating disorder is difficult to determine. There are far more people with eating or body image problems than those with full-blown eating disorders. The more we learn about eating disorders, the more we realize that there are certain individuals predisposed to develop them. These individuals are more "sensitive" to the current cultural climate and are more likely to cross the line between disordered eating and an eating disorder. When is this line crossed? We can begin with the fact that to be officially diagnosed with an eating disorder, one has to meet the clinical diagnostic criteria.

DIAGNOSTIC CRITERIA FOR EATING DISORDERS

The following clinical descriptions are taken from The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.

ANOREXIA NERVOSA

• Refusal to maintain body weight at or above a minimally normal weight for age and height (for example, weight loss leading to maintenance of body weight less than 85 percent of that expected, or failure to make expected weight gain during period of growth leading to body weight less than 85 percent of that expected). Intense fear of gaining weight or becoming fat, even though underweight.

• 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.

• In postmenarcheal females, amenorrhea (for example, absence of at least three consecutive menstrual cycles). A woman is considered to have amenorrhea if her periods occur only following hormone (for example, estrogen) administration.

Restricting Type: During the current episode of anorexia nervosa, the person has not regularly engaged in binge eating or purging behavior (for example, self-induced vomiting or the misuse of laxatives, diuretics, or enemas).

Binge Eating/Purging Type: During the current episode of anorexia nervosa, the person has regularly engaged in binge eating or purging behavior (for example, self-induced vomiting or the misuse of laxatives, diuretics, or enemas).

Despite its increase over the last decade or so, anorexia nervosa is not a new illness, nor is it solely a phenomenon of our current culture. The case of anorexia nervosa most often cited as the earliest in the literature was of a twenty-year-old girl treated in 1686 by Richard Morton and described in his work, Phthisiologia: or a Treatise of Consumption's. Morton's description of what he termed "nervous consumption" sounds eerily familiar: "I do not remember that I did ever in my entire Practice see one, that was so conversant with the Living so much wasted with the greatest degree of Consumption, (like a Skeleton only clad with Skin) yet there was no Fever, but on the contrary a Coldness of the whole Body . . . Only her Appetite was diminished, and Digestion uneasy, with Fainting Fitts, [sic] which did frequently return upon her."

The first case study where we have descriptive detail from the patient's perspective is that of a woman known as Ellen West (1900 - Å“ 1933) who at age thirty-three committed suicide to end her desperate struggle that had manifested itself through an obsession with thinness and with food. Ellen kept a diary that contains perhaps the earliest record of the inner world of the eating disordered person:

Everything agitates me and I experience every agitation as a sensation of hunger, even if I have just eaten.

I am afraid of myself. I am afraid of the feelings to which I am defenselessly delivered over every minute.

I am in prison and cannot get out. It does no good for the analyst to tell me that I myself place the armed men there, that they are theatrical figments and not real. To me they are very real.

The woman of today suffering from an eating disorder, like Ellen West, appears to exhibit rigid control of her "out of controlness," making an effort to purge herself of yearnings, ambitions, and sensual pleasures. Emotions are feared and translated into somatic (body) experiences and eating disorder behaviors, which serve to eliminate the feeling aspect of self. Through their struggle with their bodies, anorexics are striving for mind over matter, perfection, and mastery of self, all of the things for which unfortunately their peers and our society in general willingly praise and applaud them. This, of course, entrenches the patterns into the very fabric of each individual's identity. Persons with anorexia nervosa seem not to have this disorder but to become it.

Quotes like Ellen's are repeated by patients today with amazing similarity.

I am in my own prison. No matter what anyone says, I have sentenced myself to thinness for life. I will die here.

It does not matter if everyone else tells me that I am not fat, that it is all in my head. Even if it is in my head I placed the thoughts there. They are mine. I know my therapist thinks I am making a bad choice but it's my choice and I do not want to eat.

When I eat I feel. It is better if I don't feel, I am too afraid.

By Marc Darrow, MD, JD WebMD Medical Reference from "The Eating Disorders Sourcebook"

Ellen West was given several different diagnoses throughout her lifetime, including manic depression and schizophrenia, but reading back through her diaries and studying the case, it is clear that she suffered at different times from both anorexia nervosa and bulimia nervosa and that her desperate battle with these eating disorders drove her to take her own life. Ellen West and others like her are not suffering from a loss of hunger, but a hunger they cannot explain.

The term anorexia is of Greek origin: an (privation, lack of) and orexis (appetite), thus meaning a lack of desire to eat. It was originally used to describe the loss of appetite caused by some other ailment such as headaches, depression, or cancer, where the person actually doesn't feel hungry. Normally, appetite is like the response to pain, beyond the individual's control. The term anorexia alone is an insufficient label for the eating disorder commonly known by that name. Persons afflicted with this disorder have not just lost their appetites; in fact they long to eat, obsess and dream about it, and some of them even break down and eat uncontrollably.

Patients report spending 70 to 85 percent of each day thinking about food, creating menus, baking, feeding others, worrying about what to eat, bingeing on food, and purging to get rid of food eaten. The full clinical term, anorexia nervosa (lack of desire to eat due to a mental condition), is a more appropriate name for the illness. This now commonly known term was not used until 1874 when a British physician, Sir William Gull, used it to describe several patients he had seen who exhibited all the familiar signs we associate with this disorder today: refusal to eat, extreme weight loss, amenorrhea, low pulse rate, constipation, and hyperactivity, all of which he thought resulted from a "morbid mental state." There were other early researchers who pointed out individuals with these symptoms and began to develop theories about why they would behave in such a fashion. Pierre Janet, from France, described the syndrome most succinctly when he concluded that "it is due to a deep psychological disturbance, of which the refusal of food is but the outer expression."

Individuals with anorexia nervosa may eventually develop a true lack of appetite, but for the most part it is not a loss of appetite but rather a strong desire to control it that is a cardinal feature. Rather than lose their desire to eat, anorexics, while suffering from the disorder, deny their bodies even when driven by hunger pangs, and they obsess about food all day long. They often want to eat so badly that they cook for and feed others, study menus, read and concoct recipes, go to bed thinking about food, dream about food, and wake up thinking about food. They simply don't allow themselves to have it, and, if they do, they relentlessly pursue any means to get rid of it.

Anorexics are afraid of food and afraid of themselves. What begins as a determination to lose weight continues and progresses to be a morbid fear of gaining back any lost weight, and becomes a relentless pursuit of thinness. These individuals are literally dying to be thin. Being thin, which translates to "being in control," becomes the most important thing in the world.

In the throes of the disorder, anorexics are terrified of losing control, terrified of what might happen if they allowed themselves to eat. This would mean a lack of willpower, a complete "giving in," and they fear that once they let up on the control they have imposed on themselves, they will never get "in control" again. They are afraid that, if they allow themselves to eat, they will not stop, and if they gain one pound today or even this week, that they are now "gaining." A pound today means another pound later and then another and another until they are obese. Physiologically speaking, there is a good reason for this feeling. When a person is starving, the brain is constantly sending impulses to eat. The strength of these impulses to eat is such that the feeling that one may not be able to stop is powerful. Self-induced starvation goes against normal bodily instincts and can rarely be maintained. This is one reason why many anorexics ultimately end up binge eating and purging food to the point where approximately 30 to 50 percent develop bulimia nervosa.

Anorexics fear, as crazy as it may seem when looking at them, that they are or will become fat, weak, undisciplined, and unworthy. To them, losing weight is good and gaining weight is bad, period. With the progression of the illness, eventually there are no longer fattening foods but simply the dictum that "food is fattening." The anorexic mind-set seems useful at the beginning of a diet when the goal is to lose a few unwanted pounds, but when the dieting itself becomes the goal, there is no way out. The dieting becomes a purpose and what can be referred to as "a safe place to go." It's a world created to help cope with feelings of meaninglessness, of low self- esteem, of failure, of dissatisfaction, of the need to be unique, the desire to be special, to be a success, to be in control. Anorexics create a world where they can feel/be "successful," "good," and "safe" if they can deny food, making it through the day eating little if anything at all. They consider it a threat and failure if they break down and eat too much, which for them can be as little as 500 calories or even less. In fact, for some anorexics, eating any food item over 100 calories usually causes great anxiety. Anorexics seem to prefer two-digit numbers when it comes to eating and to weight. This kind of overcontrol and exertion of mind over matter goes against our understanding of all normal physiological impulses and instincts for survival. Of the eating disorders, anorexia nervosa is the most rare.

The following describes a more common manifestation of disordered eating, bulimia nervosa.

BULIMIA NERVOSA

• Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
  • Eating, in a discreet period of time (for example, within any two-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances.
  • A sense of lack of control over eating during the episode (for example, a feeling that one cannot stop eating or control what or how much one is eating).
• Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise.
• The binge eating and other compensatory behaviors both occur, on the average, at least twice a week for three months.
• Self-evaluation is unduly influenced by body shape and weight.
• The disturbance does not occur exclusively during episodes of anorexia nervosa.

Purging Type: During the current episode of bulimia nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.

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

The term bulimia is derived from Latin and means "hunger of an ox." It is commonly known that the Romans engaged in binge eating and vomiting rituals, but it was first described in medical terms in 1903 in Obsessions et la Psychasthenie, where the author, Pierre Janet, describes Nadia, a woman who engaged in compulsive binges in secret.

It is the frequency and intensity of the bingeing that separates anorexics from bulimics, even though both populations will restrict food consumption and many anorexics also binge and purge. Anorexics who purge and normal-weight individuals who do not binge but vomit whenever they eat food they consider "too fattening" are often improperly diagnosed with bulimia nervosa. Without binge eating, a diagnosis of bulimia is not correct. The disorders do seem to cross over into each other. Most people with bulimia have thought patterns and experience symptoms similar to those with anorexia. The drive for thinness and the fear of being fat appear in both disorders, and while body image distortion is present in bulimia, it is usually not to the same degree as in anorexia nervosa.

Most people with bulimia restrict caloric intake such that they try to keep a weight that is too low for them to maintain without experiencing many of the symptoms of semi-starvation. Some bulimics are at or above normal weight but nevertheless experience starvation symptoms due to their continual efforts to restrict food intake. Individuals with bulimia nervosa live in a world between compulsive, or binge eating, and starving, pulled in both directions. Bulimics are often referred to as "failed anorexics" - they have repeatedly tried to control their weight by restricting intake and have been unable to do so. These individuals end up bingeing and then, out of anxiety and desperation, purge through self-induced vomiting, laxatives, or diuretics, or use other compensatory behaviors to make up for their binges, such as fasting, exercise, saunas, or other similar means. On the other hand, many individuals with bulimia describe themselves as binge eaters first who then resort to purging after dieting fails.

Purging and other compensatory behaviors often serve to calm down bulimics and ease their guilt and anxiousness about having consumed too much food or gained weight. As the disorder progresses, bulimics will purge or compensate for eating even normal or small amounts of anything they consider "bad" or "fattening" and, eventually, any food at all. Binges can eventually be quite extreme. For example, binges of up to 50,000 calories a day have been recorded. A major university even claimed it had to put signs up in its dormitory bathrooms pleading, "Please stop throwing up, you're ruining our plumbing!" The acid from vomiting was ruining the pipes.

Overall, it is important to understand that bulimia nervosa, which appears in the beginning to be related to dieting and weight control, eventually becomes a means of mood regulation in general. A bulimic finds solace in food and often in the purging itself. The act of purging becomes powerfully addictive, not just because it controls weight, but because it is calming, or serves as a way of expressing anger, or in some other way helps the individual cope, albeit destructively.

In fact, bulimics seem to be individuals who need help regulating or modulating mood states and therefore are more prone to use a variety of coping mechanisms such as drugs, alcohol, and even sex.

Social functioning and adjustment among individuals with bul-imia vary. For one thing, unlike anorexics, bulimics are not easily identified and are able to be successful at work, in school, and in relationships, while keeping the bulimia a secret. Patients have disclosed their bulimia to therapists after successfully hiding it from everyone, including their spouses, sometimes for as long as twenty years. Some bulimics become so entrenched in the disorder, bingeing and purging eighteen or more times per day, that they have little or no ability to perform on the job or in school and have marked difficulty with relationships.

Bulimics are almost always distressed by their behaviors and at the same time are amazed, surprised, and even horrified at their own inability to control them. They often talk about their bulimia as though they were not in control of it, as if they were possessed by something, or as if monsters were inside of them. They are alarmed at the things they hear themselves saying or what they have written. Below are quotes taken from patients' journals.

I sometimes find myself in the middle of a binge not knowing how I got there, it is like something is in control of me, someone or some thing I don't even know.

I never eat bran muffins or cereal or any kind of dessert during the day, only at night. And then I binge on it. I actually go to the store during the night and get it. I keep telling myself I'm not going to do it, but I find myself at the store . . . and later eating and throwing up. Afterwards I say I won't do it again, but I always do. This is so sick.

Dinner time so I went and got a bowl of salad with tortilla chips. Then I had a corn muffin that I had bought that day. The corn muffin led to some cereal, then I just stopped and went to my room to go to sleep. Fell asleep for a while, woke up and had a corn muffin, bagel and some more cereal. Oh so full and bummed that I blew it again with bingeing. Hadn't thrown up yet, but I knew it was inevitable. I tried putting it off, I went onto the couch in the family room and tried sleeping there but that didn't work. I was too uncomfortable. I wish I was afraid to throw-up. I am tired of this whole thing. I don't like to throw-up, I don't even like bingeing as much as I use to. It doesn't feel the same now, as it use to feel, and it doesn't leave me feeling the way it use to. Then why do I keep doing it? I don't want to binge tonight, but I am afraid of what might become of me, if I don't! God, I wish I were with somebody right now. I keep trying to have this dialogue with myself.

I have been thinking about it lately in terms of license plates. Seven digits of synopsis; a Reader's Digest of my soul; and I came up with a few options. Monster, perhaps, will win the day. . . .Monster for the disgust it inspires. We could fault our narcissistic culture; we could point to a dysfunctional upbringing; and yet none of these alibis could redeem me of my status. To be a bulimic, a dumpster-snacking, bum-rolling, gutter variety bulimic, is to have transposed into such a state of Monsterdom. Perfect as a license plate, saying as it does all that really needs to be understood of me. . . .being a Monster is expensive. Monster math looks like this: assume, conservatively speaking, you have purged 5 times a day for the last four years. That is 35 times a week, 140 times a month, 1,680 times a year, 6,720 times in the four years. At each occasion, you purged 30,000 calories worth of food (sometimes much more, sometimes less) for a total of 20,160,000 calories purged. Here we have a small African village. The experts at UNICEF have agreed that a subsistence diet for each of the villagers would be 1,500 a day. One African man, on the 20,160,000 calories I either flushed down the toilet, left in a back alley, or concealed in plastic bags for later dumping, could live for almost 37 years. 500 villagers could eat for 27 days. A new twist on the "starving people in Africa" scenario, for which we clean our plates as children. This is being a Monster.

Because they feel ashamed of their behavior, out of control, taken over, and even possessed, bulimics often come into treatment seemingly more motivated than anorexics to have their eating disorders taken away. Goals have to be carefully explored due to the fact that motivation to seek help may be generated only by the desire to stop bingeing and become a better anorexic. Bulimics believe that bingeing is the root of their problem, the thing to be ashamed of and to control. It is common for bulimics to express their desire to stop bingeing but their reluctance to give up restrictive eating. Furthermore, bulimics believe that, if they could just stop bingeing, the purging would stop, so they assert their efforts toward controlling their eating, thus setting themselves up again for a binge.

Unlike in bulimia nervosa, there are individuals for whom bingeing is the primary problem. Binge eating or the compulsive consumption of food seems to be due to causes other than just restricting food. Individuals who binge eat and do not resort to some form of purging or restricting suffer from binge eating disorder, described in the following section.

BINGE EATING DISORDER

The term binge eating disorder (BED) was officially introduced in 1992 at an International Eating Disorders Conference. The term was developed to describe individuals who binge eat but do not use extreme compensatory behaviors such as fasting or purging to lose weight. In the past, these individuals were often referred to as compulsive overeaters, emotional overeaters, or food addicts. Many of these individuals suffer from debilitating patterns of eating for self-soothing rather than following physiological cues to eat. This nonhunger eating, when done on a regular basis, produces weight gain and even obesity. Physicians, dietitians, and other health professionals often focus on the individual's overweight state without inquiring about possible eating disorder behaviors such as binge eating patterns or other forms of overeating done for the purposes of psychological self-medicating.

Some professionals are of the opinion that there are two distinct subcategories of binge eating: deprivation-sensitive binge eating and addictive or dissociative binge eating. Deprivation-sensitive binge eating appears to be the result of weight loss diets or periods of restrictive eating, both of which result in binge eating episodes. Addictive or dissociative binge eating is the practice of self-medicating or self-soothing with food unrelated to prior restricting. Many individuals report feelings of numbness, dissociation, calmness, or regaining of inner equilibrium after binge eating. More research is necessary to prevent the ongoing inappropriate treatment of binge eating disorders solely with weight loss diets and exercise programs. These types of recommendations may exacerbate the eating disorder and tragically fail individuals needing more extensive help to recover.

Although the research is scarce, it suggests that approximately one-fifth of the people who present for the treatment of obesity meet the criteria for BED. In the DSM IV, binge eating disorder is not an officially recognized eating disorder but is included in the category titled, "Eating Disorder Not Otherwise Specified," which will be discussed later. However, BED is also listed in the DSM IV in a category for proposed diagnoses and includes diagnostic criteria to aid further study.

DSM IV RESEARCH CRITERIA FOR BINGE EATING DISORDER

• Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
  • Eating, in a discrete period of time (for example, within any two-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances; and
  • A sense of lack of control over eating during the episode (for example, a feeling that one cannot stop eating or control what or how much one is eating).
• The binge eating episodes are associated with three (or more) 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.
• Marked distress regarding binge eating is present.
• The binge eating occurs, on average, at least two days a week for six months. Note: The method of determining frequency differs from that used for bulimia nervosa; future research should address whether the preferred method of setting a frequency threshold is counting the number of days on which binges occur or counting the number of episodes of binge eating.
• The binge eating is not associated with the regular use of inappropriate compensatory behaviors (for example, purging, fasting, excessive exercise) and does not occur exclusively during the course of anorexia nervosa or bulimia nervosa.

Binge eating has been described as part of the diagnostic criteria of bulimia nervosa but is the central feature in binge eating disorder, which has surely existed as long as the other primary eating disorders even without its own official DSM category.

To distinguish simple overeating from binge eating, as in distinguishing dieting from anorexia, we need to look at definition and degree. According to the Oxford English Dictionary, the term binge refers to "a heavy drinking bout, hence a spree." For several years bingeing or binge drinking were terms commonly used in Alcoholics Anonymous meetings. But according to one definition in Webster's Collegiate Dictionary, tenth edition, the word binge can be applied to anything where there is "an unrestrained or excessive indulgence." In binge eating disorder, the food is binged on in a discrete period of time with the individual reporting an inability to stop or to control the behavior. According to the book Overcoming Binge Eating, by Dr. Christopher Fairburn, one in five young women today report this experience with food.

Binge eating was first observed and reported in studies on obesity in the late 1950s by Dr. Albert Stunkard of the University of Pennsylvania. In the 1980s, additional studies on obesity and bulimia nervosa showed that many people in both populations have binge eating problems without the other criteria for bulimia nervosa. A research group headed by Dr. Robert Spitzer of Columbia University proposed that a new disorder called "pathological overeating syndrome" be used to describe these individuals. Then, in 1992, the term binge eating disorder was adopted at the Inter-national Eating Disorders Conference.

Binge eating disorder seems to affect a more diverse population than the other eating disorders; for example, men and African Americans appear to be equally at risk as women and Caucasians, and the age group is broader.

It is a common misconception that all people with binge eating disorder are overweight. It is also very important to clarify that being overweight or even obese is not enough to warrant the diagnosis of binge eating disorder. There are a variety of causes for obesity. Some overweight individuals graze on food all day long or eat foods with high caloric density but do not binge. Researchers in weight control and obesity are increasingly discovering evidence that biological and biochemical predispositions play a role.

The focus of treatment for this disorder is the individual's binge eating, compulsivity with food, inability to control food intake, and using food as a method of coping with anxiety or other underlying issues. Attempting to lose weight before resolving any psychological, emotional, or relational issues will most likely result in failure.

The following are excerpts from the diaries of binge eaters.

When I start eating I can't stop. I don't know when I'm hungry or when I'm full anymore. I really don't know, I can't remember what it was like to know. Once I start, I just keep eating until I literally can't take another bite.

I like to eat when I'm tired because I don't have enough energy to enjoy doing something more active. I'd like some nachos right now, a lot of nachos right now. A lot of nachos with lots of cheese - super nachos with guacamole and jalapenos, plus everything and then I could go for some toast and cinnamon toast with lots of butter, cinnamon, and sugar. Then I wish we had some cheesecake that would be good with crunchy graham cracker crust and creamy filling. Then I would like something with chocolate such as chocolate ice cream or soft brownies with vanilla ice cream and magic shell or magic shell on coffee ice cream or Swiss almond or oatmeal cookies and vanilla Haagen Daz with magic shell! Nuked rice cakes - popcorn rice cakes, still warm.

Also I would like a whole bowl full of granola; really good granola with milk. I want granola on ice cream with magic shell! GRUB! Haagen Daz bar; vanilla with chocolate cover and almonds or coffee toffee crunch. Then I would like toast with butter and spun honey. Yum! Then soft bread biscuits with butter and spun honey. Yum! Hot, soft biscuits with butter and honey; big ones, crusty on the outside and soft on the inside. Then butter and honey melted together. Food - different taste combinations new experiences - old familiar comforts like pancakes and toast are comforting. The experiments with ice cream are new experiences - breakfast foods seem to be more comforting - toast, cereal, pancakes, etc. . . . They comfort - a reminder of safety and security. Having breakfast in the comfort of your home before embarking on the rigors of the day. It is a reminder that safety and security are tangibly accessible - symbolized in breakfast foods.

EATING DISORDERS NOT OTHERWISE SPECIFIED

Aside from binge eating disorder, there are several other variants of disordered eating that do not meet the diagnostic criteria for anorexia nervosa or bulimia nervosa but nevertheless are eating disorders requiring treatment. In fact, according to Christopher Fairburn and Timothy Walsh, in their chapter titled "Atypical Eating Disorders" from the book Eating Disorders and Obesity, roughly one-third of those who present for treatment of an "eating disorder" fall into this category. The DSM-IV places the atypical eating disorders into a category commonly referred to as EDNOS, which stands for "Eating Disorders Not Otherwise Specified." In this category are syndromes that resemble anorexia nervosa or bulimia nervosa but fall short of an essential feature or are not of the required severity, thus precluding either diagnosis. Also in this category are eating disorders that may present quite differently from anorexia nervosa or bulimia nervosa, such as binge eating disorder, described above. The diagnosis of EDNOS is used for chronic dieters who purge what is considered by them to be "fattening" foods, even though they seldom or never binge and do not restrict their eating to the point of severe weight loss. EDNOS includes: anorexics with menses; anorexics who despite significant weight loss are in the normal weight range; bulimics who don't meet the frequency or duration requirement for symptoms; purgers who don't binge; individuals who chew and spit out food; and those with binge eating disorder.

Even without meeting the full diagnostic criteria for one of the major eating disorders, it is clear that individuals with some form of EDNOS also need help. The people described in this book, no matter how varied and unique, are all suffering from disordered eating, a disordered society, and a disordered self.

EATING DISORDER STATISTICS - HOW BAD IS IT?

Definitive statistics on the prevalence and prognosis of eating disorders are impossible to come by. The research is beset with problems of sampling, of methods of assessment, of defining key terms such as binge and recovery, and of reporting - cases of eating disorder are probably underreported, due to the connection of these disorders to fear and shame.

Most of the statistics gathered on eating disorders have come from subject pools of adolescent and young adult females in predominantly white upper-class and middle-class groups. It does appear, however, that the incidence of eating disorders (especially bulimia nervosa and atypical eating disorders) is increasing in other countries and in all areas of the population, including males, minorities, and other age groups.

It should be of great concern to us all that:

• "Fifty percent of females between the ages of eleven and thirteen see themselves as overweight, and by the age of thirteen, 80 percent have attempted to lose weight, with 10 percent reporting the use of self-induced vomiting" (Eating Disorder Review, 1991).

• Twenty-five to 35 percent of college-aged women are engaging in bingeing and purging as a weight-management technique.

• Nearly a third of female college athletes have reported practicing dieting abuses such as bingeing, self-induced vomiting, and taking laxatives, diuretics, and diet pills.

Bulimia nervosa has only been recognized in the Diagnostic and Statistical Manual of Mental Disorders as a separate diagnosis since the mid-1980s, but it is more common than the better-known anorexia nervosa. In fact, 50 percent of anorexics develop the illness. Although there are fewer studies (particularly long-term studies) on bulimia nervosa than on anorexia nervosa, the following statistics were presented at a conference in January 1, by Michael Levine, president of Eating Disorder Awareness and Prevention (EDAP). These statistics should been seen as general estimates or "point prevalences," referring to the percentage of frequency for a given point or period in time.

PREVALENCE OF EATING DISORDERS

ANOREXIA NERVOSA

0.25 - 1 percent among middle-school and high-school girls

BULIMIA NERVOSA

1 - 3 percent among middle-school and high-school girls

1 - 4 percent among college women

1 - 2 percent among community samples

A TYPICAL EATING DISORDERS

3 - 6 percent among middle-school girls

2 - 13 percent among high-school girls

Combining these figures, and keeping in mind the limits imposed by methodology, a conservative estimate of the percentage of postpubertal females affected by eating disorders that cause significant misery and disruption in their lives is 5 to 10 percent of the population (e.g., 0.5 percent of the population suffering from anorexia nervosa plus 2 percent suffering from bulimia nervosa plus 4 percent suffering from atypical eating disorder would total 6.5 percent of the population)

PROGNOSIS

Eating disordered patients can fully recover. However, it is important for clinicians, patients, and loved ones to understand that such recovery can take many years and that it is not possible to predict at the outset who will be successful. Nevertheless, the following features may improve a patient's chances: early intervention, less comorbid psychological diagnoses, infrequent or no purging behavior, and supportive families or loved ones. Most medical consequences of eating disorders are reversible, but there are some conditions that may be permanent, including osteoporosis, endocrine abnormalities, ovarian failure, and, of course, death.

ANOREXIA NERVOSA

The mortality rate for anorexia nervosa is higher than that of any other psychiatric disorder. It is by twelvefold the leading cause of death in young women fifteen to twenty-four years of age (Sullivan 1997). The original American Psychiatric Association guidelines for the treatment of eating disorders reported that hospitalized or third-stage referral populations of anorexics show that about 44 percent have "good" outcomes (i.e., weight was restored to within 15 percent of recommended weight, and menstruation was regular) four years after the onset of illness. "Poor" outcomes were reported for 24 percent, whose weight never approached 15 percent of that recommended and whose menstruation remained absent or sporadic. Intermediate outcomes were reported for 28 percent of the anorexics, whose results were somewhere between those of the "good" and "poor" groups.

A long-term study conducted since the last edition of this book sheds new light on the prognosis of anorexia nervosa (Strober, Freeman, and Morrell 1997). The objective of the study was to assess the long-term course of recovery and relapse as well as predicators of outcome in anorexia nervosa. Ninety-five participants, ages twelve to seventeen, were selected from a specialized university treatment program, were assessed semiannually for five years, and were assessed annually thereafter over a period of ten to fifteen years. Recovery was defined in terms of varying levels of symptom remission maintained for no fewer than eight consecutive weeks. In this study,

• full recovery was achieved in 75.8 percent;
• partial recovery was achieved in 10.5 percent; and
• chronicity, or no recovery, was evidenced in 13.7 percent.

These results are very encouraging. By the end of the follow-up, most patients were weight-recovered and menstruating regularly. Nearly 86 percent of the patients met the study's criteria for partial, if not full, recovery, and roughly 76 percent achieved full recovery. Furthermore, none of the patients died from anorexia nervosa during the course of the study. It is important to note that relapse after recovery was relatively uncommon, while nearly 30 percent of the patients discharged from the treatment program prior to clinical recovery had relapses. It is also important to note that recovery took a substantial amount of time, ranging from fifty-seven to seventy-nine months. Other noteworthy findings include:

• Among restrictors at intake, nearly 30 percent developed binge eating within five years of intake.

• Unlike other studies, this study found no correlation between poorer outcome and longer duration of illness, lower minimum body weight, binge eating, vomiting, or prior treatment failure.

• Recovery time was lengthened significantly among patients with disturbances in family relationships. This predictor has been linked to poorer outcomes in at least four intermediate to long-term follow-up studies (Hsu 1991).

• A compulsive drive to exercise present at the time of discharge was found to be a predictor of chronic outcome.

• Being asocial prior to the eating disorder was a statistically significant predictor of chronic outcome. This too has been linked to poorer outcomes in other studies (Hsu, Crisp, and Harding 1979).

Other findings suggest the need for further research if we are to improve the recovery rate for anorexia nervosa. Although the outstanding feature of this study was the overall rate of recovery, a more important observation may be that once full recovery was achieved, relapse was rare. Previous studies showing poorer outcomes may reflect the fact that patients are often prematurely discharged from treatment - that is, before weight restoration. This finding could be useful when presenting the case to families and insurers that a patient should stay in treatment for longer periods of time.

BULIMIA NERVOSA

A recent study conducted by Fichter and Quadfling (1997) assessed the two- and six-year course and outcome of 196 consecutively treated females with bulimia nervosa - “purging type (BNP). Results showed that at the six-year follow-up, 59.9 percent achieved a good outcome, 29.4 percent an intermediate outcome, and 9.6 percent a poor outcome. Two persons were deceased, accounting for the remaining 1.1 percent. Over time, the general pattern of results showed substantial improvement during therapy, a slight (and in most cases, nonsignificant) decline during the first two years after treatment, and further improvement and stabilization from three to six years after treatment (Fichter and Quadfling 1997).

Other interesting findings from the six-year follow-up include:

• 20.9 percent had bulimia nervosa purging type BN-P.
• 0.5 percent had bulimia nervosa - nonpurging type BN-NP.
• 1.1 percent shifted from bulimia nervosa to binge-eating disorder.
• 3.7 percent had anorexia nervosa.
• 1.6 percent were classified as eating disorder not otherwise specified (EDNOS).
• 2 patients died.
• 6 percent had a body mass index (BMI) of greater than 30.
• The majority (71.1 percent) showed no major DSM-IV eating disorder.

SEXUAL ABUSE AND EATING DISORDERS

Eating disorders are often seen more prevalently in psychiatric populations suffering from various types and degrees of psycho- pathology. In the last few years, there has been an increasing amount of attention paid to the relationship between eating disorders and childhood sexual abuse (CSA). Early researchers hotly debated whether CSA was an actual risk factor for the development of eating disorders. For example, Pope and Hudson (1992) concluded that there was no evidence to suggest CSA as a risk factor for bulimia nervosa. Considerable debate arose about the methodology of the early studies and the associated conclusions (e.g., Wooley 1994). Psychologist Susan Wooley observed that, for a long time, differential prevalence (i.e, higher rates of CSA among eating-disordered subjects than among women without eating disturbances) was the primary criterion used to judge whether CSA might influence the onset or maintenance of an eating disturbance (Wooley 1994). Unfortunately, as a result of this debate, clinicians were alienated from researchers. Clinicians wanted to offer informed, quality care to patients with eating disorders whose CSA or other trauma appeared closely intertwined with their eating problems, while researchers denied that the connection existed.

New research has turned the tide of this debate. In 1994, Marcia Rorty and her colleagues found elevated rates of parental psychological abuse among women with bulimia nervosa when compared to nonbulimic women. Well-designed national studies by Dansky, Brewerton, Wonderlich, and others have supported the idea that CSA is indeed a risk factor for the development of bulimic pathology among women. Wonderlich and his colleagues found that CSA was a nonspecific risk factor for bulimia nervosa, particularly when there is psychiatric comorbidity. They also found some indication that CSA is more strongly associated with bulimic disorders than with restricting anorexia, but CSA did not appear to be associated with severity of the disturbance. Fairburn and his colleagues (1997) also provided evidence that both sexual abuse and physical abuse in childhood represent global risk factors for bulimia nervosa. According to these researchers, both factors also increase the chance that a woman will develop a variety of psychiatric problems, including mood and anxiety disorders. For more information about eating disorders and sexual trauma (including treatment aspects), see Sexual Abuse and Eating Disorders, edited by M. Schwartz and L. Cohen.

STATISTICS ON BINGE EATING DISORDER

Since binge eating disorder is newly recognized, statistics are hard to come by. There are numerous statistics on obesity, but, as previously mentioned, not all binge eaters are overweight. Studies on binge eating disorder indicate that only somewhere around 50 percent of patients are overweight. In Overcoming Binge Eating, Dr. Christopher Fairburn reports that in obese individuals, approximately 5 to 10 percent overall and 20 to 40 percent who participate in weight loss programs have binge eating habits. The continuing research on binge eating disorder will provide further data and insight into this syndrome.

Most of our knowledge and understanding of eating disorders comes from information gathered on females diagnosed with these illnesses. Since males do have eating disorders and the number of such cases has been steadily increasing, we now have information available to help us understand the origins of these disorders in males, what part gender plays in these disorders, and how males with eating disorders differ from and are similar to their female counterparts. The next chapter will discuss this issue in detail.

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