The Real Skinny on Anorexia a Merciless Battle with the Mirror

According to the National Association of Anorexia Nervosa and Associated Disorders (ANAD) (2018), at least 30,000,000 people of all ages and genders suffer from an eating disorder at any given time in the United States. Of those 30,000,000, at least one person dies every 62 minutes as a direct result of their disorder. Most often, eating disorders affect women between the ages of 12 and 35. Compared to all other mental illnesses, eating disorders have the highest mortality rate (National Association of Anorexia Nervosa and Associated Disorders, 2018).

Eating disorders are not selective, as they affect all races and ethnic groups. Genetics, environmental factors, and personality traits all intertwine to impose a risk for an eating disorder (National Association of Anorexia Nervosa and Associated Disorders, 2018).

Eating disorders are significant conditions related to persistent eating behaviors that negatively impact one's health, emotions, and ability to function in important aspects of life. Most eating disorders involve focusing excessively on weight, body shape, and food, leading to dangerous eating patterns (Mayo Clinic, 2018). These harmful habits can detrimentally impact the body's need for appropriate nutrition. In severe cases, this can cause damage to the heart, digestive system, bones, teeth, and mouth, as well as other diseases (Mayo Clinic, 2018). Aside from physical consequences, many emotional health issues can arise with an eating disorder. However, the type of eating disorder and the severity of cases vary among individuals.

This thesis will focus on anorexia nervosa, a disorder I personally struggled with and overcame. Although my case was far from severe, it significantly affected many aspects of my life as a developing adolescent girl. Throughout this thesis, I will present scholarly reviews and personal anecdotes that coincide with the progression of this disorder, including its signs, symptoms, etiology, and treatment.

DEFINITIONS

A commonly held opinion is that eating disorders are a lifestyle choice. An eating disorder is actually defined as the persistent disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food and significantly impairs health or psychosocial functioning (Dell'Osso, et al., 2016). Eating disorders are incredibly serious and often fatal illnesses that are often signaled by obsessions with food, body weight, and shape (Parekh, 2017). The most common eating disorders include anorexia nervosa, bulimia nervosa, binge-eating disorder, and avoidant restrictive food intake disorder. According to the National Institute of Mental Health (NIMH) (2017), anorexia nervosa is defined by a significant and persistent reduction in food intake which leads to extremely low body weight in the context of age, sex, and physical health; relentless pursuit of thinness; a distortion of body image and intense fear of gaining weight; and extremely disturbed eating behavior. Many people with anorexia view themselves as overweight, even though they are underweight or severely malnourished (National Institute of Mental Health, 2017). To prevent any sort of weight gain, people with anorexia excessively limit calories or use other methods to lose weight, including excessive exercise or using laxatives or diet aids (Mayo Clinic, 2018). People with anorexia nervosa do not maintain a normal weight because they refuse to eat enough and often exercise obsessively. Over time, symptoms such as cessation of menstrual periods, development of osteopenia or osteoporosis through calcium loss, drying of the skin, development of mild anemia, deterioration of muscles, including the heart muscle, severe constipation, decrease in blood pressure, slowed breathing, and a drop in internal body temperature causing the person to feel perpetually cold may develop as the body goes into starvation (Parekh, 2017).

Another eating disorder that is similar to anorexia but also has its own unique symptoms is Bulimia Nervosa. Bulimia Nervosa is a very serious and potentially life-threatening eating disorder, characterized by a relentless cycle of bingeing and compensatory behaviors such as self-induced vomiting in an effort to counteract or compensate for the effects of binge-eating (National Eating Disorders Association, 2018). An episode of binge eating is defined by consuming an amount of food in a specific time frame that is significantly larger than what most people would eat under similar conditions. There is often a sense of lack of control during these episodes, such as a feeling of being unable to stop eating despite fullness (National Eating Disorders Association, 2018). These binges typically end when interrupted by another person, falling asleep, or extreme stomach discomfort due to overextension. Fear of gaining weight and stomach pain are common reasons for individuals with bulimia nervosa to purge (Parekh, 2017). The inappropriate compensatory behaviors to prevent weight gain include self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, or excessive exercising. This cycle is often repeated several times a week, or in severe cases, several times a day. Impulse control is a common theme across eating disorders with binge-purge behaviors. To be diagnosed with bulimia nervosa, both binge eating and inappropriate compensatory behaviors must occur on average at least once a week for three months (National Eating Disorders Association, 2018).

Although people with bulimia frequently diet and exercise intensively, they can range from slightly underweight to normal weight, overweight, or even obese. They are not typically as underweight as people with anorexia (Parekh, 2017). However, they often fear weight gain, desperately want to lose weight, and are intensely dissatisfied with their body shape and size (National Institute of Mental Health, 2017). Due to the physical nature of the purges, Bulimia Nervosa can lead to symptoms such as a chronically inflamed and sore throat, swollen salivary glands in the neck and below the jaw, puffiness in the cheeks and face, tooth enamel erosion, tooth decay, gastroesophageal reflux disorder, intestinal problems, kidney problems, and severe dehydration. In severe cases, it can lead to rare but potentially fatal complications like esophageal tears, gastric rupture, and cardiac arrhythmias (Parekh, 2017).

Another eating disorder that is similar to bulimia nervosa, but has different defining qualities, is binge eating disorder. Much like bulimia nervosa, individuals with binge-eating disorder regularly eat too much food and feel a lack of control over their eating. This might mean that one eats more food than intended, even when not hungry, and continues eating even after he or she is comfortably full (Mayo Clinic, 2018). After bingeing, one might feel guilty and ashamed of the behavior, but in contrast to bulimia nervosa, one does not compensate for this behavior with purging or excessive exercise (Mayo Clinic, 2018). As a result, people with binge eating disorder are often overweight or obese (National Institute of Mental Health, 2017). Binge eating disorder is characterized by overeating during a discrete period of time, lack of control, and must be associated with at least three of the following symptoms: eating more rapidly than normal, eating until feeling uncomfortably full, eating large amounts of food when not feeling physically hungry, eating alone because of feeling embarrassed by how much one is eating, and feeling disgusted with oneself, depressed, or very guilty afterward. Binge eating disorder also causes significant distress to the individual (Parekh, 2017).

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), one more disorder that has similar symptoms to anorexia nervosa, but not for the same reasons, is Avoidant Restrictive Food Intake Disorder. This disorder is defined as an eating or feeding disturbance (such as a lack of interest in eating or food, avoidance based on the sensory characteristics of food, or concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional or energy needs. Along with these symptoms, there needs to be at least one of the following: significant weight loss (or failure to achieve expected weight gain or faltering growth in children), significant nutritional deficiency, dependence on enteral feeding or oral nutritional supplements, or marked interference with psychosocial functioning. These disordered eating patterns cannot be explained by lack of available food or by an associated culturally sanctioned practice, nor are they attributable to a concurrent medical condition or better explained by another mental disorder (DSM-V) (American Psychiatric Association, 2013). This is a new diagnosis in the DSM-V and was previously referred to as "selective eating disorder." While the symptoms of this disorder resemble anorexia nervosa in that both disorders involve limitations in the amount and/or types of food consumed, the disorder differs from anorexia nervosa because it does not involve any distress about body shape or size, or fear of gaining weight (National Eating Disorders Association, 2018). Although many children go through phases of picky or selective eating, a child suffering from Avoidant Restrictive Food Intake Disorder will not consume enough calories to grow and develop properly, and an adult suffering will not maintain basic bodily functions. For children, this can lead to stalled weight gain and vertical growth, and in adults, it will typically result in weight loss (National Eating Disorders Association, 2018).

STATISTICS

Anorexia nervosa primarily affects adolescent girls and young women, but it can affect people of all genders and ages (American Psychiatric Association, 2013). About 1-5% of all American female adolescents and young women suffer from anorexia in their lifetime (National Association of Anorexia Nervosa and Associated Disorders, 2018). A total of 0.6% of adults suffer from anorexia at some point in their life (National Institute of Mental Health, 2017). The average age of onset is 17 years old. Anorexia nervosa is very rarely diagnosed after the age of 40, but it is not unheard of for people to have a later onset of the disease (Farrar, 2014). The lifetime prevalence of anorexia is three times higher among females (0.9%) than males (0.3%) (National Institute of Mental Health, 2017).

Anorexia nervosa is the third most common chronic illness among adolescents. Fifty percent of girls between the ages of 13 and 15 believe that they are overweight, when they are not (Farrar, 2014). Oftentimes, people with anorexia do not suffer just from the eating disorder alone. Thirty-three to fifty percent of anorexia patients have a comorbid mood disorder, such as depression (National Association of Anorexia Nervosa and Associated Disorders, 2018). Unfortunately, one in every five anorexia deaths is by suicide (National Association of Anorexia Nervosa and Associated Disorders, 2018). Without treatment, up to 20% of people with anorexia nervosa die, and with treatment, only about 2-3% die. Mortality rates of anorexia nervosa are the highest of any psychological disorder. With treatment, only 60% make a full recovery in which they live a life free from any disordered eating patterns or related thoughts or behaviors. About 20% make a partial recovery so that they are able to hold a job and maintain superficial relationships, but remain very focused on food and weight. The final 20% remain dangerously underweight and are frequently seen in emergency rooms, mental health clinics, inpatient hospital units, and eating disorder treatment programs (Farrar, 2014).

The overall prevalence of bulimia nervosa is 0.3% of adults (National Institute of Mental Health, 2017). One and a half percent of American women suffer from bulimia nervosa in their lifetime (National Association of Anorexia Nervosa and Associated Disorders, 2018). The prevalence of bulimia nervosa is five times higher among females than males (National Institute of Mental Health, 2017). Based on the Sheehan Disability Scale, 78% of people with bulimia nervosa had some impairment, and 43.9% had severe impairment (National Institute of Mental Health, 2017). Nearly half of individuals with bulimia have a comorbid mood disorder, and more than half also have comorbid anxiety disorders (National Association of Anorexia Nervosa and Associated Disorders, 2018). Nearly one in ten bulimia patients have a comorbid substance abuse disorder, typically alcohol use (National Association of Anorexia Nervosa and Associated Disorders, 2018). Also, self-harm is a common comorbid condition affecting 34% of those with bulimia. Shoplifting is also common amongst those with bulimia nervosa due to the high cost of large amounts of food and possible impulse control issues. While bulimia occurs most commonly in the adolescent and young adult years, it has been diagnosed in patients as young as six and among older adults. It seems to be affecting people at younger ages, with the average age of onset being in the late teens. Bulimia also seems to have a cultural component involved, with lifetime prevalence being higher in Latino and African-American populations. Also, homosexual and bisexual males are at greater risk for developing bulimia than heterosexual males. However, eating disorders among male athletes are on the rise, especially in cases where leanness is the preferred body type or "cutting weight" is expected. Only approximately 1 in 10 people with bulimia receive treatment, and cognitive behavioral therapy is the gold standard treatment for bulimia nervosa (Ouellette, 2015).

The most common eating disorder in the United States is binge eating disorder. It is estimated that 3.5% of women, 2% of men, and 30% to 40% of those seeking weight loss treatments can be clinically diagnosed with binge eating disorder (Farrar, 2014). Nearly three percent of American adults suffer from binge eating disorder at some point in their lifetime (National Association of Anorexia Nervosa and Associated Disorders, 2018). The lifetime prevalence of binge eating disorder is 3.5% in women, and 2.0% in men. This disorder usually starts during late adolescence or in the early twenties (Farrar, 2014). Similar to bulimia nervosa, nearly half of individuals with binge eating disorder have a comorbid mood disorder, more than half have a comorbid anxiety disorder, and nearly one in ten have a comorbid substance abuse disorder (National Association of Anorexia Nervosa and Associated Disorders, 2018). Approximately half of the risk for binge eating disorder is genetic (Ulfvebrand, Birgegard, Norring, Hogdahl, et. al., 2015). Close to 43% of individuals suffering from binge eating disorder will obtain treatment (Hudson, Hiripi, Pope, & Kessler, 2007).

Avoidant restrictive food intake disorder is more common in children and young adolescents, and less common in late adolescence and adulthood. It is often associated with comorbidity with anxiety and obsessive-compulsive disorder. Preliminary estimates suggest that this disorder may affect as many as 5% of children, and boys may have a higher risk for avoidant restrictive food intake disorder than girls. However, much more research needs to be done on this newly added disorder, as 63% of pediatricians and pediatric subspecialists were unfamiliar with the diagnosis (Norris, Spettigue, & Katzman, 2016).

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