While extreme thinness may the most obvious and life-threatening aspect of anorexia, new research suggests that it is often the psychological symptoms of eating disorders that take the longest to overcome.

The study of 65 patients who underwent psychotherapy for anorexia or bulimia found that psychological symptoms, such as fear of gaining weight and distorted body image, were among the last to go into remission.

Whereas patients’ weights typically climbed into a normal range in 11 months, and they began having menstrual periods again in about 8 months, it often took two years for them to develop healthy attitudes toward their bodies.

Certain eating disorder behaviors, namely, binge-eating and purging by vomiting or abusing laxatives, also remitted long before psychological symptoms did.

However, other behaviors, including food restriction and intense exercise, were as stubborn as patients’ psychological difficulties, Dr. Loa Clausen of the University of Aarhus in Riskov, Denmark, found.

Knowing how long it typically takes different eating disorder symptoms to go into remission should help make treatment more precise, Clausen told Reuters Health.

“If we know behavioral symptoms are more likely to change first,” she explained, “we need to focus here in the beginning of therapy and accept that the psychological symptoms persist.”

In addition, Clausen noted, if patients know that it’s normal for their psychological difficulties to linger, then it may give them more hope during the healing process that these symptoms will eventually improve.

For the study, which is published in the November issue of the International Journal of Eating Disorders. Clausen interviewed 35 patients with anorexia and 30 with bulimia two-and-one-half years after they were initially assessed and treated with psychological counseling.

She found that in general, the bulimia-type behaviors of bingeing and purging, which can also affect anorexics, as well as the physical problems of excessively low weight and missed menstrual periods improved months before psychological symptoms did.

There were some differences between patients with anorexia and those with bulimia. When it came to psychological symptoms, bulimic patients were quicker to conquer their fear of gaining weight, although it took them about as long as those with anorexia to gain a healthier perception of their bodies.

This is in line with the fact that intense fear of weight gain is more a part of anorexia than it is of bulimia, according to Clausen. People with bulimia, given their cycles of binge-eating and purging, often stay within a normal weight range.

Overall, though, the findings show that both eating disorders typically improve in steps, according to Clausen.

“Therefore,” she writes in the report, “it is important to focus on the small steps and changes in the process, both in treatment and in research on treatment.”

SOURCE: International Journal of Eating Disorders, November 2004.