eating disorder

Disorders characterized by abnormal eating behaviors and beliefs about eating, weight, and shape. The three major diagnoses are anorexia nervosa, bulimia nervosa, and binge eating disorder. In addition, there are many cases of abnormal eating that have only some of the features required for an eating disorder diagnosis; these cases are classified as eating disorders not otherwise specified. Obesity is classified as a general medical condition and not as an eating disorder (a psychiatric condition) because it is not consistently associated with psychological or behavioral problems.

There are also three childhood eating disorders: (1) Pica is a persistent pattern of eating nonnutritive substances in infants or young children. (2) Rumination disorder involves repeated regurgitation and rechewing of food. This behavior is not the result of a gastrointestinal or medical condition; the partially digested food comes back into the mouth without any observable nausea, disgust, or attempt to vomit. (3) Feeding disorder of infancy or early childhood is the persistent failure to eat adequately, as reflected in insufficient weight gain for age. Pica and rumination disorder are thought to be uncommon and frequently associated with developmental delays and mental retardation. Perhaps half of the pediatric hospitalizations for inadequate weight gain (which constitute 1–5% of all pediatric hospitalizations) may be due to feeding disorder of infancy or early childhood.

Anorexia nervosa

Anorexia nervosa is characterized by a refusal to maintain a minimal normal body weight (defined as 15% below average weight for height), an intense fear of becoming fat, and, if female, amenorrhea for at least 3 months. The majority of cases of anorexia nervosa are classified as restricting type; these individuals achieve abnormally low weight by severely dieting, fasting, and often by exercising compulsively. In severe cases, patients refuse to eat and can die of starvation or severe medical complications. Another subtype of anorexia nervosa is binge eating/purging type. Despite being emaciated or dangerously thin, persons with anorexia nervosa perceive themselves as overweight (distorted body image), deny the seriousness of their condition, and have an intense fear of becoming fat.

Anorexia nervosa occurs in roughly 1% of adolescent and young adult females. Most cases (90%) are female, and the majority are Caucasian and come from middle-class or higher socioeconomic groups. Anorexia nervosa is more prevalent in industrialized countries that share western views regarding thinness as an ideal. It develops most frequently during adolescence.

Persons with anorexia nervosa frequently manifest symptoms of depression and anxiety. The restricting type of anorexia nervosa is associated with obsessionality, rigidity, perfectionism, and overcontrol, whereas the binge/purge subtype is associated with greater mood instability and impulsivity across a wide range of areas, including substance abuse.

Although some cases of anorexia nervosa show no evidence of medical problems, prolonged starvation affects most organ systems, and a wide array of medical problems tend to be present. Long-term mortality from anorexia nervosa is estimated at 5–10% with most deaths resulting from starvation, cardiac events, or suicide.

The causes of anorexia nervosa are not yet understood but are likely to involve a complex combination of genetic, familial, psychological, and sociocultural factors. The onset of anorexia nervosa tends to follow a period of dieting and is frequently triggered by a stressful life events or transitions.

Since the starvation and weight loss can be life-threatening, initial treatment efforts need to focus on weight gain and the reestablishment of regular eating patterns. Inpatient hospitalization is frequently necessary. Although significant psychological issues tend to be present, it is generally ineffective to address these until weight has been stabilized. Once weight gain is achieved, psychotherapies can become useful. Relapse rates are high. See also Anorexia nervosa; Psychotherapy.

Bulimia nervosa

Bulimia nervosa is characterized by recurrent episodes of binge eating (eating large amounts of food while experiencing a subjective sense of lack of control over the eating), the regular use of extreme weight compensatory methods (for example, self-induced vomiting), and dysfunctional beliefs about weight and shape that unduly influence self-evaluation or self-worth.

Bulimia nervosa occurs in roughly 2% of adolescents and adults. It is most common in females (90% of cases), Caucasians, and middle-class or higher socioeconomic groups. The prevalence of bulimia has increased over the past few decades, and is also becoming more common in non-Caucasian groups.

Persons with bulimia nervosa have high rates of depression, anxiety, and substance abuse problems. Although this condition is less dangerous than anorexia nervosa, medical complications can occur. Dental erosion and periodontal problems are common. Electrolyte imbalance and dehydration can result in serious medical complications, including cardiac arrhythmias. In rare cases, esophageal bleeding and gastric ruptures occur.

Bulimia nervosa is likely to result from a combination of genetic, familial, psychological, and sociocultural factors. Although many persons have weight and diet concerns, the development of bulimia is thought to arise only in vulnerable individuals and usually after a stressful event. Bulimia nervosa is a self-maintaining vicious cycle.

Bulimia nervosa can often be treated successfully with outpatient therapies. Cognitive behavioral therapy and interpersonal psychotherapy have been found to be most effective for reducing binge eating and vomiting and improving associated concerns such as depression, self-esteem, and body image. These two therapies also have the best results over the long term. Certain types of pharmacotherapy, notably antidepressant medications, are also effective.

Binge eating disorder

Binge eating disorder is characterized by recurrent episodes of binge eating but, unlike bulimia nervosa, no extreme weight control behaviors (purging, laxatives, fasting) are present. Persons with binge eating disorder have chaotic eating patterns and frequently overeat as well as binge.

Although obesity is not required for the diagnosis, many people with binge eating disorder are overweight. Binge eating disorder is estimated to occur in 3% of the general population but in roughly 30% of obese persons. Binge eating disorder occurs most frequently in adulthood, affects men nearly as often as women, and occurs across different ethnic groups.

Obese binge eaters are characterized by higher levels of psychiatric problems (depression, anxiety, substance abuse) and psychological problems (poor self-esteem, body image dissatisfaction) than non-binge eaters and closely resemble persons with bulimia nervosa. Overweight persons with binge eating disorder are at high risk for further weight gain and weight fluctuations and associated medical complications. The etiology of binge eating disorder is unknown.

Cognitive behavioral therapy is effective for reducing binge eating and improving associated concerns such as depression, self-esteem, and body image, but does not seem to result in weight loss. There is some evidence that behavioral weight control treatment can reduce binge eating and facilitate weight loss. Antidepressant medications appear to reduce binge eating but do not produce weight loss; relapse is rapid after discontinuation of the medication. See also Affective disorders.

The modern term that covers all forms of the conditions known as anorexia nervosa and bulimia nervosa. It also sometimes includes obesity. The recorded prevalence of all three has increased during the past 40 years.

Anorexia nervosa, a form of food refusal, is mostly found in young girls, though 1 in 20 cases is a boy. Sometimes it improves spontaneously and sometimes it continues throughout life. The sufferers are usually intelligent high achievers and are often ambitious, and come from families who have ample food. Some have markedly ‘hysterical’ personalities, tending to be dramatic, to overreact, and to manipulate those in their environment. Others are more obsessional, ruminate constantly about food, and develop rituals connected with it. Anorexia means a lack of appetite, but the condition is misnamed because sufferers control rather than lose their appetite. It has been called ‘the relentless pursuit of thinness’. Sufferers rigorously suppress their desire for food in order to be thinner, avoiding all food that they think contains more than the minimum of calories. They often tell lies about the food they do or do not eat, perhaps hiding it or disposing of it secretly to give the impression that it has been eaten. They think about food constantly, weigh themselves several times a day, and have distorted ideas about their bodies, believing that they look fat when they are actually dangerously thin. They tend to wear many layers of loose clothes, partly to hide their condition and partly because they suffer from the cold. Many exercise obsessively and constantly in an attempt to lose further weight. Some, like sufferers from bulimia, have episodes of binge-eating, after which they make themselves vomit to get rid of the food. The most severe cases are medical emergencies and require the most skilled care of a physician in hospital to avoid death. The underlying condition, and the full care of less severe cases, is usually managed by psychiatrists.

Bulimics, who are usually of normal weight, gorge food, but then induce vomiting, sometimes several times a day. They deliberately vomit, at least initially, in order to become thinner. However, it frequently becomes a habit that is hard to break and their whole lives may be concentrated on bingeing and vomiting. Frequent vomiting leads to unpleasant mouth odour and can promote tooth decay, so sufferers tend to be secretive, to avoid close contact with other people, and to clean their teeth several times during the day. Famous bulimics have included Princess Diana and Audrey Hepburn.

Anorexia nervosa and bulimia nervosa are sometimes regarded clinically as different forms of the same illness.

A number of ‘causes’ are believed to underlie these conditions. Those most discussed are disturbed family relationships and social pressures to be thin. Some sufferers also use their obsession with food as a means of controlling their families, perhaps by creating parental anxiety or by insisting that they do all the family cooking and preventing their parents going away because they are doing this. Some have very dominant mothers and feel that the only way in which they can gain power themselves is by controlling their intake of food.

A theory has arisen that anorexia and bulimia are ‘caused’ by sexual abuse in childhood. Sometimes there is an association between the two. However, therapists of doubtful training and repute have suggested that those with eating disorders have invariably been abused in childhood. In pursuit of this belief they may have used persuasive techniques to elicit many apparent ‘memories’ of sexual abuse of which the patient was previously unaware. This has given rise to what has been labelled ‘false memory syndrome’, which has disrupted many otherwise intact families. The current view among most psychiatrists is that true memories of sexual abuse in childhood are seldom if ever repressed and that ‘memories’ which emerge for the first time during treatment, especially with a therapist who believes that they must be there, should be treated with great caution.

Anorexia nervosa was identified by William Gull in the nineteenth century. It has certainly existed for much longer, perhaps throughout the history of civilization, wherever there was ample food. It used to be regarded as a rare condition, partly because doctors tended to believe what their patients told them, and to look for physical disease. Many cases in the past were probably misdiagnosed as tuberculosis, endocrine disease (such as Simmond's disease, a failure of the pituitary gland), or loss of weight from unknown cause. The secretiveness and deceptiveness of the patients made the diagnosis difficult for those who were unaware of this tendency. Since then doctors have realized that anorexia nervosa is usually not difficult to identify and that bulimia is much more common than was supposed.

The recorded incidence of anorexia nervosa increased greatly during the 1950s and 1960s, and it became a worrisome epidemic, especially in girls' boarding schools. This rise was undoubtedly partly due to the increasing recognition of the condition by doctors, but partly because of the fashion for thinness, which became popular and was accompanied by hostility to plumpness and fear of gaining weight. Those responsible for the care of young girls have shown hostility towards the fashion trade's flaunting of skeletal models to display and advertise clothes, but the custom persists, as does the epidemic of anorexia, which is found at ever younger ages, even as young as 6 or 7. Some of the youngest sufferers are the children of anorexics and bulimics, many of whom raise their families with bizarre attitudes towards food. Doctors have expressed anxiety about the threat to health in children who are fed on skimmed milk and high fibre food, virtually free of sugar and fat. Such a diet is unsuitable for growing bodies and can cause long-term damage. The fact that eating disorders tend to run in families may not be entirely due to parental feeding practices: it seems likely that there is a genuine genetic factor in their causation.

The ‘epidemic’ of anorexia may now have peaked as the incidence seems no longer to be rising. According to figures from the Eating Disorders Unit in the University of London, during 1988-93 the incidence of anorexia remained stable at about 20 cases per 100 000 of the population, whereas the incidence of bulimia rose from 15 to 50 cases per 100 000. This apparent dramatic rise in bulimia can be at least partly explained by the fact that the disease was first described in 1979: doctors and the public have only gradually become aware of it. Probably it was common before it was identified. Since the sufferer usually looks normal, the condition is unlikely to be diagnosed unless the sufferer admits to having the problem or their behaviour is noticed by others.

Some people with these conditions recover spontaneously but many need help, which they are often reluctant to seek. Various treatments have been tried, including incarceration with ‘rewards’ (such as having visitors) for weight gain, sedatives (to suppress activity), and various forms of psychotherapy. Antidepressant drugs are often quite effective and many clinicians believe that there is considerable overlap between eating disorders and depression.

Obesity represents the other end of the eating disorders spectrum. Classically, it is a problem of middle age, but its incidence has been rising, even among young children, especially in the developed world. It affects women more than men and lower social classes more than upper. It is associated with higher than average morbidity and mortality. Heart disease, high blood pressure, diabetes, and even accidents are much more common in overweight people than in those of normal weight. Obesity is commonest where food is ample but protein is expensive and it is particularly likely to develop in people whose diet is high in processed foods, since these often contain many ‘hidden’ calories in the form of fat and sugar. The recent increase in obesity is thought to be related to the sedentary and labour-saving characteristics of modern life in the developed world. People drive cars rather than walk, guide the vacuum cleaner rather than scrub the floor, and spend much time watching television. A sedentary lifestyle makes it difficult to lose weight. Many people control any tendency to gain weight by deliberately taking exercise, perhaps joining a gym or playing an energetic game regularly, but others dislike taking exercise. It is often harder to persuade a patient to take exercise than to keep to a slimming diet.

— Ann Dally

See also dieting; development and growth; obesity.

A potentially dangerous disturbance in the pattern of eating. It usually has an underlying psychological basis, but is sometimes caused by a malfunction of the appetite centre in the hypothalamus at the base of the brain. Eating disorders are usually classified into two main groups: anorexia nervosa and bulimia nervosa. In reality there is a spectrum of disorders and it is not always easy to assign a particular disorder neatly into either of the two main groups. Patients who do not meet all the criteria for either anorexia nervosa or bulimia nervosa are said to suffer an ‘eating disorder not otherwise specified’ (NOS).

Eating disorders of any type are more prevalent among females than males. More than 90 per cent of those with eating disorders are women, mostly adolescents. Many sociologists and psychiatrists blame the disorders on the preoccupation of Western culture with slimness and the negative stereotyping of women who are plump. Women are continually bombarded with images from the media reinforcing the notion that they have to be slim to be beautiful, successful, healthy, and happy.

There now appears to be a significant change in cultural expectations for men, with a greater emphasis on good looks and a muscular physique. This has resulted in many young men becoming compulsive exercisers and resorting to the use of anabolic steroids and special body-building diets. The obsession of men with physical appearance may parallel that of women; both can result in psychological disorders, but of different types. See also anorexia nervosa; bulimia nervosa; and eating disorder not otherwise specified.

A group of dysfunctional behaviors of nutrition, including anorexia, bulimia, or cravings for such nonfood items as ice, clay, or starch.

The term "eating disorders" encompasses a group of problems that fall into two broad categories—overeating (binging), and undereating (anorexia)—sometimes referred to as "starving or stuffing." Eating disorders are most commonly found in young females during early adolescence. However, eating disorders affect both males and females at many stages in the life cycle. Although the conditions create physical problems, the causes are usually psychological.

Eating disorders have been recognized by health experts for many years. Bulimia symptoms were described by the Egyptians, Hebrews, and Greeks; and anorexia nervosa was first described in the 1600s. However, it was not until 1980 that these conditions were categorized as psychiatric disturbances.

Eating disorders are marked by extreme dissatisfaction and preoccupation with body size and shape. People with these disorders may see themselves as overweight when their weight is actually lower than normal, or they may measure their self-worth by their weight. Emotional disturbance accompanies disordered eating, including self-loathing over amounts eaten or panic about possible weight gain. In addition to overeating or undereating, individuals with eating disorders engage in "compensatory behaviors," such as purging (self-induced vomiting or inappropriate use of laxatives, enemas, or diuretics), fasting, excessive exercise, and restricting (overly strict limiting of calories or food types).

Eating disorders can be distinguished from dieting by the psychological distress that accompanies the concern about weight; by the interference with everyday responsibilities and pleasures; and by the danger of causing medical problems, possibly even death.

Shame and secrecy often accompany eating disorders, and the problem may go undetected for years. Recognition of these disorders is necessary to begin the long process of treatment. Unlike other addictive or habit problems, food cannot be avoided, and recovery requires developing a healthier relationship to food and to one's own body, as well as improved coping skills.

Types of Eating Disorders

Mental health professionals recognize three main types of eating disorders, anorexia nervosa, bulimia nervosa, and binge eating.

Anorexia. Although the word "anorexia" literally means "without appetite," the condition is better described as "restricted eating" or "self-starvation." The person with anorexia has an appetite, and food tastes good; however, food is seen as "the enemy." One authority terms anorexia "food phobia." The disorder is characterized by a refusal to maintain a minimal normal body weight, an intense fear of gaining weight, a disturbance in the self-perception of body size and shape, and (in women) an absence of menstrual periods for three or more consecutive months. Anorexia may be further classified as a restricting type or binge-eating/purging type.

Bulimia. Bulimia (Greek for "ox hunger") is characterized by recurrent episodes of binge eating. Binging (eating an extreme amount of food) is accompanied by a sense of lack of control over amounts eaten, and a feeling of being unable to stop. The disorder is further classified as either purging or nonpurging bulimia depending on whether the individual uses fasting or exercise instead of purging to "compensate" for binging.

Binge Eating. Binge eating is sometimes termed "stress eating" or "emotional overeating." It is characterized by compulsive overeating, usually in secret and without purging, followed by guilt or remorse for the episode. It has been estimated that up to 40 percent of people with obesity may be binge eaters. The term "binge eating disorder" was officially introduced in 1992. Unlike nonpurging bulimia, there is no attempt to "compensate" for the binge by fasting or overexercising.

Causation

Eating disorders can be considered biologically based alterations filtered through cultural pressures and individual psychology. The psychological aspects of anorexia are frequently thought to include conflicts between mothers and adolescent daughters over perfection. Bulimia is often thought to involve conflicts over dependence and loneliness. Binging may share causal factors with obsessive-compulsive behavior.

Prevalence and Risk Factors

Since people commonly deny or try to hide their disordered eating behaviors, it is difficult to accurately estimate the number of people affected by these problems. Nonetheless, experts report approximately 1.2 million women in the United States are affected by anorexia or bulimia.

Anorexia is more present in developed societies, especially in societies where being attractive is linked to being thin. The prevalence of anorexia has been estimated to be 0.5 to 1 percent of the population, and rates appear to be increasing. The condition usually begins in early adolescence (13–18 years) and 90 percent of the cases are female. Occasionally, but rarely, the disorder may begin in someone over age forty. Stressful life events (e.g., leaving home for college) occasionally trigger the onset of the problem. Long-term death rates from anorexia approach 10 percent, with death usually resulting from starvation, suicide, or electrolyte imbalance.

The chances of developing an eating disorder are higher among females (female cases outnumber male cases 10 to 1), among those pressured by society or family to be thin, and among athletes. Athletes for whom weight control and/or thinness provides an advantage (e.g., gymnastics, wrestling) are particularly susceptible to eating disorders. Psychological factors that put a person at risk for disordered eating include low self-esteem, poor coping ability, perfectionism, and body image distortion. Genetics may also play a role. Risk increases among those with a close relative (a parent or sibling) with an eating disorder, especially with binging/purging.

Impact

Eating disorders cause an array of medical problems ranging from fatigue to illness, and occasionally death. Even when eating disorders do not reach this level of severity they can be significant sources of suffering for the patient and family members. Mild complications include lack of energy, cavities, cold intolerance, irregular periods, constipation and diarrhea, and difficulty with concentration. Serious complications include electrolyte instability, irregular heartbeat, suicidal tendencies, and death. Between 5 to 18 percent of those with anorexia or bulimia will die from complications of the disorder.

Malnourishment and self-starvation affect the heart, thyroid, and the digestive and reproductive systems, as well as seriously decreasing bone density. Specific problems seen in athletes with eating disorders include impaired athletic performance and an increased risk of injuries and stress fractures. Female athletes with an eating disorder may be considered to have the "female athlete triad" if they manifest symptoms of: (1) disordered eating (which leads to decreased body fat causing a lower estrogen level); (2) amenorrhea (not having a period for three consecutive cycles because of low estrogen); and (3) osteoporosis (fragile bones because of low estrogen).

Although eating disorders are not contagious, the culture in which the person lives can contribute to the spread of an eating disorder, particularly in cultures that glorify thinness. Although obesity may be a consequence of binge eating, it does not typically result from the major eating disorders. Prevention efforts may help, and early detection efforts are essential as patients do not typically request treatment for themselves. Psychological consequences of semistarvation include depressed mood, social withdrawal, insomnia, irritability, and loss of libido, as well as obsessive thoughts about food.

Treatment

The most important factor in treating people with eating disorders is the recognition of the disorder. Disordered eating is usually not self-diagnosed because of associated denial and embarrassment. Anorexics usually do not even realize there is a problem with their behavior, and bulimics usually realize the problem but try to hide their behavior. Family, friends, or health care professionals are often the people who recognize the problem. A team treatment approach is frequently employed, consisting of a physician, a nutritionist, and a psychologist. Medically, antidepressants may be needed, and complications may require treatment or hospitalization if the situation is severe enough. Nutritionally, people with disordered eating need to learn how to eat in a healthful way. Psychologically, modification of inappropriate food-related behavior and development of improved coping mechanisms are necessary. In addition, changes in body image and ideal body image may be necessary.

Treatment, especially for anorexia, can be a long drawn-out affair, and it can take a big toll on family resources and on the social productivity of the person. Recovery from these disorders is difficult, and estimates of 50 percent relapse rates for anorexia and 33 percent for bulimia are common. A difficulty in the control of disordered eating behaviors is the need to continue to eat. This it is in contrast to other disorders of habit or addiction in which treatment involves total avoidance of the abused substance.

Resources

The Academy of Eating Disorders (http://www.acadeatdis.org) is a multidisciplinary professional group devoted to the improved detection and treatment of these conditions. Efforts to expand screening are promoted through eating disorders awareness week on U.S. college campuses, and this has now been expanded to high school and the general public (http://www.nmisp.org/eat.htm).

Other valuable resources include the following:

• American Anorexia/Bulimia Association, 165 West 46th Street #1108, New York, New York 10036; (212) 575–6200, http://www.aabainc.org/
• National Eating Disorders Organization (formerly the National Anorexic Aid Society), 6655 South Yale Avenue, Tulsa, Oklahoma 74136; (918) 481–4044, http://www.kidsource.com/nedo/
• Overeaters Anonymous Headquarters, World Service Office, 6075 Zenith Court NE, Rio Rancho, New Mexico 87124;(505) 891–2664, http://www.overeatersanonymous.org/

(SEE ALSO: Anorexia; Menstrual Cycle; Mental Health; Nutrition; Social Determinants)

Bibliography

American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders. 4th edition. Washington, DC: Author.

American Psychiatric Association (2000). "Practice Guideline for the Treatment of Patients with Eating Disorders (Revision)." American Journal of Psychiatry 157 (January Supp.):1.

Browell, K. D., and Fairburn, C. G., eds. (1995). Eating Disorders and Obesity. New York: Guilford Press.

Christensen, L. (1996). Diet-Behavior Relationships: Focus on Depression. Washington, DC: American Psychological Association Books.

Danowski, D., and Lazora, P. (2000). Why Can't I Stop Eating? Recognizing, Understanding, and Overcoming Food Addiction. Center City, MN: Hazelden Information Education Services.

Fairburn, C. G. (1995). Overcoming Binge Eating. New York: Guilford Press.

Natenshon, A. H. (1999). When Your Child has an Eating Disorder: A Step-by-step Workbook for Parents and Other Caregivers. San Francisco: Jossey Bass Publishers.

Siegel, M.; Brisman, J.; and Weinshel, M. (1997). Surviving an Eating Disorder: New Perspectives and Strategies for Family and Friends. New York: Harper Collins.

Stunkard, A. J., and Wadden, T. (ed.) 1993. Obesity: Theory and Therapy. Lancaster, CA: Raven Press.

Thompson, A. K., ed. (1996). Body Image, Eating Disorders and Obesity: An Integrated Guide to Assessment and Treatment. Washington, DC: American Psychological Association Books.

— LEONARD J. HAAS; TRISHA PALMER

For more information on eating disorders, visit Britannica.com.

A continuum ranging from abnormal eating behaviours to clinical eating disorders Included in the continuum are norexia nervosa, bulimia nervosa, and eating orders not otherwise specified, as well as subclinical (subtheshold) eating problems that do not meet the clinical criteria for a disorder. Eating disorders are much more prevalent among women (especially adolescents) than men. Many sociologists blame the disorders on the preoccupation of Western culture with slimness. Eating disorders are of major concern in female athletes. Some estimates suggest that as many as 50% of elite athletes in certain sports may have an eating disorder. High-risk-sports include appearance sports (e.g. diving, figure skating, and gymnastics), endurance sports (e.g. distance running and swimming), and weight-classification ports (e.g. judo). A mild eating disorder (loss of appetite and weight) is one of the symptoms of overtraining.

Eating Disorders are a group of psychological ailments characterized by intense fear of becoming obese, distorted body image, and prolonged food refusal (anorexia nervosa) and/or binge eating followed by purging through induced vomiting, heavy exercise, or use of laxatives (bulimia). The first American description of eating disorders appeared in 1859, when the asylum physician William Stout Chipley published a paper on "sitomania," a type of insanity consisting of an intense dread or loathing of food. Clinical research in Great Britain and France during the 1860s and 1870s replaced sitomania with the term "anorexia nervosa" and distinguished the disorder from other mental illnesses in which appetite loss was a secondary symptom and from physical "wasting" diseases, such as tuberculosis, diabetes, and cancer.

Eating disorders were extremely rare until the late twentieth century. Publication of Hilde Bruch's The Golden Cage (1978) led to increased awareness of anorexia nervosa, bulimia, and other eating disorders. At the same time, a large market for products related to dieting and exercise emerged, and popular culture and the mass media celebrated youthful, thin, muscular bodies as signs of status and popularity. These developments corresponded with an alarming increase in the incidence of eating disorders. Historically, most patients diagnosed with eating disorders have been white, adolescent females from middle-and upper-class backgrounds. This phenomenon suggests that eating disorders are closely linked with cultural expectations about young women in early twenty-first century American society.

Bibliography

Brumberg, Joan Jacobs. Fasting Girls: The Emergence of Anorexia Nervosa as a Modern Disease. Cambridge, Mass: Harvard University Press, 1988.

Vandereycken, Walter, and Ron van Deth. From Fasting Saints to Anorexic Girls: The History of Self-Starvation. Washington Square: New York University Press, 1994.

—Heather Munro Prescott/C. W.

This article's citation style may be unclear. The references used may be made clearer with a different or consistent style of citation, footnoting, or external linking. (September 2009)

Eating Disorder(EDO)
Classification and external resources
ICD-10	F50.
ICD-9	307.5
MeSH	D001068

An eating disorder is a condition which affects an individuals eating habits, either as a result of their own doing (self-inflicted), or as a bodily reaction to the consumption of food. Eating disorders can range from mild mental anguish to life-threatening conditions, and can affect every aspect of an individuals daily life. According to the authors of Surviving an Eating Disorder, "feelings about work, school, relationships, day-to-day activities and one's experience of emotional well being are determined by what has or has not been eaten or by a number on a scale."^[1] Anorexia nervosa and bulimia nervosa are the most common eating disorders generally recognized by medical classification schemes,^[2] with a significant diagnostic overlap between the two.^[3] Together, they affect an estimated 5-7% of females in the United States during their lifetimes^[4] and "approximately 10% of eating disordered individuals coming to the attention of mental health professionals are male".^[5] There are several other eating disorders which are prevalent amongst certain demographics that are being investigated and defined - Rumination syndrome, Compulsive overeating, and Selective eating disorder.

Contents 1 Disorders 1.1 Anorexia nervosa 1.2 Bulimia nervosa 1.3 Rumination syndrome 1.4 Orthorexia nervosa 1.5 Selective eating disorder 1.6 Compulsive overeating 2 Causes 2.1 Environmental 2.2 Biological 2.3 Developmental etiology 2.4 Trauma 3 Gender differences 4 Diagnosis 5 Symptoms 5.1 Anorexia nervosa / Bulimia nervosa 5.2 Compulsive overeating / Binge eating disorder 6 See also 7 Notes 8 References 9 External links

Disorders

Anorexia nervosa

Main article: Anorexia nervosa

Anorexia nervosa is deliberate and sustained weight loss driven by a fear of distorted body image. It is a serious disorder that will lead to death.^[6] It is not to be confused with anorexia, which is a symptomatic general loss of appetite or disinterest in food. DSM-IV characterizes anorexia nervosa as:

• An abnormally low body weight (the suggested guideline ≤ 85% of normal for age and height, or BMI ≤ 17.5).
• For postmenarcheal females, amenorrhea (the absence of three consecutive menstrual cycles).
• An intense fear of gaining weight or becoming fat and a preoccupation with body weight and shape.^[7]

There are two types of anorexia nervosa, although eating disorders are now being considered as spectrum disorders. The two types are Restricting type and Binge/Purge type. The difference between anorexia nervosa-Binge/Purge type and bulimia can be related to whether or not the individual is at a healthy weight for their height as well as the underlying reason they are engaging in eating-disordered behavior. For example, a person suffering from anorexia Binge/Purge type may be binging due to malnutrition, while a sufferer of bulimia may be binging to control their emotions.

The appearance of anorexia often occurs during adolescence, with 76% reporting onset of the disorder between the ages of 11 and 20.^[8] It is about ten times more likely to occur with females than males.^[6] The mortality rate for those diagnosed with anorexia nervosa is approximately 6%—the highest of any mental illness—with roughly half of those due to suicide.^[9]

Anorexics have a distorted view of their body. Even when they are extremely thin, they see themselves as too fat.^[6] Anorexics are commonly perfectionists, driven to succeed; yet they set unattainable standards of performance for themselves. When they fail to meet these standards, they look for a part of their lives they can control; food and weight become that “control” for them. Low self-esteem and constant self-criticism cause anorexics to constantly fear losing control, and even consuming a small amount of food could be considered a loss of control.^[6]

Bulimia nervosa

Main article: Bulimia nervosa

Bulimia nervosa is a cyclical and recurring pattern of binge eating (uncontrolled bursts of overeating) followed by guilt, self-recrimination and overcompensatory behavior such as crash dieting, overexercising and purging to compensate for the excessive caloric intake.^[6]

Bulimics often have "binge food," which is the food they typically consume during binges. Some describe their binge episodes as a physical high they feel, numbing out, going into auto-pilot, losing all control, immediate comfort, etc. The reasoning or triggers behind a binge may serve different purposes for different people. This binge episode leads the individual to feel guilt, shame, embarrassment, and complete failure. Bulimics try to regain control of themselves and the situation by purging the food (either by self-induced vomiting or using a laxative), making up for their mistake.^[6] This leads to feeling famished and empty again, and therefore, another uncontrollable binge, followed by feeling powerless, and the vicious binge/purge cycle continues. Bulimics have extreme eating and exercising habits, instead of demonstrating moderation. This compulsive behavior is often echoed in similar destructive behavior such as sexual promiscuity, pathological lying, and shoplifting. Some bulimics not only struggle with the eating disorder, but these other harmful behaviors as well.

The appearance of bulimia nervosa often occurs during late adolescence or early adulthood.^[6] 90 Percent of bulimics are women.^[6] Roughly 70 percent of individuals who develop bulimia nervosa eventually recover.^[6]

Compulsive exercising is a type of bulimia nervosa, where those afflicted exercise excessively in order to purge excess calories.^[10][10] One that struggles with this disorder takes part of vigorous physical activity to the point that it is unhealthy and unsafe. It is often referred to as obligatory exercise or anorexia athletic. The individual usually feels compelled to exercise and has problems with anxiety and guilt until exercising. Someone that has compulsive exercising disorder will still force themselves to work out even when sick or injured. He or she will often calculate how much they have eaten and exercise on the amount of calories they have eaten and usually have low energy because of all the calories they have burned.^[11] People who struggle with this disorder usually do it to have more control in their life. Praise is often given to the individual about how in shape he/she may look which gives that person more of a drive to continue to work out. Females most commonly have compulsive exercising disorder and measure their self worth through their performance. They often take out their emotions like anger, depression, or frustration when exercising by pushing their bodies to the limit.^[12]

Rumination syndrome

Main article: Rumination syndrome

Rumination Syndrome is a rarely diagnosed chronic eating disorder of unknown prevalence. Though classically described as an illness of infancy or people with cognitive disabilities, its effects on otherwise healthy adults and adolescents is gaining increasing awareness in the medical community. Patients of this disorder experience effortless post-prandial (after ingestion) regurgitation of meals without the smells and tastes associated with normal vomitting. There is no nausea or retching preceding the event. Rumination syndrome is often misdiagnosed as bulimia nervosa by doctors, due to the lack of awareness of the disorder, the similarity in symptoms, and the common teenage onset of the disorder.^[13]

Orthorexia nervosa

Main article: Orthorexia nervosa

Orthorexia nervosa is a recently discovered disease previously thought to be Anorexia. This type of disorder is an obsession with eating only healthy types of foods. This disorder derives from the drive to become pure, so that a sufferer begins to become obsessed with everything that he or she is consuming. Someone who struggles with orthorexia nervosa will do things like planning out their meals for the next day. This means that they will have a strict planned schedule of breakfast, lunch and dinner. Thinness often results due to the restricted types and amounts of food eaten, but is a side effect rather than an intended result. People who have orthorexia nervosa are often critical of what others eat, and usually isolate themselves from surroundings.^[14]

Selective eating disorder

Main article: Selective eating disorder

Selective Eating Disorder (SED) prevents the consumption of certain foods. Although it is often viewed as a phase of childhood that is generally overcome with age, one may continue to be afflicted with SED throughout his or her adult life. Those with the disorder eat a "highly limited range of foods" and are unlikely to try new foods, as well. When the disorder persists into middle childhood and adolescence, it can result in conflict, anxiety, and social avoidance.^[15]

Sufferers of SED have an inability to eat certain foods based on texture or aroma. "Safe" foods may be limited to only certain types of food or even specific brands. Afflicted individuals may exclude whole food groups, such as fruits or vegetables.

Compulsive overeating

Main article: compulsive overeating

Obsessive Compulsive Overeating [OCO] (Also known as binge eating) is one of the most common mental disorders and is linked with Obsessive Compulsive Disorder (OCD). It is triggered not by hunger, but an emotional disturbance. An over-eater will quickly consume thousands of calories, often in one sitting. Unlike Bulimia Nervosa, food is not expelled from the body. If left untreated, a compulsive over-eater becomes obese. About 2 percent of all adults in the United States struggle with binge eating. People at any age can develop this particular disorder, but it is seen most in young adults. Clinical studies have continued to find that obese binge eaters have much higher levels of depression than other obese individuals that do not have a binge eating disorder.^[16] The individual has feelings of disgust and guilt that lead to depression.

People that struggle with binge eating are likely to have alcohol problems and engage in impulsive behavior, such as not thinking before acting out.^{[citation needed]} They do not feel that they can control themselves, are typically not close with their community, and have difficulty discussing their problems and feelings. They also have more health problems, a hard time sleeping at night, joint pain, muscle pains, menstrual problems, and headaches. Affected people often have suicidal thoughts, struggle digesting their food, and are stressed. People that have a binge eating disorder are usually ashamed and become very good at hiding the fact that they have it. They become so good at hiding that most people around them, including close friends and family members, do not even know about their disorder. ("Binge Eating Disorder", 2008)

Although it is not diagnosed very often, several factors can make it more difficult to diagnose than other eating disorders. Because COE is an eating disorder which is less commonly taught in school or talked about, a large amount of people who have the disorder just blame their weight on their binges and don't consider that there might be a psychological reason behind their binge eating, or are not even aware that the disorder exists altogether. One way to determine if a person has COE is by looking at their eating patterns. It is not uncommon in some that their food habits can be completely random: healthy foods a few days, attempted dieting or even crash dieting, which are followed by a relapse into binge eating. A very common misconception is that people who have COE do not know healthy eating habits or simply "don't know better," however, what makes this specifically an eating disorder is the addiction of eating large amounts of food and repeated relapsing in attempts to changing to healthy eating habits.^{[citation needed]} Binge eating sometimes is because of a certain emotion (boredom, anger, sadness, etc.).

Causes

Environmental

Family and friends are very influential when it comes to eating disorders. The media may be a significant influence on eating disorders through its impact on values, norms, and image standards accepted by modern society.^[17] The media sends a message that "thin is beautiful" in their choice of fashion models, which many young girls want to emulate.^[6] Both society’s exposure to media and eating disorders have grown immensely over the past decade. Researchers and clinicians are concerned about the relationship between these two phenomena and finding ways to reduce the negative influence thin-ideal media has on women’s body perception and susceptibility to eating disorders. The dieting industry makes billions of dollars each year by consumers continually buying products in an effort to be the ideal weight. Hollywood displays an unrealistic standard of beauty that makes the public feel incredibly inadequate and dissatisfied and forces people to strive for an unattainable appearance. People, such as teachers or counselors, who work closely with young women and men and who come into contact with them regularly are in a position to detect warning signs and possible eating disordered symptoms. Teachers have a particularly important role in detecting eating disorders and changes in behavior in students, as they see them everyday and are able to monitor changes frequently. A resource for teachers to reference in maintaining the health of students, as far as eating disorderes are concerned, can be found at: http://www.something-fishy.org/isf/signssymptoms.php Teachers should also be aware of unhealthy messages sent by classmates about appearance preferences and ideal images of beauty, and these messages should be addressed and corrected. ^[18] This takes an enormous toll on one's self-esteem and can easily lead to dieting behaviors, disordered eating, body shame, and ultimately an eating disorder.^[6] The surrounding culture in which an adolescent is raised greatly affects how they feel they are supposed to look, potentially contributing to an eating disorder. It has been discovered that a chemical imbalance in the brain may be linked to why some people have anorexia and others don’t. The most dangerous part of certain eating disorders is that people who have them “see themselves as overweight even though they are dangerously thin” (National Institute of Health). This fact alone suggests that the person cannot help but see themselves as overweight. Their brain is possibly distorting their image while everyone else is seeing how they really look. Bulimics very often binge and then purge because they feel guilty for eating so much food, even if they are a “weight around their normal weight range” (National Institute of Health). ^[6]

Biological

Patients with severe obsessive compulsive disorder, depression or bulimia were all found to have abnormally low serotonin levels.^[19] Neurotransmitters such as serotonin, dopamine and norepinephrine are secreted by the intestines and central nervous system during digestion.^[20]

Researchers have also found low cholecystokinin levels in bulimics. Cholecystokinin is a hormone that causes one to feel full and decreases eating. Low levels of this hormone are likely to cause a lack of satiative feedback when eating, which can lead to overeating. Another explanation researchers found for overeating is abnormalities in the neuromodulator peptides, neuropeptide Y and peptide YY. Both of these peptides increase eating and work with another peptide called leptin. Leptin is released by fat cells and is known to decrease eating. Research found the majority of people who overate produced normal amounts of leptin but they might have complications with the blood-brain barrier preventing an optimal amount to reach the brain.^[20]

Cortisol is a hormone released by the adrenal cortex which promotes blood sugar and increases metabolism.^[20] High levels of cortisol were found in people with eating disorders. This imbalance may be caused by a problem in or around the hypothalamus.^[21] A study in London at Maudsley Hospital found that anorexics were found to have a large variation of serotonin receptors and a high level of serotonin.^[22]

Many of these chemicals and hormones are associated with the hypothalamus in the brain.^[23] Damage to the hypothalamus can result in abnormalities in temperature regulation, eating, drinking, sexual behavior, fighting, and activity level. Uher & Treasure (2005) performed a study researching brain lesions effects on eating disorders. They evaluated 54 formally published cases of eating disorders and brain damage. They found many correlations between eating disorders and damage to the hypothalamus. People with brain lesions in the hypothalamus had abnormal eating behaviors; unprovoked and self induced vomiting, over concern with becoming fat, cheating with eating, frequent sleepiness, depression, obsessive compulsive behavior and diabetes insipidus.^[24]

While scientists have determined that there are possible biochemical or biological causes leading to eating disorders because certain chemicals which control hunger, appetite or digestions are out of balance, experts such as Dr. Edward J. Cumella, executive director of the Remuda Treatment Programs, states that there are three components to eating disorders: 1. The genetic component; 2. The unique environmental factors, such as personal experiences; and 3) The shared environmental factors, such as culture. According to Dr. Cumella, "Some people are born with a predisposition to having an eating disorder and there are genetic markers that can push a person in the direction of anorexia or bulimia...but it does not guarantee that a person will automatically suffer from an eating disorder. The environment - a person's life experience - still has to pull the trigger."^[25]

Developmental etiology

Research from a family systems perspective indicates that eating disorders stem from both the adolescent's difficulty in separating from over-controlling parents, and disturbed patterns of communication. When parents are critical and unaffectionate, their children are more prone to becoming self-destructive and self-critical, and have difficulty developing the skills to engage in self-care giving behaviors. Such developmental failures in early relationships with others, particularly maternal empathy, impairs the development of an internal sense of self and leads to an over-dependence on the environment. When coping strategies have not been developed in the family system, food and drugs serve as a substitute.^[26]

Trauma

Eating disorders should also be understood in the context of experienced trauma, with many eating problems beginning as survival strategies rather than vanity or obsession with appearance. According to sociologist Becky Thompson, eating disorders stemming from women of varying socio-economic status, sexual orientation and race, and finds that eating disorders and a disconnected relationship with one's body is commonly a response to environmental stresses, including sexual, physical, and emotional abuse, racism, and poverty. This reality is further detrimental for women of color and other minority women, since they are forced to live in a culture that embraces a narrowly defined conception of beauty: "people furthest from the dominant ideal of beauty, specifically women of color, may suffer the psychological effects of low self-esteem, poor body image, and eating disorders."^[27]

Gender differences

"Frequent dieting and trying to look like persons in the media were independent predictors of binge eating in females of all ages. In males, negative comments about weight by fathers was predictive of starting to binge at least weekly."^[28]

Exercise addiction is common in men and women, especially in those who suffer from eating disorders and obsessive-compulsive disorder. It is the result of a fear of becoming fat, and allowing their need to stay fit to overtake their lives. Exercise addicts are risking their health in order to get a "runner's high". ^[29] They are in search of the ideal body type and place the importance of exercise above the needs of their children, parents, friends and health.

In male and female sports there are different reasons to lose weight.^{[citation needed]} For a female many of the eating disorders are for more dancing related sports such as poms, cheerleading, and many other forms of competitive forms of dance.^{[citation needed]} While in many male predominant sports it is also necessary such as wrestling, mixed martial arts, and sports where weigh-ins are necessary.^{[citation needed]} This puts a lot of stress on the male to make the cut leading to many of the eating disorders such as bulimia and anorexia nervosa.^{[original research?]}

Education sources that we depend on don't always give us the accurate information on eating disorders. Eating disorders affect women and men but we don't recognize that fact.^{[original research?]} Men may suffer from different forms of eating disorders than women.^{[citation needed]} They may not starve themselves^{[original research?]} but sometimes they use drugs to bulk up. They have the pressure of being "strong, bulk, hot".^{[dubious – discuss][original research?]}"A survey published in Psychology Today reported that only 15% of men said that they are unhappy with their weight. Increasingly, men feel the same pressure that women feel to be attractive and slender. If these trends continue, the incidence rate for eating disorders among men will increase" (Pipher 16).

Pipher, Mary. Hunger pains: The moderns woman's tragic quest for thinness. New York: Ballantine Books, 1995.

Diagnosis

This section requires expansion.

Clinically, eating disorders are evaluated using instruments such as the Questionnaire of Eating and Weight Patterns (QEWP), which has specialized versions for adolescents and parents (QEWP-A, and QEWP-P). In addition to evaluating eating patterns, these tests also diagnose depression.^[30]

Symptoms

Anorexia nervosa / Bulimia nervosa

The most visible symptom is the extreme weight loss in a short period of time. Oral symptoms include generalized mucosal redness oral ulcerations, loss of tooth material especially due to erosion caused by acidic vomiting this erosion is especially seen on the palatal surface of the maxillary anterior teeth, and occlusal surface of mandibular molars the mandibular incisors are spared of erosive lesions as they are covered by the tongue during bouts of vomiting. The patient may also present with traumatic lesion on the uvula due to damage caused by the fingers while inducing vomiting similar lesion can be found on the corresponding finger.

Compulsive overeating / Binge eating disorder

Noticeable symptoms include rapid weight gain or the onset of obesity, significantly decreased mobility due to the gain in weight, as well as excessive perspiration and/or shortness of breath. Other symptoms include isolation, self-loathing, and poor sleepings patterns or insomnia.

See also

• Organic feeding disorders

Notes

1. ^ Siegel, Michaele, Brisman, Judith and Weinshel, Margot. Surviving an Eating Disorder. New York: Harper and Row Publishers. 1988.
2. ^ "ICD-10: Behavioural syndromes associated with physiological disturbances and physical factors". World Health Organization. 2006-04-05. http://www.who.int/classifications/apps/icd/icd10online/?gf50.htm+f50. Retrieved 2007-03-08. 
3. ^ Milos, G; Spindler, A; Schnyder, U; Fairburn, C G (2005), "Instability of eating disorder diagnoses: prospective study", The British Journal of Psychiatry 187 (6): 573–578, doi:10.1192/bjp.187.6.573, PMID 16319411 
4. ^ "Practice guidelines for the treatment of patients with eating disorders", American Journal of Psychiatry (American Psychiatric Association) 157 (1): 1–39, January 2000 .
5. ^ Find specific information regarding eating disorders in men and boys, National Eating Disorders Association 
6. ^ ^{a b c d e f g h i j k l} Santrock, J. W. (2005). Nutrition and Eating Behavior. In Mike Ryan (Ed.). A Topical Approach to Life-Span Development, Fourth Edition (pp 156-157). New York City: McGraw-Hill.
7. ^ American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR (4th ed.). American Psychiatric Association. ISBN 0890420629. 
8. ^ "Facts About Eating Disorders". National Association of Anorexia Nervosa and Associated Eating Disorders. http://www.anad.org/22385/index.html. Retrieved 2008-03-15. 
9. ^ Herzog, David B; Greenwood, Dara N; Dorer, David J; Flores, Andrea T; Ekeblad, Elizabeth R; Richards, Ana; Blais, Mark A; Keller, Martin B (2000), "Mortality in eating disorders: A descriptive study", International Journal of Eating Disorders 28 (1): 20–26, doi:10.1002/(SICI)1098-108X(200007)28:1<20::AID-EAT3>3.0.CO;2-X 
10. ^ ^{a b} Barlow, David H; Durand, V Mark (July 2004), Abnormal Psychology: An Integrative Approach, Thomson Wadsworth, ISBN 0534633625 
11. ^ Tiemeyer, 2008
12. ^ Mary L. Gavin, 2007
13. ^ Papadopoulos, Mimidis, V., K. (2007), "The rumination syndrome in adults: A review of the pathophysiology, diagnosis and treatment", Journal of Postgraduate Medicine 53 (3): 203–206, ISSN 0022-3859 
14. ^ "Eating Disorders", 2001
15. ^ Clinical Child Psychology and Psychiatry, Vol. 6, No. 2, 257-270 (2001) (available at http://ccp.sagepub.com/cgi/content/short/6/2/257)
16. ^ Susan Himes, 2005
17. ^ Harrison, K; Cantor, J (1997), "The relationship between media consumption and eating disorders", Journal of Communication (Oxford University Press) 47 (1): 40–68, doi:10.1111/j.1460-2466.1997.tb02692.x 
18. ^ Australian Idol Starlet: Shocking Anorexic Revelations
19. ^ Long, Phillip W (1993). "Eating Disorders". National Institute of Mental Health. http://www.mentalhealth.com/book/p45-eat1.html. Retrieved 2006-03-03. 
20. ^ ^{a b c} Kalat, James W (2006). Biological Psychology (8th ed.). Houston: Wadsworth Publishing. ISBN 0495090794. 
21. ^ Long, Phillip W. (1993). Eating Disorders. Retrieved March 3, 2006, from the National Institute of Mental Health website: http://www.mentalhealth.com/book/p45-eat1.html
22. ^ Yager, Joel & Anderson, Arnold E. (2005). Anorexia Nervosa. The New England Journal of Medicine, 353 (14), 1481-1488, Retrieved March 3, 2006, from Ovid web: http://mutex.gmu.edu:2076/gw1/ovidweb.cgi
23. ^ Uher, R., & Treasure, J. (2005). Brain Lesions and Eating Disorders. Journal of Neurology, Neurosurgery, & Psychiatry, 76 (6). June 2005, pp 852-857.
24. ^ Uher, R; Treasure, J (June 2005), "Brain Lesions and Eating Disorders", Journal of Neurology, Neurosurgery & Psychiatry 76 (6): 852–857, doi:10.1136/jnnp.2004.048819, PMID 15897510 
25. ^ http://my.webmd.com/content/article/48/39237.html Overcoming Eating Disorders
26. ^ Weiner, Sydell (1998), "The Addiction of Overeating: Self-Help Groups as Treatment Models", Journal of Clinical Psychology 54 (2): 163–167, doi:10.1002/(SICI)1097-4679(199802)54:2<163::AID-JCLP5>3.0.CO;2-T, ISSN 0021-9762 
27. ^ Hall, C. I. (1995), "Asian Eyes: Body Image and Eating Disorders of Asian and Asian-American Women", Eating Disorders (Taylor & Francis) 3 (1): 8–19, doi:10.1080/10640269508249141 
28. ^ "Risk Factors for Eating Disorders Vary by Gender: Rejecting media images, resilience to negative comments should be focus of prevention", Kevin McKeever, HealthDay, June 3, 2008.
29. ^ "Exercise addiction and dependence" Hollyann E. Jenkins, BrainPhysics, August 29, 2008.
30. ^ Johnson, William G.; Grieve, Frederick G.; Adams, Christina D.; Sandy, Jamie (January 1998). "Measuring Binge Eating in Adolescents: Adolescent and Parent Versions of the Questionnaire of Eating and Weight Patterns". International Journal of Eating Disorders 26: 301. doi:10.1002/(SICI)1098-108X(199911)26:3<301::AID-EAT8>3.0.CO;2-M. ISSN 0276-3478. PMID 10441246. 

References

• Natenshon, Abigail, ed. (1999), When Your Child Has an Eating Disorder: A Step-By-Step Workbook for Parents and Other Caregivers, Jossey Bass, ISBN 0-7879-4578-1 
• Thompson, K. J., ed. (2003), Body Image, Eating Disorders, and Obesity: An Integrative Guide for Assessment and Treatment, APA Books, ISBN 1-55798-726-2 
• Agras, W. Steward (2004), "The consequences and costs of the eating disorders", The psychiatric clinics of North America 24 (2): 371, doi:10.1016/S0193-953X(05)70232-X 
• Crow, S.; Praus, B; Thuras, P (1999), "Mortality from Eating Disorders—A 5- to 10-Year Record Linkage Study", International journal of eating disorders 26: 97, doi:10.1002/(SICI)1098-108X(199907)26:1<97::AID-EAT13>3.0.CO;2-D 
• Crow, S; Nyman, J. (2004), "The Cost-Effectiveness of Anorexia Nervosa Treatment", International journal of eating disorders 35 (2): 155, doi:10.1002/eat.10258 
• Lauer, C. J.; Krieg, J. C. (2004), "Sleep in eating disorders", Sleep Medicine Review 8 (2): 109, doi:10.1016/S1087-0792(02)00122-3 
• Meads, C.; Gold, L.; Burls, A. (2001), "How effective is outpatient care compared to inpatient care for the treatment of Anorexia Nervosa? A systemic review", European eating disorders review 9 (4): 229, doi:10.1002/erv.406 
• = Zeeck, A.; Herzog, T.; Hartman, A. (2004), "Day clinic or inpatient care for severe Bulimia Nervosa", European eating disorders review 12 (2): 79, doi:10.1002/erv.535 
• Zipfel, S (2000), "Long-term prognosis in anorexia nervosa: Lessons from a 21-year follow-up study", Lancet (North American Edition) 355 (9205): 721 

External links

• BALANCE eating disorder center
• F.E.A.S.T -- Families Empowered and Supporting Treatment of Eating Disorders
• National Association of Anorexia Nervosa and Associated Disorders
• National Eating Disorders Association

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