What Are Eating Disorders?

Eating disorders are serious, multilayered illnesses that manifest themselves in problems with eating, weight gain and loss, and distortions in body image. These potentially fatal illnesses involve genetic, biological, nutritional, psychological, and socio-cultural factors. These layered factors are embedded in - and are a core part of - eating disorders. For both women and men, these illnesses are complex entities that require a multifaceted treatment approach.

Patients with eating disorders need immediate attention. However, not all patients who come into a clinician’s office have a full blown eating disorder such as bulimia nervosa (BN) or anorexia nervosa (AN). Patients who present with only some of the features of AN or BN are given the diagnosis of eating disorder, not otherwise specified.

In addition to their individual treatment needs, all patients with eating disorders and eating problems need to relearn how to eat and how to disentangle food from feelings.

What are the main types of eating disorders?

The main eating disorders, according to DSM-5, are Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Binge Eating disorder (BED). BED as a diagnostic entity is addressed in a separate course. See Tables below for information on AN and BN.

TABLE 4.   DSM-5-TR Criteria for Anorexia Nervosa

TABLE 5.DSM-5-TR Criteria for Bulimia Nervosa

Eating Disorders Factoid

In each decade since the 1930s, there has been a rise in the incidence of anorexia nervosa in adolescent girls 15-19.

Source: National Eating Disorders Association (citing Houk, HW and van Hoeken, D., Review of the prevalence and incidence of eating disorders. International Journal of Eating Disorders,2003)

What is anorexia nervosa?

Anorexia means lack of appetite. The root of the word anorexia is of Greek origin. An means lack of, and orexis means appetite. This word was originally applied to other ailments that left the patient with no appetite or desire to eat.

Today, we know that anorectic patients do not initially lack hunger. Instead, they ride out their initial hunger and purposefully push themselves to avoid eating. However, after a certain period of time refusing to eat, some patients may experience a true loss of appetite. It must be understood, though, that Anorexia Nervosa is much more than excessive dieting. The anorectic restraint of food serves psychological purposes.

Unfortunately in certain individuals, starvation creates biological and chemical alterations in the body and in the mind. In certain individuals, starvation lowers serotonin levels in the brain, which may create some of the features seen in bulimia nervosa. For instance, some authors have found that zinc deficiency causes loss of appetitive and loss of acuity in tasting (51).

The essential feature of AN is a refusal to maintain a minimally normal body weight, for age and height (e.g.,, weight loss leading to maintenance of body weight less than 85% of expected; or failure to make expected weight gain during period of growth, leading to body weight less than 65% of expected). Individuals with anorexia nervosa feel an intense fear of gaining weight.

They also display significant disturbance in the perception of the shape or size of their body, even when emaciated. These individuals frequently lack insight into the severity of the problem. They consistently deny the importance and seriousness of their low body weight. Not only do they experience a relentless distortion in the appraisal of their body image, but they also give extreme importance to their body shape and weight in their self-evaluations.

Usually they are brought to professional attention by a concerned family member after marked weight loss. DSM-IV identifies two types of AN: restricting type and binge eating/purging type. In AN restricting subtype, the person suffering from anorexia restricts her food intake in desperate attempts to avoid any unwanted weight.

The individual in this subtype does not binge-eat or purge ( i.e. self-induced vomiting, misuse of diuretic or enemas). A client with AN Binge Eating/Purging subtype will engage during the episode of anorexia in binge eating and also in purging (i.e., self-induced vomiting, misuse of diuretics or enemas).


Eating Disorders Factoid

Anorexia nervosa has the highest premature fatality rate of any mental illness.

Source: National Eating Disorders Association (citing Sullivan, P. (1995). American Journal of Psychiatry, 152 (7))


What is bulimia nervosa?

The root of the word bulimia comes from Latin and it means hunger of an ox. This name is a misnomer. Bulimic men and women do not experience great hunger when bingeing. Bulimics experience a lack of control over their behavior.

Bulimia is a secretive disorder and those who suffer from it tend to have great shame and remorse. The essential features of BN are binge eating followed by intense remorse and inappropriate compensatory behaviors like fasting, vomiting, laxative use or exercising to prevent weight gain.

Clinicians began to see the syndrome of bulimia in their offices and mental health settings more routinely sometime during the seventies and eighties.
Patients who come into treatment for bulimia are, for the most part, of normal weight, or on the thinner spectrum of normal weight.

Bulimic patients fear food. Food represents the possibility of a binge, and bingeing lurks just around the corner at every meal. Binge eating is typically triggered by conscious or unconscious mood states, interpersonal stressors, and intense hunger following dietary restraints. Binges can be triggered, too, by negative feelings related to body weight and shape.

Binges can also be triggered by certain foods that are experienced as forbidden foods. Individuals are typically ashamed of their eating problems and binge eating usually occurs in secrecy. Like patients who have AN, BN patients typically restrict their total caloric consumption - between binges. Unlike patients with AN – including the Binge Eating/Purging subtypes - BN patients tend to stay within a relatively normal weight range.


Eating Disorders Factoid

The incidence of bulimia in 10-39 year old women TRIPLED between 1988 and 1993

Source: National Eating Disorders Association (citing Houk, HW and van Hoeken, D., Review of the prevalence and incidence of eating disorders. International Journal of Eating Disorders,2003)


What is the History of Eating Disorders?

In 1874, Sir William Gull, a British physician described several of his patients as having recognizable signs of an eating disorder. These women had the signs of what physicians and mental health practitioners would consider anorexia nervosa syndrome. These women displayed the same signs and symptoms that modern patients display today:

- Refusal to eat
- Extreme weight loss
- Amenorrhea
- Hyperactivity
- Lower heart rate pulse

The women that displayed this syndrome during the 18th and 19th Century were called fasting girls. These fasting girls from the Victorian Era were acquainted through their studies and their inspirational books with what we call today, holy anorexia. The holy anorectics were the Saints of Medieval times that developed what we would call anorexia nervosa. Among them we can find Catherine of Sienna, Ste. Veronica, Ste. Claire and Ste. Catherine of Vanini. (5)

It is well known that the Romans had special corridors in their dwellings (vomitoriums) where they engaged in vomiting after bingeing rituals. However, it was not until 1903 that Pierre Janet described the syndrome of bulimia in medical terms when he described a woman patient engaged in bingeing. As in today’s cases, Nadia too, engaged in secret bingeing. It was not until the 20th century that bulimia nervosa became a separate diagnostic category in the medical world.

What are the incidence and prevalence of eating disorders?

Information about incidence and prevalence, while not the most interesting aspect of this topic to study, is important in terms of understanding the prevailing trends in eating disorders, which in turn assists the clinician in knowing what population groups are at greater risk for eating disorders, and how eating disorders may vary between different groups. It is also information that helps the clinician to have a clear overview of the extent of the disorder in the public at large. For these reasons, we will spend a little time providing a solid overview of the trends and statistics.

Estimates of the incidence or prevalence of eating disorders vary depending on the sampling and assessment methods. The reported lifetime prevalence of anorexia nervosa among women has ranged from 0.5% when narrow definitions are used up to 3.7% for more broadly defined anorexia nervosa. (31, 108)

Eagles et al. (23) conducted a study of the prevalence rates of anorexia nervosa. They found conflicting results. They explained the conflicting results in terms of changes in frequency of referrals and due to increase in awareness of eating disorders by the lay public. They also found that referral rates of anorexia nervosa have risen in the past two decades. (23) Although these researchers concluded from the increase in the incidence of referral rates an increase in incidence of anorexia nervosa, they do not give a prevalence rate.

Walters and Kendler (108) looked at prevalence rates of anorexia nervosa and found that prevalence rates of anorexia nervosa ranged from 0. 10% to 1.0%.

Olivardia et al. (79) found the prevalence rate of anorexia nervosa in men to be 0.02%. These rates are considerably less than the prevalence rates of eating disorders in women, but they are still significant.

More recently, Keel and Klump (57) concluded in an impressive review that anorexia does not seem to be a culture bound syndrome. The incidence for anorexia nervosa is modest when taken into account factors such as increase in population. Even so, anorexia nervosa has been reported in the Middle East, the Indian subcontinent and East Asia where Western influence is not prevalent. However, many of these cases lack weight concern.

Moreover Bell (5) reviewed the vitae of 261 saints who lived in the Italian peninsula from AD 1200. Of those 261 reviewed vitas, 170 had adequate information on anorexia nervosa. And half of those, Bell argues, had a pattern that matches what we consider holy anorexia.

Many researchers argue that the component of weight concerns present in anorexia nervosa may be culture bound. However, researchers also do know that in the West anorexia is driven by a variety of motivations, too. The latest studies seem to have shown that anorexia has a stable prevalence through time. (57)

With regard to bulimia nervosa, estimates of the lifetime prevalence among women have ranged from 1.1% to 4.2%. (32, 58). Up to 19% of college aged women in America are bulimic (120). Unfortunately, it seems that the current trend is that eating disorders are affecting younger and younger individuals.


Eating Disorders Factoid

Studies indicate that by their first year of college, 4.5 to 18% of women and 0.4% of men have a history of bulimia.

Source: The National Center for Health Statistics

Olivardia et al. (79) found the prevalence rate of bulimia nervosa in men to be between 0.1 and 0.5%. These rates are considerably less than the prevalence rates of eating disorders in women, but they are still significant.

In the United States, eating disorders appear to be about as common in young Hispanic women as in Caucasians, more common among Native Americans, and less common among blacks and Asians. (17).

However, several studies in the Southeastern United States have shown that many eating disorder behaviors are even more common among African American women than others. (61, 110)

Black women are more likely to develop bulimia nervosa than anorexia nervosa and are more likely to purge with laxatives than by vomiting. (88) Some studies suggest that the prevalence of bulimia nervosa in the United States may have decreased slightly in recent years. (40).

Eating disorders are more commonly seen among female subjects, with estimates of the male-female prevalence ratio ranging from 1:6 to 1:10 (although 19%-30% of the younger patient populations with anorexia nervosa are male). (27, 39, 44).

The prevalence of anorexia nervosa and bulimia nervosa in children and younger adolescents is unknown. Unfortunately, men too, experience eating disorders. Although, the rates of eating disorders are relatively less in men compared to women, there are similarities between men and women concerning eating disorders. However, it is also important to acknowledge the differences in terms of motivations and the body the want to achieve. It is important that men do not feel that they have a woman’s disease which would increase shame and isolation.


Eating Disorders Factoid

While the most common age of onset is between 14 and 25 years of age, eating disorders occur in a wide range of ages, and are increasingly seen in children as young as 10.

Source: National Eating Disorders Information Centre of Canada (citing Cavanaugh, Carolyn J. and Lemberg, Ray. What we know about eating disorders: facts and statistics. In Lemberg, Raymond and Cohn, Leigh (Eds) (1999). Eating Disorders: A reference sourcebook. Oryx. Press. Phoenix, AZ)

Rates of eating disorders in men may be under-represented. Men may be more reluctant to seek treatment for eating disorders. Male with eating disorders may go undetected.

Also, the sample that Olivardia et al. (79) used was composed of only college men. Therefore, these numbers may not be characteristic of the general population of men as a whole. However, the fact that eating disorders are not just a female problem must be acknowledged and more research needs to be conducted.

In many other countries, there appears to be an overall increase in eating disorders, even in cultures in which the disorder is rare. (82) Japan appears to be the only non-Western country that has had a substantial and continuing increase in eating disorders, with figures that are comparable to or above those found in the United States. (59, 74)

In addition, eating disorder concerns and symptoms appear to be increasing among Chinese women exposed to culture clashes and modernization in cities such as Hong Kong. (19, 20)

The prevalence of eating disorders appears to be increasing rapidly in other non-English-speaking countries such as Spain, Argentina, and Fiji. (4, 76, 104)

As these figures suggest, the notion that eating disorders are associated with upper socioeconomic status and with Caucasian women is no longer tenable. Until the 70’s, it was believed that only Caucasian upper class teenagers were affected with AN. Studies in the 70’s showed that Jews, Italians, and Catholics were affected with this disorder, too. (96) Other findings suggested that African American women have as much body dissatisfaction and disordered eating as their Caucasian counterparts. (88, 45)

Several recent studies have shown that bulimia nervosa was more common in lower socio-economic groups (30) Thus, any association between wealth and eating disorders requires further study.

Levels of disordered eating attitudes among rural Appalachian adolescents that are comparable to urban rates were also reported by researchers. (71)

One of the fastest population groups in the United States is the Latino population. Although research among Latina girls in America is limited, recent studies show that Latina girls are concerned about body weight and display disordered eating behavior. These behaviors include dieting, purging and losing weight. (118)

Research has shown too, that Latina population is ingests more fatty foods and fast food compared to Caucasian and African American population. (118) It is important to note that Latina girls are more prone than Caucasian girls to use dieting and purging as a way to control their weight. (118)

For the benefit of clinicians who may not have significant contact with Latino populations, it is important to realize that Latina girls are a diverse group. Latina Hispanic girls belong to diverse countries with diverse social norms and diverse socio-economic groups. There is not one group of Latina girls or people. Statistics may not sufficiently capture the differences, and care must be taken to generalize these statistics.

Apart from issues of race and culture, lower socio-economic populations in general seem to have more of a problem battling with and are more prone to higher weights. We can hypothesize two factors on this phenomenon:

1) Socio-economic status is correlated to the ingestion of less expensive but high fat content and carbohydrate foods.
2) At the same time that acculturation brings a drive for thinness it brings less healthy eating behaviors.

The result of these two factors working in concert seems to be that second and third generation Latina girls are more likely to be obese than the first generation. (117) The effects on eating disorder statistics remains to be seen.

Prevalence and Incidence in Other Countries

Although in many in many countries outside the United States of America there is not the same drive for thinness, other countries, such as Argentina have a high incidence and prevalence of eating disorders and rank among the highest ones for pressure to have a certain look (thin and European). Fear of fat is widespread.

(Much, anecdotally, could be said about this Argentinean physical ideal; however, further studies and research on the topic of body ideal and identity, identification, and sense of, or lack of pride and Patriotism, would need to be examined to understand the phenomena).
Eating Disorders Factoid

In 1994, Essence magazine reported that over 50% of African American women responding to a survey were at risk for an eating disorder
Source: South Carolina Department of Mental Health (Citing Essence Magazine, 1994)

On the other hand, in countries like India and in Hong Kong, anorexics lack the component of fear of fat. These anorectics may fast for religions reasons. (Such behavior also was found in the descriptions of saints from the Middle Ages in Western culture, when spiritual purity, rather than thinness, was the ideal (7).

Based on this kind of information, there are those who would argue that countries that are more Westernized - in the sense of marketing and consumer culture - have people who are afraid of fat. It would follow, then, that increases in the influence of American cultural elements may contribute to an increase in eating disorders on a more global scale. However, we must await further research to see if these fears become reality.


Eating Disorders Factoid

Eating disorders are now one of the most common psychological problems facing the young women of Japan

Source: South Carolina Department of Mental Health


What are the causes of eating disorders?

As we have noted, at present no one knows the exact mechanisms or causes underlying eating disorders. There is no solid evidence that a single isolated factor causes an eating disorder. Rather, researchers and clinicians believe that these disorders are multifaceted and layered.

It is believed that eating disorders are like a puzzle, with many parts working together to complete the whole picture. While biological and psychosocial factors are clearly implicated in the development of pathology, the causes and mechanisms underlying eating disorders remain largely unknown. Vulnerability, genetics, and culture and nurture all seem to play a part in the total picture.

The possible combination of genetic, physiological, nutritional, psychological, familial and cultural aspects of the ailment make eating disorders complex and multifaceted diseases. This means that not only are the disorders difficult to assess and evaluate in an adequately thorough manner, highly complex interventions are required to treat them.

As an introduction to some of the complexities, we will briefly touch upon the impact and importance of some of these etiological factors here.

Genetic: Apparently certain people are born with genetic vulnerability for eating disorders, such as a need for perfectionism, or an eye and preference for symmetry. Given the ‘right’ environment and/or cultural forces, these people will be at higher risk to develop an eating disorder.

This genetic factor is supported by a number of studies in the literature. First-degree female relatives of patients with anorexia nervosa have higher rates of anorexia nervosa and bulimia nervosa. (101, 108)

Identical twin siblings of patients with anorexia nervosa or bulimia nervosa also have higher rates of these disorders, with monozygotic twins having higher concordance than dizygotic twins. (58) This clearly supports the idea that biological factors are involved.

The evidence regarding rates of bulimia nervosa in other first-degree female relatives remains unclear; some studies report a higher rate among first-degree female relatives while others do not. (58)

There are practical implications of this evidence in terms of assessment. Where eating disorders are suspected, it is helpful to search for a family history of problems with eating disorders. It may also be sensible to evaluate for a family tendency towards perfectionism and/or obsessive-compulsive features.

Conversely, when a client from a high risk population (e.g., college aged female) presents for treatment, and there is a family history of problems with eating disorders, perfectionism, or OCD tendencies, it is probably prudent to consider the possibility of a hidden eating disorder.

Physiological: Eating disorders create many acute and chronic physiological changes that require medical attention above and beyond psychological services. Patients with eating disorders exist in a physiological state that is abnormal, with consequences with both health and mental health implications. Some of the physiological changes – through effects on the brain's chemistry - contribute to the persistence of the eating disorders and the resistance to psychological intervention.

Accordingly, patients with eating disorders may need to be checked for: changes in electrolytes, lanugos (abnormal growth of fetal like hair), low blood pressure, cognitive distortions due to low blood sugar, cardiac problems, gum problems and thyroid problems, among other complications.

It has recently been suggested that in some patients, excessive exercise may precipitate the eating disorder. (18, 33) As we have noted above, when the body moves into starvation mode, changes in brain chemistry occur that increase the persistence of an eating disorder. It may be that the loss of body mass - through excess exercise - may contribute to the development of an eating disorder in a very similar way.

Female athletes in certain sports such as distance running and gymnastics are especially vulnerable to this effect. Male bodybuilders are also at risk, although the symptom picture often differs, since the bodybuilder may emphasize a wish to "get bigger" and may also abuse anabolic steroids.

Nutritional: When there is poor nutrition, a patient may develop headaches, low blood sugar, depression and apathy, moodiness, a resistance to hunger and - in some patients – a relatively complete absence of hunger. Improper nutrition leads to a thinning of hair in some patients. Lack of zinc in some patients' diets may create a loss of acuity in tasting.* Improper nutrition can also create problems in terms of normal bowel movements, which in turn makes patients feel full and ‘fat’.

Psychological: Eating disordered patients will frequently present with a psychology of deprivation - based on their fear of compulsive eating. At the core of all eating disorders, there appears to be a fear of compulsive eating. (9) Ultimately, patients with eating disorders will need to address their conflicts and fears with regard to food and eating.

In the psychodynamic literature, patients with anorexia nervosa have been described as having difficulties with separation and autonomy (often manifested as enmeshed relationships with parents), affect regulation (including the direct expression of anger and aggression), and negotiating psychosexual development. (121, 122, 9, 123, 124)

These deficits may make women who are genetically or biologically predisposed to anorexia nervosa more vulnerable to cultural pressures to achieve a stereotypic or ideal body image. Bulimia nervosa has also been described as a dissociated self-state, as resulting from deficits in self-regulation, and as representing resentful, angry attacks on one's own body out of masochistic/sadistic need. (50, 91)

Anorectic patients have also been shown to display certain personality traits such as:

- Obsessiveness
- Perfectionism
- Exactness
- Harm avoidance
- Preference for symmetry
- Higher degrees of anxiety

Familial: It is no longer believed that mothers are the culprit of their daughters’ eating disorder. However, family attitudes about food and eating and body are important. Researchers have determined that teaching children how to be strong and flexible is a protective factor against developing eating disorders. (78) Children are more resistant to developing eating disorders when they are taught to articulate issues of difference, objectification, power and harassment. (78).

When working with parents of eating disordered young women and men, it is important to find ways to lower both anxiety and guilt. If a family's overall level of affect is not manageable, it is very difficult to enlist the family as a useful ally of change.

Families of patients with bulimia nervosa have been found to have higher rates of substance abuse (particularly alcoholism), but transmission of substance abuse in these families may be independent of transmission of bulimia nervosa. (65) In addition, families of patients with bulimia nervosa have higher rates of affective disorders and obesity. (78)

Patients with bulimia nervosa have been described as having difficulties with impulse regulation resulting from a deficit of parental (usually maternal) involvement. (50)



Eating Disorders Factoid

According to a National Comorbidity Survey Replication, the average duration of anorexia was 1.7 years, while the average duration of bulimia was 8.3 years.

Source: HealthDay News (citing Hudson, J, lead researcher, Biological Psychiatry Laboratory, report in Biological Psychiatry, 2007)


Cultural: Although culture is only one part of the puzzle of eating disorders, it is an important part. The cultural matrix in which we live is an important factor that enables and sometimes drives the proliferation of eating disorders. The larger values of a culture are transmitted through a wide variety of formal and informal means.

Cultures define and champion ideals in many areas related to the presentation of the self, including appearance and attractiveness. Individuals who successfully approach or meet those ideals are rewarded by the culture in subtle or not so subtle ways. Individuals who do not meet the ideal may face condemnation, scorn, or rejection.

The power of the culture to shape ideals can create significant pressures on its members to conform to those ideals, no matter what the personal cost or sacrifices that may be required to reach those ideals. If extreme thinness becomes an ideal – as it appears to be in the "designer" segment of white, Western culture – then pressure will be placed upon members to strive for that ideal.

There are developmental periods of particular vulnerability to these kinds of social pressures. The most powerful of these is when a child reaches puberty. Youngsters are particularly self-conscious at this time in their lives, in addition to being more concerned about peer and social acceptance.

Furthermore, their bodies and brains are in a period of enormous change and development. Whatever equilibrium may have been reached during the latency years is destabilized to a greater or lesser degree by the physical and emotional changes of puberty.

The uncertainties of this period of a person's life may contrast poorly with the "certainties" of reaching (or at least striving for) the cultural ideals related to appearance. The process of emotionally coming together as a person takes time. It requires foresight, patience, and confidence in the developmental process – resources that are not always in good supply during this period of life. It is not easily envisioned by the newly teenaged.

Having a "perfect" figure, by contrast, is much easier to grasp as an achievable concept. There are strategies that can be easily conceptualized to reach this goal, immediate and concrete feedback about one's success, and multiple sources of positive feedback as one compares oneself to the cultural icons that serve as representatives of the ideal.

The power of these cultural ideals is not absolute, however. Families and sub-groups within the culture may raise voices of opposition that inhibit, modulate or diminish the power of these kinds of cultural ideals. This may create some degree of protection against the drive to thinness seen in eating disorders.

However, there are also instances where families or sub-groups within the larger culture may consciously or unconsciously forward, support and champion the cultural ideals espousing the value of thinness. This can reinforce the power of these ideals and increase the therapeutic challenge of working successfully with eating disorders.

In evaluating the strength and effects of these cultural messages on any particular client, it is important to see where these factors are reinforced or opposed from the values of families, peer groups, and other sub-cultural elements with which the client interacts.

Professionals who work with clients with eating disorders should make sure that parents and teachers are attuned to this cultural pull to thinness. Because the messages of valuing thinness can be so deeply embedded and integrated in a variety of mass media messages, they can become an almost invisible influence on the belief systems of all parties interacting with the client with the eating disorder. Parents and teachers may need to be directed towards a greater awareness of how they talk to their charges concerning weight, thinness, dieting and eating.

IMPORTANT: In the past researchers held the belief that ethnic groups were protected from eating disorders by their specific culture. However, it seems that acculturation and mainstream culture erodes the protective factor of cultural specificity.

Acculturation may be a powerful force, especially among young people who live in a world with seemingly no boundaries. Instant messaging and My Sites websites allow young people to be connected in ways that the older generation never has. This means that acculturation happens at a speed that has never happened before.

New values enter into the homes of immigrants at the speed of light. These values enter into dialogue and conflict with the more traditional values.

Eating Disorders Factoid

86% of patients with eating disorders report an onset by age 20.

Source: ANAD: National Association of Anorexia Nervosa and Associated Disorders


What Psychiatric Symptoms and Conditions are Co-morbid with Eating Disorders?

For mental health clinicians who do not specialize in the treatment of eating disorders, it is likely that interactions with eating disordered clients will occur in the initial assessment phase, or when an eating disorder is uncovered during the course of treating some other presenting condition. In either event, the most appropriate role of the clinician will consist of performing a thorough evaluation to determine the full range of problems and symptoms, and to understand what additional or specialized services may be required to successfully treat the client.

For this reason, it is important for each mental health clinician to be aware of the potential for co-morbid conditions and disorders. While each individual client will have a unique presentation of problems, it is nevertheless helpful for the clinician to have some basic knowledge about the more likely co-morbid symptoms and conditions.

(Additionally, this can serve as a helpful reminder for the clinician to consider the possibility of a hidden eating disorder when these other conditions and symptoms are presented as the primary problem.)

Psychiatric symptoms frequently co-morbid with eating disorders include depressive symptoms, such as depressed mood, social withdrawal, irritability, insomnia and decreased sexual interest. Anxiety symptoms are also frequently co-morbid.

It must be understood that many depressive features may be secondary to the physiological sequelae of semi-starvation. Because of this factor, symptoms of mood disturbances need to be re-assessed after partial or complete weight restoration. Within inpatient units where eating disorders are treated, it is well understood that AN patients can change dramatically when their weight is normalized.

Additionally, obsessive-compulsive features like thoughts of food, hoarding food, picking/pulling apart small portions of food or collecting recipes are common and get better when patients stop starving themselves. Fears of eating in public may also be evident, but care should be taken to distinguish fear of food / shame of eating too much – as one can see with an eating disorder – and a legitimate social phobia.

These are the frequently noted symptoms. There are also conditions or disorders that are co-morbid with eating disorders. These include major depressive disorder or dysthymia, bipolar disorder, obsessive-compulsive disorder, sexual abuse survivorship, and substance abuse. (38, 10, 42).

It is not known if the co-morbidities between eating disorders and these other conditions are the result of common genetic or environmental factors. The research to date has not been conclusive, and much more study needs to be done before conclusions can be reached. Researchers have also found out that affective disorders and eating disorders are not manifestations of common underlying genetic vulnerability. (106)

What is known is that there are significant co-morbidities with other disorders. We will look at the numbers related to these co-morbidities here.

For eating disordered patients seeking treatment at tertiary psychiatric treatment centers, there are very high rates of co-morbid psychiatric illness. Co-morbid major depression or dysthymia has been reported in 50%-75% of patients with anorexia nervosa and bulimia nervosa. (38, 10, 42)

Estimates of the prevalence of bipolar disorder among patients with anorexia nervosa or bulimia nervosa are usually around 4%-6% but have been reported to be as high as 13%. (48)

The lifetime prevalence of obsessive-compulsive disorder (OCD) among anorexia nervosa cases has been as high as 25%, and obsessive-compulsive symptoms have been found in a large majority of weight-restored patients with anorexia nervosa treated in tertiary care centers. (38, 41, 54)

OCD is also common among patients with bulimia nervosa. Co-morbid anxiety disorders, particularly social phobia, are common among patients with anorexia nervosa and patients with bulimia nervosa. (38, 10, 42)
Substance abuse has been found in as many as 30%-37% of patients with bulimia nervosa. (38)

Among patients with anorexia nervosa, estimates of those with substance abuse have ranged from 12% to 18%, with this problem occurring primarily among those with the binge/purge subtype. (38, 42).

Co-morbid personality disorders are frequently found among patients with eating disorders, with estimates ranging from 42% to 75%. (100)
Associations between bulimia nervosa and cluster B and C disorders (particularly borderline personality disorder and avoidant personality disorder) and between anorexia nervosa and cluster C disorders (particularly avoidant personality disorder and obsessive-compulsive personality disorder) have been reported. (100)

Eating disordered patients with personality disorders are more likely than those without personality disorders to also have concurrent mood or substance abuse disorders. (100)

Co-morbid personality disorders are significantly more common among patients with the binge/purge subtype of anorexia nervosa than the restricting subtype or normal weight patients with bulimia nervosa. (43)

Sexual abuse has been reported in 20%-50% of patients with bulimia nervosa and those with anorexia nervosa, although sexual abuse may be more common in patients with bulimia nervosa than in those with the restricting subtype of anorexia nervosa. (116) Childhood sexual abuse histories are reported more often in women with eating disorders than in women from the general population.

Women who have eating disorders in the context of sexual abuse appear to have higher rates of co-morbid psychiatric conditions than other women with eating disorders. (116, 117).

However, are anorexia and bulimia culture-bound syndromes? Have anorexia and bulimia nervosa increased in the last 20 or 30 years? Is the incidence of bulimia and anorexia still maintaining an upward trending? Is it true that the media has a direct influence on the rise of these disorders?

If anorexia and bulimia nervosa were influenced by the media and the cultural forces, it would follow that mental health professionals might see an increase in the incidence of both disorders and an increase in its overall prevalence.

Eating Disorders Factoid

About 72% of alcoholic women younger than 30 also have eating disorders

Source: Anorexia Nervosa and Related Eating Disorders, Inc.(Citing Health Magazine, Jan/Feb, 2002)

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