Recognition to Recovery: The Fight Against Anorexia and Bulimia

Kathryn Zerbe, MD

Professor of Psychiatry and Obstetrics & Gynecology, Vice Chair for Psychotherapy and Director of Outpatient Services, Dept. of Psychiatry, Director of Behavioral Medicine, Center for Women’s Health, Oregon Health Sciences University

According to NIMH statistics, anorexia nervosa (AN) occurs in between 0.5–3.7% of Americans over a lifetime and bulimia nervosa (BN) occurs in 1.1–4.2%. Eating disorders remain the most lethal of psychiatric disorders; in the US, long-term mortality rates for AN are 8–10%, and long-term European studies have demonstrated a mortality rate over 20 years of 18–20%. Mortality rates for BN are unknown. Some clinicians also fear that deaths from eating disorders are frequently attributed to other causes (eg, cardiovascular or gastrointestinal), and so underreported.

Kathryn Zerbe, MD was chosen to be interviewed because of her contributions to eating disorders and women’s health. Dr. Zerbe has authored 3 books, and has a fourth coming out: Integrated Treatment of Eating Disorders: Beyond the Body Betrayed. She is also a member of the APA’s Task Force on Practice Guidelines for Eating Disorders, chaired by Joel Yager, which will be publishing an update of practice guidelines this Spring.

“The good news,” says Dr. Zerbe, “is that we now know a great deal more about the genetics, epidemiology, cross-cultural impact, and presentation of a wide variety of eating disorder symptoms than we knew 5 years ago. The bad news is, we haven’t developed any new, wildly successful treatments.”

Epidemiology

Eating disorders have long been considered specific to young women, and they are 10 times as prevalent in females in males. However, the spectrum of those afflicted with eating disorders is expanding to include young children and middle-aged (and older) women. Dr. Zerbe attributes the increase in childhood rates to the loss of family meal-times (and the attendant lack of meal supervision), increased exposure of children to consumer culture, and a disturbing trend toward childhood dieting. There is also evidence that group b streptococcus infections can precipitate childhood eating disorders. As for middle-aged women, Dr. Zerbe points to the stresses, biological, psychological, and social, of middle age, and “an increasing culturally based resistance to the unavoidable fact that middle age means giving up certain things and accepting certain losses.”

Dr. Zerbe further points out that some of the middle-aged women now being diagnosed with eating disorders may have had an eating disorder, or some symptoms thereof, since they were teenagers, but may have only manifested a full disorder in response to the stresses of middle-age. Others may have always had a full-blown eating disorder, but never sought clinical help.

Causes

Part of the difficulty in treating eating disorders is the complex intertwining of proximate and ultimate causes at the heart of the disorders. As Dr. Zerbe explains, “there’s no one central factor to these diseases, so you’ve got to look at them from a bio/psycho/social perspective.”

While much of the pressure to look a certain way is no doubt socio-cultural—studies of native Fijians before and after adoption of television clearly link the prevalence of eating disorders to media influence—familial background cannot be ignored. AN in particular is often linked to OCD and other anxiety disorders, which tend to run in families.

“How were physical appearance and food dealt with in the family?” asks Dr. Zerbe. “Were there losses that couldn’t be discussed? Did the patient think he or she had to be perfect? Were his or her caretakers even available to interact with him or her?”

Absent caretakers are particularly associated with the development of BN. Abuse, sexual or otherwise, is also strongly correlated with the development of eating disorders. There are also likely biological and heritable propensities toward eating disorders: studies of monozygotic twins demonstrate a clear genetic influence for AN—the evidence is currently less clear for BN. Eating disorders also commonly present with a number of other psychiatric disorders, most prevalently depression, anxiety, personality disturbance, and alcoholism. There is no clear cause and effect relationship between eating disorders and their comorbidities; there may be biologically common causes.

Treatment

“The first part of any treatment plan for anorexia,” explains Dr. Zerbe, “is to get the patient’s weight up.” This is both because there are severe, often fatal dangers attendant to malnutrition, and because self starvation actually leaves the brain deficient of nutrients it needs to establish a healthy pattern of behavior.

Most authorities believe that psychotherapy is effective only when weight has been restored to 90–95% of normal, and in many cases the necessary weight gain can only occur in a residential or in-patient setting. Bulimia patients, who are often normal weight or overweight, are often successfully treated with a combination of interpersonal therapy (IPT), cognitive behavioral therapy (CBT), and SSRIs.

Further, Dr. Zerbe notes that “psychodynamic psychotherapy and an understanding of pertinent transference and countertransference issues are also cornerstones of treatment in refractory cases; as many as 50% of patients do not get well with short-term pharmacotherapy and/or CBT or IPT.”

Conclusion

“Eating disorder symptoms are just the tip of the iceberg of other quality of life issues,” Dr. Zerbe says. “With proper treatment—and that means a committed, long-term, team approach—these patients can be freed to enjoy a much fuller, healthier life.”