Associates in Christian Counseling

Eating Disorders, 101

An Interview with Cynthia M. Bulik, PhD FAED
Director, UNC Eating Disorders Program, UNC-Chapel Hill

What are the clinical definitions for the most common types of eating disorders?

· Anorexia nervosa…Individuals are unable or unwilling to maintain a body weight which is normal or expected for their age and height. Typically, this means that a person is less than 85% of their expected weight. Even so, they continue to be fearful of weight gain. Their thoughts and feelings about their size and shape have a profound impact on their sense of self and their self-esteem. Anorexia Nervosa has the highest mortality rate of any psychiatric disorder.

· Bulimia nervosa…Individuals with this diagnosis experience binge-eating episodes which are marked by eating an unusually large amount of food, usually in a discrete period of time, but feel out of control while doing so. The sense of being out of control is what distinguishes binge-eating from regular overeating. It is followed by attempts to “undo” the consequences of the binge by using unhealthy compensatory behaviors such as self-induced vomiting, excessive exercise, misuse of laxatives, etc.

· Binge eating disorder…Individuals with this diagnosis engage in binge eating but do not regularly use inappropriate compensatory weight control behaviors such as fasting or purging. Feelings of shame and embarrassment are prominent. It is often, but not always, associated with overweight and obesity.

How would you describe the different approaches in treatment for the various eating disorders?

· For anorexia nervosa… step one is re-nutrition and weight gain. This is best achieved in a multidisciplinary context including medical monitoring, dietary counseling, supportive psychotherapy, and family therapy which is especially important with younger patients. Once weight is restored then more effective psychotherapy can take place.

· For bulimia nervosa…cognitive-behavioral therapy is the treatment of choice. This approach addresses unhealthy thoughts that lead to and perpetuate unhealthy behaviors. The therapist works with the patient to learn how to replace the unhealthy thoughts with healthier ones in order to change the behaviors. Selective serotonin reuptake inhibitors (like Prozac) also play a role—Fluoxetine (Prozac) is the only FDA approved treatment we have for any eating disorders.

· For binge eating disorder… the therapeutic goals for binge eating disorder are often weight control and eliminating binge eating— you often need a combined approach—cognitive-behavioral therapy and medication. There is, however, no FDA approved medication for binge eating disorder.

Treatment choices include inpatient or outpatient programs as well as standard counseling. How is the type of treatment determined?

Put simply, it all depends on how ill an individual is. Often when individuals are below 75% of their expected weight, it can be very difficult to get them to a healthy weight without inpatient treatment. People become hypermetabolic (meaning they burn an enormous amount of calories) at those low weights when they are being renourished and may require 3500-4000 kcal in order to gain any weight at all. This is frightening to the patients, very hard to maintain outside of a hospital, and also, their activity needs to be restricted since they are burning calories up so fast. At UNC, we have inpatient, partial hospitalization (8:15-6:30) and outpatient programs. People can step down from inpatient, to partial hospitalization, to outpatient and get the full continuum of care.

What about relapse?

Relapse is common. With anorexia nervosa, for example, the average duration of treatment is 5 years. Relapse prevention has to be an integral part of the treatment. Parents and patients need to be prepared to identify the warning signs and have very good roadmaps for how to proceed when those signs emerge so they don’t wait too long for additional treatment.

Please describe how current genetic research is shedding new light on eating disorders--

· The importance of genetic research on ED…Genetic research offers new hope to both patients and their loved ones. For decades, parents have been unjustly blamed for "causing" the disorders. Parents have received little guidance or support in helping their child overcome these devastating illnesses. Now we can partner with parents and help them help their children on the road to recovery.

· Parents have been perplexed for decades. There is nothing in the “parent playbook” that tells you what to do when your daughter or son just stops eating. Parents need support and guidance in dealing with an eating disorder.

· The hope is that we will be able to work backwards from genetics--identify genes, figure out their function, which will give us more insight into the neurobiology of anorexia nervosa, and then move towards potential "druggable targets' for the disorder. Given that we have no medications that are effective in treating anorexia nervosa, there is plenty of room for improvement.

· To what extent are genetics liable for eating disorders…Genetic factors account for over 50% of liability to anorexia nervosa and they are similarly high for bulimia nervosa. But environment also plays a substantial role. Genes provide the predisposition and environment may act as the releaser "genes load the gun and environment pulls the trigger.” Some people, like those who live in cultures where dieting isn’t common, may have the risk genes, but might never be exposed to an environment that triggers the onset of the disorder.

In conclusion, Dr. Bulik would like our readers to be familiar with the UNC Eating Disorders Program.

Our goal is to be a world class clinical, teaching, and research program. The goal is to integrate research findings into practice so that we can deliver evidence-based treatments--not just trendy treatments that might sound attractive but have no basis in the scientific literature. Parents need to understand that these are serious mental illnesses. Anorexia nervosa has the highest mortality rate of any psychiatric disorder. Parents and family members need guidance in finding the best, most evidence-based treatment for their children and loved ones.

Our team members also teach throughout the university--undergrad, grad, and across schools--public health, nursing, medical school, residency and all sorts of allied health classes—as well as nationally and internationally, trying to increase awareness and understanding of how to detect and treat these disorders.

For additional information on eating disorders or the UNC Eating Disorders Program, visit www.unceatingdisorders.org

In addition to being Director of the UNC Eating Disorders Program, Dr. Bulik is also the William and Jeanne Jordan Distinguished Professor of Eating Disorders, Department of Psychiatry, School of Medicine and Professor of Nutrition, School of Public Health at the University of North Carolina at Chapel Hill