Frequently Asked Questions

Q: What are Eating Disorders?

A: According to the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV)¹, Eating Disorders are characterized by severe disturbances in eating behavior. There are two types of eating disorder classifications:

Anorexia Nervosa

The essential features of Anorexia Nervosa are the refusal to maintain a minimally normal body weight, an intense fear of gaining weight, and exhibiting a significant disturbance in the perception of one’s body shape or size. In order to meet criteria for this disorder an individual must have:

1. Refusal to maintain body weight at or above the minimally normal weight for age and height (i.e., below 85% of ideal body weight).
2. Intense fear of gaining weight or becoming fat, even though underweight.
3. Disturbance about one’s body weight or shape, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.
4. In women who have passed puberty, the absence of at least three consecutive menstrual cycles.

There are two subtypes of Anorexia Nervosa:

• Restricting, or not engaging in binge eating (eating excessive amounts of food) and purging (vomiting, misuse of laxatives, diuretics, or enemas)
• Binge-Eating/Purging, regularly engaging in binge eating or purging behavior

Bulimia Nervosa

The essential features of Bulimia Nervosa are binge eating and doing inappropriate interventions to prevent weight gain. In order to meet criteria for this disorder an individual must experience the following:

1. Recurrent episodes of binge eating as defined by:
1. Eating an amount of food that is significantly larger than most people would eat within any two-hour period of time; and
2. Feeling unable to control over eating behavior during the episode.
2. Doing inappropriate things to prevent weight gain (e.g., vomiting, misusing laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise)
3. Both 1) and 2) occur at least twice a week for a three month period
4. Self-evaluation is unduly influenced by body shape and weight

There are two subtypes of Bulimia Nervosa:

• Purging, or regular vomiting and/or misuse of laxatives, diuretics, or enemas
• Nonpurging, which does not involve regular purging, and instead involves fasting and/or excessive exercise

Eating Disorder Information Index
National Eating Disorder Association

Q: What is considered "normal weight"

A: Body mass index (BMI) is a measure of body fat based on height and weight that applies to both adult men and women. Calculate your BMI and determine where you fall in these BMI categories:

• Underweight = <18.5
• Normal weight = 18.5-24.9
• Overweight = 25-29.9
• Obesity = BMI of 30 or greater

Q: How common are Eating Disorders?

A: It is estimated that between one to just over four percent of females experience Bulimia Nervosa in their lifetime, and an estimated 0.5 to nearly four percent of females suffer from Anorexia Nervosa in their lifetime.² Far fewer men suffer from either of these disorders.^{1, 3} Typically Anorexia Nervosa and Bulimia Nervosa develop in adolescence or early adulthood.¹

Q: What are health risks associated with Eating Disorders?

A: There are serious, and sometimes fatal, consequences associated with the lifestyle choices made by individuals suffering with both Anorexia Nervosa and Bulimia Nervosa:^{4, 5}

Starvation

• Abnormally slow heart rate and low blood pressure
• Osteoporosis
• Muscle loss and weakness.
• Dehydration
• Dry hair and skin.
• Hair loss.
• Lanugo (growth of a fine downy hair layer to keep the body warm).
• Sensitivity to the cold.
• Abnormal or absent menstrual cycle and infertility
• Headaches
• Anemia (iron deficiency)
• Fainting

Purging

• Electrolyte imbalances
• Dental and gum problems
• Inability to menstruate and infertility
• Osteoporosis
• Dehydration
• Tears in the esophagus
• Abdominal pain
• Indigestion and heartburn

Ipecac to induce vomiting

• Serious cardiac, skeletal, and nervous system abnormalities

Frequent laxative use

• Dependence on laxatives for bowel emptying
• Irregular bowel movements
• Rectal bleeding
• Dehydration

Frequent use of diuretics

• Low potassium (can damage heart)
• Dehydration

Excessive exercise

• Stress fractures
• Abnormal or absent menstrual cycle

Q: What treatments are helpful for Eating Disorders?

A: Both psychotherapy (talk therapy) and medications may be helpful for treating Eating Disorders and/or mental health problems that typically co-occur with eating disorders.

Psychotherapy

According to the American Psychological Associations, Division 12, Society of Clinical Psychology,⁶ cognitive-behavioral therapy is a well established treatment for Bulimia Nervosa.^{7, 8} This treatment involves helping the individual think more rationally about their body size and shape, and develop healthier eating habits. Interpersonal therapy is another treatment that may be effective for treating Bulimia Nervosa.⁹ This treatment involves identifying and evaluating the interpersonal situations that are related to problematic eating behaviors. The focus of this treatment is not on eating habits or attitudes toward weight and shape.⁴

There is less evidence about the effective treatments recommended for Anorexia Nervosa compared to Bulimia Nervosa. Nutritional rehabilitation, which involves helping the individual slowly gain weight, is very important to a healthful recovery. Hospital-based programs should be considered when an individual is less than 75% of their ideal body weight.¹⁰ Unfortunately, patients suffering with an eating disorder often relapse after leaving the hospital. Cognitive-behavioral interventions through outpatient services can be effective in preventing a relapse. It is important to monitor physical health during treatment for an eating disorder, including monitoring a patient's weight, vital signs (blood pressure and pulse), electrocardiogram (ECG), and conducting routine laboratory tests. It is often useful to include nutritional counseling in the treatment protocol. For patients diagnosed with relatively recent onset Anorexia Nervosa, aged 18 and under, family therapy may be helpful.¹¹

Medications

For Anorexia Nervosa, psychotropic medications should not be routinely used when someone is actively trying to gain weight. Also, they should not be used as the sole or primary treatment for anorexia nervosa. Medications such as antidepressants maybe helpful to prevent relapse among weight-restored patients or to treat associated features of anorexia nervosa, such as depression or obsessive-compulsive problems.¹⁰

For Bulimia Nervosa, antidepressant medications can reduce symptoms of binge eating and purging and may help prevent relapse among patients in remission. ¹⁰

People who are suffering from an Eating Disorder may be experiencing other mental health problems as well, such as depression or anxiety. Medications can be helpful for treating co-occurring psychiatric problems. Not all medications work the same for all individuals. It is recommended that you work with your provider to determine the right treatment plan.

Q: How do I locate specialists or support groups?

A: You may contact any of the following organizations, which have referral capabilities:

Note: In order for eating disorder treatment to be covered by TRICARE, the provider must be TRICARE approved.

Find a TRICARE Provider or call 1-888-TRIWEST (1-888-874-9378).

Eating Disorder Referral and Information Center

Association for the Advancement of Behavior Therapy—Find a Therapist
Or call 1-212-647-1890.

American Psychological Association
Find a Psychologist or call 1-800-964-2000.

National Association of Social Workers—Search Clinical Register

Locate a Psychiatrist
Or call 1-888-35-PSYCH. Outside the U.S. and Canada, call 1-703-907-7300.

Military Spouse Career Center: Finding a Counselor

Q: Do I have to see a specialist in order to get help?

A: There are a number of steps you can take on your own to eat healthy and combat Eating Disorders. Check out the self-help tools offered by this site, which include skill training handouts, brief tips, and recommendations for self-help books. You may also find self-care information posted on this site to be helpful. Remember, not all helpers are professionals. Sometimes family, friends, or clergy can be the best sources of support.

Your primary care manager or (PCM) may be able to prescribe an appropriate medication for treatment if you develop psychiatric symptoms. If your PCM believes it is necessary to seek specialty care, they will be able to assist you to that next level of care.

Q: Are Eating Disorders a covered TRICARE benefit?

A: TRICARE policy for reimbursement requires that services must be medically necessary for a diagnosed mental disorder. The disorder must be one referenced in the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV) and must be of a severity not only to cause the patient distress but also to interfere with the patient’s usual activities.

TRICARE beneficiaries are eligible for eight behavioral health care visits per year without a referral or pre-authorization. Active duty military personnel always need a referral for care outside a military treatment facility. More

References:

¹American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association.

²American Psychiatric Association Work Group on Eating Disorders. Practice guideline for the treatment of patients with eating disorders (revision). American Journal of Psychiatry, 2000; 157(1 Suppl): 1-39.

³Hoek, H. W. (2002). Distribution of eating disorders. In C. G. Fairburn & K. D. Brownell (Eds.), Eating disorders and obesity: A comprehensive handbook (pp. 233-237). New York: The Guilford Press.

⁴Lock, J., & Schapman, A. M. (in press). Bulimia Nervosa. In J.E. Fisher & W. O’Donohue (Eds.), Practice Guidelines for Evidence Based Psychotherapy. New York: Kluwer Academic.

⁵Centre for Excellence in Eating Disorders (2006). Health risks of eating disorders. Accessed 5/30/06.

⁶Chambless, D. L., Baker, M. J. Baucom, D. H., Beutler, L. E., Calhoun, K.S. Crits-Christoph, P., Daiuto, A. et al. (1998). Update on the Empirically Validated Therapies II.  The Clinical Psychologist, 51, 1, 3-16.

⁷Agras, W.S., Schneider, J.A., Arnow, B., Raeburn, S.D., & Telch, C.F. (1989). Cognitive-behavioral and response-prevention treatments for bulimia nervosa. Journal of Consulting and Clinical Psychology, 57, 215-221.

⁸Thackwray, D.E., Smith, M.C., Bodfish, J.W., & Meyers, A.W. (1993). A comparison of behavioral and cognitive-behavioral interventions for bulimia nervosa. Journal of Consulting and Clinical Psychology, 61, 639-645.

⁹Fairburn, C. G., Jones, R., Peveler, R. C., Hope, R. A., O.Conner, M. (1993). Psychotherapy and bulimia nervosa: Longer-term effects of interpersonal psychotherapy, behavior therapy, and cognitive behavior therapy. Archives of General Psychiatry, 50, 419-428.

¹⁰American Psychiatric Association (2000). Practice Guideline for the Treatment of Patients With Eating Disorders, Second Edition. Accessed 5/30/06.

¹¹Pike, K. M., & Walsh, B. T. (in press). Anorexia Nervosa. In J.E. Fisher & W. O’Donohue (Eds.), Practice Guidelines for Evidence Based Psychotherapy. New York: Kluwer Academic.