June 23, 2004 -- Mary-Kate Olsen -- who with her twin, Ashley, is one of the world's two most-celebrated and successful teens -- reportedly is being treated for an eating disorder. She is not alone.
About one in 10 Americans suffers from some kind of eating disorder, including one in four teen girls. At least 90% of people with eating disorders are female.
Olsen is said to be getting help. That is fortunate, as this mental health problem can be deadly. Untreated eating disorders have a death rate between 10% and 20%, says Linda Paulk Buchanan, PhD, director of the Atlanta Center for Eating Disorders.
"It's considered one of the most difficult emotional disorders to recover from," Buchanan tells WebMD. "It varies according to the intensity of treatment, but it's generally accepted that about half of patients fully recover, and another third manage it fairly well. They may not fully recover, but they can be very productive despite some minor symptoms of eating disorders.
Teens at Risk
An eating disorder starts with a simple diet. Or maybe it starts before that, with the idea that a diet is a simple thing. It is not, says Craig Johnson, PhD, director of the eating disorders program at Laureate Psychiatric Clinic and Hospital, Tulsa, Okla., and past president of the National Eating Disorders Association.
What a diet does is to throw a person's metabolism off balance. This affects the brain, which is hard wired to do everything it can to restore balance. For most people, this is just a small crisis. But for about 4% of the population, Johnson says, it's a catastrophe. Just as a person predisposed to alcoholism starts down a tragic path with that first drink, so can a first diet be a first step toward disaster.
"Mary-Kate Olsen is an interesting example," Johnson tells WebMD. "Why in the world would a young woman with this wonderful career and life in front of her continue in behavior that would eventually land her in a psychiatric hospital? The only explanation is she stepped on some kind of a land mine when she started some dieting behavior -- behaviors that she could not stop doing."
While only four in 100 people are extreme cases, Johnson estimates that another 10%-15% of the population will suffer some degree of eating disorder -- usually requiring some form of treatment. And today's teens are at higher risk than those of previous generations, says Heather Bell, RD, an eating disorders specialist at the Frances Stern Nutrition Center at Tufts-New England Medical Center.
"Our kids today are vulnerable in ways they have not been in previous generations," Bell tells WebMD. "Kids today are saturated by negative and extreme media images that show extreme bodies and foods. These are impulses they are swimming in every day. With teens very focused on their bodies and wanting to have a sense of themselves to hold onto, they think that if they can adopt the 'right' way of eating, it will give them a sense of control. In that kind of environment, things can go to extremes."
The Eating Disorder Whirlpool
Buchanan describes the typical person who develops an eating disorder as an attractive, hard-driving young woman who decides to go on a diet. Her very determination is a problem, because her diet may be too strict. This throws her metabolism into the "minicrisis" Johnson describes.
Nevertheless, she wills herself to ignore her distress. But her brain rebels. It forces her to think more and more about food. And because the brain wants fast energy, the kinds of food she thinks about tend to be sweets or carbs. These constant thoughts of food make her feel guilty -- but the guilt only makes her more determined.
That determination can't last. Eventually, the obsession with food leads to periodic binges. These binges increase her guilt, so she makes up for her "sin," as Buchanan puts it, by forcing herself to vomit or by taking laxatives or by going for a day or more without eating.
This cycle repeats itself -- often for years. Her metabolism will change, and she may even gain a little weight despite eating next to nothing. Her self-esteem sinks to extreme lows, and her body begins to show signs of starvation. These include bone loss, heart disease, tooth decay, brittle hair, loss of menstruation, and even the growth of a soft down on the skin (the body's attempt to prevent heat loss as body mass shrinks relative to surface area).
Her altered thinking makes her see herself as fat, even though she's far below normal weight. She's driven to lose more and more weight. She's stuck in the descending spiral of a whirlpool pulling her to her death.
Treatment Usually Successful
There is no easy treatment for eating disorders -- no pill to take, no simple one-size-fits-all therapy. Experts tell WebMD that treatment involves a combination of psychological treatments -- family therapy, group therapy, and individual therapy. Psychiatric medications may make the process easier for some. And nutritional therapy is essential.
"We help the people learn how to name, express, and manage their emotions," Buchanan says. "They also have to learn how to set realistic goals for themselves -- so many of them are perfectionists, and they tend to think they never can do well enough. We help the families learn how to support the person through her recovery. We work on healthy eating skills -- understanding the nutritional needs of the body."
It's a long process, Johnson says, and one that is very similar to treating phobias.
"The critical piece is that at one point in time patients have developed an irrational fear of some aspect of food and weight regulation. The more they avoid this thing they fear, the more phobic they become," he says. "What we have to do is turn them around and start marching them back to what they are so terrified of. And we have to give them new coping mechanisms, everything from psychotherapy to medications, until they can march their way back to normal."
It is a long, hard, frightening march -- but it puts a patient back on the road to life.
Johnson warns, however, that trying to march the patient too fast has risks. One of these risks is trying to restore a patient's weight too quickly -- which can lead to heart problems and other medical risks.
Preventing Eating Disorders
Because eating disorders begin with a diet, Johnson says that parents should pay careful attention to teens who want to start dieting.
"The prevention message we want to drive to parents is that dieting is not an innocent behavior," he says. "Without question, most teens will be able to toy around with it and not have it deteriorate into a serious psychological illness. But for a handful, about four times in a hundred, when they start engaging in these behaviors it is going to trigger the unfolding of these very pernicious influences."
Johnson compares dieting to other ways of altering the body.
"If a child asks to go on a diet, parents need to be as conscientious as if the child asked to go on steroids for athletic performance or to take contraceptive pills," he says.
Warning Signs of Eating Disorders
The National Eating Disorders Association lists several warning signs of the most common eating disorder, anorexia nervosa:
- Dramatic weight loss
- A preoccupation with food, weight, calories, fat grams, and diets
- Refusing to eat "bad" foods
- Frequent comments about being fat despite weight loss
- Anxiety about being fat
- Food rituals such as cutting food into tiny bites or excessive chewing
- Frequent excuses to avoid meals
- Withdrawing from friends and activities
- Any indication that dieting is becoming the child's central concern
The NEDA also lists ways in which parents can help prevent eating disorders. These include:
- Examining one's own prejudices about body shape and weight, and teaching children about the ugliness of prejudice
- Looking at whether one is giving children the message that they will be better loved if they lose weight
- Learning about -- and teaching children about -- the value of a balanced diet and moderate exercise
- Not avoiding activities because they call attention to your weight and shape
- Exercising for the love of movement, not to purge the body of calories
- Valuing people for who they are, how they feel, and what they do -- not how they look
- Helping children resist media images implying that only slender bodies are normal, powerful, or popular
- Promoting children's self-esteem and self-respect
- Never suggesting that girls are less important than boys by exempting males from housework or childcare