Eating disorders are serious and life-threatening illnesses. They do not discriminate. People of all ages, socioeconomic statuses, races, and genders may develop an eating disorder. Symptoms of eating disorders may be seen in children as young as four years old, and people as old as 90+ years old are being diagnosed as well. In my experience, most people have heard of eating disorders, but many do not know much about them unless they or someone they love have experienced one first hand. Here we will learn about commonly seen eating disorder signs and symptoms and when to ask for help.
I have worked with people who struggle with eating disorders for over a decade, and in those years, the field has changed and evolved. We now have several different diagnostic categories to define eating disorders, including:
- anorexia nervosa
- bulimia nervosa
- binge eating disorder
- other specified feeding/eating disorder
- avoidant/restrictive food intake disorder.
The first two diagnoses may be more familiar to you. However, the last three have only been formally in use since late 2015. Regardless, all of the eating disorder diagnoses are serious mental, and physical, disorders that often require intervention to achieve recovery.
Symptoms Seen Across the Diagnoses
The most common symptoms of eating disorders include:
Food restriction is defined as eating less than what is needed to maintain weight and/or healthy body function. Restriction comes in many forms. For example, caloric restriction is where a person counts and decreases the amount of calories they eat in a day. People may also start skipping meals or snacks, and will often stop eating around others.
Food restraint is another form of restriction. A person may cut out entire food groups or follow strict rules regarding what foods they are allowed to eat despite possibly still eating a sufficient amount of calories.
Food restriction causes the body to go into starvation mode. In this state, one can experience:
- weight loss
- nutrient deficiency
- metabolic changes
- mood changes
- increased anxiety
- cardiac issues
- loss of reproductive function
- issues with temperature regulation
If left untreated, food restrictive behaviors can also lead to death.
Binge eating is first and foremost characterized by a sense of loss of control during eating. An objective binge episode is eating what most people would consider to be an objectively large amount of food given the context/circumstances in a discrete period of time (i.e. two hours or less) in an out of control manner. A subjective binge episode is eating a typical amount of food given the context/circumstances, but with the same sense of loss of control.
Binge eating is characterized by:
- eating more rapidly than normal
- eating despite not feeling physically hungry (i.e. for emotional reasons)
- consuming food past the point of physical fullness
- eating alone to avoid judgment from others
Individuals feel depressed, guilty, or ashamed after engaging in these behaviors.
Compensatory behaviors are any behaviors a person engages in after eating to “make up” for having eaten. This includes:
- self-induced vomiting (often referred to as purging)
- laxative abuse
- diet pill abuse
- diuretic abuse
- enema abuse
- compulsive or excessive exercise.
Compensatory behaviors can have severe, and possibly deadly, medical consequences. For example, self-induced vomiting can result in dental concerns, tearing or scarring of the esophagus, and electrolyte imbalance which can lead to heart attack and death.
Over-Evaluation of Weight and Shape/Negative Body Image
While many people struggle with negative body image, people who struggle with eating disorders almost certainly struggle, often to an extreme degree. The exception to this is those who are diagnosed with Avoidant/Restrictive Food Intake Disorder. Within this diagnosis, the underlying factors contributing to an individual’s symptoms are thought to be unrelated to body perception. Research indicates that people with anorexia nervosa also struggle with perceptual distortion when it comes to seeing their bodies; meaning they literally see themselves as larger than they are in reality. Negative body image is often one of the first symptoms to “arrive on the scene,” and one of the last resolved in the recovery process.
How Do I Know If Someone I Love Is Struggling
It can be difficult to know for sure whether someone you love might be struggling with these symptoms without them telling you, but there are signs that you can look out for.
Signs and Symptoms:
- Dramatic/noticeable weight loss (or falling off of the growth chart curve in children/adolescents) is one of the most easy to recognize. Although your loved one might try to hide their body by wearing loose or baggy clothing more often.
- Signs of food restriction might include pushing food around on the plate but not eating much, hiding food in napkins, and taking small bites. Other restrictive behaviors include not eating around others or claiming to have already eaten when asked to join a meal/snack, and increased preoccupation with food.
- Signs of bingeing include food going missing unexpectedly, or food wrappers/packaging being found in strange places (closets, under the bed, underneath the top layer of garbage).
- Compensatory behaviors include using the restroom right after meals, taking longer than normal showers, cancelling plans to exercise, and empty packages of diet pills/laxatives/enemas.
You may also hear your loved one talking more often about their body, wanting to lose weight, checking their appearance in the mirror, or weighing themselves frequently.
Unfortunately, our current society and diet/fitness culture tends to idealize and promote many of the behaviors commonly seen in eating disorders. The majority of people with eating disorders will talk about how they received praise, rather than concern, from others when they first started struggling with symptoms. If any of these symptoms feel familiar to you, I strongly encourage you to seek help for yourself or your loved one.
Regrettably, most mental health and medical providers are not specifically trained in the treatment of eating disorders. However, talking to your current psychotherapist or primary care provider about your concerns is a good place to start. They can often help identify providers in your community who are trained in working with people with eating disorders. There is also a link at the bottom of this article to find eating disorder treatment resources near you. Once you meet with a trained provider, they will complete a diagnostic assessment to determine if you or your loved one meet criteria for the following eating disorder diagnoses.
Understanding the Diagnoses
Let’s clarify the specifics of each eating disorder diagnosis.
People diagnosed with anorexia nervosa (AN) engage in food restriction to the point where they reach a significantly low body weight compared to the weight necessary for optimal bodily function. They also have an intense fear of weight gain. They may also persistently engage in behaviors that prevent weight gain despite being at a low weight. Additionally, as described above, people with AN demonstrate a disturbance in the way they experience their weight and/or body shape. People with AN may also struggle with binge eating and or compensatory behaviors, though this is not a requirement for the diagnosis.
People with bulimia nervosa (BN) struggle with engaging in objective binge episodes and compensatory behaviors at least one time per week for a period of at least 3 months. They also demonstrate negative body image as described above. In order to meet criteria for BN, a person may not experience the symptoms during an episode of anorexia nervosa. A person cannot be diagnosed with both anorexia and bulimia at the same time.
Binge Eating Disorder
People with binge eating disorder (BED) engage in objective binge episodes at least one time per week for a period of at least 3 months. Characteristics of binge episodes include at least 3 of the following:
- eating more rapidly than normal
- consuming large amounts of food when not physically hungry
- eating until feeling uncomfortably full
- eating alone because of feeling embarrassed
- feeling disgusted, depressed, or guilty/ashamed afterward.
The binge eating must cause marked distress, and the individual must not engage in compensatory behavior or meet criteria for anorexia or bulimia. Often, people with binge eating disorder will be trapped in a restrict-binge cycle of under-eating for a period of time, then binge eating when they can no longer maintain the restriction.
Other Specified Feeding/Eating Disorder
People with other specified feeding/eating disorder (OSFED) struggle with symptoms characteristic of an eating disorder that cause distress or impairment in functioning. However, they do not meet full criteria for the other disorders. For example, if a person binges and purges two times per month, they would not meet criteria for bulimia nervosa. But this person still clearly struggles with an eating disorder. In this case, the provider would diagnose OSFED.
Avoidant/Restrictive Food Intake Disorder
People with avoidant/restrictive food intake disorder (ARFID) struggle with restriction of intake leading to:
- significant weight loss/failure to remain on growth curve
- nutritional deficiency
- dependence on enteral feeding or nutritional supplements
- marked interference with functioning.
People with ARFID do not demonstrate negative body image or fear of weight gain. Rather, they often want to gain weight as they are aware of being underweight and do not want to appear as such. Instead, their food restriction is often due to an apparent lack of interest in eating or food, avoidance based on the sensory characteristics of food, and/or concern about aversive consequences (choking, vomiting, etc.).
A Path Ahead
As I’ve already mentioned, eating disorders are serious illnesses. The risk of death from an eating disorder is second only to opioid addition of all the mental health disorders. There is no known single cause of eating disorders. Yet, we do know that genetics, history of dieting, and societal and family messages can contribute to the development of an eating disorder. Unfortunately, about a third of people who develop an eating disorder will struggle with the disorder for their lifetime. The good news is that the majority of people do recover. Early identification and treatment of eating disorders lead to better lifetime outcomes.
If you think you or someone you know might be struggling with an eating disorder, seek an assessment with a professional. The worst that can happen is that you complete the assessment and learn that you don’t actually have an eating disorder! If you are diagnosed with an eating disorder, know your participation in treatment might be hard. However, it will also help you create a life not ruled by food or the number on the scale.
When my patients reach the end of treatment and are ready to continue their recovery on their own, I always ask them what they have learned that they will carry with them going forward. The response I get the most often? “The freedom to be myself.”