am concerned that my teenage daughter may be suffering from an eating disorder. After I did some research on the Internet, I am more confused than ever. What exactly is bulimia? How does it differ from anorexia?
According to a summary article in the Up To Date educational series, there are at least four main categories of eating disorders:
- bulimia nervosa
- anorexia nervosa
- binge eating disorders
- eating disorders not otherwise specified
Experts have struggled over the years to completely agree on the different criteria required to categorize these conditions. Bulimia, a term often used in describing the academic terminology of Bulimia Nervosa, has had more stringent criteria applied to its DSM-IV definition.
The DSM-IV refers to the Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition. It is published by the American Psychiatric Association and at this time it remains the main diagnostic reference of mental health professionals. For more information, see www.psychologynet.org/dsm.html.
The DSM-IV criteria for bulimia include:
- Episodes of binge eating with a sense of loss of control.
- Following binge eating are compensatory behaviors such as self-induced vomiting, laxative abuse, or diuretic abuse, and may also include excessive exercise, fasting or restrictive dieting.
- Binges and resulting compensatory behavior must occur a minimum of two times per week for three months.
- Dissatisfaction with body shape and weight.
The exact incidence of bulimia is difficult to interpret. The general prevalence rate among women is 1 to 1.5%. The rate in younger adolescents is thought to be lower than for college students. There also seems to be two peeks of eating disorders at ages 14 and 18. However, patients may present an eating disorder anywhere from late childhood through to adulthood.
According to a recent Youth Risk Behavior Survey, 36% of adolescent girls believed that they were overweight and 59% were attempting to lose weight. In the month prior to being surveyed, 8% reported they had tried vomiting or had taken laxatives to help control their weight.
Eating disorders in males seems to be on an upward trend. More male patients have been seen for treatment in the 1990s than in the 1980s. Some experts feel this reflects an increase in treatment more than an increase in prevalence. There is also speculation as to the importance of having a family history.
There is no consensus at this time regarding the precise cause of eating disorders. It is probably related to a combination of factors such as psychological, biological (decreased levels of the neurotransmitter norepinephrine), social, family history, and the environment.
We live in an era where the media play a major role in influencing children and youth. Culture seems to be obsessed with weight loss; many women's magazines have covers highlighting weight management, dieting tips, and other methods of achieving a perfect body.
Eating disorders seem to be more prevalent in patients who are involved in ballet, running, skating, and gymnastics. Young women who fail to menstruate each month (amenorrhea), who are very active, and who engage in restrictive eating have been referred to as having the "female athlete triad": the combination of an eating disorder, amenorrhea, and osteoporosis.
Screening tools may be used to detect an eating disorder. One such tool is the SCOFF questionnaire. The tool asks five simple questions:
- Do you make yourself Sick because you feel uncomfortably full?
- Do you worry that you have lost Control over how much you eat?
- Have you lost recently more than One stone (i.e., 6.35 kg)in a three month period?
- Do you believe yourself to be Fat when others say you are thin?
- Would you say that Food dominates your life?
Researchers found that a yes answer to two or more questions was associated with a sensitivity of 100% and a specificity of 87.5%.
Another diagnostic screening tool used by various academic centers is the Eating Attitudes Test (EAT). For more detail on the history and content of this test see: www.healthyplace.com/Communities/Eating_Disorders/concernedcounseling/eat/
Many medical complications can occur as a result of eating disorders including: osteoporosis, cardiac impairment, cognitive changes, difficulty in psychological functioning, slowed gastrointestinal motility, endocrinological changes, electrolyte abnormalities, dermatological abnormalities, neurological complications, dental erosions, enlarged salivary glands (in patients with bulimia), and infertility.
Taking care of these patients requires a team approach. The team should include a medical provider, a dietitian experienced in treating eating disorders, and a mental health professional. These conditions are a serious matter when it comes to mortality; patients die from complications in as high as 6% of cases.
A number of Psychiatric Associations recommend that the treatment of bulimia should include a combination of psychotherapeutic intervention and medications (such as antidepressants). The treatment for anorexia generally involves cognitive behavioral therapy (CBT). Although, some experts feel CBT may not work as well for anorexic patients as compared to patients with bulimia.
In patients with anorexia about 50% have good outcomes (i.e., return of menses and weight gain); 25% have intermediate outcomes; 25% have poor outcomes. Poor outcomes are associated with later age of onset, longer duration of illness, and lower minimal weight. About 32-70% of patients recover fully by the 20 year follow-up mark. Those who do not recover may have increased psychiatric comorbidity, where multiple conditions or disorders exist at the same time.
In Calgary, the Alberta Children's Hospital offers excellent clinical help (call 943-7211). In Canada, the National Eating Disorder Information Centre offers online resources (www.nedic.ca).
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