Fear leads to eating disorders

The vicious cycle of anorexia

Eating attacks, vomiting, starvation: People with eating disorders are often plagued by a pathological fear of becoming fat. This leads them into a vicious circle of lack of self-worth, shame and disgust that makes them sicker and sicker. Eating disorders in these mostly young patients can usually only be treated successfully if the doctor includes the parents in the treatment concept.

Hanna, 16, comes to the practice with her mother, who introduces her daughter to me as anorexic. To counter this, Hanna's mother decided to go to a clinic on Lake Constance for inpatient therapy. With her visit she only asks me to issue the briefing and to organize the recording. Hanna wears body-hugging clothing, and at 167 cm still weighs 44.4 kg. This corresponds to a body mass index (BMI) of 15 kg / m². She herself feels neither too fat nor too thin. After that, a fairly typical course can be seen. It continues to decrease within a short period of time. When admitted to inpatient therapy, she weighs only 40 kg. This is followed by four months of therapy in the clinic. The recommendation after discharge is:
  • Outpatient psychotherapy
  • Continuation of drug therapy in the case of accompanying depression (citalopram 20 mg)
  • Compliance with meals and portion sizes
  • Further weight increase up to 25 kg / m². Age percentiles with regular medical weight checks
  • Improving body acceptance and promoting self-esteem, regardless of figure and weight
  • Stabilization of mood by building positive activities as well as stable social relationships
  • Learning strategies for dealing with dysfunctional and automatic attitudes (black-and-white thinking, selective perception, over-generalization, emotional argumentation)

Like bulimia nervosa and binge eating, anorexia nervosa is one of the three major eating disorders [1]. The case report shows the full picture of anorexia nervosa before the symptom of refusal to eat and is accompanied by depression. Other comorbidities of anorexia are anxiety and obsessive-compulsive disorder.

Patients with bulimia nervosa also suffer from their constant preoccupation with food and from frequent food cravings. Large amounts of food are consumed in a short period of time, followed by an attempt to counteract the fattening effect of eating through various behaviors (e.g. vomiting, rigorous fasting, laxative and / or diuretic abuse). As with anorexia, there is a morbid fear of becoming fat. This eating disorder often precedes bulimia [3].

Binge eating disorder has episodes of binge eating. An amount of food is eaten in a defined period of time (e.g. two hours) that is definitely greater than the amount eaten by most people during this time and under similar circumstances. During the episode a feeling of loss of control over eating arises. Binge eating occurs with at least three of the following symptoms [1, 3]:
  • Eating much faster than normal
  • Eating until you feel uncomfortable full
  • Eating large amounts of food without feeling physically hungry
  • Eating alone because of shame about the crowd
  • In retrospect, feelings of self-disgust, depression or severe guilt
  • Those affected suffer greatly from the binge eating, and such episodes have to occur an average of at least two days a week for six months

All three forms create a vicious circle (Fig. 1) [3]. Eating disorders are also clinically and socially significant. Almost only young people have anorexia and bulimia nervosa. The two diseases have a strong impact on physical and mental health. The peak of the disease occurs in late adolescence or young adulthood and often has dramatic consequences for the educational and professional careers of the patient [1].

Physical changes in both diseases are manifested in disorders of hunger and satiety regulation and the hormonal balance (lack of menstrual bleeding with irreversible osteoporosis development), in growth and cardiovascular disorders (EKG changes), in stomach and intestinal complaints, damage to the Bone substance, skin, teeth (vomiting) and hair as well as changes in the blood count (only in anorexia) [2, 3].

In anorexia, about a quarter of all cases become chronic. Improvement is very unlikely after five years of illness. Mortality is 5% after ten years and 16% after 20 years. This means that mortality is ten times higher than that of the normal population of the same age [2]. The risk of suicide is also many times higher. The current guideline [1] recommends creating motivation for treatment. People with anorexia and bulimia often show no insight into the disease and often have numerous unsuccessful attempts at self-healing behind them. If they are very ashamed, they are also reluctant to come for treatment.

How do you recognize the diagnosis?

The doctor should determine the height and weight of the patient at every check-up and whenever an eating disorder is suspected. The following screening questions can help in everyday general practice:
  • "Are you satisfied with your eating habits?"
  • "Are you worried about your weight or your diet?"
  • "Does Your Weight Affect Your Self-Esteem?"
  • "Are you concerned about your figure?"
  • "Do you eat secretly?"
  • "Do you throw up when you feel uncomfortably full?"
  • "Are you worried because sometimes you can't stop eating?"

The motivation for treatment should be the focus of the first discussions and contain detailed and factual information about the eating disorder, including its risks (if possible without causing anxiety for the patient).

The information is intended to clarify the cause and course of the eating disorder, but also possible complications and comorbidities. The design of the therapeutic relationship is particularly important for children and adolescents. It is essential to include custodians in this process, because children and adolescents do not always have sufficient ability to understand the scope of the disease and its treatment due to their development. The detailed information of the parents and their involvement in the overall concept are therefore indispensable, but not infrequently conflicting! Pay attention to causal issues such as: Family structure - parent-child conflict - development of autonomy.

Today there is agreement that disorder-specific psychotherapy (e.g. cognitive behavioral therapy) is the therapy of choice for anorexia. The focus is mostly on behavioral problems (missing meal structure, eating rituals, selective food choices, etc.), cognitive misconceptions, psychodynamic aspects (e.g. self-esteem and body experience, gender role identity, dealing with affects, closeness and distance in relationships) and family dynamics. Flanking medication with selective serotonin reuptake inhibitors (SSRIs) is only approved for bulimia nervosa. The goals of therapy are to normalize body weight and eating habits and to cope with the psychological problems associated with the disease [1, 2].

The Hanna case - so it went on!

After a year, Hanna had another relapse with a renewed inpatient stay for three months. In the course of outpatient psychotherapy and drug treatment of the depression, there was sustained stability. Today Hanna is 22, has successfully passed her high school diploma and is doing a jazz dance training in Los Angeles.


1. S3 guideline for the diagnosis and therapy of eating disorders, AWMF register number 051-026, German Society for Psychosomatic Medicine and Psychotherapy and the German College for Psychosomatic Medicine.
2. Herpertz, Stephan; Hagenah, Ulrich; Vocks, Silja; Wietersheim, Jörn von; Cuntz, Ulrich; Zeeck, Almut, Diagnostics and Therapy of Eating Disorders; Dtsch Arztebl Int 2011; 108 (40): 678-85; DOI: 10.3238 / arztebl.2011.0678
3rd winter semester 2012/13, module 5.1 "Diseases of the nervous system and the psyche" Prof. Dr. phil. Dipl.-Psych. Günter Reich: http://www.psychosomatik.uni-goettingen.de/download/51%20Vorlesung%20Essstoerungen.pdf




Joint practice Norrmann / Schwenke
Practice for general and family medicine

Conflicts of Interest: The author has not declared any

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