In a well-thought editorial in the American Journal of Psychiatry, my homeboy Walt Kaye has written an editorial on eating disorders titled "Eating Disorders: Hope Despite Mortal Risk." Besides presenting good information, what I especially loved about this piece was how Kaye balanced the severity of EDs and their potential deadly nature with hope for recovery.
Kaye explains the "vicious circle" of ED behaviors with a nice diagram (below) and this summary:
Childhood personality and temperament traits, which tend to be relatively mild, appear to contribute to a vulnerability to development of an eating disorder (7). Such traits may become intensified during adolescence as a consequence of the effects of multiple factors, such as puberty and gonadal steroids, development, stress, and cultural influences. For anorexia nervosa, there is a dysphoria-reducing character to dietary restraint. In contrast, for bulimia nervosa, overeating is thought to relieve negative mood states. But chronic pathological eating leads to neurobiological changes that increase denial, rigidity, depression, anxiety, and other core traits, so that patients often enter a vicious circle. This results in a out-of-control downward spiral whereby a significant proportion of patients develop a chronic illness or die. Fortunately, a substantial portion of those with anorexia nervosa and bulimia nervosa recover by their early to mid-20s, although mild to moderate degrees of temperament and personality traits persist, often with positive attributes.
Since these personality traits usually existed before the onset of the eating disorder, they likely persist after recovery. The key, says Kaye, is to use these traits for good instead of evil. For many individuals, learning to guide their innate personalities is a major task for ongoing recovery.
But receiving effective treatment in order to reach a lasting recovery is often difficult. Access to care--whether financial, geographical, or otherwise limited--is surprisingly low in many places. Denial of treatment by insurance companies (in the US) poses a major limitation to how effectively a person can be treated.
It is important to emphasize that these individuals—and their families—suffer for many years while symptomatic and, as the Crow et al. study (3) suggests, may be at risk of dying during this period of illness. Still, it is critical that insurance providers recognize that for many individuals, anorexia nervosa and bulimia nervosa do not constitute a black hole of endless treatment costs. In fact, appropriate treatment may keep people alive and healthy during the years that they are symptomatic. Such treatment counteracts the out-of-control spiral, minimizes medical complications, and presumably increases the likelihood of a good outcome. Moreover, many families get burned out during the seemingly endless struggles during the ill state. To prevent families from giving up, it is important to explain to them that many individuals with eating disorders do get better, but only after many years.
One of the next major tasks of researchers is to find ways to decrease the length of time to recovery and reduce the chronicity and mortality rates of eating disorders.