Eating Disorders

Any of a range of psychological disorders characterized by abnormal or disturbed eating habits (such as anorexia nervosa).

What Are Eating Disorders?

Eating disorders are complex illnesses that affect people of all ages; the onset of eating disorders typically occurs during pre-adolescence or adolescence. Eating disorders affect millions of adolescents and young adults in the U.S. alone. Given the serious medical complications that may result from eating disorders, it is imperative to identify, diagnose and treat them as early as possible. With early diagnosis and proper treatment, recovery is possible.

A Parent/Caregiver's Guide to Eating Disorders

Extended Information on Treatment Options

The Data Around Adolescent Eating Disorders Is Alarming:
  • 95% of those with eating disorders are between the ages of 12 and 25 (SAMHSA)
  • 40-60% of elementary school girls (ages 6-12) are concerned about their weight or about becoming overweight. This concern endures through life. (Smolak, 2011)
  • Among high-school students, 44% of females and 15% of males attempted to lose weight. (Serdula et al., 1993)
  • 35% of “normal dieters” progress to pathological dieting. Of those, 20-25% progress to partial or full-syndrome eating disorders. (Shisslak & Crago, 1995)
  • Over one half of teenage girls and nearly one third of teenage boys use unhealthy weight control behaviors (ex, skipping meals, fasting, smoking cigarettes, purging) (Neumark-Sztainer, 2005)
Causes of Eating Disorders

Although there is a correlation between the notion of an “ideal” body and eating disorders, there is no consensus as to the root cause of eating disorders. The general belief is that eating disorders result from one or more biological, behavioral, and social factors including genetics, unpleasant experiences/trauma, peer pressure, teasing, family members with eating disorders, among others.

While eating disorders as a group are complex, most begin with either accidental or purposeful weight loss that can lead to unhealthy measures to sustain the loss.

Pre-adolescence and adolescence are particularly challenging years for those with eating disorders given emotional and physical changes, as well as academic, family and peer pressures.

Bullying/"Fat Talk”

Many teenagers report that the onset of their eating disorder involved comments or teasing by peers, usually about appearance. Whether done in the context of an innocent family nickname or in a malicious bullying event, these instances of feeling shame, or being shamed, based on size or physical appearance are powerful contributors to a teenager developing an eating disorder. The tendency for females, specifically, to ‘bond’ around ‘fat talk’ and negative body discussions have also been associated with the development of an eating disorder.

Teenagers and their families can play a significant role in preventing or stopping early-stage eating disorders by not participating in these types of conversations and by taking bullying concerns seriously.

Types of Eating Disorders:

Teen Anorexia Nervosa

Characterized by a person going to extreme lengths to lose weight, making efforts to eat as little as possible or nothing at all, in order to reduce calories. A person with Anorexia has a distorted image of their own body, often insisting they’re much heavier than they actually are. A person with Anorexia is obsessed with maintaining and controlling their weight and will go to great lengths to do so, but will also often deny the seriousness of their condition, insisting that they just want to be healthy or stay in shape. In severe cases, a person can be so insistent that their distorted image is accurate, causing them to lose weight to the point of it becoming life-threatening.

Signs of anorexia may include:

  • A distorted view of one’s body weight, size or shape; sees self as too fat, even when very underweight
  • Hiding or discarding food
  • Obsessively counting calories and/or grams of fat in the diet
  • Denial of feelings of hunger
  • Developing rituals around preparing food and eating
  • Compulsive or excessive exercise
  • Social withdrawal
  • Pronounced emotional changes, such as irritability, depression and anxiety

Physical signs of anorexia include rapid or excessive weight loss; feeling cold, tired and weak; thinning hair; absence of menstrual cycles in females; and dizziness or fainting.

Teen Bulimia Nervosa

Also characterized by an obsession of body appearance and controlling weight, a person with Bulimia tries to maintain body weight by cycles of binging (eating an excessive amount of junk food) followed by purging (self-induced vomiting, use of laxatives, enemas, or other means to rid the stomach of food.) During the binge period of the cycle, a person cannot stop eating, even after the stomach is full. Following the binge, a person often feels guilt and embarrassment over the calories and therefore has the urge to rid themselves of everything they ate by any means necessary, which can cause them to behave irresponsibly. Bulimia can also include cycles of binging and fasting, as well as excessive exercise. Often, a person with bulimia will deny any seriousness of their condition, but will nonetheless eat and binge in secret.

Signs of bulimia may include:

  • Eating unusually large amounts of food with no apparent change in weight
  • Hiding food or discarded food containers and wrappers
  • Excessive exercise or fasting
  • Peculiar eating habits or rituals
  • Frequent tips to the bathroom after meals
  • Inappropriate use of laxatives, diuretics, or other cathartics
  • Overachieving and impulsive behaviors
  • Frequently clogged showers or toilets

Physical signs of bulimia include discolored teeth, odor on the breath, stomach pain, calluses/scarring on the hands caused by self-inducing vomiting, irregular or absent menstrual periods, and weakness or fatigue.

Teenagers with bulimia often have a preoccupation with body weight and shape, as well as a distorted body image. The clinical diagnosis commonly defines a teenager as having bulimia if they binge and purge on average once a week for at least three consecutive months.

Binge-Eating Disorder

A clinical syndrome characterized by a person regularly eating a large amount of food in a quick amount of time, with no control of when to stop, as well as eating without regard to hunger or need for food. A person often eats to address emotional feelings of unrest and/or as a means of avoiding another problematic or difficult part of life. A person with Binge-Eating Disorder becomes obsessed with food and eating, regardless of feelings of hunger, but once they’ve eaten, often experience extreme feelings of embarrassment or guilt because of what they ate. This produces a sort of “cycling” effect, between the person feeling some slight relief from binging, followed by shame, which urges them to eat more, in order to improve their mood.

Signs of Binge Eating Disorder might include:

  • Eating unusually large amounts of food in a distinct period of time (within 2 hours)
  • Eating rapidy
  • Hiding food or discarded food containers and wrappers
  • Eating in secret because of feeling embarassed by how much they are eating
  • Eating when stressed or when feeling uncertain how to cope
  • Feeling that they are unable to control how much they eat and disgusted with themselves afterwards
  • Experimentation with different diets

Most of the physical signs and symptoms associated with binge eating disorder are long-term including weight gain (often leading to obesity), high blood pressure, diabetes, irregular menstrual cycle, skin disorders and heart disease.

Similar to bulimia, binge eating disorder is commonly diagnosed if teenagers binge on average once a week for at least three consecutive months.

What It Looks Like

One of the challenges regarding Eating Disorders is they can be difficult to recognize and/or diagnose, especially if a person is intentionally trying to hide behaviors, which is fairly common. Furthermore, some of the underlying behaviors or beliefs of a person with an eating disorder are not singular to this illness, and so it can be hard to judge the seriousness of a person’s experience, and whether they need treatment.

Beyond the specific symptoms listed above related to each eating disorder, there are also a number of symptoms that are commonly present in a person with an eating disorder. These symptoms include, but are not limited to:

  • Distorted self body image
  • Obsession with food in persistent thoughts and/or desires
  • Refusal to eat when hungry
  • Inability to stop eating when full
  • For people with bulimia, teeth and gum problems related to vomiting, as well as stomach lining problems, such as ulcers
  • Going to the bathroom often, immediately after meals
  • Intense emotional shame or guilt after eating
  • Obsession with exercise and control of weight
  • Fear of eating in public, leading to secret eating/binging
  • Extreme desire to control weight

Teen Eating Disorder Treatment Options

Patients with eating disorders typically require a treatment team consisting of a primary care physician, dietitian, and a mental health professional knowledgeable about eating disorders.

Research on the treatment of eating disorders is exploring how different treatments can be helpful for different types of eating disorders. The American Psychiatric Association has published a set of practice guidelines for the treatment of patients with eating disorders (American Psychiatric Association, Practice Guidelines for Eating Disorders, American Journal of Psychiatry, 2000).

There is general agreement that good treatment often requires a spectrum of treatment options. These options can range from basic educational interventions designed to teach nutritional and symptom management techniques to long-term residential treatment (living away from home in treatment centers).

Most individuals with eating disorders are treated on an outpatient basis after a comprehensive evaluation. Individuals with medical complications due to severe weight loss or due to the effects of binge eating and purging may require hospitalization. Other individuals, for whom outpatient therapy has not been effective, may benefit from day-hospital treatment, hospitalization, or residential placement.

Treatment is usually conducted in the least restrictive setting that can provide adequate safety for the individual. Many patients with eating disorders also have depression, anxiety disorders, drug and/or alcohol use disorders and other psychiatric problems requiring treatment along with the eating disorder.

Initial Assessment

The initial assessment of individuals with eating disorders involves a thorough review of the patient's history, current symptoms, physical status, weight control measures, and other psychiatric issues or disorders such as depression, anxiety, substance abuse, or personality issues. Consultation with a physician and a registered dietitian is often recommended. The initial assessment is the first step in establishing a diagnosis and treatment plan.

Outpatient Treatment

Outpatient treatment for an eating disorder often involves a coordinated team effort between the patient, a psychotherapist, a physician, and a dietitian (yet, many patients are treated by their pediatrician or physician with or without a mental health professional's involvement).

Similarly, many patients are seen and helped by generalist mental health clinicians without specialist involvement. Not all individuals, then, will receive a multidisciplinary approach, but the qualified clinician should have access to all of these resources.

Psychotherapy

There are several different types of outpatient psychotherapies with demonstrated effectiveness in patients with eating disorders. These include cognitive-behavioral therapy, interpersonal psychotherapy, family therapy, and behavioral therapy. Some of these therapies may be relatively short-term (i.e., four-months), but other psychotherapies may last years.

It is very difficult to predict who will respond to short-term treatments versus longer term treatments. Other therapies which some clinicians and patients have found to be useful include feminist therapies, psychodynamic psychotherapies and various types of group therapy.

Psychopharmacology

Psychiatric medications have a demonstrated role in the treatment of patients with eating disorders. Most of the research to date has involved antidepressant medications such as fluoxetine (for example Prozac), although some clinicians and patients have found that other types of medications may also be effective.

Nutritional Counseling

Regular contact with a registered dietitian can be an effective source of support and information for patients who are regaining weight or who are trying to normalize their eating behavior. Dietitians may help patients to gain a fundamental understanding of adequate nutrition and may also conduct dietary counseling, which is a more specific process designed to help patients change the nature of their eating behavior.

Medical Treatment

Patients with eating disorders are subject to a variety of physical and medical concerns. Adequate medical monitoring is a cornerstone of effective outpatient treatment. Individuals with anorexia nervosa may be followed quite closely (i.e., weekly or more) because of the significant medical problems that this disorder poses for patients. Individuals with bulimia nervosa should be seen regularly, but may not require the intensive medical monitoring often seen in anorexia nervosa. Individuals with binge eating disorder may need medical treatment for a variety of complications of obesity, such as diabetes and hypertension.

Day Hospital Care

Patients for whom outpatient treatment is ineffective may benefit from the increased structure provided by a day hospital treatment program. Generally, these programs are scheduled from three to eight hours a day and provide several structured eating sessions per day, along with various other therapies, including cognitive behavioral therapy, body image therapies, family therapy, and numerous other interventions. Day Hospital allows the patient to live at home when they are not in treatment, and often continue to work or attend school.

Inpatient Treatment

Inpatient treatment provides a structured and contained environment in which the patient with an eating disorder has access to clinical support 24-hours a day. Many programs are now affiliated with a day hospital program so that patients can "step-up" and "step-down" to the appropriate level of care depending on their clinical needs.

Although eating disorder patients can sometimes be treated on general psychiatric units with individuals experiencing other psychiatric disorders, such an approach often poses problems with monitoring and containing eating disorder symptoms. Therefore, most inpatient programs for eating disordered individuals only treat patients with anorexia nervosa, bulimia nervosa, binge eating disorder, or variants of these disorders.

Residential Care

Residential programs provide a longer term treatment option for patients who require longer term treatment. This treatment option generally is reserved for individual who have been hospitalized on several occasions, but have not been able to reach a significant degree of medical or psychological stability.

Therapy

Because Eating Disorders are a severe mental disorder that have significant effects on the mind and body, teen eating disorder treatment must address the mental and physical aspects of the disorder.

Teen eating disorder treatment needs to first address the physical condition by helping the person return to healthy eating habits and practices, regardless of what their comforts and urges are. Because this can be such a difficult transition for a person with an Eating Disorder, this is often most successfully carried out in a therapeutic setting where the person can be closely monitored and guided through the process. Depending on the specific disorder, a person will be monitored in different ways, geared toward their current misconceptions and unhealthy eating habits. In addition to diet, therapy also addresses any current habits or practices related to exercise and help modify them to be healthy. These foundational steps, crucial to a person’s physical well being, can then help lay the groundwork for a person to address the underlying causes and beliefs related to their Eating Disorder.

Therapy also addresses the underlying issues that cause the person to have such a distorted and unmanageable relationship to food, such as feelings of inadequacy, shame, lack of self-worth, anxiety, and/or stress surrounding a sense of a need for control. Though the misconceptions and beliefs that a person has in relation to their eating disorder can be deeply rooted, therapy can help them gain insight as to the falsity of their beliefs, understanding as to the danger of their eating habits, and also gain a sense of encouragement and self-worth to help them want to make healthy decisions and changes for themselves. This type of healing and change is especially possible when a person feels safe and un-judged, both for what they look like and their behaviors. In this regard, support from family and friends is a powerful force in allowing a person to move toward a happy, healthy life.

Questions

WHAT IF OTHER PEOPLE THINK I HAVE AN EATING DISORDER, BUT I DON’T?

It can be hard for any of us to see ourselves and our behaviors clearly, and even harder for us to admit if something’s wrong. Eating Disorders are an illness where people commonly hide their behaviors in order to convince others, and themselves, that everything’s fine. First of all, it’s important for you to know that if you do have an Eating Disorder, it’s not the end of the world and doesn’t mean someone else is going to take charge of your physical being. But if people around you who love you and whom you trust are worried you might have an Eating Disorder, it’s probably at least worth trying to think about honestly. If your life is somewhat consumed by your thoughts and behaviors surrounding food, if you exhibit some of the symptoms listed above, and/or if your behavior surrounding food is extremely different from the average person, you should try to be open to the idea that something more is going on.

WHAT IF IT’S SOMETHING I CAN CONTROL?

This is a common attitude among people with Eating Disorders and the trouble is, it’s true, but not for long. Often people with Eating Disorders start out developing some unhealthy habits but before long, the habits and beliefs spiral out of control to a point where the person is no longer seeing themselves or their behavior clearly. It may be true that for a certain amount of time, you might be able to “get away with” your Eating Disorder, but the longer you allow the behaviors and beliefs to go on, the more risk you’re putting yourself in, both physically and mentally, and the harder it will be to change, later on. It’s also important to understand that if your reason for not getting help is a fear of someone else to make decisions and have control over what you look like, this isn’t the goal of therapy. The goal of therapy is to be healthy, and there are great, supportive people who can help you get there.

ROLE OF SUPPORTERS

Parents, siblings and close friends play a significant role in guiding and supporting others. In many cases, individuals with eating disorders cannot recognize a need for help in themselves, and it takes a strong, caring individual to reach out.

Most importantly, you need to know that there is hope. Recovery can be difficult — but it is possible. The information in this section is specific to family members and friends, but you’ll also find a host of terms and topics under General Information. We recommend you start there and then augment your learning with the subjects covered here.

Our Parent Toolkit has a wealth of information for parents, friends and loved ones who are supporting someone through an eating disorder.

In addition, more support is available for parents, friends and loved ones of an eating disorder sufferer in the Find Help and Support section of our website. Similarly, NEDA’s Information and Referral Helpline is not just for those who are suffering from an eating disorder, but also for individuals who are looking for treatment options or support for someone they care about.

WHAT SHOULD I SAY? TIPS FOR TALKING TO A FRIEND WHO MAY BE STRUGGLING WITH AN EATING DISORDER

If you are worried about your friend’s eating behaviors or attitudes, it is important to express your concerns in a loving and supportive way. It is also necessary to discuss your worries early on, rather than waiting until your friend has endured many of the damaging physical and emotional effects of eating disorders. Learn more.

Consequences of Eating Disorders

PSYCHOSOCIAL

Eating disorders can have a profoundly negative impact on an individual's quality of life. Self-image, interpersonal relationships, financial status, and job performance are often negatively affected. The extent to which these problems are an inherent part of the disorders or are secondary to it is unclear. The range of the negative effects does, however, highlight the critical importance of treatment.

Eating disorders are also associated with high rates of other co-existing psychiatric disorders, particularly mood disorders, and anxiety disorders. Bulimia nervosa may be particularly associated with alcohol and/or drug abuse problems.

MEDICAL

Semi-starvation in anorexia nervosa can affect most organ systems. Physical signs and symptoms (in addition to the lack of menstrual periods in women) can include constipation, cold intolerance, abnormally low heart rate, abdominal distress, dryness of skin, hypotension, and fine body hair (lanugo). Anorexia nervosa causes anemia, kidney dysfunction, cardiovascular problems, changes in brain structure, and osteoporosis (i.e., inadequate bone calcium).

Self-induced vomiting seen in both anorexia nervosa and bulimia nervosa can lead to swelling of salivary glands, electrolyte and mineral disturbances, and dental enamel erosion. Use of ipecac to induce vomiting can lead to extreme muscle weakness, including heart muscle weakness. Laxative abuse can lead to long lasting disruptions of normal bowel functioning. Rarer complications are tearing the esophagus, rupturing of the stomach, and life-threatening irregularities of the heart rhythm.

Common Eating Disorder Myths

YOU CAN TELL IF SOMEONE HAS AN EATING DISORDER JUST BY LOOKING AT THEM

Individuals with eating disorders come in all shapes and sizes and many individuals with anorexia may not ever appear so drastically underweight. Additionally, many individuals with severe eating disorders including bulimia and binge eating disorder can be underweight, normal weight, overweight or obese and often fluctuate in weight. Even athletes who appear to be incredibly fit might be struggling with an eating disorder. You cannot define someone’s health by how much they weigh and you cannot determine whether they have an eating disorder just by looking at them.

EATING DISORDERS ARE A RESULT OF OVER CONTROLLING PARENTS AND DYSFUNCTIONAL FAMILIES

Parents are often unfairly blamed for an individual’s eating disorder. While genetic factors and family relationships can be major contributors to a teenager’s risk for developing an eating disorder, we also know that parents and families play an integral role in helping a loved one recover. For this reason family therapy is a primary therapeutic modality used for adolescents and is also strongly encouraged for adults.

EATING DISORDERS ARE A LIFESTYLE CHOICE

Eating disorders are serious illnesses with mental and physical consequences that often involve a great deal of suffering. No one ‘chooses’ to have this illness. Someone, however, can make the choice to pursue recovery. The act of recovery is a lot of hard work and involves more than simply deciding to not act on symptoms. In most cases, the eating disorder has become a person’s primary way of coping with intense emotions and difficult life events.

EATING DISORDERS ARE BENIGN

Eating disorders are serious psychological conditions and can lead to very serious medical problems. They have the highest mortality rate of any mental illness and are also associated with an increased risk of suicide.

EATING DISORDERS ARE JUST A TEEN PHASE. THEY WILL GO AWAY IF YOU IGNORE THEM.

While eating disorders generally begin during teen years they are not a normal part of growing up. Puberty is a time of great change biologically, physically and psychologically. Teenagers are often vulnerable to societal pressures and can often feel insecure and self-conscious, which are factors that increase the risk of engaging in extreme dieting behavior. Ignoring signs of adolescent eating disorders can have serious lifelong medical and psychological repercussions.

RECOVERY FROM EATING DISORDERS IS RARE

Recovery, though challenging, is absolutely possible. Recovery can take months or years, but with proper treatment, started immediately, many people do eventually recover and go on to live a life free from their eating disorder.

Resources

What to Say

How to Help

Source: Paradigm Malibu, The Healthy Teen Project, National Eating Disorders Collaboration