Understanding Eating Disorders

by Amy Hendel, P.A. Health Writer

When you think about eating disorders, the most commonly used terms are anorexia (anorexia nervosa) and bulimia (bulimia nervosa). There are actually eight categories of eating disorders as defined by the Diagnostic and Statistical Manual, Fifth Edition (DSM-5):

  • Anorexia Nervosa

  • Bulimia Nervosa

  • Binge Eating Disorder

  • Avoidant/Restrictive Food Intake Disorder

  • Other Specified Feeding or Eating Disorder

  • Unspecified Feeding or Eating Disorder

  • Pica

  • Rumination Disorder

Eating disorders are often more than just about food. The following is a short, detailed view of each eating disorder category.

What is Anorexia Nervosa?

Individuals who suffer from anorexia don’t eat enough calories, which leads to significantly low body weight that in its most extreme form can lead to death. An individual who suffers with anorexia has a fear of eating because gaining weight or gaining fat, to them, is forbidden. If the fear is not addressed and managed, they engage in feeding patterns that prevent weight gain or promote weight loss. At the core of the disorder is control – this is the only area of their life that they feel that can strictly manage. These individuals do not typically recognize the dangers of very low weight and they seem to have a skewed sense of how they look in a mirror. They do not seem to see their gaunt frame.

Symptoms of the disease can include a number of the following symptoms and behaviors:

  • Dramatic weight loss

  • Dressing in layers to hide thinness or recent weight loss

  • Preoccupation with weight, food, calories, fat grams, and dieting

  • Frequent berating comments about their size or small amounts of weight gain

  • Denial of hunger despite minimal eating

  • Food rituals

  • Difficulty eating in public or in front of others

  • Excessive and rigid workout regimen

  • Limited social spontaneity and withdrawal from social circles

  • Loss of menses

  • Strong need to control

  • Denial of seriousness of weight situation

  • A series of current and escalating health issues associated with poor nutrition or severely low body weight (heart disease, anemia, dizziness/syncopal episodes, poor wound healing, poor immune function)

  • Fine hair or lanugo on the body

  • Oral health issues

  • Constant feeling of being cold

Anorexia can be extremely difficult to treat and recovery rates are not impressive. Still, there are a number of treatment options available including full hospital inpatient treatment programs, partial inpatient/outpatient programs, residential treatment, various types of psychotherapy including ACT (Acceptance and Commitment Therapy), CBT (Cognitive Behavioral Therapy), DBT (Dialectical Behavioral Therapy), Evidence-Based Treatment, Family-Based Treatment, IPT (Interpersonal Psychotherapy) and Psychodynamic Therapy.

What is Bulimia Nervosa?

An individual diagnosed with this disorder has recurring episodes of binge eating. A binge is defined as consumption of very large volumes of food in one sitting. The large volume is typically more food than a normal individual would consume within a two-hour period. The individual feels a lack of control and an inability to stop eating, despite recognizing the enormous volume of food being consumed in one sitting. Binges usually mean consuming the food very rapidly and eating until there is a feeling of true stomach discomfort. The individual eats when they’re not hungry and they typically feel embarrassed about the eating pattern. Feelings of depression and guilt are often experienced.
Additional symptoms include:

  • Compensatory behaviors including the use of laxatives, vomiting, excessive exercise, diuretics, and intermittent fasting.

  • The binges occurring at least once a week for three months.

  • Primary and focused attention on weight and size, dieting and food control

  • Food rituals

  • Uncomfortable eating around others

  • Disappearing after eating (usually to the bathroom)

  • Excessive fad dieting

  • Skipping meals or eating very small portions at regular meals

  • Drinking excessive water

  • Excessively using mouthwash (to hide oral odor after vomiting)

  • Swelling of cheeks (chipmunk cheeks) or dental erosion from vomiting

  • Frequent concern with appearance

  • Mood swings

  • Noticeable weight fluctuations but usually normal weight or overweight

  • Menstrual irregularities

  • Health issues associated with vomiting repeatedly

Individuals with bulimia may also engage in self-harm behaviors, such as cutting, or have substance abuse issues. Diabulimia is a term specifically used when bulimia behaviors occur in the presence of diabetes. The behavior involves overuse of insulin to control weight or lose weight and other bulimia behaviors.

Treatment can include psychotherapy (CBT, Family-based Treatment, Interpersonal Psychotherapy), medications including antidepressants like Prozac that may help to directly treat the eating disorder and not just associated depression, nutrition education from a dietician or nutritionist, and in some cases, hospitalization. Since stress can trigger episodes, identifying and helping the individual to manage stress is a crucial element of the treatment program.

What is Binge Eating Disorder?

This disorder is similar to bulimia except that the individual does not typically vomit or engage in compensatory behaviors. The binges are similar to those in bulimia. These individuals also feel shame and embarrassment surrounding these large feedings and may have issues with being overweight or having obesity. Many of the symptoms and behaviors are similar to bulimia.

The goal of treatment is to reduce the number of binges and to ultimately help the individual to engage with food normally. Treatment of the mental health issues associated with the condition (shame, poor self-image, negative emotions) is also a component of the treatment program.

What is Avoidant/Restrictive Food Intake Disorder (ARFID)?

The individual with this condition struggles to meet basic nutrition or energy needs. The individual will likely experience significant weight loss or they may have deficits in their physical growth patterns. Individuals may turn to nutritional supplements in lieu of food to try and course correct and their nutritional issues may interfere with psychosocial functions. The disease is usually identified after medical causes and mental health causes for the presentation are ruled out. This phenomenon is quite often seen in children or young teens and warrants clinical attention since it can have lifelong implications and also lead to other feeding disorders.

What is Pica?

Pica is a unique eating disorder in which the individual eats items that have no nutritional value for a duration of at least one month. It can affect children, teens and adults. It is more prevalent in developing countries. Common substances ingested include soap, cloth, hair, string, wool, soil, chalk, talcum powder, gum, metal, pebbles, ash, charcoal cotton, clay or ice. This should not be confused with behaviors of young children who typically may mouth certain objects and accidentally swallow them.

Pica often accompanies other mental health conditions, especially hair pulling disorder and skin picking (excoriation). Pica is often caused by iron-deficiency anemia and malnutrition. Pregnancy can also instigate pica. Usually treating the condition with medications or vitamins resolves the issue. The condition should be evaluated for severity since not all cases require intense medical attention.

What is Rumination Disorder?

This condition involves repeated regurgitation of food for a minimum of one month. It includes re-chewing, re-swallowing or bringing food back up after eating and swallowing and spitting food out. The food is often undigested or partially digested so it’s not acidic like vomit. It usually affects infants and children. It typically occurs daily, during mealtimes, within 30 minutes of eating the mouthfuls of food. The cause is not clear but it appears to be a subconscious and not conscious decision.

The condition is sometimes confused with bulimia, GERD (gastro-esophageal reflux disease), and gastroparesis. It’s also found in people with developmental disabilities and it may be related to food rejection, initially due to taste dislike, that snowballs into a more serious issue. It requires attention so that the individual doesn’t develop nutritional deficits or weight loss.

What is Other Specified Feeding or Eating Disorder?

Some individuals meet some of the criteria for the above described eating disorders but not all the criteria. They may fall into five categories under this condition heading which include:

  • Atypical Anorexia Nervosa – These individuals have symptoms of anorexia but weight is at or above normal range

  • "Less Frequent" Binge Eating Disorder – Which does not occur with regularity to warrant the full diagnosis

  • "Less Frequent" Bulimia Nervosa – The individual has the condition with far less frequent bouts so they don’t qualify for the full-fledge diagnosis

  • Purging Disorder – When the individual purges without the binging component

  • Night Eating Syndrome – The person consumes at least 25 percent of their day’s calories after the evening meal. Many of these individuals also wake up to eat in the middle of the night.

What is Unspecified Feeding or Eating Disorder?

This diagnostic term is used for disorders which do not meet any of the other criteria, sort of nuances of disordered feeding behaviors, that still cause great emotional upset or interfere with normal, good quality day-to-day life.

Sleep disturbances may also have a link to some eating disorders. Most of us assume that there has to be an obvious emaciated look to a person or very easily identifiable signs of an eating disorder for the condition to warrant concern. It’s clear from these different diagnoses that an eating disorder can have levels of severity. An early stage of an eating disorder can progress to a more severe level or even appear and disappear for periods. If you have concerns about your eating patterns or those of a loved one, seek out the guidance of a medical professional.

Amy Hendel, P.A.
Meet Our Writer
Amy Hendel, P.A.

Known as "The HealthGal", Amy Hendel P.A. is a medical and lifestyle reporter, nutrition and fitness expert, health coach and brand ambassador. Trained as a physician assistant, she maintains a health coach private practice in New York and Los Angeles. Author of The Four Habits of Healthy Families, find her on Twitter @Healthgal1103 and on Facebook @TheHealthGal. Check “Daily Health News” at healthgal.com. Her personal mantra? “Fix it first with food, fitness, and lifestyle.”