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What would cause an otherwise normally healthy adolescents or adults to starve themselves, even to the point of death? North America and European nations are blessed with more than adequate food supplies; even people living in poverty conditions receive government subsidies in order to have sufficient food. How then to unlock the mystery of why some people actively choose self-starvation over healthy eating?

If there are physiological reasons for anorexia nervosa, none have yet been found. To date, no series of laboratory tests have discovered faulty DNA, the “heredity factor” is absent, and anorexics show no abnormalities of the brain through magnetic resonance imaging (MRI) scans.

Ruling out physical causes leaves us to turn to emotional/psychological causes of anorexia. Countless studies indicate these possible psychological causes of anorexia nervosa: Patients exhibit obsessive-compulsive features in many life areas e.g. maintaining rigid schedules, making lists, and “checking” behavior common to those with Obsessive-Compulsive Disorder.

An anorexic will rarely, if ever, bring his or her self in for treatment or be open about their situation and problem. Most of the time, anorexics come to the attention of a therapist through their physician or a concerned family member.

Anorexic patients do not see their behavior as problematic; they see themselves through distorted eyes that tell them that they need to lose even more weight through starvation and excessive exercise. Patients often have co-morbid conditions such as major depression, anxiety disorders, and obsessive-compulsive features.

Anorexics never eat in public, have feelings of personal inadequacy, have a sense of perfectionism, seldom have a social life, and display rigidity in thinking patterns.
Patients have a very restricted emotional affect; real emotional displays (either positive or negative), are superficial or completely absent.  Anorexics have an intense need to control what goes into their bodies. If they believe they lack control in other aspect of their lives, only they have the power to eat or not to eat.

A fairly recent finding in the etiology of Anorexia Nervosa suggests that many sufferers were physically and/or sexually abused as children. As a result of this intrusion to their bodies, they subconsciously seek to make themselves unattractive to avoid future sexual exploitation. They share this characteristic with those suffering from Bulimia Nervosa where sufferers become obese to make themselves unattractive sexually.

Anorexia, it appears, is the result of many psychological factors combined to push the patient to starve themselves and exercise obsessively. One thing is certain though: If left untreated, anorexia nervosa can lead to death.

We’re all familiar with the aftermath of a good holiday meal. You know the one – the kind where you’ve waited all day for that turkey or ham to come out of the oven, along with all the other goodies for side dishes.  By the time you finally sit down, you stuff yourself silly, and then kick back to relax in semi-comatose state.  You’re so full that you can’t move for the rest of the night.

If you suffer from Bulimia Nervosa, none of this happens when you overeat.  And you overeat every day, sometimes several times a day.  But there are no sighs of satisfaction, no feelings of being pleasantly full.  There is only self-hatred for your inability to control your eating.  You have to get rid of what’s making you despise yourself, so you purge your body of the food by causing yourself to vomit, you abuse laxatives and diuretics, and you exercise frantically to avoid more weight gain.  This is the world of the bulimic.

According to the Diagnostic and Statistical Manual of the American Psychiatric Association, Version Four, Text Revised (DSM-IV-TR), the following behaviors are the diagnostic features of Bulimia Nervosa, paraphrased: Frequent binges of very large amounts of food; lack of control over food. “Secret” eating; never binging when others are present, hording food to eat alone. After binge eating, the person then proceeds to engage in compensatory behavior by inducing vomiting, chronic abuse of laxatives and diuretics, enemas, and excessive exercising. Binge foods include great quantities of sweets and other carbohydrates. Binges are rapid – food is consumed very quickly. Intense feelings of shame, guilt, and self-disgust about binges are a direct result.

Co-existing symptoms of depression and/or anxiety manifest themselves. Purging by vomiting provides relief from the physical discomfort of binge eating; vomiting is induced with fingers, an instrument such as a spoon, or ingesting Ipecac syrup.  After an intense binge-purge episode, there may be total fasting for a day or two, combined with excessive, frantic exercise.  The binge and purge cycle begins all over again.

Not all bulimics go through the binge/purge cycle. There is a secondary category of bulimics called “non-purging”. Non-purging bulimics can be overweight or of normal weight; the former is obsessed with losing weight and the latter is deeply afraid of gaining weight. Non-purging bulimics will frequently binge but rather than purge, they will frantically exercise the calories off and then fast for several days before starting the cycle all over again.

Will power and good character have nothing to do with Bulimia Nervosa. Bulimics take no joy in binging and purging, and when you think about it, the act of purging isn’t all that pleasant. The only thing bulimics hate more than them is food. The situation is a constant war and if bulimics knew how to stop, they would. However, bulimics feel powerless to control anything, and the only key to changing the situation is for the bulimic to believe and understand that they do have the power to change their behavior.

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While we may prefer our world to be well-ordered and predictable, with everything neatly categorized, mental health professionals have long known that human behavior often defies neat categorization. Just as social scientists think they have everything in order, there are always mental health patients who break all the rules. The best evidence of this phenomenon is the Diagnostic and Statistical Manual of the American Psychiatric Association, Version Four, Text Revision (DSM-IV-TR), and the “bible” of classifying the diagnostic criteria for all known mental health disorders is in its fourth edition, with the fifth revision due shortly. This appears to be “proof positive” that we are still progressing in our study and the diagnosing of mental health disorders.

At present, the only eating disorders that are given full diagnostic criteria, co-morbid conditions, medical and laboratory findings, and courses of treatment are Anorexia Nervosa and Bulimia Nervosa. However, there is one more category contained in the section of the DSM-IV-TR pertaining to eating disorders: the Eating Disorder NOS (Not Otherwise Specified). Students of the DSM-IV-TR soon learn that the NOS category is merely a catch-all diagnosis; when a patient’s symptoms almost but not quite fit into a clearly defined category, the NOS diagnosis is given. Thus, Eating Disorder NOS contains eating behavior that has elements of both anorexia and bulimia. It must be emphasized that the Eating Disorder NOS is just as dangerous as clearly-defined Anorexia Nervosa and Bulimia Nervosa.

Examples of this disorder include:

With women, all the criteria for Anorexia Nervosa are present except the cessation of menstrual periods.
All diagnostic criteria for Anorexia Nervosa are met, yet the patient’s current weight is within normal limits.
All diagnostic criteria for Bulimia Nervosa are met except that binge eating and purging are infrequent.
Regular use of compensatory behaviors such as vomiting, enemas, and abuse of laxatives by individuals who eat only small amounts of food rather than large binges.
Chewing food and spitting it out, not swallowing.

There is another NOS category that is generating a great deal of attention among eating disorder specialists; the Binge Eating Disorder. Although this condition, at present, remains in the NOS category, it’s likely that by the time the DSM-V is released it will be a category of its own. The Binge Eating Disorder involves recurrent episodes of binge eating without compensatory behaviors and purges like vomiting.

The current research of the Binge Eating Disorder focuses on individuals who eat huge amounts of food in a rapid manner, eating alone to avoid embarrassment, feeling shame about their lack of control over their eating, but without compensatory behaviors, eating when they’re not particularly hungry, eating until uncomfortably full, and binges that occur at least two days a week. Unlike Anorexia Nervosa and Bulimia Nervosa, the Binge Eating Disorder appears to be a secondary diagnosis that evolves from the individual’s primary diagnosis of Major Depression, a Personality Disorder, or a Substance Abuse Disorder.  Plus, individuals with Binge Eating Disorder are virtually all morbidly obese – not the case with anorexics and bulimics. They report feeling numb or “spaced out” while binge eating – a kind of disassociate state. They continue binging and gaining weight, even though their weight interferes with social relationships, with their work, and their self-esteem. Although they seldom admit it, those with Binge Eating Disorder have even higher feelings of self-disgust and guilt than those who suffer from Bulimia Nervosa.

The eventual release of the DSM-V will be the deciding factor as to whether the Binge Eating Disorder is formally classified as a separate, different type of eating disorder with diagnostic criteria all its own. Most mental health professionals have no doubt that the condition exists; it’s now up to the social researchers to prove its existence through solid empirical research studies.

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