Starving for perfection: The changing face of anorexia

Anorexia nervosa and other eating disorders pose new diagnostic and treatment challenges as they affect younger and older patients.

By — Posted May 5, 2008

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It was a daily menu of gum and tea sprinkled with 20 or so over-the-counter diet and water pills, 10 laxatives and six hours running on the treadmill. A few times a week, she would cut on her body with knives she kept taped under chairs; a release of pain, anger and starved emotions. At night she would lie awake, agonizing about how she could stay committed to this regimen.

"I'd eat one meal a week if I had to," says Sherri Crowl, now 40, of Edinboro, Pa. "My eating disorder started when I was 8." After 30 years, Crowl was diagnosed with anorexia nervosa. "I kept thinking, if I could be thinner, people would be in awe of me and want to be that size, too."

With eating disorders often passed off as a phase, intervention can be delayed or nonexistent. "Primary care and family physicians are so underutilized in getting people into treatment," says Kimberly Dennis, MD, a psychiatrist and medical director at Timberline Knolls, a residential treatment center near Chicago that helps women with eating disorders, addictions or other destructive behaviors. "Denial is huge, and a high-functioning intelligent woman who is not maintaining a healthy weight is easier to let go. Many physicians don't know what to do."

Take Crowl. When her heart had nearly stopped beating, she assured friends, family and medical professionals she was healthy. When she finally sought help, the doctor who did the admitting tests said her heart was beating so slowly that without treatment, she would die in a month. "I was shocked," she says, explaining that she still kept thinking that she exercised six hours a day -- of course she was healthy.

Her story is not so rare. Bodies of all ages fade into wisps of what once was, and anorexics are dying at a rate of 10% to 20% from complications of starvation or from suicide. Still, skeletal frames continue to sashay down runways; extreme- makeover programs highlight body perfection; and reality shows reward weight loss and excessive exercise. In the war on obesity, thinness has become the hallmark of success. "There's this continued glorifying of unhealthy and unnatural images," says Harry A. Brandt, MD, a psychiatrist and medical director of the Center for Eating Disorders at the Sheppard Pratt Health System in Baltimore.

To further complicate diagnosis, anorexia is no longer only a disorder of white teenage girls. It affects all ages, races and cultures. It even can cross gender boundaries. About 15% of anorexics are men. "Men are underdiagnosed and undertreated," Dr. Brandt says. "If a man loses weight, the physician does a mega medical work-up. It couldn't possibly be an eating disorder."

The disorder's new faces

The face of anorexia is changing, says Brenda Woods, MD, a family physician and director of primary care medicine at Remuda Ranch in Wickenburg, Ariz., an inpatient and residential treatment facility for women and girls, with facilities in Virginia and Arizona. "We are seeing age spectrums different from what is expected. We've had a 400% increase in calls by women older than 40 and a 700% increase in the child population, age 7 and 8. That's why we started a child program."

Many anorexic children can't verbalize why they don't eat or why they will eat only certain foods at certain times. "Maybe they had a previous episode of choking and that scared them, or somewhere they developed a fear of becoming fat," Dr. Woods says. "It's very common. If Mom is always on a diet and not eating what the family eats, the child will mimic that behavior."

All the while, the pressure to be thin reaches younger ages. According to the National Center for Health Statistics, 51% of 9- to 10-year-old girls feel better about themselves if they are on a diet. Forty-two percent of first- to third-grade girls want to be thinner, and 81% of 10-year-olds are afraid of being fat.

"Extreme dieting sets up a competition among kids," Dr. Brandt says. "There's the cohort effect. One or two start dieting, and there is a competition to be thinner."

That's how it was for Ileah Foster. "I am African-American, and [dieting] is not relevant in our culture. I wasn't overweight, but I was bigger than my friends. I wanted to be skinny like them," says the now 27-year-old Houston resident who struggled with anorexia. "After I began to lose weight, I loved the way I felt, the feeling of being hungry. It was like a drug that I needed."

Foster recalls a time the family was having pizza and her father forced her to eat two pieces. "I waited until everyone was in bed and went into the garage and ran in place for an hour-and-a-half to burn it off," she says.

Images in society, however, whether on TV or in print, can make coming back from this disorder difficult. There are even more than 500 pro-anorexia Web sites. "They are promoting an illness," Dr. Brandt says. " We've tried to put pressure on providers to close these sites down."

These sites -- also known as pro-ana for those related to anorexia and pro-mia for those geared to bulimia -- deny charges that their messages perpetuate disordered eating behaviors. Still, they offer tips and tricks on dieting, self control, secrecy or ways to hide behaviors. Stanford University researchers say about 39% of America's young people visit such sites, and 96% report learning new dieting and purging techniques.

Crowl admits she was embarrassed to seek treatment because she was older. "I thought 38-year-old women don't have eating disorders."

It's estimated that the number of people older than 40 with anorexia has quadrupled in the last five years. The Renfrew Center near Philadelphia, where Crowl was treated, developed a program, Thirty-Something and Beyond, to meet the needs of this population. The symptoms are similar to those of younger patients, but the stressors and triggers are different -- spouse, children, older parents. "There are huge issues of loss," says Holly Grishkat, PhD, a clinical psychologist at the center. "Often their lives are out of control. What's difficult, especially if they've been this way for 30 or more years, the anorexia has become part of their personality."

Dr. Woods blames part of the problem on what she calls "Desperate Housewives Syndrome" after the TV show. "The boomers are getting older, and they are often the dieters of 20 years ago, still unhappy with their bodies," she says. "There is a lot of pressure to take back the body of their 20s or teens. They think, if I lose weight and get fit, I'll stay young."

People in this age stratum with anorexia can be classified into three general groups: Those who have had an eating disorder since they were 16; those who had anorexia as a teen but mid-life changes are triggering a return; and those with later-life onset. Each category has specific challenges, potential complications and comorbidities. For example, a major complication of lifelong eating disorders is osteoporosis. "They might be 35 and already had a hip fracture," Dr. Woods says. "Some younger women have the bones of a 70-year-old. They can develop pneumonia or have renal insufficiency as a result of chronic dehydration."

Intervention and treatment

Anorexia is often about control and emotion, and at its core are issues greater than food. "The general profile of the anorexic is a perfectionistic tendency," Dr. Woods says. "They are focused, organized and driven, and that goes into their attitudes about food. Anorexics are rigid, and they are preoccupied with weight, shape and size."

Some are dealing with old scars, fear of abandonment, distorted body image, feelings of inadequacy and not fitting in. For many, it is emotion management. "Their problems are often with living life, being in relationships," says Dr. Dennis of Timberline Knolls. Many anorexics also face comments from well-meaning friends, family and physicians -- "Why don't you just eat," or "Oh, it's not that bad, you look fine" -- that push them further into the disorder.

Anorexics come in many sizes. Some are able to not appear too thin. Others may be 5'4" and weigh 70 pounds. It is not only difficult to diagnose and treat, it has the highest suicide rate of mental disorders. About 5% of diagnosed patients fully recover, and 40% relapse in the first year. For 75%, it is a lifelong condition.

Children tend to get sick quickly and deteriorate medically, Dr. Woods says. "Their prognosis is good with early intervention. Still, some are missed. They are starving, but because they are growing taller, their weight doesn't change."

Dr. Woods says it's important to talk to children about what they are feeling, to find out what's behind their behavior. Are they worried about something? Are their friends dieting? Are they trying to lose weight? "Eating disorders are about feelings," she says. "It's also important in children to make sure there is not a medical cause for the weight loss."

Primary care physicians have the opportunity to make important interventions for patients young and old. They need to ask the specific questions about what patients are eating and doing in terms of diet and exercise habits. And they need to be caring and honest, Dr. Dennis says. "Don't worry if the patient responds with anger -- that's meaningful. And it might be a time to engage the family."

Once in recovery, some anorexics cannot get on a scale or know what they weigh. Yet office staff insist, Crowl says. Once she is on the scale, they often make comments about what they see. "When that happens, my mind spirals," she adds. "If I hear my weight, I will start to restrict. I'm so fixed on numbers."

It's a hard cycle to break. Dr. Brandt says new data on eating disorder prevention underscore the importance of people being comfortable in their own bodies and realizing what is overweight for one person might not be for another. "Maybe you are at your body's normal body weight. Maybe you have the genetics to be large. Discrimination against the obese drives people to change, and we encourage people to engage in unhealthy behaviors. Genetics loads the gun, and society pulls the trigger."

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Warning signs of anorexia

A person with anorexia:

  • Is thin and keeps getting thinner -- may lose 15% or more of ideal body weight.
  • Diets or restricts foods even though not overweight.
  • Has a distorted body image and feels fat even when appearing thin or underweight.
  • Is preoccupied with food, calories, nutrition or cooking.
  • Will deny hunger.
  • Will exercise obsessively.
  • May complain about feeling bloated or nauseated even from eating normal or less than normal amounts of food.
  • Gets on the scale with abnormal frequency.
  • May have hair loss or hair thinning.
  • May feel cold even though the temperature is normal or only slightly cool.
  • May stop menstruating.

Source: The Renfew Center (link)

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Dying to be thin

For some, it is a slow, methodical starvation over decades. For others, especially children, its pace is quickened. And it is this painful, silent struggle that leads anorexics to suicide at a rate 57 times greater than that of a similar population that does not have the eating disorder.

It was long believed that such high numbers were the result of this population's compromised physical health. But in a study published in the April Journal of Affective Disorders, researchers found that the rate of successful suicide attempts was a result of using highly lethal methods -- ingesting toilet bowl cleaner, jumping in front of trains, poisoning with carbon monoxide -- rather than poor health. "This suggests they have a strong determination to die," says lead author Jill Holm-Denoma, PhD, a professor of psychology at the University of Vermont in Burlington.

This study began at the University of Florida when Dr. Holm-Denoma was working with her mentor, Thomas Joiner, PhD. The findings are consistent with Dr. Joiner's theories, published in his 2006 book, Why People Die by Suicide. He concluded that individuals with anorexia may habituate to the experience of pain during their illness and accordingly die by suicide using methods that are highly lethal. "These people experience a ton of pain. They fight off hunger every day, and they often have painful medical conditions," Dr. Holm-Denoma says. "It's important for physicians to understand that anorexics have a higher capacity for suicide."

Primary care physicians need to know that suicide rates for anorexics are higher than all other psychiatric disorders. "It's important to do regular suicide checks," she says. "Patients might say, 'If I were going to kill myself I might ...' Physicians need to be thinking about what they will do if a patient discloses such information. If patients with anorexia report that they do, in fact, have suicidal intentions, there needs to be an immediate plan to keep them safe."

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