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Disorders of Eating: Anorexia Nervosa and Bulimia Nervosa

Anorexia Nervosa and Bulimia Nervosa

Understanding Anorexia Nervosa 

Throughout life, we all experience moments of concern about our body shape and weight at one point in our lives. But when these thoughts cause dangerous weight loss or dieting, it may be due to an eating disorder called anorexia nervosa. 

Anorexia nervosa is an eating disorder characterized by fear of weight gain. This fear drives people to restrict their eating, leading to dangerous weight loss or failure to make expected weight gain. 

Restrictive eating in anorexia nervosa can take many forms. It might involve skipping meals, eating smaller portion sizes, or eliminating snacks and specific foods from a person's diet. 

People with anorexia nervosa can present at any weight or shape. People in larger bodies and smaller bodies experience similar medical and psychological complications. 

Some people with anorexia may not explicitly state or even be aware that they are afraid to gain weight. On some occasions, people with anorexia will deny fear of weight gain and instead describe a preoccupation with eating healthy. However, when this pursuit leads to dangerous consequences and undermines their health, this is a characteristic of anorexia nervosa. 

The exact cause of anorexia nervosa is still unknown, but biological, psychological, and social factors increase the risk for the condition. Situations that lead to weight loss can also place people at risk. 

For example, anxiety, weight loss for any reason, medical conditions, or medications that interfere with appetite, low appetite, or fear of vomiting can put people at risk for anorexia nervosa. 

Many of the psychological and physical complications of anorexia are related to starvation. They may be difficult to notice because people with anorexia often disguise their thinness, eating habits, or physical problems. 

Associated symptoms may include depression, suicidal behavior, poor appetite, focus on pain or fatigue, preoccupation with food, and fear of weight gain. 

Anorexia nervosa is a serious, life-threatening condition that has one of the highest mortality rates of any mental illness. Anorexia affects every organ system in the body, including impairments in bone growth and heart problems. 

Depression is frequently a consequence of restrictive eating and weight loss. Notably, anorexia is associated with a very poor quality of life, with many deaths due to suicide. 

Anorexia is often difficult to diagnose, as many individuals will lack insight into the seriousness of their low weight. The fear of weight gain leads them to under-report their symptoms and attribute their weight loss to low appetite, abdominal pain, or other factors. 

Anorexia nervosa often goes undetected in people with higher weights, which commonly contributes to delays in their diagnosis. The good news is that anorexia is very treatable, particularly if caught early. 

The first and necessary goals are to restore eating and weight. Weight has to be fully restored to have a full recovery. For those in larger bodies, weight restoration may have to be higher than they want it to be in order to recover. 

Because of the fear of weight gain and lack of insight, people with anorexia need family support and assistance with meals to improve their eating and weight. If you have a loved one you're worried about, urge him or her to talk to a doctor. They are not alone, and treatment does help. 

Anorexia Nervosa and Irregular Menstrual Period

So how does anorexia nervosa affect your period? A large proportion of adult women and teenage girls with anorexia nervosa have irregular or absent periods. And the risk of having a loss of periods increases as body weight decreases. In conditions of energy deficit, the body needs to conserve energy for the more vital body functions.

So in conditions of energy deficit, the brain shuts down the reproductive axis and this manifests as a loss of periods. Now when body weight is low enough that the reproductive axis shuts down, leading to a loss of periods, fertility is impaired. And the extent to which fertility is impaired depends upon the extent of weight loss.

This will improves with weight regain and a resumption of menstrual periods. Women with anorexia nervosa and low body weight can conceive with the help of fertility-inducing drugs. However, it's highly recommended that these women get to a healthy weight before they conceive because of a very high risk of miscarriages, preterm births, and low birth weight infants in low weight women with anorexia nervosa.

We have many groundbreaking studies that have shown that estrogen deficiency leads to an impairment in cognitive status, an increase in anxiety scores, and scores of eating disorder, psychopathology, and all these measures improve with estrogen replacement. 

We now know that normal estrogen levels are very important for normal cognitive function, for reducing anxiety, and optimizing eating behaviors. These data very clearly indicate that weight regain and menstrual recovery should lead to an improvement in all these measures because of a normalization of estrogen levels.

One of the most profound consequences of anorexia nervosa is a decrease in bone density, a decrease in bone strength, and an increase in the risk of fracture. In teenage girls with anorexia nervosa, we do not see the increase in bone mass that typically occurs during the pubertal years. And this has very longstanding effects on bone health.

Among the factors that contribute to low bone density in anorexia nervosa are the decrease in body weight per se, the decrease in muscle mass that accompanies the decrease in body weight, and the hormonal consequences of low body weight.

The extent to which bone density recovers depends upon how quickly anorexia nervosa is diagnosed and treated. So the earlier the diagnosis, the earlier the treatment, the more complete is a recovery in bone density. However, if the diagnosis is delayed, or if the management is delayed, or if there are many relapses of low body weight after weight recovery, then the improvement in bone density tends to be less than optimal.

In addition to the reproductive, brain, and bone consequences of anorexia nervosa, there are also consequences with respect to the cardiovascular system and the gut. Unfortunately, we do not have as much data for men with anorexia nervosa as we do for women with anorexia nervosa. 

However, we do know that men with anorexia nervosa are also at a very high risk for low bone density and at an increased risk for fracture. Also for men, just as for women, it is very important that the diagnosis be made early and that the management be instituted early. 

So if you or a loved one has anorexia nervosa, there is hope. The best strategy we know of to reverse all these consequences that I've been talking about is weight recovery and menstrual resumption.

And the best way to achieve this is to have the diagnosis be made early and management to be implemented early. 

Some people think that vomiting can be a good way to get rid of calories after they've eaten, but actually the research shows that if you vomit, most of the calories that you eat during a binge are retained. 

Understanding Bulimia Nervosa.

Bulimia Nervosa has two hallmark features. The first one is binge eating and the second one is compensatory behaviors. 

Binge eating includes eating large amounts of food in a short period of time and feeling out of control. 

Compensatory behaviors can include purging and non-purging behaviors. Purging behaviors can include self-induced vomiting, taking laxatives or diuretics. Non-purging compensatory behaviors can include fasting or exercising really intensively.

Bulimia Nervosa is a very dangerous disorder and can even be fatal. Some of the major health consequences include dehydration, erosion of tooth enamel, swelling of the salivary glands, bleeding in the esophagus, and imbalances of body salts called electrolytes like potassium, sodium, and chloride. The electrolyte imbalances are probably the most worrisome physical health consequence of Bulimia Nervosa. 

Our bodies need these salts in order to have nerve impulses go through our body and contract our muscles, and our heart is an important muscle that needs these salts. And so unfortunately, when someone with Bulimia Nervosa has an electrolyte imbalance, it can cause them to have irregular heartbeat and even for their heart to stop beating. Probably the biggest impact on mental health of Bulimia Nervosa is low self-esteem. 

People without eating disorders typically evaluate themselves like whether they're a success or a failure based on a variety of different domains, almost like a diversified stock portfolio. They might base their self-esteem on how well they're doing in school or in their career or their relationships, how well they're doing at sports. People with eating disorders and in particular Bulimia Nervosa give an outsized level of importance to their shape and weight.

So in other words, even if they're succeeding in many areas of life, if that number on the scale changes and they feel that they've gained weight or their shape and weight isn't how they want it to be, that can ruin their whole day, make them feel like a failure, and push them further into the binging and purging cycle. 

A lot of people wonder what causes Bulimia Nervosa and that's actually an active area of research in our field. What we know more about right now is what drives the behaviors forward on a day-to-day basis. 

Individuals with Bulimia Nervosa tend to really base their self-esteem on their shape and weight and that leads them to try to use very rigid behaviors to try to diet and lose weight. So rather than just trying to eat healthy or trying to follow guidelines about eating more vegetables, they might cut out entire groups of food from their diet or try to adhere to a very strict calorie limit or have very rigid rules about not being able to eat at certain times of day or in certain places, for example. Now the problem with that is twofold.

If you're dieting very strictly, you might get really hungry and really want to eat a lot of food. Also you might start to feel psychologically deprived, which makes you then crave the foods that you're forbidding yourself. Both of those factors create a recipe for out-of-control binge eating. 

Then once individuals with Bulimia Nervosa have binged, they feel terrible about it. Remember this is occurring in the context of weight and shape feeling very important to them. So in order to counteract the effects of the binge episodes, they'll engage in those compensatory behaviors like vomiting or taking laxatives or diuretics or exercising or fasting. 

Once they've engaged in those behaviors though, unfortunately they aren't very effective at getting rid of the calories. So it causes the person with Bulimia Nervosa to want to redouble or triple their efforts at dieting to desperately gain back control over their eating, which only further fuels the cycle. We call this vicious cycle of dieting and binging and purging the cognitive behavioral model of Bulimia Nervosa.

Facts and Misconceptions about Bulimia Nervosa 

Let's talk about some misconceptions about Bulimia Nervosa. One misconception is that purging keeps you thin. Unfortunately this is wrong for two reasons.

The first reason is that there's actually been research where colleagues have invited individuals with Bulimia Nervosa to come into the laboratory and binge and purge either by vomiting or taking laxatives in the way that they normally would. 

Then the researchers measured how many calories actually came out from purging and what they tended to find is that many calories, in some cases the majority of calories, were actually retained in the digestive tract even though those individuals had engaged in purging. 

Another misconception is that just using your willpower and dieting more is the best way to get out and escape the Bulimia Nervosa cycle.

Nothing could be further from the truth. It's actually that rigid and strict dieting that keeps you locked into the cycle. Remember the dieting makes you feel hungry and it makes you feel psychologically deprived and that creates the perfect recipe for engaging and binge eating and purging. 

Another misconception is that treatment takes a really long time. A lot of the research-backed treatments for Bulimia Nervosa are quite brief, ranging from just 10 to 20 sessions. At least half of people tend to get better from those types of brief treatments. 

For other individuals they might need additional care like partial hospital, residential, or inpatient treatment. The leading evidence-based treatments for Bulimia Nervosa are psychotherapy and medication. 

For psychotherapy there are a number of different types that have been studied but the two most commonly used and first-line treatments are family-based treatment for children and adolescents and cognitive behavioral therapy for older adolescents and adults.

Closing Thought 

Bulimia Nervosa is a very serious disorder and can even be fatal. That said, treatment works and the majority of people will go on to fully recover. Thanks for joining Lafiyata today. 


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