Shani, age 15 : While I was learning to resist the temptation of hunger, I walked into the kitchen when no one was around, took a slice of bread out the packet, toasted it, spread butter on it, took a deep breath and bit. Guilty. I spat it in the trash and tossed the rest of it in and walked away. Seconds later I longed for the toast, walked back to the trash, popped open the lid and sifted around in the debris. I found it and contemplated, for minutes, whether to eat it. I brought it close to my nose and inhaled the smell of melted butter. Guilty. Guilty for trashing it. Guilty for craving it. Guilty for tasting it. I threw it back in the trash and walked away. No is no, I told myself. No is no.

… And no matter how hard I would try to always have The Perfect Day in terms of my food, I would feel the guilt every second of every day. It reeked of shame, seeped with disgust and festered in disgrace. It was my desire to escape the guilt that perpetuated my compulsion to starve.

In time I formulated a more precise list of “can” and “can’t” in my head that dictated what I was allowed or forbidden to consume…. It became my way of life. My manual. My blueprint. But more than that, it gave me false reassurance that my life was under control. I was managing everything because I had this list in front of me telling me what—and what not—to do….

In the beginning, starving was hard work. It was not innate. Day by day I was slowly lured into another world, a world that was as isolating as it was intriguing, and as rewarding as it was challenging….

That summer, despite the fact that I had lost a lot of weight, my mother agreed to let me go to summer camp with my fifteen-year-old peers, after I swore to her that I would eat. I broke that promise as soon as I got there…. At breakfast time when all the teens raced into the dining hall to grab cereal boxes and bread loaves and jelly tins and peanut butter jars, I sat alone cocooned in my fear. I fingered the plastic packet of a loaf of white sliced bread, took out a piece and tore off a corner, like I was marking a page in a book, onto which I dabbed a blob of peanut butter and jelly the size of a Q-tip. That was my breakfast. Every day. For three weeks.

I tried to get to the showers when everyone else was at the beach so nobody would see me. I heard girls behind me whispering, “That’s the girl I told you about that looks so disgusting.” Someone invariably walked in on me showering and covered her mouth with her hand like I was a dead body. I wished I could disappear into the drain like my hair that was falling out in chunks….

While everyone else was out there swimming, tanning, making out, playing sports, volunteering and team building, I hid in my tent and wrote letters to my mother reassuring her that I was eating. I told her that I ate peanut butter and jelly sandwiches every morning for breakfast….

[Upon returning to school] I was labeled the “concentration camp victim.” On my return, over the months everyone watched my body shrink as though it were being vacuum packed in slow motion…. At my lowest weight my hipbones protruded like knuckle bones under my dress and I had to minimize the increments of the belt holes until there was so much extra belt material dangling down that I did away with the belt completely. My shoes were too big for my feet; my ankles were so thin that I wore three pairs of socks at a time and still my shoes would slide off my heels. And my panties were so baggy I secured them with safety pins on the sides so they wouldn’t fall down….

On the home front things were worse than ever. I moved to the downstairs room, which had a separate entrance and bathroom, and I locked my door and forbade anyone from entering. Even so, my mother and I had screaming matches every day, with her trying to convince me that “your body needs food as fuel” and me retaliating with “I’m not hungry.” But the more she tried to appeal to my rational side, the more stubborn I became in my conviction….

For nine months my mother stood by, forbidden to interfere, while I starved myself. She had no idea what was going on, nor did I. All she knew was that I had changed. She watched me transform from an innocent, soft, kind, loving girl into a reclusive, vicious, aggressive, defiant teenager. She had lost her little girl. And there was nothing she could say or do to stop me. She knew that if my weight continued to drop radically that she might lose me. But despite all her desperate attempts to reach out to me … she had no way of getting through to me, let alone helping me because, like with food, I slowly banned her from my life….

(Raviv, 2010)

BETWEEN THE LINES

In Their Words

“Girls should be encouraged to take an interest in their appearance when they are very young.”

Ladies’ Home Journal, 1940

It has not always done so, but Western society today equates thinness with health and beauty. In fact, in the United States thinness has become a national obsession. Most of us are as preoccupied with how much we eat as with the taste and nutritional value of our food. Thus it is not surprising that during the past three decades we have also witnessed an increase in two eating disorders that have at their core a morbid fear of gaining weight. Sufferers of anorexia nervosa, like Shani, are convinced that they need to be extremely thin, and they lose so much weight that they may starve themselves to death. People with bulimia nervosa go on frequent eating binges, during which they uncontrollably consume large quantities of food, and then force themselves to vomit or take other extreme steps to keep from gaining weight. A third eating disorder, binge-eating disorder, in which people frequently go on eating binges but do not force themselves to vomit or engage in other such behaviors, also appears to be on the rise. People with binge-eating disorder do not fear weight gain to the same degree as those with anorexia nervosa and bulimia nervosa, but they do have many of the other features found in those disorders (Alvarenga et al., 2014).

Are girls and women in Western society destined to struggle with at least some issues

of eating and appearance?

The news media have published many reports about eating disorders. One reason for the surge in public interest is the frightening medical consequences that can result from the disorders. The public first became aware of such consequences in 1983 when Karen Carpenter died from medical problems related to anorexia. Carpenter, the 32-year-old lead singer of the soft-rock brother-and-sister duo called the Carpenters, had been enormously successful and was admired by many as a wholesome and healthy model to young women everywhere. Another reason for the current concern is the disproportionate prevalence of anorexia nervosa and bulimia nervosa among adolescent girls and young women.

Anorexia Nervosa

Shani, 15 years old and in the ninth grade, displays many symptoms of anorexia nervosa (APA, 2013). She purposely maintains a significantly low body weight, intensely fears becoming overweight, has a distorted view of her weight and shape, and is excessively influenced by her weight and shape in her self-evaluations (see Table 11-1 ).

table: 11-1Dx Checklist

Anorexia Nervosa
1.	Individual purposely takes in too little nourishment, resulting in body weight that is very low and below that of other people of similar age and gender.
2.	Individual is very fearful of gaining weight, or repeatedly seeks to prevent weight gain despite low body weight.
3.	Individual has a distorted body perception, places inappropriate emphasis on weight or shape in judgments of herself or himself, or fails to appreciate the serious implications of her or his low weight.
(Information from: APA, 2013.)

Like Shani, at least half of the people with anorexia nervosa reduce their weight by restricting their intake of food, a pattern called restricting-type anorexia nervosa. First they tend to cut out sweets and fattening snacks; then, increasingly, they eliminate other foods. Eventually people with this kind of anorexia nervosa show almost no variability in diet. Others, however, lose weight by forcing themselves to vomit after meals or by abusing laxatives or diuretics, and they may even engage in eating binges, a pattern called binge-eating/purging-type anorexia nervosa, which you will read about in more detail in the section on bulimia nervosa.

Ninety to 95 percent of all cases of anorexia nervosa occur in females. Although the disorder can appear at any age, the peak age of onset is between 14 and 20 years. Between 0.5 and 4.0 percent of all females in Western countries develop the disorder in their lifetime, and many more display at least some of its symptoms (Ekern, 2014; Smink et al., 2013; Stice et al., 2013). It seems to be on the increase in North America, Europe, and Japan.

Typically the disorder begins after a person who is slightly overweight or of normal weight has been on a diet (Stice & Presnell, 2010). The escalation toward anorexia nervosa may follow a stressful event such as separation of parents, a move away from home, or an experience of personal failure (Wilson et al., 2003). Although most people with the disorder recover, between 2 and 6 percent of them become so seriously ill that they die, usually from medical problems brought about by starvation, or from suicide (Suokas et al., 2013; Forcano et al., 2010).

The Clinical Picture

Becoming thin is the key goal for people with anorexia nervosa, but fear provides their motivation. People with this disorder are afraid of becoming obese, of giving in to their growing desire to eat, and more generally of losing control over the size and shape of their bodies. In addition, despite their focus on thinness and the severe restrictions they may place on their food intake, people with anorexia are preoccupied with food. They may spend considerable time thinking and even reading about food and planning their limited meals (Herzig, 2004). Many report that their dreams are filled with images of food and eating (Knudson, 2006).

This preoccupation with food may in fact be a result of food deprivation rather than its cause. In a famous “starvation study” conducted in the late 1940s, 36 normal-weight conscientious objectors were put on a semistarvation diet for six months (Keys et al., 1950). Like people with anorexia nervosa, the volunteers became preoccupied with food and eating. They spent hours each day planning their small meals, talked more about food than about any other topic, studied cookbooks and recipes, mixed food in odd combinations, and dawdled over their meals. Many also had vivid dreams about food.

Laboratory starvation Thirty-six conscientious objectors who were put on a semistarvation diet for six months developed many of the symptoms seen in anorexia nervosa and bulimia nervosa (Keys et al., 1950).

Persons with anorexia nervosa also think in distorted ways. They usually have a low opinion of their body shape, for example, and consider themselves unattractive (Boone et al., 2014; Siep et al., 2011). In addition, they are likely to overestimate their actual proportions. While most women in Western society overestimate their body size, the estimates of those with anorexia nervosa are particularly high. In one of her classic books on eating disorders, Hilde Bruch, a pioneer in this field, recalled the self-perceptions of a 23-year-old patient:

I look in a full-length mirror at least four or five times daily and I really cannot see myself as too thin. Sometimes after several days of strict dieting, I feel that my shape is tolerable, but most of the time, odd as it may seem, I look in the mirror and believe that I am too fat.

(Bruch, 1973)

This tendency to overestimate body size has been tested in the laboratory (Delinsky, 2011; Farrell, Lee, & Shafran, 2005). In a popular assessment technique, research participants look at a photograph of themselves through an adjustable lens. They are asked to adjust the lens until the image that they see matches their actual body size. The image can be made to vary from 20 percent thinner to 20 percent larger than actual appearance. In one study, more than half of the individuals with anorexia nervosa overestimated their body size, stopping the lens when the image was larger than they actually were.

Seeing is deceiving In one research technique, people look at photographs of themselves through a special lens and adjust the lens until they see what they believe is their actual image. A research participant may change her actual image (left) from 20 percent thinner (middle) to 20 percent larger (right).

The distorted thinking of anorexia nervosa also takes the form of certain maladaptive attitudes and misperceptions (Alvarenga et al., 2014; Fairburn et al., 2008). Sufferers tend to hold such beliefs as “I must be perfect in every way”; “I will become a better person if I deprive myself “; and “I can avoid guilt by not eating.”

People with anorexia nervosa also have certain psychological problems, such as depression, anxiety, low self-esteem, and insomnia or other sleep disturbances (Forsén Mantilla, Bergsten, & Birgegård, 2014; Holm-Denoma et al., 2014). A number grapple with substance abuse (Mann et al., 2014; Steiger & Israel, 2010). And many display obsessive-compulsive patterns (Degortes et al., 2014; Friederich & Herzog, 2011). They may set rigid rules for food preparation or even cut food into specific shapes. Broader obsessive-compulsive patterns are common as well. Many, for example, exercise compulsively, prioritizing exercise over most other activities in their lives (Fairburn et al., 2008). In some research, people with anorexia nervosa and others with obsessive-compulsive disorder score equally high for obsessiveness and compulsiveness. Finally, persons with anorexia nervosa tend to be perfectionistic, a characteristic that typically precedes the onset of the disorder (Boone et al., 2014).

Medical Problems

The starvation habits of anorexia nervosa cause medical problems (Faje et al., 2014; Suokas et al., 2014; Oflaz et al., 2013). Women develop amenorrhea, the absence of menstrual cycles. Other problems include lowered body temperature, low blood pressure, body swelling, reduced bone mineral density, and slow heart rate. Metabolic and electrolyte imbalances also may occur and can lead to death by heart failure or circulatory collapse. The poor nutrition of people with anorexia nervosa may also cause skin to become rough, dry, and cracked; nails to become brittle; and hands and feet to be cold and blue. Some people lose hair from the scalp, and some grow lanugo (the fine, silky hair that covers some newborns) on their trunk, extremities, and face. Shani, the young woman whose self-description opened this chapter, recalls how her body deteriorated as her disorder was progressing:

Nobody knew that I was always cold no matter how many layers I wore. And that my hair came out in thick wads whenever I wet it or washed it. That I stopped menstruating. That at night I lay awake agonizing over thoughts of the day’s consumption. That the guilt I carried every day weighed on me like lead. That my hipbones hurt to lie on my stomach and my coccyx hurt to sit on the floor. And that the concave feeling in my stomach of dying hunger left in its place an anger that would destroy all feeling.

(Raviv, 2010)

Across the generations When famous television journalist Katie Couric interviewed popular singer Demi Lovato in 2012, it turned out that the two had an important thing in common—eating disorders. Lovato has spoken openly for years about her body image issues and eating struggles, but not until this interview did Couric reveal that she had experienced similar problems in the past. She noted, “I wrestled with bulimia all through college and for two years after that.”

Bulimia Nervosa

table: 11-2Dx Checklist

Bulimia Nervosa
1.	Repeated binge eating episodes.
2.	Repeated performance of ill-advised compensatory behaviors (e.g., forced vomiting) to prevent weight gain.
3.	Symptoms take place at least weekly for a period of 3 months.
4.	Inappropriate influence of weight and shape on appraisal of oneself.
(Information from: APA, 2013.)

People with bulimia nervosa—a disorder also known as binge-purge syndrome—engage in repeated episodes of uncontrollable overeating, or binges. A binge episode takes place over a limited period of time, often two hours, during which the person eats much more food than most people would eat during a similar time span (APA, 2013). In addition, people with this disorder repeatedly perform inappropriate compensatory behaviors, such as forcing themselves to vomit; misusing laxatives, diuretics, or enemas; fasting; or exercising excessively (see Table 11-2 ). Lindsey, a woman who has since recovered from bulimia nervosa, describes a morning during her disorder:

Today I am going to be really good and that means eating certain predetermined portions of food and not taking one more bite than I think I am allowed. I am very careful to see that I don’t take more than Doug does. I judge by his body. I can feel the tension building. I wish Doug would hurry up and leave so I can get going!

As soon as he shuts the door, I try to get involved with one of the myriad of responsibilities on the list. I hate them all! I just want to crawl into a hole. I don’t want to do anything. I’d rather eat. I am alone, I am nervous, I am no good, I always do everything wrong anyway, I am not in control, I can’t make it through the day, I just know it. It has been the same for so long.

I remember the starchy cereal I ate for breakfast. I am into the bathroom and onto the scale. It measures the same, but I don’t want to stay the same! I want to be thinner! I look in the mirror, I think my thighs are ugly and deformed looking. I see a lumpy, clumsy, pear-shaped wimp. There is always something wrong with what I see. I feel frustrated trapped in this body and I don’t know what to do about it.

I float to the refrigerator knowing exactly what is there. I begin with last night’s brownies. I always begin with the sweets. At first I try to make it look like nothing is missing, but my appetite is huge and I resolve to make another batch of brownies. I know there is half of a bag of cookies in the bathroom, thrown out the night before, and I polish them off immediately. I take some milk so my vomiting will be smoother. I like the full feeling I get after downing a big glass. I get out six pieces of bread and toast one side in the broiler, turn them over and load them with patties of butter and put them under the broiler again till they are bubbling. I take all six pieces on a plate to the television and go back for a bowl of cereal and a banana to have along with them. Before the last toast is finished, I am already preparing the next batch of six more pieces. Maybe another brownie or five, and a couple of large bowlfuls of ice cream, yogurt or cottage cheese. My stomach is stretched into a huge ball below my ribcage. I know I’ll have to go into the bathroom soon, but I want to postpone it. I am in never-never land. I am waiting, feeling the pressure, pacing the floor in and out of the rooms. Time is passing. Time is passing. It is getting to be time.

I wander aimlessly through each of the rooms again tidying, making the whole house neat and put back together. I finally make the turn into the bathroom. I brace my feet, pull my hair back and stick my finger down my throat, stroking twice, and get up a huge pile of food. Three times, four and another pile of food. I can see everything come back. I am glad to see those brownies because they are SO fattening. The rhythm of the emptying is broken and my head is beginning to hurt. I stand up feeling dizzy, empty and weak. The whole episode has taken about an hour.

(Hall & Cohn, 2010, p. 1; Hall, 1980 pp. 5–6)

BETWEEN THE LINES

Royal Bulimia?

During her three years as queen of England, Anne Boleyn, King Henry VIII’s second wife, displayed a habit, first observed during her coronation banquet, of vomiting during meals. In fact, she assigned a lady-in-waiting the task of holding up a sheet when the queen looked likely to vomit (Shaw, 2004).

Like anorexia nervosa, bulimia nervosa usually occurs in females, again in 90 to 95 percent of the cases (Sanftner & Tantillo, 2011). It begins in adolescence or young adulthood (most often between 15 and 20 years of age) and often lasts for years, with periodic letup (Stice et al., 2013). The weight of people with bulimia nervosa usually stays within a normal range, although it may fluctuate markedly within that range. Some people with this disorder, however, become seriously underweight and may eventually qualify for a diagnosis of anorexia nervosa instead (see Figure 11-1 ).

figure 11-1 Overlapping patterns of anorexia nervosa, bulimia nervosa, and obesity Some people with anorexia nervosa binge and purge their way to weight loss, and some obese people binge eat. However, most people with bulimia nervosa are not obese, and most overweight people do not binge eat.

Many teenagers and young adults go on occasional eating binges or experiment with vomiting or laxatives after they hear about these behaviors from their friends or the media. Indeed, according to global studies, 25 to 50 percent of all students report periodic binge eating or self-induced vomiting (Ekern, 2014; Zerbe, 2008; McDermott & Jaffa, 2005). Only some of these individuals, however, qualify for a diagnosis of bulimia nervosa. Surveys in several Western countries suggest that as many as 5 percent of women develop the full syndrome (Ekern, 2014; Touchette et al., 2011). Among college students the rate may be much higher (Zerbe, 2008).

Eating for sport Many people go on occasional eating binges. In fact, sometimes binges are officially endorsed, as you see in this photo from the annual Nathan’s Famous International Hot Dog Eating Contest in Brooklyn’s Coney Island, New York. However, people are considered to have an eating disorder only when the binges recur, the pattern endures, and the issues of weight or shape dominate self-evaluation.

Binges

People with bulimia nervosa may have between 1 and 30 binge episodes per week (Fairburn et al., 2008). In most cases, they carry out the binges in secret. The person eats massive amounts of food very rapidly, with minimal chewing—usually sweet, high-calorie foods with a soft texture, such as ice cream, cookies, doughnuts, and sandwiches. The food is hardly tasted or thought about. Binge eaters consume an average of 3400 calories during an episode. Some individuals consume as many as 10,000 calories.

Binges are usually preceded by feelings of great tension. The person feels irritable, “unreal,” and powerless to control an overwhelming need to eat “forbidden” foods. During the binge, the person feels unable to stop eating (APA, 2013). Although the binge itself may be experienced as pleasurable in the sense that it relieves the unbearable tension, it is followed by feelings of extreme self-blame, shame, guilt, and depression, as well as fears of gaining weight and being discovered (Sanftner & Tantillo, 2011; Goss & Allan, 2009).

Compensatory Behaviors

After a binge, people with bulimia nervosa try to compensate for and undo its effects. Many resort to vomiting, for example. But vomiting actually fails to prevent the absorption of half of the calories consumed during a binge. Furthermore, repeated vomiting affects one’s general ability to feel satiated; thus it leads to greater hunger and more frequent and intense binges. Similarly, the use of laxatives or diuretics largely fails to undo the caloric effects of bingeing (Fairburn et al., 2008).

BETWEEN THE LINES

Climate Control

Women who live in warmer climates (where more revealing clothing is worn) have lower weight, engage in more binge eating and purging, and have more body image concerns than women who live in cooler climates (Sloan, 2002).

Vomiting and other compensatory behaviors may temporarily relieve the uncomfortable physical feelings of fullness or reduce the feelings of anxiety and self-disgust attached to binge eating (Stewart & Williamson, 2008). Over time, however, a cycle develops in which purging allows more bingeing, and bingeing necessitates more purging. The cycle eventually causes people with the disorder to feel powerless and disgusted with themselves (Sanftner & Tantillo, 2011; Hayaki et al., 2002). Most recognize fully that they have an eating disorder. Lindsey, the woman we met earlier, recalls how the pattern of binge eating, purging, and self-disgust took hold while she was a teenager in boarding school.

Every bite that went into my mouth was a naughty and selfish indulgence, and I became more and more disgusted with myself….

The first time I stuck my fingers down my throat was during the last week of school. I saw a girl come out of the bathroom with her face all red and her eyes puffy. She had always talked about her weight and how she should be dieting even though her body was really shapely. I knew instantly what she had just done and I had to try it….

I began with breakfasts which were served buffet-style on the main floor of the dorm. I learned which foods I could eat that would come back up easily. When I woke in the morning, I had to make the decision whether to stuff myself for half an hour and throw up before class, or whether to try and make it through the whole day without overeating…. I always thought people noticed when I took huge portions at mealtimes, but I figured they assumed that because I was an athlete, I burned it off…. Once a binge was under way, I did not stop until my stomach looked pregnant and I felt like I could not swallow one more time.

That year was the first of my nine years of obsessive eating and throwing up…. I didn’t want to tell anyone what I was doing, and I didn’t want to stop…. [Though] being in love or other distractions occasionally lessened the cravings, I always returned to the food.

(Hall & Cohn, 2010, p. 55; Hall, 1980, pp. 9–12)

As with anorexia nervosa, a bulimic pattern typically begins during or after a period of intense dieting, often one that has been successful and earned praise from family members and friends (Stice & Pressnell, 2010; Couturier & Lock, 2006). Studies of both animals and humans have found that normal research participants placed on very strict diets also develop a tendency to binge (Pankevich et al., 2010; Eifert et al., 2007). Some of the participants in the conscientious objector “starvation study,” for example, later binged when they were allowed to return to regular eating, and a number of them continued to be hungry even after large meals (Keys et al., 1950).

Bulimia Nervosa Versus Anorexia Nervosa

Miss America speaks out Kirsten Haglund is crowned Miss America at the January 2008 pageant. During her one-year reign, Haglund openly acknowledged her past struggles with anorexia nervosa. In recent years, she has continued to travel and speak about body-image issues and eating disorders. She also has started a foundation to provide treatment services for women who have eating disorders.

Bulimia nervosa is similar to anorexia nervosa in many ways. Both disorders typically begin after a period of dieting by people who are fearful of becoming obese; driven to become thin; preoccupied with food, weight, and appearance; and struggling with depression, anxiety, obsessiveness, and the need to be perfect (Boone et al., 2014; Holm-Denoma et al., 2014). People with either of the disorders have a heightened risk of suicide attempts (Suokas et al., 2014; Keel & McCormick, 2010). Substance abuse may accompany either disorder, perhaps beginning with the excessive use of diet pills (Mann et al., 2014; Steiger & Israel, 2010). People with either disorder believe that they weigh too much and look too heavy regardless of their actual weight or appearance (Boone et al., 2014; Siep et al., 2011) (see InfoCentral below). And both disorders are marked by disturbed attitudes toward eating (Alvarenga et al., 2014).

Yet the two disorders also differ in important ways. Although people with either disorder worry about the opinions of others, those with bulimia nervosa tend to be more concerned about pleasing others, being attractive to others, and having intimate relationships (Zerbe, 2010, 2008; Eddy et al., 2004). They also tend to be more sexually experienced and active than people with anorexia nervosa (Gonidakis et al., 2014). Particularly troublesome, they are more likely to have long histories of mood swings, become easily frustrated or bored, and have trouble coping effectively or controlling their impulses and strong emotions (Boone et al., 2014; Lilenfeld, 2011; Halmi, 2010). As many as one-third of those with bulimia nervosa display the characteristics of a personality disorder, particularly borderline personality disorder, which you will be looking at more closely in Chapter 16 (Reas et al., 2013; Rowe et al., 2011, 2010).

InfoCentral

BODY DISSATISFACTION

People who evaluate their weight and shape negatively are experiencing body dissatisfaction. Around 73% of all girls and women are dissatisfied with their bodies, compared with 56% of all boys and men (Mintem et al., 2014). The vast majority of dissatisfied females believe they are overweight; in contrast, half of dissatisfied males consider themselves overweight and half consider themselves underweight. The factors most closely tied to body dissatisfaction are perfectionism and unrealistic expectations (Wade & Tiggemann, 2013). Body dissatisfaction is the single most powerful contributor to dieting and to the development of eating disorders.

Another difference is the nature of the medical complications that accompany the two disorders (Corega et al., 2014; Birmingham, 2011; Mitchell & Crow, 2010). Only half of women with bulimia nervosa are amenorrheic or have very irregular menstrual periods, compared with almost all of those with anorexia nervosa. On the other hand, repeated vomiting bathes teeth and gums in hydrochloric acid, leading some women with bulimia nervosa to have serious dental problems, such as breakdown of enamel and even loss of teeth. Moreover, frequent vomiting or chronic diarrhea (from the use of laxatives) can cause dangerous potassium deficiencies, which may lead to weakness, intestinal disorders, kidney disease, or heart damage.

Turning point When soft-rock star Karen Carpenter (right) received an award from fellow musician Emmylou Harris at the 1977 Billboard Music Awards, few people paid much attention to her symptoms. Carpenter’s 1983 death helped change the public’s view of anorexia nervosa.

Binge-Eating Disorder

Like those with bulimia nervosa, people with binge eating disorder engage in repeated eating binges during which they feel no control over their eating (APA, 2013). However, they do not perform inappropriate compensatory behavior (see Table 11-3 ). As a result of their frequent binges, around two-thirds of people with binge-eating disorder become overweight or even obese (Brauhardt et al., 2014; Claudino & Morgan, 2012).

table: 11-3Dx Checklist

Binge-Eating Disorder
1.	Recurrent binge-eating episodes.
2.	Binge-eating episodes include at least three of these features: • Unusually fast eating • Absence of hunger • Uncomfortable fullness • Secret eating due to sense of shame • Subsequent feelings of self-disgust, depression, or severe guilt.
3.	Significant distress.
4.	Binge-eating episodes take place at least weekly over the course of 3 months.
5.	Absence of excessive compensatory behaviors.
(Information from: APA, 2013.)

Binge-eating disorder was first recognized more than 50 years ago as a pattern common among many overweight people (Stunkard, 1959). It is important to recognize, however, that most overweight people do not engage in repeated binges; their weight results from frequent overeating and/or a combination of biological, psychological, and sociocultural factors (ANAD, 2014; Claudino & Morgan 2012).

Between 2 and 7 percent of the population have binge-eating disorder (Smink et al., 2013; Stice et al., 2013; Hudson et al., 2007). The binges that characterize this pattern are similar to those seen in bulimia nervosa, particularly the amount of food eaten and the sense of loss of control experienced during the binge. Moreover, like people with bulimia nervosa or anorexia nervosa, those with binge-eating disorder typically are preoccupied with food, weight, and appearance; base their evaluation of themselves largely on their weight and shape; misperceive their body size and are extremely dissatisfied with their body; struggle with feelings of depression, anxiety, and perfectionism; may abuse substances; and typically first develop the disorder in adolescence or young adulthood (Brauhardt et al., 2014; Pearl et al., 2014; Stice et al., 2013). On the other hand, although they aspire to limit their eating, people with binge-eating disorder are not as driven to thinness as those with anorexia nervosa and bulimia nervosa. Also, unlike the other eating disorders, binge-eating disorder does not necessarily begin with efforts at extreme dieting. Nor are there large gender differences in the prevalence of binge-eating disorder (ANAD, 2014; Grucza et al., 2007).