Learning Objectives
- Describe how anorexia nervosa presents.
- Describe how bulimia nervosa presents.
- Describe how binge-eating disorder (BED) presents.
Feeding and eating disorders are “…characterized by a persistent disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food and that significantly impairs physical health or psychosocial functioning” (APA, 2022, pg. 371). They are very serious, yet relatively common mental health disorders, particularly in Western society, where there is a heavy emphasis on thinness and physical appearance. In fact, 13% of adolescents will be diagnosed with at least one eating disorder by their 20th birthday (Stice, Marti, & Rohde, 2013). Furthermore, a large number of adolescents will engage in significant disordered eating behaviors just below the clinical threshold (Culbert, Burt, McGue, Iacono & Klump, 2009). While there is no exact cause for eating disorders, the combination of biological, psychological, and sociocultural factors has been identified as major contributors in both the development and maintenance of eating disorders.
Within the DSM 5-TR (APA, 2022), six disorders are classified under the Feeding and Eating Disorders chapter: pica, rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, and binge-eating disorder. In this book, we will cover the latter three whose diagnostic criteria are mutually exclusive, meaning that only one of these diagnoses can be assigned at any given time due to substantial differences in their clinical course, outcome, and treatment needs, despite a number of common psychological and behavioral features.
For more on eating disorders in general, please visit the National Eating Disorders Association website below:
www.nationaleatingdisorders.org/what-are-eating-disorders
10.1.1. Anorexia Nervosa
Anorexia nervosa involves the restriction of energy intake, which leads to significantly low body weight relative to the individual’s age, sex, and development. This restriction is often secondary to an intense fear of gaining weight or becoming fat, despite the individual’s low body weight. Altered perception of self and an over-evaluation of one’s body weight and shape contribute to this disturbance of body size.
Typical warning signs and symptoms are divided into two different categories: emotional/behavioral and physical. Some emotional and behavioral symptoms include dramatic weight loss; preoccupation with food, weight, calories, etc.; frequent comments about feeling “fat;” eating a restricted range of foods; making excuses to avoid mealtimes; and not eating in public. Physical changes may include dizziness, difficulty concentrating, feeling cold, sleep problems, thinning hair/hair loss, and muscle weakness, to name a few. When the individual loses weight, they view this as an impressive achievement and a sign of extraordinary discipline, while weight gain is seen as an unacceptable failure of self-control (APA, 2022).
The onset of the disorder typically begins with mild dietary restrictions such as eliminating carbs or specific fatty foods. As weight loss is achieved, the dietary restrictions progress to more severe, e.g., under 500 calories/day. Symptoms present in adolescence or young adulthood and rarely before puberty or after age 40. The onset of the disorder typically is preceded by a stressful life event such as leaving home for college.
For more on anorexia nervosa, please visit the National Eating Disorders Association website below:
www.nationaleatingdisorders.org/learn/by-eating-disorder/anorexia
Bulimia Nervosa
Unlike anorexia nervosa where there is solely restriction of food, bulimia nervosa involves a pattern of recurrent binge eating behaviors. Binge eating can be defined as a discrete period of time where the amount of food consumed is significantly more than most people would eat during a similar time period. Individuals with bulimia nervosa often report a sense of lack of control over-eating during these binge-eating episodes. While not always the case, these binge-eating episodes are followed by a feeling of disgust with oneself, which leads to a compensatory behavior to rid the body of the excessive calories. These compensatory behaviors include vomiting, use of laxatives, fasting (or severe restriction), diuretics or other medications, or excessive exercise. This cycle of binge eating and compensatory behaviors occurs on average, at least once a week for three months (National Eating Disorder Association website; APA, 2022).
It is important to note that while there are periods of severe calorie restriction like anorexia, the two disorders cannot be diagnosed simultaneously. Therefore, it is important to determine if an individual engages in a binge-eating episode—if they do, they do not meet the criteria for anorexia nervosa.
Signs and symptoms of bulimia nervosa are similar to anorexia nervosa. These symptoms include but are not limited to hiding food wrappers or containers after a bingeing episode, feeling uncomfortable eating in public, developing food rituals, limited diet, disappearing to the bathroom after eating a meal, and drinking excessive amounts of water or non-caloric beverages. Additional physical changes include weight fluctuations both up and down, difficulty concentrating, dizziness, sleep disturbance, and possible dental problems due to purging post binge eating episode.
Making Sense of the Disorders
Though anorexia and bulimia share some common features, they differ as follows:
- Diagnosis anorexia …… if severe calorie restriction occurs alone
- Diagnosis bulimia … if severe calorie restriction occurs AND there is a binge-eating episode
Symptoms of bulimia nervosa typically present later in development – adolescence or early adulthood. Like anorexia nervosa, bulimia nervosa initially presents with mild restrictive dietary behaviors; however, episodes of binge eating interrupt the dietary restriction, causing bodyweight to rise around normal levels. In response to weight gain, patients engage in compensatory behaviors or purging episodes to reduce body weight. This cycle of restriction, binge eating, and calorie reduction often occurs for years before seeking help.
Additionally, those with bulimia are often ashamed of their eating problems and attempt to hide the symptoms. The binge eating occurs in secrecy or as inconspicuously as possible. Common antecedents of binge eating include negative affect; interpersonal stressors; dietary restraint; boredom; and negative feelings linked to body weight, shape, and food.
For more on bulimia nervosa, please visit the National Eating Disorders Association website below:
www.nationaleatingdisorders.org/learn/by-eating-disorder/bulimia
Binge-Eating Disorder (BED)
Binge-eating disorder is similar to bulimia nervosa in that it involves recurrent binge eating episodes along with feelings of lack of control during the binge-eating episode. The binge-eating episodes are associated with at least three of the following: eating quicker than usual, eating until uncomfortably full, eating large amounts even if not hungry, eating alone, and feeling disgust with oneself or being depressed. Despite the feelings of shame and guilt post-binge, individuals with BED will not engage in vomiting, excessive exercise, or other compensatory behaviors. These binge eating episodes occur on average, at least once a week for 3 months.
Because these binge-eating episodes occur without compensatory behaviors, individuals with BED are at risk for obesity and related health disorders. Individuals with BED report feelings of embarrassment at the quantity of food consumed, and thus will often refuse to eat in public. Due to the restriction of eating around others, individuals with BED often engage in secret binge eating episodes in private, followed by discrete disposal of wrappers and containers.
Making Sense of the Disorders
Though bulimia and BED are similar, they differ as follows:
- Diagnosis BED …… if binge eating occurs alone
- Diagnosis bulimia … if binge eating occurs AND there are compensatory behaviors to prevent weight gain
While much is still being researched about binge-eating disorder, current research indicates that the onset of BED is adolescence to early adulthood but can begin later in life. Those who seek treatment tend to be older than those with either bulimia or anorexia. Binge eating has been found to be common in adolescent and college-age samples and for all, is associated with social role adjustment issues, impaired health-related quality of life and life satisfaction, and increased medical morbidity and mortality (APA, 2022).
For more on binge eating disorder, please visit the National Eating Disorders Association website below:
www.nationaleatingdisorders.org/learn/by-eating-disorder/bed
Key Takeaways
You should have learned the following in this section:
- Anorexia nervosa involves the restriction of food, which leads to significantly low body weight relative to the individual’s age, sex, and development, and an intense fear of gaining weight or becoming fat.
- Bulimia nervosa is characterized by a pattern of recurrent binge eating behaviors followed by compensatory behaviors.
- Binge-eating disorder is characterized by recurrent binge eating episodes along with a feeling of lack of control but no compensatory behavior to rid the body of the calories.
Review Questions
- What does mutually exclusive mean? What does it mean with respect to eating disorders?
- What are the key differences in diagnostic criteria for anorexia, bulimia, and binge eating disorder?
- Define compensatory behavior. What disorder is this found in?
