Major Eating Disorders: Anorexia and Bulimia

Two eating disorders whose effects are alarming.

According to the most recently accepted definitions by the American Psychiatric Association (1994), anorexia nervosa (AN) and bulimia nervosa (BN) are defined as emotional disorders with high severity and interference in many areas of the sufferer's life.

Data suggest that the confluence of biological, psychological and social factors interact with the personality of the individual, leading to the development of this type of eating disorders.

Among the first set of factors, the type of temperament of the individual as well as his or her level of emotional stability can be determining factors; as for the socio-cultural components, it is worth mentioning society's idealization of maintaining a slim body, associating it with success and superiority over others; with regard to psychological factors, this type of patient presents phenomena such as low self-esteem, feelings of inefficiency in problem solving and coping or the high desire for perfectionism, which greatly hinder his or her daily functioning.

Symptoms in eating disorders

On the other hand, the presence of anxious and depressive symptomatology is frequent.characterized by continuous sadness and dichotomous (all-or-nothing) thinking.

A large proportion of people with anorexia present traits of obsession and compulsion in relation to the maintenance of rigidity and strict regulation in the control of food, practice of extreme physical exercise, body image and body weight. Finally, it is also characteristic the difficulty in expressing themselves emotionally outwardly despite being very intelligent, so they tend to isolate themselves from the circles of close relationships.

Anorexia

In the case of anorexia nervosa, this is characterized by a predominance of body weight rejection, usually accompanied by a distortion of the body.usually accompanied by a distortion of body image and an excessive fear of becoming fat. In anorexia nervosa two subtypes are distinguished, depending on whether or not binge eating or compensatory behaviors are present (AN-Purgetive vs. AN-Restrictive, respectively).

Bulimia

The second nosology, bulimia nervosa, is characterized by the maintenance of cyclical episodes of binge eating and compensatory behaviors of those by means of vomiting, the use or abuse of laxatives, excessive physical exercise or restriction in subsequent intakes.The use or abuse of laxatives, excessive physical exercise or restriction in subsequent ingestions. In this case the categories BN-Purgetive are also differentiated, if the individual uses vomiting as a compensatory behavior and BN-Non-Purgetive, if he/she resorts to fasting or excessive physical activity.

Many people who present an Eating Disorder do not meet all the criteria that allow one of the two previous diagnoses, so a third category called Unspecified Eating Disorder is distinguished where all these difficult to classify subjects can be included.

Characterization of bulimia nervosa and anorexia nervosa

Anorexia nervosa usually derives from family histories of eating disorders, especially obesity. It is more easily detectable than bulimia nervosa, due to the high Weight loss and the numerous medical complications that accompany the condition, such as metabolic, cardiovascular, renal, dermatological, etc. In extreme cases of malnutrition, anorexia nervosa can lead to death, with a mortality rate between 8 and 18%.

Unlike anorexia, bulimia is consulted much less frequently. In this case, weight loss is not so evident since the binge-eating-compensation cycles keep weight loss at more or less similar values.

Bulimic individuals are characterized by an exaggeratedly intense preoccupation with their body image.However, they manifest it in a different way than in anorexia: in this case, ingestion becomes the method to cover their emotional needs that are not satisfied by the appropriate means.

Analogously to anorexia, alterations are also observed at the psychological and social level. Normally these people show a marked isolation, so family and social interactions are usually poor and unsatisfactory. Self-esteem is usually poor. Comorbidity has also been observed between bulimia, anxiety and depression; the latter is usually derived from the former.

As for the level of anxiety, there is usually a parallelism between this and the frequency of binge eating by the subject. Subsequently, feelings of guilt and impulsivity motivate the binge eating compensation behavior. It is for this reason that a certain relationship of bulimia with other impulsive disorders such as substance abuse, pathological gambling, or personality disorders where behavioral impulsivity predominates has also been indicated.

The thoughts that characterize bulimia are also often defined as dichotomous and irrational.. They devote a lot of time each day to cognitions concerning not putting on weight and feeding distortions of the body shape.

Finally, medical pathologies are also common, due to the maintenance over time of binge-eating-compensation cycles. Alterations are observed at the metabolic, renal, pancreatic, dental, endocrine or dermatological levels, among others.

Causes of eating disorders

Three factors have been demonstrated by a majority consensus of expert authors in this field of knowledge: predisposing, precipitating and perpetuating factors. Thus, there seems to be agreement on giving the causality of causation of EDs a multicausal character where physiological, evolutionary, psychological and cultural elements are combined as intervening factors.psychological and cultural elements are involved in the onset of the pathology.

Among the predisposing aspects, reference is made to individual factors (overweight, perfectionism, level of self-esteem, etc.), genetic factors (greater prevalence in subjects whose relatives present this psychopathology) and sociocultural factors (fashion ideals, eating habits, prejudices derived from body image, parental overprotection, etc.).

Precipitating factors include the age of the subject (greater vulnerability in adolescence and early youth), inadequate valuation of the body, excessive physical exercise, stressful environment, interpersonal problems, presence of other psychopathologies, etc.

Perpetuating factors differ in terms of psychopathologies.. While it is true that negative body image beliefs, social pressure and stressful experiences are common, in the case of anorexia the most important factors are related to complications derived from malnutrition, social isolation and the development of fears and obsessive ideas about food or body shape.

In the case of bulimia, the central elements that maintain the problem are linked to the binge-compensation cycle, the level of anxiety experienced and the presence of other maladaptive behaviors such as substance abuse or self-injury.

Main behavioral, emotional and cognitive manifestations

As mentioned above, Eating Disorders result in a long list of physical (endocrine, nutritional, gastrointestinal, cardiovascular, renal, skeletal and immunological), psychological, emotional and behavioral manifestations.

By way of summary, on this second set of symptoms, the following can occur:

At the behavioral level

• Restrictive dieting or binge eating.
• Compensation of intake by means of vomiting, laxatives and diuretics.
• Alterations in the way of ingestion and rejection of some specific foods.
• Obsessive-compulsive behaviors.
• Self-injury and other signs of impulsivity.
• Social isolation.

At the psychological level

• Terrible fear of gaining weight.
• Wrong thoughts about food, weight and body image.
• Alteration in the perception of body image.
• Impoverishment of the creative capacity.
• Confusion in the sensation of satiety.
• Difficulties in the ability to concentrate.
• Cognitive distortions: polarized and dichotomous thinking, selective abstractions, thought attribution, personalization, overgeneralization, catastrophism and magical thinking.

At the emotional level

• Emotional lability.
• Depressive symptomatology and suicidal ideation.
• Anxious symptomatology, development of specific phobias or generalized phobia.

Intervention in ACT: objectives of the first personalized attention.

In a generic approach to ACT intervention, the following points can be a useful guide to offer a first individualized attention according to the case presented:

1. An approach to the problem. In this first contact a questionnaire is completed to acquire as much information as possible about the history and course of the disorder.

2. Awareness. To allow the patient to gain an adequate insight into the deviant behaviors related to the disorder so that he/she can become aware of the vital risk derived from these behaviors.

3. Motivation towards treatment. Awareness of the importance of seeking the services of a specialized psychology and clinical psychiatry professional is a fundamental step to ensure greater probability of therapeutic success, and early detection of incipient symptomatology can be a great predictor of a positive evolution of the disease.

4. Information on intervention resources. Offering addresses of interest may be useful to increase the perception of social support received, such as associations of ED patients and assistance to group therapy groups.

5. Bibliographic recommendation. The reading of certain self-help manuals can be indicated, both for the patients themselves and for their close relatives.

By way of conclusion

Given the complex nature of this type of psychopathology and the powerful maintaining factors that make a favorable evolution of these disorders very difficult, early detection of the first manifestations seems essential, as well as to ensure a multi-component and multidisciplinary as well as to guarantee a multicomponent and multidisciplinary intervention that covers all the altered components (physical, cognitive, emotional and behavioral) as well as the extensive set of vital areas affected.

Bibliographical references:

• Cervera, Montserrat. "Risk and prevention of anorexia and bulimia". Martínez Roca. Barcelona, 1996.
• Fernández, A. and Turon Gil. "Eating disorders". Masson. 2002.
• Raich, Rosa María. "Anorexia and bulimia: Eating disorders". Pirámide. Madrid, 2001.