CHAPTER 1

From Diet to Disorder: Problems and Prognosis

Disordered eating is alarmingly common, and having an eating disorder is oftenseen—except by those who have one or their family members—as a dietstrategy, a phase, or a trendy thing to do. In 2005 a television comedy seriescalled "Starved" included scenes in which eating disorder behavior was mockedand shown to be, according to the producer, "tragically comic." In one episode,a character pours detergent all over a dessert to avoid eating it, then laterretrieves it from the trash for a binge. Another scene portrays a policemanwho's been diagnosed with bulimia letting a deliveryman out of a ticket inexchange for Chinese food, on which he then binges and purges in an alley,accidentally vomiting on a homeless man. Is this funny? Is it entertainment?Would we accept a comedy about a skid-row alcoholic or heroin addict?

Groups such as the National Eating Disorder Association (NEDA) and theAssociation of Anorexia Nervosa and Related Disorders (ANAD) led a publicoutcry. Sponsors pulled out under the pressure, and the show was cancelled. Both"Starved" and the grassroots organizations that protested against it areevidence that eating disorders are now part of our culture and are increasinglyearning respect as illnesses rather than lifestyle choices as the Pro Ana (shortfor pro Anorexia) websites would have us believe. As difficult as it is tounderstand the growth of websites promoting this illness, their proliferationproves that eating disorders have come out of the closet and into our livingrooms, and few of us can remain unaware or untouched.

Elementary school girls continue to starve and purge as an acceptable method ofweight loss. Binge eating disorder (BED), although still not yet listed as aseparate diagnosis in the Diagnostic and Statistical Manual for MentalDisorders, Fourth Edition (DSM-IV), is increasingly discussed as an illness.Sadly, eating disorders have become mainstream on both ends of the spectrum. Inour current cultural climate, instead of asking, "Why do so many people developeating disorders?" one wonders, "How is it that anyone, especially a female,does not develop one?"

Are Eating Disorders More Common Now or Have They Just Been Hiding?

The first hint that eating disorders were a serious problem came from HildeBruch, who in 1973 introduced the first major work in the field, EatingDisorders: Obesity, Anorexia Nervosa, and the Person Within. This book wasgeared toward professionals and not readily available to the public. Bruchfollowed it up in 1978 with her pioneering work The Golden Cage, which continuesto this day to provide a compelling, passionate, and empathetic understanding ofthe nature of eating disorders, particularly anorexia nervosa. With the book andtelevision movie The Best Little Girl in the World, Steven Levenkron brought anawareness of knowledge of anorexia nervosa into the average home. And in 1985,when Karen Carpenter died from heart failure due to anorexia nervosa, thepicture of the emaciated singer haunted the public from the cover of Peoplemagazine.

Since then, women's magazines and television journalists have presented us withstories of people who we thought had everything—beauty, success, power,and control—but who were lacking something else, as they began to admitthat they too had eating disorders. Olympic gold medal gymnast Cathy Rigbyrevealed a struggle with anorexia and bulimia that almost took her life, andseveral others followed suit, including Gilda Radner, Princess Diana, SallyField, Elton John, Tracy Gold, Paula Abdul, and more recently Mary Kate Olson,Felicity Huffman, Jamie-Lynn DiScala, and Portia de Rossi to name just a few. Inher recent autobiography, Jane Fonda describes having led a double lifesuffering secretly from anorexia and bulimia throughout most of it even with allof her success and fame. Talk shows on eating disorders continue to feature themedia's fascination with every possible angle one can imagine: "Anorexics andTheir Moms," "A Ten-Year-Old Boy with Anorexia," and "Eating Disordered Twins."

Similar to chemical dependency in the 1970s and 1980s, eating disorder treatmentis a growing business, with hospital and residential eating disorder programsrapidly on the rise. Large corporations are now "investing" in this industry asa result of their market research. This can only mean that it is a growingproblem. The passage of the federal Mental Health Parity Act fueled the growthof this treatment industry by mandating that insurance companies cover majormental illness just as they would physical illness. However, the legislationallows each state the freedom to determine what constitutes a major mentalillness, and eating disorders are most often left out. To date, only 12 states(California, Connecticut, Delaware, Maine, Maryland, Minnesota, Rhode Island,New York, North Dakota, Vermont, Washington, and West Virginia) have state-mandatedinsurance coverage for the treatment of eating disorders, but thepressure is on to change this. To further exacerbate the struggle, for the mostpart, only medically necessary cases of anorexia nervosa and bulimianervosa—as diagnosed under DSM-IV—are insured for inpatient daytreatment and sometimes even outpatient settings. Clients with atypical or lesssevere cases often get no coverage at all.

When people ask, "Are eating disorders really more common now, or have they justbeen in hiding?" the answer is both, however, the overall trend shows that thenumber of individuals with eating disorders has been increasing continuallysince their recognition, paralleling society's growing obsession with beingthin, losing weight, and...