Eating Disorders Explained
Spotting the signs, tackling the misconceptions, and finding proper support
Eating disorders— some of the highest risk mental health conditions out there, yet many are suffering in silence. These conditions bring a unique intersection of mental and physical challenges. For many, eating disorders are a chronic uphill battle. Even healthcare providers are intimidated by them. So, how do we recognize and address them? How can we help our loved ones, friends, and patients who struggle with disordered eating?
First, let’s take a look at the statistics. Eating disorders (ED) are estimated to affect ~9% of the US population and ~8% of the global population. Sadly, there are more than 10,000 deaths related to eating disorders in the US— that’s about one death every 52 minutes. It’s very common for ED patients to also suffer from other co-occurring mental health conditions, such as anxiety, depression, OCD, and/or PTSD (Eating Disorder Statistics - National Eating Disorders Association).
Eating disorders (ED) are commonly assumed to be a condition affecting females— while it’s true that the majority of patients are females, we need to bring to light the fact that males also suffer. The overall lifetime prevalence of ED is estimated to be 8.6% in females and 4% in males.
A particularly disturbing statistic pertains to the BMI of ED patients. Patients with a higher body weight are more than 2 times as likely to engage in disordered eating behaviors as those with a “normal” BMI, but they only receive an ED diagnosis half as frequently as those who are normal weight or underweight. Having an ED does not equal low body weight. I repeat, you do not have to be of low weight to meet criteria for an eating disorder. The only official ED diagnosis that specifically includes an underweight BMI is Anorexia Nervosa (AN). However, this is only one of many disorders. In fact, the majority of folks with ED do not have AN and less than 6% of ED patients are clinically underweight. It’s time to end the narrative that ED patients are easily spotted from a mile away. Chances are, someone in your life is fighting an invisible battle. So, what are the various eating disorders and how do they present?
Anorexia Nervosa (AN)
AN typically involves persistent restriction of food intake which leads to low body weight. Patients with AN have intense fear of weight gain and a distorted perception of their body size/image. There are 2 subtypes based on the primary behaviors— restricting type and binge/purge type.
Bulimia Nervosa (BN)
BN involves a vicious cycle of binge eating and purging. Most associate BN with self-induced vomiting, but some patients engage in other forms of purging, i.e., diuretic use, laxative use, and extreme levels of physical activity. Patients with BN engage in these purging behaviors in an effort to prevent weight gain from the bingeing.
Binge Eating Disorder (BED)
BED involves recurrent episodes of binge eating, AKA consuming large amounts of food in one sitting and feeling a lack of control over these behaviors— at least once a week for at least 3 months. Patients with BED experience feelings of guilt and shame following binge episodes. The difference between BED and BN is a lack of purging behaviors to compensate for the binge eating.
Avoidant Restrictive Food Intake Disorder (ARFID)
ARFID involves avoidance or aversion to certain foods, oftentimes due to sensory concerns such as taste, texture, or smell. This avoidance can lead to dangerous consequences, i.e., weight loss and nutritional deficiencies. However, weight loss is not the goal— it’s more so a consequence. People with ARFID can really struggle in social situations, often avoiding plans that involve their trigger foods.
Other Specified Feeding & Eating Disorder (OSFED)
This is an umbrella term for disordered eating patterns that don’t quite meet formal criteria for the other disorders. One example is “atypical anorexia” which is nearly identical to AN but doesn’t require significant weight loss/low BMI. The majority of patients fall under this category.
What are the treatments and where do I start?
Many mental health conditions benefit from a multidisciplinary approach, but this is especially imperative with eating disorders. The primary care provider (PCP) should be the home base, ideally keeping a close eye on physical health, like vital signs and routine bloodwork. ED patients are at increased risk of unsafe weight fluctuations, anemia, and electrolyte imbalances, among other medical concerns.
Another important member of the team is the dietician, or nutritionist. Folks with ED often need specialized support around food choices and working towards appropriate eating habits. Finding a clinician with ED expertise is a gamechanger— these are the good ones who know how to interact compassionately yet effectively with ED patients. They will hold you accountable while also building trust.
To address the emotional and behavioral components, a qualified therapist who specializes in ED is essential. These disorders require more than standard talk therapy where you vent about your feelings once a week. To make actual progress, it’s important to dig into the why behind the disordered eating and how to address it effectively.
Many ED patients will also benefit from psychiatric medication for additional support. This becomes more of a necessity when patients are feeling stuck or struggling to make progress with other treatments. I like to explain medication as a tool in the toolbox— it doesn’t change who we are or solve all our problems but rather decreases symptom severity and helps us practice the strategies we’ve learned in therapy.
Now that we’ve covered the basics of ED treatment, I’ll explain the various levels of care available, from least to most intensive.
Outpatient- the most common place to start, outpatient treatment generally consists of regularly scheduled appointments, i.e., 1 to 2 times a week. Appointments can be held either in an office setting or virtually.
Intensive outpatient program (IOP)- a bit more time consuming but allows you to continue work or school alongside treatment. IOPs usually meet for a few hours at a time, a few days a week. A typical schedule could look like 3-4 evenings a week.
Partial hospitalization program (PHP)- also referred to as day programs, PHPs are typically full day treatment programs, i.e., ~6 hours/day, Monday-Friday. Length of treatment is typically a few weeks. Patients at this level of care need more help than outpatient programs can offer, but they don’t quite need the intensity of staying overnight at a treatment facility.
Residential treatment program- residential programs offer intensive, multidisciplinary treatment in a facility that houses patients for several weeks to months at a time. Patients become “residents” of the facility in order to focus very intentionally on recovery. These programs are voluntary, so patients seek out this kind of treatment knowing that it will involve a lot of hard work and sacrifice. The goal is to reduce symptom severity to the point where patients are ready to step down to a lower level of care, i.e., PHP.
Inpatient hospitalization- the most acute level of treatment, hospitalization is reserved for cases that are high severity— either not responding adequately to lower levels of care or involving significant medical compromise. Hospitalization can be voluntary or involuntary— meaning some patients are admitted to the hospital out of necessity rather than choice. Patients may require hospitalization for issues such as low heart rate and/or blood pressure, heart arrythmia, hypoglycemia, and acute food refusal. I have seen these cases firsthand— some patients reach the point of requiring a feeding tube if they are unable to meet their nutritional needs themselves. Hospitalization can be a stressful experience for patients and families, but medical stabilization is the first priority before being able to participate in other treatments.
Eating disorders are complicated and have many layers to them. People don’t just develop an ED out of the blue— these disorders are frequently, but not always, a product of trauma or adverse life experiences. People engage in disordered eating as a way to gain a sense of control when life feels otherwise out of control. ED’s share many commonalities with other difficult-to-treat mental health disorders, i.e., addiction and OCD— the parts of the brain affecting habit and reward are dysregulated. I often describe the recovery process as a lifelong journey— symptoms can come and go for years to decades, but remission is possible with consistency and proper treatment.
Have you, a loved one, or a patient struggled with an eating disorder? Have questions or feedback for me? Feel free to reach out!
Such a wonderful post and it comes at a time where we are seeing an alarming increase in eating disorder presentation in the neurodivergent population.
Hey Jill, great post. What part do you think our contemporary culture plays? Obviously the body-centric part, but I'm also wondering if a world that feels increasingly out of control, triggers more eating disorders. What do you think?