Eating disorders are characterized in the Diagnostic & Statistical Manual of Mental Disorders-5 (DSM-5-TR), as a severe and persistent disturbance in eating behaviors and associated distressing thoughts and emotions (DSM, 2022).There are seven identifiable eating disorders – Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder, Avoidant Restrictive Food Intake Disorder, Other Specified Feeding and Eating Disorders, Pica, and Rumination Disorder. Each type of eating disorder has specific characteristics and may only be diagnosed by a medical or mental health practitioner.
Eating disorders typically develop in adolescence and early adulthood. Additionally, several types of eating disorders usually affect women more than men. However, eating disorders can impact any gender. Eating disorders often start with a preoccupation with food, fear of gaining weight, anxiety about eating, or the consequences of consuming certain foods.
Behaviors associated with eating disorders include binge eating, purging food (via vomiting, the use of laxatives or excessive exercise), and avoidance or restriction of certain foods. These behaviors become compulsive, almost like an addiction.
Types of eating disorders.
Anorexia Nervosa is characterized by self-starvation resulting in low weight for height and age (DSM, 2022). It has the highest mortality rate of any psychiatric disorder. Dieting behavior in anorexia is often driven by the intense fear of gaining weight or becoming fat. There are two subtypes of anorexia – restrictive type and binge eating/purging type.
Over time medical conditions may begin to develop as a result of the restriction, binging, or purging behaviors. These medical conditions include:
- Lack of menstrual periods
- Cold intolerance
- Dizziness or fainting from dehydration
- Muscle weakness or wasting
- Heartburn or acid reflux
- Brittle nails/hair
- Severe constipation, bloating, or fullness after meals
- Bone fractures
- Depression, irritability, anxiety, poor concentration, and fatigue
Serious medical complications may also result and become life-threatening. These include heart rhythm abnormalities, kidney problems, and seizures (NEDA, 2022).
Treatment for anorexia involves helping those affected normalize their behaviors to restore their weight. Medical evaluation and treatment by a mental health practitioner is an important component of the treatment plan. Additionally, a nutritional plan should focus on helping the individual negate anxiety about consuming certain foods by incorporating various foods with different nutritional values.For teens, an effective approach includes parents or caregivers monitoring their child’s food intake. In severe cases when outpatient services are not effective, admission to an inpatient behavioral residential facility is warranted. Most inpatient residential treatment facilities are highly effective.
However, relapse in the first year following the treatment program discharge remains significant. It is important that during this time, the individual continues to meet with a licensed mental health practitioner to address such issues as the possibility of relapse.
Individuals with Bulimia Nervosa alternate dieting, or eating only low-calorie foods with binge eating on higher-calorie foods. Binge eating is defined as eating a large amount of food in a short period associated with a sense of loss of control over what, or how much one is eating (DSM, 2022).
Binges may be very large in the amount of food consumed to the point of feeling extremely full and even nauseous. Binge behavior is often secretive and associated with feelings of shame and guilt. Binges typically occur weekly and are often followed by compensatory behaviors to prevent weight gain.
Compensatory behaviors include purposely inducing oneself to vomit, excessive exercise, or the use of laxatives to eliminate the food consumed. As with anorexia, individuals with bulimia are excessively preoccupied with the thought of food, weight gain, the size or shape of one’s body, and self-worth.
Individuals with bulimia can be slightly underweight, normal weight, overweight or obese. If they are underweight, they are considered to have Anorexia Nervosa binge eating/purging subtype, however. The behaviors may go unnoticed. Thus, family members and friends may not even realize that the individual has bulimia because they do not appear to be underweight. Possible signs that someone may have Bulimia Nervosa include:
- Frequent trips to the bathroom right after meals
- Large amounts of food missing or unexplained wrappers and food containers
- Swelling of the salivary glands in the cheeks
- Chronic sore throat
- Heartburn and gastroesophageal reflux
- Dental decay resulting in erosion of tooth enamel
- Laxative or diet pill misuse
- Recurrent unexplained diarrhea
- Misuse of diuretics (water pills)
- Feeling dizzy or fainting from excessive purging behaviors resulting in dehydration
Bulimia can lead to rare but potentially fatal complications including esophageal tears, gastric rupture, and dangerous cardiac arrhythmias. Medical monitoring in cases of severe bulimia nervosa is important to identify and treat any possible complications NEDA, 2022).
Outpatient cognitive behavioral therapy is highly effective in treating those with bulimia nervosa. Cognitive behavioral therapy helps individuals normalize their eating behavior and manage thoughts and feelings that perpetuate the disorder. Additionally, antidepressants may also help decrease the urge to binge and purge.
Binge Eating Disorder
People with Binge Eating Disorder have episodes of binge eating in which they consume large quantities of food in a short amount of time, experience a sense of loss of control over their eating, and are distressed by the binge behavior (DSM, 2016).
However, unlike those with bulimia nervosa, individuals with Binge Eating Disorder do not regularly use compensatory behaviors to rid their bodies of food. Chronic binge eating can lead to serious health complications, including obesity, hypertension, cardiovascular disease, and hypertension (NEDA, 2022).
To meet diagnostic criteria for Binge Eating Disorder, frequent (at least once per week for three months) binges with the associated sense of lack of control must occur. The most effective treatment for individuals with Binge Eating Disorder is cognitive behavioral therapy. Interpersonal therapy has also shown to be an effective form of treatment.
Other Specified Feeding And Eating Disorders
Other Specified Feeding And Eating Disorders refers to eating disorders or disturbances of eating behavior that cause distress and impairs family, social, or work function, but that do not quite meet the criteria for another diagnosis (DSM, 2022). An example may be atypical anorexia nervosa, in which an individual has the behaviors of anorexia, but is not considered unweight based on their BMI because their baseline was above average, to begin with.
Avoidant Restrictive Food Intake Disorder
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 fussy eating (NEDA, 2022). In ARFID, food avoidance can be due to one or more of the following:
- Extreme food avoidance based on sensory characteristics of food (texture, color, appearance, smell)
- Anxiety or concern about consequences of eating, such as fear of choking, nausea, vomiting, constipation, or allergic reaction
- Lack of appetite or interest in eating food
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 the inability to eat with others)
ARFID can impact both physical and psychological health. Therefore, effective treatment includes working with a licensed mental health practitioner, registered dietician, and others.
Pica is an eating disorder in which an individual repeatedly eats things that are not food with no nutritional value (DSM, 2022). The behavior must persist for at least one month and must be severe enough to warrant clinical attention. Typical substances ingested vary with age and availability. These include paper, chalk, paint chips, soap, hair, string, cloth, metal, pebbles, coal, clay, or charcoal (DSM, 2022). A person diagnosed with Pica is at risk for intestinal blockage or toxic effects of substances consumed.
Effective treatment for Pica includes testing for nutritional deficiencies and addressing them if needed. Behavioral therapy is also used to redirect the individual from eating non-food items.
Rumination Disorder involves the repeated regurgitation and re-chewing of food after eating (DSM, 2022). It can occur at any age. To meet the diagnosis the behavior must:
- Occurs repeatedly over at least one month
- 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
Effective treatment for rumination disorder may include working with a nutritionist to ensure that there are no nutritional deficiencies and also behavioral therapy.
There are several resources for individuals struggling (or suspected to be struggling) with an eating disorder. The National Eating Disorders Association (NEDA) is a valuable tool to help individuals find the right treatment option. You can visit their website at http://nationaleatingdisorders.org for more information.
Because of the complexity of eating disorders, it is important to seek out a therapist that specializes in treating eating disorders. You can also visit www.seattlechristiancounseling.org to find a therapist that specializes in Cognitive Behavioral Therapy, interpersonal therapy, or behavioral therapy for eating disorders.
Additionally, it is also important to speak with your physician if you are struggling with an eating disorder due to underlying physical conditions that may also be present with an eating disorder.
Resources:Diagnostic & Statistical Manual of Mental Disorders (2022). American Counseling Association.
National Eating Disorders Association (2022). https://www.nationaleatingdisorders.org/
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