Eating Disorders Overview

Feeding and Eating Disorders

• Characterized by persistent disturbances in eating or eating-related behavior that significantly impair physical health or psychosocial functioning.
• Diagnostic criteria include pica, rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, and binge-eating disorder.
• Disorders differ substantially in clinical course, outcome, and treatment needs.
• Some individuals report eating-related symptoms resembling substance use disorders, such as craving and patterns of compulsive use.
• Obesity is not considered a mental disorder in DSM-5, as it results from long-term excess energy intake relative to expenditure.
• Obesity is associated with several mental disorders like binge-eating disorder, depressive and bipolar disorders, and schizophrenia.

Pica

• Diagnosed by persistent eating of nonnutritive, nonfood substances over at least 1 month, requiring clinical attention.
• Typical substances ingested vary with age and availability, including paper, soap, cloth, hair, soil, chalk, paint, metal, pebbles, and ice.
• Associated features include deficiencies in vitamins or minerals, though no specific biological abnormalities are always present.
• Clinical attention is sought following general medical complications like mechanical bowel problems, intestinal obstruction, intestinal perforation, infections, and poisoning.
• Prevalence is approximately 5% among school-age children and about one-third of pregnant women, especially those with food insecurity.
• Onset can occur in childhood, adolescence, or adulthood, most commonly reported in childhood.
• Can occur in normally developing children but is more likely in adults with intellectual developmental disorder or other mental disorders.
• Course can be protracted and result in medical emergencies like intestinal obstruction, acute weight loss, or poisoning.
• Pica can be fatal, depending on the substances ingested.
• Risk and prognostic factors include neglect, lack of supervision, and developmental delay.
• Cultural-related diagnostic issues may arise, as the eating of seemingly nonnutritive substances may be considered of spiritual, medicinal, or social value. However, this behavior does not warrant a diagnosis of pica.
• Pica occurs in both genders and may manifest during pregnancy, when specific cravings may occur. Diagnosis during pregnancy is appropriate only if cravings lead to the ingestion of nonnutritive, nonfood substances to the extent that the eating poses potential medical risks.
• A worldwide meta-analysis showed the prevalence rate of pica to be 28% during pregnancy and/or the postpartum period.
• Diagnostic markers include abdominal flat plate radiography, ultrasound, blood tests, and other laboratory tests.
• Pica can significantly impair physical functioning but rarely solely impacts social functioning.
• Differential diagnosis should be given only if the eating behavior is sufficiently persistent and severe to warrant clinical attention.
• Disorders most commonly comorbid with pica include autism spectrum disorder, intellectual developmental disorder, schizophrenia, and obsessive-compulsive disorder.

Rumination Disorder

• Repeated regurgitation of food over at least 1 month, which may be re-chewed, re-swallowed, or spit out.
• Not attributable to an associated gastrointestinal or other medical condition and does not occur exclusively during the course of anorexia nervosa, bulimia nervosa, binge-eating disorder, or avoidant/restrictive food intake disorder.
• If symptoms occur in the context of another mental disorder (e.g., intellectual developmental disorder or another neurodevelopmental disorder), they must be sufficiently severe to warrant additional clinical attention.
• The essential feature of rumination disorder is the repeated regurgitation of food occurring after feeding or eating over a period of at least one month.
• The behavior is not better explained by an associated gastrointestinal or other medical condition and does not occur exclusively during the course of these disorders.
• If symptoms occur in the context of another mental disorder, they must be sufficiently severe to warrant additional clinical attention and should represent a primary aspect of the individual's presentation requiring intervention.
• Infants with rumination disorder display a characteristic position of straining and arching the back with the head held back, making sucking movements with their tongue.
• They may give the impression of gaining satisfaction from the activity, be irritable and hungry between episodes of regurgitation, and weight loss and failure to make expected weight gains are common features in infants with rumination disorder.
• Malnutrition may occur despite the infant's apparent hunger and the ingestion of relatively large amounts of food, particularly in severe cases when regurgitation immediately follows each feeding episode and regurgitated food is expelled.
• Rumination disorder can have an episodic course or occur continuously until treated.
• In infants and older individuals with intellectual developmental disorder or other neurodevelopmental disorders, the regurgitation and rumination behavior appears to have a self-soothing or self-stimulating function, similar to that of other repetitive motor behaviors such as head banging.
• Psychosocial problems such as lack of stimulation, neglect, stressful life situations, and problems in the parent-child relationship may be predisposing factors in infants and young children.
• Malnutrition secondary to repeated regurgitation may be associated with growth delay and have a negative effect on development and learning potential.
• Some older individuals with rumination disorder deliberately restrict their food intake because of the social undesirability of regurgitation, leading to weight loss or low weight.
• Regurgitation with associated rumination can occur in the context of a concurrent medical condition or another mental disorder, and a diagnosis of rumination disorder is appropriate only when the severity of the disturbance exceeds that routinely associated with such conditions or disorders and warrants additional clinical attention.

Avoidant/Restrictive Food Intake Disorder

• Replaces the DSM-IV diagnosis of feeding disorder of infancy or early childhood, affecting older children, adolescents, and adults.
• Avoidance or restriction of food intake associated with significant weight loss, nutritional deficiency, dependence on enteral feeding or oral nutritional supplements, or marked interference with psychosocial functioning.
• Some individuals exhibit food avoidance or restriction based on sensory characteristics of food, such as extreme sensitivity to appearance, color, smell, texture, temperature, or taste.
• This behavior can manifest as refusal to eat particular brands of foods or tolerate the smell of food being eaten by others.
• In others, food avoidance or restriction represents a conditioned negative response associated with food intake following or in anticipation of an aversive experience, such as choking, a traumatic procedure involving the gastrointestinal tract, or repeated vomiting.
• The determination of whether weight loss is significant is a clinical judgment, and the impact on physical health can be similar to that seen in anorexia nervosa.
• In severe cases, malnutrition can be life-threatening, particularly in infants.
• "Dependence" on enteral feeding or oral nutritional supplements means that supplementary feeding is required to sustain adequate intake.
• Examples of individuals requiring supplementary feeding include infants with failure to thrive who require neonatal tube feeding, children with neurodevelopmental disorders who are dependent on nutritionally complete supplements, and individuals who rely on gastrostomy tube feeding or complete oral nutrition supplements in the absence of an underlying medical condition.
• Inability to participate in normal social activities, such as eating with others, attending school or work, or sustaining relationships as a result of the disturbance would indicate marked interference with psychosocial functioning.
• Substantial disruption of family functioning may also satisfy Criterion A4.
• Avoidant/restrictive food intake disorder does not include avoidance or restriction of food intake related to lack of availability of food (e.g., food insecurity) or to cultural practices (e.g., religious fasting or normal dieting).
• The disturbance is not better explained by excessive concern about body weight or shape (Criterion C) or by concurrent medical factors or mental disorders (Criterion D).
• Food avoidance or reduced food intake can be associated with various features, which may differ across ages.
• In very young infants, they may present with food refusal, gagging, or vomiting.
• In older children and adolescents, food avoidance or restriction may be associated with more generalized emotional difficulties that do not meet diagnostic criteria for an anxiety, depressive, or bipolar disorder, sometimes called food avoidance emotional disorder.
• Little information is available on the prevalence of avoidant/restrictive food intake disorder, but a study in Australia reported a frequency of 0.3% among individuals aged 15 years or older.
• Food avoidance or restriction associated with insufficient intake or lack of interest in eating most commonly develops in infancy or early childhood and may persist into adulthood.
• Adverse consequences of food avoidance can arise at any age, and there is currently insufficient evidence directly linking avoidant/restrictive food intake disorder and the subsequent onset of an eating disorder.
• Infants with avoidant/restrictive food intake disorder may be irritable and difficult to console during feeding, or may appear apathetic and withdrawn.
• Inadequate nutritional intake may exacerbate associated features and further contribute to feeding difficulties.
• Associated factors include infant temperament or developmental impairments that reduce an infant's responsiveness to feeding.
• Coexisting parental psychopathology or child abuse or neglect is suggested if feeding and weight improve in response to changing caregivers.
• Manifest more commonly in children and adolescents than in adults, and there may be a long delay between onset and clinical presentation.
• Triggers for presentation vary considerably and include physical, social, and emotional difficulties.
• Risk and prognostic factors include anxiety disorders, autism spectrum disorder, obsessive-compulsive disorder, attention-deficit/hyperactivity disorder, environmental risk factors, other medical conditions, and history of gastrointestinal conditions.
• Culture-related diagnostic issues should not be diagnosed when avoidance of food intake is solely related to specific religious or cultural practices.
• Avoidant/restrictive food intake disorder is a common condition in both boys and girls, with a male predominance.
• It can occur in physiological conditions, such as pregnancy, but is not usually extreme and does not meet full criteria for the disorder.
• Functional consequences include impairment of physical development and social difficulties that can negatively impact family function.
• Restriction of food intake is a nonspecific symptom that can accompany various mental disorders and medical conditions, and can be diagnosed concurrently with these disorders if all criteria are met and the eating disturbance requires specific clinical attention.
• This disorder can also occur in other medical conditions, especially those with ongoing symptoms such as vomiting, loss of appetite, nausea, abdominal pain, or diarrhea.
• Underlying medical or comorbid mental conditions may complicate feeding and eating.
• An additional diagnosis of avoidant/restrictive food intake disorder requires that the eating disturbance is a primary focus for intervention.
• Other conditions associated with feeding difficulties include reactive attachment disorder, autism spectrum disorder, specific phobia, social anxiety disorder, and anorexia nervosa.
• Acute-onset symptoms, late age at onset, or atypical symptoms suggest a thorough assessment to rule out obsessive-compulsive and related disorder due to pediatric acute-onset neuropsychiatric syndrome (PANS).
• Feeding difficulties are common in congenital and neurological conditions often related to problems with oral/esophageal/pharyngeal structure and function.
• Individuals with autism spectrum disorder often present with rigid eating behaviors and heightened sensory sensitivities, but these features do not always result in the level of impairment required for a diagnosis of avoidant/restrictive food intake disorder.
• Distinguishing specific phobia from avoidant/restrictive food intake disorder can be difficult when a fear of choking or vomiting has resulted in food avoidance.

Anorexia Nervosa

• Individuals restrict their energy intake to meet requirements leading to significantly low body weight.
• Fear of gaining weight or becoming fat, persistent behavior that interferes with weight gain, and specific disturbances in relation to their own body weight and shape.
• Avoidant/restrictive food intake disorder does not display these features, and the two disorders should not be diagnosed concurrently.
• Differential diagnosis between avoidant/restrictive food intake disorder and anorexia nervosa may be difficult, especially in late childhood and early adolescence, as these disorders may share common symptoms.
• Individuals with obsessive-compulsive disorder may present with avoidance or restriction of intake related to preoccupations with food or ritualized eating behavior. Avoidant/restrictive food intake disorder should be diagnosed concurrently only if all criteria are met for both disorders and when the aberrant eating is a major aspect of the clinical presentation requiring specific intervention.
• In major depressive disorder, appetite might be affected to such an extent that individuals present with significantly restricted food intake, usually in relation to overall energy intake and often associated with weight loss.
• Individuals with schizophrenia, delusional disorder, or other psychotic disorders may exhibit odd eating behaviors, avoidance of specific foods because of delusional beliefs, or other manifestations of avoidant or restrictive intake. Avoidant/restrictive food intake disorder should be used concurrently only if all criteria are met for both disorders and when the eating disturbance requires specific treatment.
• Avoidant/restrictive food intake disorder should be differentiated from factitious disorder or factitious disorder imposed on another. Factitious disorder may involve intentionally describing diets that are much more restrictive than those they are actually able to consume, as well as complications of such behavior, such as a need for enteral feedings or nutritional supplements, an inability to tolerate a normal range of foods, and/or an inability to participate normally in age-appropriate situations involving food.
• Comorbidity with avoidant/restrictive food intake disorder includes anxiety disorders, obsessive-compulsive disorder, and neurodevelopmental disorders (specifically autism spectrum disorder, attention-deficit/hyperactivity disorder, and intellectual developmental disorder).

Anorexia Nervosa (cont'd.)

• Condition characterized by three essential features:
  • persistent energy intake restriction leading to significantly low body weight,
  • intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain, and
  • disturbance in self-perceived weight or shape.
• The ICD-10-CM code depends on the subtype:
  • restriction type (F50.01) where the individual has not engaged in recurrent episodes of binge-eating or purging behavior during the last 3 months, and
  • binge-eating/purging type (F50.02), where the individual has engaged in recurrent episodes of binge-eating or purging behavior during the last 3 months.
• Severity level for anorexia nervosa is based on current BMI or the BMI percentile for children and adolescents.
• Minimum level of severity is based on the World Health Organization categories for thinness in adults, while the level of severity may be increased to reflect clinical symptoms, the degree of functional disability, and the need for supervision.
• Subtypes include mild (BMI ≥ 17 kg/m2), moderate (BMI 16-16.99 kg/m2), severe (BMI 15-15.99 kg/m2), and extreme (BMI < 15 kg/m2).
• Crossover between subtypes over the course of the disorder is not uncommon, so subtype description should be used to describe current symptoms rather than the longitudinal course.
• Criterion A requires that the individual's weight be significantly low (i.e., less than minimally normal or, for children and adolescents, less than that minimally expected).
• Weight assessment can be challenging due to differences in normal weight range among individuals and different thresholds have been published defining thinness or underweight status.
• For adults, a BMI of 18.5 kg/m2 is used as the lower limit of normal body weight, but a BMI of lower than 17.0 kg/m2 is considered moderate or severe thinness.
• An adult with a BMI between 17.0 and 18.5 kg/m2, or even slightly above 18.5 kg/m2, might be considered to have a significantly low weight if clinical history or other physiological information supports this judgment.
• For children and adolescents, determining a BMI-for-age percentile is useful, but it is not possible to provide definitive standards for judging whether a child's or an adolescent's weight is significantly low.
• The CDC has used a BMI-for-age below the 5th percentile as suggesting underweight, but children and adolescents with a BMI above this benchmark may be judged to be significantly underweight in light of failure to maintain their expected growth trajectory.

Anorexia Nervosa

• Individuals with anorexia nervosa experience intense fear of gaining weight or becoming fat, even as weight falls.
• Their perception of body weight and shape is distorted, with some feeling globally overweight and others concerned about specific body parts.
• They engage in various techniques to evaluate their body size or weight, including frequent weighing, obsessive measuring, and mirror checks.
• Their self-esteem is highly dependent on their perceptions of body shape and weight.
• Semistarvation can result in significant and potentially life-threatening medical conditions, affecting most major organ systems.
• Physiological disturbances like amenorrhea, vital sign abnormalities, and bone mineral density loss are common.
• Obsessive-compulsive features, both food-related and unrelated, are often prominent.
• Individuals may show excessive levels of physical activity, which can accelerate weight loss.
• Anorexia nervosa typically begins during adolescence or young adulthood and is most prevalent in post-industrialized, high-income countries.
• The prevalence is lower among Latinx and non-Latinx Black Americans than among non-Latinx Whites.
• The course and outcome vary, with younger individuals often manifesting atypical features, while older individuals may have a longer duration of illness and more signs of a long-standing disorder.
• Risk and prognostic factors include anxiety disorders, obsessional traits in childhood, historical and cross-cultural variability in prevalence, occupations that encourage thinness, and genetic and physiological abnormalities.
• There is an increased risk for anorexia nervosa and other eating and psychiatric disorders among biological relatives.
• Genome-wide association studies have identified specific risk loci.
• Culture-related diagnostic issues exist, with weight concerns varying across cultural contexts.
• Diagnostic markers include leukopenia, mild anemia, hypercholesterolemia, hypomagnesemia, hypozincemia, hypophosphatemia, and hypokalemia.
• Serum thyroxine (T4) levels are usually in the low-normal range, and low bone mineral density is often seen.
• There’s often a significant reduction in resting energy expenditure.
• Physical signs and symptoms are often attributable to starvation, with amenorrhea being a common indicator.
• The most remarkable finding on physical examination is emaciation.
• Some individuals develop lanugo, peripheral edema, petechiae or ecchymoses, hypercarotenemia, and scars or calluses.
• Anorexia nervosa is a disorder with elevated suicide risk, with rates reported to be 18 times greater than in an age- and gender-matched comparison group.
• Suicidal thoughts or behavior are common, with a significant percentage having suicidal ideation and attempting suicide.
• Factors contributing to suicide risk include greater exposure to sexual abuse, impaired decision-making, high rates of nonsuicidal self-injury, and comorbidity with mood disorders.
• Functional consequences may include functional limitations, such as social isolation and failure to fulfill academic or career potential.

Bulimia Nervosa

• Bulimia Nervosa is characterized by recurrent episodes of binge eating, inappropriate compensatory behaviors to prevent weight gain, and undue influenced self-evaluation.
• To qualify for the diagnosis, binge eating and compensatory behaviors must occur at least once per week for 3 months.
• An episode of binge eating is defined as eating significantly larger than most individuals would eat in a similar period under similar circumstances.
• The context in which the eating occurs may affect the clinician's estimation of whether the intake is excessive.
• A "discrete period of time" refers to a limited period, usually less than 2 hours.
• Excessive food consumption must be accompanied by a sense of lack of control.
• Individuals with bulimia nervosa are typically ashamed of their eating problems and attempt to conceal their symptoms.
• Binge eating usually occurs in secrecy or as inconspicuously as possible.
• The most common antecedent of binge eating is negative affect.
• Bulimia nervosa is characterized by recurrent use of inappropriate compensatory behaviors to prevent weight gain.
• Individuals may employ various methods to compensate for binge eating, including self-induced vomiting, laxative and diuretic misuse, and thyroid hormone misuse.
• Individuals with bulimia nervosa place an excessive emphasis on body shape or weight in their self-evaluation, which are typically extremely important in determining self-esteem.
• Associated features include being within the normal weight or overweight range, restricting total caloric consumption, experiencing menstrual irregularity or amenorrhea, and experiencing fluid and electrolyte disturbances resulting from purging behavior.
• The prevalence of bulimia nervosa is highest in populations residing in high-income industrialized countries.
• Bulimia nervosa commonly begins in adolescence or young adulthood.
• Disturbed eating behavior persists for at least several years in a high percentage of clinical samples.
• Significantly elevated risk for mortality (all-cause and suicide) has been reported for individuals with bulimia nervosa.
• Risk and prognostic factors associated with the development of bulimia nervosa include weight concerns, low self-esteem, depressive symptoms, social anxiety disorder, environmental, genetic and physiological course modifiers, childhood generalized anxiety disorder, internalization of a thin body ideal, childhood sexual or physical abuse, childhood obesity, early pubertal maturation, familial transmission of bulimia nervosa, and severity of psychiatric comorbidity.
• Bulimia nervosa is a common disorder in the U.S., with a higher prevalence among girls and women than boys and men.
• There is no specific diagnostic test for bulimia nervosa, but laboratory abnormalities may occur as a consequence of purging, such as hypokalemia, hypochloremia, and hyponatremia.
• Physical examination usually yields no physical findings, but inspection of the mouth may reveal significant and permanent loss of dental enamel due to recurrent vomiting.
• Suicide risk is elevated in bulimia nervosa, with approximately one-quarter to one-third of individuals with bulimia nervosa having had suicidal ideation or attempted suicide.
• Functional consequences of bulimia nervosa include functional limitations associated with the disorder and reduced health-related quality of life.

### Binge-Eating Disorder

• Binge-eating disorder is characterized by recurrent episodes of binge eating that occur at least once a week for three months.
• These episodes are characterized by eating much more rapidly than normal, feeling uncomfortably full, eating large amounts of food when not feeling physically hungry, eating alone because of feeling embarrassed by one's eating, and feeling disgusted with oneself, depressed, or very guilty afterward.
• The condition can be classified as partial remission or full remission.
• The current severity level depends on the frequency of episodes of binge eating.
• The essential feature of binge-eating disorder is recurrent episodes of binge eating that must occur, on average, at least once per week for three months.
• An "episode of binge eating" is defined as eating in a discrete period of time, which may vary depending on the context.
• A "discrete period of time" refers to a limited period, usually less than 2 hours.
• Excessive food consumption must be accompanied by a sense of lack of control.
• The type of food consumed during binges varies across individuals and for a given individual.
• Binge eating may minimize or mitigate factors that precipitated the episode in the short term, but negative self-evaluation and dysphoria often are the delayed consequences.
• Binge-eating disorder is a condition that affects normal-weight/overweight and obese individuals.
• It is distinct from obesity, as most obese individuals do not engage in recurrent binge eating.
• The prevalence of binge-eating disorder is comparable across ethnic groups in the United States, Canada, many European countries, Australia, and New Zealand.
• Development and course of binge-eating disorder are little known, but both binge eating and loss-of-control eating without objectively excessive consumption occur in children.
• Binge-eating disorder typically begins in adolescence or young adulthood but can begin in later adulthood.

Bulimia Nervosa

• Bulimia nervosa is associated with emotional distress and is frequently comorbid with depression, anxiety, substance abuse, or personality disorders.
• Individuals often struggle with low or distorted self-esteem and rely heavily on external validation regarding their appearance and weight, increasing the risk of relapse.
• Cognitive-behavioral therapy (CBT) is a common treatment approach, but about a third of patients with bulimia nervosa continue to experience symptoms after treatment.

Binge Eating Disorder (BED)

• BED is the most common eating disorder in the United States, characterized by recurrent episodes of binge eating, a feeling of loss of control, significant distress, and a lack of regular compensatory behaviors like purging.
• BED is frequently co-occurring with other mental health conditions, such as major depression and anxiety disorders.
• Treatment focuses on addressing medical concerns, nutritional management, re-establishing a healthy relationship with food, and reducing binge eating frequency.
• CBT has proven more effective than other treatments for BED.
• A recent shift in treatment emphasizes a diet-related approach, incorporating behavior change components into dietetic intervention.

Addressing PICA, Rumination, and Eating Disorders

• PICA, rumination, and eating disorders require accurate assessments to understand symptom presentation and feeding refusal.
• A thorough feeding history, including family history, early feeding behaviors, and current desires, is crucial in identifying these disorders.
• Validated assessment tools for rumination and rumination disorder are available to assist in diagnosis.
• Early identification of PICA and Rumination Syndrome is essential for effective mental health interventions.
• Self-report and clinician-rated scales, with strong psychometric properties, are recommended for clinical assessment.

Treatment and Management

• A comprehensive assessment, including detailed clinical interviews and standardized tools, is essential for accurate diagnosis and treatment planning.
• Multidisciplinary treatment approaches, involving healthcare professionals like dietitians, psychologists, and medical doctors, have proven effective in improving binge eating frequency, comorbid eating disorder-related issues, and overall quality of life.
• Collaboration and interprofessionalism among healthcare providers are crucial for successful evidence-based care.
• Early intervention is key, and a multidisciplinary approach is vital, involving administrative personnel and support staff for successful implementation.

Challenges and Future Directions

• Addressing workforce challenges is essential to build a safer and more robust healthcare system that prioritizes the well-being of both patients and healthcare professionals.
• More research is needed to understand the interplay of various eating disorder presentations and to develop effective interventions for these complex conditions.

This quiz covers various aspects of eating disorders, including pica and obesity. Questions explore characteristics, symptoms, and the relationship between eating disorders and mental health. Test your knowledge on these critical topics in psychology and nutrition.