The signs and symptoms of an eating disorder might not be what you think they are. 

Despite the increasing awareness, visibility, and discourse around eating disorders, societal stereotypes and preconceived notions still abound. “The stock photo on most media articles about eating disorders is a sad, thin, white woman on a scale, and the image that comes to mind is a skeletal body damaged by severe malnutrition,” says Equip’s VP of clinical programs, Cara Bohon, PhD. “But those images only represent one segment of a population and a single diagnosis. Not only that, but viewing eating disorders this narrowly does real damage to those people struggling with these illnesses who do not look like those images — and that's actually most people with eating disorders!”

Bohon explains that while anorexia — characterized by severe food restriction, malnutrition, and a fear of weight gain — is the disorder that most often comes to mind for people because of those pervasive media images, binge eating disorder (BED) and bulimia nervosa are actually more common, and there are also other, lesser known eating disorders like Avoidant Restrictive Food Intake Disorder (ARFID). In fact, according to the National Eating Disorder Association (NEDA), BED is three times more common than anorexia and bulimia combined, and it’s also more common than breast cancer, HIV, and schizophrenia.

“It's important to highlight the dangers of these other illnesses because failing to do so means that people live with dangerous disorders and don't seek treatment,” Bohon says. “Doctors miss the diagnoses in people who aren't visibly malnourished or aren't white. And behaviors that characterize illnesses like bulimia nervosa or binge eating disorder — notably binge eating and purging — are commonly kept secret, so they won't come up in a doctor visit unless explicitly asked. And yet electrolyte imbalances from frequent purging in bulimia nervosa or purging disorder can result in death if these illnesses go untreated.”

To get a better sense of the vast array of complex and nuanced eating disorders out there, take a look at the list below (but know that even these five diagnoses don’t paint the full picture of the eating disorder spectrum and individuals can exhibit symptoms of disordered eating in a myriad ways):

Avoidant Restrictive Food Intake Disorder (ARFID) 

ARFID is a diagnosis that was introduced in the most recent version of the The Diagnostic and Statistical Manual of Mental Disorders (DSM), the clinical tool published by the American Psychiatric Association that medical professionals use to formally diagnose mental illnesses. Prior to the publication of the DSM-V, ARFID was known as “Selective Eating Disorder” because it involves limiting the amounts or types of food. While ARFID is similar to anorexia in the sense of restriction, it doesn’t involve the same level of anxiety and distress over body image or fear of fatness that is characteristic of anorexia.

There are many diagnostic criteria to ARFID, but at the basic level, it involves an apparent lack of interest in food or eating based on some sort of sensory characteristic of the food itself. For example, someone with ARFID may have an aversion to specific foods because of how they taste, look, or smell.

As with all eating disorders, there are many biological, sociocultural, and psychological risk factors that may make a person more susceptible to developing ARFID, but experts do know that people with autism spectrum conditions are much more likely to develop ARFID, as are individuals with ADHD and intellectual disabilities. In a group of adolescents with eating disorders receiving treatment at a specialist clinic, 14% met criteria for ARFID, and those who had it were more likely to be young and male. 

Unfortunately, the potential long-term complications of ARFID can be severe, since the body is not receiving adequate nutrients and may shut down in an effort to conserve energy. People with ARFID may also be at risk for electrolyte imbalances, which can lead to sudden death.

Signs of ARFID include:

• Significant weight loss
• Constipation, abdominal pain, and other gastrointestinal distress
• Will only eat certain textures of food
• Dramatic restriction in types or amount of food eaten, and the list of acceptable foods grows smaller over time
• Lack of appetite or interest in food
• Fear of vomiting

Anorexia nervosa 

Anorexia nervosa is perhaps the most well known eating disorder, but far fewer people are diagnosed with it than with illnesses like BED. That said, as the diagnostic criteria for anorexia has evolved over time and researchers have started relying  on broader definitions that more accurately reflect the range of symptoms, more recent studies indicate a higher prevalence of anorexia (and all eating disorders).

In general, anorexia involves an intense fear of weight gain, even when an individual is considered medically underweight. Although it’s characterized by weight loss or lack of appropriate weight gain in growing children, anorexia can affect people of all ages, genders, sexual orientations, races, and ethnicities, and body types. That means you cannot tell if a person is struggling with anorexia (or any eating disorder) just by looking at them, and studies have found that individuals in larger bodies can also be affected by the disorder, although cultural biases, fat phobia, and prejudice may make them less likely to receive accurate diagnoses and care. 

Individuals who are at a weight that’s considered at or above an “average” range for their age, sex, height, etc. may be diagnosed with a subtype of anorexia known as “atypical anorexia.” It is important to remember, however, that medical definitions and parameters around “average” weights can be flawed, problematic, and stigmatizing, so weight alone is never a reliable or accurate way to diagnose an eating disorder.

According to NEDA, between 0.3-0.4% of young women and 0.1% of young men will suffer from anorexia nervosa at any point during their lifetimes. One study indicated that the lifetime prevalence by age 20 for atypical anorexia in females is 2.8% (compared to 0.8% for anorexia in the same population of 496 adolescent girls).

According to the DSM-V, people with anorexia nervosa restrict their food intake in a way that leads to significantly low body weight and have an overwhelming fear of gaining weight, as well as distorted body image. People with atypical anorexia typically show the same symptoms of anorexia but don’t necessarily exhibit low body weight. But again, even individuals who aren’t “underweight” can struggle with anorexia and anyone affected by the disease is subject to its very serious health risks, including cardiac arrest and death.

Signs of anorexia include:

• Extreme weight loss or not making expected developmental weight gain
• Soft, downy hair covering the body
• Constipation, abdominal pain, and other gastrointestinal distress
• Loss of period in those who have menses
• Severely restricting food intake through dieting or fasting
• Exercising excessively
• Frequently skipping meals or refusing to eat
• Preoccupation with food, which sometimes includes cooking elaborate meals for others but not eating them
• Adopting rigid meal or eating rituals, such as spitting food out after chewing
• Not wanting to eat in public

Bulimia nervosa 

Bulimia nervosa is characterized by uncontrolled episodes of overeating, otherwise known as bingeing, followed by purging. There are a variety of methods people with bulimia use to purge what they’ve consumed during a binge, but vomiting and/or the misuse of laxatives are the most common forms of purging. During a binge, a person often eats a much larger quantity of food than they normally would in a short amount of time — usually less than two hours — and feels unable to stop or control the behavior. People with bulimia may binge and purge several times a week or even multiple times throughout the day, but there are nuances and exceptions in a variety of cases. According to NEDA, 1.0% of young women and 0.1% of young men will meet diagnostic criteria for bulimia at some point in their lives.

Unlike many (but not all) individuals with anorexia, those with bulimia often maintain what is labeled by society as an “average” or “above average” body weight which can make diagnosis much tougher. It’s also important to know that not all individuals with bulimia use self-induced vomiting, laxatives, or enemas to purge — “non-purging” bulimia may involve behaviors like fasting or excessive exercise.

Signs of bulimia include:

• Frequent visits to the bathroom, particularly after meals
• Excessive exercising
• Preoccupation with body image
• Intense fear of gaining weight
• Using laxatives, diuretics or enemas after eating when they're not needed
• Fasting, restricting calories or avoiding certain foods between binges
• Using dietary supplements or herbal products excessively for weight loss
• Feeling guilty or shameful about eating
• Withdrawing socially from friends and family

Binge Eating Disorder (BED) 

Binge eating disorder is characterized by recurrent binges accompanied by a feeling of a loss of control, as well as shame, distress, or guilt after the binge. Unlike those affected by bulimia, individuals with BED don’t purge. According to NEDA, BED is the most common eating disorder in the United States. A 2007 study found that 3.5% of women and 2.0% of men had binge eating disorder during their lifetime. Some of the medical complications of BED include physical ailments like diabetes, heart disease, and some types of cancer, as well as an increased risk for psychiatric illnesses, especially depression.

BED was only recently introduced in the DSM and is now officially recognized as an eating disorder in the DSM-V. Prior to the publication of the DSM-V, BED was listed as a subtype of Eating Disorder Not Otherwise Specified (EDNOS), which is now referred to as Other Specified Feeding or Eating Disorders (OSFED). The recognition of BED as a separate disorder is significant because in many cases, insurance companies in the U.S. will not cover the cost of treatment for illnesses lacking an official DSM diagnosis. People who struggle with BED are often considered what is labeled by society as “average” or “above average” in weight, but anyone can struggle with the illness, regardless of the number on the scale.

Signs of binge eating disorder include:

• Evidence of binge eating, including disappearance of large amounts of food in short periods of time or lots of empty wrappers and containers indicating consumption of large amounts of food
• Appears uncomfortable eating around others
• Any new practice with food or fad diets, including cutting out entire food groups (no sugar, no carbs, no dairy, vegetarianism/veganism)
• 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
• Shows extreme concern with body weight and shape
• Fluctuations in weight, both up and down
• Feelings of low self-esteem
• Stomach cramps, other non-specific gastrointestinal complaints (constipation, acid reflux, etc.)

Other Specified Feeding or Eating Disorders (OSFED)

OSFED is diagnosis that used to be called Eating Disorder Not Otherwise Specified (EDNOS) prior to the publication of the DSM-V. This diagnosis is considered a general “catch-all” classification for eating disorders that may not fit the exact diagnostic criteria of other formally recognized disorders. According to NEDA, the majority of individuals with eating disorders treated in community clinics were historically diagnosed with EDNOS.

While it may be a more general diagnosis, OSFED can be just as serious as other eating disorders and can result in hospitalization for the same types of medical complications prevalent in anorexia and bulimia. In fact, individuals with OSFED are just as likely to die from their illness as people with anorexia or bulimia.

Because OSFED is such a variable condition, there are a vast array of symptoms and warning signs and the illness can look different from person to person. In general, however, people with OSFED exhibit behaviors and attitudes that suggest dieting, weight loss, and/or control of food are major concerns and sources of anxiety. Some people with OSFED experience  dramatic changes in weight, but not all, and it is impossible to diagnose an eating disorder of any kind based on appearance alone.

If you or someone you know is struggling with any symptom(s) of disordered eating, it’s important to seek out help and support as soon as possible. Recovery from all eating disorders is possible, but often requires an integrated, multipronged approach involving medical, psychological, and emotional care.

Please reach out to our Admissions team at join@equip.health or (855) 387-4378 if you are interested in learning more about eating disorder treatment with Equip.