Eating disorders impact millions of individuals and families. With the highest mortality rate of any mental illness, eating disorders continue to be a dangerous and insidious part of our world. According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, eating disorders are classified into four major categories: Anorexia, Bulimia, Binge Eating Disorder and Otherwise Specified Feeding or Eating Disorders.

Anorexia

Anorexia Nervosa is a disorder in which preoccupation with restricting food intake and thinness leads to excessive weight loss. The individual typically has an intense fear of gaining weight, a distorted body image, and weighs less than the 85% of ideal body weight.

Signs and Symptoms of Anorexia:

  • Refusal to maintain body weight at or above a minimally normal weight for age and height
  • Restrictive eating
  • Intense fear of gaining weight or becoming fat, even though underweight
  • Disturbance in way in which one’s body weight or shape is experienced
  • Undue influence of body weight or shape on self-evaluation
  • Denial of the seriousness of the current low body weight
  • Loss of period in women who have reached puberty
  • Exhibits much concern about weight
  • Complaints about “feeling” fat
  • Suffers from depression (including shame, anger and guilt)
  • Attributes social and professional successes/failures to weight gain/loss
  • Denial of hunger
  • Loathing of body, hiding shape, and weight

*Please note, that although the classic diagnosis of anorexia requires the individual to weigh less than 85% of their ideal body weight, further research has shown that people of all body shapes and sizes can experience the symptoms of anorexia and is defined as atypical anorexia.

Bulimia

Bulimia Nervosa involves frequent episodes of binge eating, almost always followed by purging and intense feelings of guilt or shame. The individual feels out of control and may recognize that the behavior is not normal.

  • Recurrent episodes of binge eating. An episode of binge eating is eating a very large quantity of food in a short period of time. The binge eating episode is often accompanied by a sense of lack of control. I.e. The feeling that one can’t moderate how much or what is consumed.
  • Recurrent purging behavior. I.e. Self-induced vomiting, misuse of laxatives, diuretics, enemas, fasting, or excessive exercise
  • Disturbance in the way in which one’s body weight or shape is experienced
  • Undue influence of body weight or shape on self-evaluation
  • Denial of the seriousness of the current low body weight

Signs and Symptoms of Bulimia:

  • Exhibits much concern about weight
  • Complains about “feeling” fat
  • Suffers from depression, including shame, anger, and guilt
  • Perfectionist personality
  • Attributes social and professional successes/ failures to weight gain/loss
  • Denial of hunger
  • Loathing of body I.e. hiding shape and weight

Binge Eating Disorder

Those struggling with Binge Eating Disorder experience uncontrollable eating, sometimes done in secret. The individual has feelings of disgust, depression and guilt about binge eating and eats when not physically hungry. Those who are obese may be struggling with binge eating disorder though body size is not always indicative of an eating disorder. Individuals diagnosed with binge eating disorder may be living in all sized bodies.

Signs and Symptoms of BED:

  • Eating large amounts of food when not physically hungry- bingeing or eating uncontrollably
  • Unable to stop eating voluntarily
  • Eating rapidly
  • Eating until feeling bloated or uncomfortably full
  • Eating alone
  • Hoarding or stealing food
  • Low self-esteem and feelings of worthlessness
  • Intense guilt about eating, including self-disgust
  • Depressed moods, mood fluctuations, impatience, irritability
  • Loathing or hiding of the body under baggy clothes

Other Specified Feeding or Eating Disorder

Other Specified Feeding or Eating Disorder (OSFED) has been previously known as Eating Disorder Not Otherwise Specified (EDNOS) in past editions of the Diagnostic and Statistical Manual. OSFED/EDNOS is a serious, life-threatening eating disorder despite the fact that it does not receive as much research or attention. Just like all other eating disorders, OSFED is treatable, and individuals who struggle with this eating disorder are capable of recovery. This category was created to encompass those individuals who did not meet the strict diagnostic criteria for anorexia nervosa or bulimia nervosa, but who still have a significant eating disorder. OSFED is one of the most common eating disorders.

Under the category of OSFED are Atypical Anorexia Nervosa, Night Eating Disorder, Purging Disorder, Bulimia Nervosa (of low frequency or limited duration), Binge-eating Disorder (of low frequency or limited duration), and orthorexia.

Signs and Symptoms

  • Noticeable fluctuations in weight, both up and down
  • Is preoccupied with weight, food, calories, fat grams, and dieting, and appears uncomfortable eating around others
  • Refuses to eat certain foods, progressing to restrictions against whole categories of food (e.g., no carbohydrates, etc.)
  • Evidence of binge eating, including disappearance of large amounts of food in short periods of time or lots of empty wrappers and containers indicating consumption of large amounts of food
  • Evidence of purging behaviors, including frequent trips to the bathroom after meals, signs and/or smells of vomiting, presence of wrappers or packages of laxatives or diuretics
  • Develops food rituals (e.g. eats only a particular food or food group [e.g. condiments], excessive chewing, doesn’t allow foods to touch)
  • Any new practice with food or fad diets, including cutting out entire food groups (no sugar, no carbs, no dairy, vegetarianism/veganism)
  • Drinks excessive amounts of water or non-caloric beverages
  • Maintains excessive, rigid exercise regimen – despite weather, fatigue, illness, or injury—due to the need to “burn off ” calories”
  • Shows unusual swelling of the cheeks or jaw area
  • Stomach cramps, other non-specific gastrointestinal complaints (constipation, acid reflux, etc.)
  • Fine hair on body, and thinning of hair on head, dry and brittle hair (lanugo)
  • Muscle weakness and impaired immune functioning

Avoidant Restrictive Food Intake Disorder

Avoidant Restrictive Food Intake Disorder (ARFID) is a new diagnosis in the DSM-5, and can often be confused with “picky” or “selective” eating. ARFID is a restrictive eating disorder in the sense that individuals struggling with this disorder limit the quantity and quality of food consumed, but unlike anorexia, ARFID does not involve any distress pertaining to body weight, shape, or size. It also does not involve any fear of gaining weight.

Although many children experience stages of picky eating, a person with ARFID is severely lacking when it comes to the nutrition necessary to grow (in children) or to function (in adults). In children, this often results in a lack of weight gain or vertical growth; in adults, this often results in weight loss. ARFID can also lead to social distress, as these people often dislike eating with others or need an extended amount of time to consume a meal.

Signs and Symptoms

  • Dramatic weight loss without body image disturbance or fear of weight gain
  • Reports constipation, abdominal pain, cold intolerance, lethargy, and/or excess energy
  • Reports consistent, vague gastrointestinal issues (“upset stomach”, feels full, etc.) around mealtimes that have no known cause
  • Dramatic restriction in types or amount of food eaten, and will only eat certain textures of food
  • Fears of choking or vomiting
  • Lack of appetite or interest in food
  • Limited range of preferred foods that becomes narrower over time (i.e., picky eating that progressively worsens).

Rumination Disorder

Rumination disorder involves the regular regurgitation of food that occurs for at least one month. Regurgitated food might be re-chewed, re-swallowed, or even spit out. Typically, when someone regurgitates their food, they do not appear to be making an effort to do so, nor do they appear to be stressed, upset, or disgusted by this behavior.

Signs and Symptoms

  • Repeated regurgitation of food for a period of at least one month. Regurgitated food may be re-chewed, re-swallowed, or spit out.
  • The repeated regurgitation is not due to a medication condition (e.g., gastrointestinal condition).
  • The behavior does not occur exclusively in the course of anorexia nervosa, bulimia nervosa, BED, or avoidant/restrictive food intake disorder.
  • If occurring in the presence of another mental disorder (e.g., intellectual developmental disorder), it is severe enough to warrant independent clinical attention.

PICA

PICA is a disorder characterized by the ingestion of items that are not categorized as food and lack nutritional value. These items might include dirt, paper, hair, or paint chips.

Signs and Symptoms

  • The persistent eating, over a period of at least one month, of substances that are not food and do not provide nutritional value.
  • The ingestion of the substance(s) is not a part of culturally supported or socially normative practice (e.g., some cultures promote eating clay as part of a medicinal practice).
  • Typical substances ingested tend to vary with age and availability. They may include paper, soap, cloth, hair, string, wool, soil, chalk, talcum powder, paint, gum, metal, pebbles, charcoal, ash, clay, starch, or ice.
  • The eating of these substances must be developmentally inappropriate. In children under two years of age, mouthing objects—or putting small objects in their mouth—is a normal part of development, allowing the child to explore their senses. Mouthing may sometimes result in ingestion. In order to exclude developmentally normal mouthing, children under two years of age should not be diagnosed with pica.
  • Generally, those with pica are not averse to ingesting food.

Diabulimia

Diabulimia is an eating disorder that is not currently included in the DSM-5, though it is a serious and life-threatening disorder. Diabulimia involves the manipulation of insulin by someone with diabetes to control their weight or shape.

Signs and Symptoms

  • Increasing neglect or secrecy of diabetes management (e.g. infrequently filled prescriptions), or discomfort testing/injecting in front of others.
  • Increased anxiety about body image and/or fear that “insulin makes me fat”
  • Unexplained weight loss, possibly with extreme changes in diet or exercise.
  • Restricting certain food or food groups to lower insulin dosages
  • Changes in mood, including social withdrawal or increased sleep patterns.
  • A1c of 9.0 or higher on a continuous basis or A1c inconsistent with meter readings
  • Constant bouts of nausea and/or vomiting
  • Persistent thirst and frequent urination, possibly with frequent bladder and/or yeast infections
  • Multiple DKA or near DKA episodes
  • Low sodium and/or potassium
  • Irregular or lack of menstruation
  • Deteriorating or blurry vision
  • Fatigue or lethargy
  • Dry hair and skin