Dying to Be Thin

ByOPINION By CYNTHIA BULIK

Nov. 16, 2006 — -- The documentary "Thin" by Lauren Greenfield, which debuted Tuesday on HBO, only shows an uncomfortable slice of treatment for eating disorders, and is not a true picture of anorexia nervosa, or of any eating disorder.

The film also does not illustrate that treatment is possible and is available.

"Thin" shows us only a narrow snapshot of eating disorders. Anorexia nervosa and bulimia nervosa exist on a spectrum of severity. The film looks at patients with more serious cases. An eating disorder isn't always easy to recognize by someone's skeletal frame.

By focusing on these difficult cases, "Thin" creates the feeling that treatment for eating disorders is futile and that there is little hope for recovery. But there is real science behind treatment for eating disorders, and people with eating disorders can and do get better.

Patients and families who are seeking help for eating disorders have the right to know that the treatment program they are entering is a solid one.

So in real life, off the documentary screen, how can we understand what it's like to have an eating disorder?

Some studies suggest that more than one in 10 women suffer from some form of an eating disorder. But it's not a strictly females-only disease. Men also suffer from these disorders, and it appears that they are now becoming more common in men and boys.

Anorexia nervosa has the highest mortality rate of any psychiatric disorder. That means, more patients die from anorexia than from depression, or schizophrenia, or any other mental disorder.

People with anorexia have low body weight and are afraid of gaining weight.

They often can't see their bodies the way other people do, and they don't think their eating disorder is a big deal, even though their entire self-esteem rests upon their body weight.

Many anorexic women stop having their periods.

Cynthia M. Bulik, Ph.D., is the director of the UNC Eating Disorders Program at the University of North Carolina at Chapel Hill; a professor of eating disorders in the department of psychiatry at the UNC School of Medicine; and a professor of nutrition at the UNC School of Public Health.

Bulimia nervosa is seen in people of all body weights, so there goes the notion that only thin people have eating disorders.

People with bulimia binge and purge. They have recurring episodes of binge eating, followed by some form of compensatory behavior, such as vomiting or taking laxatives.

Binge eating is eating an unusually large amount of food coupled with a feeling of being out of control.

The binge-eating disorder is marked by binge eating without the compensatory behaviors and marked distress regarding binge eating. People with BED are often overweight.

How common are eating disorders?

The official prevalence of anorexia nervosa is around three-tenths of a percent, of bulimia nervosa it's around 1 percent, and of the binge-eating disorder between 1 percent and 3 percent. But the numbers soar if you include people with milder forms of the disorders.

What treatment options are available and how effective are they?

Treatment for anorexia nervosa can occur inside or outside of the hospital -- and usually not in settings like "Thin" suggests. The documentary makes a true point, that inadequate insurance coverage often cuts short a recommended treatment stay. In contrast, treatment for bulimia nervosa and binge-eating disorder in the United States is typically done outside the hospital

No medications have been found to be effective in treating anorexia nervosa, although some medications can help alleviate associated depression and anxiety.

Some studies suggest that cognitive behavioral therapy may reduce the likelihood of a relapse in adults with anorexia nervosa after their weight has been restored.

The therapy focuses on the unhealthy thoughts that underlie unhealthy eating behavior and works to replace them with healthier alternatives.

One study shows that a treatment combining elements of sound clinical management and supportive psychotherapy by an eating-disorder specialist was more effective than cognitive behavioral therapy during the acute phase of anorexia.

For younger patients with a relatively short length of illness, specific forms of family therapy, which focus initially on parental control of renutrition, hold promise.

This approach in adolescents leads to clinically meaningful weight gain and psychological change.

Cynthia M. Bulik, Ph.D., is the director of the UNC Eating Disorders Program at the University of North Carolina at Chapel Hill; a professor of eating disorders in the department of psychiatry at the UNC School of Medicine; and a professor of nutrition at the UNC School of Public Health.

For bulimia nervosa, group or individual cognitive behavioral therapy can calm some of the binge and purging behaviors, and can better the psychological picture of bulimia in both the short and long term.

Cognitive behavioral therapy is the treatment of choice for bulimia nervosa.

New studies are also exploring the role of self-help and technology -- enhanced therapies for bulimia nervosa.

The only Food and Drug Administration-approved medication for any eating disorder is fluoxetine (Prozac), which has been shown to reduce the core bulimic symptoms of binge eating and purging and associated psychological features in the short term.

It is unclear whether these effects persist after the person stops taking the drug.

We still don't know how long a person needs to take the medication to get as well as possible.

Individuals with binge eating disorder often have two treatment targets -- eliminating binge eating and reducing weight. Individual and group cognitive behavioral therapy is effective in reducing binge eating, but it is unclear how well that helps with depression and weight loss.

Various medications have been tested in binge-eating disorder (including selective serotonin reuptake inhibitors, antidepressants, an anticonvulsant, and one appetite suppressant).

While short-term studies suggested that selective serotonin reuptake inhibitors helped some, most studies did not follow patients long enough to know whether the changes in binge eating, depression, and weight persisted.

For binge-eating disorder, combining cognitive behavioral therapy and medication may improve both binge eating and weight loss. Self-help also plays a role in treating binge-eating disorder, especially in less severe cases.

Ultimately, recovering from an eating disorder is a long and painful process. But what patients, family and friends should understand is that treatment and recovery are possible.

Cynthia M. Bulik, Ph.D., is the director of the UNC Eating Disorders Program at the University of North Carolina at Chapel Hill; a professor of eating disorders in the department of psychiatry at the UNC School of Medicine; and a professor of nutrition at the UNC School of Public Health.

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