Eating disorders (EDs) have been reported as serious mental and physical illnesses and involve complex relationships with food, eating, exercise, and body image. They occur in all populations, regardless of age, ethnicity, socioeconomic status, sex, religion, or gender, and have the highest mortality rate of any mental illness.1,2 EDs can be serious and fatal illnesses associated with severe disturbances in people’s eating behaviors and emotions.1
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), lists EDs under the category of “Feeding & Eating Disorders” and explains that they are “characterized by a constant disturbance of eating and related behavior that results in absorption of food.” This category includes diagnostic criteria for anorexia nervosa, bulimia nervosa, pica, rumination disorder, orthorexia, and binge-eating disorder.1,2
Emotional and Behavioral Symptoms
ED onset typically occurs in young adulthood but is not limited to this life stage. EDs are complicated disorders and vary from person to person. The following are a few emotional and behavioral symptoms that may indicate an individual lacks a good relationship with food1-3:
• Close attention to weight, food, calories, and nutritional content of food
• Eating alone or wasting food
• Skipping meals
• Strong fear of weight gain
• Misshape body image
• Mood swings
• Withdrawing from others and less socialization
• Peripheral thought processing and difficulty focusing or concentrating.
Types of EDs
The most common EDs are mentioned below. Each diagnosis has specific criteria distinguishing it from other mental illnesses and EDs. Recognizing the exact difference between these disorders can help improve treatment and recovery in patients.1-3
Anorexia Nervosa: For the diagnosis of anorexia nervosa, the DSM-5 specifies that the individual must engage in constant energy-intake restriction, have an intense fear of gaining weight or be engaging in a persistent behavior that interferes with weight gain, and have a disturbance in the individual’s perception of his or her body weight or shape.
These individuals often present with a body weight that is “below a minimally normal level for age, sex, developmental trajectory, and physical health”; however, this is not always the case. One cannot determine if someone struggles with anorexia based on their body appearance alone.
Bulimia Nervosa: Bulimia nervosa is characterized by three essential features: recurrent episodes of binge eating, recurrent compensatory behaviors to prevent weight gain, and self-evaluation that is usually influenced by body shape and weight. An individual must engage in these behaviors at least once per week for 3 months to meet the criteria for diagnosis.
Binge-Eating Disorder: Binge-eating disorder (BED) is the most common ED diagnosis among all others. The DSM-5 specifies that BED involves binge-eating episodes defined as mentioned above in the bulimia nervosa diagnosis.
BED differs from bulimia nervosa in that BED involves no recurrent use of compensatory behaviors to prevent weight gain and does not occur exclusively during anorexia or bulimia episodes. BED also does not include an individual’s perception of body shape and weight in diagnostic criteria.
Pica: Pica is considered a relatively rare disorder but is most commonly seen in pregnant women and young children. Pica involves eating one (or more) nonnutritive, nonfood substances on a persistent basis for at least 1 month. Pica is diagnosed when this behavior occurs often enough to warrant clinical attention. The DSM-5 specifies that the eating of nonnutritive, nonfood substances must be inappropriate to the developmental level of any individual.
Rumination Disorder: Rumination disorder is a condition in which people repeatedly spit up (regurgitate) undigested or partially digested food from the stomach, rechew it, and then either reswallow it or spit it out. Because the food has not yet been digested, it reportedly tastes normal and is not acidic, unlike vomit.
Diagnostic criteria for rumination disorder specify that it should not be diagnosed if behaviors can be better explained by a gastrointestinal or medical condition or if they occur exclusively during an anorexia, bulimia, or BED episode.
Orthorexia: A recent disorder is an obsessive behavior with healthy eating called orthorexia nervosa. Orthorexia generally begins as an attempt to eat more healthfully. Since it is not easy to maintain this rigid eating style, people punish themselves if temptation wins, usually through stricter eating, fasts, and exercise. Eventually, orthorexics become so restrictive and picky in their food choices—both in kind and calories—that their health suffers. The obsession with healthy eating can overshadow other activities and interests, impair relationships, and become physically dangerous.4
Risk Factors
EDs can have harsh long-term consequences. The malnourishment that results from EDs impacts all organ systems in the body, including the brain and the cardiovascular, endocrine, and gastrointestinal systems. Due to malnourishment, the body breaks down its own tissues. The electrolyte imbalance caused by vomiting or laxative use or excessive water intake can also increase the risk of heart failure. A malnourished brain can lead to difficulty concentrating, sleeping, staying asleep, sleep apnea, and dizziness or fainting.
Lack of fat and cholesterol through disordered eating impacts functions of the endocrine system, such as thyroid hormones. For this reason, individuals may experience issues regulating core body temperature, which can result in hypothermia.
Finally, EDs affect stomach emptying and absorption of nutrients, which can lead to severe stomach problems. Over time, all organs and gastrointestinal functions can become harshly disturbed by ED behaviors.1,5
Causes
There are many genetic, environmental, and sociological factors that contribute to ED advancement.1,2,6
Biological Factors: Biological risk factors for EDs include many genetic factors, such as predispositions to medical and mental illness. Individuals who have a family history of mental-illness diagnoses are more likely to experience mental illness themselves. Even if the predisposed mental illness is not an ED, EDs commonly co-occur with diagnoses such as depression, anxiety, or substance-use issues.
An individual’s medical history can also increase ED risk, as research indicates that certain illnesses, such as type 1 diabetes, are associated with increased risk for ED development.
Environmental Factors: Environmental factors, such as family-related beliefs and discussions around weight, food, and self-view, have been shown to be associated with ED diagnoses. The social views one absorbs via peers, social media, television/movies, and consumer culture are also related to the increased development of EDs.
Psychological Factors: Psychological factors for EDs include a co-occurring diagnosis of another disorder, as mentioned above. Specific personality can increase the likelihood of developing an ED, such as perfectionism, low self-worth, or distorted body image. Experiencing a past or present trauma also increases one’s likelihood of developing a disordered eating belief or pattern.
Treatment
Due to the various ways in which EDs pervade all aspects of one’s body, mind, and life, receiving the appropriate treatment is important. There are various levels of care designed to treat specific stages of ED severity. Any ED treatment center will assess a struggling individual to determine the appropriate level of care.
There are several evidence-based treatments that can support ED recovery; the best known and most commonly used are cognitive behavioral therapy, dialectical behavior therapy, and family-based treatment. Evidence suggests that medications (e.g., antidepressants, antipsychotics, or mood stabilizers) may also be helpful for treating EDs and other co-occurring illnesses such as anxiety or depression.1,7-9
REFERENCES
1. Eating Disorder Hope. What is anorexia: symptoms, complications and causes. www.eatingdisorderhope.com/information/anorexia. Accessed December 2022.2. Hauck C, Cook B, Ellrott T. Food addiction, eating addiction and eating disorders. Proc Nutr Soc. 2020;79(1):103-112.
3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC; 2013.4. Saljoughian M. Othorexia: an eating disorder emerges. US Pharm. 2017;42(12):9-10.
5. Jones W, Morgan J. Eating disorders in men: a review of the literature. J Public Mental Health. 2010;9(2):23-31.6. Hoek HW, van Hoeken D. Review of the prevalence and incidence of eating disorders. Int J Eat Disord. 2003;34:383-396.
7. Steinhausen HC. The outcome of anorexia nervosa in the 20th century. Am J Psychiatry. 2002;159:1284-1293.8. Fichter MM, Quadflieg N. Twelve-year course and outcome of bulimia nervosa. Psychol Med. 2004;34:1395-1406.
9. Couturier J, Kimber M, Szatmari P. Efficacy of family-based treatment for adolescents with eating disorders: a systematic review and meta-analysis. Int J Eat Disord. 2013;46(1):3-11.
The content contained in this article is for informational purposes only. The content is not intended to be a substitute for professional advice. Reliance on any information provided in this article is solely at your own risk.
To comment on this article, contact rdavidson@uspharmacist.com.
