References updated to reflect current advances in research and treatment of eating disorders. Text modified to reflect recent advances in eating disorder treatments.
Abstract and Keywords
Eating disorders involve maladaptive eating patterns accompanied by a wide range of physical complications likely to require extensive treatment. In addition, “eating disorders” frequently occur with other mental disorders, such as depression, substance abuse, and anxiety disorders. The earlier these disorders are diagnosed and treated, the better the chances are for full recovery” (NIMH, 2011). As of 2013, lifetime prevalence rates for anorexia nervosa, bulimia nervosa, and binge eating disorder are 0.9%, 1.5%, and 3.5% among females, and 0.3%, 0.5%, and 2.0% among males respectively (Hudson, Hiripi, Pope, & Kessler, 2007). Early diagnosis is imperative; the National Institute of Mental Health estimates that the mortality rate for anorexia is 0.56% per year, one of the highest mortality rates of any mental illness, including depression (NIMH, 2006). More recent research (Crow et al., 2009) indicates mortality rates as high as 4.0% for anorexia nervosa, 3.9% for bulimia nervosa and 5.2% for eating disorders not otherwise specified. Current research and treatment options are discussed.
Our understanding of eating disorders has evolved since the 1980s although symptoms have been documented as far back as the 1400s. They were first recognized in the psychiatric field in 1952, when anorexia nervosa was included in the DSM-I as a psychophysiological reaction. The DSM-II (1968) identified anorexia under “special symptoms.” The DSM-III (1980), recognizing differences between “dieters” and “vomiters and purgers,” placed anorexia, pica, and rumination in a newly designated eating-disorders section. Bulimia, considered a symptom, was classified as an “atypical eating disorder.” The DSM-III-R (1987) identified bulimia as an independent diagnosis and no longer classified eating disorders under “disorders usually first evident in infancy, childhood or adolescence.” A separate section under adult disorders was established (Brumberg, 1989, p. 12). The DSM-IV (1994) expanded to include “Eating Disorder Not Otherwise Specified (EDNOS).” EDNOS has been the most prevalent eating-disorder diagnosis (Thomas, Vartanian, & Brownell, 2009). The DSM-IV-TR (APA, 2000a), recognized binge eating disorder as a potential diagnosis needing more research under the section “Criteria Sets and Axes Provided for Further Study” (APA, 2000b). The DSM-5, (pending release date of May 2013) has proposed binge eating disorder as an official diagnosis, based on the ample research supporting the validity of its own separate classification, to be included in the feeding and eating disorders cluster of diagnoses. Wonderlich, Gordon, Mitchell, Crosby, and Engel (2009) report that binge eating disorder is comparable to bulimia nervosa in terms of the evidence for its distinct set of criteria.
Overview of Four Eating Disorders
1. The following is a brief overview of the four current diagnoses in the DSM-IV-TR (APA, 2000a), including a note on recent genetic evidence, and key terms used when discussing behaviors common to eating disorders:
2. Anorexia nervosa (AN) is identified with refusal to maintain body weight at or above a minimal weight for age and height, intense fear of gaining weight, disturbance in body image with undue influence of body weight, cessation of menstrual cycle (if previously established), and denial of the seriousness of the current low body weight (APA, 2000a).
3. Bulimia nervosa (BN) is identified by recurrent episodes of binge eating large amounts of food in one time period, feeling of a lack of control over eating during the episode, and using recurrent compensatory behaviors to prevent weight gain (that is, purging by vomiting, laxative abuse, excessive exercising, etc.) (SDSM-IV-TR, 2000a).
4. Eating Disorders Not Otherwise Specified (EDNOS) is identified as the category for disordered eating behaviors not meeting criteria for any specific eating disorder (SDSM-IV-TR, 2000a).
5. Binge eating disorder (BED) is identified as a combination of symptoms similar to those of bulimia, excluding recurrent compensatory behaviors on a regular basis. These behaviors include rapid eating, eating beyond feeling physically comfortable, eating large volumes of food, feeling disgusted and guilty following an episode, and eating alone due to shame associated with the amount of food one consumes. Binge eating occurs two days a week for at least six months (Striegel-Moore & Franko, 2008). Studies indicate trends in demographic profiles among persons with BED to be more diverse than those diagnosed with bulimia nervosa, suggesting a need to incorporate diverse representative samples, including men and broader ranges of ethnicity groups (Striegel-Moore & Franko, 2003).
Genetic and Emotional Factors
Mounting evidence supports a genetic component to eating disorders. Research suggests that some individuals may be as genetically predisposed to eating disorders as others are to severe mental illnesses such as schizophrenia (Kaye, Wagner, Frank, & Bailer, 2006). As medical and social science professionals are seeing more evidence of symptomology across varied ethnicities, ages, genders, and sexual orientations, genetics can now be considered alongside psychosocial factors, providing for enriched understanding and improved services for persons with eating disorders. Persons with eating disorders regulate emotional distress with behaviors such as “restricting” (reducing or eliminating intake of food or liquid), “purging” (ridding oneself of what has been ingested), and “binging” (taking in large amounts of food in one sitting). Often individuals identify “safe” and “risk” foods. A risk food is likely to be higher in caloric count or possibly associated with traumatic memories, potentially producing increased anxiety (Franko et al., 2005; Farber, 1997; U.S. Department of Health & Human Services, n.d.). While these eating behaviors initially provide a semblance of control over emotions, this false sense of control often perpetuates the cycle, instead of eliminating it (Jeppson, Richards, Hardman, & Granley, 2003).
Statistics and Demographics
The first nationally representative study of eating disorders in the United States appeared in Biological Psychiatry in 2007. The National Comorbidity Survey Replication (NCS-R) administered face-to-face surveys to 9,282 U.S. English-speaking adults, ages 18 and older, between February 2001 and December 2003. Survey results reported the lifetime prevalence of individual eating disorders was 0.6% to 4.5%, with anorexia identified in 0.9% of women and 0.3% of men, and bulimia identified in 1.5% of women and 0.5% of men. Men represented approximately one-fourth of the cases of each disorder. Binge eating is more common than anorexia or bulimia and is commonly associated with severe obesity. According to the NCS-R, results of a Harvard study suggest that binge eating disorder is the most prevalent eating disorder among both women and men (Hudson et al., 2007). Eating disorders frequently impair the sufferer's home, work, personal, and social life and substantial incidents of eating disorders often coexist with other mental disorders, which remain undiagnosed and untreated. Seventy percent of those with anorexia nervosa and 75% of those with bulimia nervosa have another co-existing mental health diagnosis, including anxiety disorders such as obsessive compulsive disorder, social phobia and post-traumatic stress disorder, and mood disorders such as major depression and bipolar disorder (Arnold & Walsh, 2007). Grilo, White, and Masheb (2008) approximate the most common patient comorbidity diagnoses alongside BED to be mood (54.2%), anxiety (37.1%), and substance use (24.8%), with mood and anxiety disorders most common. In addition, subsequent studies indicate links between sexual orientation and increased risks for eating disorders. The psychosocial relationship between sexual orientation and eating disorders thus began being explored in the second decade of the 21st century. As of 2013, empirical evidence suggested that internalized homophobia and sexual-orientation concealment may influence coping skills among those persons who self-identify as gay, lesbian, bisexual, or transgender, therefore impacting eating-disordered behaviors (Swearingen, 2007; Wichstrom, 2006).
In addition, later studies indicate substantial links between alternative variables such as race, ethnicity, culture, age, and gender to eating disorders (Podar & Allik, 2009).
Culturally competent care of eating disorders necessitates the need to replace common myths suggesting that eating disorders are exclusive to a narrow range of ethnicity, age, and gender. Although there is evidence to support the propensity of eating disorders among white, adolescent, and college-aged females, increased empirical studies in the field of eating disorders is providing evidence supporting cross-ethnic frequencies in eating-disordered behaviors (Franko, 2007; Franko, Becker, Thomas, & Herzog, 2007; Granillo, Carvajal, & Jones-Rodriguez, 2005). Research in the 2000s revealed incidents of eating- disorder presentation among both men and women (Morgan & Marsh, 2006; Hudson et al., 2007). In addition, the most current, as of 2013, eating-disorder research supports the presence of disordered eating, often evolving into active eating disorders among elderly people (Thomas et al., 2009; Manqweth-Matzek, et al., 2006). Elderly persons are often adjusting to traumatic life changes and emotional distress brought upon by deceased spouses, domestic partners, family, and friends. Behaviors primary to eating disorders can be used as a means of emotional regulation by the elderly just as by younger people.
Eating disorders are vulnerable to changes in symptoms throughout treatment. Multidisciplinary team approaches are considered essential when treating these complex disorders. If treatment focuses only on symptom management, without paying attention to the underlying etiology (biopsychosocial factors), the need for symptomatic behaviors (for example, substance abuse, starvation, and cutting) will continue to evolve (Costin, 1999 p. xxi).
A variety of treatment interventions typically are used in tandem with one another. Interventions may include pharmacological interventions (Zhu & Walsh, 2002); didactic and psycho-educational programs, computer- and media-literacy interventions, and dissonance-based programs (Yager & O’Dea, 2008); interpersonal psychotherapy, experiential therapies (for example, art and movement therapy and psychodrama), nutritional therapy, family therapy, cognitive behavioral therapy, dialectical behavioral therapy, and social problem-solving-skill training (APA, 2006; Chambless & Ollendick, 2001; NCCMH, 2004, p. 260; Safer et al., 2002;). Dialectical behavioral therapy (Safer et al., 2002) focuses on problem-solving, skill building, identifying where change is needed, and mindfulness training by developing self-awareness and balancing dichotomous thinking, thus becoming less judgmental of oneself. Family therapy is an essential component of treatment when working with an eating-disordered child or adolescent (for example, the Maudsley model of family therapy) (Keel & Haedt, 2008).
This select list of treatment options represents only a few of the most widely used interventions for eating disorders. While not all of these have been empirically tested as of 2013, the field of eating disorder treatment is rapidly moving toward evidence-based protocols. All interventions are designed to restore healthy body perceptions by attending to distortions in how clients see themselves, underlying psychological issues, and behaviors required for healthy physical functioning.
Social Work Practice Approaches
Social work clinicians must be well trained before treating a person with an eating disorder. These disorders are made up of multidimensional symptoms. Familial and interpersonal factors, the co-occurrence of other disorders (particularly anxiety and mood disorders), and suicidal ideation and self-harming behaviors are common. Villapiano and Goodman (2001) noted that clinical “skill, stylized training, and knowledge are essential to understanding ‘effects of starvation, set point theory, body image, binge eating, means of purging, and medical abnormalities,’ while simultaneously evaluating clients' thoughts, behaviors and often shameful, embarrassing, secretive and guarded feelings and behaviors” (p. 7) as well as body checking, avoidance, control accelerated by shame, and dietary restrictions (Shafran, Fairburn, Robinson, & Lask, 2004.). By working closely with a network of professionals, social workers can stay updated on new treatment interventions, through consultative activities.
Eating disorders research has predominantly comprised sample populations limited to white female adolescents or college-age women of upper economic status and heterosexual orientation. A meta-analysis studying ethnicity and body dissatisfaction among Asian American, African American, Hispanic and white women in the United states (Grabe & Hyde 2006) challenges belief systems supporting large discrepancies between white and nonwhite women’s attitudes, indicating minimal increased rates in body dissatisfaction among white women over women of other ethnicities, as well as the inclusion of the male population. Social work research is calling for a greater inclusion of variance within study populations in the field of eating disorders; as of 2013, this was still a new concept with few studies. Further empirical studies are needed to explore disparities in persons with disordered eating behaviors, particularly among disenfranchised populations. Empirical studies that include diverse samples will enhance the potential for evidence-based practice with underserved populations.
• National Institute of Mental Health (NIMH)
• Eating Disorders Coalition for Research, Policy & Action (EDC)
• Anorexia Nervosa and Related Eating Disorders, Inc. (ANRED)
• National Association of Anorexia Nervosa and Associated Disorders (ANAD)
• National Eating Disorders Association (NEDA)
• Eating Disorders Awareness and Prevention, Inc. (EDAP)
• Watch Dog (media awareness group: EDAP)
• American Anorexia Bulimia Association (AABA)
• Academy for Eating Disorders (AED)
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NEDA: National Eating Disorder Association, http://www.edap.org/
National Institute of Mental Health, http://www.nimh.nih.gov
National Association of Anorexia Nervosa and Associated Disorders http://www.anad.org
Something Fishy: (Resources, recovery information, cultural issues, and treatment finder) http://www.something-fishy.org/