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Eating disorders (ED) affect at least 9% of the world’s population and account for more deaths than any other mental health condition second only to opioid overdose. Eating disorder research has historically focused on White women from highly-educated and industrialized countries, but we are learning that other cultural groups may have even higher levels of risk. Anyone existing in a culture that promotes thinness as the ideal for attractiveness is susceptible to eating disorders. In the US, for example, gay men, transgender folks, people with autism, and Hispanic women all have greater-than-average risk of developing eating disorders. 

While the statistics are grim, there is help available. Getting better or helping someone you love on the road to recovery starts with awareness. Let’s begin by exploring the features, possible causes, and impact of eating disorders. In part 2 of this series, we’ll cover treatment approaches. 

Anorexia
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), a resource commonly used by mental health professionals for diagnosis, anorexia is characterized by severe calorie restriction, fear of gaining weight, and distorted body image. Folks with anorexia may also engage in behaviors such as over-exercising, bingeing, and purging. Ritualized eating behaviors such as cutting food into tiny bites, organizing food into patterns, or chewing their food a certain number of times before swallowing are also common. Anorexia can be very hard on the body, leading to malnutrition, electrolyte imbalances, dizziness, fainting, development of a fine layer of hair all over the body, feeling cold, and difficulty concentrating. Long-term physical risks include lowered immune function, muscle weakness, and heart failure. 

Contributing factors
Factors that contribute to ED in general and anorexia specifically occur on individual, family, and systemic levels. Certain personality features such as avoidance, perfectionism, and focus on the self seem to be predictive of higher risk for anorexia. Family environments in which children are encouraged to be thin, strong, or athletic to maintain parental affection or positive interest also increase risk for anorexia. Cultural groups in which thinness is portrayed as the ideal for beauty have some of the highest rates of anorexia compared to cultures where thinness is not considered a requirement for attractiveness. 

Genetics and brain chemistry play central biological roles in the development of anorexia. Having a first degree relative with anorexia increases risk by 11%. Dopamine and serotonin, chemical messengers that help us to regulate mood, sleep, eating, and reward-seeking behaviors, are also implicated in development of anorexia. Individuals with anorexia have up to 30% less of the byproduct of dopamine than those without anorexia, a reduction that is often maintained even after recovery, contributing to mood and anxiety symptoms.  

The Lived Experience
“Caleb” came out to his family as gay when he was 14. His father had downplayed Caleb’s news, choosing instead to focus on his hopes that Caleb would work to make the varsity basketball team. When his father passed suddenly the following year, Caleb lost significant weight; his appetite disappeared into a well of grief. The only relief he felt was on his long runs in the afternoons, which he gradually increased from one hour to two. His friend group began complimenting him on his new, sleeker appearance, and a boy he had been interested in asked him out on a date. Caleb began skipping breakfast regularly to ensure he didn’t gain any of the weight back. He felt an odd satisfaction every time he pushed through a hunger pang without eating. 

Bulimia
Bulimia is often overlooked by healthcare providers given that many folks who meet criteria are of average or larger size. People with bulimia often suffer longer without treatment than those with more visible eating disorders as a result. Symptoms include bingeing, which means eating large amounts of food in a short time in an out-of-control way, despite feeling full or physically uncomfortable. Bingeing is accompanied by behaviors to reduce the impact of binges, such as self-induced vomiting, use of laxatives or diuretics, and/or over-exercising. Just as in anorexia, people with bulimia center their self-worth primarily on body size and shape. Long-term physical consequences can include damage to the esophagus, tooth decay, and increased risk of esophageal cancers.

Contributing Factors
Similar to anorexia and other eating disorders, a complicated web of social, individual, and biological factors contribute to the development of bulimia. Folks with bulimia are more likely to rank higher on measures of sensation-seeking behaviors (similar to folks with addictive disorders), negative emotionality, and a trait called neuroticism, which includes tendencies toward worry, anxiety, fear, and assuming the worst. Eye tracking studies have found that people with bulimia spend more time gazing at their “problem” body areas than people with anorexia or no eating disorder. This hyperfocus may increase distress that folks with bulimia soothe with bingeing, and reinforce the need for behaviors such as vomiting to improve the “problem” body area. 

The Lived Experience
“Gloria” was the first person in her family to attend college. Her parents had immigrated from Mexico to the US when she was two years old and worked multiple jobs to pay for her to attend private school. An only child with an outgoing personality, she set out to make her parents proud by being an excellent student. She often felt left out of social groups at the predominantly White, upper class school she attended. The pressure to achieve and the longing to be included reached a boiling point when she was preparing her college applications her junior year. With each completed application, she would reward herself with a dozen donuts, which she intended to eat slowly over the course of several days. As she tore into the sixth donut, she felt a mix of relief and guilt - it felt good to let herself go, but shameful to be so out of control. She began vomiting to alleviate her overfullness and feelings of shame. 

Binge Eating Disorder
Binge Eating Disorder (BED) involves the same overeating behavior seen in bulimia without the drastic purging behaviors such as over-exercising or vomiting. Most folks with BED engage in frequent dieting to mitigate the weight-related impact of bingeing. Risk for high blood pressure, Type II Diabetes is doubled for folks with BED and risks are heightened for fibromyalgia. Binges are marked by feeling out of control, a sense of shame, and are often preceded by intense planning, secrecy, and food hoarding. 

Contributing Factors
Binge Eating Disorder was only acknowledged by the medical community as a discrete disorder in 2013, so research is limited regarding causal and contributing factors. There is consistent overlap between neurocognitive features in eating disorders and addiction in general, but the connections may be even more pronounced for BED. Similar to folks with addiction disorders, people with BED are more sensitive to rewards, more impulsive, and less sensitive to punishment, which likely contributes to bingeing. It’s important to note that these are involuntary cognitive processes that aren’t actively chosen by folks who exhibit features such as high impulsivity. Our tendency can be to assume that someone could decide to be less impulsive, for example, but brain imaging and psychological studies indicate that it’s not that simple. 

The Lived Experience
“Cory” was in constant motion in her life - a mom to three kids, a high school science teacher, and a support to her self-employed husband. At the start of each week, she would try to motivate herself with goals for eating healthier, going to the gym, but by Wednesday, her best laid plans were dashed as her to-do list grew. Every Thursday night for the past two years she would sit in bed, eating whole packages of cookies, bags of chips, and drinking beer. As the alcohol kicked in, she would recall how she had always meant to write a book about her sexual assault, something to help other survivors feel seen. Overwhelmed by feelings of guilt and failure, she would sneak out to dispose of her food wrappings in the community garbage so her family wouldn’t know how much she ate.  

Other Considerations
Two issues that all three eating disorders listed above have in common are high rates of trauma and co-occurring mental health and substance use disorders. Traumatic experiences are “the rule rather than the exception (Brewerton & Brady, 2014, p. 383)” for people with eating disorders. Bingeing, purging, and food restriction may help to regulate some of the discomfort associated with trauma-related symptoms, such as intrusive thoughts and memories. As for other mental health disorders, some studies show over 80% of people with eating disorders also have a mood, anxiety, or substance use disorder. This overlap highlights the necessity of comprehensive assessment and care. 

We still have much to learn about how society, biology, and personal experiences coalesce into disordered eating, but the good news is that effective treatment exists. In our next segment, we’ll explore types of eating disorder treatments and other resources for recovery.

In the meantime, if you or someone you love is struggling with an eating disorder, help is available 24/7 by phone or online through the National Eating Disorders Association.

Written for Fitness Blender by Candice Creasman Mowrey, PhD
Licensed Clinical Mental Health Counselor Supervisor

References

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