An eating disorder is defined as a condition that inhibits an individual’s ability to consume food in a manner consistent with good physical and emotional health. These disorders arise from a variety of physical, mental, and psychological origins, many of which are still not well understood. Eating disorders manifest themselves in a variety of ways. Some eating disorders present with obvious physical signs, while others may exhibit no outward physical component.
Types of Eating Disorders
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (DSM-V), is a publication that classifies mental disorders and is widely used by health-care practitioners. The DSM-V describes several eating disorders:
- Anorexia Nervosa – includes 2 subtypes:
- Bulimia Nervosa
- Binge-Eating Disorder (BED)
- Other Specified Feeding or Eating Disorder (OSFED)
- Avoidant/Restrictive Food Intake Disorder (ARFID)
- Rumination Disorder
- Unspecified Feeding or Eating Disorder
The DSM-V describes these eating disorders in such a way that they can be exclusively defined. This means that the eating disorders can be distinguished from each other and that an individual can only be described as having a single disorder at a given time. This exclusivity allows the person to receive the support and treatment that is most appropriate for the particular eating disorder. The exception to this rule is pica, which can be present concurrently with another eating disorder.
The term anorexia nervosa, was first coined in 1873 by physician Sir William Gull, to describe the condition he observed in some of his patients. It comes from the Greek, meaning, “a nervous loss of appetite.”
This disorder is characterized by:
1. Activities and behaviors that limit the consumption of calories and encourage the utilization of calories,in such a way that conflicts with the ability to maintain acceptable weight necessary for proper health.
Characteristic behaviors include food restriction, intense and prolonged exercise, and purging through self-induced vomiting and/or the employment of substances such as laxatives, diuretics, and enemas. The restrictive behavior seen in anorexia can be extreme and may present as strict dieting or fasting.
The subtypes of anorexia nervosa are differentiated by the presence or absence of purging through the use of self-induced vomiting and/or the improper use of substances such as laxatives or diuretics. This behavior is present in the binge/purge subtype, but not in the restrictive subtype. Both subtypes are characterized by restriction and excessive exercise as an attempt to compensate for calories consumed.
2. Overwhelming and often obsessive anxiety and apprehension related to weight gain.
The individual is intensely preoccupied with not becoming fat, such that they strictly monitor their weight and food intake, often on a minute scale. One extra bite of food, or the slightest perceived increase in weight can cause extreme distress. In most situations, even if the individual has succeeded in maintaining a low weight or even losing weight, they will continue to feel anxious and perceive that they are too fat and need to lose even more. One of the hallmarks of anorexia is the distorted sense that the individual is never “thin enough.” An individual suffering from this disorder frequently checks their weight and body size, often several times a day, using scales, photos, measuring tapes and even checking the body for fat by pinching various parts of the body skin folds. Persons with anorexia are described as being below normal body weight, due an inability on the individual’s part to ingest sufficient calories.
3. Distorted perceptions of body size and over-emphasis on thinness.
The individual seems to be impaired in their ability to accurately perceive their own body size and proportions, as well as those of others. Their clothes may be falling off because of their emaciation and their bones may be clearly visible, yet they view themselves in the mirror and declare themselves “fat.” The individual may compare themselves with normal weight persons, at a party, for example, and declare themselves the biggest one in the room. Another aspect of the body image distortion is the concept that as long as the person is thin, they are beautiful, no matter how terrible they may look. The individual suffering from anorexia loses interest in their other physical aspects, such as their hair or teeth, because they think that nothing matters, as long as they are thin. This distorted thinking may be considered as a requirement for the disorder to continue, for as the body begins to suffer the effects of starvation, the teeth, hair, nails, fat tissue in breasts and cheeks deteriorate. Thus, in contrast to a healthy person, the person with anorexia ignores these consequences, or, in some cases, relishes them as signs of success in their endeavor to be as thin as possible.
4. The individual with anorexia does not consider the grave consequences of the behavior.
Although the person with anorexia may be informed and warned repeatedly that the low caloric intake may lead to disability and/or death, the individual’s actions are not deterred. The individual’s mindset is so focused on body size that nothing is more important than the goal of absolute thinness. This desire is so powerful that often, the threat of debilitating physical consequences, or even death, is not strong enough to convince a person with anorexia to alter their self-destructive behavior.
The name bulimia nervosa, which translated from Greek means, “nervous ravenous hunger,” was first used in 1979, by Gerald Russell, a British psychiatrist.
This disorder is characterized by:
1. Repeated cycles of restriction followed by binge eating.
An episode of binge eating is described as consuming an extraordinary amount of food at one time. This quantity of food is considerably greater than a healthy person would consider reasonable to consume in a short period of time. During a binge-eating event, the individual experiences a feeling of loss of control over type and quantity of food they are eating.
2. Recurring episodes of behavior designed to rid the body of the calories ingested during the binge-eating event.
These behaviors are known as purging. Purging actions may consist of engaging in severe or extreme amounts of exercise, self-induced vomiting, abuse or misuse of laxatives, enemas, diuretics, extreme exercise, fasting or strict dietary restriction. These behaviors are not only extremely dangerous for the person suffering from bulimia, they are not effective in shedding the excess calories consumed during the binge-eating episode.
3. A negative self-image in terms of body size and shape.
Individuals with bulimia are dissatisfied with their weight and body shape. The cyclic behavior of restricted eating followed bingeing and purging is an attempt to lose weight in order to change the person’s body shape. Like persons with anorexia, the individual with bulimia feels that their body image is of extreme importance This perception allows them to engage in the destructive cycle of bingeing and purging despite its risks. Unlike the individual with anorexia, the person with bulimia often has a weight that falls within the normal range.
4. Episodes of restricting, bingeing and purging occur at least one time a week in a period of 3 months.
The constant preoccupation with body image leads to frequent episodes of bulimic behavior. As the vicious routine becomes more frequent, it becomes more and more difficult for the individual to break the cycle. This situation increases the person’s risk for dehydration, chemical imbalances and injury to the stomach, esophagus and oral cavity. Those with bulimia often experience a deep sense of shame concerning their eating behaviors, and so go to great effort to hide their actions from others. Wearing of the tooth enamel from stomach acid and injury to the back of the hands from eliciting a gag reflex may be clues to family that their loved one is suffering from bulimia.
This disorder was first described in 1995 by psychiatrist and researcher Albert Stunkard, who called it “night eating syndrome.” The term was changed to Binge Eating Disorder in order to include episodes that are not exclusively nocturnal.
This disorder is characterized by:
1. Repeated episodes of binge-eating.
An episode of binge eating is described as consuming an extraordinary amount of food at one time. This quantity of food is considerably greater than a healthy person would consider reasonable to consume in a short period of time. During a binge-eating event, the individual experiences a feeling of loss of control over type and quantity of food they are eating. Additionally, the episode involves 3 or more of the following characteristics:
- Very rapid consumption of food
- Continuing to eat, despite feeling full or not hungry
- Eating to a point of severe discomfort or pain
- Desire to eat alone in order to hide the amount and kind of food consumed
- Experiencing feelings of shame, self-loathing and despondency after the episode
2. The binge-eating events are not followed by purging or any method to compensate for calories ingested.
This characteristic distinguishes binge-eating disorder from bulimia nervosa.
3. Binge-eating episodes take place at least one time a week, on average, for at least 3 months.
4. Presence of severe anxiety and anguish related to binge-eating.
This category of eating disorders was first described in 1980, in the DSM-III, and was referred to as Atypical Eating Disorder. In later editions of the DSM, published in 1987 and 1994, the category was renamed Eating Disorders Not Otherwise Specified (EDNOS) and broadened to include several clinical presentations. In the latest version of the DSM, DSM-V, published in 2013, the disorder was again redefined and described as Other Specified Feeding or Eating Disorder (OSFED).
This category of disorders is characterized by irregularities in feeding patterns such that the individual experiences difficulty in significant areas of their life, but does not meet the full diagnostic criteria for the other eating disorders listed in the DSM-V.
Some examples of Other Specified Disorders:
1. Atypical Anorexia Nervosa
These individuals meet all of the diagnostic criteria for anorexia nervosa, with one exception. These persons exhibit weight that is within or above the normal parameters, despite experiencing significant weight loss.
2. Bulimia Nervosa (of low frequency and /or limited duration)
Individuals with this disorder meet all the diagnostic criteria for bulimia nervosa, with the exception of the bingeing-purging cycles occurring less often than one time a week, on average, and/or for less than 3 months’ duration.
3. Binge-eating disorder (of low frequency and/or limited duration)
Individuals suffering from this disorder meet all the diagnostic criteria for binge-eating disorder (BED), with the exception of the binge-eating episodes occurring less than one time a week, on average, and/or have been occurring for less than 3 months’ duration.
This disorder is characterized by purging activities designed to change the body shape or weight, through such behaviors as self-induced vomiting, inappropriate use of diuretics, laxatives or other substances. Although similar in this respect to bulimia, individuals with purging disorder do not participate in binge-eating behaviors.
This disorder is characterized by the consumption of unusually large amounts of food after the evening meal or upon awakening during night-time sleep. The individual suffering from this disorder is aware of and can remember the event. This disturbed eating pattern results in marked anxiety and/or hinders the ability to perform normal life activities. This eating behavior cannot be explained by any other eating disorder, mental or physical illness, or medication effects.
Prior its addition as a separate entity in the 2013 DSM-V, this eating disturbance was known as Feeding Disorder of Infancy or Early Childhood. While the difficulties associated with this disorder often begin in infancy or childhood, they may continue into adulthood.
This disorder is characterized by:
1. Failure to consume enough food to maintain caloric requirements for energy and/or growth.
This avoidance of food can be attributed to a variety of factors, including an absence of interest in eating, negative sensory qualities associated with food, such as texture or smell, and a fear of choking, gagging or otherwise becoming ill as a result of ingesting food. Interference with physical, mental and social functioning is manifested by one or more of the following:
- Failure to gain expected weight and/or height, according to predicted growth patterns in children
- Substantial weight loss
- Marked nutritional insufficiency
- Use of oral or enteral supplementation
- Impairment of overall function
2. The eating behavior cannot be attributed to an inadequate availability of food, another medical condition, or food-specific cultural observances and/or restrictions.
3. The disordered eating pattern occurs independently of a diagnosis of anorexia or bulimia, and body image distortion is not present.
The word rumination comes from the Latin, meaning, “to chew the cud.” The syndrome has been observed since antiquity, and was first clinically described in 1618 by Fabricus ab Aquapendende, an Italian anatomist. In the 1800’s, physician Charles-Édouard Brown-Séquard developed the disorder from performing regurgitation experiments on himself. Regurgitation is defined as the “voluntary or involuntary return of partly digested food from the stomach to the mouth.” The condition was not thought to be harmful, however, a recent study contradicts this thinking.
This disorder is characterized by:
1. Recurring episodes of food regurgitation during a period of time of at least 1 month.
The food regurgitated during these episodes may be chewed again, swallowed, or spit out of the mouth.
2. The episodes of regurgitation cannot be attributed to a physical cause, such as narrowing of the esophagus, gastroparesis, or gastroesophageal reflux disease.
3. The regurgitating behavior occurs independently of a diagnosis of anorexia, bulimia, binge-eating disorder (BED) or avoidant/restrictive food intake disorder. (ARFID).
4. Individuals with rumination disorder and concurrent mental illness experience sufficient distress from the rumination behavior so as to require treatment for the eating disturbance, in addition to the coexisting mental illness.
The name pica comes from the Latin word for magpie, a bird reputed to eat nearly everything. The disorder was first referenced in the medical literature in the year 1563. In the 1800’s the practice was employed by slaves in the southern United States, by eating clay in order to compensate for a nutrient-poor diet. The behavior continues today in some cultures, as a component of spiritual or medicinal rituals.
This disorder is characterized by:
1. Continued consumption of non-food materials with no nutritional benefit for a duration of at least 1 month, by individuals whose developmental stage is inconsistent with such activity.
While babies and young children may eat non-food substances, the act of consuming such items at a later age is inappropriate and should be addressed. Materials commonly consumed include chalk, wood, soil, coal, charcoal, ash, clay, ice, starch, paper, soap, hair, string, textiles, such as cloth or wool, paint, gum, metal or gravel. While pregnant women may experience the urge to ingest non-food items, such as chalk or ice, if the behavior results in the consumption of potentially dangerous materials, then a diagnosis of pica should be considered.
2. The act of eating non-food items is not component of a culturally accepted custom.
3. Individuals who ingest non-food items and have concurrent mental illness are sufficiently distressed by the eating behavior so as to require treatment for the eating disturbance, in addition to the coexisting mental illness.
Unspecified Feeding or Eating Disorder
These eating irregularities are characterized by feeding disturbance that cause the individual anxiety and/or impedes the ability to participate in normal life activities, but do not otherwise meet the full diagnostic criteria for any of the above mentioned eating disorders, as described by the DSM-V.
This designation may be used in cases where persons do not exhibit all the behaviors or symptoms characteristic of the specific eating disorders outlined above, or in situations where there is not enough information to make a specific diagnosis.
Written by Lisa S. Cline, MD – 2016
Dr. Cline can be reached at firstname.lastname@example.org
1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
2. Nicely TA, Lane-Loney S, Masciulli E, Hollenbeak CS, Ornstien RM: Prevalence and characteristics of avoidant/restrictive food intake disorder in a cohort of young patients in day treatment for eating disorders. Journal of Eating Disorders 2014, 2:21.
3 ”Clinical Definitions.” National Eating Disorder Information Centre, 2014. December 23, 2015.
4. Gull WW (1997). “Anorexia nervosa (apepsia hysterica, anorexia hysterica). 1868”. Obesity Research 5 (5): 498–502. doi:10.1002/j.1550-8528.1997.tb00677.x. PMID 9385628
5. Klein DA, Walsh BT (2004). “Eating disorders: clinical features and pathophysiology”. Physiol. Behav. 81 (2): 359–74.doi:10.1016/j.physbeh.2004.02.009. PMID 15159176
6. Douglas Harper (November 2001). “Online Etymology Dictionary: bulimia“.Online Etymology Dictionary. Retrieved 2015-12-28
7. Russell G (1979). “Bulimia nervosa: An ominous variant of anorexia nervosa”. Psychological Medicine 9 (3): 429–48.doi:10.1017/S0033291700031974. PMID 482466
8. Brewerton, Timothy. “Binge Eating: Recognition, Diagnosis, and Treatment”. Medscape Health eJournal. Retrieved Dec 2015
9. American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.) (DSM-III). Washington, DC.
10. American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed., rev.) (DSM-III-R). Washington, DC.
11. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC.
12. Brockbank, EM (1907), “MERYCISM OR RUMINATION IN MAN”, British Medical Journal 1 (2408): 421–427, doi:10.1136/bmj.1.2408.421,PMC 2356806, PMID 20763087
13. “Rumination” Dictionary.com, 2015
14. Thyer, Bruce A.; Wodarski, John S (2007). Social work in mental health: an evidence-based approach. John Wiley and Sons. p. 133. ISBN 0-471-69304-9.
15. Rose, E. A., Porcerelli, J. H., & Neale, A. V. (2000). “Pica: Common but commonly missed”. The Journal of the American Board of Family Practice 13 (5): 353–8. PMID 11001006
16. Sidhu, Shawn S; Rick, James R (2009), “Erosive eosinophilic esophagitis in rumination syndrome“, Jefferson Journal of Psychiatry 22 (1), ISSN 1935-0783