Understanding "The 4 P's" of
Eating Disorders

An eating disorder is a medical/psychiatric condition that requires treatment from health care professionals who are trained in this specialty.  Often, the treatment approach includes a coordination of various professionals including psychiatrists, primary care physicians, psychotherapists, and nutritionists, all who have clinical experience in the treatment of eating disorders.  Perhaps the best way to understand an eating disorder is to appreciate the conditions that effect one’s thoughts, behaviors, and emotions.  Dr. Schwartz, in coordination with his colleague Dr. DeSarbo, a psychiatrist in New York who is an expert in the neurobiology of eating disorders, refers to these associated factors as “The 4 P’s”.

1) Predisposing Factors

The 1st “P” refers to Predisposing Factors.  Eating disorders, like many other medical conditions, are thought to have underlying hereditary factors that are present at birth much in the same way that eye and hair color are genetically determined. Thus, several medical and psychiatric conditions, including eating disorders, have been associated with certain genetic markers that MAY predispose one to develop a certain condition.

2) Precipitating Factors

The 2nd “P” refers to Precipitating Factors.  Just because one inherits the genetic properties that may predispose them to a certain illness, this does not necessarily mean they will get that illness.  For example, it is believed that many people are genetically prone to conditions such as heart disease.  However, if these individuals eat healthy, exercise, avoid tobacco, and take generally good care of themselves then they may never develop the illness to which they are predisposed. Likewise with eating disorders, there are certain types of stressors and triggering events that can “set-off” disordered eating patterns in an individual.

3) Perpetuating Factors

The 3rd “P” refers to Perpetuating Factors.  Perpetuating factors are conditions and situations that support and maintain the disordered eating patterns. Perpetuating factors may include environmental stressors such as difficult interpersonal relationships with friends and family or they may be of a biological nature such as changes that occur in neurotransmitters and the brain’s anatomy that can be affected by an eating disorder.

4) Prescription

The 4th “P” is the Prescription. The prescription for an eating disorder is essentially the treatment plan. As mentioned above, for many patients with an eating disorder this prescription includes physician based treatments (both medical and psychiatric) working in conjunction with other health care providers including qualified licensed therapists, nutritional consultations, group therapy, and family therapy.  A medical physician experienced in the treatment of eating disorders often monitors vital signs, blood and urine chemistries, cardiac and gastrointestinal functioning and, at times, prescribes medications when indicated for co-existing medical or psychiatric conditions. Part of the prescription also involves helping the patient with the emotional states associated with the distress that exists with having an eating disorder.  As a result, a psychotherapist often utilizes cognitive behavioral therapies in the treatment to help change maladaptive thought processes and thus foster better coping skills. Perhaps the most important part of the prescription is making sure that all involved in the treatment are very well trained and experienced in working with eating disorders. 

And while many people who suffer from an eating disorder share some common feelings, obsessive thoughts, and troubling behaviors, each individual has their own combination of the “4 P’s” which makes their condition unique to them.

Facts about Eating Disorders & Body Dysmorphic Disorder Source: The Biology of Eating Disorder (DeSarbo)

* The prevalence of anorexia nervosa is
    about 1-2.2% of the general population. 
* The prevalence of bulimia nervosa is 1-2%
    of the general population with 5-10% having
    some symptoms.
* The prevalence of binge eating disorder is 1-5%
    of the general population.
* The prevalence of body dysmorphic disorder
    (BDD) is 7-12% of the general population and
     is often associated with an eating disorder.
* About 7-12% of patients undergoing plastic
    surgery suffer from BDD, and in follow-up
    studies had greater BDD issues after surgery.
* The typical person who has an eating disorder is
    intelligent, often perfectionistic, and from a family of middle to high socioeconomic status
* Eating disorders have the highest mortality rate
    of any psychiatric disorder (20%).
* In deaths related to eating disorders, about 50%
    are from medical complications and the other
    50% are from suicide. 
* Females account for about 90% of the cases of
    eating disorders.
* Nearly 70-80% of individuals with eating
    disorders also have another related psychiatric
    condition (i.e. depression, anxiety, OCD, post-
    traumatic stress disorder, ect.)
* Nearly 30% of individuals with an eating
    disorder may have coexisting alcohol or
    illicit substance use issues.  

What is an Eating Disorder?
Eating disorders can present in a variety of forms
and symptoms. While many eating disorders fit
specific criteria for a medical diagnosis, many forms of disordered eating patterns can present which do not meet specific medical criteria yet cause  significant distress and disturbances to one's life. 

Anorexia Nervosa
Anorexia nervosa (AN) is a disorder in which
individuals exhibit significant weight loss and
extreme restrictions in their food intake. Specific
criteria for the diagnosis of anorexia nervosa include:
 
• Weight loss and refusal to maintain what is 
   considered a normal body weight for that
   person’s age and height (minimally 85% of 
   expected normal weight).
• Intense fear of gaining weight despite being
   below expected weight. 
• Distorted view or denial of their actual body
   weight and/or shape.
• Loss of menstrual cycle.

Anorexia nervosa is specified into two types:

1. Restricting Type: 
Categorized as severe restriction of food intake with the absence of binge-eating or purging.

2. Binge/Purge Type: 
Categorized as engaging in binge eating or purging behavior while exhibiting behaviors classified as anorexia. Purging is characterized as a way to eliminate food from your body either through self-induced vomiting, excessive exercise, or through laxatives, diuretics, or enemas.

In addition to the diagnostic criteria, the following
are considered warning signs, or possible precursors, of anorexia nervosa:

• Restricting certain types of food and the amount
  of food intake.
• Preoccupation with weight, body shape, and
   the calorie and fat content of food.
• Dramatic weight loss.
• Excessive exercise.
• Distress over body weight and shape.
• Withdrawal from previously enjoyed activities,
   and from family and friends.