Eating Disorders

Eating disorders are a range of psychological conditions that cause unhealthy eating habits to develop. They might start with an obsession with food, body weight, or body shape.

In severe cases, eating disorders can cause serious health consequences and may even result in death if left untreated. In fact, eating disorders are among the deadliest mental illnesses, second to opioid overdose.

People with eating disorders can have a variety of symptoms. Common symptoms include severe restriction of food, food binges, and purging behaviors like vomiting or overexercising.

Although eating disorders can affect people of any gender at any life stage, they’re increasingly common in men and gender nonconforming people. These populations often seek treatment at lower rates or may not report their eating disorder symptoms at all 

Eating disorders are behavioral conditions characterized by severe and persistent disturbance in eating behaviors and associated distressing thoughts and emotions. They can be very serious conditions affecting physical, psychological and social function. Types of eating disorders include anorexia nervosa, bulimia nervosa, binge eating disorder, avoidant restrictive food intake disorder, other specified feeding and eating disorder, pica and rumination disorder.

Taken together, eating disorders affect up to 5% of the population, most often develop in adolescence and young adulthood. Several, especially anorexia nervosa and bulimia nervosa are more common in women, but they can all occur at any age and affect any gender. Eating disorders are often associated with preoccupations with food, weight or shape or with anxiety about eating or the consequences of eating certain foods. Behaviors associated with eating disorders including restrictive eating or avoidance of certain foods, binge eating, purging by vomiting or laxative misuse or compulsive exercise. These behaviors can become driven in ways that appear similar to an addiction.

Classification of eating disorders

Eating disorders are classified into different types, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), Fifth Edition. Classifications are made based on the presenting symptoms and how often these occur, and include:

Binge eating disorder (BED)

As with bulimia nervosa, people with binge eating disorder have episodes of binge eating in which they consume large quantities of food in a brief period, experience a sense of loss of control over their eating and are distressed by the binge behavior. Unlike people with bulimia nervosa however, they do not regularly use compensatory behaviors to get rid of the food by inducing vomiting, fasting, exercising or laxative misuse. The binge eating is chronic and can lead to serious health complications, including obesity, diabetes, hypertension and cardiovascular diseases.

The diagnosis of binge eating disorder requires frequent binges (at least once a week for three months), associated with a sense of lack of control and with three or more of the following features:

• Eating more rapidly than normal
• Eating until uncomfortably full
• Eating large amounts of food when not feeling hungry
• Eating alone because of feeling embarrassed by how much one is eating
• Feeling disgusted with oneself, depressed or very guilty afterward

Bulimia nervosa 

Individuals with bulimia nervosa typically alternate dieting, or eating only low calorie “safe foods” with binge eating on “forbidden” high calorie foods. Binge eating is defined as eating a large amount of food in a short period of time associated with a sense of loss of control over what, or how much one is eating. Binge behavior is usually secretive and associated with feelings of shame or embarrassment. Binges may be very large and food is often consumed rapidly, beyond fullness to the point of nausea and discomfort.

Binges occur at least weekly and are typically followed by what are called "compensatory behaviors" to prevent weight gain. These can include fasting, vomiting, laxative misuse or compulsive exercise. As in anorexia nervosa, persons with bulimia nervosa are excessively preoccupied with thoughts of food, weight or shape which negatively affect, and disproportionately impact, their self-worth.

Individuals with bulimia nervosa can be slightly underweight, normal weight, overweight or even obese. If they are underweight however, they are considered to have anorexia nervosa binge-eating/purging type not bulimia nervosa. Family members or friends may not know that a person has bulimia nervosa because they do not appear underweight and because their behaviors are hidden and may go unnoticed by those close to them. 

Anorexia nervosa 

Anorexia nervosa is characterized by self-starvation and weight loss resulting in low weight for height and age. Anorexia has the highest mortality of any psychiatric diagnosis other than opioid use disorder and can be a very serious condition. Body mass index or BMI, a measure of weight for height, is typically under 18.5 in an adult individual with anorexia nervosa.

Dieting behavior in anorexia nervosa is driven by an intense fear of gaining weight or becoming fat. Although some individuals with anorexia will say they want and are trying to gain weight, their behavior is not consistent with this intent. For example, they may only eat small amounts of low-calorie foods and exercise excessively. Some persons with anorexia nervosa also intermittently binge eat and or purge by vomiting or laxative misuse.

There are two subtypes of anorexia nervosa:

• restricting type, in which individuals lose weight primarily by dieting, fasting or excessively exercising, and
• binge-eating/purging type in which persons also engage in intermittent binge eating and/or purging behaviors.

Avoidant/restrictive food intake disorder (ARFID)

Avoidant/restrictive food intake disorder (ARFID) is a recently defined eating disorder that involves a disturbance in eating resulting in persistent failure to meet nutritional needs and extreme picky eating. In ARFID, food avoidance or a limited food repertoire can be due to one or more of the following:

• Low appetite and lack of interest in eating or food.
• Extreme food avoidance based on sensory characteristics of foods e.g. texture, appearance, color, smell.
• Anxiety or concern about consequences of eating, such as fear of choking, nausea, vomiting, constipation, an allergic reaction, etc. The disorder may develop in response to a significant negative event such as an episode of choking or food poisoning followed by the avoidance of an increasing variety of foods.

The diagnosis of ARFID requires that difficulties with eating are associated with one or more of the following:

• Significant weight loss (or failure to achieve expected weight gain in children).
• Significant nutritional deficiency.
• The need to rely on a feeding tube or oral nutritional supplements to maintain sufficient nutrition intake.
• Interference with social functioning (such as inability to eat with others).

Pica

Pica is an eating disorder in which a person repeatedly eats things that are not food with no nutritional value. The behavior persists over for at least one month and is severe enough to warrant clinical attention.

Typical substances ingested vary with age and availability and might include paper, paint chips, soap, cloth, hair, string, chalk, metal, pebbles, charcoal or coal, or clay. Individuals with pica do not typically have an aversion to food in general.

The behavior is inappropriate to the developmental level of the individual and is not part of a culturally supported practice. Pica may first occur in childhood, adolescence, or adulthood, although childhood onset is most common. It is not diagnosed in children under age 2. Putting small objects into their mouth is a normal part of development for children under 2. Pica often occurs along with autism spectrum disorder and intellectual disability, but can occur in otherwise typically developing children.

A person diagnosed with pica is at risk for potential intestinal blockages or toxic effects of substances consumed (e.g. lead in paint chips).

Rumination disorder

Rumination disorder involves the repeated regurgitation and re-chewing of food after eating whereby swallowed food is brought back up into the mouth voluntarily and is re-chewed and re-swallowed or spat out. Rumination disorder can occur in infancy, childhood and adolescence or in adulthood. To meet the diagnosis the behavior must:

• Occurs repeatedly over at least a 1-month period
• Not be due to a gastrointestinal or medical problem
• Not occur as part of one of the other behavioral eating disorders listed above
• Rumination can also occur in other mental disorders (e.g. intellectual disability) however the degree must be severe enough to warrant separate clinical attention for the diagnosis to be made.

Unspecified feeding or eating disorder (UFED)

This diagnostic category includes eating disorders or disturbances of eating behavior that cause distress and impair family, social or work function but do not fit the other categories listed here. In some cases, this is because the frequency of the behavior dose not meet the diagnostic threshold (e.g., the frequency of binges in bulimia or binge eating disorder) or the weight criteria for the diagnosis of anorexia nervosa are not met.

An example of other specified feeding and eating disorder is "atypical anorexia nervosa". This category includes individuals who may have lost a lot of weight and whose behaviors and degree of fear of fatness is consistent with anorexia nervosa, but who are not yet considered underweight based on their BMI because their baseline weight was above average.

Since speed of weight loss is related to medical complications, individuals who lose a lot of weight rapidly by engaging in extreme weight control behaviors can be at high risk of medical complications, even if they appear normal or above average weight.

Other eating disorders:

In addition to the six eating disorders above, other less known or less common eating disorders also exist.

These include:

• Purging disorder. Individuals with purging disorder often use purging behaviors, such as vomiting, laxatives, diuretics, or excessive exercising, to control their weight or shape. However, they do not binge.
• Night eating syndrome. Individuals with this syndrome frequently eat excessively at night, often after awakening from sleep.
• Other specified feeding or eating disorder (OSFED). While it is not found in the DSM-5, this category includes any other conditions that have symptoms similar to those of an eating disorder but don’t fit any of the disorders above.

One disorder that may currently fall under OSFED is orthorexia. Although orthorexia is increasingly mentioned in the media and in scientific studies, the DSM does not yet recognize it as a separate eating disorder.

Individuals with orthorexia tend to have an obsessive focus on healthy eating to an extent that disrupts their daily lives. They may compulsively check ingredient lists and nutritional labels and obsessively follow “healthy lifestyle” accounts on social media.

Someone with this condition may eliminate entire food groups, fearing that they’re unhealthy. This can lead to malnutrition, severe weight loss, difficulty eating outside the home, and emotional distress.

Individuals with orthorexia are rarely focused on losing weight. Instead, their self-worth, identity, or satisfaction is dependent on how well they comply with their self-imposed diet rules.

Signs and symptoms of eating disorders:

Different types of eating disorders have different symptoms, but each condition involves an extreme focus on issues related to food and eating, and some involve an extreme focus on weight.

This preoccupation with food and weight may make it hard to focus on other aspects of life.

Mental and behavioral signs may include:

• dramatic weight loss
• concern about eating in public
• preoccupation with weight, food, calories, fat grams, or dieting
• complaints of constipation, cold intolerance, abdominal pain, lethargy, or excess energy
• excuses to avoid mealtime
• intense fear of weight gain or being “fat”
• dressing in layers to hide weight loss or stay warm
• severely limiting and restricting the amount and types of food consumed
• refusing to eat certain foods
• denying feeling hungry
• expressing a need to “burn off” calories
• repeatedly weighing oneself
• patterns of binge eating and purging
• developing rituals around food
• excessively exercising
• cooking meals for others without eating
• missing menstrual periods (in people who would typically menstruate)

Physical signs may include:

• stomach cramps and other gastrointestinal symptoms
• difficulty concentrating
• atypical lab test results (anemia, low thyroid levels, low hormone levels, low potassium, low blood cell counts, slow heart rate)
• dizziness
• fainting
• feeling cold all the time
• sleep irregularities
• menstrual irregularities
• calluses across the tops of the finger joints (a sign of inducing vomiting)
• dry skin
• dry, thin nails
• thinning hair
• muscle weakness
• poor wound healing
• poor immune system function