Identifying Anorexia, Bulimia, Binge Eating, and More

A deconstruction of today’s most prevalent eating disorders.

Eating disorders are serious and sometimes fatal mental health conditions characterized by irregular eating habits, severe distress related to body shape or weight, and a preoccupation with food, exercise, and/or body image.

According to the National Association of Anorexia Nervosa and Associated Disorders (ANAD), 9% of the United States population, or 28.8 million Americans—men, women, and non-binary individuals—will have an eating disorder in their lifetime. Eating disorders often co-occur with other mental illnesses, such as mood and anxiety disorders, obsessive-compulsive disorder, and alcohol and substance use disorders. 

Despite their pervasiveness and impact, many people are unaware of the various types of eating disorders that exist and their key differences. This post will walk through known risk factors for developing an eating disorder, the most common types of eating disorders that exist and their diagnostic criteria, and some of the warning signs and symptoms often present in those suffering. 

What Causes an Eating Disorder?

As with any illness or disorder, there are certain risk factors that make one person more prone to developing an eating disorder.

1. They are not caused by any particular food and are not a simple food addiction.
2. They are fueled by a cultural obsession with appearance and weight.
3. Underlying risk factors make certain people more susceptible to developing an eating disorder.
4. It’s the biological makeup of you—not the biological makeup of the food you eat—that contributes to the development of an eating disorder.¹

As such, one’s biological makeup can be a precursor to developing an eating disorder, but the symptomatic and behavioral signs will not emerge unless certain environmental conditions are also present.

Cynthia Bulik, Director of the Eating Disorders Program at the University of North Carolina at Chapel Hill School of Medicine, summed this up well in stating, “Genetics load the gun; environment pulls the trigger.”

Anorexia Nervosa

Anorexia nervosa (commonly referred to as “anorexia”), is the most deadly of all eating disorders. Those suffering from anorexia have an intense fear of gaining weight, heavily restrict their food intake, and often have a distorted body image. 

Diagnostic Criteria

1. Restriction of energy intake relative to requirements, leading to significantly low body weight for the patient’s age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than the minimal normal weight or, in children and adolescents, less than the minimal expected weight.
2. Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though the patient has a significantly low weight.
3. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.

Subtype Designation

There are two subtypes of anorexia:

1. Restricting Type: During the past 3 months, the patient has not engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or laxative abuse, diuretics, or enemas). Weight loss is accomplished primarily through dieting, fasting, excessive exercise, or all of these methods.
2. Binge Eating and Purging Type: During the past 3 months, the patient has engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas).

Additional Warning Signs & Symptoms

• Restrictive eating patterns: Anorexia involves strict control over food and eating habits. Individuals may meticulously count calories, limit portion sizes, avoid certain food groups, or adopt extreme diets. They may also develop rituals around eating, such as cutting food into small pieces or arranging food on the plate without actually eating it.
• Obsessive weighing and body-checking: Individuals with anorexia often have an intense fearr of weight gain. They may constantly weigh themselves, measure body parts, and analyze their body in the mirror.
• Distorted body image: Anorexia can lead to a distorted perception of one’s body. Even when severely underweight, individuals with anorexia may believe they are overweight or have “problem areas” on their body and may frequently compare themselves to others.
• Excessive exercise: Excessive and compulsive exercise as a means to burn calories, control weight, or compensate for food intake is common. Even when they have other obligations, are feeling tired, are injured, or have unfavorable weather conditions, many suffering from anorexia feel compelled to maintain a rigid exercise routine.
• Obsession with food and rituals around eating: Anorexia often involves an intense preoccupation with food, recipes, cooking methods, and nutritional information. Individuals may spend significant time thinking about food, planning meals for others, or cooking elaborate meals without eating them. They may also exhibit rigid eating rituals or avoid eating in public.
• Withdrawal from social activities: Individuals may avoid social gatherings involving food, make excuses to skip meals, or isolate themselves to hide their eating habits.
• Physical symptoms: Fatigue, weakness, dizziness, feeling cold, hair loss, dry skin, brittle nails, constipation, and irregular menstrual periods (in females).
• Emotional and psychological changes: Anorexia often affects a person’s emotional well-being. Individuals may experience depression, anxiety, irritability, mood swings, perfectionism, low self-esteem, and a sense of control or accomplishment when successfully restricting food intake.

Bulimia Nervosa

People suffering from bulimia nervosa (bulimia) frequently consume large amounts of food (binge eating) and then engage in compensatory behaviors such as self-induced vomiting, excessive exercise, or misuse of laxatives or diuretics. They often feel a lack of control during binge episodes and are preoccupied with their body shape and weight.

Diagnostic Criteria

1. Recurrent episodes of binge eating, as characterized by both:
   1. Eating, within any 2-hour period, an amount of food that is definitively larger than what most individuals would eat in a similar period of time under similar circumstances.
   2. A feeling that one cannot stop eating or control what or how much one is eating.
2. Recurrent inappropriate compensatory behaviors in order to prevent weight gain such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting or excessive exercise.
3. The binge eating and inappropriate compensatory behaviors occur, on average, at least once a week for 3 months.
4. Self-evaluation is unjustifiability influenced by body shape and weight.
5. The disturbance does not occur exclusively during episodes of anorexia nervosa.

Specify Type

1. Purging Type: During the current episode, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.
2. Non-purging Type: During the current episode, the person has used inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.

Additional Warning Signs & Symptoms

• Frequent bathroom visits: Frequent trips to the bathroom immediately following meals, especially after binge eating, may be a sign of bulimia. Individuals may engage in vomiting or misuse of laxatives or diuretics to rid themselves of the food consumed.
• Preoccupation with body weight and shape: People with bulimia often have an intense preoccupation with body weight, shape, and perceived flaws in their appearance. They may place excessive importance on their weight and engage in constant body-checking behaviors.
• Strict dieting followed by bingeing: Individuals often cycle between strict dieting or fasting and episodes of uncontrollable binge eating. They may engage in restrictive eating patterns or follow strict rules regarding food intake before experiencing a loss of control during a binge episode.
• Secretive behavior: Many hide their eating patterns and behaviors due to shame or guilt. They may eat in secret or disappear after meals to engage in compensatory behaviors. This secretive behavior may lead to social withdrawal and isolation.
• Dental problems and mouth sores: Frequent vomiting associated with bulimia can lead to dental issues like tooth decay, gum disease, enamel erosion, and mouth sores. Dentists may notice signs of acid erosion during oral examinations.
• Physical and emotional symptoms: Bulimia can result in physical symptoms, such as dehydration, sore throat, swollen salivary glands, irregular menstrual periods, gastrointestinal problems, fatigue, and muscle weakness. Emotional symptoms may include mood swings, anxiety, depression, low self-esteem, and a distorted body image.

Binge Eating Disorder (BED)

People with binge eating disorder have recurrent episodes of eating large quantities of food in a short period of time, accompanied by a sense of loss of control. Unlike bulimia, they do not engage in purging behaviors. Contrary to popular belief, individuals suffering from BED come in an array of body shapes and sizes, including thin and slender.

Diagnostic Criteria

1. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
   1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is larger than most people would eat in a similar period of time under similar circumstances
   2. The sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)
2. Binge eating episodes are associated with three (or more) of the following:
   1. Eating much more rapidly than normal
   2. Eating until feeling uncomfortably full
   3. Eating large amounts of food when not feeling physically hungry
   4. Eating alone because of being embarrassed by how much one is eating
   5. Feeling disgusted with oneself, depressed, or very guilty after overeating
3. Marked distress regarding binge eating is present.
4. Binge eating occurs, on average, at least 1 day a week for 3 months.
5. Binge eating is not associated with the regular use of inappropriate compensatory behavior (e.g., purging, excessive exercise) and does not occur exclusively during the course of anorexia nervosa or bulimia nervosa.

Additional Warning Signs & Symptoms

• Eating in secret or hiding food: Individuals with BED often eat in secret or hide food to avoid judgment or embarrassment. They may feel ashamed or guilty about their eating habits and try to conceal their behavior.
• Feelings of guilt and shame: After a binge episode, sufferers typically experience intense feelings of guilt, shame, and self-disgust. They may criticize themselves for their lack of control and have a negative body image.
• Disturbed and restrictive eating patterns: Individuals with BED often vacillate between eating large amounts of food and heavily limiting their food intake in an effort to compensate for binge eating or manage their weight. They may also engage in grazing behavior where they continuously snack throughout the day.
• Emotional and psychological impact: BED can lead to emotional distress, including depression, anxiety, low self-esteem, and body dissatisfaction. Individuals may experience significant psychological distress related to their eating patterns and their inability to control their eating behaviors.
• Physical health consequences: BED can have physical health implications, such as high blood pressure, high cholesterol levels, diabetes, heart disease, gastrointestinal issues, and joint pain.

Orthorexia Nervosa

Orthorexia nervosa is an eating disorder characterized by an obsession with eating “pure” or “healthy” foods. Individuals with orthorexia are fixated on the quality and purity of the food they consume, often to the point where it negatively impacts their physical and mental well-being.

While orthorexia is not officially recognized as a distinct diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), it is considered an eating disorder and a form of disordered eating. 

Warning Signs & Symptoms

• Obsession with “healthy” eating: Individuals with orthorexia are consumed by thoughts and behaviors related to healthy eating. They may spend excessive amounts of time researching, planning, and preparing their meals to ensure they are “pure” or free from perceived toxins, additives, or impurities.
• Strict dietary rules: Orthorexia involves rigid dietary restrictions and self-imposed rules about what is considered “healthy” or “clean” food. Individuals may eliminate entire food groups or restrict their diets to a limited number of foods they perceive as “pure” or “safe.”
• Anxiety and guilt about food choices: People with orthorexia may experience extreme anxiety, guilt, or distress when faced with food choices that do not meet their self-imposed standards of “healthy” eating. They may feel overwhelmed or fearful in social situations where they have limited control over food options.
• Social isolation and impaired functioning: Orthorexia can lead to social isolation and impaired functioning as individuals may avoid social gatherings or situations where they cannot adhere to their strict dietary rules. They may prioritize their food choices over relationships, social activities, or other aspects of life.
• Nutritional deficiencies and physical consequences: Excessive dietary restrictions and limited food variety can lead to nutritional deficiencies and imbalances. Individuals may experience weight loss, malnutrition, fatigue, weakness, gastrointestinal issues, and other physical health problems.
• Emotional distress and rigid thinking patterns: Orthorexia can lead to emotional distress, including anxiety, guilt, and preoccupation with food and health. Individuals may have rigid and inflexible thinking patterns related to their food choices and may experience a diminished quality of life due to the restrictive nature of their eating habits.

Avoidant Restrictive Food Intake

Avoidant/Restrictive Food Intake Disorder (ARFID) is an eating disorder characterized by persistent and selective eating patterns that result in significant nutritional deficiencies, impaired functioning, and emotional distress. Individuals with ARFID may avoid entire food groups, such as fruits, vegetables, or meats, or restrict their diet to a few select foods. They may have a preference for bland or familiar foods.

ARFID was introduced as a diagnosis in the DSM-5 to capture individuals who present significant eating-related challenges but do not meet the criteria for other established eating disorders.

Diagnostic Criteria

1. An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following:
   1. Significant weight loss (or failure to achieve expected weight gain or faltering growth in children)
   2. Significant nutritional deficiency.
   3. Dependence on enteral feeding or oral nutritional supplements.
   4. Marked interference with psychosocial functioning.
2. The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder. When the eating disturbance occurs in the context of another mental disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention.
3. The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice.
4. The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced.

Additional Warning Signs & Symptoms

• Sensory sensitivities or aversions: People with ARFID may experience heightened sensitivity to the sensory aspects of food, such as taste, texture, smell, or appearance. They may find certain textures or flavors uncomfortable, leading to avoidance of foods with those characteristics.
• Lack of appetite or decreased interest in eating: ARFID often leads to a reduced interest in eating or a decreased appetite. Individuals may exhibit disinterest or indifference toward food and mealtimes, even when hungry.
• Fear of negative consequences: Intense fears related to choking, vomiting, or allergic reactions associated with specific foods are common. These fears may contribute to their avoidance of certain foods or food groups.
• Nutritional deficiencies and impaired growth: Significant nutritional deficiencies due to the limited variety of foods consumed can result in inadequate intake of essential nutrients, leading to weight loss, failure to gain weight, or impaired growth, particularly in children and adolescents.
• Emotional distress and anxiety: ARFID can cause emotional distress and anxiety related to food and eating. Individuals may experience feelings of shame, guilt, or embarrassment about their eating habits.
• Avoidance of social activities involving food: People with ARFID may avoid social activities or events that involve food, such as parties, gatherings, or restaurants, due to the limited range of foods they are willing to eat. This can lead to social isolation and difficulties in social relationships.

Other Specified Feeding or Eating Disorder

Other Specified Feeding or Eating Disorder (OSFED), previously known as Eating Disorder Not Otherwise Specified (EDNOS), is a diagnostic category in the DSM-5 that includes eating disorders that do not meet the specific criteria for anorexia nervosa, bulimia nervosa, or binge eating disorder. It captures a range of eating disorders that still cause significant distress and impairment but may not fit neatly into one of the other established eating disorder diagnoses.

OSFED includes several subtypes, such as:

• Atypical Anorexia Nervosa: Individuals meet most of the criteria for anorexia nervosa but do not exhibit significantly low body weight.
• Bulimia Nervosa of Low Frequency or Limited Duration: Individuals meet the criteria for bulimia nervosa but experience binge eating and inappropriate compensatory behaviors less frequently or for a shorter duration.
• Binge Eating Disorder of Low Frequency or Limited Duration: Individuals meet the criteria for binge eating disorder but experience binge eating episodes less frequently or for a shorter duration.
• Purging Disorder: Individuals engage in recurrent purging behaviors (e.g., self-induced vomiting, misuse of laxatives or diuretics) without engaging in binge eating episodes.
• Night Eating Syndrome: Individuals consume a significant portion of their daily caloric intake after the evening meal or during the night. They may also experience a lack of appetite in the morning.
• Other Feeding or Eating Disorders: This category includes eating disorders that do not meet the specific criteria for the above subtypes but still cause significant distress or impairment. Examples may include subthreshold anorexia nervosa, subthreshold bulimia nervosa, or specified feeding or eating disorders due to medical conditions or psychosocial factors.

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Expressing Your Concern and Getting Help

Individuals suffering from an eating disorder can be in denial about how severe their illness is and/or resistant to opening up to others about it. It’s ideal you have a close, trusting relationship with someone before approaching them with your concerns about their symptoms. Individuals may also be more receptive if you address their worrisome behaviors, versus commenting on their changes in appearance or physique.

Once you or someone you know has acknowledged there is a problem and is willing to seek help, here are some steps to take and what treatment could look like.

• Reach out to a healthcare professional: Consult with a healthcare provider who specializes in eating disorders. This could be a primary care physician, a registered dietitian, a psychiatrist, or a psychologist. They can assess your condition, provide an accurate diagnosis, and recommend appropriate treatment options.
• Build a support network: Reach out to trusted family members, friends, or support groups who can offer emotional support during your recovery journey. Consider joining a support group specifically for individuals with eating disorders, as connecting with others who have similar experiences can be helpful.
• Seek specialized treatment: Eating disorders often require specialized treatment from professionals experienced in treating these conditions. Depending on the severity of your eating disorder, treatment options may include outpatient treament, intensive outpatient programs (IOP), residential treatment, or inpatient treatment or hospitalization. Your healthcare provider can help determine the appropriate level of care for your situation.
• Individual therapy: Individual therapy, such as cognitive-behavioral therapy (CBT), dialectical behavior therapy (DBT), or interpersonal therapy (IPT), can help address the underlying emotional and psychological factors contributing to your eating disorder. Therapy can assist in developing healthy coping mechanisms, improving body image, and establishing a healthier relationship with food.
• Nutritional counseling: Working with a registered dietitian who specializes in eating disorders can help you establish a balanced and healthy approach to food. They can provide guidance on meal planning, teach you about proper nutrition, and help you challenge and modify distorted thoughts and beliefs around food and eating.
• Medical monitoring: Regular medical check-ups are crucial to monitor your physical health, as eating disorders can have severe medical complications. Your healthcare provider can perform necessary medical tests, monitor your weight, assess your overall health, and address any medical concerns that may arise during your recovery.
• Follow your treatment plan: Be committed to following the treatment plan recommended by your healthcare professionals. Attend therapy sessions, take prescribed medications (if applicable), and actively participate in your recovery process.

Remember that seeking help for an eating disorder is a courageous step, and recovery takes time. It’s important to be patient, kind to yourself, and celebrate small victories along the way.

Lastly, even if you do not meet the full diagnostic criteria for an eating disorder but feel your relationship with food is unnatural or causing you distress, you are worthy of seeking help. 

1. Costin, Carolyn. 8 Keys to Recovery from an Eating Disorder. W W Norton, 2017. ↩︎