What is the Body Attitudes Questionnaire?

Introduction

The Ben-Tovim Walker Body Attitudes Questionnaire (BAQ) is a 44 item self-report questionnaire divided into six subscales that measures a woman’s attitude towards their own body.

The BAQ is used in the assessment of eating disorders. It was devised by D.I. Ben-Tovim and M.K. Walker in 1991.

Refer to the Body Attitudes Test.

Sub-Scales

The six subscales measured by the BAQ are:

  • Overall fatness.
  • Self disparagement.
  • Strength.
  • Salience of weight.
  • Feelings of attractiveness.
  • Consciousness of lower body fat.
  • Foreign-language versions.

Portuguese Version

The BAQ was the first body attitudes scale to be translated into Portuguese. The validity of the Portuguese language version was proven in a test conducted on a cohort of Brazilian women who speak Portuguese as their native language. The test-retest reliability was 0.57 and 0.85 after a one-month interval. The test was conducted by Scagliusi et al.

Japanese Version

The BAQ was translated into Japanese and tested on 68 males and 139 females in Japan and 68 Japanese males living in Australia (Kagawa et al.) The scores were assessed against 72 Australian men using the English-language version as well as scores from previous female Australian participants. There was a significant difference between the Japanese and Australian groups (p,0.05). The BAQ was deemed adequate for use in both Japanese males and females.

References

Ben-Tovim, D.I. & Walker, M.K. (1991) The development of the Ben-Tovim Walker Body Attitudes Questionnaire (BAQ), a new measure of women’s attitudes towards their own bodies. Psychological Medicine. 21(3), pp.775-784. doi:10.1017/S0033291700022406.

Kagawa, M., Uchida, H., Uenishi, K., Binns, C.W. & Hills, A.P. (2007) Applicability of the Ben-Tovim Walker Body Attitudes Questionnaire (BAQ) and the Attention to Body Shape scale (ABS) in Japanese males and females (PDF). Eating Behaviors. 8(3), pp.2772-284. doi:10.1016/j.eatbeh.2006.11.002.

Scagliusi, F.B., Polacow, V.O., Cordas, T.A., Coelho, D., Alvarenga, M., Philippi, S.T. & Lancha Jr, A.H. (2005) Psychometric testing and applications of the Body Attitudes Questionnaire translated into Portuguese. Perceptual and Motor Skills. 101(1), pp.25-41. doi:10.2466/PMS.101.5.25-41.

What is the Body Attitudes Test?

Introduction

The Body Attitudes Test (BAT) was developed by Probst and colleagues in 1995.

Refer to Body Attitudes Questionnaire.

Background

It was designed for the assessment of eating disorders in women. The BAT measures an individual’s subjective body experience and attitudes towards one’s own body it differentiates between clinical and non-clinical subjects and between anorexics and bulimics. It is composed of twenty items which yield four factors:

  1. Negative appreciation of body size.
  2. Lack of familiarity with one’s own body.
  3. General body dissatisfaction.
  4. A rest factor.

Reference

Probst, M. Van Coppenolle, H. & Vandereycken, W. (1997) Further experience with the Body Attitude Test. Eating and Weight Disorders. 2(2), pp.100104. doi:10.1007/bf03339956.

What is an Other Specified Feeding or Eating Disorder?

Introduction

Other specified feeding or eating disorder (OSFED) is a DSM-5 category that, along with unspecified feeding or eating disorder (UFED), replaces the category formerly called eating disorder not otherwise specified (EDNOS) in the DSM-IV-TR.

It captures feeding disorders and eating disorders of clinical severity that do not meet diagnostic criteria for anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), avoidant/restrictive food intake disorder (ARFID), pica, or rumination disorder.

OSFED includes five examples:

  1. Atypical anorexia nervosa.
  2. Atypical bulimia nervosa of low frequency and/or limited duration.
  3. Binge eating disorder of low frequency and/or limited duration.
  4. Purging disorder.
  5. Night eating syndrome (NES).

Brief History

In 1980, DSM-III was the first DSM to include a category for eating disorders that could not be classified in the categories of AN, BN, or pica. This category was called Atypical Eating Disorder. Atypical Eating Disorder was described in one sentence in the DSM-III and received very little attention in the literature, as it was perceived to be uncommon compared to the other defined eating disorders. In DSM-III-R, published in 1987, the Atypical Eating Disorder category became known as Eating Disorder Not Otherwise Specified (EDNOS). DSM-III-R included examples of individuals who would meet criteria for EDNOS, in part to acknowledge the increasingly recognized heterogeneity of individuals within the diagnostic category.

In 1994, DSM-IV was published and expanded EDNOS to include six clinical presentations. These presentations included individuals who:

  • Met criteria for AN, but continued to menstruate;
  • Met criteria for AN, but still had weight in the normal range despite significant weight loss;
  • Met criteria for BN but did not meet frequency criterion for binge eating or purging;
  • Engaged in inappropriate compensatory behaviour after eating small amounts of food; or
  • Repeatedly chewed or spit out food, or who binged on food but did not subsequently purge.

A disadvantage of DSM-IV’s broad EDNOS category was that people with very different symptoms were still classified as having the same diagnosis, making it difficult to access care specific to the disorder and conduct research on the diversity of pathology within EDNOS. Furthermore, EDNOS was perceived as less severe than AN or BN, despite findings that individuals diagnosed with EDNOS share similarities with full-threshold AN or BN in the degree of eating pathology, general psychopathology, and physical health. This perception prevented people in need from seeking help or insurance companies from covering treatment costs. DSM-5, published in 2013, sought to address these issues by adding new diagnoses and revising existing criteria.

Epidemiology

Few studies to date have examined OSFED prevalence. The largest community study is by Stice (2013), who examined 496 adolescent females who completed annual diagnostic interviews over 8 years. Lifetime prevalence by age 20 for OSFED overall was 11.5%. 2.8% had atypical AN, 4.4% had subthreshold BN, 3.6% had subthreshold BED, and 3.4% had purging disorder. Peak age of onset for OSFED was 18-20 years. NES was not assessed in this study, but estimates from other studies suggest that it presents in 1% of the general population.

A few studies have compared the prevalence of EDNOS and OSFED and found that though the prevalence of atypical eating disorders decreased with the new classification system, the prevalence still remains high. For example, in a population of 215 young patients presenting for ED treatment, the diagnosis of EDNOS to OSFED decreased from 62.3% to 32.6%. In another study of 240 females in the US with a lifetime history of an eating disorder, the prevalence changed from 67.9% EDNOS to 53.3% OSFED. Although the prevalence appears to reduce when using the categorisations of EDNOS vs. OSFED, a high proportion of cases still receive diagnoses of atypical eating disorders, which creates difficulties in communication, treatment planning, and basic research.

Classification

The five OSFED examples that can be considered eating disorders include atypical AN, BN (of low frequency and/or limited duration), BED (of low frequency and/or limited duration), purging disorder, and NES. Of note, OSFED is not limited to these five examples, and can include individuals with heterogeneous eating disorder presentations (i.e. OSFED-other). Another term, UFED, is used to describe individuals for whom full diagnostic criteria are not met but the reason remains unspecified or the clinician does not have adequate information to make a more definitive diagnosis.

Atypical Anorexia NervosaIn atypical AN, individuals meet all of the criteria for AN, with the exception of the weight criterion: the individual’s weight remains within or above the normal range, despite significant weight loss.
Atypical Bulimia NervosaIn this sub-threshold version of BN, individuals meet all criteria for BN, with the exception of the frequency criterion: binge eating and inappropriate compensatory behaviours occur, on average, less than once a week and/or for fewer than 3 months.
Binge Eating Disorder of Low Frequency and/or Limited DurationIn this sub-threshold version of BED, individuals must meet all criteria for BED, with the exception of the frequency criterion: binge eating occurs, on average, less than once a week and/or for fewer than 3 months.
Purging DisorderIn purging disorder, purging behaviour aimed to influence weight or shape is present, but in the absence of binge eating.
Night Eating SyndromeIn NES, individuals have recurrent episodes of eating at night, such as eating after awakening from sleep or excess calorie intake after the evening meal. This eating behaviour is not culturally acceptable by group norms, such as the occasional late-night munchies after a gathering. NES includes an awareness and recall of the eating, is not better explained by external influences such as changes in the individual’s sleep-wake cycle, and causes significant distress and/or impairment of functioning.

Though not defined specifically in DSM-5, research criteria for this diagnosis proposed adding the following criteria (1) the consumption of at least 25% of daily caloric intake after the evening meal and/or (2) evening awakenings with ingestions at least twice per week.

Treatment

Few studies guide the treatment of individuals with OSFED. However, cognitive behavioural therapy (CBT), which focuses on the interplay between thoughts, feelings, and behaviours, has been shown to be the leading evidence-based treatment for the eating disorders of BN and BED. For OSFED, a particular cognitive behavioural treatment can be used called CBT-Enhanced (CBT-E), which was designed to treat all forms of eating disorders. This method focuses not only what is thought to be the central cognitive disturbance in eating disorders (i.e. over-evaluation of eating, shape, and weight), but also on modifying the mechanisms that sustain eating disorder psychopathology, such as perfectionism, core low self-esteem, mood intolerance, and interpersonal difficulties. CBT-E showed effectiveness in two studies (total N = 219) and well maintained over 60-week follow-up periods. CBT-E is not specific to individual types of eating disorders but is based on the concept that common mechanisms are involved in the persistence of atypical eating disorders, AN, and BN.

What is an Unspecified Feeding or Eating Disorder?

Introduction

Unspecified feeding or eating disorder (UFED) is a Diagnostic and Statistical Manual of Mental Disorders (DSM-5 category of eating disorders that, along with other specified feeding or eating disorder (OSFED), replaced eating disorder not otherwise specified (EDNOS) in the DSM-IV-TR.

UFED is an eating disorder that does not meet the criteria for: anorexia nervosa, bulimia nervosa, binge eating disorder, or OSFED. Individuals with EDNOS have similar symptoms and behaviours to those with anorexia and bulimia, and can face the same dangerous risks.

Signs and Symptoms

Rather than providing specific diagnostic criteria for EDNOS, the fourth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) listed six non-exhaustive example presentations, including individuals who:

  • Meet all criteria for anorexia nervosa except they have regular menses.
  • Meet all criteria for anorexia nervosa except their weight falls within the normal range.
  • Meet all criteria for bulimia nervosa except they engage in binge eating or purging behaviours less than twice per week or for fewer than three months.
  • Use inappropriate compensatory behaviour (such as purging, excessive exercise, or fasting) after eating small amounts of food while retaining a normal body weight.
  • Repeatedly chew and spit out large amounts of food without swallowing.
  • Meet criteria for “binge eating disorder”: recurrent binge eating and no regular inappropriate compensatory behaviours.

Despite its subclinical status in DSM-IV, available data suggest that EDNOS is no less severe than the officially recognized DSM-IV eating disorders. In a comprehensive meta-analysis of 125 studies, individuals with EDNOS exhibited similar levels of eating pathology and general psychopathology to those with anorexia nervosa and binge eating disorder, and similar levels of physical health problems as those with anorexia nervosa. Although individuals with bulimia nervosa scored significantly higher than those with EDNOS on measures of eating pathology and general psychopathology, those with EDNOS exhibited more physical health problems than those with bulimia nervosa.

Diagnosis

Although no longer in the DSM-5, the three general categories for an EDNOS diagnosis are subthreshold symptoms of anorexia or bulimia, a mixture of both anorexic or bulimic symptoms, and clinically-significant disordered eating behaviours that are not described by anorexia and bulimia. EDNOS is no longer considered a diagnosis in DSM-5. Because some diagnostic criteria were loosened and new diagnoses were introduced in DSM-5, those displaying symptoms of what would previously have been considered EDNOS are now classified under anorexia nervosa, bulimia nervosa, binge eating disorder, avoidant/restrictive food intake disorder(ARFID), other specified feeding or eating disorder (OSFED), or unspecified feeding or eating disorder (UFED).

Epidemiology

Although EDNOS (formerly called atypical eating disorder) was originally introduced in DSM-III to capture unusual cases, it accounts for up to 60% of cases in eating disorder specialty clinics. EDNOS is an especially prevalent category in populations that have received inadequate research attention such as young children, males, ethnic minorities, and non-Western groups.

Treatment

When treating any eating disorder, including unspecified disorders, it is important to include a registered dietician or nutritionist working with the treatment team. Even though eating disorders are a psychological diagnosis, psychologists are not certified or licensed in dietetics or nutrition, so it is important that psychologists are not practicing outside their bounds of competence. Medical Nutrition Therapy is vital in the treatment and management of eating disorders. The dietician assists the patient by creating a meal plan that is tailored to their individual needs and treatment goals. The dietician will also provide psychoeducation that challenges nutrition misinformation and will ideally create a space where the patient feels comfortable asking questions.

What is Binge Eating Disorder?

Introduction

Binge eating disorder (BED) is an eating disorder characterised by frequent and recurrent binge eating episodes with associated negative psychological and social problems, but without the compensatory behaviours common to Bulimia Nervosa, OSFED, or the Binge-Purge subtype of Anorexia Nervosa.

BED is a recently described condition, which was required to distinguish binge eating similar to that seen in bulimia nervosa but without characteristic purging. Individuals who are diagnosed with bulimia nervosa and binge eating disorder exhibit similar patterns of compulsive overeating, neurobiological features of dysfunctional cognitive control and food addiction, and biological and environmental risk factors. Some professionals consider BED to be a milder form of bulimia with the two conditions on the same spectrum.

Binge eating is one of the most prevalent eating disorders among adults, though there tends to be less media coverage and research about the disorder in comparison to anorexia nervosa and bulimia nervosa.

Brief History

The disorder was first described in 1959 by psychiatrist and researcher Albert Stunkard as “night eating syndrome” (NES). The term “binge eating” was coined to describe the same bingeing-type eating behaviour but without the exclusive nocturnal component.

There is generally less research on binge eating disorder in comparison to anorexia nervosa and bulimia nervosa.

Signs and Symptoms

Binge eating is the core symptom of BED; however, not everyone who binge eats has BED. An individual may occasionally binge eat without experiencing many of the negative physical, psychological, or social effects of BED. This may be considered disordered eating rather than a clinical disorder. Precisely defining binge eating can be problematic, however binge eating episodes in BED are generally described as having the following potential features:

  • Eating much faster than normal, perhaps in a short space of time.
  • Eating until feeling uncomfortably full.
  • Eating a large amount when not hungry.
  • Subjective loss of control over how much or what is eaten.
  • Binges may be planned in advance, involving the purchase of special binge foods, and the allocation of specific time for binging, sometimes at night.
  • Eating alone or secretly due to embarrassment over the amount of food consumed.
  • There may be a dazed mental state during the binge.
  • Not being able to remember what was eaten after the binge.
  • Feelings of guilt, shame or disgust following a food binge.

In contrast to bulimia nervosa, binge eating episodes are not regularly followed by activities intended to compensate for the amount of food consumed, such as self-induced vomiting, laxative or enema misuse, or strenuous exercise. BED is characterised more by overeating than dietary restriction. Those with BED often have poor body image and frequently diet, but are unsuccessful due to the severity of their binge eating.

Obesity is common in persons with BED, as is depression, low self-esteem, stress and boredom. Those with BED are also at risk of Non-alcoholic fatty liver disease, menstrual irregularities such as amenorrhea, and gastrointestinal problems such as acid reflux and heartburn.

Causes

As with other eating disorders, binge eating is an “expressive disorder” – a disorder that is an expression of deeper psychological problems. People who have binge eating disorder have been found to have higher weight bias internalisation, which includes low self-esteem, unhealthy eating patterns, and general body dissatisfaction. Binge eating disorder commonly develops as a result or side effect of depression, as it is common for people to turn to comfort foods when they are feeling down.

There was resistance to give binge eating disorder the status of a fully fledged eating disorder because many perceived binge eating disorder to be caused by individual choices. Previous research has focused on the relationship between body image and eating disorders, and concludes that disordered eating might be linked to rigid dieting practices. In the majority of cases of anorexia, extreme and inflexible restriction of dietary intake leads at some point to the development of binge eating, weight regain, bulimia nervosa, or a mixed form of eating disorder not otherwise specified. Binge eating may begin when individuals recover from an adoption of rigid eating habits. When under a strict diet that mimics the effects of starvation, the body may be preparing for a new type of behaviour pattern, one that consumes a large amount of food in a relatively short period of time.

Some studies show that BED aggregates in families and could be genetic. However, very few published studies around the genetics exist.

However, other research suggests that binge eating disorder can also be caused by environmental factors and the impact of traumatic events. One study showed that women with binge eating disorder experienced more adverse life events in the year prior to the onset of the development of the disorder, and that binge eating disorder was positively associated with how frequently negative events occur. Additionally, the research found that individuals who had binge eating disorder were more likely to have experienced physical abuse, perceived risk of physical abuse, stress, and body criticism. Other risk factors may include childhood obesity, critical comments about weight, low self-esteem, depression, and physical or sexual abuse in childhood. A systematic review concluded that bulimia nervosa and binge eating disorder are more impacted by family separations, a loss in their lives and negative parent-child interactions compared to those with anorexia nervosa. A few studies have suggested that there could be a genetic component to binge eating disorder, though other studies have shown more ambiguous results. Studies have shown that binge eating tends to run in families and a twin study by Bulik, Sullivan, and Kendler has shown a, “moderate heritability for binge eating” at 41%. More research must be done before any firm conclusions can be drawn regarding the heritability of binge eating disorder. Studies have also shown that eating disorders such as anorexia and bulimia reduce coping abilities, which makes it more likely for those suffering to turn to binge eating as a coping strategy.

A correlation between dietary restraint and the occurrence of binge eating has been shown in some research. While binge eaters are often believed to be lacking in self-control, the root of such behaviour might instead be linked to rigid dieting practices. The relationship between strict dieting and binge eating is characterised by a vicious circle. Binge eating is more likely to occur after dieting, and vice versa. Several forms of dieting include delay in eating (e.g. not eating during the day), restriction of overall calorie intake (e.g. setting calorie limit to 1,000 calories per day), and avoidance of certain types of food (e.g. “forbidden” food, such as sugar, carbohydrates, etc.). Strict and extreme dieting differs from ordinary dieting. Some evidence suggests the effectiveness of moderate calorie restriction in decreasing binge eating episodes among overweight individuals with binge eating disorder, at least in the short-term.

In the US it is estimated that 3.5% of young women and 30% to 40% of people who seek weight loss treatments, can be clinically diagnosed with binge eating disorder.

Diagnosis

International Classification of Diseases

BED was first included in the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1994 simply as a feature of eating disorder. In 2013 it gained formal recognition as a psychiatric condition in the DSM-5.

The 2017 update to the American version of the ICD-10 includes BED under F50.81. ICD-11 may contain a dedicated entry (6B62), defining BED as frequent, recurrent episodes of binge eating (once a week or more over a period of several months) which are not regularly followed by inappropriate compensatory behaviours aimed at preventing weight gain.

Diagnostic and Statistical Manual

Previously considered a topic for further research exploration, binge eating disorder was included in the DSM in 2013. Until 2013, binge eating disorder was categorized as an Eating Disorder Not Otherwise Specified, an umbrella category for eating disorders that don’t fall under the categories for anorexia nervosa or bulimia nervosa. Because it was not a recognised psychiatric disorder in the DSM-IV until 2013, it has been difficult to obtain insurance reimbursement for treatments. The disorder now has its own category under DSM-5, which outlines the signs and symptoms that must be present to classify a person’s behaviour as binge eating disorder. Studies have confirmed the high predictive value of these criteria for diagnosing BED.

According to the World Health Organization’s ICD-11 classification of BED, the severity of the disorder can be classified as mild (1-3 episodes/week), moderate (4-7 episodes/week), severe (8-13 episodes/week) and extreme (>14 episodes/week).

One study claims that the method for diagnosing BED is for a clinician to conduct a structured interview using the DSM-5 criteria or taking the Eating Disorder Examination. The Structured Clinical Interview takes no more than 75 minutes to complete and has a systematic approach which follows the DSM-5 criteria. The Eating Disorder Examination is a semi-structured interview which identifies the frequency of binges and associated eating disorder features.

Treatment

Counselling and certain medication, such as lisdexamfetamine and selective serotonin reuptake inhibitor (SSRIs), may help. Some recommend a multidisciplinary approach in the treatment of the disorder.

Counselling

Cognitive behavioural therapy (CBT) treatment has been demonstrated as a more effective form of treatment for BED than behavioural weight loss programmes. 50% of BED individuals achieve complete remission from binge eating and 68-90% will reduce the amount of binge eating episodes they have. CBT has also been shown to be an effective method to address self-image issues and psychiatric comorbidities (e.g. depression) associated with the disorder. The goal of CBT is to interrupt binge-eating behaviour, learn to create a normal eating schedule, change the perception around weight and shape and develop positive attitudes about one’s body. Although this treatment is successful in eliminating binge eating episodes, it does not lead to losing any weight. Recent reviews have concluded that psychological interventions such as psychotherapy and behavioural interventions are more effective than pharmacological interventions for the treatment of binge eating disorder. A meta-analysis concluded that psychotherapy based on CBT not only significantly improved binge-eating symptomatology but also reduced a client’s BMI significantly at posttreatment and longer than 6 and 12 months after treatment. There is the 12-step Overeaters Anonymous or Food Addicts in Recovery Anonymous. Behavioural weight loss treatment has been proven to be effective as a means to achieve weight loss amongst patients.

Medication

Lisdexamfetamine is a US Food and Drug Administration (FDA)-approved drug that is used for the treatment of moderate to severe binge eating disorder in adults.

Three other classes of medications are also used in the treatment of binge eating disorder: antidepressants, anticonvulsants, and anti-obesity medications. Antidepressant medications of the selective serotonin reuptake inhibitor (SSRI) have been found to effectively reduce episodes of binge eating and reduce weight. Similarly, anticonvulsant medications such as topiramate and zonisamide may be able to effectively suppress appetite. The long-term effectiveness of medication for binge eating disorder is currently unknown. For BED patients with manic episodes, risperidone is recommended. If BED patients have bipolar depression, lamotrigine is appropriate to use.

Trials of antidepressants, anticonvulsants, and anti-obesity medications suggest that these medications are superior to placebo in reducing binge eating. Medications are not considered the treatment of choice because psychotherapeutic approaches, such as CBT, are more effective than medications for binge eating disorder. A meta-analysis concluded that using medications did not reduce binge-eating episodes and BMI posttreatment at 6-12 months. This indicates a potential possibility of relapse after withdrawal from the medications. Medications also do not increase the effectiveness of psychotherapy, though some patients may benefit from anticonvulsant and anti-obesity medications, such as phentermine/topiramate, for weight loss.

Blocking opioid receptors leads to less food intake. Additionally, bupropion and naltrexone used together may cause weight loss. Combining these alongside psychotherapies like CBT may lead to better outcomes for BED.

Surgery

Bariatric surgery has also been proposed as another approach to treat BED and a recent meta-analysis showed that approximately two-thirds of individuals who seek this type of surgery for weight loss purposes have BED. Bariatric surgery recipients who had BED prior to receiving the surgery tend to have poorer weight-loss outcomes and are more likely to continue to exhibit eating behaviours characteristic of BED.

Lifestyle Interventions

Other treatments for BED include lifestyle interventions like weight training, peer support groups, and investigation of hormonal abnormalities.

Prognosis

Individuals suffering from BED often have a lower overall quality of life and commonly experience social difficulties. Early behaviour change is an accurate prediction of remission of symptoms later.

Individuals who have BED commonly have other comorbidities such as major depressive disorder, personality disorder, bipolar disorder, substance abuse, body dysmorphic disorder, kleptomania, irritable bowel syndrome, fibromyalgia, or an anxiety disorder. Individuals may also exhibit varying degrees of panic attacks and a history of attempted suicide.

While people of a healthy weight may overeat occasionally, an ongoing habit of consuming large amounts of food in a short period of time may ultimately lead to weight gain and obesity. Bingeing episodes usually include foods that are high in fat, sugar, and/or salt, but low in vitamins and minerals, as these types of foods tend to trigger the greatest chemical and emotional rewards. The main physical health consequences of this type of eating disorder are brought on by the weight gain resulting from calorie-laden bingeing episodes. Mental and emotional consequences of binge eating disorder include social weight stigma and emotional loss of control. Up to 70% of individuals with BED may also be obese, and therefore obesity-associated morbidities such as high blood pressure and coronary artery disease type 2 diabetes mellitus gastrointestinal issues (e.g. gallbladder disease), high cholesterol levels, musculoskeletal problems and obstructive sleep apnoea may also be present.

Epidemiology

General

The prevalence of BED in the general population is approximately 1-3%, with BED cases usually occurring between the ages of 12.4 and 24.7, but prevalence rates increase until the age of 40. Binge eating disorder is the most common eating disorder in adults.

The limited amount of research that has been done on BED shows that rates of binge eating disorder are fairly comparable among men and women. The lifetime prevalence of binge eating disorder has been observed in studies to be 2.0% for men and 3.5% for women, higher than that of the commonly recognised eating disorders anorexia nervosa and bulimia nervosa. However another systematic literature review found the prevalence average to be about 2.3% in women and about 0.3% in men. Lifetime prevalence rates for BED in women can range anywhere from 1.5 to 6 times higher than in men. One literature review found that point prevalence rates for BED vary from 0.1% to 24.1% depending on the sample. This same review also found that the 12-month prevalence rates vary between 0.1% to 8.8%.

Recent studies found that eating disorders which included anorexia nervosa, bulimia nervosa and binge-eating disorder are common among sexual and gender minority populations, including gay, lesbian, bisexual and transgender people. This could be due to the minority stress and discrimination this population experiences.

Due to limited and inconsistent information and research on ethnic and racial differences, prevalence rates are hard to determine for BED. Rates of binge eating disorder have been found to be similar among black women, white women, and white men, while some studies have shown that binge eating disorder is more common among black women than among white women. However, majority of the research done around BED is focused on White women. One literature review found information citing no difference between BED prevalence among Hispanic, African American, and White women while other information found that BED prevalence was highest among Hispanics followed by Black individuals and finally White people.

Worldwide Prevalence

Eating disorders have usually been considered something that was specific to Western countries. However, the prevalence of eating disorders is increasing in other non-Western countries. Though the research on binge eating disorders tends to be concentrated in North America, the disorder occurs across cultures. In the USA, BED is present in 0.8% of male adults and 1.6% of female adults in a given year.

The prevalence of BED is lower in Nordic countries compared to Europe in a study that included Finland, Sweden, Norway, and Iceland. The point prevalence ranged from 0.4 to 1.5% and the lifetime prevalence ranged from 0.7 to 5.8% for BED in women.

In a study that included Argentina, Brazil, Chile, Colombia, Mexico, and Venezuela, the point prevalence for BED was 3.53%. Therefore, this particular study found that the prevalence for BED is higher in these Latin American countries compared to Western countries.

The prevalence of BED in Europe ranges from <1 to 4%.

Co-Morbidities

BED is co-morbid with diabetes, hypertension, previous stroke, and heart disease in some individuals.

In people who have obsessive-compulsive disorder or bipolar I or II disorders, BED lifetime prevalence was found to be higher.

Additionally, 30 to 40% of individuals seeking treatment for weight-loss can be diagnosed with binge eating disorder.

Underreporting in Men

Eating disorders are oftentimes underreported in men. Underreporting could be a result of measurement bias due to how eating disorders are defined. The current definition for eating disorders focuses on thinness. However, eating disorders in men tend to centre on muscularity and would therefore warrant a need for a different measurement definition. Further research should focus on including more men in samples since previous research has focused primarily on women.

What is an Eating Disorder Inventory?

Introduction

The Eating Disorder Inventory (EDI) is a self-report questionnaire used to assess the presence of eating disorders:

  • Anorexia nervosa both restricting and binge-eating/purging type;
  • Bulimia nervosa; and
  • Eating disorder not otherwise specified including binge eating disorder.

The original questionnaire consisted of 64 questions, divided into eight subscales. It was created in 1984 by David M. Garner and others. There have been two subsequent revisions by Garner:

  • The Eating Disorder Inventory-2 (EDI-2); and
  • The Eating Disorder Inventory-3 (EDI-3).

Diagnostic Use

The Eating Disorder Inventory is a diagnostic tool designed for use in a clinical setting to assess the presence of an eating disorder. It is generally used in conjunction with other psychological tests such as the Beck Depression Inventory. Depression has been shown to yield higher scores on the EDI-3.

Eating Disorder Inventory

The Eating Disorder Inventory (EDI) comprises 64 questions, divided into eight subscales. Each question is on a 6-point scale (ranging from “always” to “never”), rated 0-3. The score for each sub-scale is then summed. The 8 subscale scores on the EDI are:

  • Drive for thinness: an excessive concern with dieting, preoccupation with weight, and fear of weight gain.
  • Bulimia: episodes of binge eating and purging.
  • Body dissatisfaction: not being satisfied with one’s physical appearance.
  • Ineffectiveness: assesses feelings of inadequacy, insecurity, worthlessness and having no control over their lives.
  • Perfectionism: not being satisfied with anything less than perfect.
  • Interpersonal distrust: reluctance to form close relationships.
  • Interoceptive awareness: “measures the ability of an individual to discriminate between sensations and feelings, and between the sensations of hunger and satiety”.
  • Maturity fears: The fear of facing the demands of adult life.

Eating Disorder Inventory-2

The first revision of the EDI was in 1991. The 1991 version, Eating Disorder Inventory-2 (EDI-2) is used for both males and females over age 12. The EDI-2 retains the original format of the EDI with the inclusion of 27 new items divided into three additional subscales:

  • Asceticism: reflects the avoidance of sexual relationships.
  • Impulse regulation: shows the ability to regulate impulsive behaviour, especially the binge behaviour.
  • Social insecurity: estimates social fears and insecurity.

Eating Disorder Inventory-3

The latest revision to the Eating Disorder Inventory was released in 2004. It contains the original items of the first version as well as EDI-2, and was also enhanced to reflect more modern theories related to the diagnosis of eating disorders. It was designed for use with females ages 13-53 years, and can be administered in 20 minutes. It contains 91 items divided into twelve subscales rated on a 0-4 point scoring system. Three items on the EDI-3 are specific to eating disorders, and 9 are general psychological scales that are relevant to eating disorders. The inventory yields six composite scores: eating disorder risk, ineffectiveness, interpersonal problems, affective problems, overcontrol, and general psychological maladjustment.

Eating Disorder Symptom Checklist

The Eating Disorder Symptom Checklist is a separate self-report form used to measure the frequency of symptoms (i.e., binge eating; the use of laxatives, diet pills; exercise patterns). The information provided by the checklist aids in determining whether patients meets the diagnostic criteria as set forth in the Diagnostic and Statistical Manual of Mental Disorders IV-TR for an eating disorder.

Eating Disorder Referral Form

The Eating Disorder Referral Form is an abbreviated form of the EDI-3 for use in non-clinical settings such as the allied health professions. It contains 25 questions from the EDI-3 that are specific to eating disorder risk. It also includes questions specific to the behavioural patterns of someone with or at risk of developing an eating disorder. The referral form utilizes indexes based on body mass index in identifying at risk patients.

What is an Eating Disorder Examination Interview?

Introduction

The Eating Disorder Examination Interview (EDE) devised by Cooper & Fairburn (1987) is a semi-structured interview conducted by a clinician in the assessment of an eating disorder.

Outline

The EDE is a semi-structured interview conducted by a trained clinician to assess the psychopathology associated with the diagnosis of an eating disorder. The EDE is rated through the use of four subscales and a global score. The four subscales are:

  1. Restraint.
  2. Eating concern.
  3. Shape concern.
  4. Weight concern.

The questions concern the frequency in which the patient engages in behaviours indicative of an eating disorder over a 28-day period. The test is secured on a 7-point scale from 0-6. With a zero score indicating not having engaged in the questioned behaviour.

EDE-Q

The Eating Disorders Examination Questionnaire (EDE-Q) was adapted from the EDE. The EDE-Q is a 41 item self-report questionnaire. It retains the format of the EDE including the 4 subscales and global score. It also concerns behaviours over a 28-day time period and retains the scoring system of 0-6, with:

  • 0 indicating no days;
  • 1 = 1-5 days;
  • 2 = 6-12 days;
  • 3 = 13-15 days;
  • 4 = 16-22 days;
  • 5 = 23-27 days; and
  • 6 = every day.

Reference

Cooper, Z. & Fairburn, CG (1987). The Eating Disorder Examination: A Semistructured Interview for the Assessment of the Specific Psychopathology of Eating Disorders”. International Journal of Eating Disorders. 6, pp.1-8. doi:10.1002/1098-108x(198701)6:1<1::aid-eat2260060102>3.0.co;2-9.

What is the Eating Attitudes Test?

Introduction

The Eating Attitudes Test (EAT, EAT-26), created by David Garner, is a widely used 26-item, standardised self-reported questionnaire of symptoms and concerns characteristic of eating disorders.

Background

The EAT is useful in assessing “eating disorder risk” in high school, college and other special risk samples such as athletes. EAT has been extremely effective in screening for anorexia nervosa in many populations.

The EAT-26 can be used in non-clinical as well as clinical settings not specifically focused on eating disorders. It can be administered in group or individual settings by mental health professionals, school counsellors, coaches, camp counsellors, and others with interest in gathering information to determine if an individual should be referred to a specialist for evaluation for an eating disorder. It is ideally suited for school settings, athletic programs, fitness centres, infertility clinics, paediatric practices, general practice settings, and outpatient psychiatric departments.

Scale and Referral Index

The EAT-26 uses a six-point scale based on how often the individual engages in specific behaviours. The questions may be answered:

  • Always.
  • Usually.
  • Often.
  • Sometimes.
  • Rarely.
  • Never.

Completing the EAT-26 yields a “referral index” based on three criteria:

  1. The total score based on the answers to the EAT-26 questions;
  2. Answers to the behavioural questions related to eating symptoms and weight loss; and
  3. The individual’s body mass index (BMI) calculated from their height and weight.

Generally, a referral is recommended if a respondent scores “positively” or meets the “cut off” scores or threshold on one or more criteria.

Permission to use the EAT-40 or EAT-26 can be obtained from David Garner through the EAT-26 website. Instructions, scoring, and interpretive information can be obtained from the EAT-26 website at no charge. Completion of the EAT-26 with anonymous feedback on the EAT-26 website is possible.

Brief History

The EAT was developed in response to a National Institute of Mental Health consensus panel that recognized a need for screening large populations to increase early identification of anorexia related symptoms. Additionally, the NIMH wanted a measure that could be used to examine the social and cultural factors involved in the development and maintenance of eating disorders. The original version of the EAT was published in 1979, with 40 items each rated on a 6-point Likert scale. In 1982, Garner and colleagues modified the original version to create an abbreviated 26-item test. The items were reduced after a factor analysis on the original 40-item data set revealed 26 independent items. Since then, the EAT has been translated into many different languages and has gained widespread international as a tool to screen for eating disorders. Both the original paper and the subsequent 1982 publication are 3rd and 4th on the list of the 10 most cited articles in the history of the journal Psychological Medicine, a prominent peer-reviewed journal in the fields of psychology and psychiatry.

The EAT-26 is recommended as the first step in a two-stage screening process. Accordingly, individuals who score higher than a 20 should be referred to a qualified professional to determine if they meet the diagnostic criteria for an eating disorder. The EAT-26 is not designed to make a diagnosis of an eating disorder and should not be used in place of a professional diagnosis or consultation. The EAT should only be used as a screener for general eating disorders, as research has not shown it to be a valid instrument in making specific diagnoses.

Limitations

The EAT suffers from the same problems as other self-report inventories, in that scores can be easily exaggerated or minimised by the person completing them. Like all questionnaires, the way the instrument is administered can have an effect on the final score. If a patient is asked to fill out the form in front of other people in a clinical environment, for instance, social expectations have been shown to elicit a different response compared to administration via a postal survey.

As the EAT was originally developed to screen subjects at high risk for anorexia nervosa (AN), it remains controversial whether its present items and scoring cut-off are well-suited to diagnosing other eating disorders. Although the EAT can adequately diagnose undifferentiated eating disorders in clinical settings, it may not fare well in settings unequipped to address major eating disorders.

While the EAT-26 has demonstrated good internal consistency, its test-retest reliability remains uncertain. The stability of an EAT-26 score has been demonstrated to be moderate over two years, but vulnerable to fluctuations over four years. This may be due to changes in an individual’s eating behaviours and attitudes over time naturally or in response to receiving eating disorder treatment.

Another area of debate is the cut-off score of 20 first proposed by David Garner and colleagues to diagnose anorexia nervosa. High false-positive rates and low predictive power for screening for AN and bulimia nervosa (BN) in non-clinical settings have been reported. Use of the EAT-26 as a screening tool could also result in high false-negative rates in individuals with binge eating disorder (BED) or eating disorders not otherwise specified (EDNOS). Such rates may be due to changes over time in the DSM and ICD criteria for eating disorders from which the items in the EAT are based. Another explanation may be the EAT’s inability to distinguish subthreshold forms of abnormal eating behaviour from clinical eating disorders. Lowering the cut-off score to 11 has been demonstrated to improve sensibility and sensitivity rates in individuals with BN, BED, and EDNOS and presents a promising solution to the aforementioned issue.

What is the SCOFF Questionnaire?

Introduction

The SCOFF questionnaire utilises an acronym in a simple five question test devised for use by non-professionals to assess the possible presence of an eating disorder.

Scoff is also an alternative/slang word for food.

Background

It was devised by John F. Morgan, Fiona Reid, and J Hubert Lacey in 1999.

The original SCOFF questionnaire was devised for use in the United Kingdom, thus the original acronym needs to be adjusted for users in the United States and Canada.

The letters in the full acronym are taken from key words in the questions:

  • Do you make yourself Sick because you feel uncomfortably full?
  • Do you worry that you have lost Control over how much you eat?
  • Have you recently lost more than One stone (14 lb/6.5 kg) in a 3-month period?
  • Do you believe yourself to be Fat when others say you are too thin?
  • Would you say that Food dominates your life?

Notes

  • The “S” stands for “Sick”:
    • In British English means specifically to “vomit”.
    • In American English and Canadian English it is synonymous with “ill”.
  • The “O” is used in the acronym to denote “one stone”.
    • A “stone” is an Imperial unit of weight which made up of 14 lbs (equivalent to 6.35 kg).

All participants (in Morgan and colleagues research) found the questions and the term “SCOFF” acceptable. Setting the threshold at two or more yes answers to all five questions provided 100% sensitivity for anorexia and bulimia, separately and combined (all patients: 95% confidence interval, 96.9%-100.0%; patients with bulimia: 92.6%-100.0%; and patients with anorexia: 94.7%-100.0%), with a specificity of 87.5% (79.2%-93.4%) for controls.

Scoring

One point is assigned for every “yes”; a score greater than two (≥2) indicates a possible case of anorexia nervosa or bulimia nervosa.

Reference

Morgan, J.F., Reid, F. & Lacy, J.H. (2000) The SCOFF Questionnaire. Western Journal of Medicine. 172(3), pp.164-165.

What is an Eating Disorder?

Introduction

An eating disorder is a mental disorder defined by abnormal eating habits that negatively affect a person’s physical and/or mental health.

Types of eating disorders include binge eating disorder, where people eat a large amount in a short period of time; anorexia nervosa, where people have an intense fear of gaining weight and restrict food or over-exercise to manage this fear; bulimia nervosa, where people eat a lot and then try to rid themselves of the food; pica, where people eat non-food items; rumination syndrome, where people regurgitate food; avoidant/restrictive food intake disorder (ARFID), where people have a reduced or selective food intake due to some psychological reasons (see below); and a group of other specified feeding or eating disorders. Anxiety disorders, depression and substance abuse are common among people with eating disorders. These disorders do not include obesity.

The causes of eating disorders are not clear, although both biological and environmental factors appear to play a role. Eating disorders affect about 12% of dancers. Cultural idealisation of thinness is believed to contribute to some eating disorders. Individuals who have experienced sexual abuse are also more likely to develop eating disorders. Some disorders such as pica and rumination disorder occur more often in people with intellectual disabilities. Only one eating disorder can be diagnosed at a given time.

Treatment can be effective for many eating disorders. Treatment varies by disorder and may involve counselling, dietary advice, reducing excessive exercise and the reduction of efforts to eliminate food. Medications may be used to help with some of the associated symptoms. Hospitalisation may be needed in more serious cases. About 70% of people with anorexia and 50% of people with bulimia recover within five years. Recovery from binge eating disorder is less clear and estimated at 20% to 60%. Both anorexia and bulimia increase the risk of death.

In the developed world, anorexia affects about 0.4% and bulimia affects about 1.3% of young women in a given year. Binge eating disorder affects about 1.6% of women and 0.8% of men in a given year. Among women about 4% have anorexia, 2% have bulimia, and 2% have binge eating disorder at some time in their life. Rates of eating disorders appear to be lower in less developed countries. Anorexia and bulimia occur nearly ten times more often in females than males. Eating disorders typically begin in late childhood or early adulthood. Rates of other eating disorders are not clear.

Classification

ICD and DSM Diagnoses

These eating disorders are specified as mental disorders in standard medical manuals, including the ICD-10 and the DSM-5.

  • Anorexia Nervosa (AN):
    • This is the restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health.
    • It is accompanied by an intense fear of gaining weight or becoming fat, as well as a disturbance in the way one experiences and appraises their body weight or shape.
    • There are two subtypes of AN:
      • The restricting type; and
      • The binge-eating/purging type.
    • The restricting type describes presentations in which weight loss is attained through dieting, fasting, and/or excessive exercise, with an absence of binge/purge behaviours.
    • The binge-eating/purging type describes presentations in which the individual suffering has engaged in recurrent episodes of binge-eating and purging behaviour, such as self-induced vomiting, misuse of laxatives, and diuretics.
    • Severity of AN is determined by BMI, with BMIs below 15 noted as the most extreme cases of the disorder.
    • Pubertal and post-pubertal females with anorexia often experience amenorrhea, or the loss of menstrual periods, due to the extreme weight loss these individuals face.
    • Although amenorrhea was a required criterion for a diagnosis of anorexia in the DSM-IV, it was dropped in the DSM-5 due to its exclusive nature, as male, post-menopause women, or individuals who do not menstruate for other reasons would fail to meet this criterion.
    • Females with bulimia may also experience amenorrhea, although the cause is not clear.
  • Bulimia Nervosa (BN):
    • This is characterised by recurrent binge eating followed by compensatory behaviours such as purging (self-induced vomiting, eating to the point of vomiting, excessive use of laxatives/diuretics, or excessive exercise).
    • Fasting may also be used as a method of purging following a binge.
    • However, unlike anorexia nervosa, body weight is maintained at or above a minimally normal level.
    • Severity of BN is determined by the number of episodes of inappropriate compensatory behaviours per week.
  • Binge Eating Disorder (BED):
    • This is characterised by recurrent episodes of binge eating without use of inappropriate compensatory behaviours that are present in BN and AN binge-eating/purging subtype.
    • Binge eating episodes are associated with eating much more rapidly than normal, eating until feeling uncomfortably full, eating large amounts of food when not feeling physically hungry, eating alone because of feeling embarrassed by how much one is eating, and/or feeling disgusted with oneself, depressed or very guilty after eating.
    • For a BED diagnosis to be given, marked distress regarding binge eating must be present, and the binge eating must occur an average of once a week for 3 months.
    • Severity of BED is determined by the number of binge eating episodes per week.
  • Pica:
    • This is the persistent eating of non-nutritive, non-food substances in a way that is not developmentally appropriate or culturally supported.
    • Although substances consumed vary with age and availability, paper, soap, hair, chalk, paint, and clay are among the most commonly consumed in those with a pica diagnosis.
    • There are multiple causes for the onset of pica, including iron-deficiency anaemia, malnutrition, and pregnancy, and pica often occurs in tandem with other mental health disorders associated with impaired function, such as intellectual disability, autism spectrum disorder, and schizophrenia.
    • In order for a diagnosis of pica to be warranted, behaviours must last for at least one month.
  • Rumination Disorder:
    • This encompasses the repeated regurgitation of food, which may be re-chewed, re-swallowed, or spit out.
    • For this diagnosis to be warranted, behaviours must persist for at least one month, and regurgitation of food cannot be attributed to another medical condition.
    • Additionally, rumination disorder is distinct from AN, BN, BED, and ARFID, and thus cannot occur during the course of one of these illnesses.
  • Avoidant/Restrictive Food Intake Disorder (ARFID):
    • This is a feeding or eating disturbance, such as a lack of interest in eating food, avoidance based on sensory characteristics of food, or concern about aversive consequences of eating, that prevents one from meeting nutritional energy needs.
    • It is frequently associated with weight loss, nutritional deficiency, or failure to meet growth trajectories.
    • Notably, ARFID is distinguishable from AN and BN in that there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced.
    • The disorder is not better explained by lack of available food, cultural practices, a concurrent medical condition, or another mental disorder.
  • Other Specified Feeding or Eating Disorder (OSFED):
    • This is an eating or feeding disorder that does not meet full DSM-5 criteria for AN, BN, or BED.
    • Examples of otherwise-specified eating disorders include individuals with atypical anorexia nervosa, who meet all criteria for AN except being underweight despite substantial weight loss; atypical bulimia nervosa, who meet all criteria for BN except that bulimic behaviours are less frequent or have not been ongoing for long enough; purging disorder; and night eating syndrome.
  • Unspecified Feeding or Eating Disorder (USFED):
    • This describes feeding or eating disturbances that cause marked distress and impairment in important areas of functioning but that do not meet the full criteria for any of the other diagnoses.
    • The specific reason the presentation does not meet criteria for a specified disorder is not given.
    • For example, an USFED diagnosis may be given when there is insufficient information to make a more specific diagnosis, such as in an emergency room setting.

Other

  • Compulsive Overeating:
    • This may include habitual “grazing” of food or episodes of binge eating without feelings of guilt.
  • Diabulimia:
    • This is characterised by the deliberate manipulation of insulin levels by diabetics in an effort to control their weight.
  • Drunkorexia:
    • This is commonly characterised by purposely restricting food intake in order to reserve food calories for alcoholic calories, exercising excessively in order to burn calories from drinking, and over-drinking alcohol in order to purge previously consumed food.
  • Food Maintenance:
    • This is characterised by a set of aberrant eating behaviours of children in foster care.
  • Night Eating Syndrome:
    • This is characterised by nocturnal hyperphagia (consumption of 25% or more of the total daily calories after the evening meal) with nocturnal ingestions, insomnia, loss of morning appetite and depression.
  • Nocturnal Sleep-Related Eating Disorder:
    • This is a parasomnia characterised by eating, habitually out-of-control, while in a state of NREM sleep, with no memory of this the next morning.
  • Gourmand Syndrome:
    • This is a rare condition occurring after damage to the frontal lobe.
    • Individuals develop an obsessive focus on fine foods.
  • Orthorexia Nervosa:
    • This is a term used to describe an obsession with a “pure” diet, in which a person develops an obsession with avoiding unhealthy foods to the point where it interferes with the person’s life.
  • Klüver-Bucy Syndrome:
    • This is caused by bilateral lesions of the medial temporal lobe and includes compulsive eating, hypersexuality, hyperorality, visual agnosia, and docility.
  • Prader-Willi Syndrome:
    • This is a genetic disorder associated with insatiable appetite and morbid obesity.
  • Pregorexia:
    • This is characterised by extreme dieting and over-exercising in order to control pregnancy weight gain. Prenatal undernutrition is associated with low birth weight, coronary heart disease, type 2 diabetes, stroke, hypertension, cardiovascular disease risk, and depression.
  • Muscle Dysmorphia:
    • This is characterised by appearance preoccupation that one’s own body is too small, too skinny, insufficiently muscular, or insufficiently lean.
    • Muscle dysmorphia affects mostly males.
  • Purging Disorder:
    • This is recurrent purging behaviour to influence weight or shape in the absence of binge eating.
    • It is more properly a disorder of elimination rather than eating disorder.

Symptoms and Long-Term Effects

Symptoms and complications vary according to the nature and severity of the eating disorder.

Associated physical symptoms of eating disorders include weakness, fatigue, sensitivity to cold, reduced beard growth in men, reduction in waking erections, reduced libido, weight loss and growth failure. Frequent vomiting, which may cause acid reflux or entry of acidic gastric material into the laryngoesophageal tract, can lead to unexplained hoarseness. As such, individuals who induce vomiting as part of their eating disorder, such as those with anorexia nervosa, binge eating-purging type or those with purging-type bulimia nervosa, are at risk for acid reflux.

Possible Complications

  • Acne.
  • Xerosis.
  • Amenorrhoea.
  • Tooth loss.
  • Cavities.
  • Constipation.
  • Diarrhoea.
  • Water retention and/or oedema.
  • Lanugo.
  • Telogen effluvium.
  • Cardiac arrest.
  • Hypokalaemia.
  • Death/suicide.
  • Osteoporosis.
  • Electrolyte imbalance.
  • Hyponatraemia.
  • Brain atrophy.
  • Pellagra.
  • Scurvy.
  • Kidney failure.

Frequent vomiting, which may cause acid reflux or entry of acidic gastric material into the laryngoesophageal tract, can lead to unexplained hoarseness. As such, individuals who induce vomiting as part of their eating disorder, such as those with anorexia nervosa, binge eating-purging type or those with purging-type bulimia nervosa, are at risk for acid reflux.

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder to affect women. Though often associated with obesity it can occur in normal weight individuals. PCOS has been associated with binge eating and bulimic behaviour.

Other possible manifestations are dry lips, burning tongue, parotid gland swelling, and temporomandibular disorders.

Pro-Ana Subculture

Pro-ana refers to the promotion of behaviours related to the eating disorder anorexia nervosa. Several websites promote eating disorders, and can provide a means for individuals to communicate in order to maintain eating disorders. Members of these websites typically feel that their eating disorder is the only aspect of a chaotic life that they can control. These websites are often interactive and have discussion boards where individuals can share strategies, ideas, and experiences, such as diet and exercise plans that achieve extremely low weights. A study comparing the personal web-blogs that were pro-eating disorder with those focused on recovery found that the pro-eating disorder blogs contained language reflecting lower cognitive processing, used a more closed-minded writing style, contained less emotional expression and fewer social references, and focused more on eating-related contents than did the recovery blogs.

Psychopathology

The psychopathology of eating disorders centres around body image disturbance, such as concerns with weight and shape; self-worth being too dependent on weight and shape; fear of gaining weight even when underweight; denial of how severe the symptoms are and a distortion in the way the body is experienced.

The main psychopathological features of anorexia were outlined in 1982 as problems in body perception, emotion processing and interpersonal relationships. Women with eating disorders have greater body dissatisfaction. This impairment of body perception involves vision, proprioception, and tactile perception. There is an alteration in integration of signals in which body parts are experienced as dissociated from the body as a whole. Bruch theorised that difficult early relationships were related to the cause of anorexia and how primary caregivers can contribute to the onset of the illness.

A prominent feature of bulimia is dissatisfaction with body shape. However, dissatisfaction with body shape is not of diagnostic significance as it is sometimes present in individuals with no eating disorder. This highly labile feature can fluctuate depending on changes in shape and weight, the degree of control over eating and mood. In contrast, a necessary diagnostic feature for anorexia nervosa and bulimia nervosa is having overvalued ideas about shape and weight are relatively stable and closely related to the patients’ low self-esteem.

Causes

Many people with eating disorders also have body dysmorphic disorder, altering the way a person sees oneself. Studies have found that a high proportion of individuals diagnosed with body dysmorphic disorder also had some type of eating disorder, with 15% of individuals having either anorexia nervosa or bulimia nervosa. This link between body dysmorphic disorder and anorexia stems from the fact that both BDD and anorexia nervosa are characterised by a preoccupation with physical appearance and a distortion of body image. There are also many other possibilities such as environmental, social and interpersonal issues that could promote and sustain these illnesses. Also, the media are oftentimes blamed for the rise in the incidence of eating disorders due to the fact that media images of idealised slim physical shape of people such as models and celebrities motivate or even force people to attempt to achieve slimness themselves. The media are accused of distorting reality, in the sense that people portrayed in the media are either naturally thin and thus unrepresentative of normality or unnaturally thin by forcing their bodies to look like the ideal image by putting excessive pressure on themselves to look a certain way. While past findings have described eating disorders as primarily psychological, environmental, and sociocultural, further studies have uncovered evidence that there is a genetic component.

Genetics

Numerous studies show a genetic predisposition toward eating disorders. Twin studies have found a slight instances of genetic variance when considering the different criterion of both anorexia nervosa and bulimia nervosa as endophenotypes contributing to the disorders as a whole. A genetic link has been found on chromosome 1 in multiple family members of an individual with anorexia nervosa. An individual who is a first degree relative of someone who has had or currently has an eating disorder is seven to twelve times more likely to have an eating disorder themselves. Twin studies also show that at least a portion of the vulnerability to develop eating disorders can be inherited, and there is evidence to show that there is a genetic locus that shows susceptibility for developing anorexia nervosa. About 50% of eating disorder cases are attributable to genetics. Other cases are due to external reasons or developmental problems. There are also other neurobiological factors at play tied to emotional reactivity and impulsivity that could lead to binging and purging behaviours.

Epigenetics mechanisms are means by which environmental effects alter gene expression via methods such as DNA methylation; these are independent of and do not alter the underlying DNA sequence. They are heritable, but also may occur throughout the lifespan, and are potentially reversible. Dysregulation of dopaminergic neurotransmission due to epigenetic mechanisms has been implicated in various eating disorders. Other candidate genes for epigenetic studies in eating disorders include leptin, pro-opiomelanocortin (POMC) and brain-derived neurotrophic factor (BDNF).

Psychological

Eating disorders were classified as Axis I disorders in DSM-IV. There are various other psychological issues that may factor into eating disorders, some fulfil the criteria for a separate Axis I diagnosis or a personality disorder which is coded Axis II and thus are considered comorbid to the diagnosed eating disorder. Axis II disorders are subtyped into 3 “clusters”: A, B and C. The causality between personality disorders and eating disorders has yet to be fully established. Some people have a previous disorder which may increase their vulnerability to developing an eating disorder. Some develop them afterwards. The severity and type of eating disorder symptoms have been shown to affect comorbidity. The DSM-IV should not be used by laypersons to diagnose themselves even when used by professionals as there has been considerable controversy over the diagnostic criteria used for various diagnoses, including eating disorders. There has been controversy over various editions of the DSM including the latest edition (then DSM-V).

Comorbid Disorders

Cognitive Attentional Bias

Attentional bias may have an effect on eating disorders. Attentional bias is the preferential attention toward certain types of information in the environment while simultaneously ignoring others. Individuals with eating disorders can be thought to have schemas, knowledge structures, which are dysfunctional as they may bias judgement, thought, behaviour in a manner that is self-destructive or maladaptive. They may have developed a disordered schema which focuses on body size and eating. Thus, this information is given the highest level of importance and overvalued among other cognitive structures. Researchers have found that people who have eating disorders tend to pay more attention to stimuli related to food. For people struggling to recover from an eating disorder or addiction, this tendency to pay attention to certain signals while discounting others can make recovery that much more difficult.

Studies have utilised the Stroop task to assess the probable effect of attentional bias on eating disorders. This may involve separating food and eating words from body shape and weight words. Such studies have found that anorexic subjects were slower to colour name food related words than control subjects. Other studies have noted that individuals with eating disorders have significant attentional biases associated with eating and weight stimuli.

Personality Traits

There are various childhood personality traits associated with the development of eating disorders. During adolescence these traits may become intensified due to a variety of physiological and cultural influences such as the hormonal changes associated with puberty, stress related to the approaching demands of maturity and socio-cultural influences and perceived expectations, especially in areas that concern body image. Eating disorders have been associated with a fragile sense of self and with disordered mentalisation. Many personality traits have a genetic component and are highly heritable. Maladaptive levels of certain traits may be acquired as a result of anoxic or traumatic brain injury, neurodegenerative diseases such as Parkinson’s disease, neurotoxicity such as lead exposure, bacterial infection such as Lyme disease or parasitic infection such as Toxoplasma gondii as well as hormonal influences. While studies are still continuing via the use of various imaging techniques such as fMRI; these traits have been shown to originate in various regions of the brain such as the amygdala and the prefrontal cortex. Disorders in the prefrontal cortex and the executive functioning system have been shown to affect eating behaviour.

Celiac Disease

People with gastrointestinal disorders may be more risk of developing disordered eating practices than the general population, principally restrictive eating disturbances. An association of anorexia nervosa with celiac disease has been found. The role that gastrointestinal symptoms play in the development of eating disorders seems rather complex. Some authors report that unresolved symptoms prior to gastrointestinal disease diagnosis may create a food aversion in these persons, causing alterations to their eating patterns. Other authors report that greater symptoms throughout their diagnosis led to greater risk. It has been documented that some people with celiac disease, irritable bowel syndrome or inflammatory bowel disease who are not conscious about the importance of strictly following their diet, choose to consume their trigger foods to promote weight loss. On the other hand, individuals with good dietary management may develop anxiety, food aversion and eating disorders because of concerns around cross contamination of their foods. Some authors suggest that medical professionals should evaluate the presence of an unrecognised celiac disease in all people with eating disorder, especially if they present any gastrointestinal symptom (such as decreased appetite, abdominal pain, bloating, distension, vomiting, diarrhoea or constipation), weight loss, or growth failure; and also routinely ask celiac patients about weight or body shape concerns, dieting or vomiting for weight control, to evaluate the possible presence of eating disorders, specially in women.

Environmental Influences

Child Maltreatment

Child abuse which encompasses physical, psychological and sexual abuse, as well as neglect has been shown to approximately triple the risk of an eating disorder. Sexual abuse appears to about double the risk of bulimia; however, the association is less clear for anorexia.

Social Isolation

Social isolation has been shown to have a deleterious effect on an individual’s physical and emotional well-being. Those that are socially isolated have a higher mortality rate in general as compared to individuals that have established social relationships. This effect on mortality is markedly increased in those with pre-existing medical or psychiatric conditions, and has been especially noted in cases of coronary heart disease. “The magnitude of risk associated with social isolation is comparable with that of cigarette smoking and other major biomedical and psychosocial risk factors.”

Social isolation can be inherently stressful, depressing and anxiety-provoking. In an attempt to ameliorate these distressful feelings an individual may engage in emotional eating in which food serves as a source of comfort. The loneliness of social isolation and the inherent stressors thus associated have been implicated as triggering factors in binge eating as well.

Waller, Kennerley and Ohanian (2007) argued that both bingeing-vomiting and restriction are emotion suppression strategies, but they are just utilised at different times. For example, restriction is used to pre-empt any emotion activation, while bingeing-vomiting is used after an emotion has been activated.

Parental Influence

Parental influence has been shown to be an intrinsic component in the development of eating behaviours of children. This influence is manifested and shaped by a variety of diverse factors such as familial genetic predisposition, dietary choices as dictated by cultural or ethnic preferences, the parents’ own body shape and eating patterns, the degree of involvement and expectations of their children’s eating behaviour as well as the interpersonal relationship of parent and child. This is in addition to the general psychosocial climate of the home and the presence or absence of a nurturing stable environment. It has been shown that maladaptive parental behaviour has an important role in the development of eating disorders. As to the more subtle aspects of parental influence, it has been shown that eating patterns are established in early childhood and that children should be allowed to decide when their appetite is satisfied as early as the age of two. A direct link has been shown between obesity and parental pressure to eat more.

Coercive tactics in regard to diet have not been proven to be efficacious in controlling a child’s eating behaviour. Affection and attention have been shown to affect the degree of a child’s finickiness and their acceptance of a more varied diet. finickity

Adams and Crane (1980), have shown that parents are influenced by stereotypes that influence their perception of their child’s body. The conveyance of these negative stereotypes also affects the child’s own body image and satisfaction. Hilde Bruch, a pioneer in the field of studying eating disorders, asserts that anorexia nervosa often occurs in girls who are high achievers, obedient, and always trying to please their parents. Their parents have a tendency to be over-controlling and fail to encourage the expression of emotions, inhibiting daughters from accepting their own feelings and desires. Adolescent females in these overbearing families lack the ability to be independent from their families, yet realize the need to, often resulting in rebellion. Controlling their food intake may make them feel better, as it provides them with a sense of control.

Peer Pressure

In various studies such as one conducted by The McKnight Investigators, peer pressure was shown to be a significant contributor to body image concerns and attitudes toward eating among subjects in their teens and early twenties.

Eleanor Mackey and co-author, Annette M. La Greca of the University of Miami, studied 236 teen girls from public high schools in southeast Florida. “Teen girls’ concerns about their own weight, about how they appear to others and their perceptions that their peers want them to be thin are significantly related to weight-control behavior”, says psychologist Eleanor Mackey of the Children’s National Medical Centre in Washington and lead author of the study. “Those are really important.”

According to one study, 40% of 9- and 10-year-old girls are already trying to lose weight. Such dieting is reported to be influenced by peer behaviour, with many of those individuals on a diet reporting that their friends also were dieting. The number of friends dieting and the number of friends who pressured them to diet also played a significant role in their own choices.

Elite athletes have a significantly higher rate in eating disorders. Female athletes in sports such as gymnastics, ballet, diving, etc. are found to be at the highest risk among all athletes. Women are more likely than men to acquire an eating disorder between the ages of 13-25. 0-15% of those with bulimia and anorexia are men.

Other psychological problems that could possibly create an eating disorder such as Anorexia Nervosa are depression, and low self-esteem. Depression is a state of mind where emotions are unstable causing a person’s eating habits to change due to sadness and no interest of doing anything. According to PSYCOM “Studies show that a high percentage of people with an eating disorder will experience depression.” Depression is a state of mind where people seem to refuge without being able to get out of it. A big factor of this can affect people with their eating and this can mostly affect teenagers. Teenagers are big candidates for Anorexia for the reason that during the teenage years, many things start changing and they start to think certain ways. According to Life Works an article about eating disorders “People of any age can be affected by pressure from their peers, the media and even their families but it is worse when you’re a teenager at school.” Teenagers can develop eating disorder such as Anorexia due to peer pressure which can lead to Depression. Many teens start off this journey by feeling pressure for wanting to look a certain way of feeling pressure for being different. This brings them to finding the result in eating less and soon leading to Anorexia which can bring big harms to the physical state.

Cultural Pressure

Western Perspective

There is a cultural emphasis on thinness which is especially pervasive in western society. A child’s perception of external pressure to achieve the ideal body that is represented by the media predicts the child’s body image dissatisfaction, body dysmorphic disorder and an eating disorder. “The cultural pressure on men and women to be ‘perfect’ is an important predisposing factor for the development of eating disorders”. Further, when women of all races base their evaluation of their self upon what is considered the culturally ideal body, the incidence of eating disorders increases.

Socioeconomic status (SES) has been viewed as a risk factor for eating disorders, presuming that possessing more resources allows for an individual to actively choose to diet and reduce body weight. Some studies have also shown a relationship between increasing body dissatisfaction with increasing SES. However, once high socioeconomic status has been achieved, this relationship weakens and, in some cases, no longer exists.

The media plays a major role in the way in which people view themselves. Countless magazine ads and commercials depict thin celebrities like Lindsay Lohan, Nicole Richie, Victoria Beckham and Mary Kate Olsen, who appear to gain nothing but attention from their looks. Society has taught people that being accepted by others is necessary at all costs. Unfortunately this has led to the belief that in order to fit in one must look a certain way. Televised beauty competitions such as the Miss America Competition contribute to the idea of what it means to be beautiful because competitors are evaluated on the basis of their opinion.

In addition to socioeconomic status being considered a cultural risk factor so is the world of sports. Athletes and eating disorders tend to go hand in hand, especially the sports where weight is a competitive factor. Gymnastics, horse back riding, wrestling, body building, and dancing are just a few that fall into this category of weight dependent sports. Eating disorders among individuals that participate in competitive activities, especially women, often lead to having physical and biological changes related to their weight that often mimic prepubescent stages. Oftentimes as women’s bodies change they lose their competitive edge which leads them to taking extreme measures to maintain their younger body shape. Men often struggle with binge eating followed by excessive exercise while focusing on building muscle rather than losing fat, but this goal of gaining muscle is just as much an eating disorder as obsessing over thinness. The following statistics taken from Susan Nolen-Hoeksema’s book, (ab)normal psychology, show the estimated percentage of athletes that struggle with eating disorders based on the category of sport.

  • Aesthetic sports (dance, figure skating, gymnastics): 35%.
  • Weight dependent sports (judo, wrestling): 29%.
  • Endurance sports (cycling, swimming, running): 20%.
  • Technical sports (golf, high jumping): 14%.
  • Ball game sports (volleyball, soccer): 12%.

Although most of these athletes develop eating disorders to keep their competitive edge, others use exercise as a way to maintain their weight and figure. This is just as serious as regulating food intake for competition. Even though there is mixed evidence showing at what point athletes are challenged with eating disorders, studies show that regardless of competition level all athletes are at higher risk for developing eating disorders that non-athletes, especially those that participate in sports where thinness is a factor.

Pressure from society is also seen within the homosexual community. Gay men are at greater risk of eating disorder symptoms than heterosexual men. Within the gay culture, muscularity gives the advantages of both social and sexual desirability and also power. These pressures and ideas that another homosexual male may desire a mate who is thinner or muscular can possibly lead to eating disorders. The higher eating disorder symptom score reported, the more concern about how others perceive them and the more frequent and excessive exercise sessions occur. High levels of body dissatisfaction are also linked to external motivation to working out and old age; however, having a thin and muscular body occurs within younger homosexual males than older.

Most of the cross-cultural studies use definitions from the DSM-IV-TR, which has been criticised as reflecting a Western cultural bias. Thus, assessments and questionnaires may not be constructed to detect some of the cultural differences associated with different disorders. Also, when looking at individuals in areas potentially influenced by Western culture, few studies have attempted to measure how much an individual has adopted the mainstream culture or retained the traditional cultural values of the area. Lastly, the majority of the cross-cultural studies on eating disorders and body image disturbances occurred in Western nations and not in the countries or regions being examined.

While there are many influences to how an individual processes their body image, the media does play a major role. Along with the media, parental influence, peer influence, and self-efficacy beliefs also play a large role in an individual’s view of themselves. The way the media presents images can have a lasting effect on an individual’s perception of their body image. Eating disorders are a worldwide issue and while women are more likely to be affected by an eating disorder it still affects both genders (Schwitzer 2012). The media influences eating disorders whether shown in a positive or negative light, it then has a responsibility to use caution when promoting images that projects an ideal that many turn to eating disorders to attain.

To try to address unhealthy body image in the fashion world, in 2015, France passed a law requiring models to be declared healthy by a doctor to participate in fashion shows. It also requires re-touched images to be marked as such in magazines.

There is a relationship between “thin ideal” social media content and body dissatisfaction and eating disorders among young adult women, especially in the Western hemisphere. New research points to an “internalisation” of distorted images online, as well as negative comparisons among young adult women. Most studies have been based in the US, the UK and Australia, these are places where the thin ideal is strong among women, as well as the strive for the “perfect” body.

In addition to mere media exposure, there is an online “pro-eating disorder” community. Through personal blogs and Twitter, this community promotes eating disorders as a “lifestyle”, and continuously posts pictures of emaciated bodies, and tips on how to stay thin. The hashtag “#proana” (pro-anorexia), is a product of this community, as well as images promoting weight loss, tagged with the term “thinspiration”. According to social comparison theory, young women have a tendency to compare their appearance to others, which can result in a negative view of their own bodies and altering of eating behaviours, that in turn can develop disordered eating behaviours.

When body parts are isolated and displayed in the media as objects to be looked at, it is called objectification, and women are affected most by this phenomenon. Objectification increases self-objectification, where women judge their own body parts as a mean of praise and pleasure for others. There is a significant link between self-objectification, body dissatisfaction, and disordered eating, as the beauty ideal is altered through social media.

Although eating disorders are typically under diagnosed in people of colour, they still experience eating disorders in great numbers. It is thought that the stress that those of colour face in the US from being multiply marginalised may contribute to their rates of eating disorders. Eating disorders, for these women, may be a response to environmental stressors such as racism, abuse and poverty.

African Perspective

In the majority of many African communities, thinness is generally not seen as an ideal body type and most pressure to attain a slim figure may stem from influence or exposure to Western culture and ideology. Traditional African cultural ideals are reflected in the practice of some health professionals; in Ghana, pharmacists sell appetite stimulants to women who desire to, as Ghanaians stated, “grow fat”. Girls are told that if they wish to find a partner and birth children they must gain weight. On the contrary, there are certain taboos surrounding a slim body image, specifically in West Africa. Lack of body fat is linked to poverty and HIV/AIDS.

However, the emergence of Western and European influence, specifically with the introduction of such fashion and modelling shows and competitions, is changing certain views among body acceptance, and the prevalence of eating disorders has consequently increased. This acculturation is also related to how South Africa is concurrently undergoing rapid, intense urbanisation. Such modern development is leading to cultural changes, and professionals cite rates of eating disorders in this region will increase with urbanisation, specifically with changes in identity, body image, and cultural issues. Further, exposure to Western values through private Caucasian schools or caretakers is another possible factor related to acculturation which may be associated with the onset of eating disorders.

Other factors which are cited to be related to the increasing prevalence of eating disorders in African communities can be related to sexual conflicts, such as psychosexual guilt, first sexual intercourse, and pregnancy. Traumatic events which are related to both family (i.e. parental separation) and eating related issues are also cited as possible effectors. Religious fasting, particularly around times of stress, and feelings of self-control are also cited as determinants in the onset of eating disorders.

Asian Perspective

The West plays a role in Asia’s economic development via foreign investments, advanced technologies joining financial markets, and the arrival of American and European companies in Asia, especially through outsourcing manufacturing operations. This exposure to Western culture, especially the media, imparts Western body ideals to Asian society, termed Westernisation. In part, Westernisation fosters eating disorders among Asian populations. However, there are also country-specific influences on the occurrence of eating disorders in Asia.

China

In China as well as other Asian countries, Westernization, migration from rural to urban areas, after-effects of sociocultural events, and disruptions of social and emotional support are implicated in the emergence of eating disorders. In particular, risk factors for eating disorders include higher socioeconomic status, preference for a thin body ideal, history of child abuse, high anxiety levels, hostile parental relationships, jealousy towards media idols, and above-average scores on the body dissatisfaction and interoceptive awareness sections of the Eating Disorder Inventory. Similarly to the West, researchers have identified the media as a primary source of pressures relating to physical appearance, which may even predict body change behaviours in males and females.

Fiji

While colonised by the British in 1874, Fiji kept a large degree of linguistic and cultural diversity which characterised the ethnic Fijian population. Though gaining independence in 1970, Fiji has rejected Western, capitalist values which challenged its mutual trusts, bonds, kinships and identity as a nation. Similar to studies conducted on Polynesian groups, ethnic Fijian traditional aesthetic ideals reflected a preference for a robust body shape; thus, the prevailing ‘pressure to be slim,’ thought to be associated with diet and disordered eating in many Western societies was absent in traditional Fiji. Additionally, traditional Fijian values would encourage a robust appetite and a widespread vigilance for and social response to weight loss. Individual efforts to reshape the body by dieting or exercise, thus traditionally was discouraged.

However, studies conducted in 1995 and 1998 both demonstrated a link between the introduction of television in the country, and the emergence of eating disorders in young adolescent ethnic Fijian girls. Through the quantitative data collected in these studies there was found to be a significant increase in the prevalence of two key indicators of disordered eating: self-induced vomiting and high Eating Attitudes Test-26. These results were recorded following prolonged television exposure in the community, and an associated increase in the percentage of households owning television sets. Additionally, qualitative data linked changing attitudes about dieting, weight loss and aesthetic ideas in the peer environment to Western media images. The impact of television was especially profound given the longstanding social and cultural traditions that had previously rejected the notions of dieting, purging and body dissatisfaction in Fiji. Additional studies in 2011 found that social network media exposure, independent of direct media and other cultural exposures, was also associated with eating pathology.

Hong Kong

From the early- to-mid-1990s, a variant form of anorexia nervosa was identified in Hong Kong. This variant form did not share features of anorexia in the West, notably “fat-phobia” and distorted body image. Patients attributed their restrictive food intake to somatic complaints, such as epigastric bloating, abdominal or stomach pain, or a lack of hunger or appetite. Compared to Western patients, individuals with this variant anorexia demonstrated bulimic symptoms less frequently and tended to have lower pre-morbid body mass index. This form disapproves the assumption that a “fear of fatness or weight gain” is the defining characteristic of individuals with anorexia nervosa.

India

In the past, the available evidence did not suggest that unhealthy weight loss methods and eating disordered behaviours are common in India as proven by stagnant rates of clinically diagnosed eating disorders. However, it appears that rates of eating disorders in urban areas of India are increasing based on surveys from psychiatrists who were asked whether they perceived eating disorders to be a “serious clinical issue” in India. 23.5% of respondents believed that rates of eating disorders were rising in Bangalore, 26.5% claimed that rates were stagnant, and 42%, the largest percentage, expressed uncertainty. It has been suggested that urbanisation and socioeconomic status are associated with increased risk for body weight dissatisfaction. However, due to the physical size of and diversity within India, trends may vary throughout the country.

Mechanisms

  • Biochemical:
    • Eating behaviour is a complex process controlled by the neuroendocrine system, of which the Hypothalamus-pituitary-adrenal-axis (HPA axis) is a major component.
    • Dysregulation of the HPA axis has been associated with eating disorders, such as irregularities in the manufacture, amount or transmission of certain neurotransmitters, hormones or neuropeptides and amino acids such as homocysteine, elevated levels of which are found in AN and BN as well as depression.
      • Serotonin: a neurotransmitter involved in depression also has an inhibitory effect on eating behaviour.
      • Norepinephrine is both a neurotransmitter and a hormone; abnormalities in either capacity may affect eating behaviour.
      • Dopamine: which in addition to being a precursor of norepinephrine and epinephrine is also a neurotransmitter which regulates the rewarding property of food.
      • Neuropeptide Y also known as NPY is a hormone that encourages eating and decreases metabolic rate.
        • Blood levels of NPY are elevated in patients with anorexia nervosa, and studies have shown that injection of this hormone into the brain of rats with restricted food intake increases their time spent running on a wheel.
        • Normally the hormone stimulates eating in healthy patients, but under conditions of starvation it increases their activity rate, probably to increase the chance of finding food.
        • The increased levels of NPY in the blood of patients with eating disorders can in some ways explain the instances of extreme over-exercising found in most anorexia nervosa patients.
  • Leptin and ghrelin:
    • Leptin is a hormone produced primarily by the fat cells in the body; it has an inhibitory effect on appetite by inducing a feeling of satiety.
    • Ghrelin is an appetite inducing hormone produced in the stomach and the upper portion of the small intestine.
    • Circulating levels of both hormones are an important factor in weight control.
    • While often associated with obesity, both hormones and their respective effects have been implicated in the pathophysiology of anorexia nervosa and bulimia nervosa.
    • Leptin can also be used to distinguish between constitutional thinness found in a healthy person with a low BMI and an individual with anorexia nervosa.
  • Gut bacteria and immune system:
    • Studies have shown that a majority of patients with anorexia and bulimia nervosa have elevated levels of autoantibodies that affect hormones and neuropeptides that regulate appetite control and the stress response.
    • There may be a direct correlation between autoantibody levels and associated psychological traits.
    • Later study revealed that autoantibodies reactive with alpha-MSH are, in fact, generated against ClpB, a protein produced by certain gut bacteria e.g. Escherichia coli. ClpB protein was identified as a conformational antigen-mimetic of alpha-MSH.
    • In patients with eating disorders plasma levels of anti-ClpB IgG and IgM correalated with patients’ psychological traits
  • Infection:
    • PANDAS, is an abbreviation for Paediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections.
    • Children with PANDAS “have obsessive-compulsive disorder (OCD) and/or tic disorders such as Tourette syndrome, and in whom symptoms worsen following infections such as “strep throat” and scarlet fever”.
    • There is a possibility that PANDAS may be a precipitating factor in the development of anorexia nervosa in some cases, (PANDAS AN).
  • Lesions:
    • Studies have shown that lesions to the right frontal lobe or temporal lobe can cause the pathological symptoms of an eating disorder.
  • Tumours:
    • Tumours in various regions of the brain have been implicated in the development of abnormal eating patterns.
  • Brain calcification:
    • A study highlights a case in which prior calcification of the right thalumus may have contributed to development of anorexia nervosa.
  • Somatosensory homunculus:
    • This is the representation of the body located in the somatosensory cortex, first described by renowned neurosurgeon Wilder Penfield.
    • The illustration was originally termed “Penfield’s Homunculus”, homunculus meaning little man.
    • “In normal development this representation should adapt as the body goes through its pubertal growth spurt.
    • However, in AN it is hypothesized that there is a lack of plasticity in this area, which may result in impairments of sensory processing and distortion of body image”. (Bryan Lask, also proposed by VS Ramachandran).
  • Obstetric complications:
    • There have been studies done which show maternal smoking, obstetric and perinatal complications such as maternal anaemia, very pre-term birth (less than 32 weeks), being born small for gestational age, neonatal cardiac problems, preeclampsia, placental infarction and sustaining a cephalhaematoma at birth increase the risk factor for developing either anorexia nervosa or bulimia nervosa.
    • Some of this developmental risk as in the case of placental infarction, maternal anaemia and cardiac problems may cause intrauterine hypoxia, umbilical cord occlusion or cord prolapse may cause ischemia, resulting in cerebral injury, the prefrontal cortex in the foetus and neonate is highly susceptible to damage as a result of oxygen deprivation which has been shown to contribute to executive dysfunction, ADHD, and may affect personality traits associated with both eating disorders and comorbid disorders such as impulsivity, mental rigidity and obsessionality.
    • The problem of perinatal brain injury, in terms of the costs to society and to the affected individuals and their families, is extraordinary.
  • Symptom of starvation:
    • Evidence suggests that the symptoms of eating disorders are actually symptoms of the starvation itself, not of a mental disorder.
    • In a study involving thirty-six healthy young men that were subjected to semi-starvation, the men soon began displaying symptoms commonly found in patients with eating disorders.
    • In this study, the healthy men ate approximately half of what they had become accustomed to eating and soon began developing symptoms and thought patterns (preoccupation with food and eating, ritualistic eating, impaired cognitive ability, other physiological changes such as decreased body temperature) that are characteristic symptoms of anorexia nervosa.
    • The men used in the study also developed hoarding and obsessive collecting behaviours, even though they had no use for the items, which revealed a possible connection between eating disorders and obsessive compulsive disorder.

Diagnosis

The initial diagnosis should be made by a competent medical professional. “The medical history is the most powerful tool for diagnosing eating disorders”. There are many medical disorders that mimic eating disorders and comorbid psychiatric disorders. Early detection and intervention can assure a better recovery and can improve a lot the quality of life of these patients. All organic causes should be ruled out prior to a diagnosis of an eating disorder or any other psychiatric disorder. In the past 30 years eating disorders have become increasingly conspicuous and it is uncertain whether the changes in presentation reflect a true increase. Anorexia nervosa and bulimia nervosa are the most clearly defined subgroups of a wider range of eating disorders. Many patients present with subthreshold expressions of the two main diagnoses: others with different patterns and symptoms.

It is essential to develop specific scales for people under 18 years of age, given the increasing incidence of ED among children and the need for early detection and appropriate intervention. Early detection of ED in children implies a simple and accurate evaluation at the primary care level or in schools, as the course of the disease can be sub clinical for several years. Moreover, the need for accurate scales and tele-medicine testing and diagnosis is of high importance during the COVID-19 pandemic as youth are at particular risk being psychologically affected due to disrupted education and social interactions – at a critical time.

As eating disorders, especially anorexia nervosa, are thought of as being associated with young, white females, diagnosis of eating disorders in other races happens more rarely. In one study, when clinicians were presented with identical case studies demonstrating disordered eating symptoms in Black, Hispanic, and white women, 44% noted the white woman’s behaviour as problematic; 41% identified the Hispanic woman’s behaviour as problematic, and only 17% of the clinicians noted the Black woman’s behaviour as problematic.

Medical

The diagnostic workup typically includes complete medical and psychosocial history and follows a rational and formulaic approach to the diagnosis. Neuroimaging using fMRI, MRI, PET and SPECT scans have been used to detect cases in which a lesion, tumour or other organic condition has been either the sole causative or contributory factor in an eating disorder. “Right frontal intracerebral lesions with their close relationship to the limbic system could be causative for eating disorders, we therefore recommend performing a cranial MRI in all patients with suspected eating disorders”, “intracranial pathology should also be considered however certain is the diagnosis of early-onset anorexia nervosa. Second, neuroimaging plays an important part in diagnosing early-onset anorexia nervosa, both from a clinical and a research prospective”.

Psychological

After ruling out organic causes and the initial diagnosis of an eating disorder being made by a medical professional, a trained mental health professional aids in the assessment and treatment of the underlying psychological components of the eating disorder and any comorbid psychological conditions. The clinician conducts a clinical interview and may employ various psychometric tests. Some are general in nature while others were devised specifically for use in the assessment of eating disorders. Some of the general tests that may be used are the Hamilton Depression Rating Scale and the Beck Depression Inventory. longitudinal research showed that there is an increase in chance that a young adult female would develop bulimia due to their current psychological pressure and as the person ages and matures, their emotional problems change or are resolved and then the symptoms decline.

Several types of scales are currently used:

  • Self-report questionnaires – EDI-3, BSQ, TFEQ, MAC, BULIT-R, QEWP-R, EDE-Q, EAT, NEQ – and other;
  • Semi-structured interviews – SCID-I, EDE – and other; and
  • Clinical interviews unstructured or observer-based rating scales – Morgan Russel scale.

The majority of the scales used were described and used in adult populations. From all the scales evaluated and analysed, only three are described at the child population – it is EAT-26 (children above 16 years), EDI-3 (children above 13 years), and ANSOCQ (children above 13 years). It is essential to develop specific scales for people under 18 years of age, given the increasing incidence of ED among children and the need for early detection and appropriate intervention. Moreover, the urgent need for accurate scales and telemedicine testing and diagnosis tools are of high importance during the COVID-19 pandemic.

Eating Disorder Specific Psychometric Tests

  • Eating Attitudes Test.
  • Body Attitudes Test.
  • Eating Disorder Inventory.
  • SCOFF Questionnaire.
  • Body Attitudes Questionnaire.
  • Eating Disorder Examination Interview.

Differential Diagnosis

There are multiple medical conditions which may be misdiagnosed as a primary psychiatric disorder, complicating or delaying treatment. These may have a synergistic effect on conditions which mimic an eating disorder or on a properly diagnosed eating disorder.

  • Lyme disease is known as the “great imitator”, as it may present as a variety of psychiatric or neurological disorders including anorexia nervosa.
  • Gastrointestinal diseases, such as celiac disease, Crohn’s disease, peptic ulcer, eosinophilic esophagitis or non-celiac gluten sensitivity, among others.
    • Celiac disease is also known as the “great imitator”, because it may involve several organs and cause an extensive variety of non-gastrointestinal symptoms, such as psychiatric and neurological disorders, including anorexia nervosa.
  • Addison’s disease is a disorder of the adrenal cortex which results in decreased hormonal production. Addison’s disease, even in subclinical form may mimic many of the symptoms of anorexia nervosa.
  • Gastric adenocarcinoma is one of the most common forms of cancer in the world.
    • Complications due to this condition have been misdiagnosed as an eating disorder.
  • Hypothyroidism, hyperthyroidism, hypoparathyroidism and hyperparathyroidism may mimic some of the symptoms of, can occur concurrently with, be masked by or exacerbate an eating disorder.
  • Toxoplasma seropositivity: even in the absence of symptomatic toxoplasmosis, toxoplasma gondii exposure has been linked to changes in human behaviour and psychiatric disorders including those comorbid with eating disorders such as depression.
    • In reported case studies the response to antidepressant treatment improved only after adequate treatment for toxoplasma.
  • Neurosyphilis: It is estimated that there may be up to one million cases of untreated syphilis in the US alone.
    • “The disease can present with psychiatric symptoms alone, psychiatric symptoms that can mimic any other psychiatric illness”.
    • Many of the manifestations may appear atypical.
    • Up to 1.3% of short term psychiatric admissions may be attributable to neurosyphilis, with a much higher rate in the general psychiatric population.
  • Dysautonomia: a wide variety of autonomic nervous system (ANS) disorders may cause a wide variety of psychiatric symptoms including anxiety, panic attacks and depression.
    • Dysautonomia usually involves failure of sympathetic or parasympathetic components of the ANS system but may also include excessive ANS activity.
    • Dysautonomia can occur in conditions such as diabetes and alcoholism.

Psychological disorders which may be confused with an eating disorder, or be co-morbid with one:

  • Emetophobia is an anxiety disorder characterised by an intense fear of vomiting.
    • A person so afflicted may develop rigorous standards of food hygiene, such as not touching food with their hands.
    • They may become socially withdrawn to avoid situations which in their perception may make them vomit.
    • Many who have emetophobia are diagnosed with anorexia or self-starvation.
    • In severe cases of emetophobia they may drastically reduce their food intake.
  • Phagophobia is an anxiety disorder characterized by a fear of eating, it is usually initiated by an adverse experience while eating such as choking or vomiting.
    • Persons with this disorder may present with complaints of pain while swallowing.
  • Body dysmorphic disorder (BDD) is listed as a somatoform disorder that affects up to 2% of the population. BDD is characterised by excessive rumination over an actual or perceived physical flaw.
    • BDD has been diagnosed equally among men and women.
    • While BDD has been misdiagnosed as anorexia nervosa, it also occurs comorbidly in 39% of eating disorder cases.
    • BDD is a chronic and debilitating condition which may lead to social isolation, major depression and suicidal ideation and attempts.
    • Neuroimaging studies to measure response to facial recognition have shown activity predominately in the left hemisphere in the left lateral prefrontal cortex, lateral temporal lobe and left parietal lobe showing hemispheric imbalance in information processing.
    • There is a reported case of the development of BDD in a 21-year-old male following an inflammatory brain process.
    • Neuroimaging showed the presence of a new atrophy in the frontotemporal region.

Prevention

Prevention aims to promote a healthy development before the occurrence of eating disorders. It also intends early identification of an eating disorder before it is too late to treat. Children as young as ages 5–7 are aware of the cultural messages regarding body image and dieting.[235] Prevention comes in bringing these issues to the light. The following topics can be discussed with young children (as well as teens and young adults).

  • Emotional Bites:
    • A simple way to discuss emotional eating is to ask children about why they might eat besides being hungry.
    • Talk about more effective ways to cope with emotions, emphasizing the value of sharing feelings with a trusted adult.
  • Say No to Teasing:
    • Another concept is to emphasize that it is wrong to say hurtful things about other people’s body sizes.
  • Body Talk:
    • Emphasize the importance of listening to one’s body.
    • That is, eating when you are hungry (not starving) and stopping when you are satisfied (not stuffed).
    • Children intuitively grasp these concepts.
  • Fitness Comes in All Sizes:
    • Educate children about the genetics of body size and the normal changes occurring in the body.
    • Discuss their fears and hopes about growing bigger.
    • Focus on fitness and a balanced diet.

Internet and modern technologies provide new opportunities for prevention. On-line programmes have the potential to increase the use of prevention programmes. The development and practice of prevention programmes via on-line sources make it possible to reach a wide range of people at minimal cost. Such an approach can also make prevention programmes to be sustainable.

Treatment

Treatment varies according to type and severity of eating disorder, and usually more than one treatment option is utilized.[241] Family doctors play an important role in early treatment of people with eating disorders by encouraging those who are also reluctant to see a psychiatrist.[242] Treatment can take place in a variety of different settings such as community programs, hospitals, day programs, and groups.[243] The American Psychiatric Association (APA) recommends a team approach to treatment of eating disorders. The members of the team are usually a psychiatrist, therapist, and registered dietitian, but other clinicians may be included.

That said, some treatment methods are:

  • Cognitive behavioural therapy (CBT), which postulates that an individual’s feelings and behaviours are caused by their own thoughts instead of external stimuli such as other people, situations or events; the idea is to change how a person thinks and reacts to a situation even if the situation itself does not change.
    • Acceptance and commitment therapy: a type of CBT.
    • Cognitive remediation therapy (CRT), a set of cognitive drills or compensatory interventions designed to enhance cognitive functioning.
  • The Maudsley anorexia nervosa treatment for adults (MANTRA), which focuses on addressing rigid information processing styles, emotional avoidance, pro-anorectic beliefs, and difficulties with interpersonal relationships.
    • These four targets of treatment are proposed to be core maintenance factors within the Cognitive-Interpersonal Maintenance Model of anorexia nervosa.
  • Dialectical behaviour therapy.
  • Family therapy including “conjoint family therapy” (CFT), “separated family therapy” (SFT) and Maudsley Family Therapy.
  • Behavioural therapy: focuses on gaining control and changing unwanted behaviours.
  • Interpersonal psychotherapy (IPT).
  • Cognitive Emotional Behaviour Therapy (CEBT)u
  • Art therapyu
  • Nutrition counselling and medical nutrition therapy.
  • Medication:
    • Orlistat is used in obesity treatment.
    • Olanzapine seems to promote weight gain as well as the ability to ameliorate obsessional behaviours concerning weight gain. zinc supplements have been shown to be helpful, and cortisol is also being investigated.
  • Self-help and guided self-help have been shown to be helpful in AN, BN and BED; this includes support groups and self-help groups such as Eating Disorders Anonymous and Overeaters Anonymous.
  • Psychoanalysis.
  • Inpatient care.

Two pharmaceuticals, Prozac and Vyvanse, have been approved by the FDA to treat bulimia nervosa and binge-eating disorder, respectively. Olanzapine has also been used off-label to treat anorexia nervosa. Studies are also underway to explore psychedelic and psychedelic-adjacent medicines such as MDMA, psilocybin and ketamine for anorexia nervosa and binge-eating disorder.

There are few studies on the cost-effectiveness of the various treatments. Treatment can be expensive; due to limitations in health care coverage, people hospitalized with anorexia nervosa may be discharged while still underweight, resulting in relapse and rehospitalisation.

For children with anorexia, the only well-established treatment is the family treatment-behaviour. For other eating disorders in children, however, there is no well-established treatments, though family treatment-behaviour has been used in treating bulimia.

A 2019 Cochrane review examined studies comparing the effectiveness of inpatient versus outpatient models of care for eating disorders. Four trials including 511 participants were studied but the review was unable to draw any definitive conclusions as to the superiority of one model over another.

Outcomes

For anorexia nervosa, bulimia nervosa, and binge eating disorder, there is a general agreement that full recovery rates are in the 50% to 85% range, with larger proportions of people experiencing at least partial remission. It can be a lifelong struggle or it can be overcome within months.

  • Miscarriages:
    • Pregnant women with a binge eating disorder have shown to have a greater chance of having a miscarriage compared to pregnant women with any other eating disorders.
    • According to a study done, out of a group of pregnant women being evaluated, 46.7% of the pregnancies ended with a miscarriage in women that were diagnosed with BED, with 23.0% in the control.
    • In the same study, 21.4% of women diagnosed with Bulimia Nervosa had their pregnancies end with miscarriages and only 17.7% of the controls.
  • Relapse:
    • An individual who is in remission from BN and EDNOS (Eating Disorder Not Otherwise Specified) is at a high risk of falling back into the habit of self-harm.
    • Factors such as high stress regarding their job, pressures from society, as well as other occurrences that inflict stress on a person, can push a person back to what they feel will ease the pain.
    • A study tracked a group of selected people that were either diagnosed with BN or EDNOS for 60 months.
    • After the 60 months were complete, the researchers recorded whether or not the person was having a relapse.
    • The results found that the probability of a person previously diagnosed with EDNOS had a 41% chance of relapsing; a person with BN had a 47% chance.
  • Attachment insecurity:
    • People who are showing signs of attachment anxiety will most likely have trouble communicating their emotional status as well as having trouble seeking effective social support.
    • Signs that a person has adopted this symptom include not showing recognition to their caregiver or when he/she is feeling pain.
    • In a clinical sample, it is clear that at the pre-treatment step of a patient’s recovery, more severe eating disorder symptoms directly corresponds to higher attachment anxiety.
    • The more this symptom increases, the more difficult it is to achieve eating disorder reduction prior to treatment.

Anorexia symptoms include the increasing chance of getting osteoporosis. Thinning of the hair as well as dry hair and skin are also very common. The muscles of the heart will also start to change if no treatment is inflicted on the patient. This causes the heart to have an abnormally slow heart rate along with low blood pressure. Heart failure becomes a major consideration when this begins to occur. Muscles throughout the body begin to lose their strength. This will cause the individual to begin feeling faint, drowsy, and weak. Along with these symptoms, the body will begin to grow a layer of hair called lanugo. The human body does this in response to the lack of heat and insulation due to the low percentage of body fat.

Bulimia symptoms include heart problems like an irregular heartbeat that can lead to heart failure and death may occur. This occurs because of the electrolyte imbalance that is a result of the constant binge and purge process. The probability of a gastric rupture increases. A gastric rupture is when there is a sudden rupture of the stomach lining that can be fatal. The acids that are contained in the vomit can cause a rupture in the oesophagus as well as tooth decay. As a result, to laxative abuse, irregular bowel movements may occur along with constipation. Sores along the lining of the stomach called peptic ulcers begin to appear and the chance of developing pancreatitis increases.

Binge eating symptoms include high blood pressure, which can cause heart disease if it is not treated. Many patients recognize an increase in the levels of cholesterol. The chance of being diagnosed with gallbladder disease increases, which affects an individual’s digestive tract.

Risk of Death

Eating disorders result in about 7,000 deaths a year as of 2010, making them the mental illnesses with the highest mortality rate. Anorexia has a risk of death that is increased about 5 fold with 20% of these deaths as a result of suicide. Rates of death in bulimia and other disorders are similar at about a 2 fold increase.

The mortality rate for those with anorexia is 5.4 per 1000 individuals per year. Roughly 1.3 deaths were due to suicide. A person who is or had been in an inpatient setting had a rate of 4.6 deaths per 1000. Of individuals with bulimia about 2 persons per 1000 persons die per year and among those with EDNOS about 3.3 per 1000 people die per year.

Epidemiology

In the developed world, binge eating disorder affects about 1.6% of women and 0.8% of men in a given year. Anorexia affects about 0.4% and bulimia affects about 1.3% of young women in a given year. Up to 4% of women have anorexia, 2% have bulimia, and 2% have binge eating disorder at some point in time. Anorexia and bulimia occur nearly ten times more often in females than males. Typically, they begin in late childhood or early adulthood. Rates of other eating disorders are not clear. Rates of eating disorders appear to be lower in less developed countries.

In the US, twenty million women and ten million men have an eating disorder at least once in their lifetime.

Anorexia

Rates of anorexia in the general population among women aged 11 to 65 ranges from 0 to 2.2% and around 0.3% among men. The incidence of female cases is low in general medicine or specialised consultation in town, ranging from 4.2 and 8.3/100,000 individuals per year. The incidence of AN ranges from 109 to 270/100,000 individuals per year. Mortality varies according to the population considered. AN has one of the highest mortality rates among mental illnesses. The rates observed are 6.2 to 10.6 times greater than that observed in the general population for follow-up periods ranging from 13 to 10 years. Standardised mortality ratios for anorexia vary from 1.36% to 20%.

Bulimia

Bulimia affects females 9 times more often than males. Approximately one to three percent women develop bulimia in their lifetime. About 2% to 3% of women are currently affected in the US. New cases occur in about 12 per 100,000 population per year. The standardised mortality ratios for bulimia is 1% to 3%.

Binge Eating Disorder

Reported rates vary from 1.3 to 30% among subjects seeking weight-loss treatment. Based on surveys, BED appears to affected about 1-2% at some point in their life, with 0.1-1% of people affected in a given year. BED is more common among females than males. There have been no published studies investigating the effects of BED on mortality, although it is comorbid with disorders that are known to increase mortality risks.

Economics

  • Since 2017, the number of cost-effectiveness studies regarding eating disorders appears to be increasing in the past six years.
  • In 2011 US dollars, annual healthcare costs were $1,869 greater among individuals with eating disorders compared to the general population.
    • The added presence of mental health comorbidities was also associated with higher, but not statistically significant, costs difference of $1,993.
  • In 2013 Canadian dollars, the total hospital cost per admission for treatment of anorexia nervosa was $51,349 and the total societal cost was $54,932 based on an average length of stay of 37.9 days.
    • For every unit increase in body mass index, there was also a 15.7% decrease in hospital cost.
  • For Ontario, Canada patients who received specialised inpatient care for an eating disorder both out of country and in province, annual total healthcare costs were about $11 million before 2007 and $6.5 million in the years afterwards.
    • For those treated out of country alone, costs were about $5 million before 2007 and $2 million in the years afterwards.