Diagnostic Categories of Specific Eating Disorders
The American Psychiatric Association classifies five different types of eating disorders in the Diagnostic and Statistical Manual, 5th Edition (DSM-5):
- Anorexia Nervosa
- Bulimia Nervosa
- Binge Eating Disorder (BED)
- Avoidant Restrictive Food Intake Disorder (ARFID)
- Other Specified Feeding or Eating Disorder (OSFED).
Individuals with eating disorders may be at risk for co-occurring conditions such as mood and anxiety disorders, substance abuse (alcohol, marijuana, cocaine, heroin, methamphetamines, etc.), self-harm (cutting, etc.) and suicidal thoughts and behaviors.
Myths and Facts About Eating Disorders
Myth: An eating disorder is a choice that is all about my loved one’s appearance. I need to take a stand and insist on an end to this crazy behavior.
Fact: Eating disorders are not a choice and no amount of insisting will solve the problem. In fact, taking a stand may even make it worse by damaging the relationship you have with your loved one at a time when s/he needs you the most. Feeling guilty usually leads to more isolation and most people with an eating disorder are already very isolated.
Myth: As a parent, I have to assume that it is my fault my child has an eating disorder.
Fact: Parents don’t cause eating disorders, although family dynamics do play a role. ED’s are essentially family disorders, i.e. they typically develop within the context of the family and are usually “diagnosed” by a family member. In most cases, much of the therapy also takes place while the patient resides at home. In this sense, families are never neutral. They either have a positive or a negative impact on the course that an ED takes. I tell my patients that families are never neutral. They are either helping or they are hurting, and it often seems like the best families have the worst impact because they try harder. Sometimes the harder you try when it comes to an eating disorder, the worse it gets. Sound familiar? Without expert help, everything you do could backfire. In the case of Anorexia for example, a primary characteristic is reactance, or the tendency to go in the opposite direction. Pushing this person to eat, can result in even less eating. At the end of the day eating disorders are family matters, they almost always begin in a family setting, and the research is clear, that recovery is more likely when the family is involved in treatment.
Myth: Residential treatment is the best strategy for someone that is really ill.
Fact: Residential treatment has a very high failure rate. Research demonstrates that the most effective recovery strategy for Anorexia, for example, is one involving family members. (I have found this to be true for Bulimia, Bulimarexia, Binge Eating Disorder and to a lesser degree the treatment of obesity.) Ironically, most therapists will not even speak with a family member, as they view this as a boundary violation. Likewise, their default, when treatment is failing, is to insist upon residential placement despite the fact that research has shown residential treatment to be the least effective form of treatment with a success rate of less than 30 %.
It is ironic that the role the family plays in the development of an ED is often the focal point of therapy, while the role of the family in the resolution of the ED is virtually ignored. In other words, a small percentage of practitioners actually include family therapy in their treatment regimen. The ineffectiveness of residential treatment may be case in point: Effectiveness is compromised by the fact that family members are less likely to be involved as most residential facilities are not local for the family. Given that many ED’s are the result of a dysfunctional family system, therapy that does not include the family may not address the dynamic that is driving the symptomatic behavior. If the patient returns to the same environment that helped to create the problem, with no new skills for dealing specifically with that particular dynamic, it is unlikely that treatment gains will be maintained.
The harder a family member tries to help, the worse the situation can become and a vicious cycle may be set in motion. Although this often occurs unintentionally the impact can be significant. As in the tennis example, the parent of a child with Anorexia feels compelled to help. Most often, this involves pushing the child to eat, or trying to shame the child into giving up purging. The child may become reactant and eat even less and/or purge more as a result. This is not an act of defiance, as most loved ones and some practitioners interpret it, but an issue of the child’s trying to control intense levels of anxiety. Since the parent’s underlying assumption is incorrect, the more the parent insists, the more symptomatic the child may become. As with any vicious cycle, if the underlying assumption is incorrect, the greater the effort to change, the more negative the impact.
Myth: Eating disorders are caused by a fear of fat.
Fact: Eating disorders are driven by many factors, not the least of which is an intense fear of gaining weight, but this is not the only cause. Losing control, compensating for a sense of failure in life, or fearing abandonment all play a role, depending upon the person.
There is also good research suggesting that there is a biological basis for many eating disorders. Because the human body was designed to maintain homeostasis, it has various checks and balances that are designed to keep all of these systems working in synch. When researchers studied these chemical balances, they discovered that a connection exists between certain hormones and eating disorders:
- Excess levels of depression-related hormones, such as Cortisol, are present in some people with anorexia.
- Brain-chemistry similarities exist between people with eating disorders and those with obsessive-compulsive disorder (OCD)
- Many people with bulimia and anorexia have severe OCD. Likewise many people with OCD have eating disorders.
- Researchers have also shown that a hormone called Leptin, which regulates the feeling of being satisfied after eating and fat storage, is out of balance among those who are obese, anorexic and bulimic.
- Researchers have shown that Leptin levels are adversely impacted by neurotoxins in the form of food additives such as processed L Glutamate (MSG), High Fructose Corn Syrup (HFCS) and sweeteners, Aspartame and Acesulfame. These substances, which are found in the vast majority of packaged, bottled and processed foods, destroy Leptin receptors in the brain, causing “Leptin Resistance” and major disturbances in eating and fat storage.
Myth: This is just a phase, my loved one isn’t in serious danger.
Fact: Most people do not just outgrow their eating disorder and require very specialized treatment. Eating disorders have the highest mortality rate of any psychiatric illness. Up to 20% of individuals with chronic anorexia nervosa die of the disorder or its complications. When it comes to bulimia, individuals who abuse laxatives or diuretics or force themselves to vomit are at significantly higher risk of sudden death from heart attacks due to electrolyte imbalances. Excessive exercise also can increase the risk of death in individuals with eating disorders by increasing the amount of stress on the body.
Myth: Anorexia is more dangerous than bulimia or binge eating disorder.
Fact: Recent studies of anorexia, bulimia, and eating disorder not otherwise specified (OSFED) show that all eating disorders have similar mortality rates. The medical complications from binge eating, purging, starvation, and over-exercise, are serious and significantly compromise the victim’s health. Suicide is also common among individuals with eating disorders. People who struggle with eating disorders also have a severely impacted quality of life. Many are underemployed or on welfare because the disease is so debilitating.
Myth: I would know if she was doing something really unhealthy. If I cannot see it, she must not really be sick.
Fact: Many of those suffering from specific eating disorders are positively brilliant at keeping their symptoms secret. The anorexic may wear loose baggy clothes to cover up her bone thin frame and the bulimic, who experiences intense shame and fear of discovery, goes to great lengths to cover up the amount of food s/he eats.
Purging in secret is much easier than you might imagine and takes forms other than vomiting. If you suspect that s/he is hiding things from you, the worst thing you can do is confront your loved one in an accusatory manner. The best approach is a non-judging compassionate approach.
Myth: Treatment won’t work unless it is his/her idea.
Fact: Most individuals with these terrible disorders are too sick to make the decision to get help. Without the proactive involvement of a family member, they often remain in limbo, helpless against the strength of their disordered thinking. Fortunately, what they won’t or can’t do for themselves, they will often do for a loved one. Family members are usually the driving force for behind the decision to get treatment and remain in treatment long enough to recover.
Myth: This is a personal matter between my child and her therapist, which means that I should not participate in her treatment.
Fact: The research is pretty clear that a family systems approach is best. (The Maudsley Method, a family based treatment, gets the best results with Anorexia cases.) As a family therapist, this has certainly been my experience. It is impossible to effectively treat a teen without the active involvement of the parents. I explain to parents that we are a team and we are fighting the Anorexic mind. Not their child. We are not fighting her, we are fighting the part of her that has taken over her healthy mind, and we have to be on the same team to win. Eventually the patient will join us and we will all be on the same team, but in the beginning she may not be able to help very much.
Myth: Unless we uncover the underlying cause, my loved one will not recover.
Fact: What triggered the disorder, does not necessarily prolong it. It usually takes on a life of it’s own. It may start one way and morph into something else entirely. Recovery involves taking the person where they are today and helping them develop new coping strategies other than restricting, bingeing, purging or overeating.On the other hand, I do find it helpful to discover the mistaken beliefs that my patient has had from childhood (using an Adlerian test called the Lifestyle Analysis) as these beliefs are likely to impact her ability to develop new coping behaviors.
Myth: My loved one is only slightly below a normal weight, she just has a lot of rules about food and eating, so she is probably fine.
Fact: While it is about the food, it is not about the weight. Rituals and strict rules about eating are usually signs of specific eating disorders. Weight, on the other hand, does not determine how ill a person is. I have treated people that were stable at 75 pounds and others that were not at 135 pounds. Many people suffering from bulimia, bulimarexia, binge eating disorder and sometimes, even anorexia, are a “normal” weight. In fact those who binge and purge are often slightly over weight because purging only eliminates about half the calories eaten.
Myth: My loved one says s/he isn’t worried about weight, so it must not be an eating disorder.
Fact: Though most eating disorders do involve a fear of being overweight, not all do. Some individuals actually have a specific anxiety disorder, called obsessive-compulsive disorder (OCD). OCD is a way of compensating for or managing anxiety. The symptoms of anorexia can develop because the individual gets stuck on numbers having to do with food intake (calories) and/or weight (pounds). That person could just as easily have gotten stuck on germs and developed a hand washing obsession or neatness and developed a paralyzing need for organization and order. Another way that managing anxiety can drive an eating disorder, such as anorexia, is that anxiety is uncomfortable and anorexia gives the anxiety a focus. In other words, anxiety, unlike fear, is global and has no focus. Fear, on the other hand is specific. If you are born with a predilection to be anxious, you may “choose” to be afraid of being overweight as a way of focusing your anxiety. Fear of gaining weight has the advantage of having a built in problem-solving strategy, restricting, with a solution, losing weight. Many of my patients can verbalize how much more comforting it is to fear weight gain than to deal with the anxiety that life generally causes them. But this causes a vicious cycle to ensue.
Myth: It’s not about the food.
Fact: Actually, it is about the food, at least to some degree. The incidence of eating disorders has climbed in the past 10 years and is affecting younger children, older women, and more men than ever before. My theory is that eating disorders are on the rise in part because of the poor quality of our food. In the U.S. the food supply is becoming increasingly more polluted with dangerous sugars, fats, glutens, GMOs, damaging forms of MSG, carcinogens, and addictants. I call this food pollution. I believe that food pollution is driving a new phenomenon, Eating Deficiency Disorder (EDD) which I define as: a diet so devoid of the necessary nutrients and/or containing so many pollutants, that the body, which is under constant attack, can no longer regulate itself and loses functionality over time. It is my belief that Eating Deficiency Disorder is epidemic in the U.S. It is at the heart of the obesity epidemic, the proliferation of specific eating disorders and the myriad of illnesses plaguing Americans that are on the rise. But it is below the radar of most Americans who have been led to believe that the food supply is safe and that they will be healthy if they eat it in moderation. This theory leads to dieting and dieting leads to disordered eating. It also leads to guilt as most people blame themselves for the problems they are having with food and weight management.
Myth: Healthy eating involves eating in moderation.
Fact: Eating polluted food in moderation is not healthy, it is a recipe for disaster, disease and disordered eating. In addition to which, it is virtually impossible to eat polluted food in moderation as it was designed to be eaten in large quantities. That’s right, the majority of processed foods are designed for bingeing. They are purposely loaded with addictants, obesogens and sugars that are as addicting as heroin.
Myth: The U.S. food supply is just as safe as any other food.
Fact: The U.S. has gone from being one of the top ten healthiest developed nations in the world, to dead last. We are the most obese country in the world, with the most obese children. We are also getting shorter and we have one of the lowest infant survival rates in the developed world. All of these things are largely the result of a polluted food supply.
Myth: It is impossible to recover from an eating disorder. Treatment fails far more than it succeeds.
Fact: While it is true, treatment does fail more often than it succeeds, there is a way. My patients get well because they learn to eat clean foods and in so doing they learn to trust food again.
Research on Incidence
When researchers followed a group of 496 adolescent girls for 8 years, until they were 20, they found:
- 5.2% of the girls met criteria for DSM- 5 anorexia, bulimia, or binge eating disorder.
- When the researchers included nonspecific eating disorder symptoms, a total of 13.2% of the girls had suffered from a DSM-5 eating disorder by age 20.
- Combining information from several sources, Eric Stice and Cara Bohon (2012) found that;
- Between 0.9% and 2.0% of females and 0.1% to 0.3% of males will develop anorexia
- Subthreshold anorexia occurs in 1.1% to 3.0% of adolescent females
- Between 1.1% and 4.6% of females and 0.1% to 0.5% of males will develop bulimia
- Subthreshold bulimia occurs in 2.0% to 5.4% of adolescent females
- Between 0.2% and 3.5% of females and 0.9% and 2.0% of males will develop binge eating disorder
- Subthreshold binge eating disorder occurs in 1.6% of adolescent females
The bottom line is that 10 million females and 1 million males have life threatening eating disorders and 87% are children and adolescents under the age of twenty.
Dr. Norton offers an alternative to residential treatment, called Intensive Outpatient Treatment (IOP) that focuses on intensive therapy, clean food and the value of getting sunshine, which restores the levels of hormones that support general health and well-being. Dr. Norton has a 90 to 96% recovery rate for patients who remain in treatment. Recovery rates for most other forms of treatment, including residential treatment, are generally below 50%.
Dr. Norton’s approach offers several advantages over residential and other semi-residential or IOP programs:
- Patients can usually remain in school, or keep their jobs while in treatment because treatment is more targeted.
- Patients get 5 to 10 hours of actual therapy with a licensed psychologist, Dr. Norton, instead of 1 hour of therapy, as is the case with the majority of residential and semi-residential programs.
- Patients learn to shop for and prepare clean scrumptious foods that heal the body and allow for a slow but steady weight gain.
- Norton has adapted Dialectical Behavioral Therapy by Marsha Lenihan, to the treatment of eating disorders, which many patients have found to be life saving when it comes to regulating emotions
- Norton is a family psychologist, which is critical to the success of treatment. Anorexia begins within the context of the family. Healing takes place there as well.
- A 2010 study compared the success of individual therapy and family-based therapy and family therapy offered a distinct advantage over individual therapy.