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Information On Eating Disorders

   Eating disorders are characterized by a persistent pattern of aberrant eating or dieting behavior. These patterns of eating behavior are associated with significant emotional, physical, and relational distress.

   The line between normal variations in eating patterns and eating disorders can be hard to delineate. Formal diagnoses are best made by clinicians on the basis of specific criteria from The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (American Psychiatric Association, 1994). However, the following descriptive information provides a basic overview of eating disorders. Please note that although most individuals with eating disorders are female, the criteria and descriptions also apply to the 5-10% of individuals with these disorders who are male.

Anorexia Nervosa | Bulimia Nervosa | Binge Eating Disorder | Eating Disorders Not Otherwise Specified (EDNOS) | Summary | Prevalence of Eating Disorders | Consequences of Eating Disorders | Eating Disorders and Health Insurance | Course and Outcome of Eating Disorders | Etiology | Treatment | Bibliography | Special Topics in Eating Disorders
   Individuals with anorexia nervosa are unable or unwilling to maintain a body weight that is normal or expectable for their age and height. There is no precise boundary dividing "normal" from "too low", but most clinicians use 85% of normal weight as a reasonable guide. Individuals with anorexia nervosa usually display a pronounced fear of weight gain and a dread of becoming fat even though they are markedly underweight. Concerns about their weight and about how they believe they look have a powerful influence on the individuals' self-evaluation. The seriousness of the weight loss and its health implications is usually minimized, if not denied, by the individual. Women with the diagnosis of anorexia nervosa have missed at least three consecutive menstrual cycles.

   There have been recent refinements in the diagnostic criteria for this eating disorder. The diagnosis of anorexia nervosa now includes two subtypes of the disorder that describe two behavioral patterns. Individuals with the Restricting Type maintain their low body weight purely by restricting food intake and, possibly, by exercise. Individuals with the Binge-Eating/Purging Type usually restrict their food intake as well, but also regularly engage in binge eating and/or purging behaviors such as self-induced vomiting or the misuse of laxatives, diuretics or enemas. Available data indicate that the Binge-Eating/Purging Type of Anorexia Nervosa is more frequently associated with other impulse control problems, substance misuse and mood lability. The development of binge/purge behaviors may also be associated with the duration of the disorder.
   Individuals with bulimia nervosa regularly engage in discrete periods of overeating which are followed by attempts to compensate for overeating and to avoid weight gain. There can be considerable variation in the nature of the overeating but the typical episode of overeating involves the consumption of an amount of food that would be considered excessive in normal circumstances. The individual's subjective experience is dominated by a sense of a lack of control over the eating. Binge eating is followed by attempts to "undo" the consequences of overconsumption though self-induced vomiting, misuse of laxatives, enemas, diuretics, severe caloric restriction, or excessive exercising.

   Profound concerns about weight and shape are also characteristic of individuals with bulimia nervosa. Self-evaluation is centered on the individual's perceptions of her body image.

   The formal diagnosis of bulimia nervosa requires that the individual not simultaneously meet criteria for anorexia nervosa. (In other words, if an individual simulatenously meets criteria for both anorexia nervosa and bulimia nervosa, only the diagnosis of Anorexia Nervosa, binge-eating/purging type is given.) The criteria also specify minimal frequency and duration cut-offs for the diagnosis: individuals must binge eat and engage in inappropriate compensatory behavior at least twice weekly for three months.

   As with anorexia nervosa, there are two subtypes of bulimia nervosa. The Purging Type describes individuals who regularly compensate for the binge eating with self-induced vomiting or through the use of laxatives, diuretics, or enemas. The Non-Purging Type is used to describe individuals who compensate through excessive exercising or through dietary fasting.
   The term, Binge Eating Disorder (BED), was officially introduced in 1992. The term was developed to describe individuals who binge eat but do not regularly use inappropriate compensatory weight control behaviors such as fasting or purging to lose weight.The eating may involve rapid consumption of food, uncomfortable fullness after eating, and eating large amounts of food when not hungry. Feelings of shame and embarassment are prominent. Binge Eating Disorder is often associated with obesity. In the past these individuals were often referred to as compulsive overeaters, emotional overeaters, or food addicts. Available research evidence suggests that approximately one fifth of the people who seek professional treatment for obesity meet the criteria for Binge Eating Disorder. In the DSM IV, binge eating disorder is not an officially recognized eating disorder but is included in the category titled Eating Disorder Not Otherwise Specified .
   There are numerous variants of disordered eating in addition to binge eating disorder that do not meet the diagnostic criteria for anorexia nervosa or bulimia nervosa, but nevertheless are eating disorders requiring treatment. A substantial number of individuals with eating disorders fit only this category. Individuals with eating disordered behaviors that resemble anorexia nervosa or bulimia nervosa but whose eating behaviors do not meet one or more essential diagnostic criteria may be diagnosed with EDNOS. Examples of EDNOS include individuals who regularly purge but do not binge eat, individuals who meet criteria for anorexia nervosa but continue to menstruate, and individuals who meet criteria for bulimia nervosa, but binge eat less than twice weekly.

   The diagnostic scheme endorsed by the American Psychiatric Association has been criticized for its lack of specificity since a substantial fraction of patients requesting treatment for an eating disorder do not meet formal diagnostic criteria for either Anorexia Nervosa or Bulimia Nervosa. It is widely acknowledged that community-based studies are needed to fully characterize the complete range of eating disorders.
   The diagnosis of an eating disorder can be difficult. The boundaries between normal and disordered eating are somewhat blurry. Many patients with clearly disordered eating do not meet the formal diagnostic criteria for one of the specific disorders and are classified as having Eating Disorder NOS. The failure to meet formal criteria does not necessarily mean that the individual does not have a serious and significant disorder. Formal evaluations for diagnosis and treatment should only be made by qualified clinicians.

   For a more thorough review of diagnostic issues refer to Walsh, B.T. & Garner, D.M. Diagnostic Issues. In Garner, D.M. & Garfinkel, P.E.(Eds.) Handbook of Treatment for Eating Disorders, Second Edition. New York: The Guilford Press, 1997.

Prevalence Of Eating Disorders

It is generally agreed that the incidence of eating disorders has increased, but the complete syndromes are not common.

Anorexia nervosa - Approximately 0.5% to 1.0% of late adolescent or adult women meet criteria for the diagnosis of Anorexia nervosa.

Bulimia nervosa - Approximately 1.0% to 2.0% of late adolescent and adult women meet criteria for the diagnosis of Bulimia nervosa.

Sub-syndromal symptoms - At any given time 10% or more of college aged women report symptoms of eating disorders. Although these symptoms may not satisfy full diagnostic criteria, they do cause distress. Interventions with these individuals may be helpful and may prevent the development of more serious disorders.

Consequence Of Eating Disorders


   Eating disorders can have profoundly negative impact on an individual's quality of life. Self-image, relationships, and professional performance are often negatively affected. The extent to which these problems are an inherent part of the disorders or are secondary is unclear. The range of the negative effects does, however, highlight the critcal importance of treatment.

   Eating disorders are also associated with high rates of of other co-existing psychiatric disorder, particularly mood disorders, anxiety disorders, and personality disorders. Bulimia nervosa may be particularly associated with substance abuse problems. Anorexia nervosa is often associated with obsessive-compulsive symptoms.


   Semistarvation in Anorexia Nervosa can affect most organ systems. Physical signs and symptoms (symptoms (in addition to the lack of menstrual periods in women) include constipation, cold intolerance, abnormally low heart rate, abdominal distress, dryness of skin, hypotension, and fine body hair (lanugo)). Anorexia Nervosa causes anemia, kidney dysfunction, cardiovascular problems, changes in brain structure, and osteoporosis (inadequate bone calcium).

   Self-induced vomiting can lead to swelling of salivary glands, electrolyte and mineral disturbances, and dental enamel erosion. Use of ipecac to induce vomiting can lead to extreme muscle weakness, including heart muscle weakness. Laxative abuse can lead to long lasting disruptions of normal bowel functioning. Rarer complications are tearing the esophagus, rupturing the stomach, and developing life-threatening irregularities of the heart rhythm.

Course And Outcome Of Eating Disorders

   The course and outcome of Anorexia Nervosa are variable, and include recovery after a circumscribed episode, a fluctuating pattern, a chronic, debilitating course and death.

   Less is known about the long term outcome of Bulimia Nervosa, but among clinic cases, intermittent and chronic courses are common.


   The precise causes of eating disorders are unknown but it is virtually certain that a variety of factors contribute to their development.

Sociocultural Factors

   Undue emphasis on low body weight and slimness in the presence of plenty, and the easy availability of high fat, high calorie, highly palatable foods have been implicated as contributing causes of eating disorders. Persistent and pervasive media messages encouraging dieting almost certainly lead to high rates of chronic dieting in at-risk groups of adolescents. Chronic dieting has been strongly implicated in the development of disordered eating.

Psychological Factors

   Self esteem is fragile in adolescence. It is now widely recognized that the group most at risk for eating disorders, namely adolescent girls, generally experience a marked decrease in self-esteem in mid-adolescence. Low self esteem seems to represent a significant risk factor for the development of eating pathology. Psychological tendencies to be perfectionistic and to set rigid standards for oneself may represent other risk factors. Characteristic personality tendencies to avoid harm (in anorexia nervosa) or to have a very emotional nature (in bulimia nervosa) have been identified as risk factors.

Family Factors

   Family factors such as obesity in the family, parental preoccupation with eating and weight, unrealistic expectations for achievement, and family disharmony also have been identified as factors that may promote the development of disordered eating.

Biological Factors

   Genetic tendencies contribute to eating disorders. If one of two identical (monozygotic) twins suffers from anorexia nervosa or bulimia nervosa, the second twin is at much higher risk than chance to also have the same condition. And, if one identical twin has an eating disorder, the second identical twin is also at much higher risk than she would be if they were non-identical (dizygotic or fraternal) twins. Inherited factors may include tendencies toward obesity and genetic factors contributing to temperment and personality like those mentioned above. Other factors that influence the individual’s constitution, such as maternal alcohol or cigarette use during pregnancy, low birth weight, severe early traumas, and other harmful factors, may also contribute to vulnerability. Neurotransmitter deficits (e.g., reduced serotonin activity) that persist with recovery also have been identified in eating disorder patients.


   Many patients with uncomplicated bulimia nervosa and binge eating disorders respond well to cognitive behavior therapy and other treatments. Patients with anorexia nervosa more usually require a treatment team consisting of a primary care physician, such as a pediatrician or adolescent medicine specialist, and other health and mental health professionals knowledgable about eating disorders. The treatment of individuals with more complex combinations of eating disorders and other psychiatric disorders is usually more complex. The multidisciplinary membership of the Academy for Eating Disorders reflects the consensus view that treatment must often involve clinicians from different health disciplines including psychotherapists, physicians, nutritionists, and nurses. Research on the treatment of eating disorders is exploring the various ways in which specific treatments can be matched to specific subtypes of these disorders. The American Psychiatric Association (American Psychiatric Association, Practice Guidelines for Eating Disorders. Am. J. Psychiatry, 1993, 150, 207-227) has published a set of practice guidelines for the treatment of patients with eating disorders. A new revised set of guidelines is due to be published soon.

   There is general agreement that good treatment often requires a spectrum of treatment options. These options can range from basic psychoeducational interventions designed to teach basic nutritional and symptom management techniques to long term residential placements.

   Most individuals with eating disorders are treated on an outpatient basis after a comprehensive evaluation. Individuals with medical complications due to severe weight loss or due to the effects of binge eating and purging may require hospitalization. Other individuals, for whom outpatient therapy has not been effective, may benefit from day-hospital treatment, hospitalization, or residential placement. Treatment is usually conducted in the least restrictive setting that can provide adequate safety for the individual. Many patients with eating disorders also have depression, anxiety disorders and other psychiatric problems requiring treatment along with the eating disorder.

Initial Assessment

   The initial assessment of individuals with eating disorders involves a thorough review of the patient's history, current symptoms, physical status, weight control measures, and other psychiatric issues or disorders such as depression, anxiety, substance abuse, or personality issues. Consultation with a physician and a registered dietician may also be recommended. The initial assessment is the first step in establishing a diagnosis and treatment plan.


   Outpatient treatment for an eating disorder often involves a coordinated effort between the patient, a psychotherapist, a physician, and a nutritionist. Yet, many patients are treated by their pediatrician or physician with or without a mental health clincian’s involvement. Similarly, many patients are seen and helped by generalist clinicians without specialist involvement. Not all individuals, then, will require a multidisciplinary approach but the qualified clinician should have access to all of these resources.

   There are several different types of outpatient psychotherapies with demonstrated effectiveness with patients with eating disorders. These include cognitive-behavioral therapy, interpersonal psychotherapy, family therapy, and behavioral therapy. Other therapies which some clinicians and patients have found to be useful include feminist therapies, psychodynamic psychotherapies and expressive therapies such as psychodrama, art and movement therapies.

   Psychiatric medications have a demonstrated role in the treatment of patients with eating disorders. Most of the research to date has involved antidepressant medications such as fluoxetine (Prozac), although some clinicians and patients have found that other types of medications may also be effective.

Nutritional Counseling:
   Regular contact with a registered dietician can be an effective source of support and information for patients who are regaining weight or who are trying to normalize their eating behavior.

Physical/Medical Care:
   Patients with eating disorders are subject to a variety of physical and medical concerns. Adequate medical monitoring is a cornerstone of effective outpatient treatment.

Day Hospital Care

   Patients for whom outpatient treatment is inadequate may benefit from the increased structure provided by a day-hospital treatment program. These programs provide structured eating situations and active treatment interventions while allowing the individual to live at home and, in some cases, to continue to work or to attend school.

Inpatient Care

   Inpatient treatment provides a structured and contained environment in which the patient with an eating disorder has access to clinical support 24-hours a day. Many programs are now affiliated with a day-hospital program so that patients can "step-up" and "step-down" to the appropriate level of care depending on their clinical needs.

Residential Care

   Residential programs provide a longer term treatment option for patients who require longer term treatment.

   For a full review of the treatment of eating disorders please refer to Garner, D.M. & Garfinkel, P.E.(Eds.) Handbook of Treatment for Eating Disorders, Second Edition. New York: The Guilford Press, 1997.

Eating Disorders And Health Insurance

AED Position Statement on Equity in Insurance Coverage for Eating Disorders:

   Providing adequate insurance coverage for medically appropriate treatment for eating disorders has become increasing difficult to do in today’s managed care environment. The Academy for Eating Disorders has taken an active role in advocating for the preservation of treatment availability and coverage. Please join our efforts by volunteering to contact and discuss these issues with your managed care contacts. Please contact the Academy office for more information.

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