Eating Disorders

Eating disorders are a group of conditions characterized by disordered eating patterns, preoccupation with body size and weight, and distorted body image, often involving biological, psychological, and societal factors

ANATOMY OR SYSTEM AFFECTED: Abdomen, bones, gastrointestinal system, intestines, mouth, psychic-emotional system, reproductive system, stomach, teeth, throat

CAUSES: Psychological disorder

SYMPTOMS: Intense preoccupation with food and weight, disordered eating; may include ingestion of laxatives, depression and suicidal feelings, nutritional deficiencies, dehydration, hormonal changes, gastrointestinal problems, changes in metabolism, heart disorders, persistent sore throat, teeth and gum damage

DURATION: Chronic

TREATMENTS: Psychotherapy, nutritional counseling, medication

Causes and Symptoms

Identified eating disorders include anorexia nervosa, bulimia nervosa, and binge-eating disorder. These disorders are not always distinct, and many individuals exhibit symptoms of more than one. Their prevalence has increased during the latter twentieth and early twenty-first centuries. According to the US National Eating Disorders Association (NEDA), in 2024, it was estimated that 28.8 people, or 9 percent of the population, will have an eating disorder at some point in their lives. A 2024 study based on global data and published on NEDA's website found that 22 percent of children and adolescents worldwide experienced disordered eating. Anorexia and bulimia disproportionately affect adolescent and young adult women. However, they can also occur in men and older people, and binge-eating disorder occurs more frequently in men. The rising incidence of eating disorders in men may be associated with sports (such as wrestling), bodybuilding, and the performing arts (including dance), though part of this rise in reported cases can perhaps be attributed to a greater willingness among men to seek help for mental health issues. Eating disorders can be chronic and recur across the life span of an individual. Studies have also demonstrated that transgender people and some other LGBTQ+ individuals are at a greater risk of developing eating disorders. Recognition of eating disorders in older people has also increased, as have the negative health effects of the conditions on this population.

Anorexia is characterized by refusal to maintain normal body weight (less than 85 percent of expected weight), extreme fear of becoming overweight, and relentless pursuit of thinness. Individuals with have a distorted perception of body weight and size, and consider themselves to be overweight even when the opposite is true; some people with anorexia may have symptoms that meet the criteria for body dysmorphic disorder, an extreme obsession with one's appearance and fixation on perceived flaws that may not actually exist. Their view of themselves is heavily dependent on factors such as their level of adherence to a restrictive diet or the fit of their clothes. They often deny the negative aspects of low weight even in the face of serious health problems. Anorexia is the deadliest mental health condition, with an estimated fatality rate of 5 to 10 percent; roughly one in five of anorexia-related deaths is due to suicide, and men are more likely than women to die from the condition, often due to delayed diagnoses.

Two types of anorexia have been identified: the restricting type, involving dieting, fasting, or skipping meals, but not bingeing/purging; and the binge-eating/purging type, involving binge eating and purging (self-induced or misusing laxatives, enemas, or diuretics). The latter type is primarily distinguished from bulimia by refusal to maintain 85 percent of normal body weight. Dieting regimens may be severe, with intake reduced to between three hundred and six hundred kilocalories (calories) per day and strict habits regarding food selection and eating.

Individuals with anorexia commonly display a set of personality and behavioral characteristics including being goal driven, perfectionistic, and overtly competent at school or work. Underlying these tendencies is often a lack of confidence and low sense of self-worth. As dieting increases, individuals may become depressed and fatigued, causing school or work to suffer and further eroding self-perception. Rigid “all or nothing” thinking influences the severity of dieting. Thus, anorexic people might believe that if they permit themselves even one lapse in dieting, then they will become obese. As starvation develops, focus on food and weight increases, and behaviors such as hoarding food, gazing in mirrors, or seeking reassurance about appearance may be observed. Significant energy is expended to keep secret the severity of weight loss efforts. Consequently, exercise may be conducted privately, family meals and public eating avoided, or food disposed of surreptitiously. In some cases, anorexia is not discovered until after a health problem has developed consequent to malnutrition.

A number of serious health problems stemming from starvation and malnutrition are seen in people with anorexia. Among the most serious are those associated with cardiac functioning, including cardiomyopathy, arrhythmias, and altered heart rates. In rare cases, sudden death can occur as a result of irregular heart muscle contractions. Other health problems caused by anorexia involve the system (bloating and constipation), the (amenorrhea, hormonal abnormalities, and infertility), and the skeletal system (osteoporosis and osteopenia). Additional complications include lowered metabolism, cold intolerance, weakness, loss of muscle mass, low body temperature, and growth suppression. While older adults with anorexia may not exhibit a drive for thinness, behaviors such as food refusal, the hoarding or hiding of food, and distorted body image are often observed. The health effects of anorexia in this population are significant and worsen coexisting illnesses, sometimes hastening death. A very serious condition known as the “female athlete triad” can worsen the impact of eating disorders on women, and is a combination of factors involving athletic training: disordered eating, amenorrhea, and osteoporosis. Permanent damage to bone strength can result from this condition. Despite the numerous medical problems caused by anorexia, many with the disorder appear superficially healthy even after significant weight loss.

Bulimia is characterized by recurrent episodes of binge eating followed by purging or other inappropriate efforts to avoid weight gain. The episodes are accompanied by feelings of being out of control and subsequent self-disgust, guilt, and depression. Bingeing involves eating over a limited period of time an amount of food that is markedly larger than most people would under similar circumstances. Caloric intake during binges may range from two thousand to ten thousand. Social interruption, fear of discovery, or physical discomfort (nausea or abdominal pain) typically terminates the binge episode. The binge-purge cycle may occur several times per day, with considerable effort directed toward keeping the episodes secret. Typically, bulimics recognize that their behavior is abnormal and desire to change (as opposed to those with anorexia). The disorder is divided into two types. The purging type involves self-induced vomiting or laxative, diuretic, or misuse as methods to avoid weight gain. The nonpurging type involves fasting or excessive exercise to prevent weight gain. The majority of bulimia sufferers are female.

Self-induced vomiting is the most frequent method of purging and is typically accomplished by initiating the gag reflex by placing fingers down the throat. Over time, many bulimics are able to vomit reflexively without the need to use their fingers. Though employed less frequently as the sole methods of purging, laxatives, enemas, and rarely diuretics may be used in conjunction with vomiting. Abuse of laxatives is more common among older adults.

Individuals with nonpurging bulimia, especially men, engage in hours of exercise every day or fast after bingeing. Typically, the fast is broken by another binge episode and the cycle continues.

Those with bulimia place strong emphasis on appearance, and their mood and view of themselves are highly dependent on their weight and body shape. Most are at a normal weight, but some are underweight or overweight. Bulimia is often initiated by a restrictive diet that appears to cause many of the unusual behaviors and thinking patterns associated with anorexia, such as secretive behavior, food hoarding, and extreme focus on food and eating. There may be signs of and , as well as compulsive behavior. As opposed to anorexia, those with bulimia are more likely to be interested in social relations and to worry more about how others perceive them. Some engage in impulsive behaviors such as or shoplifting.

Serious medical complications can result from bulimia. Chronic vomiting or laxative abuse and consequent loss of body fluids may cause dizziness, cardiac abnormalities, dehydration, and weakness. Tooth decay caused by repeated exposure to acids from vomiting may occur. Erosion or tearing of the can result from chronic vomiting. Bingeing is associated with gastrointestinal disturbances including bloating, diarrhea, and constipation.

Binge-eating disorder is one of the most prevalent eating disorders in the United States. Older people suffer from binge-eating disorder at a greater rate than other eating disorders. The disorder is similar to bulimia, but does not involve efforts to avoid weight gain (such as purging). Individuals with the disorder regularly engage in binges lasting up to several hours, during which from two thousand to ten thousand calories may be consumed. Eating during binges is typically at a rapid pace and continues despite feeling discomfort or pain. Bingeing may occur when an individual is not very hungry, after attempting to keep a strict diet, or as a means to reduce stress. It is usually done in private and kept secret. Feeling out of control during binges is common, followed by feelings of self-disgust and shame. Preoccupation with food and unusual food-related behaviors (such as hiding food) are common. Individuals with binge-eating disorder are typically overweight and unhappy with their body shape and size. General mood and self-perception may be dependent on their weight and size. Depression and anxiety are common coexisting conditions. Distorted body image is less likely than with anorexia and bulimia. The health problems related to obesity are seen in those with binge-eating disorder. They include high blood pressure, diabetes, high cholesterol, and heart disease. Gastrointestinal problems may also result from binging.

During the first decades of the twenty-first century, researchers and medical professionals proposed the existence of an eating disorder known as orthorexia nervosa, which involves an extreme and ultimately debilitating fixation on healthy eating. The term was first introduced in 1997 by physician Steven Bratman, who proposed that people with orthorexia could experience a number of complications or comorbid conditions, including severe anxiety, social isolation, and/or malnutrition. Throughout the 2010s and 2020s, as more researchers began studying orthorexia, the condition still lacked official recognition from a number of key medical bodies, including the American Psychiatric Association (APA), which in 2013 did not include orthorexia in the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders (2013), nor the updated version (DSM-5-TR), which was published in 2022. Still, the proposed condition had begun to draw significant attention from researchers by that time, with many studies noting the obsessive nature of orthorexia-related behaviors and suggesting the proposed eating disorder should instead be classified under the umbrella of obsessive-compulsive disorder (OCD).

Other specified feeding or eating disorders (OSFED), formerly known as eating disorder not otherwise specified (EDNOS), describes serious, life-threatening, and treatable eating disorders that do not meet the DSM criteria for anorexia, bulimia, or binge-eating disorder. Examples of OSFED include atypical anorexia nervosa; binge-eating disorder of low frequency and/or limited duration; bulimia nervosa of low frequency and/or limited duration; purging disorder without binge eating; and night eating syndrome. According to the NEDA, OSFED is the most commonly diagnosed eating disorder in the United States.

The precise causes of eating disorders are unknown; however, a number of factors involving biological, psychological, and social variables have been identified as contributing to the conditions. The primary biological influences on all eating disorders are related to hunger and starvation. Research indicates that in healthy individuals, severe dieting produces moodiness, irritability, depression, food obsessions, social isolation, and apathy. These symptoms are also found in eating disorders and become more pronounced as starvation emerges. Thus, anorexia, bulimia, or binge-eating disorder may develop after food deprivation has occurred as a result of purposeful dieting to lose weight or enhance athletic performance, or consequent to food restriction resulting from illness (especially in older adults) or stress. Hunger resulting from restrictive dieting is the major for binging. Because a majority of those who diet do not develop eating disorders, there is likely some as yet unidentified biological or genetic predisposition in some individuals. Biological abnormalities associated with the and have been identified in some individuals with anorexia, while other research points to neurochemical or hormonal imbalances. In older adults, medications, coexisting health problems, and even poorly fitting dentures may initiate restricted eating, leading to anorexia. Irregular levels of the serotonin may influence binging in bulimia and binge-eating disorder since it is associated with triggering signals of satiety to the brain. Knowledge of the causes of binge-eating disorder is limited; however, as with bulimia, there often is a history of being overweight or obese prior to developing the disorder.

A number of psychological factors have been identified as causing eating disorders. Most of these are not mutually exclusive, and none has been universally accepted as the primary causative factor for the conditions. Factors proposed to account for anorexia include phobic responses to food and weight gain, conflicted feelings over adolescent development and sexual maturity, and reactions to feelings of personal ineffectiveness by “controlling” hunger and the body. Faulty thinking, known as cognitive distortions, may cause misperceptions in body image and undue emphasis on the importance of appearance. Powerful needs to demonstrate self-discipline and to develop feelings of uniqueness and independence may also contribute to anorexia. Individuals with bulimia often exhibit mood fluctuations as well as impulsive behaviors. Bulimia is thought by some to be a variant of OCD in which bingeing results from irresistible urges to eat and purging is engaged in to alleviate overwhelming anxiety. Fewer psychological causes have been identified in binge-eating disorder. Some research suggests that characteristics seen in bulimia, such as impulsivity and mood changes, are also associated with this disorder. Depression, especially in older adults, appears to play a role in all eating disorders. Middle-aged and older individuals may employ behaviors such as extreme dieting, binging, and purging to reduce anxiety or to exert control in their lives.

Societal factors appear to also contribute to eating disorders. Popular media increasingly promotes physical appearance, and thinness is held up as the ideal body type. Since the 1950s, there have been steady decreases in the weights of influential persons such as actors, fashion models, and musicians. Many popular role models for women and men are underweight. Significant social approval is often associated with weight loss and disapproval with weight gain. Thus, women and men may feel pressured to attain an unhealthy weight or unrealistic body shape. No reliable family characteristics have been conclusively associated with eating disorders; however, some families appear to have higher than usual levels of depression, difficulties in communication, conflict, and focus on weight and appearance.

Treatment and Therapy

Treatment of eating disorders incorporates medical, behavioral, and psychological interventions. Typically, those with anorexia believe that their diet is justified, and resistance to treatment is the norm. Men may be especially resistant. Weight is the central focus of initial treatment. Hospitalization is recommended for persons with more serious medical complications or who have less than 75 percent of expected weight. During hospitalization, daily monitoring of weight and caloric intake occurs, as well as any other necessary medical management. Behavioral therapy is employed to facilitate eating habits, and privileges such as social activity or family visits are made dependent upon increased eating and daily weight gains. Individual and family therapy are introduced as eases and irritability, depression, and preoccupation with diet diminishes. Lengths of hospital stays vary from weeks to months depending on severity of illness and treatment progress.

Outpatient treatment may be recommended with individuals who have less severe medical complications, who are motivated to cooperate with treatment, and who have families that can independently monitor diet and health status. Weight restoration is facilitated by supervision of caloric intake and regular measurements as well as behavioral therapy techniques. Individual therapy focuses on altering cognitive distortions and assumptions about diet, weight, and body image and developing more effective means of dealing with stress. Family therapy aims to improve communication patterns, eating habits, and supportive behaviors.

No medications have been identified as effective agents in treating the core symptoms of anorexia, though antidepressants and antianxiety medications may be prescribed for some patients with coexisting conditions. Medications that promote hunger may be used during the initial stages of treatment to facilitate eating.

Most patients with bulimia do not require hospitalization unless medical complications are severe. Outpatient treatment involves individual psychotherapy, family therapy, and pharmacotherapy. Individual addresses cognitive distortions involving appearance and body image as well as behaviors, thoughts, and emotions that lead to binge episodes. Skills for problem solving and stress are also taught. Treatment methods used for obsessive-compulsive disorder may also be employed, involving exposure to stimuli that usually trigger binge-purge behaviors while preventing them from occurring. Family therapy for bulimia aims at strengthening support and communication and developing healthy eating habits. With adolescents, impulsive behaviors associated with bulimia may be addressed by helping parents develop more effective methods of discipline and behavior management.

Antidepressant medications that regulate the neurotransmitter serotonin have been found to reduce bingeing, improve mood, and lesson preoccupation with weight and size. These same medications are useful in treating depression and anxiety, which are also commonly seen in those with bulimia.

Treatment of binge-eating disorder is similar to that of bulimia. Psychotherapy aims toward identifying and altering behaviors and feelings that lead to binging and developing effective methods of dealing with stress. Group therapy and weight loss programs with medical management may also be utilized. Antidepressants have also been found effective with binge-eating disorder.

Perspective and Prospects

Behaviors associated with eating disorders have been identified in the earliest writings of Western civilization, including those by the ancient Greeks and early Christians. Formal identification of eating disorders as medical illnesses occurred in the nineteenth century when case studies were first recorded. Treatment methods at that time were limited and often involved “mental hygiene” measures such as rest, fresh air, and cold or hot baths.

In the early to mid-twentieth century, psychological theories influenced by Sigmund Freud, an Austrian psychiatrist, dominated treatment methods for eating disorders. These conditions were viewed as resulting from early childhood experiences that caused problems with psychological and sexual development. Treatment involved psychoanalysis, a form of psychotherapy, often lasting several years. Limited evidence for the success of this approach caused its decline in use.

More recent and successful treatment approaches involve cognitive behavioral therapy that aims to alter thinking and behavior contributing to eating disorders. Medications have increasingly been used in treating eating disorders since the 1980s. Identifying biological causes of the conditions and refining pharmacotherapy may offer the best hope for improving treatment in the future.

Eating disorders were once thought to occur exclusively among young White women from middle- and upper-class families. Consequently, research into the disorders has historically focused on this population. Increased awareness of these illnesses has revealed that they occur in all socioeconomic classes and races, as well as in men and older adults. Additional research into groups traditionally overlooked in studies of eating disorders has continued. Men make up an estimated 25 percent of people with anorexia, though appear to be more likely to suffer from other eating disorders, particularly binge eating disorder and bulimia. While eating disorder symptoms typically appear in adolescence or early adulthood, older adults can also develop eating disorders; for example, a 2023 study by Yale School of Medicine found nearly 3 percent of US women ages fifty to sixty-four and nearly 2 percent of women sixty-five and older had an eating disorder. The presence of eating disorders in older adults can have severe health consequences, with a related mortality rate of 21 percent. Transgender adolescents and adults have also been identified as having greater risk for developing eating disorders; a 2022 study published in the Annals of Epidemiology found that the risk of an eating disorder in college students who were genderqueer and/or nonconforming was 38.8 percent relative to gender expansive students (12.3 percent). The risk for trans men and/or transmasculine students was 10.5 percent and for trans women and/or transfeminine students was 6.3 percent.

Awareness of eating disorders and their dangers has expanded among the general public since the 1970s, and some prevention efforts, including raising awareness of healthy eating habits and early signs of eating disorders, have proven helpful. Nevertheless, rates of these disorders are rising, due to a range of possible factors. As people of all ages began spending more and more time using various forms of social media by the beginning of the 2020s, health experts grew concerned about the potential link between social media and mental health issues, including the development or exacerbation of eating disorders. The link remains complicated, as research and surveys had shown that while some people who interact with pages or influencers regarding eating, exercise, or dieting experience a positive outcome, others' experiences with such images and content could contribute to negative outcomes such as weight obsessions or even eating disorders. Young people, in part due to the amount of time they spend on social media, are thought to be particularly vulnerable to these negative influences.

The prevalence of eating disorders rose across the world during much of the twentieth and twenty-first centuries; one study compared two six-year periods (2000–2006 and 2013–18), and found the rate of eating disorders rose worldwide from 3.5 percent to 7.8 percent. A notable spike in reported eating disorder symptoms occurred during the COVID-19 pandemic, which began in late 2019 and spread around the world beginning in early 2020. Quarantine measures, widespread economic fallout, and the fear of the pandemic itself all contributed to a surge in reported mental health issues, including eating disorders. This rise was particularly dramatic among teenagers and adolescents, due to the disruption of school and other routines, increased food insecurity, and social isolation.

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