Feeding & Eating Disorders

Characteristics of Feeding and Eating Disorders

File photo | Credit: CNN HealthOpens in new window Changes in eating and eating-related behavior may be a feature of various mental disorders (e.g., losing weight during a depression because the individual does not have an appetite); thus, eating disturbances in and of themselves do not indicate that a Feeding & Eating Disorder is present.

However, the disorders classified in the DSM-5 chapter “Feeding & Eating Disorders” are those whose primary manifestations are persistent disturbances in “eating or eating-related behavior that result in the altered consumption or absorption of food and that significantly impair physical health or psychosocial functioning” (DSM-5, p. 329).

American Psychiatric Association’s DSM-5 diagnostic criteria include picaOpens in new window, rumination disorderOpens in new window, avoidant/restrictive food intake disorderOpens in new window, anorexia nervosaOpens in new window, bulimia nervosa, and binge-eating disorders.

With these disorders, a person’s eating can be disturbed in any of several ways, including by persistently eating things that are not normally considered food (a condition known as PicaOpens in new window), repeatedly regurgitating food before it has been absorbed in the gastrointestinal tract (called Rumination DisorderOpens in new window), not eating enough food for a variety of reason other than to be thin (called Avoidant/Restrictive Food Intake Disorder; ARFIDOpens in new window), starving oneself in order to be extremely thin (called Anorexia NervosaOpens in new window), binge eating and purging (called Bulimia NervosaOpens in new window), and binge eating without purging (called Binge-Eating DisorderOpens in new window). (Table X-1 lists characteristic features of these Feeding & Eating Disorders.).

Eating disorders involve unhealthy attitudes about food that are associated with abnormal eating behaviors. People experiencing these disorders struggle with low self-esteem and emotional difficulties linked to the demands of adult roles, occupations of daily living, and relationships (Crisp, 2006b; Morris, 2012). They experience a constant battle to eat in a normal, healthy way, resulting in either “over-controlled” (restrictive) or “out of control” (dysregulated) eating patterns, or both. Their daily occupations become focused on either weight reduction or weight gain avoidance. They develop maladaptive eating and lifestyle habits because of limited stress management, psychological, social, and life skills (Bulik, Brownley, Shapiro, & Berkman, 2012; Cusack, 2014).

Eating disorders are associated with psychological disorders as well as compulsive behaviors, including excessive exercise and food hoarding. They are complex disorders and can interfere with general health as well as the ability to maintain a healthy body weight.

Restricted eating can lead to low blood pressure, bone thinning, and organ failure in individuals who are severely underweight. Individuals who are overweight or obese are at risk for cardiovascular disease, diabetes, and metabolic syndrome.

In general, females have a higher incidence of eating disorders than males. The onset of eating disorders is generally adolescent or young adult years, but children and adults are also susceptible. In particular, older adults can become disinterested in eating or less sensitive to physiological signals of hunger.

Disordered eating is more discreet and difficult to recognize than eating disorders because it encompasses a wide spectrum of eating patterns that may not necessarily be perceived as abnormal behaviors and may not be regularly or consistently practiced daily. Examples of disordered eating include the restriction or elimination of certain foods from one’s diet, for example, eliminating fats or carbohydrates.

Other disordered eating behaviors may include general caloric restriction, compulsive dieting or fasting, poor food selections, and the use of laxatives, diuretics, or diet pills for the purpose of losing weight or increasing lean body mass.

Individuals who adopt vegetarian (and vegan) diets for the sole purpose of losing weight or becoming lean may also practice behaviors that fall under the classification of disordered eating. Often the rationale for adopting the behavior, rather than the behavior itself, may be the delineating factor between normal behavior and a pathological response.

Disordered eating is often considered benign to the health of an individual because it may not inevitably affect one’s long-term health or ability to function in society. In children, adolescents, and some genetically susceptible individuals, however, disordered eating may be a risk factor for the development of a clinical eating disorder.

While there is no DSM category specific to orthorexia, the obsessional preoccupation with eating “healthy foods,” focusing on concerns regarding the quality and composition of meals with rigid avoidance of foods believed to be “unhealthy” may be considered within the avoidant/restrictive food intake disorder (ARFID)Opens in new window.

PicaOpens in new window is the persistent eating of nonnutritive, nonfood substances over a period of at least one month. Rumination disorderOpens in new window is characterized by the repeated regurgitation of food over a period of at least one month, and regurgitated food may be rechewed, reswallowed, or spit out.

It has been suggested recently by the International Olympic Committee that the term relative energy deficiency in sport (RED-S) be introduced. The syndrome of RED-SOpens in new window refers to impaired physiologic functioning caused by relative energy deficiency and includes, but is not limited to, impairments of metabolic rate, menstrual function, bone health, immunity, protein synthesis, and cardiovascular health. The etiological factor of this syndrome is low energy availability (LEA). A consensus on the use of this term is still being discussed.

Etiology and Risk Factors

The etiology of eating disorders is discussed elsewhereOpens in new window. However, relevant risk factors include personality traits or disorders such as perfectionism, rigidity, and risk aversion. Dieting and family history of eating disorders, social pressure such as military personnel obligated to adhere to certain weight requirements, elite athletic performance, or activities valuing thinness such as dancing, gymnastics, modeling, and acting are also common risk factors.

A personal or family history of obesity, drug or alcohol abuse, depression, or sexual abuse or other forms of trauma are additional risk factors for this type of disorder. Family issues such as separation, divorce, parental/guardian overinvolvement, or abandomment are risk factors for eating disorders. Critical comments about eating from teacher/coach/siblings and a history of depression have also been reported as potent risk factors.

Disordered eating can occur in male and female individuals alike. Any factor that causes a person to restrict dietary intake or exercise for prolonged periods of time could be considered a risk factor for disoredered eating and low energy availability, whether the behavior is intentional or not.

Gender differences in body composition and societal influences and expectations regarding body image may explain why women may be more susceptible to disordered eating than men. Risk factors for disordered eating may go unrecognized because these practices are often considered to be acceptable and harmless.

Up to 20% of women with type 1 diabetes mellitus have an eating disorder; this, in turn, predisposes them to further complications with glucose control.

The treatment of diabetes mellitus greatly emphasizes weight control, dietary habits, and food. This focus, combined with stress, poor self-esteem, and altered body image that can result from any chronic illness, contributes to the risk of eating disorders in this population.

In addition, these individuals may discover that they can lose weight through excessive urination, noting that by skipping insulin injections, hyperglycemia can be induced. This practice leads to a higher mortality rate for individuals who have anorexia coupled with type 1 diabetes mellitus and is commonly referred to as diabulimia.

Treatment

Prevention, early detection, and early treatment are critical in the management of eating disorders. Education efforts should be focused on students in early middle school or junior high because of the rapid bone formation during puberty and the increased role of hormones on health that will continue for the rest of their lives.

Targeting preventive interventions when there are high weight and shape concerns, a history critical comments about eating, weight, and shape, and a history of depression may reduce the risk for eating disorders.

The prevention of eating disorders in at-risk college-age women has been demonstrated using an eight-week internet-based cognitive behavioral psychosocial intervention. Women with weight and shape concerns participated with follow-up for three years with appropriate weigth reduction and decreased risk for eating disorders. Other online family-based programs for adolescents have provided easily accessible, brief programs when therapist support is minimal or unavailable.

Prognosis

The role of pharmacology has increased in the treatment of eating disorders with the availability of antidepressants such as SSRIs and SNRIs. These medications help control depression, anxiety, and compulsive behaviors (especially around food and exercise) so that behavioral, cognitive, and family therapy can be more effective.

Seventy (70) percent of people with eating disorders can be cured. However, it may take years, and the chance of relapse on the road to recovery is as high as 30%, but the overall prognosis is better than for individuals with bulimia nervosa.