About Eating Disorders

About Eating Disorders

The Academy for Eating Disorders is committed to disseminating information regarding these disorders to both educate, prevent and assist those in need. Below are facts about eating disorders for concerned friends, family members, healthcare providers, and individuals struggling with their eating. Eating disorders affect individuals irrespective of age, weight, gender, and race/ethnicity. It is important to keep in mind that there is significant symptom overlap among the eating disorder categories listed below, and that individuals can move from one diagnostic category to another over time.

 
 

Anorexia Nervosa (AN) 

AN is characterized by failure to maintain an adequate body weight, body image disturbance, and excessive dietary restriction(1). It may be accompanied by periodic binge eating and purging (e.g., self-induced vomiting, laxative use). It affects approximately .4 out of every 1000 women in any 12 month period(1) and 9 out of 1000 at some point in their lives(2). Men are affected less often than women; the exact ratio of women to men who are affected by AN is difficult to determine, but estimates range from 3:12 to 10:11, and these may be underestimates because men are less likely to seek treatment and healthcare providers may fail to assess or diagnoseeating disorders in males(2).

WilfleyEffects of Anorexia; Wilfley

Family-Based Treatment

Family-Based Treatment (FBT) for Anorexia Nervosa; Celio-Doyle 

AN typically begins during early- to mid-adolescence(4), and warning signs include sudden weight loss, extreme dieting, food rituals (e.g., taking very small bites, eating foods in a certain order), hair loss, dry skin or hair, brittle nails, growth of fine, downy hair on the face and body. Certain medical conditions may co-occur with AN and include bone loss, difficulties with temperature regulation, loss of menstrual periods, low heart rate, and low blood pressure(1,5).

Similarly, certain psychological conditions and features that often coincide with AN include anxiety, depression, social isolation, and perfectionism(6). Approximately 50-60% of individuals with AN recover over time, with better recovery rates observed in younger patients and those with a shorter duration of illness when diagnosed(7). For adolescents with AN, a form of family-based treatment has been shown to be successful in improving recovery from the illness(8). Unfortunately, the risk of death in AN is increased due to medical complications and suicide(7).

Bulimia Nervosa (BN)

BN is characterized by binge eating (consuming large amounts of food while feeling out of control) accompanied by compensatory behaviors to prevent weight gain, and body image disturbances(1). These compensatory behaviors may include self-induced vomiting, laxative, diuretic, or enema use or excessive exercise, fasting, or the misuse of certain medications such as insulin. Estimates of what percent of individuals are affected by BN vary between 1-1.5% over the course of their lives(2,3) to 1-1.5% of women in any 12 month period(1). Men are affected less often than women; the exact ratio of women to men who are affected by BN is difficult to determine, but estimates range from 3:12 to 10:11. These may be underestimates because men are less likely to seek treatment and healthcare providers may fail to assess or diagnose eating disorders in males(2). The typical age of onset is mid- to late-adolescence(9), and early warning signs include the disappearance of large amounts of food, frequent trips to the bathroom after meals, calluses on knuckles from using fingers to induce vomiting, and swelling of the face. Certain medical conditions that may accompany BN include electrolyte imbalance, esophageal ulcers, and tooth decay(5).

Psychological conditions and features that often co-occur include anxiety, depression, substance use, and difficulties with impulse control(6). Approximately 70% of individuals with BN recover over time, and patients with fewer accompanying psychiatric problems seem to fare better(7). Treatments for BN in adults include cognitive-behavioral therapy, which has been successful in improving recovery from the illness(11), and the anti-depressant medication fluoxetine, which has been FDA-approved for the treatment of adults with BN(12). Unfortunately, risk of death is increased in BN, particularly death due to suicide(10).

Binge-Eating Disorder (BED) 

BED is characterized by binge-eating without compensatory behaviors (as observed in BN; see above)(1). It affects 16 out of every 1000 women in any 12 month period(1) and 35 out of 1000 at some point in their lives(2). Estimates for men are that approximately 8 out of 1000 are affected in any 12 month period(1) and 20 out of 1000 at some point in their lives(2). The typical age of onset is during adolescence or young adulthood, but most individuals don’t present for treatment until middle adulthood(3,13). Warning signs include sudden weight gain and the disappearance of large amounts of food. Specific medical conditions that co-occur with BED include obesity(14) and other related conditions (e.g., type II diabetes, hypertension) and gastric problems(15). Related psychological conditions include anxiety, depression, and substance use(6). Approximately 70-80% of individuals with BED recover over time, and those with fewer interpersonal problems appear to have a better likelihood of recovery(7). For adults with BED, cognitive-behavioral and interpersonal treatments have been successful in increasing recovery from the illness while behavioral weight loss treatment may be helpful with weight loss(16). 

Avoidant and Restrictive Food Intake Disorder (ARFID)

ARFID is characterized by an avoidance of eating that leads to a failure to meet nutritional or energy needs(1). This avoidance may be due to concerns regarding uncomfortable consequences of eating, displeasure with the tastes and/or textures of foods, or a number of other reasons. Importantly, this avoidance must not be explained by a normal culture practice or a food allergy. The results of this avoidance may be that the individual loses a significant amount of weight, or for children, fails to gain weight as expected, experiences a deficiency in important nutrients, requires food supplements or special feedings, or experiences substantial impairment in his/her life as a result of the avoidance (e.g., is unable/unwilling to socialize with others if food is involved). Although many of these features may be present in anorexia nervosa, a corresponding fear of weight gain and disturbance in body image is not present in ARFID. Information on the prevalence of AFRID are not yet available; however, ARFID most commonly begins in infancy or early childhood(1). Although picky-eating in young children is not unusual, warning signs of ARFID include such “pickiness” leading to a failure to gain weight as expected or the necessity of administering nutritional supplements in order to avoid experiencing a nutritional deficiency. ARFID may negatively affect family functioning, especially around mealtime(1). Related psychological conditions include anxiety disorders, autism spectrum disorder, obsessive-compulsive disorder, and attention deficit-hyperactivity disorder.

Eating Disorder Not Otherwise Specified (ED-NOS) or Feeding or Eating Disorders Not Elsewhere Classified (FED-NEC)

  • Characterized by disturbances in eating behavior that don’t fit exactly with the disorders described above (1)
  • Behaviors may be less frequent or qualitatively different than those seen in the primary eating disorder, but are just as distressing
  • Examples include:
    -Restrictive eating resulting in substantial weight loss despite normal weight status (atypical AN)
    -Binge eating and compensatory behaviors occurring less frequently than required for a diagnosis of BN (subthreshold BN)
    -Purging without binge eating (purging disorder)
    -Recurrent episodes of night eating, defined by eating after awakening from sleep or excessive food consumption after the evening meal (night eating syndrome)
  • Most common eating disorder diagnosis; affects ~4-5% of the population (17) 
  • ~4:1 female to male ratio (17)
  • Typical age of onset is adolescence or young adulthood (18)
  • Related medical and psychological conditions are similar to those for the other eating disorders
  • These complications are just as severe for those with ED-NOS as for those with full-syndrome eating disorders (19)
  • Warning signs are similar to those for related eating disorder diagnoses
  • ~70% of individuals with ED-NOS recover over time, with the best outcomes observed for individuals with high social support (7)
  • Some data suggest an increased risk of death in ED-NOS (10), but more research is needed on this understudied group
     

References 

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, text revision. 4th ed. Washington, DC: American Psychiatric Association; 2000.
2. Hudson JI, Hiripi E, Pope HG, Jr., Kessler RC. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatry. 2007;61(3):348-358.
3. Swanson SA, Crow SJ, Le Grange D, Swendsen J, Merikangas KR. Prevalence and correlates of eating disorders in adolescents. Results from the national comorbidity survey replication adolescent supplement. Arch Gen Psychiatry. 2011;68(7):714-723.
4. Keski-Rahkonen A, Hoek HW, Susser ES, et al. Epidemiology and course of anorexia nervosa in the community. Am J Psychiatry. 2007;164(8):1259-1265.
5. Fairburn CG, Harrison PJ. Eating disorders. Lancet. 2003;361(9355):407-416.
6. Berkman ND, Lohr KN, Bulik CM. Outcomes of eating disorders: a systematic review of the literature. Int J Eat Disord. 2007;40(4):293-309.
7. Keel PK, Brown TA. Update on course and outcome in eating disorders. Int J Eat Disord. 2010;43(3):195-204.
8. Stiles-Shields C, Hoste RR, Doyle PM, Le Grange D. A review of family-based treatment for adolescents with eating disorders. Rev Recent Clin Trials. 2012;7(2):133-140.
9. Smink FR, van Hoeken D, Hoek HW. Epidemiology of eating disorders: incidence, prevalence and mortality rates. Curr Psychiatry Rep. 2012;14(4):406-414.
10. Crow SJ, Peterson CB, Swanson SA, et al. Increased mortality in bulimia nervosa and other eating disorders. Am J Psychiatry. 2009;166(12):1342-1346.
11. Hay PP, Bacaltchuk J, Stefano S, Kashyap P. Psychological treatments for bulimia nervosa and binging. Cochrane Database Syst Rev. 2009;7(4):CD000562.
12. Aigner M, Treasure J, Kaye W, Kasper S. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the pharmacological treatment of eating disorders. World J Biol Psychiatry. 2011;12(6):400-443.
13. Spurrell EB, Wilfley DE, Tanofsky MB, Brownell KD. Age of onset for binge eating: are there different pathways to binge eating? Int J Eat Disord. 1997;21(1):55-65.
14. de Zwaan M. Binge eating disorder and obesity. Int J Obes Relat Metab Disord. 2001;25 Suppl 1:S51-55.
15. Cremonini F, Camilleri M, Clark MM, et al. Associations among binge eating behavior patterns and gastrointestinal symptoms: a population-based study. Int J Obes (Lond). 2009;33(3):342-353.
16. Wilson GT. Treatment of binge eating disorder. Psychiatr Clin North Am. 2011;34(4):773-783.
17. Le Grange D, Swanson SA, Crow SJ, Merikangas KR. Eating disorder not otherwise specified presentation in the US population. Int J Eat Disord. 2012;45(5):711-718.
18. Milos G, Spindler A, Schnyder U, Fairburn CG. Instability of eating disorder diagnoses: prospective study. Br J Psychiatry. 2005;187:573-578.
19. Thomas JJ, Vartanian LR, Brownell KD. The relationship between eating disorder not otherwise specified (EDNOS) and officially recognized eating disorders: meta-analysis and implications for DSM. Psychol Bull. 2009;135(3):407-433.