An "eating disorder" refers to a group of behaviors that continue for an extended period of time and do not align with healthy patterns of eating. Usually associated with extreme restriction or extreme consumption, eating disorders can result in many health problems and even death.

While eating disorders is not part of the discussion in the "Substance-Related and Addictive Disorders" section of psychiatry's Diagnostic and Statistical Manual of Mental Disorders (DSM-5), it is important to include them here because of the many similarities and high incidence of comorbidity with addiction – especially drugs and alcohol.

The most common eating disorders are:

Anorexia: The person continuously seeks weight loss (despite typically being underweight) and goes without eating or restricts themselves to extremely low calorie consumption, resulting in starvation.

Bulimia: The person first binges (consumes an extreme amount of food - much more than a normal person would eat during a regular meal) and then purges (induces vomiting) or otherwise compensates for the binge (e.g., extreme exercise). This two-part process often results in weight maintenance although many health problems may emerge.

Binge Eating Disorder: The person binges but does not purge or compensate, often resulting in weight gain and/or obesity.

Avoidant/Restrictive Food Intake Disorder (ARFID): Added to DSM-5, this diagnosis applies when the person refuses to eat certain foods or food groups and does not meet criteria for anorexia. More commonly found in children and adolescents than adults, this severe restriction (beyond "picky eating") stunts growth or causes weight loss, and interferes with the individual's daily life.

In addition to these, the DSM-5 recognizes that individuals may exhibit mixed or different symptoms; thus, a person may receive a diagnosis of "other specified feeding or eating disorder," which includes 6 subcategories. Although many people struggle with weight issues throughout their lives, the statistics [1] about these extreme forms of disordered eating are troubling:

  • Roughly half of those with an eating disorder also have depression.
  • Of all mental health conditions, eating disorders have the highest death rate. Among those with anorexia, 20% die early from heart problems or suicide.
  • Females are more at risk than males; elite female athletes, especially in sports like figure skating, gymnastics, and ballet, are one of the highest risk groups.
  • Because of social perceptions and stigma, only 10% of men with eating disorders get treatment.
  • Binge eating disorder affects 3.5% of American women and about 2% of men. [2]

In light of these issues, it is important to recognize and address the signs of an eating disorder as early as possible.

Signs and Symptoms

Doctors understand that eating disorders vary in their presentation. The table below gives some signs to look for when attempting to determine if you or a loved one suffers from an eating disorder.

Sign

Anorexia

Bulimia

Binge ED

ARFID

Not eating

X

Binge eating

X

X

Extreme exercise

X

X

Laxative abuse

X

X

Weight loss

X

X

Weight gain

X

Stable weight or frequent fluctuations

X

Visiting the bathroom after meals

X

Discolored or decaying teeth

X

X

Calluses on knuckles

X

Food-related rituals

X

X

Self-esteem linked to body image

X

X

X

Frequently looking in the mirror

X

X

Swollen jaw or cheeks

X

Avoiding specific food groups

X

X

Avoiding meals and social situations

X

X

Hiding food

X

X

Often talking about weight, calories, etc.

X

X


It is important to remember that eating disorders often develop gradually so many of these signs may not be present until the condition is more advanced. Also, the above is not a comprehensive list and does not include behaviors that may fall under the "not otherwise specified" guidelines, such as chewing food but not swallowing it. The longer the eating disorder goes untreated, the more likely that the person will develop other health problems associated with it, and these could be considered additional red flags for family and friends.

Effects and Consequences

Because these eating disorders are characterized by different behaviors, the effects depend on the specific disorder.

Anorexia

  • Anemia (red blood cell deficiency causing fatigue and weakness)
  • Muscle loss resulting in weakness that may begin to impede activities of daily living
  • Loss of menstrual cycle in females and lowered testosterone in males
  • Arrhythmias (abnormal heart beats), heart failure, or mitral valve prolapse
  • Electrolyte imbalance, which can affect multiple body systems and cause seizures or even death
  • Inadequate calcium resulting in increased fracture risk, bone loss, and elevated risk for later development of osteoporosis
  • Bloating, nausea, severe constipation, and other GI problems
  • Decaying teeth from inadequate nutrition
  • Hair loss, brittle nails, and dry skin
  • Impaired memory and cognitive function, which may lead to poor productivity and achievement at school or work
  • Decreased body temperature, resulting in the growth of "lanugo," fine hair that may appear anywhere on the body
  • Impaired renal (kidney) function or failure
  • Worsened mental health conditions and/or suicide attempts
  • Delayed sexual and physical development in adolescents
  • Increased risk of miscarriage, birth defects, and infertility

Bulimia

  • Electrolyte imbalances that affect cardiac (heart) and renal (kidney) function, potentially resulting in seizures or death
  • Discolored and/or decaying teeth from contact with stomach acids when purging
  • Chronic sore throat and swollen saliva glands from repeated exposure to stomach acid; increased risk of esophageal rupture and acid reflux disease
  • Development or exacerbation of mental health problems like depression and anxiety
  • Irregular or absent menstrual cycles in females
  • Problems with digestion and needing to use laxatives to have a bowel movement
  • Development of a substance-use disorder (e.g., alcohol, drugs)
  • Increased risk for suicide attempts
  • Impaired cognition and memory
  • Increased risk of miscarriage, birth defects, and infertility
  • Peptic ulcers

Binge Eating Disorder

  • Exacerbation or development of mental health conditions like depression or anxiety
  • Insomnia
  • Greater risk for fibromyalgia and irritable bowel syndrome (IBS)
  • Problems with fertility
  • Complications related to weight gain and obesity, such as type 2 diabetes, hypertension, obstructive sleep apnea, multiple types of cancer, high cholesterol, arthritis (from pressure on the joints), and heart disease
  • Decreased self-esteem
  • Degenerative arthritis is further complicated by imbalances in nutrition and hormones
  • Development of gall bladder disease as the organ increases hormone production to keep up with binges and facilitate digestion
  • Avoidance of social situations
  • Problems with career or relationships

Because ARFID is a relatively new diagnosis, its long-term effects are not as well understood. The two most notable effects are (a) the potential for stunted growth and development from malnutrition, and (b) the possibility of social isolation because many social events involve foods that may be perceived to be unsafe.

Although the exact effects of these eating disorders vary, all of them inevitably wreak havoc on the body by shifting hormones, electrolytes, and nutrients out of balance. Therefore, it is crucial to begin treatment for an eating disorder as early as possible.

Causes and Risk Factors

The causes of eating disorders seem to be complex and not fully understood. There are, however, some factors associated with increased risk of developing one of these disorders.

  • A larger percentage of individuals with eating disorders are female, but males are also susceptible and warning signs in males should not be ignored.
  • Disordered eating behaviors seem to run in families, which is likely a combination of genetic predisposition and environmental exposure to these behaviors.
  • Emotional and/or mental health issues – like low self-esteem, depression, anxiety, stress, and poor body image – frequently accompany eating disorders although it is not always clear which causes the other or if they develop concurrently.
  • Whether from magazines, career expectations, or relationship aspirations, pressure to match a certain ideal body type can fuel disordered eating behaviors.
  • Although an eating disorder can occur at any age, most cases have an onset during adolescence or young adulthood with far fewer cases presenting after age 40.

Treatment

Because of the potential for serious health complications – particularly for urgent cases of anorexia and bulimia – involving medical professionals in the treatment of any eating disorder case will be necessary. In addition to directing the patient on the road to recovery, physicians will also be able to address any physical conditions and mental health issues that co-occur or have resulted from disordered eating.

In all cases, individual, family, and group therapy can help the individual identify emotions and triggers associated with disordered eating. Family therapy may be particularly important when the patient still lives with and continues to be influenced by family members who may themselves suffer from disordered eating. For patients with anorexia and bulimia, hospitalization – with the goal of helping the patient achieve a healthy weight – may be necessary.

Depending on the exact symptoms, medications may be added to the treatment plan. Because there is such a high prevalence (50%) of depression among individuals with eating disorders, antidepressants may be prescribed. Patients with binge eating disorder may respond well to the anticonvulsant Topamax (topiramate) or to Vyvanse (lisdexamfetamine dimesylate), recently approved for use in binge eating disorder. At present, only Prozac (fluoxetine) has been approved for treating bulimia, but physicians may consider other medications with similar mechanisms of action for off label use. Likewise, although the Food and Drug Administration (FDA) has not yet approved any pharmacological options for anorexia treatment, many doctors try antidepressants or appetite stimulants like Mirtazapine. Very little is known about effective treatments for ARFID.

Remember that, in all eating disorders, bodily systems are affected. By the time loved ones observe behavioral abnormalities, the condition may be dangerous. If you suspect that you or someone you know has an eating disorder, please seek treatment quickly.