Eating Disorders

Guidance for Patients, Families, and Friends

Publication Date: July 17, 2022

Last Updated: May 25, 2023

INTRODUCTION

Eating disorders are medical conditions characterized by frequent and problematic eating behaviors as well as distressing thoughts and emotions about food.
Behaviors commonly associated with eating disorders include restrictive eating or avoidance of certain foods, binge eating, purging by vomiting or laxative misuse, and compulsive exercise.
Eating disorders are serious conditions that can reduce overall quality of life. Also, if left untreated, the physical and mental side effects of eating disorders can last for decades, or even a lifetime.
Types of eating disorders include: anorexia nervosa (anorexia), bulimia nervosa (bulimia), binge-eating disorder, avoidant/restrictive food intake disorder (ARFID), pica, rumination disorder, and other specified feeding and eating disorders. This guide will focus on three of the most common: anorexia, bulimia, and binge-eating disorder.
Current estimates show eating disorders will affect between 2 to 3 out of every 100 people in the United States at some point during their lifetime (roughly 6 to 10 million people). Many other people may have features or symptoms of an eating disorder but not have an official diagnosis.
Eating disorders are more common in women, and often appear in teenage years and early adulthood. However, eating disorders can affect any person at any time, regardless of age, gender, race, ethnicity, weight, size, or body shape.
Recovery from eating disorders is a gradual process unique to each person. When identified and treated, patients are able to change their relationship with food, have improved health, and enjoy a good quality of life.
This guide will help patients and their families understand how eating disorders are diagnosed, the treatment options that are available, and what can be done to achieve the best possible outcomes.

INITIAL ASSESSMENT AND EVALUATION

Seeking medical help is the first step in the care process and the path to recovery.

Early intervention greatly increases the chances of recovery from eating disorders. The problem is that it is not always easy to identify when someone has an eating disorder.
To help identify issues as early as possible, primary care clinicians and mental health professionals may ask screening questions that explore a person’s relationship with food, weight, and self-image.
One questionnaire that can be used to help identify an eating disorder is the Eating Disorder Screen for Primary Care (pictured below; answers marked with an asterisk suggest a possible eating disorder).

Eating Disorder Screen for Primary Care

Are you satisfied with your eating patterns?	Y / N*
Do you ever eat in secret?	Y* / N
Does your weight affect the way you feel about yourself?	Y* / N
Have any members of your family suffered with an eating disorder?	Y* / N
Do you currently suffer with or have you ever suffered in the past with an eating disorder?	Y* / N

Source: Eating Disorder Screen for Primary Care (Cotton et al. 2003)

If the answers to screening questions suggest that an eating disorder may be present, the clinician will ask for more information to determine the type of eating disorder that is present and its severity.
Other information that may be asked as part of an assessment includes:
- Height and weight history, including any recent weight changes.
- Eating habits, including foods that are typically eaten or avoided, binge eating, or other eating behaviors.
- Efforts to control weight by eating less food, self-inducing vomiting after eating, compulsive exercising, or taking medications to affect weight.
- Preoccupations with food, weight, or body shape.
- Effects of eating behaviors and body image concerns on school or work functioning and relationships with family and others.
- Family history of eating disorders or other medical conditions, including mental health.
- Previous treatment including psychotherapy and any medications currently or recently taken, including prescriptions and over the counter medications, such as laxatives.
Individuals struggling with eating disorders are often dealing with other physical and mental health challenges as well. Mental health conditions such as depression, anxiety, or substance use can be present along with an eating disorder and can affect treatment choices and outcomes. For this reason, it is important for patients to mention any stresses and psychological or physical health concerns that they may be experiencing.
A physical exam will also be done that includes measuring height, body weight, pulse, blood pressure, temperature, and looking for other physical changes that can occur as part of an eating disorder. Depending on the results of the history and physical exam, the clinician may suggest laboratory tests and an electrocardiogram (ECG) to monitor the heart.

TREATMENT

What Will Treatment Include?

Every person's situation is different, so choosing the best treatment options will be a shared decision between the patient and treating clinicians, with adjustments in the plan made as treatment progresses.
Often family members or others in the person's support network will give input on decisions about treatment.
Typically, treatment of an eating disorder will be given by a team of individuals with medical, psychiatric, psychological, and nutritional expertise.
Psychotherapy is a crucial element in the treatment of an eating disorder.
Medications may be suggested in some circumstances.

Determining the Best Level of Care

There are multiple levels of care and care settings available to help patients with eating disorders.
The most common levels of care include outpatient, intensive outpatient, residential, and hospital-based care.
Within a level of care, some programs may have additional capabilities, such as staff and facilities for managing serious physical health complications.
Because the right setting and level of care will depend on multiple factors, the patient and family should discuss the most appropriate level of care with the clinician.

Identifying Goals of Treatment

Goals of treatment will usually include:
- Providing education to the patient and family about eating disorders and their treatment.
- Reducing the severity of symptoms.
- Promoting healthy behaviors and addressing any physical health issues.
- Improving the patient's level of functioning and quality of life.
Patients will often have their own goals for treatment related to issues such as school or employment, living situation, past experiences, and personal, family, or other intimate relationships.
Other goals will depend on the patient's specific eating disorder.

Anorexia Nervosa

Anorexia is characterized by self-starvation and weight loss resulting in low weight for height and age. It is usually driven by an intense fear of gaining weight.
There are two subtypes of anorexia:
- Restricting type, in which individuals lose weight primarily by dieting, fasting, or excessively exercising.
- Binge eating/purging type in which persons also engage in intermittent binge eating and/or purging behaviors, such as vomiting or taking laxatives.
Patients with anorexia will require renourishment and weight restoration to assist with recovery.
Individualized goals will be set for each patient that include target weight and weight gained for each week.
Psychotherapy is another essential treatment for anorexia to help in normalizing eating and weight-related behaviors. In addition to treating symptoms of the disorder, it will focus on addressing any underlying fears or concerns that contributed to the disorder, such as a fear of weight gain or other body image concerns.
A number of different psychotherapies are effective in treating anorexia, including cognitive-behavioral therapies, focal psychodynamic psychotherapy, interpersonal psychotherapy, the Maudsley Model of Anorexia Nervosa Treatment for Adults, and specialist supportive clinical management.
For adolescent and young adult patients, family-based treatment is recommended and teaches family members to help the patient normalize eating and weight control behaviors.

Bulimia Nervosa

Individuals with bulimia have frequent episodes of binge eating that are followed by behaviors to try to prevent weight gain from the binge-eating episode.
Binges occur at least weekly and are typically secretive and associated with feelings of shame or embarrassment. Behaviors that follow binges can include purging through self-induced vomiting, excessive exercising, or use of laxatives, diuretics (i.e., water pills), or other medications to influence weight.
If untreated, bulimia can lead to physical complications including esophageal tears, gastric rupture, and dangerous cardiac arrhythmias.
Treatment with cognitive-behavioral therapy (CBT) is recommended for adults with bulimia.
CBT focuses on examining and changing beliefs and behaviors about food and weight. There can also be a focus on changing beliefs that contribute to eating disorders such as perfectionism and low-self-esteem.
Family-based treatment is suggested for adolescent and young adult patients with bulimia.
In addition to psychotherapy, adults with bulimia may be prescribed a type of medication called a serotonin reuptake inhibitor (e.g., fluoxetine). When a serotonin reuptake inhibitor is used, it can be started at the very beginning of treatment or if there is minimal or no improvement after 6 weeks or more of therapy alone.

Binge-Eating Disorder

Similar to bulimia, people with binge-eating disorder have frequent episodes of binge eating in which they consume large quantities of food in a brief period, experience a sense of loss of control over their eating, and are distressed by the binge behavior. The main difference from bulimia is that patients with binge-eating disorder do not usually try to counteract the effects of the binge episode by inducing vomiting, exercising, or misusing laxatives or other medications.
Binge-eating disorder can lead to health complications, including diabetes, hypertension, and cardiovascular diseases.
Patients with binge-eating disorder should be treated with eating disorder-focused CBT or interpersonal therapy.
Adults with binge-eating disorder who prefer medication or have not responded to psychotherapy alone may be treated with either an antidepressant medication or lisdexamfetamine.

Path to Recovery

An active support system often plays a key role in recovery.
Family and friends can encourage their loved ones to stay in therapy, eat regular meals, and use new coping skills. They can also provide support during difficult meals and help build a healthy life.
Involvement of a caregiver or family member is especially important for adolescent or young adult patients.
Relapse can occur when struggling with eating disorders. This is why regular monitoring and ongoing therapy are important stepping stones on the path to recovery.
Each person’s recovery is unique. Recovery is not a straight line but rather a winding road that may include bumps and potholes as well as smooth sailing.
It's important to remember and recognize that the first step is reaching out and seeking help.

FREQUENTLY ASKED QUESTIONS

What are the warning signs of an eating disorder?

Warning signs of an eating disorder can differ for each person, but some of the most common signs include:
- Constant focus on weight, food, calories, dieting, and/or body image.
- Development of unusual, secretive, extreme, or ritualized eating habits.
- Evidence of binge eating, such as the disappearance of a large amount of food.
- Evidence of purging behaviors, including frequent trips to the bathroom after meals and/or laxative, diet pill, or diuretic use.
- Compulsive or excessive exercising.
- Discoloration or staining of the teeth.
- Other changes in mood and behavior such as depression, anxiety, irritability, or withdrawal from friends and activities.

Can someone who looks healthy still have an eating disorder?

YES! This is a very common misconception. People can look healthy yet still be experiencing an eating disorder.

What causes eating disorders?

The exact cause of eating disorders is unknown. Current research shows eating disorders are caused by a complex interaction of factors. These include genetic, biological, behavioral, psychological, and social factors. There is no single factor to determine whether someone will develop an eating disorder.

What is ARFID and how is it different from anorexia?

Avoidant/restrictive food intake disorder (ARFID) is associated with dramatic restriction in the types or amounts of food that is eaten, and it can cause slowed growth in children or weight loss in older individuals. Individuals with ARFID, unlike those with anorexia, do not have concerns about body image or fear of weight gain. Instead, they avoid food based on fears of choking or vomiting or because they are distressed by food related sensations such as textures, colors, smells, or other features of food.

Do only women get eating disorders?

While eating disorders are more common in women, eating disorders can affect anyone. People of all ages, genders, socioeconomic statuses, shapes and sizes, sexual orientations, abilities, races, and ethnicities can experience an eating disorder.

Why can’t someone with an eating disorder just eat more or less food?

Simply put — eating disorders are not fads, phases, or lifestyle choices that can be addressed by trying to eat more or less food. Rather, they are serious, and sometimes life-threatening medical conditions.

How long does treatment take?

Initial therapy may last anywhere from a few months to multiple years. Every person and situation are different. Ongoing therapy may be needed for many years after that. Slips, backslides, and relapse are common. Re-learning normal eating habits and coping skills can take a long period of time and often requires lots of support from professionals, friends, and family.

Can someone with an eating disorder make a full recovery?

Early detection and intervention are extremely important, and recovery from eating disorders is a gradual process that is unique to each person — but full recovery is absolutely possible.

ADDITIONAL RESOURCES

In the links below you can find additional resources such as:

signs and symptoms of eating disorders
healthcare provider locators
support groups
meal plans
resources for special and underserved populations
and so much more.

National Center of Excellence for Eating Disorders
https://www.nceedus.org/

American Psychiatric Association
https://www.psychiatry.org/patients-families/eating-disorders

National Institute of Mental Health
https://www.nimh.nih.gov/health/topics/eating-disorders

National Eating Disorders Association
https://www.nationaleatingdisorders.org/

National Association of Anorexia Nervosa and Associated Disorders
https://anad.org/

Families Empowered And Supporting Treatment for Eating Disorders
https://www.feast-ed.org/

If you or someone you know may be struggling with an eating disorder, please seek help immediately.

In addition, the 988 Suicide & Crisis Lifeline (https://988lifeline.org/) provides 24/7, free and confidential support for people in distress by calling or texting 988 or chatting through the website (https://988lifeline.org/chat/). If you suspect a medical emergency, seek medical attention or call 911 immediately.

Source Citation

American Psychiatric Association: Practice Guideline for the Treatment of Patients with Eating Disorders, Fourth Edition. Washington, DC, American Psychiatric Publishing 2023.

Expert Authors/Reviewers

The review of the content included in this Pocket Guide was funded in part by the Gordon and Betty Moore Foundation through a grant program administered by the Council of Medical Specialty Societies.

Disclaimer

This resource is for informational purposes only, intended as a quick-reference tool based on the cited source guideline(s), and should not be used as a substitute for the independent professional judgment of healthcare providers. Practice guidelines are unable to account for every individual variation among patients or take the place of clinician judgment, and the ultimate decision concerning the propriety of any course of conduct must be made by healthcare providers after consideration of each individual patient situation. Guideline Central does not endorse any specific guideline(s) or guideline recommendations and has not independently verified the accuracy hereof. Any use of this resource or any other Guideline Central resources is strictly voluntary.