All the facts you need to know to aid in your own, or a loved one’s, eating disorder recovery.

Do I have an eating disorder? 

Anorexia Nervosa
Bulimia Nervosa
Binge Eating Disorder
Orthorexia
Diabulimia
Laxative Abuse
Compulsive Exercise
Other Specified Feeding or Eating Disorder (OSFED)
Avoidant Restrictive Food Intake Disorder (ARFID)
Increased Risk Factors
Co-Occurring Disorders
Myth Busting
Recovery Process

Anorexia Nervosa

Anorexia is characterized by weight loss or lack of appropriate weight gain. Those who struggle have a hard time maintaining a healthy body weight for their age, height, and body build. Many of those who are diagnosed also have distorted body image (body dysmorphia). Generally, people who have anorexia restrict caloric intake and are extremely picky about the foods that they do eat. Some can also show behaviors like compulsive exercising, purging via laxatives or vomiting, and binge eating.

There is no characteristic appearance of someone struggling with anorexia. A person with anorexia does not need to be extremely underweight, and can be larger-bodied. Most of these people are not diagnosed due to stereotypes of being fat and overweight.

DSM-5 Diagnostic Criteria

  • Persistent restriction of energy intake leading to significantly low body weight (in context of what is minimally expected for age, sex, developmental trajectory, and physical health) .
  • Either an intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain (even though significantly low weight).
  • Disturbance in the way one’s body weight or shape is experienced, undue influence of body shape and weight on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.
    **If all criteria for Anorexia Nervosa are not met, it does not mean there is not a serious eating disorder present. People can meet this criteria and not be underweight.**

Symptoms and Signs

Physical Signs

  • Dramatic weight loss
  • Stomach cramps, other non-specific gastrointestinal complaints (constipation, acid reflux, etc.)
  • Abnormal laboratory findings (anemia, low thyroid and hormone levels, low potassium, low blood cell counts, slow heart rate)
  • Dizziness or fainting
  • Feeling cold
  • Not sleeping well
  • Menstrual irregularities
  • Cuts and calluses across the top of fingers because of induced vomiting
  • Dental problems, such as enamel erosion, cavities, and tooth sensitivity, discoloration
  • Dry skin and brittle nails
  • Swelling around area of salivary glands
  • Fine hair on body and thinning of hair on head
  • Muscle weakness or fatigue
  • Cold, mottled hands and feet or swelling of feet
  • Poor wound healing
  • Impaired immune functioning

Behavioral and Emotional Signs

  • Dresses in layers to hide weight loss or stay warm
  • Is preoccupied with weight, food, calories, fat grams, and dieting
  • Refuses to eat certain foods, progressing to restrictions against whole food groups
  • Frequently talks about feeling “fat” despite weight loss
  • Complains of constipation, abdominal pain, cold intolerance, lethargy, and/or excess energy
  • Denies feeling hungry
  • Develops food rituals
  • Cooks meals for others without eating
  • Consistently makes excuses to avoid mealtimes or situations involving food
  • Needs to “burn off” calories taken in
  • Maintains an excessive, rigid exercise regimen –regardless of weather, fatigue, illness, or injury
  • Withdraws from usual friends and activities and becomes more isolated, withdrawn, and secretive
  • Seems concerned about eating in public or in front of people
  • Has limited social spontaneity
  • Resists or is unable to maintain a body weight appropriate for their age, height, and build
  • Has intense fear of weight gain or being “fat,” even though underweight
  • Has disturbed perception of body weight or shape
  • Postpuberty female loses menstrual period
  • Has strong need for control
  • Shows inflexible thinking
  • Has overly restrained initiative and emotional expression

Consequences

Anorexia is starvation of the body and the essential nutrients it needs to function properly. The body is forced to slow down and do what it can to protect the resources that it feels are left, leaving it no choice but to start shutting down organs and systems it doesn’t deem as important as others. The human body is extremely resilient and can function under high stress. Many times blood tests and other lab reports can come back normal even when someone is at high risk of system failures. Cardiac arrest and electrolyte imbalances can kill without any warning signs. It is crucial to be aware of other ways the body will react to eating disordered behaviors and understand the effects that these behaviors can have on the human body.

Bulimia Nervosa

Bulimia is characterized by a cycle of binge eating and purging to compensate for it. Whether the purge is self-induced vomiting, compulsive exercise, or some other behavior, it is intended to undo the effects of binge eating episode.

DSM-5 Diagnostic Criteria

  • Frequent binge eating episode. An episode of binge eating is characterized by the following:
    • Eating, in a short time period, an amount of food that is plainly larger than most people would eat during a relative period of time and circumstances.
    • A feeling of loss of control over eating behavior during the episode.
  • Frequent compensatory behavior in order to prevent weight gain, like:
    • self-induced vomiting
    • misuse of laxatives, diuretics, or other medications
    • fasting
    • or excessive exercise.
  • The binge eating and the behaviors to compensate both occur, on average, at least once a week for three months.
  • Self-evaluation is disproportionately influenced by body shape and weight.
  • The disturbance does not occur exclusively during episodes of Anorexia Nervosa.

Symptoms and Signs

Physical Signs

  • Visible fluctuations in weight
  • Body weight is typically within the normal weight range; may be overweight
  • Non-specific gastrointestinal complaints
  • Abnormal laboratory findings (anemia, low thyroid and hormone levels, low potassium, low blood cell counts, slow heart rate)
  • Dizziness
  • Fainting
  • Feeling cold
  • Looks bloated from fluid retention
  • Problems sleeping
  • Cuts and calluses across the top of finger joints because of self-induced vomiting
  • Dental problems, such as enamel erosion, cavities, and tooth sensitivity
  • Dry skin and brittle nails
  • Unusual swelling around cheeks and jaw area
  • Fine hair on body and thinning of hair on head
  • Discoloration of teeth from vomiting
  • Muscle weakness
  • Cold hands and feet
  • Menstrual irregularities
  • Impaired immune functioning

Some common co-occurring conditions that appear with bulimia:

  • Self-injury without suicidal intention
  • Substance abuse
  • Impulsivity
  • Diabulimia (intentional misuse of insulin for type 1 diabetes)

Emotional and Behavioral Signs

  • Difficulty concentrating
  • Usually, behaviors and attitudes express that weight loss and dieting are becoming primary concerns of the individual
  • Evidence of binge eating
  • Evidence of purging behaviors, including frequent trips to the bathroom after meals, signs and/or smells of vomiting, presence of wrappers or packages of laxatives or diuretics
  • Appears uncomfortable eating around others
  • Develops food rituals
  • Skips meals or takes small portions of food at regular meals
  • Disappears after eating, often to the bathroom
  • Any new practice with food or fad diets, including cutting out entire food groups
  • Fear of eating in public or with others
  • Steals or hoards food in strange places
  • Drinks excessive amounts of water or non-caloric beverages
  • Uses excessive amounts of mouthwash, mints, and gum
  • Hides body with baggy clothes
  • Maintains excessive, rigid exercise regimen – despite weather, fatigue, illness, or injury
  • Creates lifestyle schedules or rituals to make time for binge-and-purge sessions
  • Withdraws from usual friends and activities
  • Frequently diets
  • Shows extreme concern with body weight and shape
  • Frequent checking in the mirror for perceived flaws in appearance
  • Extreme mood swings

Consequences

Bulimia is a frequent binge-and-purge cycle that severely disrupts the digestive tract. This can lead to imbalances in the body and effect major systems from functioning properly. The human body is extremely resilient and can function under high stress. Many times blood tests and other lab reports can come back normal even when someone is at high risk of system failures. Cardiac arrest and electrolyte imbalances can kill without any warning signs. It is crucial to be aware of other ways the body will react to eating disordered behaviors and understand the effects that these behaviors can have on the human body.

Binge Eating Disorder

BED is a severe and life-threatening eating disorder that is characterized by frequent episodes of eating large amounts of food in a short amount of time. Often times these episodes leave the person feeling extremely uncomfortable by how full they have become. They might experience a feeling of no control over their consumption of food during a binge episode and usually experience a deep feeling of shame or guilt after. Binge Eating Disorder is different from others because there is no compensatory behaviors after a binge episode. This is the most common eating disorder in the United States and is the newest recognized eating disorder of the DSM-5.

DSM-5 Diagnostic Criteria

  • Frequent binge eating episode. An episode of binge eating is characterized by the following:
    • Eating, in a short time period, an amount of food that is plainly larger than most people would eat during a relative period of time and circumstances.
    • A feeling of loss of control over eating behavior during the episode.
  • The binge eating episodes are identified by three or more of the following criteria:
    • 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, ashamed, or very guilty afterward
  • Marked distress regarding binge eating is present
  • Binge eating occurs, on average, at least once a week for three months

** Binge Eating Disorder is less common than overeating, but much more severe. It is associated with more stress and shame due to the eating behavior, and often shows up with co-occurring psychological problems.**

Signs and Symptoms

Physical Signs

  • Visible fluctuations in weight
  • Non-specific gastrointestinal complaints

Emotional and Behavioral Signs

  • Evidence of binge eating, like large amounts of food disappearing or empty containers and wrappers laying around
  • Appears uncomfortable eating around others
  • Any new practice with food or fad diets, including cutting out entire food groups
  • Fear of eating in public or with others
  • Steals or hoards food in strange places
  • Creates lifestyle schedules or rituals to make time for binge sessions
  • Withdraws from usual friends and activities
  • Frequently diets
  • Shows extreme concern with body weight and shape
  • Frequent checking in the mirror for perceived flaws in appearance
  • Has secret and frequent episodes of binge eating
  • Disruption in normal eating behaviors
    • grazing throughout the day with no planned meals
    • skipping meals or taking small portions of food
    • engaging in random fasting
    • constant dieting
  • Developing food rituals
  • Eating alone out of embarrassment at the quantity of food being eaten
  • Feelings of disgust, depression, shame, or guilt after overeating
  • Feelings of low self-esteem

Consequences

The consequences of Binge Eating Disorder are usually associated with clinical obesity, yo-yo dieting, and weight biases. Of the people who are clinically obese, most of them do not have BED, but of individuals with BED, up to two-thirds are. Most who are diagnosed with BED are of normal or above average weight, but BED can be diagnosed at any weight.

Orthorexia

Orthorexia is not classified as a formally recognized eating disorder in the DSM-5. The term was coined in the late 90s and basically means that a person is obsessed with eating healthy- to the point of damaging their own well-being. Because it is not formally recognized it is hard to know how many people struggle with this disorder. It is still unknown if this would be classified under an already recognized disorder, if it is a stand-alone eating disorder, or if it is a severe form of obsessive-compulsive-disorder (OCD). It is likely that this disorder has co-occurring psychological conditions and other behaviors that are associated with other eating disorder diagnoses.

Signs and Symptoms

  • Obsessive checking of ingredient lists and nutritional labels
  • An obsessive interest about the health of ingredients
  • Eliminating entire food groups from diet
  • An inability to eat anything but the foods that the say are ‘healthy’ or ‘pure’
  • Unusual interest in the health of what others are eating
  • Obsessively thinking about what food might be served at upcoming events
  • Showing high levels of distress when ‘safe’ or ‘healthy’ foods aren’t available
  • Obsessive following of food and ‘healthy lifestyle’ blogs on Twitter and Instagram
  • Body image concerns may or may not be present

Consequences

Most often orthorexia involves restriction of certain food and food groups making malnutrition possible. In severe cases the consequences could be the same as anorexia nervosa.

Diabulimia

Diabulimia was a term created by the media and refers to an eating disorder in someone with diabetes (typically type I). Generally it is characterized by a person purposefully restricting insulin with the primary goal being weight loss.

Those with Type I have to focus on food, labels, A1C levels, and are told to be in control as often as possible. With these requirements and the disruption that occurs in a person’s metabolic system, it creates a high-risk circumstance for the development of an eating disorder. Someone may develop diabulimia at any age or at any point after their diagnosis. It can begin with body image issues or a desire to lose weight. However, many people who are diagnosed with diabetes can experience a sense of burnout that causes them to rebel against the requirements of their disease. Despite its beginning, treatment is challenging for diabulimia and has one of the highest dropout rates.

DSM-5 Diagnostic Criteria

Diabulimia does not have its diagnostic code. An individual’s diagnosis depends on their unique eating disorder behaviors. The DSM-5 says that insulin omission is a purging behavior, so it could be classified as bulimia nervosa if there is any binge behaviors. It could also be diagnosed as anorexia nervosa if the individual is severely restricting both food and insulin.

Signs and Symptoms

Physical

  • Low sodium and/or potassium
  • Frequent bladder and/or yeast infections
  • Irregular or lack of menstruation
  • Deteriorating or blurry vision
  • Fatigue or lethargy
  • Dry hair and skin
  • A1c of 9.0 or higher on a continuous basis
  • A1c inconsistent with meter readings
  • Unexplained weight loss
  • Constant bouts of nausea and/or vomiting
  • Persistent thirst and frequent urination
  • Multiple DKA or near DKA episodes

Emotional and Behavioral

  • Uncomfortable testing/injecting in front of people
  • Obsessively strict rules around food
  • Obsession with food, weight and/or calories
  • Compulsive exercise routine
  • Increase in sleep patterns
  • Disengaged from friends and/or family activities
  • Depression and/or anxiety
  • Not filling prescriptions
  • Increased refusal to manage diabetes
  • Hiding diabetes management
  • Skipping diabetes related appointments
  • Fear of low blood sugars
  • Belief that “insulin makes me fat”
  • Extreme increase or decrease in amount of food eaten
  • Distressed about body image
  • Restricting certain foods to lower insulin usage
  • Avoids eating with people

Consequences

The human body is extremely resilient and can function under high stress and those who suffer from diabulimia are able to live with much higher blood sugars that should be possible. The main consequences of diabulimia are related to prolonged high blood sugar. These consequences are severe and are unable to be reversed once the damage is done. The body isn’t able to use the nutrients put into its body without the help of insulin, so in many cases people with diabulimia are malnourished and their body is in starvation mode. So much like anorexia, cardiac arrest and electrolyte imbalances can kill without any warning signs. It is crucial to be aware of other ways the body will react to eating disordered behavior when it is also effected by diabetes.

Short Term Consequences:

  • Electrolyte imbalance
  • Yeast infections
  • Menstrual disruption
  • Severe dehydration
  • Diabetic Ketoacidosis
  • Muscle atrophy
  • Slow wound healing
  • Staph and other bacterial infection

Long Term Consequences:

  • Heart Disease
  • Liver Disease
  • Kidney Disease
  • Retinopathy
  • Chronic diarrhea
  • Gastroparesis
  • Vasovagel Syncope
  • Peripheral Neuropathy
  • Macular Edema

**Many of these consequences have fatal effect leading to stroke, coma, or death.**

Laxative Abuse

Laxative abuse is a behavior that is characterized by inappropriate and frequent use of laxatives- often after a binge episode. Those who use them believe that they are emptying their body of what they just ate and want to feel ’empty.’ These behaviors are serious and oftentimes very dangerous. Health complications arise out of an imbalance of necessary nutrients that the laxatives are flushing out of the body, and can sometimes be life-threatening.

**Laxatives can not flush out food that is consumed before calories, fat, or sugar is absorbed. When abused and used frequently laxatives are flushing out electrolytes, minerals, water, and colon waste. This “weight” will return once the person drinks a glass of water.**

Consequences

  • Electrolyte and mineral imbalance
  • Laxative dependancy
  • Severe dehydration
  • Interal organ damage

Compulsive Exercise

Also not formally recognized as an eating disorder, but is commonly co-occurring with other eating and psychological disorders. However, treatment and psychological intervention is often necessary.

Signs and Symptoms

  • Avoiding friends and family
  • Secretive or hidden exercise
  • Exercising for the purpose of purging
  • Uncomfortable with rest or inactivity
  • Intense anxiety, irritability, depression, guilt, and/or distress if unable to exercise
  • Exercise that significantly interferes with normal life activities
  • Exercising in spite of exhaustion, injury, or other medical complication
  • Excessive and rigid exercise routine
  • Exercises for the purpose of managing emotions
  • Exercising for the permission to eat food
  • Over-training because of the feeling of not being “enough;” competition

Consequences

  • Frequent illness and upper respiratory infections
  • Frequent fatigue
  • Chronic pain
  • Female Athlete Triad (disordered eating, amenorrhea, and osteoporosis)
  • Loss of menstrual cycle
  • Bone density loss
  • Chronic muscle soreness
  • More frequent injuries
  • Altered resting heart rate

Other Specified Feed or Eating Disorder (OSFED)

Previously known as Eating Disorder Not Otherwise Specified (EDNOS) in the DSM-5. This diagnosis is considered a “catch-all” classification for those who do not fit the strict diagnostic criteria of the other DSM-5 recognized eating disorders, but still had a serious eating disorder. In the past this diagnosis, although the most common in local clinics, was considered less serious and life-threatening than anorexia nervosa and bulimia nervosa. Research is showing that this diagnosis is just as serious and life-threatening as the others.

DSM-5 Diagnostic Criteria

The most recent revisions to the DSM-5 were made to the criteria of anorexia, bulimia, and binge eating disorders so they could be more accurately diagnosed. Because of these revisions OSFED has seen a decrease in diagnoses, but is still common. To be diagnosed with OSFED you must show signs of significant feeding or eating behaviors that causes signs of clinical distress or impairment, but not meet the full criteria of other diagnoses.

Signs and Symptoms

Signs and symptoms of OSFED can be a combination of any other sign or symptoms of the other disordered eating behaviors, compulsive exercise, or laxative abuse.

Consequences

The health consequences for OSFED comes down to the eating disorder behaviors that are actually be expressed. The consequences presented for all other disorders are possible for someone diagnosed with OSFED.

Avoidant Restrictive Food Intake Disorder (ARFID)

Previously referred to as Selective Eating Disorder, ARFID is similar to anorexia in that it is characterized by severe restriction of foods and food groups. However, those who struggle with ARFID do not struggle with body image and are not preoccupied with weight or fears of fatness. In children this is often caused by picky eating, but is extreme in the sense that it stalls weight gain and vertical growth to the point of being behind in development. In adults these behaviors result in weight loss.

DSM-5 Diagnostic Criteria

  • An eating or feeding disturbance that shows itself by frequent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following:
    • Severe loss of weight (or inability to achieve expected weight gain or delayed growth in children).
    • Significant nutrient deficiency
    • Dependence on enteral feeding or oral nutritional supplements
    • Noticeable interference with psychosocial functioning
  • The behavior is not better explained by lack of available food or by an associated cultural environment.
  • The behavior does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way one’s body weight or shape is experienced.
  • The eating behaviors are not attributed to a medical condition, or better explained by another mental health disorder. When this does occur in the presence of another condition or disorder, the behavior exceeds what is usually associated. This would warrant additional clinical attention.

Risk Factors

Just like all eating disorders, the risk factors for ARFID involve a range of biological, psychological, and sociocultural issues. All factors would influence an individuals experience with the diagnosis depending on the unique perspective that the individual has. Not much is known about what increases the risk of ARFID, but here is what they have found:

  • Those with autism spectrum conditions, ADHD, and intellectual disabilities are much more likely to develop ARFID.
  • Children who don’t outgrow normal picky eating, or those who show abnormally severe pickiness, appear to be more likely to develop ARFID.
  • Many children with ARFID also have a co-occurring anxiety disorder.
  • Those with ARFID are at higher risk of having other psychiatric disorders.

Signs and Symptoms

Physical

Because anorexia and ARFID involve the risk of being malnourished, both disorders have similar physical signs and medical consequences.

Emotional and Behavioral

  • Noticeable weight loss
  • Dresses in layers to hide weight loss or stay warm
  • Reports frequent, vague gastrointestinal issues around mealtimes that have no known cause
  • Significant restriction in types or amount of food eaten
  • Only certain textures of food are acceptable
  • Fears of choking or vomiting
  • Lack of appetite or interest in food
  • Short list of preferred foods that becomes shorter over time
  • No body image issues or fear of weight gain

Increased Risk Factors

Social

  • Historical Trauma to a people group or region
  • Assimilation to Western culture
  • Bullying and/or teasing
  • Weight stigma (e.g. the message that ‘thinner is better’)
  • Internalization of the ideal appearance
  • Loneliness and isolation; limit of social networks

Biological

Psychological

  • Behavioral inflexibility
  • Dissatisfaction with body image
  • Perfectionism
  • Personal history of an anxiety disorder

Co-occurring Disorders

Eating disorders are often joined by a co-occurring disorder. These disorders could have preceded the eating disorder, developed because of the distressed caused by the eating behaviors, or could have begun around the same time as the eating disorder.

  • Anxiety
  • Depression
  • Obsessive Compulsive Disorder (OCD)
  • Pregnancy
    • Due to stress of change and difference in hormones this season can trigger an eating disorder or bring about disordered eating behaviors
  • Substance Abuse
  • Trauma & PTSD

Myth Busting

  1. Do parents cause eating disorders? No.
  2. Does everyone have an eating disorder these days? No.
  3. Are eating disorders really that serious? Yes. Click Here to find out why.
  4. Are eating disorders a gender thing? No.
  5. Are eating disorders an age thing? No.  Click Here for 4 things you learned as a child that are ruining your relationship with food now.
  6. Does recovery take a long time? Depends on the person.
  7. If it is biological, can I recover? Yes
  8. Are eating disorders a choice? No.

Recovery Process

Eating disorder recovery is a long process that is not linear, but rather a cycle, nor does it look the same for any two people. A successful recovery requires a team of qualified professionals and a support team of friends and family for the individual fighting for recovery.

Click Here to learn how to help a loved one with an eating disorder.

Stages of Change

Pre-contemplation

Here, the person is in denial and does not believe that there is an issue with their behavior. Oftentimes the individual will get very defensive on the topic of food or their behaviors toward it. It is crucial to gently make the person aware of their behaviors and the effects that the disorder is having on their health and life.

Contemplation

In this stage the individual is willing to accept that there might be a problem and might be open to receiving help. Most of the time this stage is accompanied by fear of change, but they are much more likely to be persuaded by a therapist or loved ones of the benefits and hope there is in recovery.

Preparation

This is the stage where the person is willing to change, and wants to, but has no idea how to do it. They spend time evaluating coping mechanisms, creating tangible practices to fight off negative E.D. thoughts, setting appropriate boundaries, and tending to their needs in terms of self-care. This is the time that a team of professionals comes together with the family and individual to create a plan of action for treatment.

Action

Here, the individual implements their strategy for treatment and starts fighting the eating disorder head-on. They start practicing their new behaviors and ways of thinking, as well as implementing regular and healthy self-care and coping mechanisms.

Maintenance/Relapse

Reaching this point is evidence of a successful action stage for 6 months or longer. During this stage it is also crucial to revisit past/potential triggers to prevent possible relapse in the future. They are also encouraged to find new hobbies and interests to fill the space that was preoccupied with the eating disorder before and go on to live life in a meaningful way.

Possible 6th Stage

This part of recovery (click here for my own story.) is about choosing whether or not to continue treatment and meeting with the treatment team. The best way to find out if they are ready to discontinue treat is to sit down with their team and talk about the plan of action for a life without treatment. Most often they would have a relapse prevention plan in place, and also commit to returning to treatment in the case of relapse.

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