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Formally classified as “feeding and eating disorders” in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the term “eating disorders” represents a group of complex mental health conditions that can seriously impair health and social functioning
Because of the physical nature of their defining symptoms, eating disorders can cause both emotional distress and significant medical complications. They also have the highest mortality rate of any mental disorder.
Eating disorders are serious conditions related to persistent eating behaviors that negatively impact your health, your emotions and your ability to function in important areas of life. The most common eating disorders are anorexia nervosa, bulimia nervosa and binge-eating disorder.
Most eating disorders involve focusing too much on your weight, body shape and food, leading to dangerous eating behaviors. These behaviors can significantly impact your body’s ability to get appropriate nutrition. Eating disorders can harm the heart, digestive system, bones, and teeth and mouth, and lead to other diseases.
Eating disorders often develop in the teen and young adult years, although they can develop at other ages. With treatment, you can return to healthier eating habits and sometimes reverse serious complications caused by the eating disorder.
Types
There are many types of feeding and eating disorders, and they all come with their own defining characteristics and diagnostic criteria. The eating disorders formally recognized the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the official guidebook to the diagnosis of psychiatric disorders used by mental health providers, include the following.
Binge Eating Disorder (BED)
Binge eating disorder, the most recently recognized eating disorder, is actually the most common. It is characterized by repeated episodes of binge eating—defined as the consumption of a large amount of food accompanied by a feeling of loss of control. It is found in higher rates among people of larger body size. Weight stigma is commonly a confounding element in the development and treatment of BED.
Bulimia Nervosa (BN)
Bulimia nervosa involves recurrent episodes of binge eating followed by compensatory behaviors—behaviors designed to make up for the calories consumed. These behaviors may include vomiting, fasting, excessive exercise, and laxative use.
Anorexia Nervosa (AN)
Anorexia nervosa is characterized by the restricted intake of food which leads to a lower than expected body weight, fear of weight gain, and disturbance in body image. Many people are unaware that anorexia nervosa can also be diagnosed in individuals with larger bodies. Despite the fact that anorexia is the eating disorder that receives the most attention, it is actually the least common.
Other Specified Feeding and Eating Disorder (OSFED)
Other specified feeding and eating disorder is a catchall category that includes a wide range of eating problems that cause significant distress and impairment but do not meet the specific criteria for anorexia nervosa, bulimia nervosa, or binge eating disorder. OSFED, along with unspecified feeding or eating disorder (UFED), replaced the eating disorder not otherwise specified (EDNOS) category in previous versions of the DSM.
People who are diagnosed with OSFED often feel invalidated and unworthy of help, which is not true. OSFED can also be as serious as other eating disorders and can include subclinical eating disorders.
Research shows that many people with subclinical eating disorders will go on to develop full eating disorders. Subclinical eating disorders can also describe a phase that many people in recovery pass through on their way to full recovery.
Avoidant/Restrictive Food Intake Disorder (ARFID)
Previously called selective eating disorder, avoidant/restrictive food intake disorder (ARFID) is an eating disorder that involves a restricted food intake in the absence of the body image disturbance commonly seen in anorexia nervosa. It is manifested by persistent failure to meet appropriate nutritional and/or energy needs.
Orthorexia Nervosa
Orthorexia nervosa is not an official eating disorder in the DSM-5, though it has attracted a great deal of recent attention as a proposed diagnosis for future editions. It differs from other eating disorders because the unhealthy obsession does not typically come from a desire to lose weight. Further, the focus is not on food quantity, but rather food quality. Orthorexia nervosa is an unhealthy obsession with healthy eating and involves adhering to a theory of healthy eating to the point that one experiences health, social, and occupational consequences.
Other Eating Disorders
In addition to the ones listed above, other eating disorders include:
- Night eating syndrome
- Pica
- Purging disorder
- Rumination disorder
Pica
Pica is another eating disorder that involves eating things that are not considered food.
Individuals with pica crave non-food substances, such as ice, dirt, soil, chalk, soap, paper, hair, cloth, wool, pebbles, laundry detergent, or cornstarch.
Pica can occur in adults, as well as children and adolescents. That said, this disorder is most frequently observed in children, pregnant women, and individuals with mental disabilities.
Individuals with pica may be at an increased risk of poisoning, infections, gut injuries, and nutritional deficiencies. Depending on the substances ingested, pica may be fatal.
However, to be considered pica, the eating of non-food substances must not be a normal part of someone’s culture or religion. In addition, it must not be considered a socially acceptable practice by a person’s peers.
Summary Individuals with pica tend to crave and eat non-food substances. This disorder may particularly affect children, pregnant women, and individuals with mental disabilities.
Rumination disorder
Rumination disorder is another newly recognized eating disorder.
It describes a condition in which a person regurgitates food they have previously chewed and swallowed, re-chews it, and then either re-swallows it or spits it out.
This rumination typically occurs within the first 30 minutes after a meal. Unlike medical conditions like reflux, it’s voluntary.
This disorder can develop during infancy, childhood, or adulthood. In infants, it tends to develop between 3–12 months of age and often disappears on its own. Children and adults with the condition usually require therapy to resolve it.
If not resolved in infants, rumination disorder can result in weight loss and severe malnutrition that can be fatal.
Adults with this disorder may restrict the amount of food they eat, especially in public. This may lead them to lose weight and become underweight.
Summary Rumination disorder can affect people at all stages of life. People with the condition generally regurgitate the food they’ve recently swallowed. Then, they chew it again and either swallow it or spit it out.
Symptoms
Symptoms vary, depending on the type of eating disorder. Anorexia nervosa, bulimia nervosa and binge-eating disorder are the most common eating disorders. Other eating disorders include rumination disorder and avoidant/restrictive food intake disorder.
Anorexia nervosa
Anorexia (an-o-REK-see-uh) nervosa — often simply called anorexia — is a potentially life-threatening eating disorder characterized by an abnormally low body weight, intense fear of gaining weight, and a distorted perception of weight or shape. People with anorexia use extreme efforts to control their weight and shape, which often significantly interferes with their health and life activities.
When you have anorexia, you excessively limit calories or use other methods to lose weight, such as excessive exercise, using laxatives or diet aids, or vomiting after eating. Efforts to reduce your weight, even when underweight, can cause severe health problems, sometimes to the point of deadly self-starvation.
Bulimia nervosa
Bulimia (boo-LEE-me-uh) nervosa — commonly called bulimia — is a serious, potentially life-threatening eating disorder. When you have bulimia, you have episodes of bingeing and purging that involve feeling a lack of control over your eating. Many people with bulimia also restrict their eating during the day, which often leads to more binge eating and purging.
During these episodes, you typically eat a large amount of food in a short time, and then try to rid yourself of the extra calories in an unhealthy way. Because of guilt, shame and an intense fear of weight gain from overeating, you may force vomiting or you may exercise too much or use other methods, such as laxatives, to get rid of the calories.
If you have bulimia, you’re probably preoccupied with your weight and body shape, and may judge yourself severely and harshly for your self-perceived flaws. You may be at a normal weight or even a bit overweight.
Binge-eating disorder
When you have binge-eating disorder, you regularly eat too much food (binge) and feel a lack of control over your eating. You may eat quickly or eat more food than intended, even when you’re not hungry, and you may continue eating even long after you’re uncomfortably full.
After a binge, you may feel guilty, disgusted or ashamed by your behavior and the amount of food eaten. But you don’t try to compensate for this behavior with excessive exercise or purging, as someone with bulimia or anorexia might. Embarrassment can lead to eating alone to hide your bingeing.
A new round of bingeing usually occurs at least once a week. You may be normal weight, overweight or obese.
Rumination disorder
Rumination disorder is repeatedly and persistently regurgitating food after eating, but it’s not due to a medical condition or another eating disorder such as anorexia, bulimia or binge-eating disorder. Food is brought back up into the mouth without nausea or gagging, and regurgitation may not be intentional. Sometimes regurgitated food is rechewed and reswallowed or spit out.
The disorder may result in malnutrition if the food is spit out or if the person eats significantly less to prevent the behavior. The occurrence of rumination disorder may be more common in infancy or in people who have an intellectual disability.
Avoidant/restrictive food intake disorder
This disorder is characterized by failing to meet your minimum daily nutrition requirements because you don’t have an interest in eating; you avoid food with certain sensory characteristics, such as color, texture, smell or taste; or you’re concerned about the consequences of eating, such as fear of choking. Food is not avoided because of fear of gaining weight.
The disorder can result in significant weight loss or failure to gain weight in childhood, as well as nutritional deficiencies that can cause health problems.
When to see a doctor
An eating disorder can be difficult to manage or overcome by yourself. Eating disorders can virtually take over your life. If you’re experiencing any of these problems, or if you think you may have an eating disorder, seek medical help.
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Urging a loved one to seek treatment
Unfortunately, many people with eating disorders may not think they need treatment. If you’re worried about a loved one, urge him or her to talk to a doctor. Even if your loved one isn’t ready to acknowledge having an issue with food, you can open the door by expressing concern and a desire to listen.
Be alert for eating patterns and beliefs that may signal unhealthy behavior, as well as peer pressure that may trigger eating disorders. Red flags that may indicate an eating disorder include:
- Skipping meals or making excuses for not eating
- Adopting an overly restrictive vegetarian diet
- Excessive focus on healthy eating
- Making own meals rather than eating what the family eats
- Withdrawing from normal social activities
- Persistent worry or complaining about being fat and talk of losing weight
- Frequent checking in the mirror for perceived flaws
- Repeatedly eating large amounts of sweets or high-fat foods
- Use of dietary supplements, laxatives or herbal products for weight loss
- Excessive exercise
- Calluses on the knuckles from inducing vomiting
- Problems with loss of tooth enamel that may be a sign of repeated vomiting
- Leaving during meals to use the toilet
- Eating much more food in a meal or snack than is considered normal
- Expressing depression, disgust, shame or guilt about eating habits
- Eating in secret
If you’re worried that your child may have an eating disorder, contact his or her doctor to discuss your concerns. If needed, you can get a referral to a qualified mental health professional with expertise in eating disorders, or if your insurance permits it, contact an expert directly.
Causes
Eating disorders are complex illnesses. While we do not definitively know what causes them, some theories exist.
It appears that 50% to 80% of the risk for developing an eating disorder is genetic, but genes alone do not predict who will develop an eating disorder. It is often said that “genes load the gun, but environment pulls the trigger.”6
Certain situations and events—often called “precipitating factors”—contribute to or trigger the development of eating disorders in those who are genetically vulnerable.
Some environmental factors implicated as precipitants include:
- Abuse
- Bullying
- Dieting
- Life transitions
- Mental illness
- Puberty
- Stress
- Weight stigma
It has also become common to blame eating disorders on the media. While media influence is recognized as a complicating factor, it isn’t considered an underlying cause of eating disorder development in individuals. Ultimately, a person must also have a genetic vulnerability in order for eating disorders to develop.
The exact cause of eating disorders is unknown. As with other mental illnesses, there may be many causes, such as:
- Genetics and biology. Certain people may have genes that increase their risk of developing eating disorders. Biological factors, such as changes in brain chemicals, may play a role in eating disorders.
- Psychological and emotional health. People with eating disorders may have psychological and emotional problems that contribute to the disorder. They may have low self-esteem, perfectionism, impulsive behavior and troubled relationships
Diagnosis
Eating disorders can be diagnosed by medical physicians or mental health professionals, including psychiatrists and psychologists. Often, a pediatrician or primary care doctor will diagnose an eating disorder after noticing symptoms during a regular check-up or after a parent or family member expresses concern over their loved one’s behavior.
Although there is no one laboratory test to screen for eating disorders, your doctor can use a variety of physical and psychological evaluations as well as lab tests to determine your diagnosis, including:
- A physical exam, during which your provider will check your height, weight, and vital signs
- Lab tests, including a complete blood count, liver, kidney, and thyroid function tests, urinalysis, X-ray, and an electrocardiogram
- Psychological evaluation, which includes personal questions about your eating behaviors, binging, purging, exercise habits, and body image
There are also multiple questionnaires and assessment tools used to assess a person’s symptoms, including:
- Eating Disorder Inventory
- SCOFF Questionnaire
- Eating Attitudes Test
- Eating Disorder Examination Questionnaire (EDE-Q)
Risk factors
Teenage girls and young women are more likely than teenage boys and young men to have anorexia or bulimia, but males can have eating disorders, too. Although eating disorders can occur across a broad age range, they often develop in the teens and early 20s.
Certain factors may increase the risk of developing an eating disorder, including:
- Family history. Eating disorders are significantly more likely to occur in people who have parents or siblings who’ve had an eating disorder.
- Other mental health disorders. People with an eating disorder often have a history of an anxiety disorder, depression or obsessive-compulsive disorder.
- Dieting and starvation. Dieting is a risk factor for developing an eating disorder. Starvation affects the brain and influences mood changes, rigidity in thinking, anxiety and reduction in appetite. There is strong evidence that many of the symptoms of an eating disorder are actually symptoms of starvation. Starvation and weight loss may change the way the brain works in vulnerable individuals, which may perpetuate restrictive eating behaviors and make it difficult to return to normal eating habits.
- Stress. Whether it’s heading off to college, moving, landing a new job, or a family or relationship issue, change can bring stress, which may increase your risk of an eating disorder.
Complications
Eating disorders cause a wide variety of complications, some of them life-threatening. The more severe or long lasting the eating disorder, the more likely you are to experience serious complications, such as:
- Serious health problems
- Depression and anxiety
- Suicidal thoughts or behavior
- Problems with growth and development
- Social and relationship problems
- Substance use disorders
- Work and school issues
- Death
Prevention
Although there’s no sure way to prevent eating disorders, here are some strategies to help your child develop healthy-eating behaviors:
- Avoid dieting around your child. Family dining habits may influence the relationships children develop with food. Eating meals together gives you an opportunity to teach your child about the pitfalls of dieting and encourages eating a balanced diet in reasonable portions.
- Talk to your child. For example, there are numerous websites that promote dangerous ideas, such as viewing anorexia as a lifestyle choice rather than an eating disorder. It’s crucial to correct any misperceptions like this and to talk to your child about the risks of unhealthy eating choices.
- Cultivate and reinforce a healthy body image in your child, whatever his or her shape or size. Talk to your child about self-image and offer reassurance that body shapes can vary. Avoid criticizing your own body in front of your child. Messages of acceptance and respect can help build healthy self-esteem and resilience that will carry children through the rocky periods of the teen years.
- Enlist the help of your child’s doctor. At well-child visits, doctors may be able to identify early indicators of an eating disorder. They can ask children questions about their eating habits and satisfaction with their appearance during routine medical appointments, for instance. These visits should include checks of height and weight percentiles and body mass index, which can alert you and your child’s doctor to any significant changes.
If you notice a family member or friend who seems to show signs of an eating disorder, consider talking to that person about your concern for his or her well-being. Although you may not be able to prevent an eating disorder from developing, reaching out with compassion may encourage the person to seek treatment.
Treatment
Early intervention is associated with an improved outcome, so please do not delay seeking assistance. Life may even need to be put on hold while you focus on getting well. And once you are well, you will be in a much better position to appreciate what life has to offer. Help is available in a variety of formats, although it is common to start treatment with the lowest level of care and progress to higher levels as needed.
Self-Help
Some people with bulimia nervosa and binge eating disorder may be helped by self-help or guided-self help based on the principles of cognitive behavioral therapy (CBT). The person may work through a workbook, manual, or web platform, to learn about the disorder and develop skills to overcome and manage it. Self-help is contraindicated for anorexia nervosa.
Cognitive Behavioral Therapy (CBT)
CBT is the best-studied outpatient therapy for adult eating disorders and includes the following elements:7
- Cognitive restructuring
- Body image exposure
- Delays and alternatives
- Food exposure
- Limiting body-checking
- Meal planning
- Regular eating
- Relapse prevention
- Self-monitoring via paper or applications
Family-Based Treatment (FBT)
Family-based treatment (FBT) is the best-studied treatment for children and adolescents with eating disorders.8 Essentially, the family is a vital part of the treatment team. Parents commonly provide meal support, which allows the young person to recover in their home environment. Another important element of FBT is externalizing the eating disorder.
Nutritional Therapy
A registered dietitian can help you learn (or relearn) the components of a healthy diet and motivate you to make the needed changes.
Weekly Outpatient Treatment
Weekly outpatient treatment is the usual starting point for those who have access to treatment and typically includes treatment by a team of professionals including a therapist, a dietitian, and a medical doctor. Other successful outpatient therapies for adult eating disorders include:
- Dialectical behavior therapy
- Cognitive remediation therapy
- Interpersonal psychotherapy
Intensive Treatment
For people needing a higher level of care, treatment is available at multiple levels, including intensive outpatient, partial hospitalization, residential, and hospital levels of care. In these settings, treatment is almost always provided by a multidisciplinary team.
Coping
Caring for your physical and mental health will go a long way toward helping you cope with an eating disorder. In addition to talking to a therapist or joining a support group (like Eating Disorders Anonymous), seek support from a trusted friend or family member who can be there for you along your path to recovery.
Beyond self-care, it’s also important to identify a few healthy distractions you can turn to when you find yourself obsessing about food and weight or experiencing the urge to turn to disordered eating or behaviors. Here are a few to consider:
- Explore a new hobby, like photography, painting, or knitting
- Invest in an adult coloring book
- Practice mindfulness meditation
- Take a leisurely walk
- Try a yoga class or DVD
- Write in a journal
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