Diagnosis and treatment
Anorexia nervosa, bulimia and binge-eating disorder are part of the eating disorders group.
Except for the most severe cases, in which there are very significant weight changes, eating disorders can be difficult to diagnose. The reason for this, is that commonly, individuals suffering from this disorder don’t seek help, usually due to an extreme fear of weight gain, even if they are underweight, and/or because they feel ashamed.
Besides the negative consequences on physical health, these disorders involve a huge emotional distress and suffering, with a suicide rate in the case of anorexia of 12 per 100.000.
A specific training as a therapist is key in order to properly help these patients, as well as a multidisciplinary approach that includes psychotherapy.
Dr. Moreno has been working at a specific eating disorders unit at Son Espases Hospital, in Palma de Mallorca, and therefore has experience on this matter. If you think you or a loved one might have an eating disorder, don’t hesitate to make an appointment.
When should we suspect that there is a case of an Eating Disorder (ED)?
People suffering an ED (Eating Disorder) become obsessed with food and their body image; everything revolves around this, and their life spheres become affected (socially, professionally, emotionally, etc.). It is not a whim or a fad for the person who suffers it, but an acute psychological conflict, which causes emotional and cognitive problems and results in a very intense dissatisfaction with the body itself, as well as an abnormal diet, which varies according to the type of disorder.
The subject may lose weight in a drastic way through extreme food restriction, excessive physical activity, self-induced vomiting, laxative use as well as other pharmacy or parapharmacy products; they may also practice bingeing, which consists of ingesting large amounts of food in a short time, under a feeling of control loss. In women, they can experience an absence of menstruation (amenorrhea), which has very negative long-term consequences in health, such as early osteoporosis. Constipation, flatulence, abdominal bloating and gastroesophageal reflux are also frequent.
Other evidence of self-induced vomiting can be erosion of teeth or pharyngeal mucosa, dental cavities, or hypertrophy of the parotid glands, which are the salivary glands, resulting in a widening of the face below the jaw; this has a clear negative impact since the subject will perceive a more voluminous image of their face.
Blood tests can be misleading at first, as they can turn out normal in many cases, which does not rule out an ED. Perhaps the most important thing to take into account are potassium alterations, which are more frequent in cases of self-induced vomiting or purging, since these alterations can cause heart arrhythmias.
Beyond the physical symptoms and signs, there are certain emotional alterations and behaviors that should make us suspect that we are dealing with an eating disorder. For example, an avoidance of social gathering where eating is involved (going out to dinner or tapas) or making an excuse to avoid eating (“I already ate at home”); if they do not avoid it, they usually look for ways to compensate for the intake, which is also associated with a very intense discomfort due to the fear of “getting fat.” They will also tend to be more sad, irritable, or prone to social isolation; moreover, school performance can also be negatively affected.
What types of EDs are there?
The best known are anorexia nervosa, mainly characterized by food restriction patterns, and bulimia nervosa, where bingeing is the common practice. However, these practices may appear in one same subject, which in fact are the most common. It is also likely that the same subject will go from one type of disorder to the other, resulting in a whole spectrum of ED combinations. One thing they all have in common, though, is a very significant dissatisfaction with their own body image.
What is the age of onset for an ED?
Generally, these disorders begin in adolescence or preadolescence, thus making these stages of life essential for a timely diagnosis. Sadly, there are more cases emerging this disorder at a younger age still; this could be due to earlier exposure to impossible ideals of beauty on social networks (i.e., Instagram), magazines or television.
How should parents respond if they suspect their child has an ED?
The fundamental thing is to be attentive to the first signs and symptoms that may appear as well as establish an open communication relationship with your child(ren); it is important to express your concerns without accusations or judgements.
Children may consciously, or unconsciously, deny or minimize the situation. In addition to that, it is a priority to ask for professional help, preferably interdisciplinary support, in which a psychiatrist, psychologist, nutritionist and endocrinologist will intervene.
If the ED is detected and treated early, it will improve the prognosis since the weight loss has not been drastic, there has not been time for all symptoms to emerge, and the health of the patient has not been so compromised. Cognitive distortions and emotional consequences tend to respond better to treatment if the disorder has been present for a short period time.
What can be done if the subject with ED refuses professional help?
It is not uncommon for ED patients to deny having this disorder or symptoms; those who suffer from it are not aware of the seriousness of the matter or they may also tend to minimize it. Furthermore, that disproportionate fear of gaining weight makes it even more difficult for them to be willing to start treatment. It is usually desperate relatives that come to seek professional help: they rarely know what to do or what to say to the patient, after undergoing various failed attempts at getting the ED patient to eat.
It is very important to advise family members so that they gradually establish adequate eating patterns to move away from the established level of malnutrition or undernourishment, as well as teaching them about the disorder and offering them the necessary tools to manage the disorder in a more effective way. Family members are provided guidelines for behavioral management and emotional support so as to start treatment as soon as possible.
In the most serious cases, where significant physical damage and risk to physical integrity has been done (i.e., complete lack of awareness of disorder), an involuntary hospitalization through judicial order will be needed. Upon a sign of recovery in physical health, the patient will go on to a Day Hospital program, to finally continue with outpatient follow-up appointments.
Which factors contribute to teenagers’ developing this behavior towards food?
From a biopsychosocial model, factors of vulnerability have been detected at the level of genetics, personality, gender (ratio of 10 females to 1 male) and environment (western countries or westernized cultures where there is greater social pressure for being thin).
Nonetheless, the most salient factor leading to ED is to carry out a diet without the adequate advice and monitoring of a nutritionist.
What types of treatments are there? What types of professionals treat cases of ED?
The treatment is based on three main pillars: nutrition, psychology, and family. As for nutrition, it has proven that malnutrition affects the body and brain, since the malnourished patient decreases their brain activity as a compensatory way to save energy. This causes a decrease in mood, develops bizarre eating patterns, and increases obsessive behavior.
As for the psychological pillar, it is crucial to identify that false perception on weight, myths about eating and inadequate conduct that sustain ED behavior.
The last and fundamental pillar requires the cooperation of family members by maintain an effective channel of communication, providing information, and changing certain behavioral patterns. They should try to understand the patient’s behavior as well as their fears; in this manner, they can support the patient in a process that can become painfully slow.
How can this type of disorder affect the subject’s closest relatives?
Any illness within the family is stressful and they must adapt to the new experienced reality; nonetheless, this stress will become greater if we lack awareness on the disorder and its consequences. In the words of French writer Alexander Dumas (1803-1870): “unknown dangers inspire the most fear”. It is important to seek professional help on these disorders and how to handle them. During the process of recovery, there may be relapses; it should be understood that ED treatment can range from 2-4 years. Sometimes the family members also need help since the process can be emotionally draining and affect their physical and emotional help.
Are these disorders characteristic of a time period or have they always existed?
Although in recent decades great progress has been made in the diagnosis and detection of ED, this is not a new disorder; the act of intentional starvation through fasting goes back to biblical times; however, talk of anorexia nervosa began in the 17th century. We know historical figures such as Catherine of Siena who suffered from an anorexia nervosa very similar to those currently described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
Other documents date back to Ancient Rome, which describe behaviors more typical of bulimia nervosa, binge eating. They describe how after copious ingestion, some people practiced purging or self-induced vomiting. The first cases of bulimia nervosa appeared in Germany in the 30s, but it was in the late 70s when an American doctor named Russell defined bulimia nervosa as we know it today.
Although we are discussing teenagers, can an ED originate in adulthood?
Anorexia nervosa is more common in adolescence, between 12 and 18 years; while bulimia nervosa will commonly show in later stages of life, between 25 and 40 years. Although they are increasingly showing up at a younger age, 8 years, or at much older, over 50. Sometimes the eating disorder may take longer to show and it is detected late. Bulimia nervosa symptoms may go more unnoticed since they do not show the degree of malnutrition that anorexia nervosa does.