MGH Eating Disorders Clinical and Research Program: Frequently Asked Questions
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Frequently asked questions about eating disorders.
Frequently Asked Questions
The following responses to frequently asked questions may be helpful to you but should not substitute for a doctor’s advice.
- How common are eating disorders?
- What is binge eating disorder?
- What causes an eating disorder?
- I'm worried that my daughter might have an eating disorder. How can I talk to her about this?
- I think I have an eating disorder, but I feel embarassed to tell my doctor about my symptoms. What should I do?
- My friend has an eating disorder but won't get help. What can I do?
- Can an eating disorder be treated with group therapy?
- What is cognitive behavioral therapy like for an eating disorder?
- Do eating disorders cause medical problems?
- I've heard that anorexia nervosa can cause osteoporosis. Is there a way to treat this?
- I've finally recovered from my eating disorder but still haven't gotten my menstrual period. Should I be worried?
- What is a healthy body image?
ResourcesFor information about eating disorders, here are some publications and organizations that may help.
How common are eating disorders?
Eating disorders affect millions of people at any given point in time. Rates of eating disorders are particularly high among females between the ages of 12 and 35. Estimates indicate that approximately 0.5 to 3.7% of females have anorexia in their lifetime, while 1.1 to 4.2% of females experience bulimia and 2-5% of men and women have binge eating disorder in their lifetime. The documented incidence of eating disorders has doubled since the 1960's; some of this increase may reflect greater awareness and identification of problems. Our culture is keenly aware of body weight and shape, and concerns begin early in life, as reflected by reports that 40-60% of high school girls diet, and 13% of high school girls purge. Eating disorders most often develop during adolescence or early adulthood, but there are some reports of onset in early childhood and older adulthood.
Eating disorders have long been thought of as problems affecting affluent white females. Although the prevalence of eating disorders in other socio-demographic groups is lower, we are seeing an increase in eating disorders among males and individuals from a variety of socio-economic and cultural backgrounds. The specific nature of the eating disturbance, as well as protective and risk factors, may vary, but the distress and impact on functioning occurs across gender and culture. It is estimated that approximately 5-15% of people with anorexia or bulimia and 35% of people with binge eating disorder are male.
What is binge eating disorder?
Most of us have times when we feel that we overate, but simply eating a lot of food on certain occasions does not necessarily mean that you have binge eating disorder. Experts agree that binge eating involves eating an unusually large amount of food (someone else observing would agree that the amount was large) in a discrete period of time and feeling as though it is hard to control the eating behavior (i.e., it's hard to stop even though you really want to). Binge eating:
- People with binge eating disorder also have additional habits such as eating rapidly, past satiety or when not hungry, or alone.
- They commonly feel distressed or bad after such an episode.
People with binge eating disorder do not use purging behaviors on a regular basis, such as self-induced vomiting, laxatives, excessive exercise or fasting. This distinguishes binge eating from bulimia nervosa. Binge eating disorder is associated with more severe obesity, earlier onset of weight problems and dieting, more frequent dieting, and significant weight and shape concerns. In addition, as many as half of all people with binge eating disorder are depressed or have experienced depression in the past. Individuals with binge eating disorder are usually overweight, but some individuals maintain a weight in the average range. Researchers have shown that people with binge eating disorder report more stress, health problems, trouble with sleep, and suicidal thoughts compared to people without an eating disorder. Binge eating is often linked with great distress and feeling badly about oneself, and sometimes the behavior and associated feelings can interfere with social situations, relationships, work or school.
If you think that you have binge eating disorder, you are not alone, and there are effective treatments available.
What causes an eating disorder?
This is an excellent question, and one that does not have an easy answer. Over the years, our understanding of the underlying cause of eating disorders has changed significantly. Eating disorders were once thought to be found only in high-achieving, affluent, Caucasian teenagers with demanding families. Adolescent girls were thought to starve themselves to prevent the body changes and social expectations associated with becoming a woman. Now, we believe that eating disorders are related to a combination of biologic, psychologic, and social factors. They affect men and women of every age, socioeconomic, ethnic, and cultural group.
Eating disorders are associated with other psychiatric illnesses such as substance abuse, depression, anxiety, and obsessive-compulsive disorder. Like other psychiatric illnesses, they tend to run in families, which suggests an underlying genetic component. Eating disorders typically arise during life transitions (puberty, starting college, getting married, childbearing, changing jobs), or other stressful events (moving, death in family, divorce, loss of significant relationship, trauma or abuse). Sometimes, there are clear family problems that contribute to the development of an eating disorder. At other times, they arise in people with very loving, supportive families.
Finally, cultural and societal expectations of beauty, which are perpetuated by the media, can lead to negative body image, which can in turn lead to disordered eating and exercise. For most people struggling with an eating disorder, several of the above factors converge to cause eating disorder symptoms. Effective treatment often involves teasing apart the underlying factors, and targeting each with an appropriate intervention.
I'm worried that my daughter might have an eating disorder. How can I talk to her about this?
It is important to approach your daughter in a calm, empathic, and non-judgmental manner. Tell her that you've noticed a change in her weight, exercise patterns, or attitudes toward food, and that you're concerned that she may have a problem with eating or exercise. It is important for her to hear that you are interested in understanding what is going on rather than trying to blame her or to control the situation. Encourage her to respond to your concerns. Ask her what she would like you to do. Parents often need to learn to walk the fine line between being helpful and supportive on one hand, or having their child perceive them as being overly intrusive.
Adolescents vary considerably in their need/desire for parental involvement, and they like to be included in discussions about this. If she says that she doesn't know how you can be helpful, offer to speak to her pediatrician, or to set up an evaluation with a nutritionist or mental health professional. If she is resisting help, or says that there is nothing to worry about, tell her that you are still worried, and would like a professional's advice. While adolescents can resist limits, they need them, and despite their protests feel reassured that their parents are involved and concerned. If you ever become concerned about your child's safety, due to low weight, threats of self-harm or threats of harm to others, seek emergency care immediately.
I think I have an eating disorder, but I feel embarassed to tell my doctor about my symptoms. What should I do?
You are not alone. Many people struggling with an eating disorder feel too ashamed or embarrassed about it to tell anyone, including their doctors. Yet there are some important reasons not to let your embarrassment stop you from telling your physician or counselor.
First, because eating disorder symptoms can lead to many potentially serious and even life-threatening medical risks, it is necessary to obtain a careful medical examination. Second, letting a doctor or counselor know about an eating disorder is a crucial step in the recovery process. Research has shown that telling a doctor or counselor about an eating disorder is linked with a greater likelihood of getting treatment for it.
We offer the following suggestions to help you summon your courage to talk with your doctor or counselor. Keep in mind that doctors, nurses, and counselors have heard the eating disorder story many times before and are comfortable hearing detailed descriptions of the symptoms. If you do not feel you can trust your doctor, ask friends (maybe even someone who has been in your situation) or family members that you do trust for the names of physicians and counselors they have found helpful. You might even consider bringing a friend or family member along to your appointment for support. Some people find it easier to complete a questionnaire about eating disorder symptoms prior to the appointment and then show it to their doctor.
My friend has an eating disorder but won't get help. What can I do?
First of all, she is fortunate to have your friendship. It is impossible to force someone into treatment unless they are ready to get help. That being said, you can sit down with your friend and let her know that you have noticed that her eating patterns have changed, and that you are worried that she might have a problem with eating or exercise. It is important to approach the discussion in an empathic, non-shaming manner. Your friend may become angry, or may accuse you of being jealous or wanting to make her fat. This may be very difficult to hear, but try not to take it personally.
Due to the underlying eating disorder, people who are struggling with poor self-esteem and distorted body image sometimes lash out at the people who care about them. If your friend responds in this manner, calmly tell her that you regret that she feels that way, but that you are concerned and want to find a way to help her. Remain available to her in case she changes her mind. If your friend agrees to get help, she should contact her primary care physician for referrals to a dietician and mental health clinician. If your friend is a child or teenager, you really need to let her parents know why you are concerned, so that they can help her. You should also find a family member, teacher, or counselor to talk to so that you don't feel so alone with this problem.
Can an eating disorder be treated with group therapy?
Group therapy has been shown to be a powerful and effective method for treating bulimia nervosa for almost two decades. Patients with bulimia nervosa suffer from the isolation of shame about their disorder and lack of information on how to treat it. The context of a group provides immediate support with others who are addressing the same concerns. Most patients with bulimia have symptoms five to eight years before seeking treatment because they believe they can stop the symptoms at will, but this is difficult to do alone.
Group therapy provides support while learning healthy eating patterns, setting behavioral goals, and learning interpersonal relational strategies that empower individuals to be more effective in their roles outside the group by practicing within the safety of a group setting. The types of group therapy range from long-term, open-ended, psychotherapy groups, to time-limited cognitive-behavioral groups (CBT) and interpersonal psychotherapy groups (IPT) to integrative models that combine strategies. (See Riess H, Dockray-Miller M: Integrative Group Treatment for Bulimia Nervosa. Columbia University Press, New York, 2002)
Group therapy for patients with anorexia nervosa are helpful once denial about the illness is addressed and if the patient feels comfortable in a group setting. Often the first group experience will be on an in-patient unit. It is generally advised not to combine patients with bulimia nervosa and anorexia nervosa in the same groups because of differences in treatment focus.
What is cognitive behavioral therapy like for an eating disorder?
People enter treatment for an eating disorder with different expectations and ideas about what therapy will be like, perhaps based on previous experience, what others have said, or media portrayals. It can be helpful to clarify expectations before beginning treatment. Cognitive-behavioral therapy (CBT) has received increasing attention over the past decade as studies have shown its effectiveness in the treatment of eating disorders, anxiety disorders, and depression. But, many people wonder what exactly is CBT, and what is the treatment like?
CBT is a type of psychotherapy that emphasizes the role of our thoughts in how we feel and what we do. It is an active and collaborative process that focuses on behavior change and identifying, challenging, and modifying thoughts and beliefs (cognitions). It is structured, goal-oriented, and focused on current problems. Sessions usually follow a pattern, such as a brief check-in about the week, review of any home work, setting the agenda and then discussing items on the agenda, and finally a summary and wrap-up of the appointment with a plan for between-session homework or behavioral experiments. Patients are encouraged to participate in setting the agenda to reinforce the collaborative approach and to practice skills of identifying problem areas, prioritizing, and advocating for oneself. Homework sounds worse than it is! It could consist of filling out a daily form (e.g., a food log or thought record) or of trying a new behavioral experiment (e.g., adding breakfast, delaying purging, checking out an assumption about what someone else thinks). The idea behind homework is that when trying to learn anything new, including new ways of thinking/interpreting events or new behaviors, it takes practice in one's day-to-day life.
One important aspect of CBT is learning more about the chain of events that surround a behavior. For instance, the therapist and patient might spend time examining the thoughts, feelings, and circumstances that precede binge eating or purging. Early in treatment, this kind of "functional analysis" can provide insights into the reasons why a person is engaged in eating disorder behaviors (e.g., to cope with interpersonal difficulties or to reduce anxiety/stress). It can also help identify specific high-risk situations. Early treatment often consists of education, self-monitoring (to learn more about patterns of behavior and thinking), and behavioral experiments. Gradually, the work begins to focus more specifically on thoughts that influence feelings and behavior. Generally, treatment focuses on the present, but it can be useful to understand how certain behaviors or thoughts developed. So, sometimes treatment will look to past experiences and relationships to better understand current ones.
CBT is usually short-term and time-limited (16 weeks is typical); for individuals with anorexia nervosa, descriptions of CBT highlight that treatment is often a longer-term process.
Do eating disorders cause medical problems?
Eating disorders are the psychiatric illnesses with the highest rates of medical complications, including death. Because eating disorders can be associated with severe physical problems, patients should be closely followed by a primary care physician or, if indicated, a medical specialist. Some of the complications are minor and bothersome, while others can be life threatening. The following paragraphs outline some common medical complications of eating disorders:
Eating disorders can commonly be associated with weakness, inability to tolerate cold temperatures, and hair loss due to malnutrition and low body weight. Sometimes, because the body is trying to conserve energy, starvation can cause problems with thinking, poor concentration, poor energy, problems with sleeping, and loss of interest in previously enjoyable activities. These symptoms closely resemble depression, so it is important to have a mental health clinician evaluate the situation. The above symptoms will usually improve as nutritional status improves and weight is restored to a healthy range.
Stomach acid, which comes in contact with teeth during vomiting, can erode the enamel and can cause severe dental cavities. Patients who induce vomiting should seek help from a dentist to prevent ongoing dental problems. Patients with eating disorders commonly report stomachaches or constipation, which can be related to dehydration, and lack of bulk in the diet. Again, these symptoms often resolve as the body gets used to refeeding, and can also be treated by increasing fluid and fiber intake to a healthier range.
Furthermore, when body weight is very low, patients will sometimes grow downy hair, called lanugo, on their body. This happens because there is not enough body fat present to insulate the body. Almost like fur, this special hair helps keep the body warm; it typically goes away as weight normalizes.
In addition, many women with eating disorders experience changes in their menstrual periods. Their periods may become irregular, or may disappear completely. Some women have difficulty getting pregnant when they are struggling with eating problems. However, it is important to remember that one can still get pregnant, even when periods are irregular or absent, so it is important to continue to protect yourself against pregnancy if you do not wish to be pregnant. As nutritional status improves, periods will often become more regular, and fertility can be restored. Sometimes, a gynecologist or endocrinologist will be involved in treating these issues.
Binge-eating can lead to obesity, which can subsequently lead to high blood pressure, heart disease, diabetes, and increased risk for cancer. Monitored, moderate weight loss and regular exercise can decrease the risk of each of these health problems.
More severe medical side effects include life-threatening irregularities in heartbeat, which can cause cardiac arrest and sudden death. These are most commonly caused by abnormalities in electrolytes, such as potassium, which are necessary for the heart to beat properly. Vomiting and diarrhea, which often results from laxative or enema abuse, can lead to very low levels of potassium. Water pills can also cause electrolytes to become abnormal. However, it is important not to take potassium supplements unless directed to do so by your doctor, as high levels of potassium can also cause heart problems.
Syrup of ipecac, which is used to cause vomiting, is very dangerous and should not be used. It can lead to an abnormal thickening of the heart muscle, which also can cause life-threatening heart problems.
Repeated retching during vomiting can cause tears in the esophagus, which can bleed. It is very important to let your doctor know immediately if you see blood in vomit, or have blood in the stool or black stools that look like tar. Finally, chronic laxative and enema use can damage the bowel and may cause it to become dependent on medicine to have regular bowel movements.
I've heard that anorexia nervosa can cause osteoporosis. Is there a way to treat this?
"Osteopenia" is thinning of the bones and "osteoporosis" is severe thinning of the bones. This results in weakening of the bones. About 90% of young women with anorexia nervosa suffer from bone loss, putting them at increased risk for fractures.
Nutritional recovery, particularly if accompanied by resumption of menstrual function (periods), can result in large improvements. Therefore, a multidisciplinary team approach to recovery of anorexia nervosa is highly recommended. In addition, adequate calcium and vitamin D intake are important but do not themselves, particularly in the absence of weight recovery, result in improvements in bone density. Because recovery can be a long process for many women with anorexia nervosa and residual bone loss common, finding effective therapies for bone loss in women with anorexia nervosa is important.
Despite the fact that estrogen therapy is effective in reversing bone loss in postmenopausal women, it does not increase bone density in women with anorexia nervosa in their twenties and older. In fact, there are no established effective therapies for bone loss in women with anorexia nervosa at this time.
The Neuroendocrine Unit is actively investigating whetherphysiologic estrogen replacement may be effective in increasing bone density in adolescent girls and studying several potential therapies for adults and welcomes participants in its studies.
I've finally recovered from my eating disorder but still haven't gotten my menstrual period. Should I be worried?
It is not uncommon for menstrual period recovery to lag behind nutritional recovery. This phenomenon is not fully understood but may relate to the following.
First, emotional stress, in the absence of low weight, can lead to lack of menstrual periods. Some women who are weight-recovered may still be experiencing emotional distress, which may contribute to the delay in return of menstrual periods.
Second, normal reproductive function appears to depend on amount of body fat, not just weight, and the lowest weight at which women menstruate may change over time. For women who recover weight but exercise excessively, very low body fat may prevent the return of menstrual function. Third, the part of the brain that controls menstrual function, the hypothalamus, and pituitary, may take a while to wake up after having been inactive for a long time in a woman with an eating disorder. Although menstrual periods return in most women with eating disorders, lack of periods is permanent in a minority of such women.
It is also possible that your menstrual periods have not returned for some reason unrelated to your eating disorder. Although this will not be the case for most women with histories of eating disorders, it is important to see a physician to make sure that there is not an additional cause that it would be important to treat. Signs of another problem can include production of breast milk, headaches or facial hair growth, but there may be no specific warning signs, so a visit to the doctor is strongly recommended.
The good news is that most women whose menstrual periods do not return after recovery from an eating disorder can become pregnant with the help of fertility treatments. Your doctor can advise you when it is medically safe to plan a pregnancy if you have had an eating disorder. Also, of note, lack of periods while taking a birth control pill is rarely a cause for concern.
What is a healthy body image?
Your body image is the way you perceive, think, and feel about your body. It is how you see yourself when you imagine yourself in your mind or when you look at your reflection. It is the beliefs you have about your body, including memories and assumptions. It is how you feel about your size, shape, and weight and also how you feel in your body.
With a healthy body image, you have a real perception of your size and shape (you see it as it really is), you have positive thoughts about your body (accepting and respecting), and you feel comfortable and confident in your body most of the time. A healthy feeling about your body includes an appreciation of your natural body shape and all that your body allows you to do.
One very important component of a healthy body image is understanding and believing that physical appearance is not a reflection of a person's character and value.
In reality, everybody has days when they feel uncomfortable in their body or they feel unhappy about how they look. But, if you work on developing and maintaining a healthy body image, those kinds of days will be fewer and will have less of an impact on how you feel in general. Work towards a healthy body image:
- Challenge cultural norms that promote the idea that looking a certain way will bring happiness, wealth, success, or love.
- Appreciate what your body can do, not just what it looks like.
- Respect your body and treat it with kindness, including rest, fuel, and moderate exercise.
- Remember that every body is different and we all have unique genetics that influence our bone structure, weight, shape, and size.
- Surround yourself with people and activities that allow you to feel good about yourself and your abilities. If you feel good about yourself, the size and shape of your body will be less important in how you define yourself as a person.
- Wear clothes that feel comfortable.