Eating disorders are characterized by excessive and persistently disturbed eating or eating-related behaviours that lead to changes in the person's consumption of food to a degree that is harmful to their health and well-being.
Every individual is different, but common signs of eating disorders can include:
- Preoccupied with body appearance, weight and food
- Distorted view of their body
- Extreme dissatisfaction with their body
- Intense fear of weight gain
- Becoming irritable and/or withdrawing from friends and family
- Anxiety around food or meal times
- Feeling a loss of control around food
- Excessive dieting, binge eating or exercising
- Use of laxatives or vomiting (e.g. frequently going to the bathroom during or after meals
- Avoidance of social situations involving food or wanting to eat alone
- Developing rigid beliefs, patterns or rituals around food (e.g. only eating certain foods, insisting on eating at a certain time, cutting food up into small pieces)
- Excessive body checking behaviours (e.g. repeatedly weighing self, pinching waist)
- Change in clothing style (e.g. wearing loose fitting clothing to hide weight loss)
- Secretive behaviours around food (e.g. hiding food, throwing food out)
- Rapid weight loss or fluctuating weight
- Difficulty concentrating
- Lethargy and low energy levels
- Sensitivity to cold, even when it is warm
Eating disorders include anorexia nervosa, bulimia nervosa, binge eating disorder, and other specified feeding or eating disorder (OSFED).
Onset, prevalence, and burden of eating disorders
Eating disorders are common in young people, especially in female adolescents and young women, although males can also be affected (1). In their lifetime, about 0.3% of adolescents aged 13 to 18 years have anorexia nervosa (same % for males and females), 0.9% have bulimia nervosa (males 0.5%; females 0.9%), and 1.6% have a binge-eating disorder (males 0.8%; females 2.3%) (2).
While the prevalence of eating disorders appears low in the general population, it has been suggested that previous studies that used strict diagnostic criteria (e.g. from the DSM-IV) failed to accurately identify many young people with anorexia nervosa or bulimia nervosa (2). Instead, many of these individuals were diagnosed with eating disorder not otherwise specified (EDNOS), which was a broad category that covered clinically significant eating disorders that did not meet diagnostic criteria for anorexia nervosa or bulimia nervosa. Therefore, the actual prevalence of eating disorders is likely to be considerably higher than previously estimated. The latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has addressed this issue by implementing substantial changes to the diagnostic criteria of eating disorders (for example, reducing the frequency of binge eating and compensatory behaviours that people with bulimia nervosa must exhibit, from twice weekly in DSM-IV to once a week in DSM-5) (3).
Eating disorders are a serious, potentially life-threatening mental health illness and can have significant physical and emotional effects. People with eating disorders can have reductions in cognitive function, emotional changes and may stop participating in their normal activities of daily life (4).
Young people with eating disorders are over ten times more likely to die prematurely than their peers without an eating disorder (5-7). This increased risk includes increased risk of suicide (8) and serious physical health issues arising from effects of bingeing, purging and starvation on the body's organs and metabolism.
In Australian females aged 15-24 years, bulimia nervosa and anorexia nervosa are the eighth and tenth leading causes of burden of disease and injury respectively (9). In young Australian females aged 12-24 years, eating disorders account for 14% of hospital admission for a behavioural or mental disorder (second only to depression, which accounts for 19% of admissions) (9).
The beginning of adolescence and the late teens are peak periods for people with eating disorders to experience their first symptoms, although eating disorders may first occur at any age. Anorexia nervosa is most likely to occur between the ages of 13 to 18 years, while bulimia nervosa usually occurs later, with the ages from 16-18 years having the highest risk of onset (10). Binge-eating disorder is more likely to have a later onset, in the early to mid-20s (11,12).
It is common for eating disorders to co-occur with other mental health and substance use disorders. It has been estimated that 56%-95% of individuals with an eating disorder meet diagnostic criteria for at least one other mental disorder (13). These often include anxiety, depression, and substance abuse (13,14).
Possible risk factors for developing an eating disorder include (15-17):
- Genetic vulnerability and family history
- Being female
- Body dissatisfaction or elevated weight/body shape concerns
- Negative evaluation of self
- Idealization of thinness
- Dieting (Australian adolescent females who diet at a severe level are 18 times more likely to develop an eating disorder within 6 months (18))
- History of sexual abuse and other adverse experiences
1. Striegel‐Moore, R. H., Rosselli, F., Perrin, N., DeBar, L., Wilson, G. T., May, A., & Kraemer, H. C. (2009). Gender difference in the prevalence of eating disorder symptoms. International Journal of Eating Disorders, 42(5), 471-474.
2. Swanson, S. A., Crow, S. J., Le Grange, D., Swendsen, J., & Merikangas, K. R. (2011). Prevalence and correlates of eating disorders in adolescents: Results from the national comorbidity survey replication adolescent supplement. Archives of General Psychiatry, 68(7), 714-723.
3. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association.
4. Klump, K. L., Bulik, C. M., Kaye, W. H., Treasure, J., & Tyson, E. (2009). Academy for eating disorders position paper: eating disorders are serious mental illnesses. International Journal of Eating Disorders, 42(2), 97-103.
5. Birmingham, C. L., Su, J., Hlynsky, J. A., Goldner, E. M., & Gao, M. (2005). The mortality rate from anorexia nervosa. International Journal of Eating Disorders, 38(2), 143-146.
6. Steinhausen, H. C., Weber, S., & Phil, C. (2009). The outcome of bulimia nervosa: findings from one-quarter century of research. The American Journal of Psychiatry, 166(12), 1331-1341.
7. Steinhausen, H. C. (2009). Outcome of eating disorders. Child and Adolescent Psychiatric Clinics of North America, 18(1), 225-242.
8. Preti, A., Rocchi, M. B. L., Sisti, D., Camboni, M. V., & Miotto, P. (2011). A comprehensive meta‐analysis of the risk of suicide in eating disorders. Acta Psychiatrica Scandinavica, 124(1), 6-17.
9. Australian Institute of Health and Welfare 2007. Young Australians: their health and wellbeing 2007. Cat. no. PHE 87 Canberra: AIHW.
10. Paying the Price: The economic and social impact of eating disorders in Australia. (2012). The Butterfly Foundation
11. Kessler, R. C., Berglund, P. A., Chiu, W. T., Deitz, A. C., Hudson, J. I., Shahly, V., ... & Xavier, M. (2013). The prevalence and correlates of binge eating disorder in the World Health Organization World Mental Health Surveys. Biological Psychiatry, 73(9), 904-914.
12. Smink, F. R., van Hoeken, D., & Hoek, H. W. (2012). Epidemiology of eating disorders: incidence, prevalence and mortality rates. Current Psychiatry Reports, 14(4), 406-414.
13. Hudson, J. I., Hiripi, E., Pope, H. G., & Kessler, R. C. (2007). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological psychiatry, 61(3), 348-358.
E14. Swanson, S. A., Crow, S. J., Le Grange, D., Swendsen, J., & Merikangas, K. R. (2011). Prevalence and correlates of eating disorders in adolescents: Results from the national comorbidity survey replication adolescent supplement. Archives of General Psychiatry, 68(7), 714-723.
15. Jacobi, C., Hayward, C., de Zwaan, M., Kraemer, H. C., & Agras, W. S. (2004). Coming to terms with risk factors for eating disorders: application of risk terminology and suggestions for a general taxonomy. Psychological Bulletin, 130(1), 19.
16. Stice, E. (2002). Risk and maintenance factors for eating pathology: a meta-analytic review. Psychological Bulletin, 128(5), 825.
17. Keel, P. K., & Forney, K. J. (2013). Psychosocial risk factors for eating disorders. International Journal of Eating Disorders, 46(5), 433-439.
18. Eating Disorders Prevention, Treatment and Management - An Evidence Review. (2010). National Eating Disorders Collaboration Publications
Formal systems for the diagnosis of mental illness (1,2) describe a number of different types of eating disorders, including:
- Persistent restriction of energy intake, resulting in body weight that is significantly lower than the normal and healthy weight
- Intense fear of gaining weight or of becoming overweight, or persistent behaviours that interfere with weight gain
- Disturbed body image (distorted view of own body, self-worth unduly influenced by their body shape/weight, or persistent lack of recognition of the seriousness of current low body weight
- Subtypes: Restricting type (weight loss mainly through dieting, fasting, and/or excessive exercise) and Binge-eating/purging type
- Repeated episodes of binge-eating (ie. consuming a very large amount of food within a relatively short period of time (e.g. 2 hours) and feeling a loss of control over their eating during this episode)
- Repeated compensatory behaviours in order to prevent weight gain (e.g. self-induced vomiting, misuse of laxatives or other medications, fasting, or excessive exercise)
- Episodes of binge-eating and compensatory behaviours occur, on average, at least once a week for at least three months
- Self-worth unduly influenced by their body shape/weight
- Weight often fluctuates, and the person is usually within the normal weight range or overweight
Binge eating disorder
- Repeated episodes of binge-eating (ie. consuming a very large amount of food within a relatively short period of time (e.g. 2 hours) and feeling a loss of control over their eating during this episode)
- A binge-eating episode is associated with at least three of the following:
- Eating more rapidly than usual
- Eating until uncomfortably full
- Eating large amounts despite not feeling hungry
- Eating alone due to feeling embarrassed about amount of food consumed
- Feeling disgusted with self, depressed, or guilty after the episode
- Significant distress about binge eating
- Episodes of binge-eating occur, on average, at least once a week for at least three months
- Weight can be in the normal range, but more commonly the person is overweight or obese (however, binge-eating disorder is distinct from obesity and most people who are obese do not engage in repeated binge-eating)
Other Specified Feeding and Eating Disorders (OSFED)
- Symptoms of other eating disorders (as above) that do not meet the full criteria for a diagnosis of those disorders, but cause the person significant distress or functional impairment
- Includes Atypical anorexia nervosa, Purging disorder, Night eating syndrome
Early detection of eating disorders symptoms is important to improving the chances of achieving better outcomes for people experiencing, or at high risk of, eating disorders. To decide whether a young person is experiencing an eating disorder, a comprehensive assessment by a mental health professional is required. As a first step, the assessment involves asking questions about a range of aspects of a person's life including:
- Home and environment;
- Education and employment;
- Drugs and alcohol;
- Relationships and sexuality;
- Conduct difficulties and risk-taking;
- Anxiety and eating;
- Depression and suicide;
- Psychosis and mania
A comprehensive assessment by a mental health professional trained in clinical assessment is required to assess specifically for the presence of an eating disorder, physical health risks, and risk of suicide.
There are several assessment tools available to assess or screen for eating disorders. These include the Eating Disorder Examination (EDE) (3), the Structured Interview for Anorexic and Bulimic Disorders (SIAB-EX) (4), the Eating Disorders Inventory (EDI) (5), and the SCOFF questionnaire (6). These questionnaires are not a diagnostic tool but rather to assist with identifying when a more detailed assessment is warranted.
1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association.
2. Cooper, Z., & Fairburn, C. (1987). The eating disorder examination: A semi‐structured interview for the assessment of the specific psychopathology of eating disorders. International Journal of Eating Disorders, 6(1), 1-8.
3. Fichter, M. M., Herpertz, S., Quadflieg, N., & Herpertz‐Dahlmann, B. (1998). Structured interview for anorexic and bulimic disorders for DSM‐IV and ICD‐10: Updated (third) revision. International Journal of Eating Disorders, 24(3), 227-249.
4. Morgan, J. F., Reid, F., & Lacey, J. H. (1999). The SCOFF questionnaire: assessment of a new screening tool for eating disorders. BMJ, 319(7223), 1467-1468.
5. World Health Organization. (1992). The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. Geneva: World Health Organization.
Garner, D. M., Olmstead, M. P., & Polivy, J. (1983). Development and validation of a multidimensional eating disorder inventory for anorexia nervosa and bulimia. International Journal of Eating Disorders, 2(2), 15-34
Treatment of eating disorders needs to address not only the issues related to mental illness, psychological impairment and distress, but also the complicated and potentially very serious physical and nutritional effects of the disorder. For most cases, this means that a multidisciplinary team is needed, ideally including members who have expertise in treating young people with eating disorders. Community-based treatment is the preferred setting for care but emergency care, specialist unit referral or consultation may be necessary depending on the severity of the presentation and the capabilities of the local team.
Key aspects of treating eating disorders include (1,2):
- Treatment in the least restrictive environment possible (e.g. outpatient or day patient), with hospital admission for those at risk of medical and/or psychological compromise
- A multidisciplinary and collaborative approach is recommended in order to consider psychological, social, medical, and nutritional aspects of treatment
- Beginning treatment as early as possible
- Providing good information on the nature and course of the disease to the young person and their family. This may include information on appropriate self-help or support groups.
- For young people with eating disorders in particular, family members, including siblings, should be included in the treatment. Interventions may include sharing of information, advice on behavioural management and facilitating communication.
- Management of physical complications, which include metabolic changes, dental damage, possible medication abuse, bone fracture risk, nutritional needs and monitoring of growth and physical development
With support and appropriate treatment, young people with eating disorders can recover successfully, and early detection and treatment of eating disorders is associated with better outcomes.
Research has shown that, for individuals showing early signs of disordered eating and body image, cognitive behaviour therapy, cognitive dissonance approaches, and literacy programs can have positive effects on reducing the risk of developing further eating disorder symptoms (3,4).
Family-based therapies have the strongest evidence base for the treatment of young people with anorexia nervosa (1,5,6). Self-help and guided self-help strategies can reduce eating disorder symptoms for adults with bulimia nervosa, binge eating disorder and eating disorder not specified (EDNOS) (7) and has been recommended as a first step in therapy for these disorders (1). Other psychological therapies such as cognitive behavioural therapy (CBT, including a specifically adapted forms of CBT for bulimia nervosa and binge eating), interpersonal therapy (IPT), and modified dialectical behaviour therapy for binge eating are effective in reducing bulimia and binge eating behaviours (1,8). Other therapies for anorexia nervosa are less well studied. Approaches thought to be helpful include cognitive analytic therapy (CAT), cognitive behaviour therapy (CBT), interpersonal psychotherapy (IPT) and focal psychodynamic therapy (1).
Antidepressant medication, in particular fluoxetine, has also been shown to be effective for adults experiencing bulimia- and combing this medication with psychological therapies is even more effective -but individuals receiving treatment may prefer psychological therapy alone (9,10). Antidepressants have not been shown to be effective for people experiencing anorexia nervosa, however, and caution is recommended in the use of any medication as treatment for anorexia (1, 11).
1. Eating disorders: Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. 2004; NICE clinical guideline CG9.
2. Hay, P., Chinn, D., Forbes, D., Madden, S., Newton, R., Sugenor, L., ... & Ward, W. (2014). Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of eating disorders. Australian and New Zealand Journal of Psychiatry, 48(11), 977-1008.
3. Stice, E., Shaw, H., & Marti, C. N. (2007). A meta-analytic review of eating disorder prevention programs: encouraging findings. Annu. Rev. Clin. Psychol., 3, 207-231.
4. Watson, H, Elphick, R, et al. Eating Disorders prevention, treatment and management: An Evidence Review. National Eating Disorders Collaboration. 2010.
5. Watson, H. J., & Bulik, C. M. (2013). Update on the treatment of anorexia nervosa: review of clinical trials, practice guidelines and emerging interventions. Psychological Medicine, 43(12), 2477-2500.
6. Fisher CA, Hetrick SE, Rushford N. Family therapy for anorexia nervosa. Cochrane Database of Systematic Reviews 2010, Issue 4. Art. No.: CD004780. DOI: 10.1002/14651858.CD004780.pub2.
7. Perkins SSJ, Murphy RRM, Schmidt UUS, Williams C. Self-help and guided self-help for eating disorders. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD004191. DOI: 10.1002/14651858.CD004191.pub2.
8. Hay PPJ, Bacaltchuk J, Stefano S, Kashyap P. Psychological treatments for bulimia nervosa and binging. Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD000562. DOI: 10.1002/14651858.CD000562.pub3.
9. Hay PPJ, Claudino AM, Kaio MH. Antidepressants versus psychological treatments and their combination for bulimia nervosa. Cochrane Database of Systematic Reviews 2001, Issue 4. Art. No.: CD003385. DOI: 10.1002/14651858.CD003385.
10. Bacaltchuk J, Hay PPJ. Antidepressants versus placebo for people with bulimia nervosa. Cochrane Database of Systematic Reviews 2003, Issue 4. Art. No.: CD003391. DOI: 10.1002/14651858.CD003391.
11. Claudino AM, Silva de Lima M, Hay PPJ, Bacaltchuk J, Schmidt UUS, Treasure J. Antidepressants for anorexia nervosa. Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD004365. DOI:10.1002/14651858.CD004365.pub2.
The following authoritative guidelines provide evidence-based information about the practical treatment of eating disorders:
Hay, P., Chinn, D., Forbes, D., Madden, S., Newton, R., Sugenor, L., ... & Ward, W. (2014). Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of eating disorders. Australian and New Zealand Journal of Psychiatry, 48(11), 977-1008.
Eating Disorders: A Professional Resource for General Practitioners. (2014). The National Eating Disorders Collaboration.
Eating disorders prevention, treatment and management: an evidence review. (2010). The National Eating Disorders Collaboration.
Eating disorders toolkit, a practice based guide to the inpatient management of adolescents with eating disorders, with special reference to regional and rural areas. (2008). MH-Kids, New South Wales Health.
Eating disorders: Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. 2004; NICE clinical guideline CG9.
The following selected articles provide more information about eating disorders:
Paying the Price: economic and social impact of eating disorders. (2012). The Butterfly Foundation.
Centre of Excellence in Youth Mental Health. Myth Buster: Eating Disorders. (2010). Melbourne: Orygen Youth Health Research Centre.
Eating Disorders information and support for Australians: Resources review. (2010). The National Eating Disorders Collaboration.
Couturier, J., & Lock, J. (2007). A review of medication use for children and adolescents with eating disorders. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 16(4), 173.
Pratt BM, Woolfenden S. Interventions for preventing eating disorders in children and adolescents. Cochrane Database of Systematic Reviews 2002, Issue 2. Art. No.: CD002891. DOI: 10.1002/14651858.CD002891.