We typically encounter and are prepared to treat several types of eating disorders. Some you may be familiar with and others the general public may not be familiar with. Below are descriptions of all the major eating disorders and some more colloquial information about how we have seen them present.
Anorexia Nervosa
According to the DSM-5, there are three primary symptoms of Anorexia Nervosa (AN), which are described below:
- 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.
In other words, individuals restrict their food intake, resulting in a lower-than-normal body mass. Often, individuals will irrationally decide how much or how much food they can consume daily. This restriction can result in a gaunt or emaciated appearance, although not always. The restriction will often leave individuals struggling with poor motivation/energy, increased focus on food, and difficulty concentrating.
- Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight.
For individuals with this disorder, the fears of weight gain are intense. Some individuals will go to the extremes of refusing medications because of concerns about caloric content. This can also be accompanied by compulsive behaviors of checking weight anywhere from one to twenty times in a single day. Compulsions can also be seen in what kind of food individuals are willing to eat.
Some individuals will compulsively check the caloric and nutritional content of food, other individuals will rule out entire food groups because they may result in weight gain or the perception of weight gain. Compulsions of extreme exercise can also be observed where individuals may rarely be comfortable sitting down, on the move almost constantly throughout the day, or spend several hours in the gym each day.
- Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of low body weight.
We often call this trait body dysmorphia. Essentially, individuals that struggle with this trait do not have a realistic or objective view of their bodies. They will perceive their body to be bigger than they actually may appear. They may talk about the continued need to lose weight or feeling “fat” despite appearing thin or even gaunt to more objective observers.
Often individuals will judge their entire sense of self-worth on the appearance of their body. They are under the impression that the only way to measure their own worth as a person is through how little they weigh or whether or not they are “skinny.”
Additionally, these individuals often do not recognize or will downplay the medical information they receive about their condition. They can be unfazed about serious heart conditions, menopause in their early 20s, or other concerning lab results that often indicate their life is in danger.
AN can also occur with episodes of binging. Extended restriction can lead to intense cravings for food, resulting in significant amounts of food in a single sitting. However, individuals that struggle with AN can have a skewed idea of how much food is “normal.” These individuals will sometimes report binges when eating an amount deemed appropriate for a single meal or even less.
Bulimia Nervosa
According to the DSM-5, the criteria for Bulimia Nervosa (BN) are as follows:
- Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
- Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances.
- A sense of lack of control over eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating).
Sometimes in our lives, we may engage in what could be qualified as a binge. Holidays, like Thanksgiving, are prime examples of this, however, these are normative cultural events. Individuals who struggle with BN engage in this behavior anywhere from several times per day to once weekly. Typically these events are followed by intense feelings of shame. Individuals that struggle with binging behaviors will often try to hide evidence of their binge or binge in secret.
- Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuses of laxatives, diuretics, or other medications; fasting; or excessive exercise
All of the above are what we call purge behaviors. Purge behaviors can serve many functions for individuals that struggle with eating disorders. Although the intention may be to avoid weight gain, often these behaviors serve as a means of emotion regulation. These binge behaviors can often be followed by a sense of relief or release by those who engage in them.
- The binge eating and inappropriate compensatory behaviors both occur, on average at least once per week
Again, these behaviors do not occur in isolation. Binging and purging are a pattern of behaviors that will typically increase in frequency over time.
- Self-evaluation is unduly influenced by body shape and weight
Much like Anorexia, there is an intense focus on body size and shape with individuals that struggle with BN. Individuals often believe that their worth as human beings is mostly or entirely based on their bodies.
Binge Eating Disorder
According to the DSM-5, Binge Eating Disorder (BED) can be characterized by the following symptoms:
- Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
- Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances.
- A sense of lack of control over eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating).
- The binge-eating episodes are associated with three (or more) of the following:
- 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
- Feeling disgusted with oneself, depressed, or very guilty afterward
Often these binge episodes can feel mysterious to the individual engaging in them. They may not be sure why they have started eating or continue eating. They are also uncomfortable in a variety of ways. Individuals who engage in binges will often feel physically uncomfortable due to the amount of food they have eaten and emotionally uncomfortable due to feelings of shame that follow binge behaviors.
- Marked distress regarding binge eating is present
As stated above, individuals who struggle with binge eating can feel any number of emotions like feelings of shame, fear, anger, sadness, and guilt, to name a few
- The binge eating occurs, on average, at least once a week for 3 months
Much like Anorexia and Bulimia, BED is a pattern of behaviors. It occurs repeatedly and may increase in frequency over time or due to stress.
- The binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa
Avoidant/Restrictive Food Intake Disorder (ARFID)
According to the DSM-5, the following are symptoms of Avoidant/Restrictive Food Intake Disorder, or ARFID:
- An eating of feeding disturbance (e.g. apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following:
- Significant weight loss (or failure to achieve expected weight gain or faltering growth in children)
- Significant nutritional deficiency
- Dependence on enteral feeding or oral nutrition supplements
- Marked interference with psychosocial functioning
ARFID is primarily characterized by avoiding particular foods or food groups for sensory reasons. Some individuals struggle with particular textures of food. Others struggle with taste or taste inconsistency (for example, one carrot may taste different than another, but all potato chips in a bag tend to taste the same). Others still may struggle with the colors of foods or liquids.
Individuals that struggle with ARFID tend to experience a significant impact on their daily nutritional intake. They may not be getting enough nutrients, which can result in significant health concerns. Other individuals may be nutritionally deficient in calorie intake because they are unwilling to eat available foods.
- The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice
Individuals with ARFID will typically have a good variety of foods available. However, because of the sensory sensitivity described above, they will limit their intake to safe or no food. Additionally cultural practices, like eating kosher or halal, would not characterize someone as meeting the criteria for ARFID.
- The disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced
The body dysmorphia inherent in anorexia and bulimia is absent in individuals that struggle with ARFID. Individuals that struggle with anorexia and bulimia may cut out foods or refuse to eat entire food groups, however, the motivation tends to be related to body shape or weight. In fact, there can even be times when individuals with ARFID want to gain weight but struggle with the limited foods they feel comfortable eating.
Rumination Disorder
According to the DSM-5, the following are the criteria for Rumination Disorder:
- Repeated regurgitation of food over a period of at least 1 month. Regurgitated food may be re-chewed, re-swallowed, or spit out
In other words, individuals that struggle with Rumination Disorder will begin the digestive process of chewing their food. There are a number of presentations of Rumination Disorder, including spitting out food after chewing or vomiting within the mouth and then swallowing the food back down.
- The repeated regurgitation is not attributable to an associated gastrointestinal or other medical condition (e.g., gastroesophageal reflux, pyloric stenosis)
- The eating disturbance does not occur exclusively during the course of anorexia nervosa, bulimia nervosa, binge-eating disorder, or avoidant/restrictive food intake disorder
Other Specified Feeding or Eating Disorders (OSFED)
According to the DSM-5, “this category applies to presentation in which symptoms characteristic of a feeding and eating disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the feeding and eating disorders diagnostic class.”
The following are presentations that are identified in the DSM-5 which would qualify under the Other Specified Feeding or Eating Disorder, or OSFED, category:
- Atypical anorexia nervosa: All of the criteria for anorexia nervosa are met, except that despite significant weight loss, the individual’s weight is within or above the normal range
With significant restrictions and attempts to lose weight, this can also be the case. The staff at Virtue Recovery have had experience with individuals restricting diets to 500 or even 300 calories per day and remaining within a normal weight range
- Bulimia Nervosa (of low frequency and/or limited duration): all of the criteria for bulimia nervosa are met, except that the binge eating and inappropriate compensatory behaviors occur, on average, less than once a week and/or for less than 3 months
- Binge-eating disorder (of low frequency and/or limited duration): all of the criteria for binge-eating disorder are met, except that the binge eating occurs, on average, less than once a week and/or for less than 3 months
- Purging disorder: Recurrent purging behavior to influence weight or shape (e.g., self-induced vomiting; misuse of laxatives, diuretics, or other medications) in the absence of binge eating
- Night eating syndrome: Recurrent episodes of night eating, as manifested by eating after awakening from sleep or by excessive food consumption after the evening meal. There is awareness and recall of the eating. The night eating is not better explained by external influences such as changes in the individual’s sleep-wake cycle or by local social norms. The night eating causes significant distress and/or impairment in functioning. The disordered pattern of eating is not better explained by binge-eating disorder or another mental disorder, including substance use, and is not attributable to another medical disorder or to an effect of medication.
It is important to note that although these presentations are technically “sub-clinical,” they can still be dangerous for an individual’s health and cause significant distress in an individual’s life. We still highly encourage anyone identifying with the above descriptions to seek treatment.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
