Crystal T.

Clark, MD, MSc

Arkes Pavilion
676 St. Clair, Suite 1000
Crystal.clark@northwestern.edu

Eating Disorders
READING
American Psychiatric Publishing Textbook, Hales and Yudofsky et al., Chapter 17: Feeding
and Eating Disorders, Sections on Anorexia Nervosa, Bulimia Nervosa, and Binge-Eating
Disorder
OBJECTIVES
1. The learner will be able to accurately differentiate between the diagnostic criteria for anorexia
nervosa, bulimia nervosa, and binge-eating disorder.
2. Given the eating disorder diagnosis, the learner will be able to list risk factors and preventative
measures.
3. Given a case example of an eating disorder, the learner will be able to recommend next steps
for evaluation of the patient and recommend a treatment plan.

DIAGNOSTIC CRITERIA
Anorexia Nervosa is the restriction of energy intake resulting in significantly low body weight
as it relates to the individuals age, sex, developmental trajectory and physical health; an
intense fear of gaining weight or persistent behavior that interferes with weight gain; distorted
body image or lack of recognition of the seriousness of the low body weight. Amenorrhea for
3 months or more used to be a criterion of DSM-IV-TR but is now only a marker of severity in
DSM-V.
Anorexia has both a restricting type and a binge-eating/purging subtype. The restricting type
is classic starvation behavior alone, whereas in the binge-eating/purging type of anorexic
engages in subjective binges and then compensatory behavior (i.e. laxatives, diuretics, selfinduced vomiting, exercise).
Bulimia Nervosa is marked by recurrent episodes of binge eating (eating a larger than most
people would eat in a discrete period of time) in a normal or overweight individual followed by
inappropriate compensatory behaviors to undo the binge episodes. Bingeing and
compensatory behaviors occur 1x/week for at least three months.
Bulimia has both a purging type, self-induced vomiting alone, and a non-purging type, where
the compensatory behavior is something other than vomiting (i.e. exercise, laxatives,
diuretics).
Binge Eating Disorder (BED) is marked by recurrent episodes of binge eating (at least once
a week for three months) in which two binges include at least three of the following features:
eating until uncomfortably full, eating alone, sense of loss of control, eating in a state of selfdisgust and shame.
EPIDEMIOLOGY
Prevalence
Anorexia: 0.4% of young women (late adolescence and early adulthood)
Bulimia: 2% of young women (late adolescence)
BED: 2.6% of young adults (20s)

Gender
Anorexia: 85-95% women
Bulimia: Male to female ratio is 10:1 to 20:1
BED: 3.5% of females and 2% of males
Course and Outcome
Anorexics have a higher rate of remaining highly symptomatic (10-20%), or dying due to
complications of the illness (1-5%).
CO-OCCURING PSYCHIATRIC DISORDERS
Anorexia: social phobia, OCD, MDD
Bulimia: MDD, bipolar disorder, substance abuse, anxiety disorders
BED: panic disorder/agoraphobia, MDD, PTSD, personality disorders (dependent
personality disorder)
MEDICAL COMPLICATIONS
Anorexia: bradycardia, hypotension, hypothermia, dehydration, hypoglycemia, anemia,
decreased GI motility, lanugo hair, hair loss, amenorrhea, osteopenia, headaches
Bulimia: dehydration, orthostatic hypotension, metabolic alkalosis, metabolic acidosis,
hypokalemia, dental enamel erosion, parotid gland enlargement, esophageal tears
BED: diabetics, hypertension, hormone irregularities, skeletal/muscular problems (back,
knees, hips)
ETIOLOGIC THEORIES OF EATING DISORDERS
Psychoanalytic Theory points to dysregulations and disruptions in mother-infant bonding
leading to disturbed body image and problematic associations to food and feeding.
Additionally, psychoanalytic theory focuses on problems in adolescent identity/sexuality
developments and separation/launching issues.
Family System Theory suggests that anorexics come from more rigid, enmeshed families
and bulimics tend to come from more disengaged and chaotic families.
Behavior Theory accounts for the addictiveness of these disorders. It suggests that even
safe diets can create increased cravings and increased self-punishment for lapses in
discipline. Restrictions can be reinforced because it makes a person fell successfully in
control over hunger impulses. Purging can be reinforced because it relieves a person, after a
binge, of the fear of weight gain.
Biologic Theories of eating disorders emphasize how satiety is biologically mediated in the
brain and genetically predetermined. Biological theories also emphasize how undercontrol
and overcontrol of impulses may be genetically determined.
TREATMENT
Multidisciplinary, team approach: medical, nutrition, family therapy, individual therapy,
psychiatry, group and residential
First treatment goal: medical and nutritional stabilization
After medical stabilization, psychotherapy is the primary mental health treatment