Eating Disorders

Eating disorders can cause emotional distress and significant medical complications. Formally classified as "feeding and eating disorders" in the most recent Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), eating disorders are complex conditions that can seriously impair health and social functioning. They also have the highest mortality rate of any mental disorder.

Who Is Affected?

Contrary to popular belief, eating disorders do not only affect teenage girls.

They occur in people of all genders, ages, races, ethnicities, and socioeconomic statuses. However, they are more commonly diagnosed in females.

Males are underrepresented in eating disorder statistics—the stigma of having a condition associated primarily with females often keeps them from seeking help and getting diagnosed. Furthermore, eating disorders may also present differently in males.

Eating disorders have been diagnosed in children as young as six as well as in the elderly.

The different ways in which eating disorders manifest in these populations can contribute to their unrecognizable nature, even by professionals.

While eating disorders affect people of all ethnic backgrounds, they are often overlooked in non-white populations as a result of stereotyping. The mistaken belief that eating disorders only affect affluent white females has contributed to the lack of public health treatment for others—the only option available to many marginalized populations.

And, although not well-studied, it is postulated that the experience of discrimination and oppression among transgender populations contribute to higher rates of eating and other disorders among transgender individuals.

Most Common Types

• Binge Eating Disorder (BED), 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) 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) 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) 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. 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.

Other Eating Disorders

• 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.
• Orthorexia Nervosa is not an official eating disorder, though it has attracted a great deal of recent attention as a proposed diagnosis. It involves adhering to a theory of healthy eating to the point that one experiences health, social, and occupational consequences.

Symptoms

Although symptoms of different eating disorders vary, there are some that may indicate a reason to investigate further:

• Frequent weight changes or being significantly underweight
• Dietary restriction
• Presence of purging, laxative or diuretic use
• Presence of binge eating
• Presence of excessive exercise
• Negative body image

It is not uncommon for people with eating disorders, especially those with anorexia nervosa, to not believe they are ill. This is called anosognosia.

Co-Occurring Issues

Eating disorders often occur along with other mental disorders, most often anxiety disorders, including:

• ​​Obsessive-compulsive disorder
• Generalized anxiety disorder
• Social phobia
• Body dysmorphic disorder

Anxiety disorders usually predate the onset of an eating disorder. Often, individuals with eating disorders also experience depression and score high on measures of perfectionism.

Genetics and Environment

Eating disorders are complex illnesses. While we do not definitively know what causes them, some theories exist.

It appears that 50 percent to 80 percent 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.”

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 dieting, weight stigma, bullying, abuse, illness, puberty, stress, and life transitions. It has also become common to blame eating disorders on the media. But if the media caused eating disorders, everyone would have them. You must have a genetic vulnerability in order for eating disorders to develop.

How Eating Disorders Affect Health

Because food is essential for regular functioning, eating disorders can significantly affect physical and mental operations. A person does not have to be underweight to experience the medical consequences of an eating disorder. Eating disorders affect every system of the body:

• Bones may become weaker, leading to irreversible issues.
• Brains may lose mass, although this seems to be reversible with full and sustained weight restoration and continued full nutrition.
• Cardiovascular problems may develop in response to both restriction and purging.
• Dental problems are common side effects of self-induced vomiting.

Getting Help

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:

• Stepped-Care Approach. It is common to start treatment with the lowest level of care and progress to higher levels as needed.
• Self-Help. Some individuals 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 individual works through a workbook, manual or web platform, to learn about the disorder and develops skills to overcome and manage it. Self-help is contraindicated for anorexia nervosa.
• Cognitive Behavioral Therapy (CBT). The best-studied outpatient therapy for adult eating disorders, CBT commonly includes the following elements:
  • Self-monitoring via paper or applications
  • Meal planning
  • Delays and alternatives
  • Regular eating
  • Cognitive restructuring
  • Limiting body-checking
  • Food exposure
  • Body image exposure
  • Relapse prevention
• Family-Based Treatment (FBT). This is the best-studied treatment for children and adolescents with eating disorders. 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.
• Weekly Outpatient Treatment. This 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 and interpersonal psychotherapy. Cognitive remediation therapy is a relatively new treatment under investigation for anorexia nervosa.
• Intensive Treatment. For individuals 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.

Lending Support

If you are the parent of a minor with an eating disorder, then it is wise for you to seek treatment on their behalf. Supporting a child with an eating disorder is hard work, but there are resources for you. If your loved one with an eating disorder is an adult, you can still play an important role in helping them too.

Since people with eating disorders often do not believe they have a problem, family members and significant others play a critical role in getting them help. Although recovery from an eating disorder can be challenging and sometimes long, it definitely is possible.

Sources:

Kaye, W. H., Bulik, C. M., Thornton, L., Barbarich, N., & Masters, K. (2004). Comorbidity of Anxiety Disorders With Anorexia and Bulimia Nervosa. American Journal of Psychiatry, 161(12), 2215–2221.

Thomas, J.J. & Schaefer, J. Almost Anorexic: Is My (or My Loved One's) Relationship with Food a Problem? (The Almost Effect) (Harvard University, 2013).