Eating Disorders

Decade of the Brain

Each year millions of people in the United States are affected by 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. For example, one in ten cases of anorexia nervosa leads to death from starvation, cardiac arrest, other medical complications, 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 teenager 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, cutting 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 sit-ups 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 is 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 and 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 on 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

Medical complications can frequently be a result of eating disorders. Individuals with eating disorders who use drugs to stimulate vomiting, bowel movements, or urination may be in considerable 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 houghts 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 hands when fingers are pushed down the throat to induce vomiting. Further, the esophagus becomes inflamed and 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 other 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 father 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. Incontrast 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 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 functionsof 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 andnorepinephrine 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. 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.

Common Symptoms of Eating Disorders

Following are some common symptoms of eating disorders. Although many of the symptoms listed are specific to certain types of eating disorders, it's not uncommon for the afflicted person to have more than one type of eating disorder at different times. Also, some eating disorders share the same symptoms. (Adapted from related table.)

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 required. 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, 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, benefited 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.


Helping the Person with an Eating Disorder

Treatment can save the life of someone with an eating disorder. Friends, relatives, teachers, and physicians all play an important role in helping the ill person start and stay with a treatment program. Encouragement, caring, and persistence, as well as information about eating disorders and their dangers, may be needed to convince the ill person to get help, stick with treatment, or try again.

Family members and friends can call local hospitals or university medical centers to find out about eating disorder clinics and clinicians experienced in treating the illnesses. For college students, treatment programs may be available in school counseling centers.

Family members and friends should read as much as possible about eating disorders, so they can help the person with the illness understand his or her problem. Many local mental health organizations and the self-help groups listed at the end of this brochure provide free literature on eating disorders. Some of these groups also provide treatment program referrals and information on local self-help groups. Once the person gets help, he or she will continue to need lots of understanding and encouragement to stay in treatment.

NIMH continues its search for new and better treatments for eating disorders. Congress has designated the 1990s as the Decade of the Brain, making the prevention, diagnosis, and treatment of all brain and mental disorders a national research priority. This research promises to yield even more hope for patients and their families by providing a greater understanding of the causes and complexities of eating disorders.


For More Information

For additional information on eating disorders, check local hospitals or university medical centers for an eating disorders clinic, or contact: For information on Eating Disorders Awareness Week, contact: For information on other mental disorders, contact:

Message from the National Institute of Mental Health

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 develop new therapies that can help more people overcome mental illness.

The National Institute of Mental health is 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. Dept. of Health and Human Services.

All material in this pamphlet is free of copyright restrictions and may be copied, reproduced, or duplicated without permission from the Institute; citation of the source is appreciated.

Acknowledgments

This pamphlet was rewritten by Lee Hoffman, Office of Scientific Information (OSI), National Institute of Mental Health (NIMH). An earlier version was prepared by OSI staff member Marilyn Sargent.

Scientific review was provided by NIMH staff Susan J. Blumenthal, M.D.; Harold Goldstein, Ph.D.; Harry E. Gwirtsman, M.D.; and Susan Z. Yanovski, M.D.

U.S. Dept. of Health and Human Services
Public Health Service

National Institutes of Health
National Institute of Mental Health

NIH Publication No. 94-3477
Printed 1993, Reprinted 1994

Bulk sales (Stock No. 017-024-01499-1) by the U.S. Government Printing Office, Superintendent of Documents
Mail Stop: SSOP, Washington, DC 20402-9328.

Need to talk to someone who understands eating disorders? Send e-mail to Robert Terwilliger at raterwil@ucla.edu.
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Updated: March 18, 1998