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Frequently Asked Questions About Eating Disorders

The Johns Hopkins Eating Disorders Program

What is an eating disorder?

Eating disorders include anorexia nervosa, a form of self-starvation;bulimia nervosa, in which individuals engage in repetitive cycles of binge-eating alternating with self-induced vomiting or starvation; binge-eating disorder, which resembles bulimia but without compensatory behaviors (e.g. vomiting, excessive exercise, laxative abuse) to avoid weight gain; and atypical eating disorders, in which people may have fears and unusual behaviors (e.g. chewing and spitting or fear of choking) associated with eating. Although young women comprise the majority of people affected, eating disorders can occur in any age group. One in ten people with an eating disorder is male.   

Anorexia nervosa and bulimia are psychiatric illnesses that center on food and its consumption and are usually characterized by:

  • Excessive preoccupation with food and dissatisfaction with one’s body shape or weight
  • A compulsion to engage in extreme eating habits and unhealthy methods of weight control such as:
    o    Fasting or binge-eating
    o    Excessive exercise
    o    Self-induced vomiting
    o    Chewing and spitting or regurgitating food
    o    Laxative, diuretic, or diet pill abuse.

These unhealthy behaviors and preoccupations develop into a ruling passion interfering with physical, psychological and social well-being.

Eating disorders have many causes. They may be triggered by stressful life events, including a loss or trauma; relationship difficulties; physical illness; or a life change such as entering one’s teens, starting college, marriage or pregnancy. An eating disorder may develop in association with another psychiatric illness such as a depressive disorder, obsessive-compulsive disorder, or substance abuse. Current research indicates some people are more genetically predisposed to developing an eating disorder than others.

How common are eating disorders?

The eating disorders anorexia nervosa and bulimia nervosa, respectively, affect 0.5 percent and 2-3 percent of women over their lifetime. The most common age of onset is between 12-25. Although much more common in females, 10 percent of cases detected are in males.

What is the difference between anorexia nervosa and bulimia?

Both anorexia nervosa and bulimia are characterized by an overvalued drive for thinness and a disturbance in eating behavior. The main difference between diagnoses is that anorexia nervosa is a syndrome of self-starvation involving significant weight loss of 15 percent or more of ideal body weight, whereas patients with bulimia nervosa are, by definition, at normal weight or above.

Bulimia is characterized by a cycle of dieting, binge-eating and compensatory purging behavior to prevent weight gain. Purging behavior includes vomiting, diuretic or laxative abuse. When underweight individuals with anorexia nervosa also engage in bingeing and purging behavior the diagnosis of anorexia nervosa supercedes that of bulimia.

Excessive exercise aimed at weight loss or at preventing weight gain is common in both anorexia nervosa and in bulimia.

What causes an eating disorder?

Eating disorders are believed to result from a combination of biological vulnerability, environmental, and social factors. Once an eating disorder develops, physiological changes play a role in sustaining the behaviors and irrational patterns of thinking involved. For example, starvation increases preoccupation with food and the risk of binge-eating. For underweight patients, achievement of a low normal weight is therefore a priority for successful treatment.

Are certain personality traits more common in individuals with eating disorders?

Women with eating disorders tend to be perfectionistic, eager to please others, sensitive to criticism, and self-doubting. They often have difficulty adapting to change and are future- oriented. A smaller group of patients with eating disorders have a more extroverted temperament and are often novelty-seeking and impulsive with difficulty maintaining stable relationships.

What forms of treatment are effective for anorexia nervosa?

Treatment of anorexia nervosa involves behavioral monitoring and nutritional rehabilitation to normalize weight. Psychotherapy is aimed at correcting irrational preoccupations with weight and shape and preventing relapse. Interventions include monitoring weight gain, prescribing an adequate diet, and admitting patients who fail to gain weight to a specialty inpatient or partial hospitalization program. Specialty programs combining close behavioral monitoring with psychological therapy are generally very effective in achieving weight gain in patients unable to gain weight in outpatient settings. The fear of fatness and body dissatisfaction characteristic of the disorder tend to extinguish gradually over several months if target weight is maintained, and 50-75% of patients eventually recover. No medications have been shown to facilitate weight gain. In the case of patients under 18 years of age, family therapy has been found to be more effective than individual therapy alone.

What forms of treatment are effective for bulimia nervosa?

Most uncomplicated cases of bulimia nervosa can be treated on an outpatient basis although inpatient treatment is occasionally indicated. The best psychological treatment is cognitive-behavioral therapy, which involves self-monitoring of thoughts, feelings, and behaviors related to the eating disorder. Therapy is focused on normalizing eating behavior and identifying environmental triggers and irrational thoughts or feeling states that precipitate bingeing or purging. Patients are taught to challenge irrational beliefs about weight and self-esteem. Antidepressants have also been shown to be effective in decreasing bingeing and purging behaviors in bulimia.

Is there a biological basis to eating disorders?

Social pressure for thinness is known to influence dieting behavior. However, it does not sufficiently explain why less than five percent of women and girls develop a full-blown eating disorder because the majority of women in the United States diet at some time in their lives. Additional vulnerability factors must characterize the affected population. Family and twin studies suggest that genes predispose to an eating disorder and genetic studies are currently underway to attempt to isolate genes involved in the development of eating disorders. Abnormalities in the brain's serotonergic and dopaminergic systems are thought to play a role in the cause and or maintenance of eating disorders. Taken together these studies suggest that there may be an inborn genetic vulnerability to eating disorders in at-risk individuals, and that once dieting behavior starts it leads to biological changes that help sustain disordered eating behavior.

How do I know if I need inpatient treatment?

If you think you have an eating disorder, if your symptoms have persisted or worsened despite attempts at outpatient treatment, or if you feel constantly preoccupied by thoughts of food and weight, then a good place to start is with a comprehensive evaluation in our Consultation Clinic. You will be seen by a psychiatrist and undergo a thorough review of your history and symptoms, as well as medical tests when indicated. We ask that whenever possible you attend the consultation with a close family member or significant other, since we believe family support and involvement is very important when you are struggling with an eating disorder.  The doctor will also be interested in any medical or psychiatric problems you may have besides the eating disorder.

Common co-occuring psychiatric conditions include depression, anxiety, substance abuse and obsessive compulsive disorder. Co-occuring medical conditions that may bring patients to treatment include gastrointestinal complaints, infertility problems or mentrual irregularities, osteoporosis, or chronic pain conditions.  At the end of your evaluation, the consulting physician will review his or her impression and diagnosis of your condition and will make suggestions regarding the best next step for you in terms of treatment. These suggestions may include recommendations for medication, psychotherapy, further testing, or consultation with another medical specialist in The Johns Hopkins Health System. 

What insurance does the hospital take?

If you are being admitted to the hospital programs, both inpatient and day hospital, our business office will verify your benefits beforehand, and the admissions coordinator will contact you with information about your coverage as it applies to our program. Admission to our program qualifies as a mental health admission through the Johns Hopkins Hospital Department of Psychiatry and will be authorized under the mental health portion of your insurance, not the medical portion. Please see the Admissions page for more information.

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