Most individuals meet the criteria for two or more eating disorders at different times. Many people do not meet the criteria for an eating disorder, but do show behaviours and concerns that fit in an eating disorder. They are diagnosed with other specified feeding or eating disorder.

Anorexia nervosa

People with anorexia nervosa are hungry themselves, while they are already well under a healthy weight. They do this by not eating or eating for a long time. Although they are already very thin, they insist that they have to lose even more weight. People with anorexia refuse to maintain a healthy, normal weight. Although these people are very emaciated, they have an intense fear of weight gain or fat. They have a disturbed idea about their bodies and think they are fatter than they actually are and therefore have to lose weight.

The self-esteem of these people depends entirely on their body weight and the control over their eating behavior; they feel good when they lose weight and are guilty or worthless if they do not succeed. Due to the loss of weight, people with anorexia nervosa are often chronically fatigued. Despite this fatigue, they continue to draw up heavy training programs to lose weight.

Anorexia nervosa usually starts between 15 and 19 years. 90 to 95 percent of all cases with anorexia nervosa are women. Due to the weight loss, the menstrual cycle stops in girls and women with anorexia, this is called amenorrhea . In the DSM-V the criterion for amenorrhea has been removed from the diagnostic criteria, because many girls with anorexia nervosa still have menstrual activity. Anorexia is, in a physical sense, a dangerous disorder. Serious complications such as a very low heart rate or damage to the kidneys may be the result; 5 to 8 percent of people with anorexia will die of it.

There are two types of anorexia nervosa. People with the restricting type of anorexia nervosa refuse to eat, or eat very small amounts, to prevent them from gaining weight. Some do not eat anything for days. People with the restricting type of anorexia nervosa often have a feeling of distrust towards others and the tendency to deny their problems.

The other type is the binge / purge type of anorexia nervosa. These people have binge eating (binges) that alternate with actions to prevent weight gain (purge). This often happens through deliberate vomiting or use of laxatives. People with the binge / purge type of anorexia nervosa often have varying moods, problems with the control of their impulses, problems with alcohol and self-mutilation.

The binge / purge type of anorexia nervosa is very similar to bulimia. The difference is that people with the binge / purge type of anorexia nervosa do not have a healthy weight, while people with bulimia nervosa generally have a healthy weight or even a bit of overweight.

Just like in the DSM-IV, people with anorexia nervosa have a significant low body weight. The DSM-V suggests that a BMI of 18.5 is the lower limit of a healthy body weight. Anorexia nervosa is mild if the BMI is greater than or equal to 17, on average if the BMI is 16 to 16.99, and serious if the BMI is 15 to 15.99. The severity is determined not only by the BMI, but also on the basis of clinical symptoms, the degree of functional impairment, or the need for supervision.

The prevalence of anorexia nervosa is higher since working with the DSM-V, because two criteria that were still in the DSM-IV have been removed. The first criterion was that someone had to be at least 15% below the normal body weight, and that women should have amenorrhea. Not all girls met this, so the prevalence was lower.

Ten to fifteen years after diagnosis, about 70% are no longer diagnosed with anorexia nervosa, but many of them continue to have eating problems or other psychopathology, such as depression. People with the binge / purge type often have more comorbid mental disorders than people with the restricting type. In particular, impulsive, suicidal and self-damaging behavior occurs.

Bulimia nervosa

The important characteristics of bulimia nervosa are uncontrolled binge eating, followed by actions that prevent weight gain. The definition of binging, the uncontrolled binge eating, is described in the DSM-IV when, in a short time (such as 1 to 2 hours), it is consuming an unusually high amount of food in a given situation and can not control it. They eat more than a normal person in such a situation and can eat in that time frame. Binge eating can vary in size per person. Most people with these binge eating are actually not hungry at all. At such a moment they lose control of their eating behavior.

As with patients with anorexia, the self-esteem of a bulimic patient is highly dependent on their figure and body weight. However, they have no disturbances in their body image. After the binge eating they want to make sure they do not arrive. Surrendering is often associated with bulimia. However, excessive exercise or fasting can also be used by patients to control their weight. In the DSM-V the criteria for bulimia nervosa have been relaxed compared to the DSM-IV. The minimum number of times per week in which binge / purge behavior is to be shown is reduced from 2 to 1 time per week. The prevalence will therefore increase. Bulimia nervosa is more common in Western cultures than in non-Western cultures. It often occurs in adolescence. Bulimia can also cause serious medical complications and result in death. One of the most serious complications is an imbalance of electrolytes, which is due to the loss of fluid after excessive and chronic vomiting. Suicide is also 7.5 times more common in people with bulimia nervosa. Bulimia nervosa is often chronic.

Binge-eating disorder

People with Binge-eating disorder appear in behavior on people with bulimia nervosa but do not show the actions to compensate for the binge eating and to prevent them from arriving, such as vomiting, fasting or excessive exercise. These people are often too heavy, disgusted by their bodies and are ashamed of their behavior. They can often eat throughout the day without any planned eating moments for breakfast or lunch. There are also people who eat a lot at certain scheduled times. They usually do this as a result of stress, depression or anxiety. People with this disorder often have obesity and a history of dieting. Most people have family with obesity. This eating disorder is also more common in women. People with binge-eating disorder often also have depression or an anxiety disorder. In addition, they are more likely to have alcohol abuse and personality disorders. This disorder also appears to be chronic.

Other eating disorders

Some people present patterns of behavior that are very similar to anorexia or bulimia nervosa, but does not fully meet the criteria of these disorders. This eating disorder is called partial syndrome eating disorder . For example, people with this syndrome suffer from a binge only a few times a month. They can weigh too little, but are not far below their normal weight. They derive their self-esteem from their weight. The symptoms are therefore the same as those of anorexia or bulimia, but they are not serious enough to get the diagnosis of this eating disorder. The people with this syndrome often have psychological problems such as an anxiety disorder, substance abuse, depression and sometimes suicidal tendencies. They have a lower self-esteem, poorer health and a lower appreciation for life than healthy people.

The DSM-V has added a new diagnostic category called other specified feeding or eating disorder. This includes expressions of eating disorders that cause clinically significant stress or defects, but do not meet the diagnostic criteria for one of the eating disorders discussed. The partial-syndrome eating disorder just discussed falls within this new category. In the DSM-IV this category was called 'eating disorders not otherwise specified' (EDNOS). EDNOS is often as severe and persistent as bulimia nervosa or anorexia nervosa. The DSM-V category of other specified feeding or eating disorder includes disorders such as atypical anorexia nervosa, in which all criteria for anorexia nervosa are met, except for the underweight. Another example is bulimia nervosa of low frequency and / or limited duration. All criteria for bulimia are met, except that the binge eating and compensation behavior occurs less than once a week or for less than three months. A final example is the night eating syndrome, a new disorder in the DSM-V. People with this disorder eat excessive amounts of food after dinner and at night. They often suffer from insomnia and believe they must eat to fall asleep. People with this disorder are often overweight and often have depression.

Obesity

Obesity is defined as a BMI of 30 or more (weight / height²). It is not an eating disorder in the DSM-V, but it is a risk for a person's health because of a higher risk of heart disease, strokes, diabetes and cancer. The higher your BMI, the greater the chance of dying earlier.

We live in a poisonous society, where you can find food with a lot of calories that is cheap. We play less, and often do not get the necessary movement. Not everyone who comes in such an environment is overweight or even obese. Genes influence how your metabolism works and how much fat you store.

Many people diets to no longer have excess weight. Many do not keep the whole diet full and are disappointed with the results, because more is promised than is realized in them. There are even medicines to lose weight, although they do have side effects. The best way to eat fewer calories and exercise more. There are also possible operations, such as a stomach reduction. It is difficult to get weight off, but even harder to keep it off.

Cultural and historical trends

It is said that eating disorders are culture-related because they occur mainly in the West, where thin is the ideal image. There is also a historical trend for eating disorders. The number of cases of anorexia and bulimia increased between 1930 and 1970 and then remained almost the same. In Curaçao, where mostly black people live, there is less of an eating disorder. This while the disorders on Curaçao do occur.

Statements for eating disorders

It is very plausible that the development of an eating disorder is caused by a combination of biological, cultural-social and psychological factors.

There is evidence that the predisposition for both anorexia and bulimia nervosa is hereditary: 33-84% is in the genes. Much biological research is performed on the hypothalamus, because the hypothalamus plays a major role in regulating eating behavior. The hypothalamus receives messages about food intake and nutritional values ​​and ensures that people stop eating when they are satisfied. These messages are delivered by neurotransmitters and hormones. The deviant eating behavior can be caused by these substances being out of balance or improperly regulated, or by problems in the structure of the hypothalamus.

People with anorexia nervosa have a less well functioning hypothalamus, and abnormal levels of the neurotransmitters serotonin and dopamine The only question is whether this is the cause or the result of the behavior of anorexia patients.

Many people with bulimia show abnormalities in the neurotransmitter serotonin. A lack of serotonin seems to make the body hungry for carbohydrates.

How it is that people with anorexia or bulimia have such a wrong self-image can unfortunately not be explained biologically.

Cultural-social norms regarding beauty ideals play an important role in eating disorders. In the past 45 years the ideal image of women has become thinner. This slimming ideal, which is mainly promoted by advertising, influences the self-image and causes the feeling not to comply with the norm. Role models such as actresses and models are almost always slim and promoting this idea of beauty. Anorexia and bulimia are more common in women than in men, probably because thinness is more valued in women than in men In women's magazines there are also more diets. The social pressure to be thin and beautiful is even more emphasized in TV shows with make-overs. All these things can be a reason for an eating disorder. Of course there is also social pressure in your environment, namely of family and friends.

These disorders occur less frequently in less developed countries. Certain groups within a culture, such as athletes, also have an increased chance of developing unhealthy eating behavior, especially if their body weight is experienced as an important factor in mutual competitions. Women who practice a sport in which you have to be thin, such as gymnastics, often struggle with their bodies during puberty. For their sport a girl's body is desired and not the curves of a woman. They try to counteract the origin of the female forms through diets.

Eating disorders are also more common among athletes, especially those who do sports where weight is an important factor in the competition. Think of dancing, horseback riding, wrestling and bodybuilding.

Eating disorders can sometimes be a way to deal with painful emotions. Thin people then develop anorexia or bulimia, people with preponderance develop binge eating to deal with their problems (binge-eating disorder).

Having depressive symptoms has proven to be a predictive factor in the development of an eating disorder. A distinction is made between two types of deviant eating patterns in which binge eating is central to the regulation of emotions: the dieting subtype and the depressive subtype. People with the dieting subtype are very concerned about their figure and their body weight. They vomit or do exercises to prevent them from arriving. People with the depressive subtype of eating patterns also worry about their figure and weight, but suffer from depressive feelings and low self-esteem; they often eat to not feel anything. They have greater social and psychological problems.

For people with an eating disorder the appearance is very important. They think that achieving the ideal, slender figure produces social and psychological benefits. Eating disorders are common in people who are dissatisfied with their bodies, are often perfectionists and have low self-esteem. Other research has shown that people with eating disorders are more attracted by the opinions of others, want to conform more to the wishes of others and are rigid in their opinion about themselves and others (something is either good or bad). Many are obsessed with their eating habits and plan their days around it.

Girls with eating disorders were often very good and listened carefully to what the parents said. They used to be very good at everything they did, want to achieve a lot, are dutiful and are often compliant daughters who want to be perfect. The parents often have high expectations of the child and the child is not allowed to express negative feelings. In these families the family members are very dependent on each other and it is difficult to develop their own identity. They do not learn to identify their own feelings and desires and therefore do not learn to deal with negative emotions. If even physical sensations, like hunger, are not recognized, this can lead to anorexia nervosa.

In adolescence, especially girls develop an eating disorder due to separation anxiety of the parents and fear of independence. This is especially the case with families who are too involved, where especially little freedom is given to girls. Control over the food gives them the feeling of regaining control over their lives.

Treatments of eating disorders

Treatments for anorexia nervosa

People with anorexia nervosa often do not want psychotherapy. They want to keep control over their behavior and can hardly deal with a therapist's attempts to change behaviours. They also want to keep their weight and body as it is now, they often do not want to arrive at a healthy weight. Winning the trust of the patient is therefore very important. Most anorexia patients are first forced into hospital because their underweight has reached an extreme form. If there is therapy to be given, gaining trust is even more difficult, because the patient has to come against her will. Psychotherapy helps, but it is a lengthy process. The patient must first reach a healthy weight and then the self-image must rise. Unfortunately, many people with this disorder fall back into old habits after the therapy has been completed.

In individual therapy the emphasis is placed on learning to recognize one's own feelings and the trust in them. Only then can people react to feelings of hunger in the right way. This therapy is usually cognitive behavioral therapy, in which the patient is confronted with the overvaluation of being thin. The patient must also arrive at a healthy weight in a natural way. In behavioral therapy patients are rewarded when they arrive in body weight. Because taking food often provokes fear and tension, they also learn relaxation exercises, which they can use during eating. Another frequently used method is family therapy. The anorexia patient and the family are treated as a unit. Sometimes parents must first be reminded of the severity of the eating disorder because they consciously or unconsciously stimulated eating behavior. The therapist will map the interaction problems within the family and show the role of anorectic behavior within the family. Often the parents are over-protective, controlling, have too high expectations and children are not allowed to express their feelings. The therapy lasts half a year to a year, with ten to twenty sessions.

Psychotherapy is usually a very lengthy process. Usually it takes years before the anorexia patient is cured. It often happens that people return to old habits or to bulimia nervosa after a good period of time.

Therapy for bulimia nervosa and binge-eating disorder

Cognitive behavioral therapy appears to be most effective for the treatment of bulimia nervosa. Cognitive behavioral therapy is based on the assumption that anxiety about the figure and body weight are the central characteristics of the disorder. Wrong cognitions are identified, and the patient is confronted with this. In addition, healthy eating patterns are taught using behavioral therapeutic methods. The patient must eat three healthy meals per day. Here, 'forbidden food' as bread must also be reintroduced into the diet. In interpersonal therapy, the therapist tries to solve the interpersonal problems related to the patient's eating problem with bulimia. Supportive-expressive therapy has the same goal as the interpersonal therapy, but in this therapy the therapist deals with the patient in a non-directive manner. The patient must talk about the problems related to the eating disorder.

Only behavioral therapy can be given. Here the diet is adjusted, with food that is healthier and prevents a binge.

For bulimia nervosa, cognitive behavioral therapy works best because it addresses both the thoughts and the behavior. This is also the best approach for binge eating disorder.

Because depression is often associated with eating disorders, antidepressants are prescribed to patients. By tricyclic antidepressants take bingeing and vomiting sometimes get bulimia nervosa patients more control over their eating behavior. Patients, however, fall back into their old behavior when the medication is stopped. Research into the effects of SSRIs also shows a decrease in bingeing and vomiting, but no change in behavior. Antidepressants are not effective in anorexia patients and SSRIs can only help anorexia patients when they have reached their normal weight.