Currently recognized in medical manualsSpecified as mental disorders in standard medical manuals, such as the ICD-10* or the DSM-IV.*
Not currently recognized in standard medical manuals
CausesThere are many causes of eating disorders, including biological, psychological and/or environmental abnormalities. Many people with eating disorders suffer also from body dysmorphic disorder, altering the way a person sees himself or herself. There are also many other possibilities such as environmental, social and interpersonal issues that could promote and sustain these illnesses.* Also, the media are oftentimes blamed for the rise in the incidence of eating disorders due to the fact that media images of idealized slim physical shape of people such as models and celebrities motivate or even force people to attempt to achieve slimness themselves. The media are accused of distorting reality, in the sense that people portrayed in the media are either naturally thin and thus unrepresentative of normality or unnaturally thin by forcing their bodies to look like the ideal image by putting excessive pressure on themselves to look a certain way.*
Cognitive Attentional bias issuesAttentional bias may have an effect on eating disorders. Many studies have been performed to test this theory. (Shafran, Lee, Cooper, Palmer & Fairburn (2007), Veenstra and de Jong (2012) and Smeets, Jansen, & Roefs (2005)).
Personality traitsThere are various childhood personality traits associated with the development of eating disorders.* During adolescence these traits may become intensified due to a variety of physiological and cultural influences such as the hormonal changes associated with puberty, stress related to the approaching demands of maturity and socio-cultural influences and perceived expectations, especially in areas that concern body image. Many personality traits have a genetic component and are highly heritable. Maladaptive levels of certain traits may be acquired as a result of anoxic or traumatic brain injury, neurodegenerative diseases such as Parkinson's disease, neurotoxicity such as lead exposure, bacterial infection such as Lyme disease or viral infection such as Toxoplasma gondii as well as hormonal influences. While studies are still continuing via the use of various imaging techniques such as fMRI; these traits have been shown to originate in various regions of the brain* such as the amygdala* and the prefrontal cortex* Disorders in the prefrontal cortex and the executive functioning system have been shown to affect eating behavior.*
Child maltreatmentChild abuse which encompasses physical, psychological and sexual abuse, as well as neglect has been shown by innumerable studies to be a precipitating factor in a wide variety of psychiatric disorders, including eating disorders. Children who are subjected to abuse may develop eating disorders in an effort to gain some sense of control or for a sense of comfort, or they may be in an environment where the diet is unhealthy or insufficient. Child abuse and neglect can cause profound changes in both the physiological structure and the neurochemistry of the developing brain. Children who, as ward (law)|wards of the state, were placed in orphanages or foster homes are especially susceptible to developing a disordered eating pattern. In a study done in New Zealand 25% of the study subjects in foster care exhibited an eating disorder (Tarren-Sweeney M. 2006). An unstable home environment is detrimental to the emotional well-being of children, even in the absence of blatant abuse or neglect the chronic stress|stress of an unstable home can contribute to the development of an eating disorder.*
Social isolationSocial isolation has been shown to have a deleterious effect on an individual's physical and emotional well-being. Those that are socially isolated have a higher mortality rate in general as compared to individuals that have established social relationships. This effect on mortality is markedly increased in those with pre-existing medical or psychiatric conditions, and has been especially noted in cases of coronary heart disease. "The magnitude of risk associated with social isolation is comparable with that of cigarette smoking and other major biomedical and psychosocial risk factors." (Brummett et al.)
Social isolation can be inherently stressful, depressing and anxiety-provoking. In an attempt to ameliorate these distressful feelings an individual may engage in emotional eating in which food serves as a source of comfort. The loneliness of social isolation and the inherent stressors thus associated have been implicated as triggering factors in binge eating as well.*Waller, Kennerley and Ohanian (2007) argued that both bingeing–vomiting and restriction are emotion suppression strategies, but they are just utilized at different times. For example, restriction is used to pre-empt any emotion activation, while bingeing– vomiting is used after an emotion has been activated.*
Parental influenceParental influence has been shown to be an intrinsic component in the development of eating behaviors of children. This influence is manifested and shaped by a variety of diverse factors such as familial genetic predisposition, dietary choices as dictated by cultural or ethnic preferences, the parents' own body shape and eating patterns, the degree of involvement and expectations of their children's eating behavior as well as the interpersonal relationship of parent and child. This is in addition to the general psychosocial climate of the home and the presence or absence of a nurturing stable environment. It has been shown that maladaptive parental behavior has an important role in the development of eating disorders. As to the more subtle aspects of parental influence, it has been shown that eating patterns are established in early childhood and that children should be allowed to decide when their appetite is satisfied as early as the age of two. A direct link has been shown between obesity and parental pressure to eat more.
Coercive tactics in regard to diet have not been proven to be efficacious in controlling a child's eating behavior. Affection and attention have been shown to affect the degree of a child's finickiness and their acceptance of a more varied diet.*
Peer pressureIn various studies such as one conducted by William L. McKnight|The McKnight Investigators, peer pressure was shown to be a significant contributor to body image concerns and attitudes toward eating among subjects in their teens and early twenties.
Eleanor Mackey and co-author, Annette M. La Greca of the University of Miami, studied 236 teen girls from public high schools in southeast Florida. "Teen girls' concerns about their own weight, about how they appear to others and their perceptions that their peers want them to be thin are significantly related to weight-control behavior," says psychologist Eleanor Mackey of the Children's National Medical Center in Washington and lead author of the study. "Those are really important."
According to one study, 40% of 9- and 10-year-old girls are already trying to lose weight.* Such dieting is reported to being influenced by peer behavior, with many of those individuals on a diet reporting that their friends also were dieting. The number of friends dieting and the number of friends who pressured them to diet also played a significant role in their own choices.*Elite athletes have a significantly higher rate in eating disorders. Female athletes in sports such as gymnastics, ballet, diving, etc. are found to be at the highest risk among all athletes. Women are more likely than men to acquire an eating disorder between the ages of 13-30. 0-15% of those with bulimia and anorexia are men.
Cultural pressureThere is a cultural emphasis on thinness which is especially pervasive in western society. There is an unrealistic stereotype of what constitutes beauty and the ideal body type as portrayed by the media, fashion and entertainment industries. "The cultural pressure on men and women to be "[perfect]" is an important predisposing factor for the development of eating disorders" (Prof. Bryan Lask).* Further, when women of all races base their evaluation of their self upon what is considered the culturally ideal body, the incidence of eating disorders increases.* Eating disorders are becoming more prevalent in non Western countries where thinness is not seen as the ideal, showing that social and cultural pressures are not the only causes of eating disorders.* For example, observations of anorexia in all of the non-Western regions of the world point to the disorder not being “culture-bound” as once thought.* However, studies on rates of bulimia suggest that it might be culturally bound. In non-Western countries, bulimia is less prevalent than anorexia, but these non-Western countries where it is observed can be said to have probably or definitely been influenced or exposed to Western culture and ideology.*Socioeconomic status has been viewed as a risk factor for eating disorders, presuming that possessing more resources allows for an individual to actively choose to diet and reduce body weight.* Some studies have also shown a relationship between increasing body dissatisfaction with increasing socioeconomic status.* However, once high SES has been achieved, this relationship weakens and, in some cases, no longer exists.*
Pressure from society is also seen within the homosexual community. Homosexual men are at greater risk of eating disorder symptoms than heterosexual men.* Within the gay culture, muscularity gives the advantages of both social and sexual desirability and also power.* These pressures and ideas that another homosexual male may desire a mate who is thinner or muscular can possibly lead to eating disorders. The higher eating disorder symptom score reported, the more concern about how others perceive them and the more frequent and excessive exercise sessions occur.* High levels of body dissatisfaction are also linked to external motivation to working out and old age; however, having a thin and muscular body occurs within younger homosexual males than older.*
It is important to realize some of the limitations and challenges of many studies that try to examine the roles of culture, ethnicity, and SES. For starters, most of the cross-cultural studies use definitions from the DSM-IV-TR, which has been criticized as reflecting a Western cultural bias. Thus, assessments and questionnaires may not be constructed to detect some of the cultural differences associated with different disorders. Also, when looking at individuals in areas potentially influenced by Western culture, few studies have attempted to measure how much an individual has adopted the mainstream culture or retained the traditional cultural values of the area. Lastly, the majority of the cross-cultural studies on eating disorders and body image disturbances occurred in Western nations and not in the countries or regions being examined.*While there are many influences to how an individual processes their body image, the media does play a major role. Along with the media, parental influence, peer influence, and self-efficacy beliefs also play a large role in an individual's view of themselves. The way the media presents images can have a lasting effect on an individual's perception of their body image. Eating disorders are a worldwide issue and while women are more likely to be affected by an eating disorder it still affects both genders (Schwitzer 2012). The media has an impact on eating disorders whether shown in a positive or negative light, it then has a responsibility to use caution when promoting images that projects an ideal that many turn to eating disorders to attain.*
Symptoms-complicationsSymptoms and complications (medical)|complications vary according to the nature and severity of the eating disorder:*
Some physical symptoms of eating disorders are weakness, fatigue, sensitivity to cold, reduced beard growth in men, reduction in waking erections, reduced libido, weight loss and failure of growth.* Unexplained hoarseness may be a symptom of an underlyingeating disorder, as the result of acid reflux, or entry of acidic gastric material into the laryngoesophageal tract. Patients who induce vomiting, such as those with anorexia nervosa, binge eating-purging type or those with purging-type bulimia nervosa are at risk for acid reflux.* Polycystic ovary syndrome (PCOS) is the most common endocrine disorder to affect women. Though often associated with obesity it can occur in normal weight individuals. PCOS has been associated with binge eating and bulimic behavior.*
Pro-Ana SubcultureSeveral websites promote eating disorders, and can provide a means for individuals to communicate in order to maintain eating disorders. Members of these websites typically feel that their eating disorder is the only aspect of a chaotic life that they can control.* These websites are often interactive and have discussion boards where individuals can share strategies, ideas, and experiences, such as diet and exercise plans that to achieve extremely low weights.* A study comparing the personal weblogs that were pro-eating disorder with those focused on recovery found that the pro-eating disorder blogs contained language reflecting lower cognitive processing, used a more closed-minded writing style, contained less emotional expression and fewer social references, and focused more on eating-related contents than did the recovery blogs.*
In menTo date, the evidence suggests that the gender bias of clinicians means that diagnosing either bulimia or anorexia in men is less likely despite identical behavior. Men are more likely to be diagnosed as suffering depression with associated appetite changes than receive a primary diagnosis of an eating disorder. Using examples from a Canadian context below, it is possible to engage with some of the more nuanced issues facing men suffering from disordered eating.
Until recently, eating disorders have been characterized as an almost exclusively female problem (Maine and Bunnell 2008). The majority of early academic scholarship during the early 1990s tended to dismiss the prevalence in men as largely, if not entirely, irrelevant when compared to that in women (Weltzin et al. 2005.). Only recently have sociologists and feminist thinkers expanded the scope of eating disorders to identify with the unique challenges facing male sufferers.
Eating disorders are the third most common chronic illness in adolescent boys (NEDIC, 2006). Using currently available data, it is estimated that 3% of men will be affected by eating disorders in their lifetime (Public Health Agency of Canada, 2002). Eating disorder rates are not only increasing among females but also males are more concerned with their body image than ever before. The Public Health Agency of Canada (2002) found that almost one in every two girls and almost one in every five boys of grade 10 either were on a diet or wanted to lose weight. Since 1987, hospitalizations for eating disorders in general hospitals have increased by 34% among young men under the age of 15 and by 29% among men between 15–24 years old (Public Health Agency of Canada, 2002). Across Canada, age-standardized hospital separation rates for eating disorders were highest among men in British Columbia (15.9 per 100,000) and New Brunswick (15.1 per 100,000) and lowest in Saskatchewan (8.6) and Alberta (8.6 per 100,000) (Public Health Agency of Canada, 2002).
Part of the challenge with addressing the prevalence of eating disorders in men is a lack of research and statistics that are both current and appropriate. Recent work, such as that by Schoen and Greenberg (Greenberg & Schoen, 2008) suggests that the same prevailing social factors which led to a rise in eating disorders amongst women in the late 1980s may have also clouded public perceptions of similar male vulnerabilities. As a result, male eating disorders and prevalence have been under-reported and misdiagnosed. Specifically, attention has recently been drawn to the gendered nature of diagnosis and dissimilar methods of presentation in men; diagnostic criteria focusing on weight loss, fear of fat and physical symptoms such as amenorrhea are cannot be applied to male sufferers, many of whom exercise excessively, are concerned with muscularity and definition rather than absolute weight loss and rebel against terms such as ‘fear of fat', which they view as disempowering and effeminising (Derenne & Beresin, 2006). As a result of these earlier attempts to express eating disorders amongst men using the language and concepts of non-comparable disorders amongst women, there is a substantial lack of data on prevalence, incidence and burden of disease for men, with much of what is available difficult to evaluate, poorly reported or simple incorrect.
The message that there is no ideal size, shape or weight that every individual should strive to achieve is still largely targeted at women, and those campaigns which include men still prominently feature gendered iconography (such as the ribbon), further raising the barrier to access for male sufferers (Maine & Bunnell, 2008). Male body image is not as homogenous in the media (that is, there range for ‘acceptable' male physiques is wider), but instead focuses on perceived or projected masculinity (Gaughen, 2004, 7 and Maine & Bunnell, 2008). More pressingly, there is no consensus in the literature regarding unique risk factors as they relate to gay or bisexual men; the US center for Population Research in LGBT health estimates prevalence in the LGBT community to be about twice the national average for women and approximately 3.5 times higher for men. At the same time, a similar research study (Feldman & Meyer, 2007) fails to establish an explanatory framework to address these findings, and a subsequent study (Hatzenbuehler et al., 2009) suggests that membership in the LGBT community offers some protection against psychiatric morbidity, including that from eating disorders. As mentioned above, a distinct lack of research is continues to present a barrier to drawing a broad conclusion on this topic.
Existing treatment for men with eating disorders occurs in a similar environment as that for women. Men living in isolated, rural or small communities who are experiencing violence that sometimes lead to eating disorders face barriers accessing the treatment, as well as additional stigma due to suffering from a ‘feminine' disease (Public Health Agency of Canada, 2002). The Public Health Agency of Canada (2011 report) also states that integrated treatment approaches to family violence and eating disorders are likely to become increasingly scarce as the resources required to ensure accessibility to services, appropriate medical care, sufficient staffing, shelters and transition houses and counseling for underlying abuse issues are no longer available. Many cases in Canada are referred to USA for the treatments due to the lack of appropriate services offered (Vitiello & Lederhendler 2000). For example, in one case, a patient suffering from anorexia nervosa, originally admitted to The Hospital For Sick Children in Toronto was later recommended for a transfer to a facility in Arizona (Jones, 2007). In 2006, the province of Ontario alone sent 45 patients (36 of them male) to the US for eating disorder treatment at a gross cost of $ 3,719,440 (Jones, 2007), a decision motivated by the lack of specialized facilities domestically.
Speaking from the feminist relational position, Maine and Bunnell (2008) suggest a unique approach towards managing eating disorders in men. They advocate for counseling that focuses on how patients respond to pressures and expectations rather than on addressing the individual pathology of disordered eating. Current treatments in this vein show some success (Public Health Agency of Canada, 2011), but lack patient-based review and feedback. Monitoring of physical symptoms, behavioral therapy, cognitive therapy, body image therapy, nutritional counseling, education and medication if necessary are currently available in some form, yet all of these programs are delivered regardless of patient gender (Public Health Agency, 2002 and Maine & Bunnell, 2008). Up to twenty percent of patients with eating disorders eventually die of their illness, and another fifteen percent resort to suicide. With access to treatment, 75 to 80% of female adolescents recover, yet less than half of males do (Macleans, 2005). Moreover, there are several limitations in the collection of data, as most studies are based on clinical samples, which make it hard to tell about the findings to general population. People with eating disorders require a broad range of treatment for both physical complications and psychological issues, at a cost of about $ 1 600 per day (Timothy & Cameron, 2005, 100). Treatment for patients who were diagnosed following a hospitalization resulting from their condition is both more expensive (approximately three times more), and also less successful, with a corresponding drop of over twenty percent in women and forty percent in men (Macleans, 2005).
Here are many societal, familial and individual factors that can influence the development of an eating disorder. Individuals who are struggling with their identity and self-image can be at risk, as well as those who have experienced a traumatic event (A Report on Mental Illness in Canada, 2002). In addition, many sufferers of eating disorders report feeling powerless about their socioeconomic environment, and view dieting, exercise and purging as empowering means of controlling their lives. The conventional approach (Trebay, 2008 and Derenne & Beresin, 2006) to understanding the root causes of disordered eating focuses on the role of media and sociocultural pressures; an emphasis on thinness (for women) and muscularity (for men) often goes beyond simple body image. There is an implicit media message that not only are those with ‘ideal' bodies can be more confident, successful, healthy and happy but that slimness is associated with positive character qualities, such as reliability, trustworthiness and honesty (Harvey & Robinson, 2003).The traditional understanding of eating disorders reflects a media construct where thin and attractive people are not only the most successful and desirable members of the community, but rather they are the only members of the community who can be attractive and desirable.
In such a view, society is focused on appearance; body image becomes central to young people's feelings of self-esteem and self-worth — overshadowing qualities and achievements in other aspects of their lives (Maine & Bunnell, 2008). Teenagers may associate success or acceptance by their peers with achieving the ‘perfect' physical standard portrayed by the media. As a result, during the period where children and teenagers become increasingly more exposed to prevailing cultural norms, both males and females are at risk of developing skewed conceptions of self and their bodies (Andersen & Homan, 1997). When the desired goals are not met of achieving the ideal body image, they might experience feelings of failure that contribute to further drop in self-esteem, confidence, and an increase in body image dissatisfaction. Some also suffer psychological and physical costs such as feelings of shame, failure, deprivation, and yo-yo dieting (Maine & Bunnell, 2008). Eating disorders may cause individuals to feel tired and depressed, decreased mental functioning and concentration, and can lead to malnutrition with risk to bone health, physical growth, and brain development. There are also increased risks of osteoporosis and fertility problems, weakened immune system, heart rate, blood pressure and metabolic rate is also decreased (NEDIC, 2006). Additionally, sufferers from eating disorders show the third highest susceptibility for self-abuse and suicide, with rates 13.6 and 9.8 times higher than the Canadian average, respectively (Löwe et al., 2001).
PsychopathologyThe psychopathology of eating disorders centers around body image disturbance, such as concerns with weight and shape; self-worth being too dependent on weight and shape; fear of gaining weight even when underweight; denial of how severe the symptoms are and a distortion in the way the body is experienced *
DiagnosisThe initial diagnosis should be made by a competent medical professional. "The medical history is the most powerful tool for diagnosing eating disorders"(American Family Physician).* There are many medical disorders that mimic eating disorders and comorbid psychiatric disorders. All organic causes should be ruled out prior to a diagnosis of an eating disorder or any other psychiatric disorder is made. In the past 30 years eating disorders have become increasingly conspicuous and it is uncertain whether the changes in presentation reflect a true increase. Anorexia nervosa and bulimia nervosa are the most clearly defined subgroups of a wider range of eating disorders. Many patients present with subthreshold expressions of the two main diagnoses: others with different patterns and symptoms.*
MedicalThe diagnostic workup typically includes complete medical and psychosocial history and follows a rational and formulaic approach to the diagnosis. Neuroimaging using fMRI, MRI, positron emission tomography|PET and SPECT scans have been used to detect cases in which a lesion, tumor or other organic condition has been either the sole causative or contributory factor in an eating disorder. "Right frontal intracerebral lesions with their close relationship to the limbic system could be causative for eating disorders, we therefore recommend performing a cranial MRI in all patients with suspected eating disorders" (Trummer M et al. 2002), "intracranial pathology should also be considered however certain is the diagnosis of early-onset anorexia nervosa. Second, neuroimaging plays an important part in diagnosing early-onset anorexia nervosa, both from a clinical and a research prospective".(O'Brien et al. 2001).*
PsychologicalAfter ruling out organic causes and the initial diagnosis of an eating disorder being made by a medical professional, a trained mental health professional aids in the assessment and treatment of the underlying psychological components of the eating disorder and any comorbid psychological conditions. The clinician conducts a clinical interview and may employ various psychometric tests. Some are general in nature while others were devised specifically for use in the assessment of eating disorders. Some of the general tests that may be used are the Hamilton Depression Rating Scale* and the Beck Depression Inventory.* longitudinal research showed that there is an increase in chance that a young adult female would develop bulimia due to their current psychological pressure and as the person ages and matures, their emotional problems change or are resolved and then the symptoms decline.*
Diagnostic and statistical manualThe most obvious concern in the DSM-IV is the criteria for anorexia nervosa (AN) and bulimia nervosa (BN), and how most patients in a clinical setting do not meet the full criteria for either one of the two main types of eating disorders. Instead, these clients are classified under eating disorder not otherwise specified (EDNOS).* In order to resolve this issue, the DSM-5 is making the proposed changes:
Differential diagnosesThere are multiple medical conditions which may be misdiagnosed as a primary psychiatric disorder, complicating or delaying treatment. These may have a synergistic effect on conditions which mimic an eating disorder or on a properly diagnosed eating disorder.
Psychological disorders which may be confused with an eating disorder, or be co-morbid with one:
PreventionPrevention aims to promote a healthy development before the occurrence of eating disorders. It also intends early identification of an eating disorder before it is too late to treat. Children as young as ages 5–7 are aware of the cultural messages regarding body image and dieting. Prevention comes in bringing these issues to the light. The following topics can be discussed with young children (as well as tweens and young adults).
TreatmentTreatment varies according to type and severity of eating disorder, and usually more than one treatment option is utilized.* However, there is lack of good evidence about treatment and management, which means that current views about treatment are based mainly on clinical experience. Therefore, before treatment takes place, family doctors will play an important role in early treatment as patients suffering from eating disorders will be reluctant to see a psychiatrist and a lot will depend on trying to establish a good relationship with the patient and family in primary care.* That said, some of the treatment methods are:
There are few studies on the cost-effectiveness of the various treatments.* Treatment can be expensive;* due to limitations in health care coverage, patients hospitalized with anorexia nervosa may be discharged while still underweight, resulting in relapse and rehospitalization.*