Diagnosing eating disorders isn't straightforward. For one thing, eating disorders don't look how many people think they look, allowing them to hide in plain sight. For another, there are several different eating disorder diagnoses, and some of them aren't widely known about or understood.
There's been increasing awareness, visibility, and discourse around eating disorders, but 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 eating disorder diagnosis. Not only that, but viewing eating disorders this narrowly does real damage to the 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—which is 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 eating disorder diagnoses in people who aren't visibly malnourished or aren't white. And behaviors that characterize illnesses like bulimia nervosa or binge eating disorder—like binge eating and purging—are commonly kept secret, so they often won't come up in a doctor visit, even if a patient is explicitly asked." This is deeply concerning given that, left untreated, the health repercussions of these other eating disorder diagnoses are significant and include potential death, either as a direct or indirect result.
To provide a better sense of the complex and nuanced ways that eating disorders show up in the world, we're taking a close look at the five eating disorder diagnoses currently in 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. But remember, even these five diagnoses can't paint the full picture of the eating disorder spectrum; people can exhibit symptoms of an eating disorder or disordered eating in countless different ways. If you're concerned about yourself or a loved one, seek out help from a professional.
Avoidant Restrictive Food Intake Disorder (ARFID)
ARFID is an eating disorder diagnosis that was introduced in the most recent version of the DSM, which was published in 2013. 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 a person will eat. While ARFID is similar to anorexia in that it involves restriction, that restriction is almost never tied to the body image distress or fear of fatness that is characteristic of anorexia.
There are many diagnostic criteria for ARFID, but at the basic level, it involves an avoidance of food and eating. There are three subtypes of ARFID, which are related to the particular reason that a person avoids food:
- General lack of interest in eating (often with an inability to feel hunger cues)
- Sensory issues (i.e., avoiding certain textures, colors, or smells)
- Fear of an averse consequence from eating (like choking, vomiting, or an allergic reaction
As with all eating disorders, there are many biological, sociocultural, and psychological risk factors that may make a person more susceptible to developing ARFID, making it difficult to pinpoint one cause. However, experts do know that people with autism spectrum conditions are much more likely to develop ARFID, as are individuals with ADHD and intellectual disabilities.
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 is perhaps the most well known eating disorder diagnosis, but far fewer people are diagnosed with it than with other eating disorder diagnoses described here. 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 body sizes. It also affects people across ages, genders, sexual orientations, races, and ethnicities. That means you cannot tell if a person is struggling with anorexia (or any eating disorder) just by looking at them.
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. Individuals who are at a weight that’s considered at or above an “average” range for their age, sex, and height, but who exhibit the other symptoms of anorexia, may be diagnosed with an eating disorder known as “atypical anorexia.” It is important to remember, however, that atypical anorexia carries almost all the same health risks as anorexia, including cardiac arrest and death, and 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).
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 is characterized by episodes of uncontrolled overeating, otherwise known as binges, followed by episodes of purging to "get rid of" the calories consumed. 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 after binge eating. 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 diagnosis 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), a diagnosis that has now been replaced by 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 an illness if it's not one of the official DSM eating disorder diagnoses. 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 eating disorder diagnoses. 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.
Eating disorders are serious, life-threatening mental illnesses, but lasting recovery is possible with the right treatment. Of course, the difficulty of diagnosing eating disorders often means that many people go without treatment—so we're hopeful that educational articles like this will open more eyes to the variety of different eating disorder diagnoses and the different ways they might show up in the world.
If you think you or someone you love is struggling with an eating disorder, early intervention is critical. Schedule a consultation to get a professional assessment and learn about treatment options.
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