Question: Can you briefly define eating disorders? (Some of the different types and general causes?)

Answer: Eating disorders can be understood based on three core underlying features. First, individuals with eating disorders have an extreme preoccupation and over-concern with body shape and weight. Body image is so important that the individual's self-worth and self-image are linked to, and strongly affected by, changes in weight. Second, because controlling weight is so significant, and fear of weight gain is so strong, individuals with eating disorders are perpetually dieting.

Whether successful at dieting or not, the attempt at dieting is almost always there (what we call "cognitive dietary restraint"). Eating patterns are often unstable, erratic, and extreme. The person with an eating disorder is either trying to lose or maintain weight, and often imposes rigid dietary rules and restrictions. Because dietary rules are typically arbitrary and extreme (e.g., "NO carbohydrates today!"), individuals may often feel like they have "blown it" and may be inclined to react by going to extremes (i.e., further bingeing, purging, greater restriction). Individuals typically feel great shame and remorse for their perceived transgression.

Finally, there are primary core beliefs and needs underlying the individual's preoccupation with food and attempts at controlling weight. Whether the behaviors involve restrictive dieting and over-exercising, or episodes of "out-of-control" bingeing and purging, these behaviors are learned and conditioned strategies for coping with other problems and issues. Whether being used to numb or escape from painful emotions, provide a sense of mastery and control, cope with stress and anxiety or build self-esteem, the individual with an eating disorder is using food and weight as a means of regulating difficult emotions and coping with stressful life events. The goal is to help the individual learn to tolerate and cope with difficult issues directly and more effectively.

The three most common eating disorders are anorexia, bulimia, and binge eating disorder. Anorexia is characterized by the following key features: a. extreme food restriction leading to weight loss and a lower than normal body weight, b. intense fear of gaining weight or becoming fat, and c. unrealistic body image. Bulimia is characterized by: a. recurrent episodes of binge eating (i.e., eating large quantities of food in a discrete period of time and feeling a lack of control over eating during the episode), b. recurrent inappropriate behaviors to prevent weight gain, and c. preoccupation with body shape and weight. Binge eating disorder is characterized by: a. episodes of binge eating in which the amount of food eaten is perceived as excessive and the eating episode is experienced as "out-of-control," b. extreme feelings of distress and upset during and after the eating episode, and c. unlike bulimia, there are no regular attempts to engage in compensatory behaviors to "make-up" for the binge.

Several risk factors have been identified in the onset eating disorders. We generally think of eating disorders as arising from a complex interaction of genetic and environmental variables. Genetic variables include the individual's biological and personality make-up. Common personality attributes include being highly perfectionistic and achievement oriented, obsessional, highly self-critical, impulsive, fearful, and avoidant. Other common factors include being prone to depression, suffering from low self-esteem, anxiety, and mood instability. Genetics and psychobiology play a role in the tendency to crave or like certain foods, and the tendency to be comforted and soothed by eating. Other predisposing variables include past struggles with weight and family history of eating disorders. Environmental variables include a history of being bullied or teased, trauma history and disruptive life events. Dieting is a risk factor because of the deleterious biological consequences and maladaptive thoughts and beliefs about food and weight that result from extreme dieting. Finally, cultural images and messages also play a profound role in shaping unrealistic expectations and demands, especially in individuals who are highly self-critical and suffer from low self-esteem.

Q: What role does high fashion and the glamorized image of the perfect, impossibly thin body type have in developing eating disorders?

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A: High fashion plays a significant role for a number of reasons. First, as the question itself indicates, the images shown in the media are "impossibly thin." There is no such thing as "perfect." Not all, but many models themselves adopt disordered eating behaviors to maintain an unnaturally low body weight. Images portrayed in the media are either the extreme exceptions, maintained with lots of hard work and/or disordered behaviors, or presented to the public after lots of doctoring and airbrushing. Most human beings are not genetically programmed to look the way the glorified models and actors are portrayed (neither are they). Unfortunately, eating disorders are alive and well in Hollywood. Consider the model who dines on cotton balls to offset hunger and to avoid appearing bloated.

We are all born into the world with natural body weights. Most of us are not designed to look the way "the perfect model" is presented. Take an impressionable young adolescent girl who doesn't have very high self-esteem, struggles with her identity, and wants to feel good about herself. She only has to look as far as a magazine cover for the image of that "perfect" person she wishes she could be. That perfect, unattainable image holds hope for her happiness. If only she could look like the girl on the cover, then all of her problems would be solved. She would be happy, confident, popular, accepted. ... (But an adolescent with low self-esteem who is looking to improve self-worth views that image as the "quick fix solution to all her problems.") These images create impossible standards which impressionable, struggling children are particularly vulnerable. They believe that looking like these glamorous images is the gateway to true happiness. ... Why doesn't it work? Well, first, the image is unattainable and unnatural. It's an image, an illusion, designed to create a reaction. But most important, true self-esteem does not come from "fixing" yourself to look like an image on a magazine cover. It doesn't come from fixing yourself, it comes from accepting yourself.

Q: Who does it affect? (Teens? Boys as well as girls? Age groups?)

A: The images can affect anyone. The images send powerful messages: if you look like me you will be happy, successful, have it all. Anyone might be affected in varying degrees, but the greatest risk period for the onset of an eating disorder is during puberty. Teens are especially vulnerable for a number of reasons. Adolescence is a time of enormous change and development. It is a time when personality and identity development is occurring. They are under enormous social and academic pressure. They have a great need to be accepted and liked and to fit in. Normal hormonal and physical changes (such as increased fat stores) are also occurring at a time when kids are most vulnerable to the social pressures to be thin and the emphasis on appearance is so high. Kids often report feeling "betrayed" by their bodies. The physical and emotional changes of puberty, combined with the over-emphasis on appearance in our culture, can trigger all kinds of disordered eating in sensitive children who have low self-esteem and want to be seen and accepted.

Boys and girls alike are influenced by media images and social pressures to maintain a particular body type. While girls are more inclined than boys to be dissatisfied with their bodies (55 percent of girls vs. 41 percent of boys), the percentage of boys is significant. Boys who have been teased for "being chubby" or participate in sports with weight requirements and high athletic demand are particularly at risk for developing eating disorders. While girls are compelled to achieve a slender image as seen in the modeling industry, it is more common for boys to seek the physique shown in the body building fitness industry. Boys are bombarded with images of male models and actors, shirts off, flashing their "six pack abs" surrounded by beautiful women. Males more commonly suffer from a condition called "muscle dysmorphia," or "bigorexia." This is a condition where the individual works out compulsively but never quite feels that he is "muscular enough." The emphasis is on body building and sculpting.

Q: How do you treat eating disorders that are related to the pressures of living up to that sort of cultural ideal?

A: A. By teaching the individual to question and challenge the media ideals. By teaching them to look beyond the image and consider the underlying reality. By teaching them how to recognize the unnatural and unattainable nature of these images and to get angry at the messages. By teaching them to question their assumptions and beliefs about what these images mean. By teaching them to recognize what these images are intended to convey and why (certainly not designed for their best interest). To recognize that the cultural ideal is just that, an impossible ideal. To recognize how achieving that ideal would require self-punishment, deprivation, and, ironically, feeling even more inadequate. To recognize how maintaining that ideal, if even possible to achieve, would come at a heavy cost.

B. By helping people understand how and why they are vulnerable to these images. By helping them recognize the deeper source of their unhappiness that leads to being vulnerable to these images. By understanding the source of one's core issues and self-esteem deficits and making positive changes to support healthy self-esteem. By developing effective skills for managing difficult emotions and challenging situations, both of which are unavoidable aspects of life. By helping them realize the irony of trying to achieve greater self-esteem by punishing themselves to look like unattainable images. By promoting healthy and balanced self-care. By learning to separate feelings of adequacy and self-worth from physical appearance. By teaching that self-esteem does not come from complying with an artificial social image (it doesn't work -- it is fleeting and superficial). True self-esteem comes from greater self-acceptance, and from making positive changes that support deeply held values and life goals.

Q: How effective is treatment and how important is early detection?

A: Early detection and intervention are extremely important. Data are very strong showing a correlation between early intervention and recovery. On the flip side, we know that the longer an eating disorder persists, the more difficult it is to treat. Not impossible, but more difficult.

Behavior patterns become deeply conditioned and reinforced over time; engrained habit patterns form. Consider, for example, a marble at the top of a hill, it will roll down whatever path it is pushed. Eventually, the path of the marble becomes so established it is almost impossible for it to go down any other way. If the marble is pushed in a different direction before the groove is formed, a new path will form and it will naturally go down this one instead. In the same way, with early intervention, we can retrain the brain to learn new coping mechanisms before negative behaviors become entrenched.

In terms of recovery, it is estimated that approximately 30 to 50 percent of people with anorexia have a full recovery and approximately 50 to 70 percent of people with bulimia have full recovery; approximately 30 percent have a partial recovery from both illnesses, and approximately 20 percent have no substantial improvement in symptoms. Typically, recovery from bulimia is faster and has an overall higher success rate than anorexia.

Comprehensive treatment should include psychotherapy along with nutritional counseling and close monitoring by a medical doctor. Successful treatment of an eating disorder requires directly targeting the eating disorder behaviors and beliefs, as well as the core underlying emotional issues.

Q: What are some early warning signs to look for?

A: There are many signs of an eating disorder; listed below are some key "red flags" suggesting there might be a problem. Of course, many of these behaviors can exist in the normal adolescent -- watch for the pervasiveness, number, and consistency of these signs. Prominent behavioral signs include sudden and dramatic weight loss or gain, restrictive or chaotic eating patterns, such as skipping meals, going on a "diet," eliminating food groups, and refusing to eat certain foods because they are "fattening." Other changes in eating include switching to veganism or vegetarianism and avoiding family meals and social events involving food. Watch for food rituals such as picking food apart, cutting food into tiny bites and eating extremely slowly.

Other important behavioral signs include wearing baggy clothes to hide one's body, weighing oneself frequently, increased time spent in front of mirrors, talking about food and dieting, counting calories and fat grams, extreme exercise routines (e.g., can't miss a day; runs despite bad weather, injury, or illness), and frequent trips to the bathroom after meals.

There are many emotional signs suggesting the presence of an eating disorder. Such changes in mood include: increased irritability and moodiness, loss of interest in activities, social isolation and withdrawal, difficulty with attention and concentration. The individual may suddenly appear sad and sullen, anxious or depressed, express feelings of worthlessness, or make disparaging remarks about "being fat or ugly." The individual's mood may be strongly affected by perceptions and thoughts about appearance.