Anorexia and Bulimia Nervosa: Is Recovery Possible?
David B. Herzog, MD; Professor of Psychiatry & Pediatrics
President of the Harvard Eating Disorders Center Director: Eating Disorders Unit, Mass. General Hospital
Q:When and how did you first become interested in eating disorders?
A:My interest started when I was a pediatric resident at the University of Wisconsin where I would see teens with eating disorders. This was back in the 1970s when it was more of a teen phenomenon. The psychiatrists thought these patients were too ill medically to handle and the pediatricians thought it was a psychiatric problem. No one wanted to own the problem. I became curious as to why these patients starve themselves and want to lose weight.
Q:Could you tell us briefly about the different types of eating disorders?
A:The two major eating disorders are anorexia nervosa (AN) and bulimia nervosa (BN). AN is characterized by the relentless pursuit of thinness and low body weight (less than 85% of expected body weight). There is an intense fear of weight gain, disturbed body image and loss of menses. There are two types of AN, the restricting subtype and the binge/purging subtype.The latter is characterized by binge eating/purging.
BN is characterized by binge eating, which is the consumption of an excessive amount of food in a discrete period of time and feeling out of control during the binge episode. In order to avoid weight gain, the BN patient compensates for the binge by purging through vomiting, using laxatives, exercising excessively, or fasting. Like those with AN, persons with BN are consumed by thoughts of body weight and shape. Binge Eating Disorder (BED) is a provisional diagnosis in the DSM-IV characterizing a subgroup of the obese who binge eat but do not purge. BED came out of studies of the obese seeking treatment in weight-loss clinics.
In the past there wasn’t a psychiatric diagnosis that insurance would cover for the obese who wanted mental health treatment. It will likely be a formal diagnosis in the next iteration of the DSM. There is also Eating Disorders NOS (Not Otherwise Specified), which is the most common presentation for those seeking treatment for an eating disorder. These individuals present with nearly all symptoms of AN or BN. For example, an individual with EDNOS may meet nearly all the criteria for AN except they are menstruating, or they may meet all criteria for BN but are binge eating less than twice a week.
Q:In your 1999 NEJM article there is a table of the physical findings...is there anything you would add?
A:Yes, I would add neurological complications and neuropsychiatric issues; also, changes in CT Scans and MRI’s that at least partially normalized with weight gain, decreased white & gray matter and increased CSF in spaces.
Q:What about laboratory testing and other diagnostic studies; you described some in that paper, is there anything you recommend?
A:Lab tests that I recommend are: 1) measurements of serum electrolyte and serum glucose levels 2) complete blood count 3) thyroid-function tests if thyroid disease is suspected.
Q:What is the life expectancy of someone with anorexia?
A:Although mortality is high, those who recover have a normal life expectancy.
Q:Which of the physical findings occur as a result of starvation, binge eating, vomiting, or laxative use?
A:Please see the following table.
Q:What is a favorable outcome for anorexia?
A:Recovery or substantial improvement. A favorable outcome is being able to lead a productive life without medical or psychiatric impairment. It is important to know that these patients can recover or substantially improve. In general we are talking about limited symptomatology that minimally impacts on functioning. With AN we expect that they will regain weight, be fertile, and become less obsessed with their weight.
Q:For bulimia, what is a favorable outcome?
A:Recovery, but generally having limited symptomatology. This is important to note since BNs who have persistent symptomatology are more likely to relapse. Outcomes may vary, but it is favorable if the binging and purging has decreased to minimal frequency so that they no longer affect medical or psychiatric functioning.
Q:Is anorexia the same if a girl never menstruates vs. one who develops the disease late in life or in college?
A:There are different complications, for example starvation in the pre-teen years may affect ultimate growth. Those who manifest AN as a young teen and get help early have the best outcome. However, to answer your question, the college age student or adult who develops AN has a similar clinical presentation as the young teen with AN.
Q:How is anorexia the same and different than concentration camp or starvation?
A:There have been interesting studies addressing this question, such as the study by Ansel Keyes in which men were starved in a laboratory setting. Many behaviors observed among these men were similar to those commonly seen in AN, such as irritability, binge eating, and obsessionality with food. What is different with AN is a marked denial of illness or the severity of illness. In AN, there is also severe body image disturbance. ANs often report they feel better when they restrict, making treatment more difficult.
McKnight Brain Institute
Editor in Cheif: Mark S. Gold, MD
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