My personal story: I struggled with eating as a child. We had the ‘eat all that is on your plate” rule at my house. I did not like some of the food and later discovered I was allergic to milk, beef, bread, and other foods. As I matured, I found I had other allergies that made it hard to eat a normal diet.
At one point in my teen years, I was raped. That event had many emotional triggers and relationship issues, including body image and relationship with food. I did not know much about anorexia nervosa and did not realize I was starving my body.
I noticed I was never hungry, I was always tired, and strangest of all, I had hair growing on my back. Years later, I realized this was all part of being Anorexic. I struggled with body image, and as a mature adult, I still struggle with it but have learned to love myself at any weight. I am not saying it is or was easy for me. It was one of the hardest things I had to overcome. I never got hungry, I counted calories, I took out foods from my diet, I walked a lot, and I would cry when I went up a pant size.
Learning CBT and trusting in my higher power (Jesus) for strength allowed me to come to a place where I began to learn to like myself and eventually love myself. Is my ED over? I would say; ‘no’ only because I have gained that middle-age weight and tend to hate myself from time to time but do I starve myself? no, I don’t over -exercise, bindge or purge, I don’t restrict my diet, but I do try to keep things in moderation and use thought stopping to remind myself- I am ok just as I am.
We work with clients who suffer from eating disorders to use CBT. We understand eating disorders and their severity on a client and their family. We also work with the family to understand this disorder’s signs, symptoms, and challenges.
According to the American Psychiatric Association–
“Eating disorders are behavioral conditions characterized by severe and persistent disturbance in eating behaviors and associated distressing thoughts and emotions. They can be severe conditions affecting physical, psychological, and social function. Types of eating disorders include anorexia nervosa, bulimia nervosa, binge eating disorder, avoidant restrictive food intake disorder, other specified feeding and eating disorder, pica and rumination disorder.”
The DSM5 classifies eating disorders in the following categories:
Anorexia nervosa is characterized by self-starvation and weight loss resulting in low weight for height and age. Body mass index or BMI, a measure of weight for height, is typically under 18.5 in an adult individual with anorexia nervosa. Anorexia has the highest mortality of any psychiatric diagnosis other than opioid use disorder and can be a severe condition.
Dieting behavior in anorexia nervosa is driven by an intense fear of gaining weight or becoming fat. Although some individuals with anorexia will say they want and are trying to gain weight, their behavior is inconsistent with this intent. For example, they may only eat small amounts of low-calorie foods and exercise excessively. Some persons with anorexia nervosa also intermittently binge eat or purge by vomiting or laxative misuse.
There are two subtypes of anorexia nervosa:
- restricting type, in which individuals lose weight primarily by dieting, fasting, or excessively exercising, and
- binge-eating/purging is when people also engage in intermittent binge eating and/or purging behaviors.
Over time, some of the following symptoms may develop related to starvation or purging behaviors:
- Menstrual periods cease
- Dizziness or fainting from dehydration
- Brittle hair/nails
- Cold intolerance
- muscle weakness and wasting
- Heartburn and reflux (in those who vomit)
- Severe constipation, bloating, and fullness after meals
- Stress fractures from compulsive exercise as well as bone loss resulting in osteopenia or osteoporosis (thinning of the bones)
- Depression, irritability, anxiety, poor concentration, and fatigue
Serious medical complications can be life-threatening and include heart rhythm abnormalities, especially in those patients who vomit or use laxatives, kidney problems, or seizures.
Treatment for anorexia nervosa involves helping those affected normalize their eating and weight control behaviors and restore their weight. The nutritional plan should focus on assisting individuals in countering anxiety about eating and consuming a broad and balanced range of foods of different calorie densities across regularly spaced meals. For adolescents, the most effective treatment involves training parents to support and monitor their child’s meals. Addressing body dissatisfaction is also essential, but this often takes longer to correct than weight and eating behavior. Medical evaluation and treatment of any co-occurring psychiatric or medical conditions is a crucial component of the treatment plan.
In the case of severe anorexia nervosa, when outpatient treatment is not practical, admission to an inpatient or residential behavioral specialty program may be indicated. Most specialty programs are effective in restoring weight and normalizing eating behavior, although the risk of relapse in the first year following program discharge remains significant.
Individuals with bulimia nervosa typically alternate dieting or eating only low-calorie “safe foods” with binge eating on “forbidden” high-calorie foods. Binge eating is defined as eating a large amount of food in a short period associated with a sense of loss of control over what, or how much one is eating. Binges may be massive, and food is often consumed rapidly, beyond fullness to nausea and discomfort. Binge behavior is usually secretive and associated with feelings of shame or embarrassment.
As in anorexia nervosa, persons with bulimia nervosa are excessively preoccupied with thoughts of food, weight, or shape, which negatively affect and disproportionately impact their self-worth. Binges occur at least weekly and are typically followed by what are called “compensatory behaviors” to prevent weight gain. These can include fasting, vomiting, laxative misuse, or compulsive exercise.
Individuals with bulimia nervosa can be slightly underweight, average, overweight, or obese. If they are malnourished, however, they are considered to have anorexia nervosa, binge-eating/purging type, not bulimia nervosa. Family members or friends may not know that a person has bulimia nervosa because they do not appear underweight and because their behaviors are hidden and may go unnoticed by those close to them. Possible signs that someone may have bulimia nervosa include:
- Frequent trips to the bathroom right after meals
- Large amounts of food disappearing or unexplained empty wrappers and food containers
- Chronic sore throat
- Swelling of the salivary glands in the cheeks
- Dental decay resulting from erosion of tooth enamel by stomach acid
- Heartburn and gastroesophageal reflux
- Laxative or diet pill misuse
- Recurrent unexplained diarrhea
- Misuse of diuretics (water pills)
- Feeling dizzy or fainting from excessive purging behaviors resulting in dehydration.
Bulimia can lead to rare but potentially fatal complications including esophageal tears, gastric rupture, and dangerous cardiac arrhythmias. Medical monitoring in severe bulimia nervosa is essential to identify and treat possible complications.
Outpatient cognitive behavioral therapy for bulimia nervosa is the treatment with the most substantial evidence. It helps patients normalize their eating behavior and manage thoughts and feelings that perpetuate the disorder. Antidepressants can also help decrease urges to binge and vomit.
As with bulimia nervosa, people with binge eating disorder have episodes of binge eating in which they consume large quantities of food in a brief period, experience a sense of loss of control over their eating, and are distressed by the binge behavior. However, people with bulimia nervosa do not regularly use compensatory behaviors to eliminate the food by inducing vomiting, fasting, exercising, or laxative misuse. Binge eating is chronic and can lead to serious health complications, including obesity, diabetes, hypertension, and cardiovascular diseases.
The diagnosis of binge eating disorder requires frequent binges (at least once a week for three months), associated with a sense of lack of control, and with three or more of the following features:
- Eating more rapidly than normal
- Eating until uncomfortably full
- Eating large amounts of food when not feeling hungry
- Eating alone because of feeling embarrassed by how much one is eating
- Feeling disgusted with oneself, depressed, or very guilty afterward
As with bulimia nervosa, the most effective treatment for binge eating disorder is cognitive-behavioral psychotherapy for binge eating. Interpersonal therapy has also been shown to be effective, as have several antidepressant medications.
This diagnostic category includes eating disorders or disturbances of eating behavior that causes distress and impairs family, social or work function but do not fit the other types listed here. In some cases, this is because the frequency of the behavior does not meet the diagnostic threshold (e.g., the frequency of binges in bulimia or binge eating disorder) or the weight criteria for the diagnosis of anorexia nervosa are not met.
An example of other specified feeding and eating disorder is “atypical anorexia nervosa.” This category includes individuals who may have lost a lot of weight and whose behaviors and fear of fatness are consistent with anorexia nervosa but are not yet considered underweight based on their BMI because their baseline weight was above average.
Since the speed of weight loss is related to medical complications, individuals who lose a lot of weight rapidly by engaging in extreme weight control behaviors can be at high risk of medical complications, even if they appear normal or above average weight.
Avoidant/restrictive food intake disorder (ARFID) is a recently defined eating disorder that involves a disturbance in eating resulting in persistent failure to meet nutritional needs and extreme picky eating. In ARFID, food avoidance or a limited food repertoire can be due to one or more of the following:
- Low appetite and lack of interest in eating or food.
- Extreme food avoidance is based on sensory characteristics of foods, e.g., texture, appearance, color, and smell.
- Anxiety or concern about consequences of eating, such as fear of choking, nausea, vomiting, constipation, an allergic reaction, etc. The disorder may develop in response to a significant adverse event such as an episode of choking or food poisoning followed by the avoidance of an increasing variety of foods.
The diagnosis of ARFID requires that difficulties with eating are associated with one or more of the following:
- Significant weight loss (or failure to achieve expected weight gain in children).
- Significant nutritional deficiency.
- The need to rely on a feeding tube or oral nutritional supplements to maintain sufficient nutrition intake.
- Interference with social functioning (such as inability to eat with others).
The impact on physical and psychological health and degree of malnutrition can be similar to that seen in people with anorexia nervosa. However, people with ARFID do not have excessive concerns about their body weight or shape, and the disorder is distinct from anorexia nervosa or bulimia nervosa. Also, while individuals with autism spectrum disorder often have rigid eating behaviors and sensory sensitivities, these do not necessarily lead to the level of impairment required for a diagnosis of avoidant/restrictive food intake disorder.
ARFID does not include food restriction related to lack of availability of food; regular dieting; cultural practices, such as religious fasting; or developmentally normal behaviors, such as toddlers who are picky eaters.
Food avoidance or restriction commonly develops in infancy or early childhood and may continue in adulthood. It can, however, start at any age. Regardless of the person’s age, ARFID can impact families, causing increased stress at mealtimes and in other social eating situations.
Treatment for ARFID involves an individualized plan and may involve several specialists, including a mental health professional, a registered dietitian, a nutritionist, and others.
Pica is an eating disorder in which a person repeatedly eats things that are not food with no nutritional value. The behavior persists for at least one month and is severe enough to warrant clinical attention.
Typical substances ingested vary with age and availability and might include paper, paint chips, soap, cloth, hair, string, chalk, metal, pebbles, charcoal or coal, or clay. Individuals with pica do not typically have an aversion to food in general.
The behavior is inappropriate to the individual’s developmental level and is not part of a culturally supported practice. Pica may first occur in childhood, adolescence, or adulthood, although childhood onset is most common. It is not diagnosed in children under age 2. Putting small objects into their mouth is normal for children under 2. Pica often occurs with autism spectrum disorder and intellectual disability but can occur in otherwise typically developing children.
A person diagnosed with pica is at risk for potential intestinal blockages or toxic effects of substances consumed (e.g., lead in paint chips).
Treatment for pica involves testing for nutritional deficiencies and addressing them if needed. Behavior interventions used to treat pica may include redirecting the individual from the nonfood items and rewarding them for setting aside or avoiding nonfood items.
Rumination disorder involves the repeated regurgitation and re-chewing of food after eating, whereby swallowed food is brought back into the mouth voluntarily and re-chewed and re-swallowed or spat out. Rumination disorder can occur in infancy, childhood, adolescence, or adulthood. To meet the diagnosis, the behavior must:
- Occurs repeatedly over at least 1 month
- Not be due to a gastrointestinal or medical problem
- Not happen as part of one of the other behavioral eating disorders listed above
- Rumination can also occur in other mental disorders (e.g., intellectual disability); however, the degree must be severe enough to warrant separate clinical attention for the diagnosis to be made.”