Bulimia Disorder: Theories And Treatment

ABSTRACT

Lots of people, at some point in life, worry about their weight. But for some people it leads to really serious health problems. The role of social media, in our perception of beauty, is significant in explaining noticeable the increase in the number of people diagnosed with eating disorders. His report is going to consider number of explanations for anorexia nervosa and bulimia nervosa, and evaluate treatments for it. The DSM-5 classification recognises two specific diagnoses of eating disorders:

1. Anorexia nervosa - this is an eating disorder, which makes people to lose an unhealthy amount of weight. Anorexia is more common in females than males. However, it can affect anyone of any age, gender and background. People with this disorder drastically restrict the amount of the daily food intake, they may also exercise to burn the calories after eating. Anorexia nervosa is serious mental disorder and may lead to death ( Pinheiro, Root and Bulik, 2010).
2. Bulimia nervosa is an eating disorder characterised by eating a large quantity of food in a short amount of time, followed by vomiting or taking laxatives. People affected by anorexia may excessively try to stop gaining weight. Anyone can get bulimia but it is most common in young females (NHS, 2017).

BIOLOGICAL EXPLANATION

GENETICS

The studies have shown that if the closest relatives (parents, children and siblings) suffer from anorexia the risk of developing anorexia are very high. A study has shown that one of identical twins is 55% more likely to develop anorexia if the other twin has it. However, the chances of developing anorexia, for non-identical twins is only 7% ( Holland, 1984). Studies have shown that the genetic link for bulimia is lower than for anorexia. Kendler et al. (1991), in his research reported that 23% of identical twins suffer bulimia compared to 8,7% for dizygotic twins, (Cardel, Clark and Meldrum, 2000; Hill, 2009).

PHYSIOLOGY

Eating disorders may be linked to biochemical imbalance. Research has shown that the lateral hypothalamus (LH) and the ventromedial hypothalamus (VH) work together in controlling weight. LH is responsible for production of hunger and VH is involved in terminating hunger. Once either hormone is activated, the hypothalamus sends signals to the areas of the brain responsible for thinking and behaviours that will gratify whatever is activated. A fault in this part of the hypothalamus is a possible explanation for eating disorders. Low levels of endocrine, which can cause loss of the menstrual cycle, is very common in eating disorders, this is associated with a hypothalamus dysfunction. However, not enough research and evidence have been conducted to support this thesis ( Cardel, Clark, and Meldrum, 2000). Low levels of norepinephrine, dopamine and serotonin has been found to have a link to binge eating. Eating disorders have been associated with depression, which is linked to serotonin dysfunction (Hill, 2009).

EVALUATION

Biochemical imbalances are as likely to be a result as a reason, of the eating disorder, because it can be an effect of starvation and purging. Starvation has a significant effect on the human body and it may cause an imbalance in biochemical functioning. Environmental influence plays a bigger role in eating disorders than genetic impact. In the current studies, environment has not always been controlled. It is not clear what is actually inherited. Research says that some personality traits, like perfectionism, obsessionists and inflexibility, or predisposition to inherit mental illness, may be a reason for a person to develop an eating disorder. The MZ studies are nowhere near to 100% , which shows that environmental factors do appear to be involved. However, antidepressants that raise serotonin levels are very effective in treating bulimia, which proves that increasing levels of serotonin helps to treat it. Loss of the menstrual cycle can happen before weight loss, which suggests a low level of endocrine, which is related to a hypothalamus dysfunction. However, postmodern studies have not exposed damage in the hypothalamus of those with eating disorder. One of the strengths of this model is that the anorexic is not blamed for their behaviour, and is seen as a victim of a disorder, over which they have no control. This takes away problem of accountability and labelling the person, and places the blame firmly on the disorder. The biological approach is using scientific methods, which can be verified for reliability, ( Cardel, Clark and Meldrum, 2000; Hill, 2009).

One of the weaknesses is shown the twin study, which does not take in to consideration twins who not live together and assume that both twins have an identical environment in all research cases, (Cardel, Clark and Meldrum, 2000; Hill, 2009).

TREATMENT

Antidepressants (Prozac) have been shown to be helpful for treatment of bulimia nervosa. Researchers have found out that 60mg a day of fluoxetine produced a better reduction of bulimic symptoms compared to 20mg a day and placebo (Fluoxetine Bulimia Nervosa Collaborative Study Group, 1992; Goldstein et al. 1995). For some patients the side effects of taking antidepressants may be worse than symptoms of the mental disorder and in many cases when treatment is stopped, the problem reappears. On the other hand, by reducing depression and anxiety, antidepressants help to change a patient’s perception about their body image and reduces binge eating and purging urges. Antidepressants should be a part of recovery process, as they treat symptoms, not the causes, of eating disorders. They should be used along with psychotherapy like cognitive behavioral treatment because bulimia is a complex mental illness. The cognitive treatment concentrates on changing a distorted body image and believes that the person with the eating disorder cannot be valued unless he or she has ideal physical appearance. Effectiveness of antidepressants is a proof that chemical imbalance is the cause of eating disorders. However, some psychologists argue that it could be a result, rather than reason, for eating disorders. Long-term usage of antidepressants may lead to dependency upon the drug, ( Cardel, Clark and Meldrum, 2000; Hill, 2009).

PSYCHANALITICAL THEORY

In this theory the anorexic’s refusal to eat has been understood as denial of the adult role and the wish to continue to be a child or relapse to the childhood. This theory is supported by the timing onset of anorexia (puberty) and loss of menstruation. Hilde Bruch (1979) suggested that anorexia is linked to psychosexual immaturity. In one of the theories women unconsciously associate fatness with pregnancy. They think that eating will lead to pregnancy, therefore they starve themselves. Another suggestion is that the mother may want to limit her daughter’s independence and thus want to stop her from growing up. For the daughter it is a way of continuing to be reliant on her mother, ( Cardel, Clark and Meldrum, 2000; Hill, 2009).

Eating disorders have been linked to early traumatic experiences. Thirty percent of eating disorder patients had an early experience of sexual abuse ( McLelland et al. 1991). Sexual abuse may lead to rejection, by victim, of their own body. In puberty and adolescent it may lead to disgust and desire to destroy their own body (starving themselves, self-harm).

A study of anorexia and bulimia in males, suggests that sexual orientation is the main factor. Carla et al. (1997) observed 135 patients, from 1980 to 1994. The research conducted showed that 42 percent of the bulimia group were homosexual or bisexual, and 58 percent of the anorexia group identified themselves as asexual, (Cardel, Clark and Meldrum, 2000; Hill, 2009).

According to Freud, oral fixation may lead to the development of eating disorders like bulimia. People with oral fixation are preoccupied with eating and drinking, biting nails, mouth-base aggression or smoking, which helps them reduce tension. Anal fixation, on the other hand, leads to the development of expulsive personality; compulsive seeking order, tidiness and perfectionism. People who suffer from anorexia can be described as perfectionists, with a desire to achieve the ‘perfect’ body. Added to this, Freud believed that anorexia could be explained as the patient’s way of blocking sexual instincts. He also believed that the strong influence of the superego strictly limits the id, and explains the development of eating disorders. The superego stops a person from eating, and makes him or her feel guilty, or tells them they are fat and ugly if they do eat, (Cardel, Clark and Meldrum, 2000; Hill, 2009).

EVALUATION

Psychodynamic theories focus on psychological explanations of mental disorders. Freud’s ideas had a large influence on psychology and psychiatry, and are used today. He focussed on individual patients and analysed them in detail, which is a strength. However, Freud’s concept is hard to test and verify scientifically. His concept is very subjective, it can be used to explain anything but which can predict very little. Freud used very small samples and his technics are open to bias in his research. Many of psychoanalytical concepts can be explained better and in a more scientific way (for example, the cognitive approach). Research has shown that early trauma in a female causes them to be self-critical and may lead to self-harm. Males, however, are expressing dominant and externally expressive behaviours, which may lead to aggression towards others. This can be used to explain why eating disorders are mainly female illnesses, ( Cardel, Clark and Meldrum, 2000; Hill, 2009).

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ACCEPTANCE AND COMMITMENT THERAPY

The ACT is a mindfulness based therapy. The goal of this therapy is to change the actions (eating problems), and to reduce psychological inflexibility. It helps the patients to understand that they are not their thoughts. The ACT helps patients create new narratives for their lives and helps patients to shift attention from what they have no control over (eating habits) to what is in their control. Patients are encouraged to set the goals and are taught to identify fundamental values. The goal of ACT is to live an authentic life, not to feel good. The patients are encouraged to separate themselves from emotions and they learn that pain and anxiety are an ordinary part of life. ACT can be an effective treatment for eating disorders and it could be combined with the usage of antidepressants to reduce anxiety around food and eating, (Englen, 2017).

BEHAVIOURAL THEORY

This theory focusess on the symptoms, and behaviour of the patients. It does not take biological or psychodynamic factors in to consideration. Behaviourists state that eating disorders are learnt, through classical conditioning, operant conditioning, and social learning.

• FAMILY SYSTEM THEORY (also used in the humanistic and psychodynamic system) – controlling and high expectation people are more likely to be parents of children with anorexia. Minuchin et al. (1978) applied family system approach in the development of anorexia in children. He explained that families have very strong emotional connection, strict beliefs and loyalty towards each other. As a result, children very often feel like they cannot become individual because the family is over controlling them, (Cardel, Clark and Meldrum, 2000; Hill, 2009).

Kramer (1983) identified that people with eating disorders did have higher level of family dysfunction than people from a control group (no eating disorder).

In this explanation family dynamics could be blame for an eating disorder which is not always true. Also, this theory only describes the development of eating disorders in people living at home, which is not always a case. Correspondingly, young people and adults can develop eating disorder at any time at live, (Cardel, Clark and Meldrum, 2000; Hill, 2009).

• SOCIAL LEARNING THEORY – This states that environment affects behaviour through modelling, observation, imitation and reinforcement. As a result, people copy those they admire, for example actors or celebrities. In Western culture being slim is associated with being beautiful. The actors and models, or family members may appear to be successful because they are slim. Young people may observe and imitate behaviour of the role models, and alter their own actions to try to accomplish the same rewards (praise for being slim and attention). They may get admired at first for losing weight, and looking better. However, they may then continue to lose weight, which can lead to the development of anorexia nervosa, (Cardel, Clark and Meldrum, 2000; Hill, 2009).

Classical conditioning means that dieting becomes a habit. The person who diets, get positive comments about his or hers appearance. In result, they learn to associate being slim with approbation from others. Social worth and admiration from a society may praise weight loss and control, (Cardel, Clark and Meldrum, 2000;Graham Hill, 2009).

Operant conditioning happens as approbation from others further strengthens the dieting behaviour. As an addition, it can be rewarding, in the form of attention and concern gained from parents, doctors or partner. It can also be supported by online forums and groups where it can become a competition between the members. On the other hand, it can be a way of punishing parents or a partner, (Cardel, Clark and Meldrum, 2000; Hill, 2009).

Promotion of being thin, from magazines, television and social media, makes people associate being slim with being beautiful. Social media is taking over our lives and has an impact on our society. This is predominantly true when it comes to young people and eating disorders. Keel and Klump (2003) recognised the role of media influences. Rodin ( 1991) found out that pressure from a perfectionist mother, overly concerned with appearance, on daughter to be thin, may lead to anorexia. The University of Pittsburgh School of Medicine found that people who spend most of the day on social media are twice more likely to have an eating disorder (Allie Shah, 2018).

EVALUATION

Not all women develop eating disorders, but all are subject to the same pressures from the media. This proves that other factors are involved in an explanation for eating disorders (genetic or neural factors). However, social learning theory helps to explain why a number of people with an eating disorder has increased in recent years. Social media has more significant meaning in our lives, which has an effect on people’s perception of beauty. The behavioural model takes cultural and social differences in to consideration, which is a positive. However, it does focuse mainly on symptoms not causes of the illness, which may lead to recurrence of the illness, through different symptoms. Behaviourists believe if the behaviour has been learned it can be unlearned, through classical and operant conditioning, (Cardel, Clark and Meldrum, 2000 ; Hill, 2009).

TREATMENT

Family-based treatment for anorexia nervosa

This is an efficient and cost effective treatment for anorexia nervosa. This treatment recognises importance of parents being involved in a child’s recovery. They are in charge of recovery of the child and require their child to eat. Parents are the leaders of the child’s care, a therapist works as an adviser to them. It is an advantage because parents are people who know and love a child the best and this allows a child to have treatment at home. Parents are in charge of food choices, which helps the child to overrule the controlling need to restrict food. This treatment focuses on prompt weight gain, which very often leads to a decrease or disappearance of many symptoms of anorexia.

However, this treatment has its limitations. It is not recommended for families in which parents are physically or sexually abusive, take drugs or are abusing alcohol. For some families this type of treatment is impossible to implement, due to financial problems, working full time or other responsibilities. Some patients may not be able to gain weight at home and need to be hospitalised even with family support. Also, some patients may have other medical or psychiatric issues, that make home-based treatment dangerous. This treatment could be used with ACT to reduce psychological inflexibility, and change the patient’s negative self-evaluation and through that, reduce the chances of recurrence of the eating disorder, (Cardel, Clark and Meldrum, 2000; Hill, 2009).

CONCLUSION

Eating disorders are serious and complex mental illnesses. The consequences of using laxative and starvation are serious and permanent, and can lead to a person becoming infertile or even to death. There is some evidence suggesting a genetic link but it should not be isolated from the environmental impact. The behavioural model joins social and cultural ideals of slim being beautiful, and proposes that dieting is a habit powered by the media. The cognitive model, on the other hand, blames development of eating disorders on an illogical and faulty perception of body and weight. The psychodynamic and humanistic theories, recognise the connection between family dynamics, (Cardel, Clark and Meldrum, 2000; Hill, 2009).

BIBLIOGRAPHY

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