P SI Y HEO PSYCHOLOGY N CD NL TO I SG TY RYI N

D E N T I S T R Y

Psychological Aspects of Bulimia and Anorexia

MICHELE L. CROSSLEY
Abstract: Basic information relating to eating disorders (EDs) will be presented. After
first outlining incidence, mortality rates and diagnostic criteria, the actual experience of living with an ED will be explored. Finally, various casual theories will be discussed as well as treatment principles and strategies. Dent Update 2004; 31: 154158

Clinical Relevance: Dental practitioners play an important role in the early recognition of bulimia and anorexia. Intervention is imperative.

anorexia nervosa and bulimia nervosa. Table 1 shows the diagnostic criteria for the two major EDs (anorexia nervosa and bulimia nervosa), listed in DSM IV,2 a manual produced by the American Psychiatric Association which identifies the diagnostic criteria used in the identification of all psychiatric disorders.

THE EXPERIENCE AND CLINICAL COURSE OF EATING DISORDERS

he aim of this article is to present some basic information in relation to Eating Disorders (EDs). In the first instance, the incidence and mortality rates will be presented. Then the diagnostic criteria used for establishing whether a person is suffering from an ED will be outlined, followed by an exploration of what the actual experience of suffering from an ED is like. Various theories pertaining to the causes of EDs will also be discussed. What role do biological, social and psychological factors play in EDs? Finally, a number of treatment principles and strategies will be outlined.

INCIDENCE AND MORTALITY RATES

The UK Eating Disorders Association1 estimate that the incidence of EDs in the
Michele L. Crossley, PhD, BA (Hons), Liverpool JMU, Faculty of Health, and Applied Social Studies, Josephine Butler House, Myrtle Street, Liverpool L1 7DN.

UK is approximately 165,000, with an approximate 10% mortality rate. The International Eating Disorders Centre claims that no other psychiatric disorder (e.g. depression or schizophrenia) has a higher death rate than that incurred by patients with EDs. An average GPs list includes approximately 2000 patients at any one time and is likely to have one or two patients with anorexia nervosa and 18 patients with bulimia nervosa. It has been estimated that 510% of adolescent girls use weight reducing techniques other than dieting, e.g. vomiting, laxatives, diuretic abuse and excessive exercising. Eating Disorders usually start during adolescence and are most common amongst adolescent girls and young women although there is now an increased recognition that young boys are also suffering from EDs (about 10% of diagnosed ED cases are male). Peak ages of onset are between 14 and 18 years, though figures suggest ED patients are getting younger. Eating Disorders often persist throughout life and people tend to fluctuate between

The DSM IV criteria tell us very little about the actual subjective experiences of people with eating disorders. In order to explore this, probably one of the best sources is still the well known classic The Golden Cage: The Enigma of Anorexia Nervosa,3 first published in 1978, and written by an American psychiatrist, Hilda Bruch. Writing on the basis of her own psychiatric clinical case material obtained from working with anorexic patients, Bruch provided the first detailed account of the experience of anorexia nervosa. The foreword to the new edition of this book shows how Bruchs work, published over 20 years ago, continues to illuminate the experience of eating disorders and contains important lessons in terms of clinical treatment. Bruchs original work was published in a climate in which health professionals had little idea of how to treat anorexic patients. Im going to put you in hospital and stick a tube down your throat and fatten you up if you dont gain weight immediately! Now eat!, was the typical thrust of such treatment (Bruch, ibid.,
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Anorexia Nervosa l Refusal to maintain body weight over a minimum normal weight for age and height (i.e. weight loss leading to body weight 15% below that expected; or failure to make expected weight gain during a period of growth, leading to body weight 15% below that expected. l Intense fear of gaining weight or becoming fat even though underweight. l Disturbance in the way in which ones body weight, size or shape is experienced, undue influence on body shape and weight on self-evaluation, or denial of the seriousness of low body weight. l In females, absence of at least three consecutive menstrual cycles when otherwise expected to occur (primary or secondary amenorrhoea).

Bulimia Nervosa l Recurrent episodes of binge eating, i.e. eating in a discrete period of time (e.g. any 2hour period) an amount of food that is definitely larger than most people would eat during a similar period of time in similar circumstances; and l A sense of lack of control over eating during the episode (e.g. a feeling that one cannot stop eating or control how much one is eating). l Recurrent inappropriate compensatory behaviour in order to prevent weight gain such as: self-induced vomiting, use of laxatives, diuretics or other medications, fasting or excessive exercise. l A minimum average of two binge eating episodes and inappropriate compensatory behaviours per week for at least three months. l Self evaluation is unduly influenced by body shape and weight. l The disturbance does not occur exclusively during episodes of anorexia nervosa. Source: APA, Draft for the DSM IV (1993)2

Table 1. Diagnostic criteria for the diagnosis of Eating Disorders.

p.ix). In this context, Bruch set out to show the need for understanding anorexia as a real thought disorder, rather than, as appearances suggest, a simple refusal to eat. Her work illustrates that in ED cases, food is being used by young people to try to cope with lives which, to them, have become too painful and unmanageable. Focusing on food and control over eating enables them to substitute the painful and difficult problems in their lives. Control over food intake is used to hide far more complex underlying psychological problems. In terms of the typical anorexic experience, Bruch clearly characterized the chief symptom as one of severe starvation leading to a devastating weight loss; s/he looks like the victim of a concentration camp is not an uncommon description (ibid., p.xix). The outstanding feature of anorexia nervosa is the relentless pursuit of excessive thinness (ibid., p.xxi) which is, in turn, related to excessive concern with body size and rigid control over eating. Perhaps more importantly, however, is the way in which this attempt to control
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eating hides underlying psychological problems relating to the (typically) female adolescents attempt to achieve a sense of independence and identity. Anorexia typically begins with a diet the same kind of dieting that we all frequently practice. But then the dieting begins to yield a powerful sense of control over the individual and his/her body becomes the main arena in which they can assert control. In a totally pathological way, the loss of weight and, ultimately, the anorexic pursuit of ultimate thinness, becomes attached to feelings of power and control. In a strange way, it fulfills the anorexics urgent desire to be special and outstanding. What frequently begins as a half-playful effort to become thinner, gradually spirals out of control as the individual begins to feel a sense of pride and pleasure at being able to do something so difficult (i.e. exist without food for prolonged periods of time). As I once heard an anorexic 18-year-old boy say when he had reduced his weight from 12 stones to 6.5 stones, Im going to prove that Im the best anorexic ever.

Of course, in addition to this sense of internal control, there is also the external control and manipulative power that the ED patients symptoms gain within the family. In a situation where s/he previously felt discounted and ineffective, the refusal to eat gets a powerful response from others, an assertion of her presence that can no longer be ignored. As dieting is transformed into fasting and wilful starvation, the anorexic gradually withdraws from normal life and relationships. Alongside this withdrawal, there is often an obsession with other projects relating to weight loss. For instance, it is not uncommon to find the intensification of already existing excessive exercise regimes. The mother of the same boy I referred to above found his diary in which, in the early stages of his ED he documented doing 1200 sit ups per day. This gradually increased as time went by and was up to 2500 by the time she read the diary. Other patients become totally obsessed with thoughts of food, details of dieting and calorie counting, and their own image in the mirror. Like other addictions, ED patients begin to experience a fasting high, a sense of euphoria; but of course this is shortlived; the longer the period of abstention from food, the more a sense of depression sets in. This is especially so when the anorexic almost inevitably breaks the starvation by a ravenous feeding binge. With the terrible fear of weight gain, nothing could be more disastrous than this crime of gorging. When this happens the food, synonymous with all that is bad, must be got rid of. This normally occurs through self-induced vomiting, laxatives, or renewed efforts at starvation. Here we see the cross-over between anorexia and bulimia bulimic episodes tend to occur in 40 to 50% of anorexic patients.

BIOPSYCHOSOCIAL FACTORS AFFECTING EATING DISORDERS

Numerous theories have been put forward to account for what causes EDs.
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These relate mainly to biological, social and psychological factors. For instance, the fact that 90% of cases of EDs affect women has led to speculation about the role of biological factors. Laboratory studies, for example, have shown that female animals are more able to withstand starvation than males. Does this have some evolutionary significance? In times of food scarcity, the female animals ability to tolerate starvation may have adaptive value (e.g. in continuing species propagation). Could it therefore be the case that females are more likely to draw on selfstarvation as a means of coping with stress? Consistent with this explanation is the higher ratio of fat to lean tissue in females relative to males. In times of food scarcity, reserve stores of fat tissue sustain pregnancy and lactation. In cultures emphasizing thinness in women, perhaps females experience more stress in efforts at dieting, given their biological predisposition towards adiposity? Other biological explanations relate to the relative complexity of female pubertal development with respect to hormonal function and connected brain mechanisms possibly these are more susceptible to disruption under stress? And finally, the fact that females are more vulnerable to certain other mental disorders, such as endogenous depression, may possibly be linked to eating disorders. Perhaps more convincing are explanations relating to social factors. Eating Disorders have traditionally been regarded as a disease of affluence. Over the past 30 years or so, they have increased throughout Western Europe, US and Japan, whereas there is relatively low prevalence in the nonWestern world. In some way, preoccupation with weight control, appearance and body image has something to do with increasing Westernization and consumerism, as thinness becomes a symbol of status in rich societies. Likewise, in the UK, EDs have been dubbed a disease of White, middle-class affluence the little rich girl syndrome. Recent research, however, has suggested that EDs are becoming increasingly common amongst
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Anorexia Nervosa l l l l l l l l Weight loss. Excessive exercising. Wearing baggy clothes. Increasing isolation and loss of friends. Moodiness. Perfectionism (especially obsessions about food, calories and ritualistic behaviour). Feeling cold, poor circulation. Growth of downy hair all over the body.

Bulimia Nervosa l l l l l l l Disappearing to the lavatory after meals in order to get rid of food eaten. Secretive behaviour. Feeling out of control, helpless and lonely, mood swings. Sore throat and erosion of tooth enamel caused by vomiting. Dehydration, poor skin condition. Hamster cheeks (enlarged salivary glands from vomiting). Lethargy.

Source: Hogg (1995: 7)1

Table 2. Early signs of Eating Disorders.

children from working class backgrounds, and also amongst Black and Asian girls. Another important social factor relates to changes in female socialization and identity. The prevalence of EDs has increased exponentially since the 1960s. This is thought to be a reaction to the altered social expectations of young women as they face new sets of pressures and demands to achieve, compete and become independent. These expectations conflict sharply with more traditional images of women as mothers and nurturers of children the traditional female role. It has been suggested that the imposition of multiplicity of role demands on women creates intense pressure which is refocused on to the intense pursuit of thinness and obsessive preoccupation with becoming fat. Another explanation comes from social modelling theories which suggest that EDs spread in the form of a fashion or contagion. In recent years, for instance, EDs seem to have been transformed from an individual into a social disease with young girls competing with each other as to who can become gauntest and the best at starvation. This is especially the case in relation to bulimia which has become faddish on university campuses. One study of a college campus in the USA, for instance, concluded that one floor in the halls of residence became known as the bulimic floor and the bathroom was

reported as smelling like a Roman vomitoira as all of the girls engaged in the fashionable activity of binging and purging.4 The mass media obviously plays an important part in this process. We exist in an entire culture of dieting and dieting books and tips all of which create a breeding ground for EDs. When media stars become associated with EDs (e.g. Princess Diana, Geri Halliwell, Posh Spice), this may create further imitation models for young girls. But even though we all live in the context of these social forces, we do not all succumb to EDs. Does this suggest a role for other factors, such as those deriving from psychological explanations? Many studies have looked at the role of family dynamics in the incidence of EDs. For instance, Bruch characterized the parents of ED patients as placing an overly strong emphasis on academic and cultural achievement. Up until the advent of problems with eating, these parents typically thought of, and referred to, their child as being perfect, no trouble, the kind of child that every parent would wish for. However, Bruch argued that what is actually happening in these families is that the child is being used (unconsciously) to fulfil the parents goals and make their own lives more complete and satisfying. For the whole of their life, up until the point when the ED person begins to refuse food, they have passively complied with
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Principles for helping people with EDs l l l l l l l Treatment must address psychological factors associated with EDs, e.g. low self-esteem and anxiety, as well as manifest eating problems. EDs need to be recognized as early as possible before habits are firmly established. Services need to be accessible and confidential to encourage people to ask for help. In both assessment and treatment, the therapists knowledge and understanding of EDs is more important than his/her specific profession. Effective treatment requires the active commitment of the patient. All approaches to treatment should promote autonomy, be flexible, provide choice and enable the development of trust between patient and therapist. Care and support may be needed over many years for people with severe problems. Family and friends need support for themselves, both to help the person with an ED and in order to cope with the impact on their own lives.

Source: Hogg (1995: 9)1

Table 3. Treatment principles.

the expectations and desires of their parents. In doing so, they may also have been covering up communication problems within the family, and possibly marital problems between the parents. As Bruch writes: An imbalance of power has existed throughout the childs life: The childs agreeable compliance conceals the fact that she had been deprived by the parents of the right to live her own life. The childs refusal to eat is the beginning of a power struggle in which the child is no longer willing passively to comply

with parental demands.

TREATMENT PRINCIPLES AND STRATEGIES

The importance of early recognition and intervention in EDs cannot be sufficiently emphasized. Early detection in schools and colleges is important because, like so many other conditions, the earlier the diagnosis, the more successful the treatment. Accordingly, Table 2 shows some of the early signs of anorexia and bulimia nervosa (N.B.: from

a dental point of view, dentists may see signs of enamel erosion as the result of self-induced vomiting). A number of treatment principles are shown in Table 3. As should be clear, getting the anorexic to eat, whether through forced feeding or behaviour modification programmes, is never a sufficient treatment in and of itself. It is critical to appreciate fully the ED patients ambivalent feelings about control. This is sometimes referred to as the control paradox for, although the anorexic patient overemphasizes control, it must be understood that s/he does so because s/he feels so profoundly out of control. Any treatment must, therefore, work from a full appreciation of the patients powerlessness and search for self-esteem, otherwise it is doomed to failure.

REFERENCES
1. 2. Hogg C. Eating Disorders: A Guide for Primary Care. Eating Disorders Association, 1995. American Psychiatric Association. Draft for the Diagnostic and Statistical Manual IV. Washington DC, USA, 1993. Bruch H. The Golden Cage:The Enigma of Anorexia Nervosa. Cambridge, Massachusetts: Harvard UP, 2001. Gordon R. Anorexia and Bulimia: Anatomy of a Social Epidemic. Oxford: Blackwell, 1992.

3. 4.

BOOK REVIEW
Treatment Planning in Primary Dental Care. By Ann Shearer and Anthony Mellor. Oxford University Press, Oxford, 2003 (109pp., 24.95 p/b). ISBN 0-19850895-6. This book is primarily aimed at the final year undergraduate dental student who requires to learn the key principles of treatment planning. It will be particularly useful to students who have to produce final case presentations, as they have to be able to demonstrate not only their practical skills, but also their ability to plan treatment well. The book has nine succinct chapters, is clearly laid out and is adequately illustrated, with no less than 42 illustrations. It has a fairly relaxed style of writing which makes for easy reading. It opens with a short chapter on principles of planning care, followed by chapters on
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gathering information, patient management, reaching a diagnosis, decision-making, clinical choices,

organizing care and continuing care. The final chapter gives treatment planning examples which are well thought out and well illustrated, but a slight criticism in this section is the lack of emphasis on the necessity of detailed pocket charting following BPE scores of 3 or more. The book also suggests that written treatment plans are a sensible precaution and are important in certain circumstances, but I do think that undergraduates should be taught that written treatment plans, however simple, are mandatory in this day and age. The book contains a wealth of useful facts and will undoubtedly be of great use to undergraduate students in their clinical years. Those who are keen to learn more on this topic will find the short section (at the end of the book) detailing references and further reading to be of interest. May Hendry GDP, Ayrshire
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