Eating Disorders

 

From The Harvard Mental Health Letter Internet Site

Part 1

The conflicting feelings about food and eating that trouble so many young women take an especially demoralising and debilitating form in the eating disorders, anorexia and bulimia. Anorexia nervosa (its Greek and Latin roots mean "lack of appetite of nervous origin") usually appears in early or middle adolescence. A girl or young woman begins to starve herself and sometimes exercise compulsively as well. Her weight falls and her health deteriorates, but she persists in denying that her behaviour is abnormal or dangerous. She may say she feels or looks fat, although everyone else can see that she is gaunt. To conceal her weight loss from parents and others, she may wear baggy clothes or secretly pocket and discard food instead of eating it. Despite her refusal to eat (and despite the misleading term "anorexia"), her appetite is usually normal, at least at first. Her reasons for rejecting food are a mystery that researchers are still trying to solve.

According to the current diagnostic manual of the American Psychiatric Association (DSM-IV), a woman is suffering from clinical anorexia, not just dieting or fasting, when her weight has fallen to 15% below the normal range and she has not menstruated for at least three months. Sometimes the diagnosis is made because of drowsiness and lethargy that are affecting her schoolwork. Other symptoms are dry skin, brittle nails and hair, lanugo (fine downy hair on the limbs), constipation, anaemia, and swollen joints. The level of female hormones in the blood of an anorectic woman falls drastically, and her sexual development may be delayed. Her heart rate and blood pressure can become dangerously low, and loss of potassium in the blood may cause irregular heart rhythms. Over a 10-year period, about 5% of women diagnosed as anorectic die, mainly from infections or cardiac failure. Other serious long-term dangers are osteoporosis and kidney damage.

Bulimia

Bulimia nervosa ("oxlike hunger of nervous origin") is defined as two or more episodes of binge eating (rapid consumption of a large amount of food, up to 5,000 calories) every week for at least three months. The binges are sometimes followed by vomiting or purging (use of laxatives or diuretics) and may alternate with compulsive exercise and fasting. The symptoms can develop at any age from early adolescence to 40, but usually become clinically serious in late adolescence.

Bulimia is not as dangerous to health as anorexia, but it has many unpleasant physical effects, including fatigue, weakness, constipation, fluid retention (bloating), swollen salivary glands, erosion of dental enamel, sore throat from vomiting, and scars on the hand from inducing vomiting. Overuse of laxatives can cause stomach upset and other digestive troubles. Other dangers are dehydration, loss of potassium, and tearing of the oesophagus. Women with diabetes, who have a high rate of bulimia, often lose weight after an eating binge by reducing their dose of insulin. According to recent research, this practice damages eye tissue and raises the risk of diabetic retinopathy, which can lead to blindness.

Many anorectic women also indulge in occasional eating binges, and half of them make the transition to bulimia. About 40% of the most severely bulimic patients have a history of anorexia. It is not clear whether the combination of anorexia with bingeing and purging is more debilitating, physically or emotionally, than anorexia alone (which is also called restricting anorexia). According to some research, anorectic women who binge and purge are less stable emotionally and more likely to commit suicide. But one recent study suggests that, on the contrary, they are more likely to recover.

The prevalence of eating disorders

Anorexia is rare compared to most other serious psychiatric disorders. Its prevalence in the United States is 0.1% to 0.6% in the general population and several times higher in adolescent girls. Ninety percent of the sufferers are women (there is some evidence that homosexuality and concerns about sexual identity are common among the few boys and men with anorexia). Bulimia is at least two or three times as common. A survey based on interviews with more than 2,000 people in the early 1990s found a prevalence of 1% in the general population and 4% among women aged 18 to 30. As many as 10% of women may suffer from bulimia at some time in their lives. In a questionnaire answered by 2,000 college women in 1986, nearly 5% reported a current eating disorder and 4% admitted symptoms of bulimia.

Some believe that eating disorders are becoming more common, but the evidence from systematic surveys is inconclusive. What is clear is that fewer cases are going undiagnosed. One reason is that the average age of puberty in American women has retreated three or four years during this century, probably because of better nutrition and less infectious disease. That means a girl is more likely to develop anorexia while she is still living with her parents, and the disorder is more likely to be noticed and acknowledged as the serious problem it is. Bulimia was not even recognised as a distinct psychiatric disorder until the 1970s, and it did not appear in the diagnostic manual of the American Psychiatric Association until 1980.

As social critics like to point out, drawing a line between eating disorders and the consequences of "normal," socially approved dieting is not easy. Many women have symptoms that resemble anorexia or bulimia in milder forms -- they may be losing too much weight but still menstruating, or binge eating without vomiting or using laxatives, or bingeing less often than twice a week. According to one estimate, more than two-thirds of college women indulge in an eating binge once a year, 40% at least once a month, and 20% once a week. As many as 4% of all adults (60% of them women) and 30% of the seriously overweight are thought to be binge eaters. Binge eating without attempts to compensate by vomiting or using laxatives is one of the conditions included in the current APA diagnostic manual under the label "eating disorders not otherwise specified."

Genetic influence

Like most psychiatric disorders, anorexia and bulimia run in families. The rate of anorexia among mothers and sisters of anorectic women is 2% to 10%. In one study, researchers found that 20% of anorectic patients but only 6% of people with other psychiatric disorders had a family member with an eating disorder. Several twin studies suggest that this family susceptibility is largely hereditary. In one comparison, anorexia was found in 9 of 16 identical twins of anorectic patients but only 1 of 14 fraternal twins. In another study, researchers found that when one of a pair of identical twins had bulimia, the chance that the other would also have it was 23% -- eight times higher than the rate in the general population. For fraternal twins, the rate was 9%, or three times higher than average. The authors calculate a heritability (the genetically determined proportion of individual differences in susceptibility) of 55%.

One cause of eating disorders could be abnormalities in the activity of hormones and neurotransmitters that preserve the balance between energy output and food intake. This regulation is a complex process involving several regions of the brain and several body systems. Nerve pathways descending from the hypothalamus, at the base of the brain, control levels of sex hormones, thyroid hormones, and the adrenal hormone cortisol, all of which influence appetite, body weight, mood, and responses to stress. The neurotransmitters serotonin and norepinephrine are found in these hypothalamic pathways. Serotonin activity is low in starving anorectic patients but higher than average when their weight returns to normal. According to some reports, bulimic patients respond weakly to serotonin and to cholecystokinin, a hormone that induces fullness. Their response improves when they take antidepressant drugs that enhance the effects of serotonin.

Another speculation is that eating disorders are influenced by enkephalins and endorphins, the opiate-like substances produced in the body. Some studies have found that the spinal fluid of anorectic patients contains high levels of these endogenous opioids, and some of the patients gain weight when given naloxone, which inhibits opioid activity. It is interesting that the German word for anorexia is Puberttsmagersucht, pubertal addiction to thinness.

An unusual, not widely accepted but interesting theory is that in some cases anorexia results from excessive physical activity. Evidence for this theory comes from experiments in which rats are allowed to exercise on a wheel at will but fed only a single daily meal (adequate for survival) and given only a brief time to eat it. When put on this regime, they start to run more and more and eat less and less. Eventually they may die of starvation. According to the theory, these conditions are equivalent to self-imposed diet and exercise regimens. Normally people eat more when physical activity rises. But if food intake is restricted at the same time, a self-perpetuating cycle may develop in which restricted food intake heightens the urge to move, and constantly increasing exercise depresses interest in eating.

Psychology of eating disorders

In the vast psychological and sociological literature on eating disorders, a wide variety of influences has been suggested, from peer pressure to sexual anxieties. One common theme is starvation as a form of self-punishment with the unacknowledged purpose of pleasing an introjected (internalised) parent who is seen as needing to impose harsh restrictions. Most anorectic women -- before, during, and after the illness -- are serious, well behaved, orderly, perfectionist, hypersensitive to rejection, and inclined to irrational guilt and obsessive worry. Anorexia has been described as one way a girl with this kind of personality may respond to the prospect of adult sexuality and independence. She wants to be strong and successful, but is afraid of asserting herself and separating from her family. Being a good girl and pleasing her parents and teachers no longer sustain her. She is unable to acknowledge her sexual desires and may regard her developing woman's body as an alien invasion. Her fear of adult femininity may also be a fear of becoming like her mother. According to this theory, fasting restores a sense of order to her life by allowing her to exert control over herself and others. She is proud of her ability to lose weight, and self-imposed rules about food are a substitute for genuine independence.

Some students of anorexia believe that these girls starve themselves to suppress or control feelings of emotional emptiness. They struggle for perfection to prove that they need not depend on others to tell them who they are and what they are worth. According to some psychodynamic theories, a young woman has come to this desperate pass because her parents have never responded adequately to her initiatives or recognised her individuality. Now that she is an adolescent, they are implicitly making conflicting demands: show your capacity for adult independence, but do not separate yourself from the family. According to this theory, the anorectic girl has trouble distinguishing her own wants from those of other people, and she fears abandonment if she takes any action on her own. Denying her needs is the only way she knows how to show that she will not permit anyone else to control her. She will not allow outside influences, including food, to invade her.

Since women with anorexia are usually living with their parents when the symptoms develop, psychotherapists have often found it helpful to work with the whole family. The resulting discoveries and speculations are an important source of family systems theory, in which the family is conceived as a social unit with internal structures and processes that have a life of their own. Psychiatric disorders are regarded as defences that compensate for disturbances and preserve family stability in a way analogous to the preservation of individual stability by neurotic symptoms in psychodynamic theory. Family systems theorists speak of family rules, roles, rituals, and myths; they analyse the distribution of power within a family and the workings of subsystems of various combinations of parents and children. According to the theory, families with inflexible self-regulating mechanisms often produce psychopathology in one member, the person with obvious psychiatric symptoms, who is sometimes called the "identified patient."

A daughter who refuses to eat may be seen as trying to keep the family together by providing an object of common concern for parents who would otherwise be drifting apart. Or she may be trying to restore the balance of the family by siding with one parent in a conflict with the other. Families with anorectic daughters are often said to be smothering or "enmeshed." The responsibilities of each person and the boundaries between them are indistinct. Everyone in the household is said to be over-responsive to and overprotective of everyone else. Conventional social roles are maintained, but individual needs are not met, feelings are not honestly acknowledged, and conflicts are not openly resolved. When the daughter reaches puberty, her parents are reluctant to make necessary changes in the family rules and roles. In this view, anorexia is a symptom of a rigid family system's need and inability to adapt to a new stage of development.

Bulimia has been recognised for a much shorter time than anorexia, and there is less research on its origins. One theory is that bulimic women lack all the parental affection and involvement they need and soothe themselves with food as compensation. The overeating subdues feelings of which they are barely conscious, at the price of later shame and self-hatred. One recent study found that bulimic women differed from depressed and anxious women in several ways. They were more likely to be overweight, to have overweight parents, and to have begun menstruating early. They were also more likely to say that their parents had high expectations for them but limited contact with them. The parents themselves were not interviewed.

In some families of women with anorexia and bulimia, the problem may be more serious than rigidity, overprotectiveness, or inadequate nurturing. Child sexual abuse, an increasingly common explanation for psychiatric symptoms in women, has naturally been proposed as a cause of eating disorders. The connection has not been confirmed, and some recent studies raise serious doubts about it. Women with anorexia and bulimia do not report more sexual abuse than anxious and depressed women in general.

Related physical disorders

Like most psychiatric patients, women with eating disorders often have more than one diagnosis. The rate of alcoholism in bulimic women and their parents may be somewhat higher than average, although the evidence is disputed. Bulimia has also been associated with personality disorders, especially borderline personality. In a recent Swedish study, researchers found that one-third of anorectic women had what the researchers interpreted as mild autistic symptoms as well as personality disorders of the avoidant, dependent, or obsessive type.

The symptoms of eating disorders overlap with depression, and some of the hormonal and neurotransmitter disturbances are also similar. According to one estimate, women suffering from major depression have twice the average lifetime rate of bulimia and eight times the average rate of anorexia. Some 40% of anorectic patients have been or are seriously depressed, and identical twins of anorectic women also have a high rate of depression. Mood disorders are common in the families of women with eating disorders; in one study, major depression was found in the families of 28% of bulimic patients and only 9% of the controls.

All these explanations of anorexia and bulimia, whether based on physiology, family, personality, or trauma, must be regarded as tentative and unproven, because a woman's abnormal eating habits and compulsive physical activity have powerful effects of their own on her body, her family, and her feelings. For example, not all the abnormalities in hormone and neurotransmitter regulation associated with eating disorders are directly related to weight loss. Menstruation, which is largely governed by sex hormones, stops in a third of anorectic women even before their weight has fallen drastically. The relationship of eating disorders to depression is also unclear. Physiological changes caused by abnormal eating and exercise habits may result in depressive symptoms. In fact, there are studies suggesting that prior depression has little effect on the outcome of anorexia, and women are at least as likely to be depressed because they are starving as the other way around. In an often-cited experiment, 36 young male conscientious objectors volunteered to undergo starvation. Over a period of six months, as their weight fell to 75% of its original level, they developed many symptoms typical of anorexia, including a preoccupation with food, depression, irritability, and anxiety. Even their responses to a personality questionnaire changed.

Parental influences

Theories about the influence of parents raise similar questions of cause and effect. The mother and father of a child who is starving herself are under great strain, and the family is bound to be in turmoil. In any case, an unhappy woman with an eating disorder will naturally be dissatisfied with her family. A parent who tries to intervene may be regarded as intrusive, one who tries to avoid conflict as uninvolved. Researchers have found that anorectic women are likely to describe their fathers as distant or their mothers as over-controlling,, but their brothers and sisters do not necessarily agree. These and other psychological and biological explanations can be reliably tested only by difficult, expensive (and so far unavailable) long-term studies in which girls who develop eating disorders are compared with others before as well as after the symptoms appear.

Part II

In Part I we discuss the symptoms and possible biological and psychological sources of anorexia and bulimia. In this part we consider cultural aspects of the eating disorders and describe the standard treatments.

Thin culture

Eating disorders can also be regarded as a cultural phenomenon and a social problem, one that has naturally attracted the attention of feminists. Anorexia nervosa may illuminate the influence of culture on psychopathology better than any other disorder. In this country women are becoming heavier with each generation, while the body presented as ideal for health or beauty becomes slimmer. Possibly as a result, more than half of American women say they are on a diet. In a recent survey of fifth- to eighth-grade girls, 31% said they were dieting, 9% said they sometimes fasted, and 5% had deliberately induced vomiting. In a 1950 survey, 7% of men and 14% of women said they were trying to lose weight. By the early 1990s, 37% of men and 52% of women thought they were overweight; 24% of men and 40% of women said they were dieting.

The more intense the social pressure for slenderness, the more likely it seems that a troubled young woman will develop an eating disorder rather than (or in addition to) other psychiatric symptoms -- especially if she believes that control over one's appetite is the way to win admiration and attain social success. A wish to mold one's body is also consistent with cultural ideals of achievement and self-sufficiency. Anorexia and bulimia are especially common among girls committed to the demanding disciplines of ballet, competitive swimming, and gymnastics. According to one survey, 15% of female medical students have had an eating disorder at some time. But the common belief that high social status raises the risk for eating disorders may no longer be correct, at least for American women. In a 1996 review of 13 surveys, researchers found that eating disorders were equally common among whites and blacks and in all social classes.

Wealth and social status may be more important in underdeveloped countries, where eating disorders are generally thought to be rare. Certainly self-starvation cannot be a form of self-discipline unless the supply of food is abundant and reliable, as it usually is for the vast majority in Western industrial societies. For most women at most places and times, food has not been so easy to come by. But that does not mean eating disorders are uniquely a product of modern social conditions and the ideal of body shape promoted by contemporary Western culture. Rules about food have carried many other meanings as well.

Fasting and a denial of womanhood

Prolonged fasting, a recognised religious discipline, is usually practiced by men but was also used by certain noblewomen of medieval Europe to demonstrate their moral strength and spiritual purity. The most famous of these women was Catherine of Siena, born in 1347. At age 15, after seeing visions of Christ, she decided to preserve her virginity and devote her life to helping the poor. She died at 33, presumably from the effects of starvation, and was later beatified by the Catholic Church. Saint Catherine wrote: "Make a supreme effort to root out that self-love from your heart and to plant in its place this holy self-hatred. This is the royal road by which we turn our back on mediocrity and which leads us without fail to the summit of perfection." The choice of words may seem peculiar to most anorectic patients, but the sentiment is not alien.

Historians have suggested that female saints of the Middle Ages wanted to liberate themselves from subordinate social roles, including marriage and childbearing, to which they considered themselves unsuited. Catherine of Siena is said to have begun fasting soon after a customary aristocratic marriage had been arranged for her. What Saint Catherine had in common with the fasting male ascetics of India or early Christianity was a socially accepted way to satisfy her unusual needs and ambitions. In more completely male-dominated cultures, like parts of the Moslem world today, eating disorders among women are practically unknown. In these societies women have no alternatives to subordination and no opportunities to gain recognition as exceptional. The prestige of female religious fasting eventually declined in Europe, and by the 17th century the attitude of the Church had changed. Women like Catherine of Siena were no longer considered candidates for sainthood. It is probably no coincidence that at this time physicians made the first known clinical observations of anorexia as a disorder of the mind.

Presumably neither Saint Catherine nor male religious ascetics were worried about being slim or beautiful. In a recent study of anorectic Chinese women in Hong Kong, researchers found that they too deny concern about their weight and their looks. They say only that they have family problems, lack appetite, or cannot explain their behaviour. Whether they seek slenderness or saintliness or simply "don't know" why they act as they do, women who starve themselves may be rejecting unacceptable biological and social demands -- a woman's body and a woman's place. If this idea is right, some women with eating disorders are making an inarticulate social protest -- a hunger strike (as it has been called) without a conscious political purpose. Fear of gaining weight may be just one cultural expression of the illness rather than its central feature. As if acknowledging this, the American Psychiatric Association now includes in its diagnostic manual, among eating disorders not otherwise specified, a condition with all the symptoms of anorexia nervosa except an obsession with body shape.

Cultural comparisons and historical studies confirm evidence from our own society that eating habits and preoccupation's with similar effects may have different causes in different circumstances. For example, a woman is temperamentally predisposed to depression or anxiety, or suffers from family troubles or a neurochemical imbalance. The value her culture places on slenderness (or holy self-abnegation) encourages her to diet (or fast). The weight loss causes physical and emotional changes that make it still more difficult to eat normally. The resulting hunger may lead to eating binges followed by vomiting and purging with laxatives. These episodes cause anxiety and depression that lead to further bingeing and further dieting.

Weight gain: the first therapeutic step

In the treatment of eating disorders, several therapeutic techniques are used in different combinations with different patients. The services of psychiatrists, physicians, and dieticians may be needed. An anorectic woman must first eat until her weight is normal. She is hospitalised in the most severe cases -- when her weight has been more than 20% below normal for several months, serious physical symptoms are developing, or she is in mortal danger. Occasionally tube feeding may be needed at first just to keep the patient alive. Simple forms of operant conditioning (behaviour therapy) are used to encourage her to eat. She may be started on a liquid diet or frequent small meals and told every day how much she has eaten and how much she weighs. Nurses may have to sit with her during meals to provide moral support, make sure she eats, and prevent vomiting. The reward for gaining weight is greater freedom of movement and more visitors; if she does not eat, she may be confined to bed until she does. Laxatives are forbidden, and she must clean up if she vomits. Recent research suggests that strict regimes with detailed schedules, graduated privileges, and careful recording of food consumption may be less effective than more limited programs that use only the threat of bed-rest for not eating. In the looser arrangements, the patient is more likely to cooperage and hospital staff members have less need to compromise their therapeutic function by acting as a police force.

Gaining weight while hospitalised is no guarantee of long-term success; anorectic patients are sometimes said to "eat their way out of the hospital" and then stop. Their emotional condition may improve when their weight is closer to normal, but preventing relapse is difficult, partly because of the tendency to deny the illness. Drugs, even those that tend to cause weight gain, are not especially useful. Anorectic patients are predictably reluctant to take them, and the side effects can be uncomfortable or dangerous to their enfeebled bodies.

Behaviour and cognitive therapies

When the patient's health is no longer (if it ever was) in immediate danger, various behavioural and cognitive techniques can be used to preserve and promote weight gain. One of these is systematic desensitisation -- muscle relaxation with visual imagery or direct exposure to a graded series of situations that involve food and eating. Cognitive techniques are used to correct the patient's false beliefs about food and about herself, including harsh self-criticism, perfectionism, and exaggerated fears of separation from her parents. Questioning is a common device. The therapist and patient explore the patient's tendency to all-or-nothing thinking, her superstitions about food and exercise, and her unjustified interpretations of other people's behaviour (for example, the belief that strangers will notice if she gains a few pounds). The therapist asks the patient to articulate half-conscious automatic thoughts that may be ruling her life. She may be told to look at herself from another point of view (for example, she feels fat but says that others of the same height and weight are too thin), make vague fears explicit ("What would be the worst thing that could happen if you ate more?"), test hypotheses ("Will other people think you are gluttonous if you eat dessert?"), and achieve a more accurate impression of the size of her body and the amount of food she is consuming.

Some therapists move on to an insight-oriented approach at a later stage, when the patient must learn to do without the comforting discipline that has given life a meaning and goal. Interpersonal therapists examine the patient's present situation and her recent and future relations with others. Psychodynamic therapists also try to explore and resolve emotional problems that may have created the need for self-starvation. Some speak of providing an experience that serves as a symbolic equivalent of the relationship between a mother and a child. If child sexual abuse is part of the story, treatment for post-traumatic stress may be needed.

Most families of anorectic patients can use some help, if only education and counselling. Parents may also be asked to record family conversations and listen to them. They may be told to answer the anorectic daughter's requests and provocations in new ways, spend time with her in unfamiliar settings, or communicate with her in writing to make it clear what everyone in the family wants. Parents are usually instructed not to beg, plead, or scold, and told to avoid discussing food while eating with their daughter. She should not be told that she looks better if she gains weight, since she may already be convinced that people care only about her appearance. Food and eating should be discussed only in connection with health. Therapists influenced by family systems theory also try to change what they see as the family's overprotectiveness, inability to admit conflicts, and uncertainty about the roles of parents and children.

Bulimia and obesity

Bulimia is often treated more successfully than anorexia, partly because bulimic patients usually want to be treated. Most antidepressant drugs relieve the symptoms, usually more quickly than they relieve depression. Selective serotonin re-uptake inhibitors (SSRIs) are probably most useful, because they have relatively few side effects and tend to cause weight loss rather than weight gain. In 1997 fluoxetine (Prozac) became the first drug specifically approved by the Food and Drug Administration (FDA) as a treatment for bulimia.

The problem of bulimia is closely related to the problem of obesity, since almost all bulimic women either are or think they are overweight. According to a widely accepted theory, each person's body weight has a biological setpoint that is strongly influenced by heredity and difficult to change. Studies in several countries have found that mothers and their biological daughters have a similar weight-height ratio, while the correlation between adoptive parents and adoptive children is low. According to the setpoint theory, metabolism during a diet slows to counteract the effect of reduced intake until it settles at a lower level consistent with the new weight. A person who continues the same diet will eventually regain weight until the setpoint is reached.

The setpoint may be determined by a brain centre in the hypothalamus that regulates the amount of fatty tissue stored by the body. A substance called leptin is produced by fat cells and circulates in the blood until it reaches the brain. When this hypothalamic region detects sufficient leptin, it tells the body to stop storing fat. An animal in which the region has been cut out cannot "know" it is already fat enough and will continue to gain weight even on a restricted diet. Neurones in this region use serotonin, and enhancement of serotonin activity is the main effect of the only diet drug approved by the FDA, dexienfluramine (Redux). Some bulimic patients seem to be otherwise emotionally stable women whose concern about weight is more or less realistic given their social circumstances and cultural expectations. If a woman is bingeing and purging merely to circumvent her fat storage mechanism in order to pursue a body shape incompatible with her biological setpoint, a weight-reducing drug might be useful, but only as long as she continues to take it -- probably for a lifetime, with all the attendant risks, which include possible heart valve damage and pulmonary hypertension (dangerously high blood pressure in the arteries carrying blood to the lungs) in the case of fenfluramine. Exercise may be a better way, since, apart from the expenditure of energy involved, it seems to reduce fat storage by altering the leptin mechanism.

Behavioural and group therapies

More often bulimic patients are given behaviour therapy. One behavioural treatment for self-induced vomiting is exposure and response prevention. The patient is allowed to eat until she is nauseated and then asked to concentrate on her discomfort and write down her thoughts and feelings. Bathrooms are locked so that she will be ashamed to vomit and has to tolerate her anxiety. The effectiveness of this method is disputed. Bulimic patients are also asked to examine self-defeating beliefs, such as the fear that any momentary lapse must precipitate a binge, the conviction that a slight weight gain is obvious to everyone, or the illusion that their worth depends on their looks. Insight-oriented or exploratory psychotherapy may be especially useful for the many bulimic women who have other emotional problems or psychiatric disorders. If they are living with their families, family therapy may also help.

Group therapy is popular with both bulimic and anorectic patients. Groups are an efficient setting in which to present information and advice on eating habits. They are also used to apply a variety of therapeutic techniques, with cognitive and behavioural methods dominant. Apart from any specific therapeutic procedures, groups provide a sense of belonging and a source of friendship. The members learn from one another, teach, comfort, and are comforted. They watch one another for signs of relapse. They feel less ashamed when they realise that they are not alone, and they can correct distorted notions about themselves by watching and imitating others. Self-help groups are available as well as professional group therapy; Overeaters Anonymous, an organisation modelled on Alcoholics Anonymous, provides support and advice for these groups.

Prospects for recovery

Treatment of anorexia can be frustrating, and recovery is usually prolonged and difficult. Even women whose most serious symptoms are relieved often relapse or suffer from various residual effects and chronic troubles. In long-term studies covering periods from 4 to 30 years, 50% to 70% are found to be no longer clinically anorectic: they are menstruating and maintaining a weight in the normal range. About 25% show some menstrual irregularities, and their weight is sometimes low. The outcome is poor for another 25%; they are not menstruating and their weight is far below normal. Whether they recover or not, many of these women are still preoccupied with weight and dieting. Bulimia is the most frequent diagnosis, and depression and anxiety disorders are also common. Women with personality disorders and those who have symptoms for a long time before seeking treatment are least likely to recover.

Full recovery from bulimia is more common. In a 1997 meta-analysis (combined statistical analysis) of studies on the outcome of treatment, researchers found an average recovery rate of 50% after periods of 6 months to 5 years. Relapse was common (about 30% in 6 years), but so was a second recovery. In a recent meta-analysis examining the effectiveness of various treatments, researchers found no differences between group and individual therapy. The best treatments concentrated on emotional problems and family relations, without reference to therapeutic theory or persuasion. In one recent study with a 6-year follow-up, both cognitive-behavioral and interpersonal therapies were effective even when eating habits and weight were not made the centre of interest. Simple behaviour therapy was less successful, with a high dropout rate. In another study, bulimic patients improved more with a combination of cognitive-behavioural therapy and a drug than with either treatment alone. Patients are least likely to recover if they have other disorders, especially alcoholism and borderline personality. In one recent study, the lowest recovery rate was found among women who were seriously overweight or whose fathers (not mothers) were overweight. In the long run, symptoms of bulimia often fade even without treatment, and the disorder is uncommon (although not unknown) in women over 40.

Evidence on the effectiveness of treatment is limited. Many women with anorexia or bulimia are never treated, and in long-term studies many drop out -- possibly those who are doing worst. Researchers are calling for further cross-cultural research and more studies in which women are interviewed for the first time before developing symptoms. More information about self-help groups is needed. Researchers must examine more closely the relationship between eating problems and other psychiatric disorders, including addictions and compulsive behaviour, partly so that treatments can be modified for different combinations of symptoms. An especially important goal of research is finding ways to prevent eating disorders or recognise and treat them at an early stage.

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Overeaters Anonymous

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