Feeding and Eating Disorders

 This chapter deals with several feeding and eating disorders, including anorexia nervosa, bulimia nervosa, binge-eating disorder, and other specified feeding and eating disorders. There are different feeding and eating disorders that are typically associated with childhood and adolescence (e.g., pica, rumination disorder, and avoidant/restrictive food intake disorder); Neurodevelopmental Disorders and Other Childhood Disorders (Chapter 2) covers those disorders.


Anorexia Nervosa

The term anorexia nervosa comes from the Greek term for “loss of appetite” and a Latin word implying nervous origin. Anorexia nervosa is a syndrome characterized by three essential criteria, one behavioral, one psychopathological, and the last, physiologic. The first is self-induced starvation, to a significant degree (behavioral). The second is a relentless drive for thinness or a morbid fear of fatness (psychopathological). The third criterion is the presence of medical signs and symptoms resulting from starvation (physiologic). Anorexia nervosa is often, but not always, associated with disturbances of body image, the perception that one is distressingly large despite evident medical starvation. The distortion of body image is disturbing when present; it is, however, not pathognomonic, invariable, or required for diagnosis. Two subtypes of anorexia nervosa exist: restricting and binge/purge. The theme in all anorexia nervosa subtypes is the highly disproportionate emphasis placed on thinness as a vital source of self-esteem, with weight, and to a lesser degree, shape, becoming the overriding 

and consuming daylong preoccupation of thoughts, mood, and behaviors.

Approximately half of anorexic persons will lose weight by drastically reducing their total food intake. The other half of these patients will not only diet but will also regularly engage in binge eating, followed by purging behaviors. Some patients routinely purge after eating small amounts of food. Anorexia nervosa is much more prevalent in females than in males and usually has its onset in adolescence. Hypotheses of an underlying psychological disturbance in young women with the disorder include conflicts surrounding the transition from girlhood to womanhood. Some have also suggested that psychological issues related to feelings of helplessness and difficulty establishing autonomy also contribute to the development of the disorder. Bulimic symptoms can occur as a separate disorder or as part of anorexia nervosa. Persons with either disorder are excessively preoccupied with weight, food, and body shape. The outcome of anorexia nervosa varies from spontaneous recovery to a waxing and waning course to death.

Bulimia Nervosa

People with bulimia nervosa have episodes of binge eating combined with inappropriate ways of stopping weight gain. Physical discomfort—for example, abdominal pain or nausea—terminates the binge eating, which is often followed by feelings of guilt, depression, or self-disgust. Unlike patients with anorexia nervosa, those with bulimia nervosa typically maintain average body weight.

The term bulimia nervosa derives from the terms for “ox-hunger” in Greek and “nervous involvement” in Latin. For some patients, bulimia nervosa may represent a failed attempt at anorexia nervosa, sharing the goal of becoming very thin, but occurring in an individual less able to sustain prolonged semistarvation or severe hunger as consistently as classic restricting anorexia nervosa patients. For others, eating binges represent “breakthrough eating” episodes of giving in to hunger pangs generated by efforts to limit eating to maintain a socially desirable level of thinness. Still, others use binge eating as a means to self-medicate during times of emotional distress. Regardless of the reason, eating binges provoke panic as individuals feel that their eating has been out of control. The unwanted binges lead to subsequent attempts to avoid the feared weight gain by a variety of compensatory behaviors, such as purging or excessive exercise.

Binge-Eating Disorder

Individuals with binge-eating disorder engage in recurrent binge eating during which they eat an abnormally large amount of food over a short time. Unlike bulimia nervosa, patients with binge-eating disorder do not compensate in any way after a binge episode (e.g., vomiting, laxative use). Binge episodes often occur in private, generally include foods of dense caloric content, and, during the binge, the person feels he or she cannot control his or her eating.

Other Specified Feeding or Eating Disorders

This diagnostic category also includes eating conditions that may cause significant distress but do not meet the full criteria for a classified eating disorder. Conditions included in this category include night-eating syndrome, purging disorder, and subthreshold forms of anorexia nervosa, bulimia nervosa, and binge-eating disorder.

Night-Eating Syndrome. Night-eating syndrome is characterized by the consumption of large amounts of food after the evening meal. Individuals generally have little appetite during the day and suffer from insomnia.

Purging Disorder. Purging disorder is characterized by recurrent purging behavior after consuming a small amount of food in persons of average weight who have a distorted view of their weight or body image. Purging behavior includes self-induced vomiting, laxative abuse, enemas, and diuretics. This behavior should not be associated with anorexia nervosa. Purging disorder is differentiated from bulimia nervosa because purging behavior occurs after eating small quantities of food or drink and does not occur as a result of a binge episode.


Anorexia Nervosa

The onset of anorexia nervosa usually occurs between the ages of 10 and 30 years. We summarize the diagnostic criteria in DSM-5 and ICD-10 for the disorder in Table 13-1.

Intense fear of gaining weight and becoming obese is present in all patients with the disorder and undoubtedly contributes to their lack of interest in and even resistance to therapy. Most aberrant behavior directed toward losing weight occurs in secret. Patients with anorexia nervosa usually refuse to eat with their families or in public places. They lose weight by drastically reducing their total food intake, with a disproportionate decrease in high-carbohydrate and fatty foods.

The term anorexia is a misnomer because the loss of appetite is usually rare until late in the disorder. Evidence that patients are frequently thinking about food is their passion for collecting recipes and for preparing elaborate meals for others. Some patients cannot continuously control their voluntary restriction of food intake, and so have eating binges. These binges usually occur secretly, often at night, and are frequently followed by self-induced vomiting. Patients abuse laxatives and even diuretics to lose weight, and ritualistic exercising, extensive cycling, walking, jogging, and running are everyday activities.

Patients with the disorder show peculiar behavior surrounding food. They hide food all over the house and frequently carry large quantities of candies in their pockets and purses. While eating meals, they try to dispose of food in their napkins or hide it in their pockets. They cut their meat into tiny pieces and spend a great deal of time rearranging these pieces on their plates. If someone confronts the patient about the behavior, they often deny that it is unusual or flatly refuse to discuss it.

Obsessive-compulsive behavior, depression, and anxiety are other psychiatric symptoms of anorexia nervosa most frequently noted clinically. Patients tend to be rigid and perfectionist, and somatic complaints, especially epigastric discomfort, are usual. Compulsive stealing, usually of candies and laxatives but occasionally of clothes and other items, may occur.

Patients with the disorder frequently have poor sexual adjustment. Many adolescent patients with anorexia nervosa have delayed psychosocial sexual development; in adults, a markedly decreased interest in sex often accompanies the onset of the disorder. A minority of anorexic patients have a premorbid history of promiscuity, substance abuse, or both, but during the disorder show a decreased interest in sex. Patients usually come to medical attention when their weight loss becomes apparent. As the weight loss grows profound, physical signs such as hypothermia (as low as 35°C), dependent edema, bradycardia, hypotension, and lanugo (the appearance of neonatal-like hair) appear, and patients show a variety of metabolic changes. These and other medical complications are listed in Table 13-2. 

Subtypes. Anorexia nervosa has two clinical subtypes: food restricting and purging. In the food-restricting category, present in approximately 50 percent of cases, food intake is highly restricted (usually with attempts to consume fewer than 300 to 500 calories per day and no fat grams) and the patient may be relentlessly and compulsively overactive, with overuse athletic injuries. In the purging subtype, patients alternate attempts at rigorous dieting with intermittent binge or purge episodes. Purging represents a secondary compensation for the unwanted calories, most often accomplished by self-induced vomiting, frequently by laxative abuse, less frequently by diuretics, and occasionally with emetics. Sometimes, repetitive purging occurs without prior binge eating, after ingesting only relatively few calories. Both types may be socially isolated and have depressive disorder symptoms and diminished sexual interest. Overexercising and perfectionistic traits are also common in both types.

Those who practice binge eating and purging share many features with persons who have bulimia nervosa without anorexia nervosa. Those who binge eat and purge tend to have families in which some members are obese, and they have histories of heavier body weights before the disorder than do persons with the restricting type. Binge eating–purging persons are likely to be associated with substance abuse, impulse control disorders, and personality disorders. Persons with restricting anorexia nervosa often have obsessive-compulsive traits concerning food and other matters. Some persons with anorexia nervosa may purge but not binge.

and resist treatment. In almost all cases, relatives or intimate acquaintances must confirm a patient’s history. The mental status examination usually shows a patient who is alert and knowledgeable on the subject of nutrition and who is preoccupied with food and weight.

A young woman who weighed 10 percent above the average weight but was otherwise healthy, functioning well, and working hard as a university student joined a track team. She started training for hours a day, more than her teammates, began to perceive herself as fat, and thought that her performance would be enhanced if she lost weight. She started to diet and reduced her weight to 87 percent of the “ideal weight” for her age according to standard tables. At her point of maximum weight loss, her performance declined, and she pushed herself even harder in her training regimen. She started to feel apathetic and morbidly afraid of becoming fat. Her food intake became restricted, and she stopped eating anything containing fat. Her menstrual periods became skimpy and infrequent but did not cease. (Courtesy of Arnold E. Andersen, M.D. and Joel Yager, M.D.)

Bulimia Nervosa

People with bulimia nervosa have binge episodes with compensatory behaviors. Like persons with anorexia nervosa, they fear becoming fat; however, they are not severely thin. We summarize the diagnostic criteria in DSM-5 and ICD-10 for the disorder in Table 13-3.

Feeding and Eating Disorders Feeding and Eating Disorders Reviewed by Web of Psychiatry on December 07, 2021 Rating: 5

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