Distorted Beauty: Recognition of Eating Disorders as Real and Treatable Cases

At 15, Julie was overweight, weighing 140 pounds at five feet one inch. Her mother, a well-meaning but overbearing woman nagged her incessantly about her appearance. Julie’s friends were kinder but no less relentless. After being told that she would have no trouble getting dates if she lost some weight, Julie began a strict diet and exercise regimen. After every meal, she exercised with one or two workout videos until, in her opinion, she had burned all the calories off that she had just consumed. After several weeks, she began losing weight. She felt great. But the problem was she was losing weight too fast. She stopped menstruating. But this did not bother her. She continued to lose weight until reaching 17. Julie did not initially seek treatment for her eating behavior until she had developed numbness in her left leg. A neurologist determined it was caused by peritoneal nerve paralysis, due to poor nutrition. She weighed only 75 pounds. The neurologist referred Julie to a mental health clinic where she was diagnosed with Anorexia Nervosa, a serious eating disorder.

Eating Disorders

Eating disorders are widespread among us. They began to increase during the 1950’s and early 1960’s (Barlow & Durand, 2009). There are two major types of eating disorders: Anorexia Nervosa and Bulimia Nervosa. These disorders are more than a restrictive diet; they involve serious disturbances in physical and psychological functioning. Anorexia Nervosa involves eating nothing more than what is essential for survival. A person’s body weight will drop drastically, resulting in serious health complications. In Bulimia Nervosa, out of control eating episodes, or binges, are followed by self-induced vomiting, excessive use of laxatives, or other attempts to get rid of food. This binge-purge cycle does not lead to weight loss as dramatic as in Anorexia. Both of these disorders share commonalities: a desire for control, medical and psychological complications, and similar causes. The mortality rate from eating disorders is the highest for any psychological disorder, even depression (Harris & Barraclough, 1998). Recognition of eating disorders as real and treatable disorders, therefore, is critically important.

Anorexia Nervosa

As shown by Julie, individuals suffering from Anorexia Nervosa put their lives in considerable danger. Once Anorexia develops, its course seems chronic. The average individual suffering from Anorexia seeks treatment with their body weight 25% to 30% below what is considered normal and healthy weight (Hsu, 1990). Anorexia is characterized by intense fear of gaining weight and losing control over eating. This disorder is less common than bulimia. Individuals with this disorder are proud of both their diets and extraordinary control (Brownell & Fairburn, 1995). Dramatic weight loss is achieved through severe caloric restriction (restricting type) or by combining caloric restriction and purging (binge-eating-purging type). Unlike bulimia, binge-eating-purging anorexics binge on relatively small amounts of food. They are never satisfied with their weight loss and often this leads to intense panic, anxiety, and depression. It is not uncommon to see someone with Anorexia exercising relentlessly.

Individuals with Anorexia suffer from many medical complications. One common one is cessation of menstruation, or amenorrhea, as demonstrated by Julie. Individuals can also suffer from cardiovascular problems such as low blood pressure and heart rate. Cardiac and kidney problems are also evident in individuals who often purge. Other medical signs and symptoms include dry skin, brittle hair or nails, and sensitivity or intolerance of cold temperatures. Lanugo, down hair on the limbs and cheeks, is also of common occurrence.

Not only do these individuals suffer from medical issues, but often mood and anxiety disorders are also present. It is noted that depression occurs in 33% of cases. That is 1 out of every 3 individuals presenting with symptoms of Anorexia (Agras, 2001). Anxiety disorders such as Obsessive-Compulsive Disorder (OCD) often co-occur with Anorexia (Keel et al., 2004). Unpleasant thoughts (obsessions) include gaining weight, and individuals engage in a variety of behaviors to rid themselves of these thoughts (compulsions). Substance abuse is also common in individuals with anorexia nervosa.

Bulimia Nervosa

Bulimia Nervosa was first recognized as a distinct psychological disorder in the 1970’s (Boskind-Lodahl, 1976). The hallmark of Bulimia Nervosa is eating larger amounts of food, typically more junk food than fruits and vegetable. This binge is very distressing emotionally to someone with Bulimia. The individual will then purge all that they had consumed in an effort to regain control. Often, this binge-purge routine is carried out discretely. Purging can be accomplished through use of laxatives, diuretics, and sometimes excessive exercise, but vomiting is the most common method. Purging, however, is not a particularly effective means of reducing caloric intake. Vomiting alone reduces around 50% of calories consumed, even less so if it is delayed. And laxatives have little effect in reducing calories (Kaye, Weltzin, Hsu, McConoha, & Bolton, 1993). Due to this fact, many individuals suffering from Bulimia fluctuate between weights. Once Bulimia develops, it tends to be chronic if untreated (Fairburn et al., 2000). Among those who present for treatment, 90%-95% are white, middle to upper-middle class women. Males seeking treatment have a later age of onset and are predominantly gay or bisexual (Rothblum, 2002). Cases of Bulimia have been found to begin as early at 10 years of age. Bulimia Nervosa is not uncommon among athletic males. This is because many sports require weight regulation (Ricciardelli & McCabe, 2004).

There are many medical consequences associated with Bulimia Nervosa. To begin, salivary gland enlargement can be caused by repeating vomiting, giving the face a chubby, swollen appearance. Repeated vomiting erodes dental enamel and esophagus lining. The body’s chemical balance, including sodium and potassium levels, is often upset, resulting in an electrolyte imbalance. If left alone, serious complications such as cardiac arrhythmia, seizures, and renal failure can develop; all of which are fatal. Intestinal problems, including constipation and permanent colon damage, resulting from laxative overuse are common.

As in Anorexia Nervosa, anxiety and mood disorders are common among individuals suffering from Bulimia Nervosa. 75% of patients present with an anxiety disorder, such as social phobia or generalized anxiety disorder (Schwalberg, Barlow, Alger, & Howard, 1992). Mood disorders, such as depression, are present in 50%-70% of cases (Agras, 2001). Interestingly enough, studies have shown that depression follows bulimia and may be a reaction to it (Brownell & Fairburn, 1995; Hsu, 1990). Substance abuse is also common among these individuals.


As with all psychological disorders, psychological, biological, and social factors contribute to the development of eating disorders. Psychological influences include ones sense of self, their attributions about themselves, as well as individual emotions. Biological dimensions are the inherited tendencies and vulnerabilities that carry through genetics. And finally, social factors include those images portrayed in the media through advertisements, television, products, etc. The family may be the strongest social influence of all.

Psychological dimensions are a key influence to the development of eating disorders. This involves beliefs about oneself and those surrounding an individual. Many individuals with eating disorders suffer from a low sense of control and confidence. Women with eating disorders are intensely preoccupied with how they appear to others (Fairburn, Stice, et al., 2003). They also experience strong levels of social anxiety (Smolak & Levine, 1996). Distortions in body shape perception also occur commonly. A study found bulimic women judged their body size to be larger and their ideal weight to be less than same-size controls (McKenzie, Williamson, & Cubic, 1993).

Biological dimensions are the genetic component of eating disorders. No, there is not one known gene for any psychological disorder, but inherited vulnerabilities and traits run through families. Relatives of patients with eating disorders are four to five times more likely than the general population to develop eating disorders themselves (Hudson, Pope, Jonas, & Yurgelun-Todd, 1983). Nonspecific personality traits such as emotional instability and poor impulse control can be “adopted” from a family member. If this is the case, an individual might inherit a tendency to be emotionally responsive to stressful life events and may eat impulsively in an attempt to relieve stress and anxiety. This biological vulnerability might then produce an eating disorder (Strober, 2002). In addition, new discoveries have been made regarding the hypothalamus and neurotransmitters of the brain. Neurotransmitters such as norepinephrine, dopamine, and serotonin that pass through the hypothalamus may determine whether something is malfunctioning when eating disorders occur (Vitiello & Lederhendler, 2000). Low levels of serotonergic activities are associated with impulse control and may contribute to binge eating.

In the case of eating disorders, social dimensions are one of the most important and dramatic factors. For young females in middle to upper class competitive environments, self worth, happiness, and success are largely determined by body measurements and percentage of body fat, factors that have little or no correlation with the personal happiness and success in the long run. The “cultural norm” directly results in dieting, which leads to eating disorders in many cases. Over many years what has been considered desirable in body sizes has changed dramatically. The curvy and voluptuous woman, desired in 1950s and 1960s, would be considered overweight by today’s standards. The average female model weighs up to 25% less than the typical woman, and maintains a weight at about 15 to 20 percent below what is considered healthy for her age and height. 400-600 advertisements appear on billboards, TV, in magazines, and in newspapers. One in eleven has a direct message about beauty. Barbie: not only do these dolls have fictionally proportioned, small body sizes, but they lean towards escalating the belief that materialistic possessions equate happiness.

There has been growing evidence related to family interaction patterns in cases of eating disorders. One report found that the typical family of someone with anorexia is successful, hard-driving, concerned about external appearances, and eager to maintain harmony. These families often deny or ignore conflicts or negative feelings, attributing these problems to outside forces (Fairburn, Shafran, et al., 1999). A study conducted by Josenfik and Pilecki (2010) showed that patterns among mothers can lead to eating disorders in their children, such as fear-avoidance attachment pattern, inability to take responsibility, lack of respect of opinions of other family members, lack of openness, limited emotions, and an inability to solve conflicts. They also found that autonomy and intimacy issues within a family often lead to eating disorders within adolescents (Josenfik & Pilecki, 2010).

Impact on Famlily

Eating disorders have a strong impact on the family. Family relationships can deteriorate quickly after the onset of an eating disorder, often leading to violence, feelings of guilt, and anguish. Eating disorders in families have been found to impact parents’ levels of distress, marital life, and perceived family functioning, even in foreign countries such as China (Ma, 2011). It is also important to note that eating disorders within a family affect more than just the parents, they also impact siblings. Siblings may feel a range of different emotions once a loved one has been diagnosed with an eating disorder. Often, they may experience grief, sadness, anger at the loss of a sibling relationship. They may also face feelings of neglect, isolation, and stress when their sibling is perceived to be prioritized or the cause of strife. It is important to keep siblings in mind and to remind them that their support is a key factor in treatment. The Eating Disorders Foundation of Victoria suggests ten tips for siblings

  1. Accept your sibling’s illness is not your fault.
  2. Educate yourself about the type of eating disorder you sibling has, in particular the behavioral changes they may experience.
  3. Know that your sibling is distressed and confused, but that they have not stopped caring about you.
  4. Realize that it is the eating disorder that makes your sibling moody.
  5. Talk to your friends, parents, and relatives about your feelings and fears.
  6. Try to continue normal sibling activities that you shared.
  7. Respect that it may be difficult for your sibling to talk about what they are experiencing.
  8. Enjoy time away from home.
  9. Consider seeking professional help for yourself to talk about your experiences and feelings.
  10. It is important to talk about what is going on, as eating disorder can affect all members of family in different ways.

Treatment of Eating Disorders

Drug Treatments

Currently, drug treatments have been found ineffective in the treatment of Anorexia Nervosa. There is evidence supporting the use of antidepressants in some cases of Bulimia Nervosa to reduce the frequency and occurrence of binge eating. In 1996, the Food and Drug Administration approved Prozac as effective for eating disorders. Although antidepressants may enhance the effects of psychological treatment somewhat, evidence suggests that antidepressant drugs alone do not have substantial long lasting effects on Bulimia (Wilson & Fairburn, 2002).

Individual Therapy

Short term Cognitive Behavior Therapy, lead by Fairburn (1985), seems to have the greatest prognosis when treating eating disorders, especially in the case of bulimia. This form of therapy targets the eating behavior and an individual’s associated attitudes regarding the importance of body weight and shape. In the first stage, the patient is taught the medical complications associated with eating disorders, as well as the ineffectiveness of vomiting and laxative abuse for weight control. They are then scheduled to eat small portions amounts of food five or six times per day. At this stage, the desired goal is to bring the patient to a healthy weight. In later stages of treatment, therapy focuses on altering abnormal thoughts and attitudes about body shape, weight, and eating. Coping strategies to increase ones sense of control while eating are also developed (Fairburn, Marcus, & Wilson, 1993). In the case of Anorexia Nervosa, focus is placed on weight gain, the patient’s anxiety levels, and dysfunctional attitudes about body shape in the first stage. Without this, the patient will almost always relapse. In addition, it is important to include the family during therapeutic sessions in order to accomplish two goals. First, negative and dysfunctional communication regarding food and eating must be eliminated. Second, attitudes toward body shape are discussed (Eisler, et al., 1997). Under these circumstances, Eisler and colleagues found that substantial benefits lasted for five years. Cognitive Behavior Therapy is the preferred psychological treatment for eating disorders, because it works quickly and the results last. Evidence also suggests that the combination of antidepressants and psychosocial treatments might boost the overall outcome, at least in the short term (Whittal et al., 1999).

A study by Shapiro, Bauer, and colleagues (2010) explored the use of technology in Cognitive Behavior Therapy in Bulimia Nervosa. In this study, patients used text messaging for self-monitoring and treatment delivery. It was hypothesized to increase the frequency of patient-provider contact, reach individuals who may not have access to specialty care, and result in better treatment acceptability in today’s technological society. Self monitoring is one hallmark feature of Cognitive Behavior Therapy for bulimia. Before, patients would keep a journal of their thoughts, feelings, and behaviors. They would then have to wait until their next appointment for feedback on their behaviors. Through text messaging, behaviors are recorded quickly and discretely and individuals are provided with immediate support and feedback. Each nights participants submitted a text message to the program indicating their number of: (1) binge eating episodes, (2) purging episodes, (3) peak urge to engage in binge, and (4) peak urge to engage in a purge. They then received an immediate feedback message. They also met in groups of 5-8 participants for 12 consecutive weeks. Treatment provided skills and techniques of Cognitive Behavioral Therapy treatment. Results indicated that patients found this form of communication to be highly convenient, flexible, and well tolerated. It also showed that patients adhered to self-monitoring 87% of the time, which is higher than many published self monitoring adherence rates. In addition, participants improved on self reported measures of binge eating and purging from baseline treatment, as well as improvements in depression.

Family Therapy

In one study, conducted by Isserlin and Couturier (2012), researchers investigated the effectiveness of the Therapeutic Alliance and Family Based Treatment on individuals with adolescents suffering from Anorexia Nervosa. This therapy focused of behavior, family systems, and structural family therapy. It enlisted parents as a resolution to the problem and emphasized blame reduction. This short term therapy consisted of three phases: The first focused on encouraging parents to take responsibility for changing their child’s abnormal eating behaviors into healthy ones. The second phase focuses on gradually returning the responsibility of eating and related behaviors to the adolescent. The final phase focuses on issues the adolescent faces as they relate to the eating disorder. The results of this study indicated importance in therapeutic alliances, including the family, in treating anorexia nervosa and yielded positive results.

Another study investigated the effectiveness of family workshops. The family day workshops were a structured intervention that involved working with two families over the course of three days. The primary aim of the workshop was for families to build an understanding of eating disorders and promote communication through the use of cognitive behavioral therapy (CBT). Day one focused on understanding the stress-appraisal coping method. Lazarus and Folkman’s (1984) coping paradigm conceptualized family appraisals about the impact of illness and the responsibilities of care giving. Day two focused on reducing criticism and hostility, and increasing warmth. Day three of the workshop involved improving communication and planning to change unhealthy target behaviors. The family workshops proved to be successful.


In the case of eating disorders, it is clear that urgent treatment is important. As discussed, there are severe medical and psychological complications associated with these disorders. Cognitive Behavior Therapy seems to be the best choice for treatment. It has shown strong, lasting results in a short time frame. Evidence does support the use of antidepressants in combination with this therapy; however, these drugs are often accompanied by a long list of serious complications, sometimes worse than what the drug is supposed to be treating. Dependence on drugs can become a serious problem. The use of developing technologies coupled with Cognitive Behavior Therapy has also shown promising results. Keeping a log of behaviors and having feedback within minutes can be a serious motivator for an individual suffering from an eating disorder. Unfortunately, this form of therapy may not receive positive feedback from older patients or from individuals who do not have access to these new technologies. Also, it seems impersonal to receive feedback via text message. More research regarding this form of therapy may yield even stronger results in time. Finally, including the family in therapeutic sessions is an important factor to keep in mind, especially for adolescents. The family is a strong bond that any individual should be able to rely on. As previously mentioned regarding causes of eating disorders, family relationships can quickly deteriorate after the onset of an eating disorder, often leading to violence, feelings of guilt, and anguish. It is important to keep the family involved, especially in treatment.


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