Kathryn J. Zerbe, M.D., Professor, Department of Psychiatry, was recently feeatured as a consultant in a New YorK Time online forum on eating disorders. Information is available here.

 The following article, also quoting Dr. Zerbe, was also recently published in the Oregonian:

Amanda Johnson was like thousand of girls across Oregon, worried about her body.

She was at a healthy weight at the end of high school, 5 feet 4 inches tall and 120 pounds. But after graduating in 2006, she and her boyfriend split and she started to worry whether she could attract college boys.

"I thought I had to compete with all those cute Oregon State girls," the Tualatin resident says.

So Johnson started working out and dieting, fiercely. She cut her calories to 1,000 a day, then 700, then 500. By the time she was a freshman in Corvallis, she was down to 200 or 300 calories, mostly veggies, on the days that she ate.

"Other days," she says, "you'd try to challenge yourself to a 'No Eat Day,' to see if you could do it."

She was below 90 pounds at the end of her freshman year when her family sent her to Remuda Ranch, a residential treatment program in Arizona for women and girls with eating disorders. But when she saw the frighteningly skinny women around her, Johnson thought she was in the wrong place.

"Then one of the girls came up to me and said, 'Oh, you're one of the skinniest girls I've seen,'" she says. "That's when I thought, 'Oh, my gosh, I belong here.'"

Across Oregon, 5,000 to 15,000 women have anorexia, and maybe 1,000 boys and men -- statistics are fuzzy because eating disorders are shrouded in shame. More women and men may have bulimia, an eating disorder involving food binges followed by efforts to purge the excess calories through forced vomiting, massive laxative use, or unhealthy fasts and exercise.

A third, less-known diagnosis -- EDNOS, for Eating Disorder Not Otherwise Specified -- may affect more people than anorexia and bulimia combined. This category includes people who don't meet all the criteria for other disorders, such as nearly anorexic women who lack the menstrual irregularities needed to officially diagnose that disease. It also includes binge eating disorder, a condition in which people eat massive amounts, perhaps 10,000 calories a day, but make no effort to purge.

A 90-pound woman who can't bear to eat and a 300-pound man who can't stop bingeing seem very different. But all eating disorders share important features: unhealthy obsession with food; meals marked by ritual, shame and secrecy; and often a history of trauma such as sexual abuse or other mental illness, including anxiety disorders and alcoholism.

"The eating disorder becomes a way of dealing with life issues," said Dr. Kathryn Zerbe, an Oregon Health & Science University psychiatrist who specializes in the conditions.

That's a big factor separating binge eating disorder from obesity. While obese people generally eat too much, only some obese people regularly feel uncontrollably driven to eat huge amounts, then shamed by the binges. By some estimates, 8 to 10 percent of obese people may have the psychiatric diagnosis of binge eating disorder.

Underlying cause
Michelle Watson used to stop at store after store on her way home from work, buying a bag of doughnuts here, a box of cookies there, so no one would see how much food she was eating. Her binges drove her weight from 125 to 185 pounds.

"It was a way to not have to think or deal with life," she says. "And then, afterward, self-hatred, self-loathing times 10 ... I remember coming home one afternoon and looking in the mirror, looking at my body, and just running to my bedroom and sobbing."

What causes eating disorders isn't entirely clear. Genetics, family pressures, trauma and cultural pressures may all play roles. But there are indications that eating disorders may be on the rise. And American culture is well-geared now to create strange and tortured relationships with food, Zerbe said.

"We have an increasingly obese population, but media is saying, 'Be skinnier, be skinnier,'" she said.

Those pressures especially pile on adolescent women, the main group at risk for eating disorders. Sufferers usually are "beautiful, talented, amazing, gifted girls," said Watson, now a counselor in Tigard who focuses on eating disorders. "But the lies in their heads are so loud -- that they're a burden or ugly."

Terri Weber-Harris of Beaverton remembers being an overweight girl who slimmed down by high school, but had a mom who was always dieting and a boyfriend who focused on her weight. By college, she was drinking heavily and throwing up after eating to avoid gaining weight.

"It was awful," she says of her bulimia. "It was secretive. I was ashamed. I thought I was the only one in the world who had this problem, and I just didn't know what to do."

Disorders treatable
The good news is that eating disorders are usually treatable -- though treatment is a long and often expensive process.

"All of the treatments begin with education and helping the patients understand they have an illness that's difficult to get over, because so much emphasis is put on body image," Zerbe said. "The psychological work with any of these disorders is to help the person accept who they are and what they look like, and to be less afraid to be in the weight range they are in."

Treatment always involves individual counseling and often family counseling and care for medical problems related to eating disorders. Drugs help some people, especially those with bulimia and binge eating disorder. But getting prompt treatment is crucial -- the sooner an eating disorder is found and treated, the better the chances for recovery and healthy life.

Where and how to get treatment varies widely with how sick someone is and how much they can pay. People who are dangerously sick and malnourished need to be hospitalized for "refeeding," a process in which food is reintroduced slowly to avoid possibly deadly problems of eating after a long fast.

Just getting people back to their right weight often helps dramatically because malnutrition affects the brain and worsens eating disorders, said Dr. Jason Stone, a psychiatrist with the Providence St. Vincent Eating Disorders Program.

A step down from inpatient care are residential programs, like the one Johnson attended in Arizona. Those facilities often report good success rates, but they are scarce. There is only one, 10-bed residential facility in the Northwest, Eugene's Rainrock Treatment Center.

At Rainrock, residential patients eat three meals and three snacks a day with staff and a therapist at their table, said Anthony Laughlin, program administrator. Residents have at least three individual therapy sessions a week, and usually take part in two or three group-therapy or education sessions a day. As residents progress, they start planning meals, grocery shopping and working in the kitchen, learning to deal with food again in a healthy way.

Rainrock, St. Vincent and other clinics also offer "partial hospitalization" or intensive outpatient treatment, where treatment is like a full-time job -- eight or nine hours a day, five days a week. As people improve, Stone said, they may come less often, eventually moving to individual therapy as they would for other diseases.

Progress varies
Not every patient makes a neat progression from residential care to weekly therapy, though. Relapses and returns to treatment happen. Laughlin said Rainrock is seeing more people relapse in recent months, as insurance companies have grown less willing to pay for long stays. While a 90-day stay used to be standard, may insurers now will only pay for half that, if anything, Laughlin said.

Even getting insurers to pay for outpatient counseling can be a huge challenge, therapists said, especially for people with an EDNOS diagnosis.

"It's really hard to get benefits," said Weber-Harris, who is now a counselor at Beyond Addictions clinic in Beaverton. She has recovered from her bulimia, but still struggles with "trying to be a normal eater" and accepting her body.

"I still look in the mirror and wonder if there's a fat person there," she said.

Johnson said it took more than a year of hard work for her to pull out of anorexia. She spent 60 days at Remuda Ranch -- at a cost of tens of thousands of dollars -- learning to plan and eat normal meals again.

"The very first meals were hard, because I felt like I still had to do my behaviors of restricting," she said. "It becomes so much a part of you that you're afraid to lose that control over food."

At first, she drank five Ensure nutrition supplements a day to gain some weight back. Gradually, she ate more food, starting with "safe foods" like salads and chicken, then adding in more frightening items -- fatty foods such as pizza and burgers.

"Every two weeks, they'd have a challenge, like an ice cream challenge or a brownie challenge, one of the most feared foods ... to show you that can be part of your normal diet," Johnson says.

After leaving Remuda, Johnson was in charge of her own meals and struggled, losing a little weight. But she started seeing Watson, the former binge eater, for counseling and began to improve.

"It was a tough struggle, but eventually it becomes a routine," Johnson says. Now, she said, she rarely avoids food and usually eats nutritious, balanced meals. Last month, Johnson went back to school to get a nursing degree. She'd like to work in Oregon, helping people with eating disorders.

Types of eating disorders
The key feature of all eating disorders is an unhealthy relationship with food and your body's weight and shape. Women are affected far more often than men, though perhaps one-third of people with a binge-eating disorder are male. Doctors officially recognize three categories of the disorders:

Anorexia is marked by what the National Institutes of Health calls "a relentless pursuit of thinness." Sufferers grow so thin and malnourished that they stop having menstrual periods and face serious physical effects, including heart damage. Anorexia is among the deadliest psychiatric illnesses, fatal in 5 to 15 percent of cases.

Bulimia, like anorexia, involves poor body image and often fear of weight gain. People with bulimia binge-eat often, then use unhealthy behaviors to fend off weight gain, such as making themselves throw up or taking lots of laxatives. Bulimics may be normal weight or overweight, and may have gut, throat, tooth or kidney problems related to their condition.

EDNOS stands for Eating Disorders Not Otherwise Specified, and this catch-all category seems more common than anorexia and bulimia combined. Some people are diagnosed with EDNOS when they don't quite meet the criteria for anorexia or bulimia, for instance a woman who would be anorexic except she still has periods. A major kind of EDNOS is binge eating disorder, in which people uncontrollably eat large amounts of food without trying to purge later. By some estimates, 1 in 12 obese people may have binge eating disorder.

Warning signs
Consider discussing your eating habits and body image with a doctor or psychologist if you:
--Weigh yourself several times a day.
--Regularly avoid eating when hungry or eat large amounts without feeling like you can stop.
--Use laxatives or diuretics or make yourself vomit to lose weight.
--Spend a lot of time thinking about your weight or body shape.
--Are always unhappy with your weight or body shape.
--Use food to cope with feeling depressed, anxious or lonely.
--Have a history of physical or sexual abuse.

Andy Dworkin: 503-221-8271; andydworkin@news.oregonian.com