Eating, and our relationship with food, fulfills a basic physiological need for everyone. For many, eating when hungry comes naturally and effortlessly. These people respond to their hunger cues by eating and providing their bodies with nutrition and energy. For some, eating can consist of harmful patterns and moderate levels of distress often resulting in restriction, binging, or purging. In these cases, individuals may be suffering from an eating disorder.
According to the National Eating Disorder Association (NEDA), 20 million women and 10 million men in the U.S. will suffer from an eating disorder at some point during their lives (reference NEDA). There is not one isolated cause for the development of an eating disorder, but rather a broad range of contributing factors including genetics, family history, and combined social and cultural factors. Fortunately, effective treatment options are available to assist those who suffer from an unhealthy relationship with food and disordered eating.
Types of Eating Disorders
Eating disorders are characterized by a continual disruption of eating or eating-related behavior that results in altered consumption of food. These altered eating patterns are harmful in nature and create significant impairment in both physical and mental health, as well as daily functioning.1 Four common eating disorders include: avoidant/restrictive food intake disorder (ARFID); anorexia nervosa; bulimia nervosa; and binge eating disorder.
Avoidant/Restrictive Food Intake Disorder (ARFID)
Avoidant/Restrictive Food Intake Disorder is a disturbance in eating often triggered by lack of interest in eating or food. One may avoid specific food items due to sensory characteristics of the food such as temperature, color, smell, or texture. A persistent concern with potential negative consequences of eating of specific foods may also be present such as fear of vomiting or choking.
These aversions to food contribute to inadequate nutrition and the body’s energy needs are not met, often manifesting as weight loss in adults and failure to meet growth expectations for children. Significant nutritional deficiencies or medical concerns may also be present and one may develop a dependency on supplements in an attempt to meet nutritional needs. When someone is struggling with ARFID they will often have difficulty engaging in daily activities and relationships with others due to these eating behaviors.
Avoidant/Restrictive Food Intake Disorder is equally common in male and female infants and children, although when co-occurring with autism spectrum disorder, is more prominent in males.1 Research has also suggested that those suffering from ARFID tend to be younger and male, compared to other eating disorders.2
Anorexia Nervosa (AN)
Anorexia Nervosa is characterized by persistent restriction of food, combined with an intense fear of being fat or gaining weight.There is a disturbance of body-image and irrational thoughts pertaining to one’s body shape and size. Significant effort is also utilized to engage in behaviors that interfere with weight gain such as excessive exercise and calorie counting. The presence of these characteristics results in significantly low body weight.
There are two subtypes of anorexia nervosa, restricting type and binge-eating/purging type. Restricting type describes when someone is primarily engaging in dieting, fasting, and excessive exercise whereas binge-eating/purging type consists of eating significantly larger quantities of food in a short period of time compared to most people followed by vomiting or use of laxatives or enemas.
Approximately .3%-.4% of females and .1% of males will suffer from anorexia nervosa at any given time.3 Some studies have suggested a higher prevalence of anorexia nervosa where .9% – 2% of females and .1% and.3% of males will develop anorexia.4
Bulimia Nervosa (BN)
Bulimia Nervosa is characterized by recurrent incidences of binge eating consisting of eating significantly larger quantities of food in a short period of time compared to most people. This is combined with an overwhelming sense of lack of control where one does not feel they have the ability to stop eating or control how much they eat.
Binge-eating typically continues until the individual is physically uncomfortable or in pain. Binge-eating is then followed by attempts to offset the eating behavior in order to prevent weight gain. These behaviors are termed purge behaviors and may include vomiting, use of laxatives or enemas, fasting, or excessive exercise. One’s self-evaluation is also unjustifiably influenced by body shape and weight.
Some studies have suggested a higher prevalence of bulimia nervosa where 1.1% – 4.6% of females and .1% and .5% of males will develop bulimia.4 Bulimia nervosa commonly begins in late adolescence or young adulthood. Onset prior to puberty or after the age of 40 is uncommon.
Similar to bulimia nervosa, binge-eating disorder is characterized by recurrent episodes of binge eating consisting of eating significantly larger quantities of food in a short period of time compared to most people. This is combined with distress and an overwhelming sense of lack of control where one does not feel they have the ability to stop eating or control how much they eat. Binge-eating episodes are associated with at least three of the following:
- Eating much more rapidly than usual.
- Eating until feeling physically uncomfortable.
- Eating large amounts of food when not feeling physically hungry.
- Eating alone because of feeling embarrassed by the amount of food one is eating.
- Feeling disgusted with oneself, depressed, and guilty afterwards.
Binge-eating disorder has a less defined gap in prevalence between genders compared to anorexia nervosa and bulimia nervosa. Approximately 1.6% of females and .8% of males will suffer from binge-eating disorder at any given time.1 Some studies have suggested a higher prevalence of binge-eating where 3.5% of females and 2% of males will develop binge-eating disorder.5
Other Kinds of Eating Disorders
On occasion, someone struggling with an unhealthy relationship with food and disordered eating may not meet every characteristic or behavior described for a particular eating disorder. When this occurs, and behaviors contribute to significant disturbances and difficulty with functioning, an alternative diagnosis of other specified feeding or eating disorder or unspecified feeding or eating disorder may be given. These alternative diagnoses allow for communication of concerns and needs in order to receive effective treatment.
Treatment of Eating Disorders
There are a variety of evidenced based treatment interventions to assist in the management of symptoms and behaviors related to eating disorders. Recovery can be established and maintained by engaging in treatment as soon as possible. Treatment plans can be individualized to fit the unique needs of each individual and a variety of levels of care are available depending on the severity of symptoms and behaviors.
The standard approach to the treatment of individuals with an eating disorder is the establishment of a treatment team for each individual. These outpatient treatment teams consist of a licensed psychotherapist, a primary care physician, a psychiatrist, and a registered dietitian. Each member of the treatment team has a specific role in supporting an individual diagnosed with an eating disorder.
Licensed Psychotherapist: The licensed psychotherapist assists the individual in working towards their treatment goals using a variety of therapeutic approaches including cognitive behavioral therapy, dialectical behavior therapy, acceptance and commitment therapy, eye movement desensitization reprocessing, and family therapy.
Regardless of the theoretical approach that is determined to be the best fit for the individual, the goal of therapy would be to address the distress and overwhelming emotions that trigger disordered eating. Many times this includes challenging irrational beliefs about food and body image as well as processing daily stressors, chronic stressors, and prior exposure to trauma.
Primary Care Physician: The primary care physician monitors and evaluates the individual regularly to ensure physical stability and assess for any potential medical complications. Significant medical concerns, such as irregular heartbeats and cardiac arrest, can result from malnutrition and disordered eating at which time the primary care physician may recommend hospitalization to assist in establishing medical stability.
Unfortunately, eating disorders can be life threatening, therefore having a designated medical provider for continual evaluation is vital.
Psychiatrist: The psychiatrist will evaluate the role of psychotropic medications to assist in providing support for the management of symptoms and behaviors. Often, co-occurring conditions are present, such as depression and anxiety, which can effectively be managed by medications. While medication will not fully resolve symptoms and behaviors related to an eating disorder, relief can be provided while the individual works towards establishing change.
Registered Dietitian: The registered dietitian will assist in monitoring for weight loss and weight gain while also partnering with the individual to establish a meal plan that will meet the individual’s nutritional needs. Registered dietitian’s also commonly provide support to the individual to address various food challenges.
Therapy to Treat Eating Disorders
There are a number of therapy options that have been shown to be effective in treating eating disorders. Those include:
Cognitive Behavioral Therapy (CBT)
Cognitive Behavioral Therapy (CBT) has been shown to be effective in the treatment of many mental health concerns, including eating disorders. The foundational principles of CBT include:
- Concerns and distress are at least partially due to faulty or irrational ways of thinking.
- Concerns and distress are at least partially due to learned patterns or unhelpful behavior.
- Individuals are capable of learning better ways to think and behave therefore improving their daily lives and overall functioning.
CBT involves learning to change both thinking patterns and behavioral patterns. For example, a psychotherapist utilizing CBT will assist a client with an eating disorder to identify their cognitive distortions and faulty thinking that are contributing to restricting, binging, or purging. The psychotherapist will further assist the client in evaluating their thoughts by challenging these distortions with reality.
In addition, the psychotherapist will assist the client in facing their fears instead of avoiding them, such as consuming challenging foods. At the same time, the client will also be provided with instruction on how to calm and relax one’s body particularly during distressing times.
Dialectical Behavior Therapy (DBT)
Dialectical Behavior Therapy (DBT) is a type of cognitive therapy and has become one of the more popular treatment options for those suffering from an eating disorder. DBT is a skills-based approach to learning to manage symptoms and behaviors and has four main components:
- Mindfulness: Mindfulness is learning to be present in the moment while also accepting the moment without judgment.
- Emotional Regulation: Emotional regulation is learning to manage and transform overwhelming emotions.
- Distress Tolerance: Distress tolerance is increasing one’s ability to handle negative emotions without becoming destructive or attempting to escape the negative emotion.
- Interpersonal Effectiveness: Interpersonal effectiveness is developing communication skills to successfully resolve conflict, express needs, assert self, and maintain healthy relationships.
As an individual with an eating disorder begins to engage in DBT, they will learn a variety of skills to use in real-time to address the emotions, distress, and behavioral patterns that are interfering with having a healthy relationship with food, themselves and others.
Acceptance and Commitment (ACT)
Acceptance and Commitment Therapy (ACT) is an action-orientated method that utilizes acceptance and mindfulness strategies, combined with commitment and behavior change strategies. When engaging in ACT, one learns to refrain from their tendency to avoid and deny their negative emotions. Rather they learn to accept these emotional responses to certain experiences and acknowledge these same emotions should not prevent them from living their lives and progressing forward. An individual then commits to making the necessary changes in their behavior.
For example, an individual with an eating disorder that is participating in ACT will learn to accept their thoughts and emotions pertaining to food without impulsively acting on these thoughts and emotions which could lead to restricting, binging, purging, or engaging in excessive exercise. ACT gives an individual the support needed to recognize they can be in control of how they react, think, and feel.
Eye Movement Desensitization Reprocessing (EMDR)
Eye Movement Desensitization Reprocessing (EMDR) assists individuals in healing from traumatic experiences or distressing life events using bilateral stimulation of the brain involving eye movements, sounds, or taps. Eating disorders are often viewed as coping skills that developed in response to adverse experiences. Our brains possess the natural ability to heal from traumatic or adverse experiences although on occasion assistance may be needed.
An individual participating in EMDR will identify their negative beliefs and associated adverse experiences or memories, and will process these experiences to reduce and eliminate their symptoms and behaviors associated with an eating disorder. EMDR helps the brain process and allows normal healing to resume. Often, relief from symptoms and behaviors comes sooner with EMDR than other traditional therapies.
Family Based Treatment (FBT)
Family Based Treatment (FBT), also known as the Maudsley Method, has been found to be effective in the treatment of eating disorders, involving the entire family in the treatment process. Parents are viewed as a resource for the child or adolescent while being empowered to support their child to recovery. Within this treatment model, the eating disorder is viewed as an external force and analysis of the development of the eating disorder does not occur. The goal of FBT is to achieve full nutrition and family meal time is often observed in order to identify various behaviors within the family as well as provide coaching.
There are three phases to family based treatment of eating disorders:
Phase 1 Weight Restoration: During phase 1, weight restoration is the goal. Parents are normally in charge of meals and snacks, seeking support and coaching from the therapist as needed. Increase in food intake is a priority and steady weight gain is expected.
Phase 2 Gradual Return of Control: Phase 2 typically begins when weight has been fully restored and the child/adolescent begins to resume age-appropriate control of snacks and meals. Parents are ready to provide redirection and support as needed.
Phase 3 Age-Appropriate Level of Independence: When the child/adolescent has demonstrated and maintained age-appropriate independence the focus of treatment in phase 3 becomes establishing a sense of identity without the eating disorder. During this phase, co-occurring concerns such as depression and anxiety will be addressed.
Intended Treatment Outcome and Timeline of Therapy
Early intervention is important when addressing the symptoms and behaviors associated with eating disorders. Eating disorders are not “just a phase,” and the longer the cognitive distortions and disordered eating behaviors continue, the more stubborn they can appear, often reinforcing feelings of hopelessness. Individuals struggling with eating disorders need support as soon as possible in order to reduce the risk of prolonged concerns.
The treatment methods previously mentioned are all evidenced based methods and have documented successes with treating eating disorders. There is no specific timeline when treating eating disorders and the duration of treatment varies from individual to individual. Often, the earlier the intervention, the shorter the duration of treatment that is needed.
Medication for Eating Disorders
There is no medication cure for eating disorders. Medication management is often utilized as a support or supplement to therapeutic interventions and psychotherapy. Medications can often assist an individual in managing behaviors and urges to binge, purge, or compulsively exercise. Medications can also assist with managing preoccupations and racing thoughts regarding food, diet, and body image. It is not unusual to try more than one medication before finding the right fit.
Four common classes of medication are often utilized to treat the symptoms and behaviors associated with eating disorders:
Selective Serotonin Reuptake Inhibitors (SSRIs)
SSRIs are the most commonly prescribed antidepressants. This medication functions by increasing the levels of serotonin found in the brain by blocking the reabsorption of this neurotransmitter serotonin, improving an individual’s mood. The SSRI fluoxetine (Prozac) has an indication for use in patients with bulimia to reduce the episodes of binging and purging. They would also be prescribed to help with symptoms of anxiety.
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
Similar to SSRIs, SNRIs function by increasing the levels of serotonin and norepinephrine found in the brain by blocking the reabsorption of these neurotransmitters, therefore improving mood and decreasing anxiety
Benzodiazepines function by assisting the central nervous system in slowing down allowing for a more relaxed state and reduction in anxiety. Sometimes these medications are taken prior to meals if there are high levels of anxiety around eating. But their potential for misuse and addiction means judicious prescribing is crucial.
Antipsychotic medications function by blocking dopamine receptors in the brain. These medications can assist individuals with weight restoration as well as changing obsessive thoughts. Despite the label of “antipsychotic”, these agents are used to treat a wide range of conditions. Antipsychotic medications are often prescribed as adjunct medications when treating eating disorders.
When a Higher Level of Care is Needed
Every individual seeking treatment for an eating disorder is unique and several levels of treatment are available. It is not uncommon for an individual diagnosed with an eating disorder to flow between various levels of treatment over the duration of their care, therefore it is important to know the differences to ensure the appropriate level of care is received. Insurance companies and residential treatment specialists can also assist in finding the appropriate level of treatment.
Here are the four levels of eating disorder treatment:
An individual is appropriate for outpatient therapy if they are medically stable and the level of impairment in functioning is not severe. Outpatient treatment can be used when an individual engages with their therapist and is making progress towards resolution of their disordered eating.
An individual is appropriate for partial hospitalization if they are medically stable although have impaired functioning without significant risk. Partial hospitalization programs usually consist of sessions in a treatment facility multiple days a week. Assessment of daily mental status is also needed. An individual in partial hospitalization is actively restricting, binging, and purging, and may be engaging in weight control strategies such as excessive exercise or use of laxatives.
Residential treatment is often sought out following an unsuccessful attempt at partial hospitalization or outpatient therapy. A patient will stay at a specific program for eating disorders for weeks or months getting intensive therapy. An individual in residential treatment should be medically stable.
An individual is appropriate for inpatient treatment when they are medically unstable as assessed by vital signs and laboratory findings. The primary goal is to stabilize medical complications of their disorder in a hospital unit. Medical complications may be present, needing frequent medical monitoring.
How to Get Help For Yourself or a Loved One
The good news is, if you are considering getting help for yourself or a loved one that you believe is suffering from an eating disorder, you have already taken the first step! Learning the fundamental information regarding eating disorders is the most important action needed to begin the process towards change.
A common initial step is to meet with your primary care doctor and express your concerns. Being open and honest with your primary care doctor is vital to assessing your needs and finding the appropriate treatment option for you. If you are seeking help for your child or adolescent, your family pediatrician will be able to provide useful information to your treatment team by sharing your child’s growth charts that are generally maintained since birth.
You may also find it useful to simultaneously seek an evaluation from an outpatient psychotherapist who specializes in eating disorders. Online directories are available to search for an appropriate therapist and insurance companies typically have listings as well. Having an assessment completed by a knowledgeable psychotherapist is a fundamental step to beginning the treatment process.
Eating Disorder Statistics
30 million people in the United States will experience an eating disorder during their lifetimes. It is suspected that 20 million will be female and 10 million will be male.8
Eating disorders have the highest mortality rate of any mental illness, with nearly 1 person dying every hour as a direct result of an eating disorder.3
Anorexia is the 3rd most common chronic illness among adolescents, after asthma and obesity.3
Over 70 percent of those who suffer with eating disorders will not seek treatment due to stigma, misconceptions, lack of education, diagnosis and lack of access to care.3
Young people between the ages of 15 and 24 with anorexia have 10 times the risk of dying compared to their same-aged peers.7
Males represent 25% of individuals with anorexia nervosa, and they are at a higher risk of dying, in part because they are often diagnosed later since many people assume males don’t have eating disorders.6
80 percent of patients who receive and complete eating disorder treatment will recover or improve significantly.3