Types of Eating Disorders
There are currently six eating disorders recognized in the DSM-5: anorexia nervosa, bulimia nervosa, binge-eating disorder, pica, rumination disorder, and avoidant/restrictive food intake disorder. Each has a unique set of symptoms, but treatments are often effective for people struggling with any eating disorder.
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Anorexia occurs when someone does not eat enough to maintain a healthy body weight, due to an intense fear of gaining weight or feeling fat. They might have a distorted perception of their own body and fail to see the seriousness of their low weight.
Anorexia is up to 10 times more common in women than in men. It most often begins in adolescence or young adulthood, but a second peak seems to occur after age 40.
Anorexia emerges due to a combination of genetics, life circumstances such as childhood trauma, and cultural beauty ideals—which can play a role but are never fully responsible. Social comparison, especially in college, can also lay the foundation for a disorder to develop. People with anorexia tend to struggle with obsessive-compulsive tendencies, anxiety, and perfectionism; they may have a strong need for control or display rigid and inflexible thinking.
These traits manifest in how people with anorexia consume food. They may only eat at specific times of day or use specific cutlery. They may obsess over nutrition labels and measurements of their food. They may eat alone or constantly make excuses for not eating. They may restrict their consumption to the degree that they develop stomach problems, electrolyte imbalances, hair loss, brittle bones, dizziness or fainting. People with anorexia can die from the disorder and by suicde. It is the most deadly mental illness.
But through a team approach, recovery is possible. Treatment involves a nutritionist, physician, and psychologist. In an outpatient setting, effective treatments include cognitive behavioral therapy, and a version specifically designed for eating disorders called enhanced cognitive behavioral therapy (CBT-E), and family-based treatment. Recovery requires ongoing work, but continuing to forge ahead can allow individuals to create a happy, fulfilling life.
Bulimia occurs when someone repeatedly binge eats and then takes steps to prevent gaining weight, such as by vomiting, taking laxatives or diuretics, fasting, or exercising. Binges encompass a lack of control and consuming an unusually large amount of food in a discrete time period.
The disorder is diagnosed when that pattern occurs once a week for at least three months. Bulimia often begins in adolescence, and the risk factors include childhood physical or sexual abuse, stressful events, childhood obesity, early puberty, mental health challenges such as low self-esteem, anxiety, and depression. A biological component is also at play.
Shame and secrecy are often enmeshed in bulimia—it’s sometimes referred to as the “secretive syndrome.” People with bulimia tend to have a typical body weight or are overweight. The disorder can elicit anxiety and shame, and purging specifically can feel like an addictive that the person finds “unwanted,” “out of control,” or “disgusting.” This shame can prevent people from seeking treatment.
Yet treatment is key because bulimia can produce medical complications in addition to deep distress. People with bulimia can become dehydrated, lose electrolytes, erode their dental enamel, and have gastrointestinal problems.
The team to treat bulimia includes a nutritionist, primary care physician, and mental health professional, so that both medical and psychiatric care can be provided. Cognitive behavioral therapy and family-based treatment are common therapeutic approaches, and patients are sometimes prescribed antidepressants to address co-occurring conditions.
Binge-eating disorder occurs when someone repeatedly binge eats, consuming an abnormal amount of food in a short time and without a sense of control. Binges can involve eating very rapidly, eating until uncomfortably full, eating a lot without feeling hungry, eating alone due to embarrassment, and feeling guilty or disgusted with oneself afterward.
It’s diagnosed when binges occur once a week for at least three months, when binges aren’t followed by purges or laxatives as in the case of bulimia, and when the experience leads to distress in the person’s life. Some people with binge-eating disorder are overweight, but not all are.
Binge-eating disorder is the most common eating disorder in the U.S. Many people also shift between different eating disorders over the years, such as struggling with anorexia at one time and binge-eating at another.
During a binge, someone might feel out of control, or even a sense of dissociation from the experience. As a result, they may function as a release, the ability to avoid difficult emotions or experiences in their world. People with binge-eating disorder often struggle with intense shame and self-criticism about it.
Binge-eating disorder is treated by addressing underlying challenges—such as poor body image, low self-esteem, perfectionism, and depression—and developing healthy coping skills. Cognitive-behavioral therapy is often used, but a variety of therapy types can be helpful.
Pica occurs when someone consistently eats things that aren’t food. This could include paper, soap, cloth, paint chips, crayons, dirt, or ice—foods that contain no nutritional value and may be dangerous to digest.
The disorder is diagnosed when the behavior has continued for at least one month, it’s incompatible with the child’s age or developmental stage, the practice isn’t typical of cultural or social norms, and it doesn’t occur in the context of another condition order, such as intellectual disability or autism. Pica is typically diagnosed only after two years old, and it particularly affects children and pregnant women.
Why would someone eat nonfoods? Some people with pica say they enjoy the taste, texture, or smell. Others say that eating certain nonfoods ease stress and anxiety. The behavior may manifest as compulsive for others. And some consume items like clay due to religion, cultural practice, or medicinal purposes (although these cultural norms would rule out a diagnosis.) Risk factors for the disorder include malnutrition, stress, abuse, and other mental health conditions.
Doctors can’t always identify when a patient is consuming nonfoods, and people often don’t tell their doctor due to shame or because they don’t believe it’s unusual. Yet pica can have dire consequences—such as choking, poisoning, and nutritional deficiencies—so it’s critical to seek treatment. Treatment can involve medically addressing complications and therapy to understand and incentivize healthy eating.
Rumination occurs when people consistently regurgitate their food after eating. They then chew it, swallow it, or spit it out. Regurgitation occurs without a sense of disgust, nausea, or involuntary gagging.
The disorder is diagnosed when regurgitation has continued for at least one month and the behavior isn’t due to another medical problem, eating disorder, or mental health condition. The person may have weight stagnation, weight loss, or show developmental challenges.
Rumination often occurs in infancy and childhood, but it can affect adults as well. Stress and anxiety are risk factors for babies and children, while anxiety and depression are risk factors for adults.
Some people describe the condition as habitual or out of their control, and therapy may focus on interrupting and reversing those habits.
Avoidant/Restrictive Food Intake Disorder
Avoidant/Restrictive Food Intake Disorder (ARFID) occurs when someone doesn’t eat enough to get proper energy or nutrition. Someone with ARFID might avoid eating due to sensory characteristics of foods like texture or smell, fear the consequences of eating, or not show interest in eating at all. Weight loss, nutritional deficiencies, and developmental problems can occur as a result.
The disorder often emerges in infancy and childhood. It’s diagnosed when the avoidance can’t be explained by lack of food availability or cultural practice. Medical problems, eating disorders, and mental health conditions must also be ruled out. Risk factors for ARFID include anxiety, OCD, and autism as well as gastrointestinal problems.
People are often confused by the line between picky eating and ARFID. Picky eating verges into a disorder when the person fails to meet their caloric or nutritional needs. They may not be able to gain weight, have an inappropriate weight for their height, or depend on supplements. If it begins to interfere with their functioning on a daily basis, they could have a disorder.
ARFID is also distinct from anorexia; the food aversion that marks ARFID is not driven by fears around body image or gaining weight, as in the case of anorexia.
ARFID can be addressed by a nutritionist and aided by a variety of clinicians, including pediatricians, gastroenterologists, and psychologists, to understand and address the root of the disorder.