Eating Disorders

The different types of eating disorder diagnoses include:

• Anorexia nervosa
• Bulimia nervosa
• Binge eating disorder
• Pica disorder
• Rumination disorder
• Avoidant restrictive food intake disorder
• Other specified eating disorder
• Unspecified eating disorder

Anorexia nervosa, often simply called anorexia, is an eating disorder characterized by an abnormally low body weight, an intense fear of gaining weight, and a distorted perception of one’s body weight. A diagnosis of anorexia is based on the following:

• Restriction of food intake relative to a person’s requirements, leading to a significantly low body weight in the context of age, sex, growth development, and physical health. “Significantly low weight” is defined as a weight that is less than minimally normal, or for children and adolescents, less than what is minimally expected.
• Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though the person is underweight.
• Distorted view of one’s body weight or shape, undue influence of one’s body weight or shape on self-worth, or persistent lack of recognition of the seriousness of one’s current low body weight.

The diagnosis of anorexia has two subtypes that may be specified. These include:

• Restricting type – During the last 3 months, the individual has not engaged in recurrent episodes of binge eating or purging behavior. Instead, the person achieves weight loss primarily through dieting, fasting, and/or excessive exercise.
• Binge-eating/purging type – During the last 3 months, the individual has engaged in recurrent episodes of binge eating or behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas).

Epidemiology

The most common ages of onset of anorexia are the mid-teens, between 14 and 18 years. However, up to 5 percent of patients have the onset of the disorder in their early 20s. Anorexia is estimated to occur in about 0.5 to 1 percent of adolescent girls. It occurs 10 to 20 times more often in females than in males.

Psychological Factors

Anorexia appears to be a way for adolescents to express a form of autonomy. Many adolescents with anorexia experience their bodies as somehow under the control of their parents, so that self-starvation may be an effort to gain validation as a unique and independent person. Only through acts of extraordinary self-discipline can an anorectic patient develop a sense of autonomy and selfhood. Psychotherapists who treat patients with anorexia generally agree that these young patients have been unable to separate psychologically from their mothers. The body may be perceived as though it were controlled by an intrusive and unempathetic mother. Starvation may unconsciously mean rebelling from this controlling presence.

Individuals with anorexia have high rates of major depressive disorders. The suicide rate is higher in patients with the binge eating-purging type of anorexia than in the restricting type. Patients with anorexia are often secretive, deny their symptoms, and resist treatment. In almost all cases, relatives or intimate friends must confirm a patient’s history.

Because of the complicated psychological and medical implications of anorexia, a comprehensive treatment plan, including hospitalization when necessary, is recommended. Both individual and family therapy are recommended. Cognitive-behavioral therapy has proved effective for inducing weight gain. In many cases, medication may be needed. Participation in support groups, such as those provided by the National Association of Anorexia Nervosa and Associated Disorders, may also be helpful.

Bulimia nervosa, often simply called bulimia, is an eating disorder characterized by a cycle of binge eating and purging. A diagnosis of bulimia is based on:

• Eating an abnormally large amount of food in a discrete period of time (e.g., within any 2-hour period)
• A sense of lack of control over one’s eating during the episode, such as feeling that one cannot stop eating or control what or how much one is eating.
• Recurrent compensatory behaviors to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.
• The binge eating and compensatory behaviors both occur, on average, at least once a week for 3 months.
• The individual’s self-worth is unduly influenced by body shape and weight.
• The behavior does not occur exclusively during episodes of anorexia nervosa.

Cognitive-behavioral therapy (CBT) is considered the first-line treatment for bulimia. Effective treatment is based on strict adherence to detailed guided treatments that include 18-20 sessions over 5 to 6 months. CBT aims to interrupt the patient’s behavioral cycle of binging and dieting, and correct dysfunctional thoughts about food, weight, body image, and overall self-concept.

Antidepressant medications have also proven helpful in treating bulimia to reduce binge eating and purging.

Epidemiology

Bulimia is more prevalent than anorexia. Estimates of bulimia range from 1 to 4 percent in young women. As with anorexia, bulimia is more common in women than in men, but its onset is often later in adolescent than that of anorexia. The onset may also occur in early adulthood. Approximately 20 percent of college women experience transient bulimic symptoms at some point during their college years. In the United States, bulimia may be more prevalent among Hispanics and blacks than non-Hispanic whites.

Social Factors

Individuals with bulimia, as with those with anorexia, tend to be high achievers and to respond to societal pressures to be slender. As with anorexia patients, many patients with bulimia are depressed and have increased familial depression. The families of patients with bulimia, however, are generally less close with more conflict than the families of those with anorexia. Patients with bulimia describe their parents as neglectful and rejecting.

Binge eating disorderis characterized by recurrent episodes of earing large quantities of food. A diagnosis of binge eating disorder is based on:

• Eating, in a discrete period of time (e.g., within any 2-hour period) an amount of food that is definitely larger than what most people would eat in a similar period of time under similar circumstances.
• A sense of lack of control while over-eating, for example, feeling that one cannot stop eating or control how what or how much one is eating.
• The binge eating episodes are associated with three or more of the following:
  • Eating much more rapidly than normal.
  • Eating until feeling 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.
• Marked distress regarding binge eating is present.
• The binge eating occurs, on average, at least once a week for 3 months.
• The binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa.

The cause of binge eating disorder is unknown. Impulsive and extroverted personality styles are linked to the disorder, as are individuals who place themselves on a very low-calorie diet. Binge eating may also occur during periods of stress to reduce anxiety or to alleviate depressive moods.

Epidemiology

Binge eating disorder is the most common eating disorder. It occurs in approximately 25 percent of patients who seek medical care for obesity and in 50 to 75 percent of those with severe obesity. It is twice as common in females (4 percent) than in males (2 percent).

The most effective treatment for binge eating disorder is usually a combination of psychotherapy and antidepressant medications such as selective serotonin reuptake inhibitors (SSRIs). Cognitive behavioral therapy (CBT) is the most effective type of psychotherapy for treating binge eating disorder. Exercise has also shown a reduction in binge eating when combined with CBT. Two other types of effective treatment include interpersonal psychotherapy (therapy focused on interpersonal problems) and participation in self-help groups such as Overeaters Anonymous.

Avoidant restrictive food intake disorder (ARFID), previously known as “selective eating disorder,” is characterized by highly selective eating habits, disturbed feeding patterns, or both. It often results in significant nutrition and energy deficiencies, and for children, failure to gain weight.

A diagnosis of avoidant restrictive food intake disorder is given when a person has one or more of the following symptoms:

• Significant weight loss, failure to achieve expected weight gain, or faltering growth in children.
• Significant nutritional deficiency
• Dependence on enteral feeding or oral nutritional supplements
• Marked interference with psychosocial functioning

ARFID is similar to anorexia in that both disorders involve limitations in the amount and/or types of food consumed, but unlike anorexia, ARFID does not involve any distress about body shape or size, or fears of fatness.The disorder is not better explained by lack of available food or by an associated culturally sanctioned practice. A diagnosis of ARFID also requires that the eating problem is not attributable to a concurrent medical condition or other mental disorder.

Pica is a compulsive eating disorder in which people eat nonfood items, such as dirt, hair, and pant chips. A diagnosis of pica disorder is based on:

• Persistent eating of nonnutritive, nonfood substances over a period of at least 1 month.
• The eating of nonnutritive, nonfood substances is inappropriate to the developmental level of the individual.
• The eating behavior is not part of a culturally supported or socially normal practice.
• If the eating behavior occurs in the context of another mental disorder (e.g., intellectual developmental disorder, autism spectrum disorder, schizophrenia, or medical condition (including pregnancy), it is severe enough to warrant serious clinical attention.

Rumination disorder involves the regular regurgitation of food that may be re-chewed, re-swallowed, or spit out. A diagnosis of rumination disorder is based on:

• Repeated regurgitation of food over a period of at least 1 month.
• The repeated regurgitation is not attributable to an associated gastrointestinal or other medical condition (e.g., gastroesophageal reflux, pyloric stenosis).
• The eating disorder does not occur exclusively during the course of anorexia nervosa, bulimia nervosa, binge-eating disorder, or avoidant/restrictive food intake disorder.
• If the symptoms occur in the context of another mental disorder (e.g., intellectual disability or another neurodevelopmental disorder), they are severe enough to warrant serious clinical attention.

Other specified eating disorder diagnoses are used when an individual’s behavior does not meet the criteria for any specific eating disorder. Examples include:

• Atypical anorexia nervosa -- All of the criteria for anorexia nervosa are met, except that despite significant weight loss, the individual’s weight is within or above the normal range.
• Bulimia nervosa of low frequency and/or limited duration -- All of the criteria for bulimia nervosa are met, except that the binge eating and compensatory behaviors occur, on average, less than once a week and/or for less than 3 months.
• Binge eating disorder of low frequency and/or limited duration -- All of the criteria for binge eating disorder are met, except that the binge eating occurs, on average, less than once a week and/or for less than 3 months.
• Purging disorder -- Recurrent purging behavior to influence weight or shape (e.g., self-induced vomiting; misuse of laxatives, diuretics, or other medications) in the absence of binge eating.
• Night eating syndrome – Recurrent episodes of night eating, as manifested by eating after awakening from sleep or by excessive food consumption after the evening meal. There is awareness and recall of the eating. The night eating is not better explained by external influences such as changes in the individual’s sleep-wake cycle or by local social norms. The night eating causes significant distress and/or impairment in functioning. The pattern of eating is not better explained by binge-eating disorder or another mental disorder, including substance use, and is not attributable to another medical disorder or to an effect of medication.

A diagnosis of “unspecified eating disorder” is given when an individual has eating disorder symptoms that cause significant distress or impairment in social, occupational, or other important areas of functioning but the behavior does not meet the full criteria for any specific eating disorder. This diagnostic category is used in situations when there is insufficient information to make a more specific diagnosis (e.g., in emergency room settings).