Riverview Psychiatric Center

Psychology Articles by Dr. Arthur Dingley - Eating Disorders

Dr. Art Dingley

Our relationship with food has become complex, and more than a little ironic. While much of the developing world struggles to obtain even a subsistence diet, most of the Northern Hemisphere struggles with its expanding waistline. While diseases of malnutrition plague the Third World, diseases of obesity plague North America and most of Europe.

The federal, state, and local governments have slowly begun to turn their attention to aspects of our nutrition. Some people, tired of waiting for national and world leaders to take action, have changed their eating habits, and their buying habits, reflecting a sense that we should look more carefully at these issues. Through public-service information campaigns, and the mainstream news media, Americans have become more aware of the consequences of unhealthy eating. Unfortunately, this general awareness is met by a limitless supply of bonehead diet “experts” serving up bad nutritional advice, and hucksters promoting weight loss gimmicks. While we are being scolded for gaining weight, and being given bad information on what to do about it, we are bombarded with advertising images of thin attractive people having some type of wardrobe malfunction.
Our relationship with food has become a Rorschach (inkblot) test – everyone gets to say what it means. Although this can be quite revealing of the individual speaker, is usually doesn’t add much to the knowledge base.

Meanwhile, back at the office, mental health professionals have been seeing individuals with Eating Disorders - difficulties with food which severely affect their lives. Obesity, by the way, is not a psychiatric disorder. Obesity is a general medical condition. There is no evidence that obesity is associated with any particular psychological symptoms or syndrome. There is no psychiatric diagnosis of “food addiction” as an explanation for obesity. There are two types of Eating Disorder: Anorexia Nervosa and Bulimia Nervosa.

Anorexia Nervosa is refusal to maintain even a minimally normal body weight. This is not a function of diminished appetite. People with Anorexia Nervosa refuse to eat an adequate diet despite being very hungry. In one important sense, this is an anxiety-driven disorder. The person develops an intense fear of gaining weight or becoming fat. She becomes very focused on her body shape or the size of some body parts and may measure, examine, or weigh herself repeatedly. She spends a great deal of time thinking about food. She interprets her abnormal weight loss as a great achievement and any weight gain as a failure of her self-control. People with this disorder accomplish their extreme weight loss by refusing to eat an adequate diet, by exercising frequently, by using drugs or laxatives, or by causing themselves to vomit after eating.

Who gets Anorexia Nervosa? Less than one-percent of the population has this disorder. However, at least 90% of that number are young women. The average age of onset is 17. Anorexia Nervosa is very rare in poor countries where food is scarce. It is much more common in industrialized countries like the USA, Canada, Australia, and Japan. People with this disorder are more likely to be rigid thinkers, and to show limited spontaniety and emotional expression in social situations. People with Anorexia Nervosa who achieve weight loss by binge-eating and vomiting are more likely to be impulsive, to abuse drugs and alcohol, and to have mood swings.

Most people with this disorder experience depression, irritability, insomnia, and diminished sex drive. These problems are often the direct result of extreme weight loss and resolve when body weight returns to the normal range. Some people recover after a single episode of starvation. Some get better, and then worse again, over long periods. Some people have a downward course and do not recover. The physical consequences of chronic starvation include anemia, kidney damage, heart damage, and bone loss. The teeth may decay from frequent vomiting of stomach acid. In women of childbearing age with Anorexia Nervosa, menstruation always stops as body weight falls below the minimum necessary for endocrine functioning. The long-term death rate from Anorexia Nervosa is about 10%, and death most often occurs from heart dysrhythmias, starvation, or suicide.

Bulimia Nervosa is a disorder in which the person binges on large amounts of high-Calorie food and then causes herself to vomit, or takes some other measure to prevent weight gain. In addition to vomiting, people with this disorder may use excessive exercise, laxatives, or other drugs to prevent weight gain from binge eating. Unlike Anorexia Nervosa, refusal to maintain a minimally normal body weight is not part of this disorder.
Food binges usually last less than two hours. (Continual snacking is not binge eating.) Binges are usually not confined to one type of food or one type of nutrient, such as fats or carbohydrates. It’s the sheer amount of food consumed that defines a binge.

Interestingly, most people with Bulimia Nervosa are in the normal weight range. This disorder is uncommon in obese people. People who develop this disorder are overly concerned with their body shape or their weight. Binges commonly follow a period of dieting and are often brought on by some unpleasant interaction or by being in a bad mood. During a binge, the person consumes a large amount of food very rapidly. She feels that she has no control over her behavior and believes that she cannot stop eating. Binges occur at least once a week. The person is often ashamed of her behavior and always binges secretly.

Who gets Bulimia Nervosa? Although perhaps 2% of the population has Bulimia Nervosa, 90% of that number are female. Onset is in late adolescence or young adulthood. Depression and anxiety are more common in these people than in the general population. At least a third are drug or alcohol abusers. About half have personality disorders. Compared to Anorexia Nervosa, severe medical problems are uncommon because normal body weight is maintained. However, tooth erosion is common with frequent vomiting.

The cause of eating disorders is unknown. It is tempting to speculate that our cultural “fixation” on idealized physical beauty is driving young women to extremes as they attempt to achieve an unattainable standard of physique. Unfortunately, there is little evidence for this. In fact, people with Anorexia Nervosa completely ignore culturally accepted norms of female beauty in pursuit of their idiosyncratic goals.

How are eating disorders treated? Anorexia and Bulimia Nervosa are disorders of behavior. In most cases, the person simply decides “enough is enough” and stops. Although self-help groups would be an ideal treatment, the shame and secrecy of people with eating disorders makes this unworkable. Bulimia Nervosa often gets better with medicine and psychotherapy aimed at emotional problems. Anorexia Nervosa, because of its dangerous medical consequences, may need hospital treatment. Patients with this disorder are not reliable historians and will lie to caregivers about their intentions. They must be observed closely in the hospital to prevent vomiting after meals and must be weighed daily to monitor progress toward some agreed normal body mass. Medicine may help with the anxiety these people experience at mealtime. Psychotherapy may help to correct the thinking errors which result in refusal to eat.

Dr. Dingley is a psychiatrist at Evergreen Behavioral Services in Farmington. He may be contacted at adingley@fchn.org

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Psychology Articles by Dr. Arthur Dingley - Eating Disorders

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