Understanding the Spectrum of Eating Disorders and Disordered Eating

Eating Disorders are complex mental illnesses that present in many ways. They are emotional disorders that involve a variety of associated behaviors. I hope to provide some basic starting points to foster greater understanding and empathy:

1. Anorexia Nervosa:
   Anorexia Nervosa often manifests as an intense fear of gaining weight, leading to severe restrictions in food intake. Anorexia often involves a desire for control, negative body image/body dysmorphia, and complex underlying emotional factors such as anxiety, depression and PTSD. Someone who struggles with anorexia might skip meals, but it also might not be that obvious. They might cut out certain food groups (often carbs, fats etc), reduce portion sizes, eat in front of others but not when alone, only eat low calorie foods, lie about what they have eaten, avoid social events with food and find other ways to disguise the restriction. It's essential to remember that anorexia is not solely about appearance; it is a psychological condition that requires compassionate support and professional intervention. There is no “look” for anorexia, you cannot look at someone and tell if they are struggling. Most individuals struggling with anorexia are not underweight. Someone can still experience physical side effects/consequences of malnourishment without being underweight such as fatigue, irritability, sensitivity to cold, hair thinning, insomnia, dizziness/lightheadedness.

2. Bulimia Nervosa:
   Bulimia Nervosa is characterized by a cycle of binge-eating followed by compensatory behaviors to prevent weight gain, such as self-induced vomiting, excessive exercise, or laxatives/diuretics. Individuals often also struggle with poor body image or body dysmorphia, feeling a loss of control around food, restricting between binging or purging. Individuals struggling with bulimia often experience shame and guilt after the purging behavior, which can further perpetuate the cycle of behaviors. People may go to great lengths to hide their behaviors. Similar to all other eating disorders, you cannot look at someone and know if they are struggling with bulimia. Bulimia can have life-threatening health consequences at any weight such as cardiac issues due to electrolyte fluctuations, dehydration, teeth decay, digestive and intestinal problems, and many more. 

3. Binge Eating Disorder:
   Binge Eating Disorder involves consuming large amounts of food within a short period, often feeling a lack of control during these episodes and/or eating past the point of fullness or when not physiologically hungry. The binging often occurs in secret and followed by feelings of guilt, shame, depression etc. Binging might be brought on by a variety of factors such as emotional triggers as a coping mechanism, habitual triggers like time of day, being alone, specific foods/settings, physiological hunger etc. It is essential to emphasize that binge eating disorder is separate from occasional eating slightly past fullness, and it deserves recognition as a valid mental health condition. Binge Eating is often misunderstood and there is often some sort of restriction associated with binge eating (could be mental restriction, caloric restriction, not enough of certain nutrients etc). Once again, people in all body sizes struggle with binge eating disorder. 

4. Avoidant/Restrictive Food Intake Disorder (ARFID):
   ARFID is characterized by the selective avoidance or restriction of food, causing significant disruptions in an individual's nutritional intake and daily life. There are a few different subtypes of ARFID but someone can experience more than one at once: 1. Avoidant - when someone avoids certain foods due to negative sensory experiences of the food. 2. Aversive - fear of negative consequences when eating a certain food such as getting sick, choking, allergic reaction etc. This could be related to past traumatic experiences with the food but not always  3. Restrictive - when someone has little or no interest in food which might involve low to no hunger cues or very few foods that are appetizing at all. Understanding the underlying causes, such as sensory issues (not always, but sometimes it is comorbid with Autism Spectrum or ADHD) or traumatic experiences, is essential to tailor appropriate support and treatment. Along with a doctor, dietitian and therapist, some people with ARFID benefit from working with an occupational therapist that can assist in food exposures and the sensory aspect from a physiological perspective such as mouth muscles, chewing and swallowing as well. Some individuals might have body image challenges, but that is not a diagnostic criteria or significant component of ARFID. If someone is struggling with fear of weight gain and body image distress in addition to these symptoms, it is worth speaking with a professional to determine what diagnosis(es) fit best. It is possible to struggle with sensory aspects of food (ARFID) in addition to anorexia. 

5. Other Specified Feeding or Eating Disorders (OSFED):
   OSFED refers to a range of eating disorders that do not meet the specific diagnostic criteria for other disorders. It acknowledges that individuals may still experience significant distress and require support, even if their symptoms may not fit neatly into predefined categories. This inclusive approach allows for personalized treatment plans and acknowledges the diverse experiences of those struggling with eating disorders.

6. Orthorexia:

   While this is not an official diagnosis in the DSM-V, it has become an increasingly popular term. Orthorexia refers to an obsession with “healthy or clean eating”. This often involves worry about ingredients in foods, quality of food/ingredients, avoiding eating out, limiting variety of foods, rules around food and anxiety or shame when breaking the rules. The dietary rules/restrictions may escalate over time and lead to malnutrition. For some, this obsession might be more driven by “purity”, morality, and disease prevention/”health promotion” compared to fear of weight gain in anorexia. Body image/self-esteem may be dependent on compliance to one’s rules/restrictions set by themselves and it might also involve social isolation and anxiety. 

Contributing Factors to Developing an Eating Disorder
Behind each diagnosis lies a unique individual with their own stories, struggles, and strengths.  Eating disorders do not have one sole cause but are often a result of a combination of genetics, societal pressure/influences such as diet culture (including anti-fat bias and thin-privilege), trauma, perfectionism, anxiety, pre-existing or comorbid mental health diagnosis, family history, others’ relationship with food and body (especially role models like parents and siblings) around them. 

The Treatment Team

It is important to have a treatment team that specializes in eating disorders and this often involves a licensed mental health therapist, registered dietitian (that specializes in anti-diet/intuitive eating and eating disorders), a psychiatrist or psychiatric nurse practitioner for medication management, and primary care doctor to monitor medical status and potential side effects/impacts of the eating disorder. 

Pros and Cons of Diagnoses

A diagnosis can often be validating for individuals who are struggling and might not be aware of what they are experiencing or feel stuck in their symptoms. A diagnosis also allows individuals to access appropriate services (insurance requires a diagnosis for mental health coverage). A diagnosis can also inform what treatments are appropriate and most effective and instill hope for relief being possible. It can also make someone feel less alone in their struggle as others have experienced similar sets of symptoms. 

While those things named above are great benefits to a diagnosis, diagnoses are not the end all be all. Diagnoses can miss things, not encompass someone’s full experience/distress, leave out large groups of people, and even increase stigma depending on the diagnosis and how society views it. Diagnoses often do not acknowledge or explain underlying causes or societal factors contributing to mental illness. Also, behaviors and the way a mental illness presents can shift and vary over time, so someone might not fit neatly into one diagnosis that explains their symptomatology. 

Some examples of eating disorder diagnoses having criteria that exclude large numbers of people include specific frequency and weight criteria. For bulimia, the DSM specifies “binge eating and inappropriate compensatory behaviors occur, on average, at least once a week for 3 months” as one of the criteria. If the binging/purging is occurring a couple times a month, that individual still deserves support and intervention and hearing they don’t “meet criteria” for bulimia could feel very invalidating keeping them from seeking help or reinforcing the eating disorder leading to more intense symptom use.

Similarly, the diagnostic criteria for anorexia nervosa includes “a significantly low weight” that is based on BMI (body mass index) to indicate severity of the disorder. Don’t get me started on body mass index and how this is not an indicator of health (that will be its own blog post). The point is, that this leaves out an extremely large proportion of individuals who are struggling with all of the distressing symptoms of anorexia without being underweight. As mentioned earlier, one does not have to be medically underweight in order to suffer negative consequences of malnourishment and the psychological distress that anorexia causes. This invalidates the experience of all of those living in larger and even mid-size bodies and struggling with significant restriction. 

Disordered Eating

You might hear the term “disordered eating” refer to a level of restriction, purging, excessive or compulsive exercise, binging and/or an overall strained relationships with food and one’s body that does not necessarily meet the criteria for a clinically significant eating disorder. However disordered eating that goes untreated can often lead to an eating disorder if not addressed. 

For me as a clinician, the most important thing I want to understand is if these symptoms are causing any psychological, emotional, social or physical distress. For many people a strained relationship with food causes distress long before they meet diagnostic criteria for an eating disorder. The earlier we can identify and intervene when disordered eating is occurring, the better the prognosis.  Check out my other article on why someone might struggle with ambivalence or avoidance when considering seeking help or struggling with an eating disorder here!

Get Professional Help

If you or someone you know is struggling with disordered eating or an eating disorder, seek professional help and take the first step into recovery. Eating disorder therapy can provide you with the education, tools, and support to reach full recovery. Reach out to schedule your free consultation call today here!