df'
."
"r'::_it._--:
-
Anorexia
;~crvosa
2nd
Bulimarexl~:
By
.i 1!.' ~; i :;
::t;;;cie,
-
) i .'
j
• (.
t
("!'
J:ldian~
DRn~erous
Dietin~?
.....
" · · .. em ... •
-
,,
When d O(~8
occupation?
;)
fact
C(:80('
to be a fno and turn .i n to a pre-
Fow far will our society go in the pursuit of
the body beautiful?
In modern day America, the glorification
of thinness has gone a bit too far.
What started as a
healthy concern for physical fitness seems to have blossomed
into an all out obsession.
Individuals are constantly bom-
barded by the notion of the ideal body and what should be done
to achieve it.
Diets, exercise programs, and an unending number of
fads proclaim the easy way to the perfect figurp.
also extends this emphasis by
images.
pro~oting
The media
extremely conflicting
Consumers see aDd hear that "thin i8 in,"
bu~
at the
same time are overwhelr::ed with food commercials and acts to
t.C'!1irt thcT:' ;l't!::,v
from
thjnncs~3.
Tn reaLity, for r::o:-,t inJivld-
uals, the two messages are not conpatible.
What actually constitutes the ideal physique?
An ultra-
slim sleek aprearance is achieved only by precious few high
fashion models.
Why then are we so driven to reach this
often unattainabJ e and unhealthy goal?
completely clear, but this phenomenon
so:r.c
[~cr iOlls
con~;equenc('s.
-
~ay
have brought about
.Ao a 1 iX ely resul t of our soch' ty' s
preoccupation with thinness, eating
more and more prevalent.
rrhis anrc;wer is not
disord~rs
are becoming
It is of little wondpr that many
have turned to food or its denial
a3
a crutch.
In rr.ar,y c2.ses,
1'-- -
,
2
-
these eating disorders are not merely an extreme form of
dieting, but are often a manifestation of underlying emotional problems.
Individuals affected with eating disorders
involve food in their attr·mpt to solve problems.
two such
disorders that involve food as a means to solve problems,
arl' Rnorexic) n crvosa and bul irnarexia.
J~ 1_
thouC;h
ev(~ry
is distinct in its own way, many similarities and
can be drawn.
casC'
~Jarall
cIs
The signs, symptoms, treatments and prognoses
surrounding these disorders will be
pres~nted
in ttis paper
in an attcmrt to offer insi r;ht into pro1)lcms.
Defininf thr disorders
tiThe condition of self-inflicted starvation, without
recognizable organic disease and in thE: midst of ample food
is usually diagnosed as 8norexia nervosa. tI 1
There seems to
be vast agreement that anorexia nervosa involves the willful
and irrational starving of oneself.
It is an extreme pursuit
of weight Joss that often timeD becomes life ihrcateninr.
This disorder, although receiving much recent attention,
has in actL1 8li t:~T been in existence for many hundreds of years
Dating fron almost 300 years ago,
can finel various evidence
we
of the existence of 2.r..orexia nerVOS8.
In 1629, an T'nglis>_
physician, l-:ic!:1ard j'orton, publishE:d a dissertation on
.he termed "nervous consul.ption." 2
V/['cit
VIi th his discri}Jtion of
3
emaciation, amenorrhea and other symptoms, one can now see
that he was describing anorexia nervosa.
The actual term "anorexia nervosa" originated in 1873.
ately described tr]e symptoms of tne disorder "md so named
l"t •
3
These early accounts were fairly accurate descriptions,
even by today's standards.
fairly accurate
But while these citings were
in their descriptions, these findings were
considered very rare.
In 1960, researchers Bliss and
ranch defined anorexia
ncrvosa as "a nonspecific diagnosis relatinc: to woight lOGS
from any emotional cause.,,4
They believed that anorexia
nervosa was a sysmptom of psychiatric disorrlers rather than
a distinct disorder in itself.
The patients in their studies
had nothing ~ore in common than weight 10ss.5
After 1960, there was in increase in research :md
mnterials put 1 1isi:C'd, prohabJ.y due to the frlct. th:Jt cn.;,('s of
anorexia nervosa have been increasing in frequency.
This in-
crease SeeTllS to be linked with society's attitudes and t'1P
'
u
ro 1 e 0 f wo~cn t ouay.
At thp present tiMe, it is est.imatpd
/'
t.hat as many as one in tvro ilw_dred fifty fern.a182 between -the
ages of twelvE" 211d eighteen years of
"
7
dlsorder.'
~~e
8[;e
condition also occurs in
olll'-tenth tile Crr'qucncy.
vii 11 develop the
~a1es,
but with only
f~
Wi th the increase in roSC?rCll, the sY:l1ptorrs of anorexia
-
4
-
nervosa have noVl been better defined.
In recent years, Hilde
Professor of Psychiatry at Baylor College of r.ledicine, Pruch
is one of the foremost authorities on anorexia nervosa.
t!ot
W1til her research, was anorexia nervosa considered a distinct
disorder. 9
Now experts have agreed upon three major criteria
for diagnosis which include:
(1) loss of at least twenty-five
percent of original body weight, (2) amenorrhea for at least
three months and (3) a distorted body image. 10
The first characteristic, that of weight loss, is
fairly self-explanatory.
Original body weieht refers to
weight before the illness and before any measurable loss.
This loss of 25 per cent of the
often is a result cf
slim~ing
pati~nts
bcdy weieht most
gone haywire.
loss program, but as the anorectic finds that
For the majority
s~e
is suc-
cessful at losing weight, this in itself becomes reward
eno;)~:h
to continue lowering her weiE'ht to extremes.
The second diagnostic characteristic, amenorrhea,
occurs i.n virtually all aIlorectic patients..
This cessation
of the menstrual cycle may well be linked to the loss of
body fat.
~tudics
have indicated that the beeinning of the
menstrual cycle is most influenced by body-fat composition
(often reflected in weight) rather than age, so in effect,
.-
this loss of body weieht causes something like a reversal of
5
-
puberty.11
It is in tersting to note, however , that in ma."'1Y
cases, the cessation of menstruation preceeds weight 108s_
And in many cases, even with weight gain, there may still be
menstrual problems.
12
The third characteristic is a disorted body image.
Hilde Bruch vms trw first to suggest that
ih(~re
is an identi-
fiable disturbance in body image among anorectics.
Since then,
it has been accerted and is used as a major characteristic
for
l;ven ire ('xtreme cases, tho ;wlor,'ctic nati"Y't
di[1c;no~3is.
will deny that her state of emaciation is abnormaJ.
Various
studies, support tbe belief that anorecti cs bav,::' a deluded
body conception.
~:ussC'11,
OilS
Using instruments designed by Slade and
rCfJ"clrcllers
h;lV(:'
asked anorectiCE! to (,[;timate vc1ri-
objects and body dimensions.
It has generally been
fc)und that anorectics overestimate body width, v.'hile they
can fcli.rly accur2.tely estimate their height cmd widths of
inanimate
otjects~
It is true that all females in general
overestimate lody width.
The difference, however, lies in
the dRcreo of overestimation and sl1bsefjuent denj.aJ of weir;ht
-,.oss even
1
. ~
('
ponn,
t ·nc
2'~
0f
. t·
cmaCla'
,lnrl. 1)
'c':hile these three characteristics are 8grecd upon as
di~g~ostic
of anorexic nervosa, there are also other
0'ristics that
t~ao
-
[iTe:
c~ar~ct-
useful in fnrther::1cfh:ihg thf; disorder.
of resrarchrrs in St. LoUis, ;issouri furthered the
definition in 19 7 2 with what are now teroed the Feighner
6
Criteria.
F'sychiatrists l"eighner, ;\obins, and Guz(' produced
a helpful guide for distinguishing cases of anorexia TIervosa
from other disorders. 14 Cne ?Eig~~cr char2cteristic states
that the onset of t}2C disorder nust
is most likely due to the fact that girls of this age are
concerned with fitting in with their peers.
become weight
~onscious
Teens often
as they are very aware of their
bodies and the changes occuring in them.
bodies seems to be an easy
\'JaY
Forming their
to self-improvement.
Other
characteristics di stinguish separate phases of fltti tud('s
toward food and nutrition, and toward the handling of food
itself.
These attitudes include the denial of the experi-
ence of hun.ger and the refusal to eat.
Other 8.tti tudes to-
':lard food refer to ri tuals and behaviors concerninE preparation,
eating, and hoarding of
food~
The final Fci[hner character-
istic states that there must be no other illnpss t1lat could
DcC'olmt fnr !;~(; vf('j(~ht
1 r~
}O[;s.
j
T}'J's(' cri~.(,l'i;l "irq)],"
to better (('fin (' the line between ?ctual
(O~nor·::xia
~-'(rv('
nervosa
amI other disorders.
ts indicated earlier, certain physical characteristics
serve as criteriR for c'-Ylorexia nervosa.
such characteristic.
Cth~r
\:!eight Joss 18 onp
physical characteristics also
Rccompa.."1y the disorder, although they are hot necessarily
diagnostic in nature as is weight
-
loss~
takes hold, the entire body is affected.
When the disease
Because of the
7
-
extreme loss of body fat, the bones show through the surface
of the skin, and the anorectic mny hav(! trouh Le
3
i ttinr~ or
remaining in one position for any period of time,
The skin
becomes dry and develops an ashen yellow coloring.
and nails become very brittle.
The hair
Low blood pressure and a
d er. 16
·
slow pu 1 se a 1 so accompany th e d lsor
The second disorder that involves the use of food as a
means of resolving problems is bulimare:da, also known as
bulimia.
Coined in 1974 by Harlene Boskind-Lode_hl, "bulirna-
rexia" is a fairly recent term used to describe the practice
of gorcing followed by fasting, vomiting, or purginc.17
While the
Clllcient
ter~
~~OI:1C,
is fairly new, the practice is not.
[rU0sts
and then continue to
W:1S
at
In
feasts would gorge thcr1[:;elv r-,;s, voni t,
In
e2~t.
!~ome,
prnctj('{,r1 rrc-dorninonUy by rnr'n,
..
t 18
th
1 e
prlTI:ary par t lClpans.
0
however, thj.s ri tuaJ
1:!hilr'
today,
WOr:1('n
nT'('
inh
.
.1.• 1S
prac tOO
lce lS h~elnG used as
0
a means of weight control, mainly amone young wonen today.
The number of
p~rsons
demonstrating bulimarectic weight con-
trol is not accurately known, since patients with this disorder are typically very secretive e.bout their problem.
studies, however, indicate that one out of every five college
a p; e
°t '0 1
mp n m(3 y (' x, ~ 1 tn·
u 1 In arC' c t'1
0
W0
\
0,
J
C
1) C h
a vO
lor I
n \,
~)
0 met 1
0
rn c • 1CJ-
Since the nature of bulimarexia is very secretive, it
is diffic(ll t to pinpoint specific criteria.
UYl~~iK
(; 31'.orexia
nervosa, there is not necessarily a marked weight loss to
-
8
-
signal the disorder.
Some patients are only slightly under-
weight, while most are of normal weight or slightly overweight. 20
rrhe majority, howevl'?r, have had weight problems
in the past.
21
As with anorexia nervosa, a preoccupation with food
exists, but this preoccupation manifests itself in quite a
different JT1rumer.
rrhe bulimarectic does not decrease her
intake of food, bqt rather will
eatinE binges.
a:r:r;:meJ~
to overeat in 3ecrpt
She will then rid her body of the food by
secretly vomiting or using laxatives.
It is likely that
most cases, therefore, go unnoticed because of this secrecy.
The bulimarectic will veil her actions in secrecy because of
and relatives then are often of little help in detecting the
problem, since v/eight remains fairly constant and social
' b '1 t s may seem norma 1 • 22
·
ea t lng
ha
In the late 1970's, there VIas an increase in the amount
l' "'terf'p.t
c,
~
of re. ~p-earch_ ~n.c!
>
4L
.
th
. e
0n
1 -J' e c
SUI)
Since that tine, three diagnostic
r~\hc:Je
drfinc tht' disorder.
t
0
f b u l'1 mDT ex 1. a • 23
fe~tures h~ve
criteric~
been used to
arc (1) a powerful
\lrr~('
to overeqt, (2) an attempt to compensate for overeating by
vOfTlitin[; or
11.::C
. ' t galn.
.
';lslgn
,/;;
In
1[·x~.t.i'!e3,
and (3)
8
rror:olJ.Dced fC8r of
.
'-~,
a study by Gcr21d
cf Psychiatry of
-
of
t~c
po:\r~l
v
~
•
Russe]~,
}'rep
-
of the Acqdcmic Dcpartmpnt
l~oC"rl·tal
uk"
- .1'1"
"
'"
lonnon
.,_cc
_.,
[>('tics dcscrih(c[ thf':lr po",!prfl:l ur[':c to ovprC!1t.
;~cvprrtl
9
-
bulimarectics said th8t their thOllr:hts wprp C'o stantly
Y1
food and some even had dreams abollt food.
Oil
\!!'lile thei:r thoughts
were constantly about food, it was not because of hunccr.
(ine p8.ti en t described her reasons for overea tir~[:
cause of hunger, but to fill a void.
and fill an
emotional gap.25
!ating
:0-
not
8G
to neet
seem~d
'1'0 the bulimarectic, any prob-
lem or stressful situation could trigger an episode of binging.
These bouts of binging seem to stem from a lack of impulse
control.
This lack of control can also manifest itself in
other ways, such as kleptomania or alcoholism. 26
The binge, which is most often described as lIan action
to fill an emotional gap", has many striking similari tif:'S
between cases.
The typical binge is always done while alone,
although it is still not kept as secretive as the actual
"'7
V-()'nl'+inrJ" .::
I·
L -'-
\......'"'.
In a personal intcrvie 1:! v:i th"Carric" (fictitious name)
char8.cteristi c binge.
"I'::l typi cal hinge a1 way s tooi( rlacc
when I was a1c,r'.e, and usually at home.
pIa;} as mu ch as
8
Fany tinies, I \'!ouJd
day at cad what I was goinG to eat.
r~08t
often, I ate things that were simp10 to make, Jiko to?st for
example.
Foods that need little or no preparation were what
,
I ate most •••• things like ice cream and junk food.
1I
28
Carrip's
case is amazingly similar to those reported in the literature.
-
------.-~---~~---~~..
.
......
(
10
On other occasions, Carrie reported planning her route home
from work in (lrd cr to stop at various fast food
C'~ctabli
shrlicn tc
where she would consume whole dinners in the car.
Once the tinging has taken place, the bulimarectic
will then resort to the second of the diagnostic criteria,
that of ridding herself of the binged food.
In Carrie's case,
this behavior was learned from peers as a means to prevent
weight gain.
To many, it initially seems to be an easy
al ternati ve to dieting.
In a study hy Suzanne F. Abraham anrl
P. J. V. Beumont of the University of Sydney, Australia,
32 patients were studied with regard to thpir tinging and
purging behavior.
Out of those 32 patients, the majority re-
ported use of laxatives at one time or another.
~ost
often,
these medications were taken in large amounts promptly after
a binge.
(f those who used varni t.inF':
83
{l
rn('[1n~;
of food
elimination, one-half of the patients did so by simply contracting their stomach muscles.
The remaining half had to
use their fjngers or other objects to induce vomiting. 29
Again, it must be remembered that the major contributing factor in this cycle is the patients extreme fear of
fatness.
This pronounced fear of weight gain iE the third
and final fe8tl.lre of the disorder.
'Phis is morc easily
understood if one recalls that the vast majority of bulimarectics have had WRight problems and feel themselves to
11
-
be over their desired weight.
In bulimarexia, as with anorexj.a nervosa, v8Tious
problems aCCOT'lpany the disorder.
:ec2.use of the fr<"cuent
vomiting "oehaviClr, problems w.tth the digE-;stivp E:ystem are'
almost inevitable.
In some casps, stomach acid
fro~
the
bouts of vomiting havf: hoem known to hurn th e f'f:orhar;us cHln
other areas involved in the regurgitation process.
This
regurgitation of stomach acid 8.1so causes tooth decay, and
"l:.l)
can infect the salivary glands • ./
'This vomiting behavior
can even alter the patients ability to swallow properly.
In a 1979 study of bulimarectic behaviors by Gerald
Russell, it was concluded that in patients employing both
vomi tine: nnd ttl e usc of 18xati V0S, vorrlJ. t i
dangerous of the two. 31
n{~
was th p rnorr
The resulting complications were
of a more serious and harmful nature.
Besides the comrlications
associated with the actual dieestive processes, other very
serious disorders have also been know:: to accollI)any the
disorder.
Potassium deficiency as weIJ. as other deficicnrj
disorders,
SiJ.C'"
as aner:1.ia, often occur in the m2.jori-cy of
LiuJimarectic patients.
arp
r:8SP9
fI'o a lesser
ext~'ntt
of }':J]!C'rtens.i on, rena] faUllr('
CJY1(]
but worthy or note,
('vC'n ('pi] f'rtir:
.
32
SPIzures.
In both
a~orexia
nervosa and
bulimare~ia,
there tend
to be very similar traits from one patient to another.
mho
typical anorectic is female and in her mid to late teens or
-
12
-
early twenties. 33
This seems logical because of the added
pressures of adolescence a.Yld young adul theod.
11.:3 ste. ted
earlier, she is often at that point in her life when she
wants to fi t in with her reers, and
conformin,~
with her body
is a way to do so.
The typical anorectic is usually of middle or upper
c 1 ass b ac k groun d , an d more
0 ft
·
en th an no t ,lS
caucaSlan.
. 34
In the past few years, however, the occurrence of the dis-
ease has spread to a lesser extent to almost all
socioe~o-
nomic backgrounds.
the anorectJc pati0nt iE; one wilo has been
rrypicall~!,
considered ~,~e 'rr:rfFct. chiJd.,,35
Eually of fairly
intelliBsnc-, the
t~haved,
model stndeYlt.
a~orectic
is well
':"ten she is seen as an
~igh
pretty, and a
ove:!:'~H'hi',:vcr,
and
this overachievinr: is ol'ten fUE:lecl by parental pressure.
family is DoSt often close knit.
male.
l;er
Usually, there are two
Dominant mothers and/or very authoritative parents
~
t ·e ro 1
. t ure. '1/ h
seem t ·0 P 1 ay a GCIlnl
e ·In th C PlC
UnlikE' the anorectic patient, there is no detailed
_1
•
•
pe:!:'sonality profile on the bulimarectic at this time.
This
may be due to the fact that the behavior is so secretive.
In comparison to tl1 e anorecti c, hO\,lever,
clew!:;
800m
bnl.imarecti c
to l)(~ more 300ial1y (1ctiv(' 8.nd outgoinC. =~7
while she is
-
tht:~
~ore
outEoinS, she hac
2
[),llt
definite lack of splf
13
-
esteem, as does the anorectic.
Bulirnarcctics GcneralJy start
late teens.
1,0
pat in binecs in their
Vomiting behavior then usually
one year later.
around
begin~
This vomiting behavior continues for the
average duration of 4.5 years.
r:[.1his duration of the illness
is much loncer than that. or anorexi;} ncrvoS8, and when hr:·lp
is sought, the prognosis is often not as promising. 38
As stated, most bulimarectics llRve had some type of
weight problem in the past.
This bulimarectic behavior may
well then be [) result of frustration 8t
ke('rint~
their vleigllt
at their desired lpvel.
UnderJ.ying lToblems
severe weight loss, this weieht loss is only one of the
problems.
The underlying
severity.
'.Illile the typical anorectic viaS ini tially a model
proble~s
~ay
be of
eve~
greater
child, once the disease starts to take hold, there are mark0d
c~1an8es
in
~ler
personali t2' as well as in bodily appearance.
v:1thdravl frm rclationshil's and llsual activi tics 8.::d ber'orle
unal}proachable in many cOD'JersatioY'.al 2reas.
'Ine underlying probler:-is are difficult to define.
nervosa cannot be pinpointed to one specific cause.
Anorexia
Rathpr,
-
the r0asons behind anorexia nervosCl 8re nany
C1.nrl
v~Jrie(l.
There are several typical underlying factors whict Gay have
"'>:'9
(1) biolofical, (2) psychological, and (3) environr:lental bases./
Whereas psychological factors were once thought to be of
sole or prir:1ary importance in the development of anorexia
nervosa, now biologic factors are
tensively.
hein~
resc8rchcrt morc px-
Studies now seem to support that there may be a
hypothalamus/pituitary/ovary dysfunction. 40
The hypothalamus
seems to regulate some basic behavors such as eating, ag.
gresslon,
2.nd
hypothalamus
rl41
r100 __ S.
It is now thoueht that perhaps the
~~:isreeulatinG
hormones may be a rredetermining
factor for a!'ore:-:ia nervosa.
The dYGfunctioTI. of the hyroo I.
I'
type of rosc2rch
i~
ctilJ in the
(~~ly
ste[Ps, so no dcfi-
nite conclusions are available yet.
}sycl!olorical factors do seen to play
th e cl E:veloprTI(,n t
of a~"-orexia
nervo sa.
8.
central rolf' i'1
en e con tribu ting
fa(~tor
mRy be the patient's self-p0rceived inability to live up to
11 er own expect~ltions or those of her authori tati.ve :par en ts
w
t'c 3
Such behavior seEDS logical, since the anorectic is often a
hic:h achiever.
,:!i th
-
Cften hieh paTPntal
()Y.:l)cctatioD~j,
couplc:d
contiDual conrlicancc, lead her to feel totally inadequate.
15
--
In an attempt to overcome these feelings of inadequacy, the
anorectic-to-be will start to diet as a means of conquering and controlling those feelings, givinG her a measure of
indepenctenco in hcr own mind.
Control itself, seems to be another important issue in
the development of anorexia nervosa. 44 Eilde Bruch aCCl1rately expresses the dilemma of the anarectic in terms of
"a sparrow in a golden cage".45
'rho anorectic has all of
the luxuries and privileges she could "lant, but is deprived
of the freedon to do
83
ste wishes.
Fruch describes the
anorectics whole life as an attempt to livp up to the f'xp(>cta"
t lons
i"
0_
,ner Inml
~'l y. 46
As the model Child, always doing
what she is told, anorectic behavior may well he an attempt
to control something in her life.
With weight control or
reduction, shp can control her body, as well.
those around ~er.47
form of a
P01.'I'<T
AD m8nirulat~
In a sense, her loss of weight, is a
p1ay. 48
Another factor in the development of the disorder rnay
be a major Ch2-Dge in the lifo of the anorectic.
may be a bodil.y change such as puberty.
0_1
t.n.",.
~noY>.·.
c<.•
00.1.:.1'
r-t:o-np
__
_
-,
~
'cc(iini~c;
a
"ro-".
"C,~_
',1[0"';:1:1
it comes sCX0al feelines.
t'''->l' nD'
-t:.,
J.L.
can be
Also,
A change in thp body
aho1J+
thp
fp"'r
of'
•. v
.• _.
""0
_
~~
heCOYnl'
U,.
1 , ' _ n'T
t.
vcr;,' frtgh-Lenjnc, for vlLtn
m~tur~tioo
~ith
-
This change
~ri~gs
t~c
with it
lose of WGi
II
I
I
of
.'
'eM
-
•
16
-
this reversal of puberty
ma~T
he a vJay to dela:\c this matur8.-
~<J
tion process. .
I'~any
of the preceeding psycholoGical factors sef?r2 to
stem frorn an environnental basis.
Although the anorectic's
family life seems ideal on the surface, oftf?D there are
underlying conflicts.
As seen in the psychological factors,
family pressures and the issue of control seem central to
the disorder.
So then, it appears, rsycholoEical factors
and environmental factors almost
SeE:~m
to be one in the samo.
The cause or etiological factors underlyinr bulimarexia
Rgain seem to point to tile extreme feaT of \·!eigr.t 52-in.
the
of
sa~e
r~:arTi
~1ctly
tine, however, several of the factors tiat contribute
e, her llulil1areci: ie behavior
\,/2.S
as the rrofi 1e of the anorectic.
as being
lit
2.D
a
'!!?:,;l
to control
':!i th Carrte, as well
clel:lont of control, her binging and vomiting was
a [loans of letting her ferlings And frustrations out.
:~hr:
had always complied ",!ith everyone's wishes and thus had nf:ver
learned to express her oVln feelings.
Eer binging and vomit-
ing then, was Ila way to take out my frustrations.
If I am
mad at someone, it is easier to binge and Eet mad at myself
instead of someone else.
It's less of a threat to get mad at
myself; it makes me take no chances. 1150
-
«
,
17
--
Thus it appears that the bulimarectic, like the anorectic,
has
811
extreme lack of self esteem.
The bulimarectie, however,
has a much greater fear of becoming fat than does the anorectic.
Again, this points back to the extreme fear of weight gain as
the primary determinant of bulimarcctic behavior.
Treatment
Ju~t
as the problems underlying eating disorders have a
complex basis, the treatment must be focused on many levels.
It is importcmt that the patient return to heal t!lY nutri tiona1 status, psychological lJ;roblems must be resolved, and
';1
family conflicts must he addressed.-
}'irst and foremost, the patient's physical health f'!wst
be upgraded.
In some cases, the patient may be rear the
point of death.
In these very serious instances, the issue
of saving her life comes first.
In these, as well as the
less serious instances, the anorectic vJill be easier to
reason with once the body has returned to a somf"Vlhat heal th ipr
state.
,~.J1orcctic
patients are irrational in their thinkin/:,
nnd until normal body processes are resumed, there will be
little
rrogress~
Weight cain seems to be agreed upon aE being the most
urgent of
tr~at~cnt
procedures.
~here
is a
Ques~ion,
how-
ever, as to wrl ",ttl r:r this should be accompli shed through
-
'" _.
18
-
hospi talization, or on an outpatient basis.
therapy will clcIwnd
8.
gr(~at
reasons.
h()spi Lal
j
y,(I
'·/2.S
Lion ('or
lost.
':ost
[;c'.ur(11
First, hospitalization allows for thorough physical
assessment.
from the
r(~nuc'~;l
rrode of
deal upon the (}r;1ount of "/f'jrht
lost and on the time period over "/hicn it
rhysicians t('nri to
~'he
Secondly, hospitalization removes the patient
fa~ily
setting.
This is beneficial to both patient
and family, because it helps to alleviate some of the stress
encountered.
Thirdly, hospitalization allows for the treat-
ine; physician to
for~
an
understandin[~
rolationship with
') ')
the patient. - (
Weight gain has been accomplished in illc'..IlY we_yS.
DruGs
are sometimes used to stimulate the 2norectic's appetite.
other times, intravenous f&cding is implemented.
of forty per
v,ould
~pnt
co~sti tl1te
These
body weight or lass of twenty-five to
rri t0ri8 for intraverous fONline.
'1'110
r.lost successful met.hod, however, is to encourage oreel feeding. 53
A lwl12.vior modification prograrr: can
regard to eating habits.
11(,
undertaken with
Reinforcers or special privileees
may be used to try to coax the patient to eat.
In this way,
the p2tient, unless near death, is allowed ,to feel in control
of her eatine.
With this method of treatment also comes the
deemphasis on eating.
With the focus taken off of the
,
PH'
." --------i-':;
~',
i
,,·W1b
(
19
-
patient t
S
eati:r:'g habits,
trollinf~ not only
lH'r
Glee
if allovled to feel slle is con-
1tlPiCJlt, hut (·v(·n tho;~p in chnrl~r'. S4
By gaining weight, the anorectic nay be alJowed visitinG privelezes or
so~c
similar reinforcement.
Since the
anorectic is usually extremely afraid of ar:d opposed to
wei£ht gain, bargains can be made as to small amounts of
weir;ht gain.
}(eeping the amount of weight gain expected in
small quanti ti es ',.Iill keep the anorectic t s distress to a
minimum.
Often times a "contract" can be aGreed upon by physicians
and patients as to what behavior will receive rewards.
Cne
riust reRli z e, however, th at th ere \·!i11 rro ba bly be s etbad~ s
in the treatrr:cnt of the Ci.llOrectic.
i1osl'i t21i~('d patients
or the
~morcctic
Day
,,!eight in ordr'I' to be released frofl) trd? hospi tal Clnd then
return to her previous behavior.
Anorectics have also beEn
kno1tm to hide or dispose of their
food~
feli
intr~-l.v('no11s1y,
Sone, when beinG
h::lVe evcfI disconnected their 1Vs.
If
there are others also suffering from anorexia nervosa ni='ar
staff.
These setbacks are normal, but it does not necessari-
ly mean failure in the enrt.
Recovery from anorf'xia nervosa is a slo\·/ process, and
-
it is impor-::;ant to rpalize that si!TiI'le wcigrt
c8in
does not
...
.-,-~--
.
"e
-- -.- _.
". ". . • • . -
"."
. .........
I
-
___ _
ttl
'
ft'
!
.*
_cc
?O
-
mcc.n that the (-morcctic patient is cl)rcd.
':-v('n a ft0r fair-
ly norMal ':!eicht and J'1.utri tion arC' rssuf1Pc'!, the
l'1reoccu~ation
fication is I'Iost successful when counled with psychological
and far;1.ily therapy.
To rcsolv()
tllE'
inner conflicts that overpowpr the ano-
rectic, she must be made to feel in control of her life.
Successful therapy must help the anorectic to mature emotionally and be able to understand and properly channel her
feelines.
This must aleo be coupled with
~hernpy
to improve
her self imace.
1'nc fOTldly of tll(> n.norf'ct.iei" cr.i.ticnl
in
h(lpi.nr~
v!jth
this therapy.
The family of the anorectic must be made to
understand t~~ not only the patient has problpms. 56 Ano-
re:xia is a lJroblem of the 1thole fal:"i ly, anr' a problerrJ that
needs family
8~PTort.
Therefore, the family support system
must be strFllztliE.ned ;oJxtd reir:.forced.
2..
support
2yste~n
Use of the
fanil~r
depeY1ds la,rgely on their ab-ili ty to
as
c}~2.nfc
J\norc:xia Fcrvos8, by st",vC'rl J:evcnkron, the author provid ('s
hasic behavi0Ts for parents copine: with an anorectic chi1d.
One basic theme that runs throughout Levenkron' book is that
of not ci.emandine; decisions of thp anorf?cti,c.
Fewer choices
forced upon the patient will ease her distress in copine
with situations.
-
!tbove all, :rJPvenkron states tho n?;cd to
'ZOP
c
21
-
adopt a
11
nur turant yet authori tativel! l)osture toward their
anorectic child. 57
In con tr8.ot to anorectics, bul5.rnar p ct1or.: eTe hard er to
treat.
With the extrAme secrecy surrounding the behavior,
it is oftentimes hard to get thc bulimarectic to admit she
proble~.
has a
Cnce the problem hac been discovered thouGh,
treatment is usually
the
treatin~
u~dertaken
of thes0 individuals,
gins, and the' second is to
2re used, rlus
c, p,
treatment./
2.
t~e1'c
chang('t)~c
\'/81'd ('atiY'E ,,!lid V!eif:ht Gain.
In
on an outpatient hasis.
2re two
pri~ary
p8ti(onts 8ttit.udes to-
rehavior modifj r:atioYl techniques
ch8DgC in thinkinG is rCeJuired for full
It takes a skilled thprapist to build trust
and start to 1'pvcrse the cycle.
At the onset of treatment, much is needed to help
t1'ol the "nC'f'flv.ior.
spelled out
she eats.
~nd
i11hc'
COfl-
r1FUlfc1's of thr: lwhnvior arf' oftcrt
the patient is asked to record when 2nd
~lat
In this manner, tbe doctor can exanine ca.tinES
habits and attitudes about those pating hahits.
The
p8tipnt
is instructed to only eat at certein times and ways to increase
self-co~trol
are discuss8ct,
f'lent is the r::rcrd;ion of
E:
rccepti ur:
Important in th0 treatenvi1'onl~'F:nt
for recover:,'.
22
-
cllanL~(:'
ll(:r nti.ituc i C3 t(1\',r,rri,'ourl <Inri
to\'/':rd
!I('r'~-(
If.
c, Ci
-
}'rognosic
Tr..e road to recovery from an
one.
e~tinE
disorder is
::1,
tou2~h
It takes a great deal of time and patience on the part
of the patient, and by all those around her.
At the prespnt
time, the mortali ty rate from anorl)xia ncrvosa ranees from
flO
six to fifteen per cpnt.
John EopKins Univf'rsity statistics show thE't
on(~-fourth
treatment, oYle-r.alf
of anorectics 2re not
i~prove
h(~lped
by
but 2r(' vulnerable to develop-
inc future })roblems, nnd ()nly th" rcrrC'lininC one-fourtl1 rr'61
cover complctf?ly.
:::t2tistics silow, hO\,lever, that the
the chance for recovery.
treat~~nt
~
fcv! satisfactor:,: rcport~o
67,
of tulinarexia. / There have
vIell-ciocUJl'1rntu.l, thcTP
on the
rr:>
llc:~v('r;een
incff('ctiv(- trF:atTJlents attempted, anci
probler;1~
cocplicatect hy lack of trainpd therarists.64
)'[:''1{8
l:Jeen
~uccessful
tr('a\1::C'nt {;('p(·nd~· on the pat.i.cnt'~~ rlbility La ;]('I~nO"ll('drl­
the problem 8nd want to chanGe. 65
~\.t this point, only a
limited prognosis can bp made hecause of tnt:' linitpd ar~ollnt
of research 2vailable.
-.
It can be said that at this point
in time, the treatment outco~e of tulimarexia is less favour2,[-le than that of anorexia nervosa.
3ulimarectic patients
·-
are vcr:,' rcsisbu;t to trf';Jil'(Tlt:, Nl('Olmtf'T'
cations, and Rre very prone to
There is still much to be
(inl~1
..
compli-
rj'''"t'[,,0Tnllf'
u;
SU1Cldf'.lear~cd
about
eEtin~
disorders.
VIi th Lil.1c B_wi patif'rlcc \t!ill ::Fly :.:::olutiOrl ever be reached.
In the mcantime,
~owever,
there are nation?l support groups
as \'Jell as 10ra1 solI-help Groups.
'L'WO 2'.wh groups clTe trlc
National Anorectic Aid Society in Columbus, C'hio, and thp
-T
' +.
l'.
crvosa A
SSOCla
"lon
.
t
.
Amerlcan
"u'!oreXla
.
T eance,
k
IT
J erscy. 67
ln
~j ew
Ifhese group:: can be contacted for information on v,here to
~he
seek help.
~ating
that
first step, though, is just asking for hplp.
disorders are a serious problem, and not somethine
C2TI
bf' overcome alone.
1.
r.bsc['~::ion
C c' loy'
LL' s,
2?tin:'1
v!it-,-: foon, hoarri,-,r;., (;(JllP-i:inr
f 0 0 d a cor' s t :'1. n t. ::: 1) i ~ j c c t (J _=- C () Y1 11 I" r -
7/.
4.~xcrciDjr[
5.
to extremcs
Cr 2.:- e in personali ty
1
6.
Above a.ll,
j
her to seek help.
--
f
someone :you knoVi does have a problen, lJrr-:e
~ating
disorders are a
s~rious
problprn,
and a problen that is increasine in frequency.
tt present,
we are far fror ' possessing All of thp; answers.
\'!f' know thp.t
,
__
~
___
f ___
_____
d~~
______________________________
__
~~~~·.·~~~~~
~
_ • • •
_~
___ •
_ _ _ _ •• _ _ .~.
0 ______
~!.~
__
-.
~~~'~'.~.~~.~,,_.
________
24
-
simply repairine; thehody
1~
not
E'1!.Ol)f}l,
hrt W'lat
i,~
to be cione?
As with eny problem, the best solution must stem fran the
disorders, perhaps we should focus on the Bttitudes underlyin!3
t~e
problcFls.
}\norexia nervosa :mcl rmltrr:arcxj.8 arc only
two more escape mechanisms in a long list.
In a f30cif'ty
with such other problems as alcoholism and drug abuse,
would not the better solution be to teach people to cope?
Before there will he any
chanf~e,
in the attitudes of our society.
ther(' must lie a
eh"nr~r;
l!prhaps it is time that
we try to break the myths that are starting to rule the lives
of our younG, and in the words of :!ilde
"Golden cacoll.69
:~~ruch,
[Teak th:.1t
~
--._.....-----------
,
-'-~--~---
-_.-
.--
-.-
_ _~ _ _- - - '.........':...._~.
(eM
.1
••
'
....
-1Eruch, Eilde, UA.norexia Nervosa and its Differential
Diagnosis," 'Ehe LTournal of Nervous and Iv1 ental Disease, 141,
no. 5, 1966, p. 555.
2~acleod, Sheila, The Art of Starvation
Schocken Books, 1981) p. 4.
3Pa~mer,
1
P •L•
-"
(New York:
:uide for sufferers
ttd. 1981)
and their families
p. 6.
4carfinkf'1, J)aul E., et al. "1'he Heterogeneity of
Anorexia Nervosa, 11 j\.rchi ves of Gen eral "Psychiatry, vol. 37,
September 1980, p. 1036.
5~-~ruch, Lilde, 11;'l.nor(!xia Nervosa and its DifferF:nti2.1
Diagnosis," p. 555.
6prucfl, ]!ilde, "Anorexia l'!ervosa: r~'hpTapy cmd ':::'heory,"
The Ameri can LlournaJ of Vsy chia try, 139, no. 12, Cecember
1982, p. 1531.
7(',-iulio, ?'2.Tbero, al"-c1 ,James I. Ch8rel, "Anorf?xia Fer'll(1 S!:t , 11
~;ci('n('r-? r.uid~': TinivCTsit',T of !'jc'sollri- :-'nlllmlyi n
\,icdiCcll ~':('tltcr, ~c:rics 1, no. 2: ,lune19b(), 1). -I.
-~-f('alth
ST'rlle>' I'lole'e IItl 110T'PXloa t 1 ('rvos3. II T:E:'r:~Llon"'c, c'lYld tn0ir
l,~edical ::;,ip:l'l.ificance, vol. 18, no. r:-, !':overnbr:r7Dccernher
1976, p. 2~J.
..l...-)u
.. l f - ' - L
'-,
~
I·
........' _
C,
___
'_,_."
~l~
... - ' - , _
9carfinkpJ, p. 1036.
10Boyle, ])atricia r'1. p.t ale lI/\Sspssment and 1':ana~(.~mF'nt
of Anorexia I'; prvosa, II r,Taternal- Child Hursing Journal,
vol. 6, November/December, 1981,p. 412.
11 1~'a
, 1
mer, P.! .• , p. 5R.
12~)inaikin, Phillip, "1'reatment of Anorex12, llervosa,
Arizona Medicine, Vol. 39, no. 3, Parch 1982, p. 182
II
1 3TT
F
('
t
b
.'p
l'SU, ..il.ic.
",eorge, II I s T'nere a 1\
J~lS llr. ance ll1 _;ody
Ir.2.ge in Anorexia I'Tervosa?" The Journal of Eervous and
Lental Disease, vol. 170, no. 5, 1982, p. 305-306
T
°
14}Jalmer, :po 14
-
15Giulio and Chap01, p. 1
16
Ferrar2, Corlpss ~ro"'m, "./I.l1oreyia IT erV0 sa:
Choosinf, to
~~t('n'vf',"
,lollrnal of i:ursjnc: C:rlrc, If:::, ,T8.nU;1r:/ 1022,1'. 1r;.
25
(
.... _ _ _
. _ .....
~ _ _ ~_:?_
. _ . : . , _ ....... _ _ _ ••
_~~_.-L-,..;.,~~___----.;_ _ _._ _ _ _ _ _ _ _ _ _ _---'............ .:.-.......
_ _...
, ......................_"...-.....d. . . . . . ._. '. . . . ._ - . . {
17Lucao, Alexander, "Bulimia and Vorni ting ~~yndrorne,"
New York state Journal of Medicine, vol. 3, I~arch 1982, p.398
18 Ibid ., p. 398
19"Anorexia: The'Starving Disease' r,;pidernic,"
and World Report, August 30 1982, p. 47.
News
20Hussell, Gerald, "l:ulimia tl ervosa:
An ominous variant
of anorexia nervosa," Psychological r'iedicine, voL 9, 1979,
p. 430
21 Halmi, Kath erine A., James R. }<'alk, and "::stelle Schwartz,
IlBinge-eating and Vomiting: A survey of a colI e;~e popula tion, "
Psychological f.:edicine, vol. 11, 1981, p. 703
22Fcdr1-'llrn, ('hristorner r.. [1)[C 1 h-,tf>r J. Cooper, lf~clr­
induced VOTIli_tinc; an.d bulir;!ia nervosa:
an undetected problcIT., II
13rj_tish Ledieal Journal, vol. 284, ':pril 17, 1982, p. 1153.
r) • ~
, ")
~ .....·)';·1
.
}I:! j ,
;'.
t)t)'/.
r.
43-1.
"(:
L:':_'c~spcr, !:ccina r;.
ct 8.1. ".!::lJli!'lia:
Its lncic!cnce em r ]
Clinic2,1 Ir1pori;;:lnce iF Patients 1::i th. i'nore::d_a ::ervosa,"
Archivc2 of Seneral Psychiatry, vol. 37, Spptember 19 8 0, p. 1043
27pcbra!lal'1, :::uaznne l~. and P. J. V. T)eumon t, "Eo1t: pa ti CYl ts
describe bulimi8 or binge eating,1! Fsychological Ledicin p ,
12, 1982, p. 629.
?PJ'erson;:~l i r ltcrvlCw with (;arric (fictitLouf-i narnc) ?1
year old bulir1arectic-- Indianapolis, Indiana, ._Tune 1, 1983.
29Abr2ha~ and Bcumont, p. 631.
7.0
/ russell, p. 438.
31 Ib'10.
, p. 437.
3;',)~ b'Ie.
j
33l'ruch,
') 4~: C;~l v!ab E', .:.\rth 11r
lntc'rnri] i (r1 i cj nf',
Sign i fie an c e ,
--! ---~
-
.:. ,T J.. \.,n em 1. C ,
35t1Anor8xia:
II
p.
!)
7•
36ReccC', Foli('rt [~. tl1\norr-;::d 8 i;crr'02::o., II .t\r~r'ric;:]n i~r1mn~1
JOhy si ci an, vo 1. '1~";, n (). -1-, !\ Pl' i 1 1 q' (C, p. 1,-;:r.-'.=...::--.:.----..:...--"'-
37 .K. . . e urn 0 n t , .'
~l-' • J- • 'T\ ., u.
"(~'~I "J~'. l..'
r'eorp'e
and T\
C'r'1
- C - ,
......... '. .._'
_c rt-. ,
I!Dieters and Vomiters a.nd rurgers in Anor8x:i8 '-ervClsa,
Psycholoeical [~edicine, 6, 1976, r. (117.
Cl
•
II
38 Bh 8.nji, S. and D. !~attingly, "Anorexia EenlOsa:
Observations on ':0ietcrs' and 'Vomi ters' ,"
of Psychiatrl, 139, 19 8 1, p. 238.
}~Ti ti8h
::":orlC
Journal
39Ciulio and Chapel, p. 2.
40 Ibid •
41:palmer, p. 55
42Giulio and Chapel, p. 2.
43!"o'k
I
II\,r~
t · })a t·len t
1.1....,1 , .rene,
.. ,.en th c jI.norpC1C
You ••• II Nursinc;, December 1981, p. 47.
l}
Ch aengps
44pellmon.t, George, and Smart, p. 620.
4 5·n.brucn,
, '.~1
... 1 d e,
C 1 d en
f'"
.:.'~1(~O
University IJress, 19m p.
23.
(Lassachusetts:
~iC3.rvard
46 11
'.-l
.. n.lI.
117
,
II Anorr'"l'
.. ./. c",.
.....
~"
q
'J~chwate,
/1
The
'Starving Jiisease'::pidpITri,c ll ,
r.
4'1.
p. 378.
1983
51
;jruc~),Feelin.gs
ano their Fodical Significanc p
,
p. 31
52c:'
,--,lnal'k'J.n, p. 183.
r) '.I,
. "Jbid.
54Zeller, Clifford, tlTreatment of Sgo J)eficits in Anorexia Hervosa,11 American Journal of Orthopsychiatry, 52,
no. 2, April 1982, p. 358.
.-
27
-
55ruSik, p. 47
56
Reece, p. 125
57 Levenkron, Steven, rrrf~atinfT and Ovprcomin.
Nervosa (New York: Charles
•
58pairburn, p. 710.
59 Ibid •
60
Reece, p. 125.
61 !I HnoreXla:
fI
.
62
r~he
I
Starving Disease 'r~pictemic," P. 48.
Reece, p. 125.
63pairburn, p. 707.
64JJllcas, p. 399.
ir
l'usse l~.1,
00··
C7,
, 1,11 eel S
,
p.
68"Anorexia:
-'('C)
').1
'11he 'StarvinE
DisC'(~sc'
h9-~l_rucu,
h ' ' 'J.n
' e G
~
. o.Id pn Cage,
p. 1 c..:.O
/.
28
:·;pio.f'r:de,lI p.
~(.:.
,
-_.--
BIBI.:ICGRJ\H~Y
Ab r ah am , S u. Z 8...11 n e F. and P. J • V. Be\) rn 0 n t •
describe bulimia or "binge eating."
[V;edicine, 12, 1982, (;25-G35.
"!~ow :patients
Psychological
"Anorexia: 'l'he 'Starving Disease'~'~pidemic,
World Report, August 30, 1982, 47-48.
f'!evls and
fl
Beumont, P.J.V., G.C.\'I. George, and D.E. Smart. TlDieters
and Vomiters and Purgers in Anorexia Nervosa.1! Psychological Gedicine, 6, 1976, 617-622.
~;ome
Bhanji, S. and D. T';attingly.
"Anorexia Nervosa:
Observations on 'Dieters' and ''lomiters','' British
Journal of Psychiatry, 139, 1981, 238-241.
I~oy1e,
Yatricia T.l. et ale
.\noY'f':\j:,
vol.
£),
i'I('r'.lt)~n.11
1I,~,ssessment
clOd j.:.qn2{!c])!ent of
~~l'J'rn~II-('fliJrJ
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at"..d ('c t a.>.+' 1~ rh
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J\PF?lTDIX
Information on eating disorders Rnd support groups caD he
obtained from the National Aid Society, Inc., }.0. Box
294(;1, r;oJ 111lhlS (\;1 ~ 3229 and the f.nl('I'i(~a,n /,norc:xio tir'rv03<l
AssoC:iation, Inc:., 133 C~edar Tane, ':'r8.nr'CK ii,} 0766f..
31