Dr. Val Farmer
Rural Mental Health & Family Relationships

Eating Disorder Dangerous, Difficult to Treat

July 19, 2000

Question: What is the most lethal psychiatric disorder, the one that is the most likely to result in premature death?

Answer: An eating disorder called Anorexia Nervosa. Twenty percent die within 20 years of diagnosis.

The gravity of eating disorders was underscored by psychologist Stephen Wonderlich, immediate past president of the Academy for Eating Disorders and professor at the University of North Dakota School of Medical and Health Science. He can be reached at the Eating Disorder Institute in Fargo, North Dakota.

There are three types of eating disorders - Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder with Obesity. Wonderlich estimates that 10 to15 percent of the population has some form of disordered eating behavior either in the clinical or sub-clinical range.

Binge Eating Disorder. This disorder is characterized by rapid, intense uncontrolled eating. There is no purging of the food. Most people with this disorder are older, obese and have a history of weight fluctuations. Research showed that 30 percent of people in medically supervised weight control programs have this disorder.

Anorexia Nervosa. Only one percent of the population, this group is overwhelmingly composed of adolescent and young adult women who intentionally starve themselves. Any weight loss below 15 percent below normal body weight is indicative of this disorder. Starvation damages the heart and brain.

They think they are fat even when their actual appearance is thin and emaciated. They are terrified of gaining weight. Food and weight become obsessions. They may have strange eating rituals or refuse to eat in the presence of others. The may also engage in compulsive exercise to keep off weight. Menstrual cycle loss is common.

Some of the personality characteristics include: obsessive and compulsive behavior, a drive for perfection, low self-esteem, sensitive to the opinion of others, extremely cautious, black and white thinking, socially withdrawn and an intense preoccupation with diet and exercise. This disorder starts in early teens and is driven by media images of female beauty and dieting behavior in western industrialized counties.

Bulimia Nervosa. People with this eating disorder consume large amounts of food and then rid their bodies of the excess calories by vomiting, abusing laxatives and diuretics, taking enemas or by exercising obsessively, or they may use a combination of these methods.

The "binging and purging" is done in secret and the young women involved have normal or above body weight. They binge and purge from once or twice a week to several times a day to relieve stress and anxiety. In between episodes of binging and purging they diet frequently. One quarter of anorexics will regain their weight but then go on to develop bulimic behavior.

The reason that this is a dangerous disorder is that the purging increases the risk of heart failure caused by electrolyte imbalance and dehydration. Other complications include gastrointestinal problems and erosion of the enamel on the teeth due to exposure to acid during vomiting.

Many victims of bulimia also struggle with drug and alcohol addiction, compulsive stealing, depression and anxiety. These problems along with their impulsive tendencies places them at an increased risk for suicide.

Treatment issues with anorexics. Wonderlich states that there is a 40-50 percent success rate with a 20 session cognitive/behavioral treatment program that emphasizes normal eating and reducing cognitive distortions about body shape and weight.

With Anorexia Nervosa, the preferred treatment program is a multi-modal approach that involves psychotherapy, dietary supervision, medical management, medication and family therapy. Despite all these efforts, an estimated 25 percent never improve or they die. Those who are reasonably motivated and compliant can be managed through outpatient treatment.

The level of denial about body image is remarkable. They have extreme difficulty letting go of the perfectionism and anxiety that has driven their lives. Inpatient treatment has a lot more control over actual food intake. The goal is to keep them in a controlled setting long enough to establish normal weight. Research shows that relapse is much more frequent when they are discharged at a sub-optimal weight.

Treatment issues with bulimics. One group of bulimics have heightened levels of anxiety and perfectionism and can be treated similarly to those witb anorexia. A second group of bulimics have personality disorders which are associated with self-destructive and impulsive behavior.

This second group is a harder group to treat. They often have impulsive personality traits that also lead to related disorders such as substance abuse, mood and anxiety disorders, impulsive spending, sexual promiscuity, rage, self-mutilation and suicide attempts. One third of bulimics have a drug or alcohol problem. Victims need to be drug-free before the eating disorder can be effectively addressed.

A significant percentage of this group have experienced physical, sexual and emotional abuse during childhood. Wonderlich feels there is a strong connection between childhood abuse, unstable moods and impulsivity. If a victim of child abuse is then raped as a young adult, the second traumatization further accentuates moodiness and impulsivity.

Wonderlich believes that this second group of bulimics binge eat in order to regulate their negative moods. The more impulsive a person is, the more likely it is that she will binge eat to reduce negative feelings. Binge eating is not triggered by hunger, but by unhappy and negative feelings about the bulimic’s personal life.

Binge eating is just one aspect of self-destructive, impulsive behavior and unstable moods set in motion by adverse childhood trauma. Treatment goals focus on bulimics using better coping strategies to manage their moods and interpersonal interactions to minimize binge eating and other self-destructive acts.