When Dieting Becomes Dangerous: A Guide to Understanding and Treating Anorexia and Bulimia


This primer on anorexia and bulimia is aimed directly at patients and the people who care about them. Written in simple, straightforward language by two experts in the field, it describes the symptoms and warning signs of eating disorders, explains their presumed causes and complexities, and suggests effective treatments.

The book includes:

• guidance about what to expect and look for in the assessment and ...

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When Dieting Becomes Dangerous: A Guide to Understanding and Treating Anorexia and Bulimia

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This primer on anorexia and bulimia is aimed directly at patients and the people who care about them. Written in simple, straightforward language by two experts in the field, it describes the symptoms and warning signs of eating disorders, explains their presumed causes and complexities, and suggests effective treatments.

The book includes:

• guidance about what to expect and look for in the assessment and treatment process;
• emphasis on the critical role of psychotherapy and family therapy in recovery;
• explanation of how anorexia and bulimia differ in their origins and manifestations;
• information on males with eating disorders and how they are similar to and different from female patients;
• a separate chapter for health care professionals who are not specialists in the diagnosis and treatment of individuals with eating disorders;
• up-to-date readings, Internet sites, and professional organizations in the United States and in Europe.

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Product Details

  • ISBN-13: 9780300092332
  • Publisher: Yale University Press
  • Publication date: 12/28/2002
  • Pages: 172
  • Sales rank: 706,302
  • Product dimensions: 5.50 (w) x 8.50 (h) x 0.40 (d)

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When Dieting Becomes Dangerous

A Guide to Understanding and Treating Anorexia and Bulimia
By Deborah Marcontell Michel Susan G. Willard

Yale University Press

Copyright © 2003 Deborah Marcontell Michel, Ph.D., and Susan G. Willard, L.C.S.W
All right reserved.

ISBN: 0-300-09232-6

Chapter One


Historically, anorexia nervosa and bulimia nervosa may have existed in some form since the days of "starving saints" and Roman vomitoriums. Yet not until 1973, when Hilde Bruch published her classic text entitled Eating Disorders: Obesity, Anorexia Nervosa, and the Person Within, did anorexia become widely recognized as a psychological disorder. Bulimia did not receive much attention until the late 1970s, and in fact was not even given a distinct name until Gerald Russell coined the term bulimia nervosa in 1979.

Today eating disorders constitute a major health concern. According to the National Eating Disorders Organization, between 5 million and 10 million girls and women, and 1 million boys and men, have some type of eating disorder. The American Psychiatric Association reports that more than 90 percent of those who have a diagnosis of anorexia or bulimia are female. In addition, there is evidence of an increasing prevalence of eating disorders, especially in countries that are more "Westernized" or "Americanized" in terms of cultural ideas of beauty and societal pressures to be thin. Complicating matters further, the options and resulting pressures on young women with regard to education and career are greater than in decades past, while the traditional values of success based on marriage and children prevail as well.

Our young women are supposed to do it all: be thin and beautiful; have husbands and children; have professions, power, and money. In addition, our culture allows and promotes greater sexual freedom for women and girls, a phenomenon of our times that generates anxiety and fear around growing up. Thus, we see a frightening physical obsession begin to develop in girls as young as eight or nine years of age. The end product is that many girls and young women choose dieting as an imagined solution to their problems. This misguided attempt at coping may well lead to eating disorders.

Eating disorders are complicated psychiatric illnesses in which food is used to help deal with unsettling emotions and difficult life issues. When the suspicion or realization of an eating disorder hits, many questions arise. We attempt to answer some of them as simply as is possible for such multidimensional disorders. Chapter 2 describes the diagnosis of eating disorders, the emotional features that are often seen, and the medical complications that may be present. Warning signs and symptoms are included. Chapter 3 provides general information on the typical characteristics-age, race, and level of education-of people with eating disorders. Chapter 4 explains the multiple factors that contribute to the development of an eating disorder. These include biological factors, sociocultural factors, individual personality characteristics, and family characteristics. Chapter 5 advocates a multidisciplinary approach to the treatment of eating disorders, and each professional's role is examined. We also give information on getting and staying well, treatment outcomes, and how one can assess quality and level of care. We raise the matter of insurance, as well. In Chapter 6 we give practical information and general advice to concerned individuals on their roles in effective intervention and treatment of someone with an eating disorder. In Chapter 7 we discuss the similarities of and differences between males and females in the development and treatment of eating disorders. The final chapter, intended for nonspecialist physicians, dentists, mental health professionals, and nutritionists, gives basic information on the assessment and care of persons with eating disorders. References for more detailed information are included.

When Dieting Becomes Dangerous can be used as a reference book dealing with major questions about the development, diagnosis, and treatment of anorexia and bulimia. It will help you understand these disorders, and know what to do if you suspect that you, or someone you care about, has one of these illnesses. Our book can also be used to obtain advanced references for a more thorough understanding of these and related disorders. Finally, it can put you in touch with organizations that offer help.

Chapter Two

What Is an Eating Disorder?


Features of the Disorder The formal psychiatric name for this illness is anorexia nervosa, but it is often shortened to simply "anorexia." Anorexia nervosa should not be confused with general anorexia, which means loss of appetite. People who have anorexia nervosa do not lose their appetites; rather, they refuse to maintain a normal body weight. They lose at least 15 percent of normal weight for height and have an intense fear of gaining it back or becoming obese. They often weigh themselves several times a day for fear of gaining weight and/or to see if they are continuing to lose. Anorexics also have a highly unrealistic view of their bodies, most often believing that they are fat even when they are severely emaciated. Their self-esteem and self-worth are based on size, weight, and body shape. Many anorexics wear baggy clothes to hide their bodies, while others wear revealing clothes to show off their underweight condition. Females stop having menstrual cycles after a certain amount of weight is lost or, in prepubescent girls, the menstrual cycle may not begin because of weight loss. Occasionally the period ceases some weeks or months before the onset of weight loss, thus highlighting the psychological origins of the illness.

As the disease progresses, strange behaviors evolve relative to food and eating. The anorexic will often cut her food into tiny pieces, measuring and weighing everything she eats or drinks. She is likely to keep careful calorie and fat counts of every morsel of food she ingests. She may perform certain rituals, such as using particular plates or utensils or arranging her food items in lines or patterns. Even when she is at an unhealthy weight, the anorexic may exercise excessively and compulsively, insisting that she feels fine. Although she will deny hunger, her hunger pangs will become intense. She may be obsessed with reading and collecting recipes and may enjoy preparing food for others, but will not touch a bite herself. She may eat only when alone, for the presence of others at this time may feel like an intrusion.

Some anorexics start a pattern of binge eating followed by purging behavior to eliminate the calories they consume. Binge eating refers to eating a large amount of food in a relatively short period of time. The anorexic who binges feels out of control, as if she cannot stop herself, then feels tremendous anxiety over all she has eaten. Other negative feelings too, such as shame and guilt, cause her to use some means to get rid of the calories she has ingested. The most frequent form of purging is self-induced vomiting. Other means include laxatives, diuretics (fluid pills), enemas, and syrup of ipecac (a substance that induces vomiting). Some anorexics may use nonpurging methods such as fasting or excessive exercise. Studies have shown that anorexics who binge and purge are at greater risk for substance abuse than those who do not.

Personality changes, often observed along with physical changes, may include angry outbursts, isolative behavior, and depression. The depression may be secondary to the eating disorder, or it may be a primary problem. Anxiety, too, can be a primary problem or may be related to fears about food, body shape, and weight. It may also result from stressful or anxiety-provoking life circumstances. Anxiety disorders are quite common in anorexics and frequently occur before the eating disorder develops. Two studies showed that 60 percent and 83 percent, respectively, had an anxiety disorder at some point in their lives. Obsessive-compulsive traits can also be present, and may or may not be directly related to the anorexia. Obsessions are unwanted thoughts that repeatedly enter a person's mind and cause anxiety; compulsions are the behaviors that a person feels driven to do in order to decrease the anxiety caused by the obsessions. Examples of obsessive-compulsive behavior that are directly related to anorexia include constant calculation of calories and fat grams, frequent weighing, and compulsive exercising. Examples not directly related to an eating disorder may be frequent hand washing for fear of germ contamination, or checking repeatedly to confirm that appliances are turned off and doors are locked. At times, obsessive-compulsive behavior may be severe enough to warrant a diagnosis of obsessive-compulsive disorder and require treatment specifically designed for that disorder.

In addition to the emotional features already mentioned, the anorexic is likely to become irritable, indecisive, and defiant as she becomes entrenched in her illness. Typically, she withdraws from friends as her symptoms increase, and family quarrels over food and other issues intensify as her condition worsens. Sometimes family and friends feel she has become "another person," someone they no longer know. Her social withdrawal causes serious peer relationship problems, and her increasing physical debilitation creates panic, anxiety, and chaos within the family. The despair, isolation, and hopelessness of anorexia may even result in suicide. Observation of any combination of the warning signs and symptoms of anorexia should cause concern and provoke investigation into a potential problem.

Medical Complications Anorexia is a life-threatening condition that must be taken seriously, as it has one of the highest mortality rates of any psychiatric disorder. The death rate increases with the length of illness, and is as high as 20 percent for those who have been followed for twenty years. Anorexics often suffer from organ failure, as the body can no longer withstand the stress of starvation. For anorexics who use laxatives and/or diuretics to purge, important body chemicals such as potassium are frequently lost. This deficit can result in irregular heartbeats or even death from cardiac arrest or kidney failure. Chronic abuse of laxatives adversely affects the gastrointestinal system. The syrup of ipecac that some anorexics take to induce vomiting can cause a variety of heart problems as well as gastrointestinal and neuromuscular difficulties. Finally, a number of diet pills and so-called diet aids (for example, herbal supplements with the stimulant "ma huang," or ephedrine) are used for weight loss. As with laxatives and diuretics, anorexics will often abuse diet pills or diet supplements by taking more than the recommended dosage and taking them more frequently than suggested. These products can be quite dangerous; it is a mistake to believe that the diet products marketed as "all natural" and sold in health-food stores are safe. In truth, these products often contain ingredients that can produce potentially lethal side effects. In fact, deaths related to these products have been documented by the Food and Drug Administration. Identification of any such risky behavior constitutes cause for serious concern and immediate intervention.

The weight loss seen in anorexic patients is an obvious and invariable complication. The body reacts to starvation by slowing down to preserve calories for continued functioning of the heart and brain. Specific symptoms include a slower heart rate and lowered blood pressure, as well as hormonal disturbances. Reduced body fat leads to lowered body temperature and intolerance for cold. Prolonged starvation and malnutrition can also cause irregular heartbeats, heart failure, and cardiac arrest. The major medical complications of anorexia affect the brain, the heart and circulatory system, the blood, the kidneys, the stomach and intestines, and the body's overall metabolism.

Amenorrhea (loss of three consecutive menstrual cycles) is a characteristic of anorexia in females that may precipitate additional medical complications. The menstrual cycle is a complicated system, and the exact cause of amenorrhea remains unclear. It is known, however, that abnormally low body fat content in addition to other biochemical disturbances contributes to the condition. While the dangers of amenorrhea may not be readily apparent, the consequences can be severe. Loss of bone mineral density can occur, which places girls and women at risk for osteopenia and osteoporosis. Various types of bone fractures may ultimately result. Current evidence suggests that these medical complications may persist even after the anorexic has restored her weight to normal. In terms of reproductive function, women who have a lifetime history of anorexia have been found to be at increased risk of obstetric complications, with the risk of miscarriage twice as great as for women with no history of anorexia. Furthermore, women who have been anorexic for a long period with chronic amenorrhea may compromise their reproductive function to the point of infertility.

Course of the Disorder Progress of anorexia over time varies greatly. Some anorexics recover fully after one episode of the illness; others return intermittently to a normal weight and then relapse. Unfortunately, some anorexics display a chronic course of symptoms that worsen over the span of many years, often ending in death. Females with anorexia are twelve times more likely to die than females the same age who have not had anorexia. Death most frequently results from the physical complications of starvation, electrolyte imbalance, or suicide. Chapter 5 gives relevant information and statistics.


Features of the Disorder Although the formal diagnostic name for this illness is bulimia nervosa, it is better known by the public as bulimia. The disorder is characterized by binge eating, followed by eliminating the calories consumed in compensation for the binge. The bulimic usually either self-induces vomiting or takes laxatives or diuretics in an effort to eliminate the calories. She may diet strictly or fast between eating episodes to undo the damage, or she may exercise excessively in order to prevent weight gain. When binge eating, she feels out of control and believes she cannot stop. To meet the criteria for formal diagnosis, her binges occur at least twice a week over a three-month period, and she is persistently overconcerned with her body size, shape, and weight. This focus on the body strongly influences her negative self-image.

In spite of repeated binge eating, bulimics often manage to stay within five to ten pounds of normal weight. The typical bulimic is a professional dieter who often gains back the weight she loses and repeatedly feels like a failure.


Excerpted from When Dieting Becomes Dangerous by Deborah Marcontell Michel Susan G. Willard Copyright © 2003 by Deborah Marcontell Michel, Ph.D., and Susan G. Willard, L.C.S.W. Excerpted by permission.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

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Table of Contents

1 Introduction 1
2 What Is an Eating Disorder? 5
3 Who Is Likely to Develop an Eating Disorder? 23
4 Why Does Someone Develop an Eating Disorder? 30
5 How Is an Eating Disorder Treated? 50
6 What Can Family, Friends, and Others Do to Help? 80
7 Are Eating Disorders Different in Males? 91
8 How Does a Nonspecialist Assess, Treat, and Refer Someone with an Eating Disorder? 101
Afterword 128
App. a Professional Resources and Organizations with Information on Eating Disorders 131
App. b Supplemental Readings 138
Index 145
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  • Anonymous

    Posted November 11, 2010

    Needs updating to reflect recent research

    This is 7 years post our incredibly difficult year when our then 14 year old daughter was treated by the philosophy described here. I've become a parent advocate for others going through what my family did. I've learned a great deal and the field is changing rapidly. However, at the time of my daughter's illness we were in a huge crisis and sinking rapidly. As I worked with special needs children in my own career, my initial gut instinct was very 'behavioral'. "You can't go to school if you haven't eaten. You need to stay at the table until you eat. Not eating is a non-option." I didn't know that my instincts were precursor to the most successful to date treatment for anorexia nervosa in adolescents there is. However, I backed off. Why? Because of extreme/scary behaviors I'd never seen before and didn't know to expect as part of the illness. Because of lack of adequate support/education. Because I was told not to be the food police, that she needed to be "in control" and decide. I ended up believing this illness was a choice and about control; that her unhappiness was linked to something we'd done/not done. I was devastated, but WRONG. I wish I'd known that then. The good things I can say about this book is that the people who wrote it were kind and caring. But, the book badly needs updating to reflect new research showing (in most cases) putting families in charge and supporting them gives young people the best chance at the fastest track back to health with less risk of relapse. Families can be critical to healing, rather than expendable. This turns traditional therapy upside-down. It's called family-BASED treatment. It doesn't exclude/presume guilt. It doesn't presume overprotectiveness, chaos, or underinvolvement as a family style. The ILLNESS ITSELF can cause these reactions in a family where it didn't pre-exist. You have to separate out REACTION from CAUSE. Mental health providers have a duty to respect the family's mental health too. It's part of the living system of the adolescent (or adult sufferer). If the family feels blame or alienation, who will stick around to help the sufferer for the longer term that may be needed? How will family relations fare post-illness if family/sufferer is seen as causal? Damaged?
    What do I want now?

    I want:
    - inpatient units to look hard at their practices...separation of children and families for weeks, limiting of phone calls, the search for underlying `causes' of the disorder. It reeks of guilt, sometimes subtly, sometimes not.
    - parents to be able to stay near by/visit often their ill adolescents throughout their hospitalizations just as parents of cancer stricken children do. Separation presumes guilt. You take away emotional support of regressed, ill adolescents when most needed by the ones that love/know them best.
    -I want parents included as part of the team to wellness.
    -I want parent education based on evidenced-based practice. I want all information out there updated to`best practice'. I want clinicians who practice it. I want to know when something is theory.
    -I want parents presented with choices when they present at the door of their pediatrician with an eating disordered child.
    -I want parents included in doctor, therapist and nutritionist meetings so the ED does not triangulate. Not kept outside as the chauffeur only.
    -I want the eating disordered world to know that parents are speaking up.

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  • Anonymous

    Posted November 21, 2007

    A Parent's Perspective

    This is a difficult commentary for me to post as my daughter was treated according to the philosophy in this book. Hospital staff were very dedicated and kind. However, when my daughter was hospitalized, I had no idea exactly what the treatment philosophy would be as our family was operating in crisis mode (as you might imagine). It is now several years post our incredibly difficult year. I will be forever grateful for the help we received in re-feeding our very ill daughter at a point in time when she could not eat by herself and we, her family, seemingly could not force her to. However, after a great deal of reading, research and time in the interim, I have become convinced that there are problems and assumptions inherent in some of the philosophy in this book and with this approach. Re- feeding, first and foremost is critical to the return of health and wellness so, in that sense, anorexia IS very much about food. Underlying psychological problems and depression sometimes even dissipate with full nutrition-- but certainly not always. They can even be caused by starvation itself¿and if not caused by it, then greatly increased. I also feel there is a subtle 'what's wrong with the family attitude' in traditional ED treatment and this book does state that the family is generally where the young person grows up. Parents should know (and most don¿t ahead of time) that there is very little 'evidence based' research out there on the effectiveness of most treatments (including individual counseling). All this I did not know when we really needed help and needed it in a hurry. Were I to have to do it all over again knowing what I know now, I would opt for the Maudsley Method approach for treating anorexia. It is evidenced-based with more and more research behind it, it is agnostic as to cause, and it looks at parents as part of the 'team to wellness' for their ill family member. That is SO empowering and healing. I just can't tell you. I cried when I found out about it. Why had no one told me about this as an option? And, if there are underlying psychological problems, they are addressed once weight is restored. The theory is that the mind must be nourished enough to make use of counseling help. Children are typically treated within their own homes with the support of a team of professionals backing up the parents, although hospitalization has its place when needed. Again, this book has much information that is good, but it also has some that I feel is outdated--or at least certainly at odds with the Maudsley Approach which is having documented success and is so inclusive of families.

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  • Anonymous

    Posted November 7, 2004

    A pithy gem

    Deborah Michel and Susan Willard have drawn from their wealth of experience treating patients in one of the most enduring and effective inpatient eating disorders programs to create a concise introduction to anorexia nervosa and bulimia. When Dieting Becomes Dangerous is written plainly enough to provide a working knowledge of eating disorders to patients and families while going into sufficient depth to give treating professionals a valuable resource. It provides an elegant model of the treatment team, clearly defining the roles of each member as the team deals with both the target behaviors and the underlying struggle to create an enduring sense of self beyond the limits of body image.

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