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Eating Disorders

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Author:    David Tilton (RN, BSN)


Eating disorders are one of the most common psychiatric problems directly affecting young women in America today. The high burden of illness and death that these conditions impose on our youth is totally unacceptable. Unfortunately, the diagnosis of eating disorders can be elusive, and more than one half of all cases will go undetected. It is up to healthcare providers of all disciplines to be on the alert for eating disorders in both men and women, young and old. Without an active watch being kept for these conditions it simply is not possible to identify the presence of an eating disorder, much less initiate treatment in a timely fashion. By becoming aware of the signs and symptoms of these crippling conditions, we make a significant positive impact on our communities, the individuals, and the families so devastated by these horrendous diseases.

The Diseases

Eating disorders occur most commonly in adolescents and young adults. They are also ten times more common in females than in males. Their presence has been observed in all ethnic groups yet are most typically seen among white ethnic background individuals in industrialized nations. The principal eating disorders are anorexia nervosa and bulimia although other types of eating disorders are observed on a less frequent basis. One of these less common types in particular, Binge Eating Disorder, is a significant condition in its own right, though it is often misdiagnosed as one of the two major eating disorders due to the interlocking of symptoms (Pritts, 2003).

The compulsions for frequent dieting and an intense desire for weight loss are much more common than any overt, high visibility, eating disorder. In 1999, the Youth Risk Behavior Surveillance Survey reported that 58 percent of students in the United States had exercised to lose weight, and 40 percent of students had restricted caloric intake in an attempt to lose weight. Many of them are unnecessary. It is not uncommon for adolescents and young adults who do not meet the strict diagnostic criteria for eating disorders to have disordered eating patterns, which can have a significant adverse impact on their health. The distinction between normal dieting and disordered eating is based primarily on whether or not that person possesses a distorted body image (Pritts, 2003).

Anorexia Nervosa

Anorexia Nervosa is an eating disorder in which a person intentionally starves her or his self. This disorder usually begins in young people around the time of puberty and involves a serious mental self-perception problem, in which that individual sees himself or herself as grossly overweight. The condition involves extreme weight loss, at least 15 percent below that person’s ideal body weight. Many of those who have this disorder become so emaciated that they look like they just stepped out of a genocide camp, yet remain convinced that they are overweight. Sometimes, even frequently, they must be hospitalized to prevent death by starvation. Body Mass Index is one measurement tool that can help identify patients with anorexia.

Using Body Mass Index
(CDC, 2003)

Body Mass Index or BMI is a tool for indicating weight status in adults. It is a measure of weight for height. For adults over 20 years old, BMI falls into one of these categories:

Weight Status

Below 18.5
18.5 – 24.9
25.0 – 29.9
30.0 and Above

Body Mass Index can be calculated using pounds and inches with this equation:


_______Weight in Pounds ______ x 703


(Height in inches) x (Height in inches)


For example, a person who weighs 220 pounds and is 6 feet 3 inches tall will have a BMI of 27.5.


  220 lbs. x 703


  (75 inches) x (75 inches)

Remember ~ BMI alone is not diagnostic. It is one of many risk factors for disease and death. As a person's BMI increases the risk for many diseases increases as well.


Be aware that many individuals become adept at hiding their true degree of emaciation. Loose clothing, clothing layering and artistic application of makeup can hide the fact that little but a tight covering of skin remains to cover a skeletal framework. As a healthcare provider, family member or friend, learn to carefully look at people, not just a glance or casual purview. Look at the eyes, notice the relationship of the orbit depth to the eye orb. Compare the jaw line to the throat musculature. Watch the hands especially. Much can be learned by getting a good look at how the skin and muscle tone of a person’s hands appear.

Case Study

April is a shy, studious teenager of 16. She tries so very hard to please everyone. She is of average height, and possessed a slightly overweight figure. Just last year she became more interested in boys and since then has been plagued by a gnawing fear that she is not attractive enough to get their attention. On her last birthday her older brother joked that if she did not lose some weight she would never get a date. She hit him at the time, in the manner of siblings; but, since then just has not been able to get that remark out of her head. She became resolved to lose weight, and began to aggressively diet.

Currently April is seriously underweight. Her menstrual periods have stopped, first growing longer between cycles, and then halting altogether. She feels that she is drastically obese and continues to diet. She has become obsessed with food. Recently April began to exhibit strange, almost obsessive rituals about the food she did eat. Lining each item up by size and shape, then methodically cutting and cutting at them until little was left but a liquid paste, which she would then pick at. She also has developed a drastic exercise regimen that she continues to pursue even when ill with a cold or flu. Her clothing has gone from a stylish mix of bright colors to baggy layers of dark heavy cloth, and she tends to wear hats or hair coverings even when sitting at the family dinner table, which she takes great measure to avoid.

April’s parents and family have become increasingly concerned with her condition. Whenever someone would try to talk with her about his or her concerns she would break off the conversation using whatever means were needed. Even to the point of screaming that her parents were trying to kill her with their abuse.

Now April has fainted at school. She was found in the restroom where she goes to exercise during the lunch break.


Sadly, April is fairly typical. Those who suffer from anorexia starve themselves, even though they suffer terribly from hunger pains. One of the most frightening aspects of the disorder is that people with anorexia continue to think they are overweight even when they are bone thin. For reasons not yet understood, they become truly terrified of gaining any weight.

Food and weight tend to become obsessions. Often this compulsiveness shows up in strange eating rituals or the refusal to eat in front of others. It is not uncommon for people with anorexia to collect recipes and prepare gourmet feasts for family and friends, but not partake in the meals themselves. Frequent trips to the scales are common, and they may adhere to strict exercise routines to keep off any perceived chance of weight gain. The loss of monthly menstrual periods is typical in women with the disorder while men with anorexia often become impotent.

Among young women, the risk of developing anorexia is 0.5 to 1 percent of the overall population. The mortality rate among this group who have developed anorexia is estimated to be from 4 to 10 percent, although it very well may be higher as the listed cause of death may be a secondary condition brought on by malnutrition or the intensive bodily stresses caused by the anorexia (Pritts, 2003).

Diagnostic criteria for ANOREXIA NERVOSA
(based on DSM IV)

A. Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected or a body mass index, a.k.a. BMI, of less than 17.5). - OR – The failure to make expected weight gain during periods of growth, leading to body weight less than 85% of that expected).

B. Intense fear of gaining weight or becoming fat even though underweight.

C. 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 denial of the seriousness of the current low body weight.

D. In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen, administration.)

(Meyers, 2001)



Among the population of young women the risk of developing bulimia is from 2 to 5 percent. Be aware that the incidence of disordered eating that does not meet the strict criteria for eating disorder listed in the DSM IV (Diagnostic and Statistical Manual of Mental Disorders, issue Four) is probably greater then twice that of the accepted figures (Pritts, 2003).

Those individuals with bulimia typically consume large amounts of food and then rid their bodies of the excess calories by vomiting, abusing laxatives and/or diuretics, taking enemas, or exercising obsessively. Some use a combination of all these forms of purging. Because many individuals with bulimia binge and purge in secret and maintain normal or above normal body weight, they can often successfully hide their problem from others for years.

Case Study

Roberto had regarded himself as fat all through high school. Now he is 19, and has become determined to lose weight by dieting. He started on a good, well-known diet regimen and in order to hurry things along developed an exercise program for himself. Unfortunately, he often finds himself skipping meals, then eating huge amounts of food, which he then attempts to get rid of by self inducing vomiting and taking laxatives in an attempt to limit caloric absorption. What he considers his own lack of self-control makes him so angry that he is often an emotional blender, fighting feelings of rage, determination and depression.

Roberto’s personal feelings of failure and shame have led him to isolate himself, as he is sure no one can understand him. This tends to lead to sadness and depression during which he is overcome with an uncontrollable desire to eat. At times, he finds himself eating until all available food is consumed, or he becomes to full to continue. Then, in disgust and guilt, he makes himself vomit.

Often Roberto thinks of ending it all. He has formed several suicide plans, which he dwells on frequently. He has even gone so far as buying a gun, a knife, and tying a noose. Occasionally after vomiting he places them on the kitchen table and stares at them.


Dieting heavily between episodes of bingeing and purging is very common. These episodes can range in frequency from once or twice a week to several times a day. It is also estimated that eventually around half of those with chronic anorexia will develop bulimia.

As with anorexia, bulimia typically begins during adolescence. The condition occurs most often in women. It is found more frequently in men then anorexia. Many individuals with bulimia are ashamed of their strange habits and do not seek help until they reach their thirties or forties. By this time, their eating behavior is deeply ingrained and much more difficult to change.

Diagnostic criteria for BULIMIA

A. 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 definitely larger than most people would eat during a similar period of time and under similar circumstances.


(2) A sense of lack of control over eating during the episode (i.e., a feeling that one cannot stop eating or control what or how much one is eating)

B. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, enemas, or other medications, fasting, or excessive exercise.

C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months.

D. Self-evaluation is unduly influenced by body shape and weight.

E. The disturbance does not occur exclusively during episodes of Anorexia Nervosa.

(Meyers, 2001)


Binge Eating

Binge eating disorder stands on its own as an eating disorder, though many clinicians prefer to consider it to be more of a subtype of one or both of the other major eating disorders rather then its own disease process. The fact that it commonly manifests without the proper major diagnostic criteria needed to be either anorexia or bulimia however makes it a separate, though definitely related, disorder. Recently it has been claimed as a newly discovered eating disorder, and studies of it are in progress (Meyers, 2001).

Although it has only recently been recognized as a distinct condition, binge eating disorder is thought, by those who acknowledge it, to be the most common of all the eating disorders. Most people with binge eating disorder are obese (more than 20 percent above a healthy body weight) although normal weight, and even under weight, people also can be affected. Binge eating disorder probably affects more then 2 percent of all adults, or about 1 million to 2 million Americans. Among those who are considered to be in the mildly obese category and who are also in self-help or commercial weight loss programs, 10 to 15 percent have diagnosable binge eating disorder. The disorder is even more common in those with severe obesity. Unlike anorexia or bulimia, binge eating disorder is only slightly more common in women, with just three women affected for every two men. This disorder affects blacks as often as whites. Its frequency in other ethnic groups is not yet known. One defining characteristic is that obese people with binge eating disorder frequently become overweight at a younger age than those without the disorder. They also may have more frequent episodes of losing and regaining weight (i.e. yo-yo dieting) (NIDDK, 2001).

Case Study

Julius belongs to a popular weight loss organization. He is 43, single, African American and a professional banker in a large urban area. Obsessively he goes to the Club for the twice weekly meetings where he weighs in and then has to watch others get the prizes for the weight loss he is not sharing with them. Though regularly disappointed he smiles and congratulates the winners on their steady progress, before he pays the ritual monetary penalty for failing to lose weight and heads home for the evening.

On the way home he always passes a roadside diner that specializes in All-You-Can-Eat pasta. His favorite. It seems as though the car turns into the diner all on its own. He regularly eats himself sick so that all he can do is go home and collapse into bed while vowing in self-loathing to stick to his diet and do better next time.


Individuals with binge eating disorder tend to feel that they lose control of themselves when eating. Typically they eat large quantities of food and do not stop until they are uncomfortably full. This tends to offset their other attempts at weight gain, as unlike bulimia sufferers, they do not attempt to purge the large amounts of food they have eaten. Due to this compulsive pattern, they have more difficulty losing weight and keeping it off than do people with other serious weight problems. Most people with the disorder are obese with a history of frequent weight fluctuations.

Diagnostic criteria for BINGE EATING DISORDER
(Sometimes referred to as compulsive overeating)

A. 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 definitely larger than most people would eat during a similar period of time and under similar circumstances.


(2) A sense of lack of control over eating during the episode (i.e., a feeling that one cannot stop eating or control what or how much one is eating)

B. The 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.

C. Marked distress regarding binge eating is present.

D. The binge eating occurs, on average, at least 2 days a week for 6 months.

E. The binge eating is not associated with the regular use of inappropriate compensatory behaviors (e.g., purging, fasting, excessive exercise) and does not occur exclusively during the course of Anorexia Nervosa or Bulimia.

(Meyers, 2001) (NIDDK, 2001)


Medical Problems

Eating disorders go hand in hand with medical problems. Individuals with eating disorders who use drugs to stimulate vomiting, bowel movements, or urination may be in considerable danger, as this practice increases the risk of heart failure (NIDDK, 2001).

In those individuals who are suffering with anorexia, starvation can damage vital organs such as the heart and brain. To protect itself, the body shifts into starvation mode. Monthly menstrual periods stop, breathing, pulse, and blood pressure rates drop, and thyroid function slows. Nails and hair become brittle. The skin dries, yellows, and becomes covered with soft hair called lanugo. Excessive thirst and frequent urination normally occur. Dehydration contributes to constipation, and reduced body fat leads to lowered body temperature and an inability to withstand cold.

Mild anemia, swollen joints, reduced muscle mass, and light-headedness also commonly occur in anorexia. If the disorder becomes severe, individuals may lose calcium from their bones, making them brittle and prone to breakage. They may also experience irregular heart rhythms and heart failure. In some of the sufferers, the brain shrinks, causing personality changes. Fortunately, this condition can often be reversed when normal weight is reestablished (NIDDK, 2001).

Basic Diagnostic Analyses
(APA, 2003)

Patient Indications

  • Blood chemistry studies
  • Complete blood count (CBC)
  • Serum electrolyte level
  • Blood urea nitrogen (BUN) level
  • Creatinine level
  • Thyroid function test
  • Urinalysis

Consider for all patients with eating disorders

Additional analyses

Patient Indications

  • Blood chemistry studies
  • Calcium level
  • Magnesium level
  • Phosphorus level
  • Liver function tests
  • Electrocardiogram

Consider for malnourished and severely symptomatic patients

Osteopenia and osteoporosis assessments


  • Dual-energy X-ray absorptiometry (DEXA)
  • Estradiol level
  • Testosterone level in males

Consider for patients underweight more than 6 months

Non-routine assessments

Consider only for specific unusual indications

  • Serum amylase level

Possible indicator of persistent or recurrent vomiting

  • Luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels

For persistent amenorrhea at normal weight

  • Brain magnetic resonance imaging (MRI) and computerized tomography (CT)

For ventricular enlargement correlated with degree of malnutrition

  • Stool

For blood


Research sponsored by the National Institute of Mental Health (NIMH) has found that many of those who suffer with anorexia also have other psychiatric illnesses. While the majority has co-occurring clinical depression, others suffer from anxiety, personality disorders, substance abuse disorders, and many are at risk for suicide. Obsessive-compulsive disorder (OCD), an illness characterized by repetitive thoughts and behaviors, has also been found to frequently accompany anorexia. Individuals with anorexia are typically compliant in personality but may have sudden outbursts of hostility and anger or become socially withdrawn (NIDDK, 2001).

In bulimia sufferers the condition can severely damage their bodies due to the frequent binge eating and purging. This is true even when the sufferer is within the normal weight range. In rare instances, binge eating has been known to cause the stomach to rupture. The process of repetitive purging may result in heart failure due to loss of vital minerals, such as potassium. Vomiting also can cause other less deadly, yet serious, problems such as the acid in vomit wearing down the outer layer of the teeth. Acid can also cause scarring on the backs of the hands when fingers are pushed down the throat to induce vomiting. Further, the esophagus almost inevitably becomes inflamed with the glands near the cheeks becoming swollen. As in anorexia, bulimia may lead to irregular menstrual periods. Interest in sex also typically diminishes.

The binge and purge cycle characteristic of bulimia also tends to affect multiple organ systems. The gastrointestinal system for example can be affected by the overeating associated with binge episodes in both bulimia and binge eating disorder. This overeating stretches the stomach and delays gastric emptying. The purging process can induce esophagitis or esophageal rupture due to vomiting. Pancreatitis also can occur from the abnormal stresses produced. Electrolyte abnormalities will happen and can include hypokalemia and hypochloremia. Cardiovascular abnormalities can lead to arrhythmias, arrest, cardiac rupture, or pneumomediastinum. The pulmonary system can be damaged by aspiration of gastric contents upon vomiting. Renal function impairment is also possible (Moreno, 2003).

Bulimia Diagnostic Workup
(Monero, 2003)

Lab Studies

  • No single diagnostic lab study exists for bulimia.
  • A chemistry panel may be ordered if dehydration or electrolyte imbalances are suspected. Common findings include the following:
    • Hypokalemia - Secondary to vomiting
    • Increased BUN
    • Decreased magnesium
    • Decreased chloride
  • Patients with bulimia may exhibit the following abnormal endocrine findings:
    • Increased basal serum prolactin
    • Positive dexamethasone suppression test result
  • If ipecac use is suggested, the following lab studies may be indicated:
    • Stool and urine for emetine (byproduct of ipecac)
    • Cardiac assessment - Muscle enzyme values, lipid levels, magnesium, zinc, electromyography
  • Drug screen is indicated for patients with possible drug use.
  • GI tests may exhibit the following:
    • Increased amylase secondary to vomiting
    • Liver function test results usually normal

Imaging Studies

Imaging studies are not indicated; however, CT scan and MRI of head have demonstrated pseudoatrophy in some patients with bulimia, suggesting problems with malnutrition. The degree of atrophy with bulimia is less than that observed with anorexia.


No diagnostic procedures are indicated.

Other Tests

  • ECG should be considered in the following conditions:
    • Suspected ipecac abuse
    • Hypokalemia
    • Patient has experienced symptoms and signs of arrhythmias
  • Gastric motility studies should be considered in the following conditions:
    • Prolonged history of bulimia
    • History of constipation
    • Other unexplained abdominal pain


Obtaining a thorough history is essential in any patient in whom bulimia is suggested.

  • Patients often deny a problem exists; however, thorough and careful questioning may reveal clues that the patient has bulimia.
  • Often, the patient has a history of dieting attempts, and patients may admit to feeling fat even when they appear thin.
  • Patients often state that their self-esteem is linked closely to their body weight or shape.
  • The patient may have a history of using diet pills, laxatives, ipecac, or thyroid medication to lose weight.
  • Patients may become vegetarians.
  • Diabetic patients may withhold insulin.
  • Patients who admit to purging behavior often describe a history of uncontrolled eating binges at least twice weekly.
    • During these binges large amounts of food are consumed in private. Some patients plan ahead for binges by hoarding food secretly.
    • Patients may describe feeling a loss of control when the binge begins, then a period of frenzied and rapid eating.
    • The binge is followed by inappropriate compensatory behavior, usually self-induced vomiting.


Some individuals with bulimia struggle with additional addictive behaviors, including the abuse of drugs and alcohol, and compulsive stealing. Like individuals with anorexia, many people with bulimia suffer from clinical depression, anxiety, and other psychiatric illnesses. These problems, combined with their impulsive tendencies, place them at increased risk for suicidal behavior.

Those suffering with binge eating disorder are usually overweight, so they are prone to the serious medical problems associated with obesity, such as high cholesterol, high blood pressure, and diabetes. Obese individuals also have a higher risk for gallbladder disease, heart disease, and some types of cancer. Research at NIMH and elsewhere has shown that individuals with binge eating disorder have high rates of co-occurring psychiatric illnesses, especially depression.

Common Symptoms of Eating Disorders
(NIDDK, 2001)




Binge Eating Disorder

Excessive weight loss over short time interval




Continuation of dieting past achieving ideal body weight




Dissatisfaction with appearance, belief body is fat despite underweight appearance




Loss of monthly menstrual period in women / Impotency in men




Unusual interest in food items and strange eating rituals




Eating in secret




Obsession with exercise




Serious depression




Binging – rapid consumption of large amounts of food




Vomiting or use of drugs to stimulate emesis, bowel movements, and urination




Binging with no noticeable weight Gain




Disappearance into bathroom for long periods of time to induce vomiting




Abuse of drugs and/or alcohol






Determining the cause of an eating disorder is quite trying. In an effort to understand the causes of these disorders, researchers have studied the personalities, genetics, environments, and biochemistry of multitudes of individuals with these illnesses. The more that is learned, the more complex the roots of these disorders appear to be.

Be aware that a wide variety of medical problems can masquerade as eating disorders. Hyperthyroidism, malignancy, inflammatory bowel disease, immunodeficiency, malabsorption conditions such as celiac sprue, the presence of chronic infections, Addison's disease, and especially diabetes should be considered before making a diagnosis of an eating disorder. One diagnostic key clue is that most individuals with a medical condition leading to eating problems express concern over their weight loss. However, patients with an eating disorder have a distorted body image and tend to express a desire to be underweight (Pritts, 2003).

The presence of psychiatric comorbidity is extremely confusing when trying to pin down causes of eating disorders. Common co-existing illnesses that are present such as affective disorders, obsessive-compulsive disorder, somatization disorder, and substance abuse must all be considered, weighed, and filtered out when patients present with such symptoms.

Major depression is the most common co-existing condition found among individuals with anorexia, with a lifetime risk rated as high as 80 percent. Anxiety disorders, especially social phobia, are also very common. Obsessive-compulsive disorder has a prevalence of greater than 30 percent among patients with eating disorders. While substance abuse prevalence is estimated at 12 to 18 percent in patients with anorexia and 30 to 70 percent in patients with bulimia. The personality disorders (Axis II diagnoses) also are common, with comorbidity rates reported from 21 to 97 percent. This wide range is related for the most part to the complexity of evaluating these diagnoses. Patients with bulimia are more likely to have a Cluster B diagnosis (dramatic / erratic), whereas patients with anorexia are more likely to have a Cluster C diagnosis (avoidant / anxious). Binge eating has yet to be looked at to the degree that the other major eating disorders have been studied (Pritts, 2003).


It is common to hear someone say, she just seems like the type that would have anorexia. Research confirms what intuition already knows. It seems that the majority of those with eating disorders do share certain personality traits. The traits are low self-esteem, a feeling of helplessness, and most certainly an all-consuming fear of becoming fat. In anorexia, bulimia, and binge eating disorder, maladaptive eating behaviors seem to develop as ways of handling these, as well as other, stresses and anxieties.

Of those individuals possessing anorexia it has been said that they seem just too good to be true. Typically this personality type rarely disobeys authority, keeps feelings private, tends to be a perfectionist, is a good student, and commonly is an excellent athlete. One theory that has been developed by researchers is that people with anorexia restrict food, particularly carbohydrates, in order to gain a sense of self-imposed control in some area of their lives. Having followed the wishes of others for the most part, it is thought that they have not learned how to cope with the problems typical of adolescence, growing up, and becoming independent. Aggressively controlling their weight may to offer two advantages, at least initially.

  1. They have control of their bodies.
  2. They can gain approval from others.

On the other hand, Individuals who develop bulimia and binge eating disorder typically consume huge amounts of food, often junk food, in an effort to reduce or self-distract from feelings of stress and anxiety. With binge eating in particular this results in guilt and depression. For bulimics, the process of purging can bring relief from feelings of worthlessness; but, purging is only a temporary release. Those individuals afflicted with bulimia tend to be impulsive and more likely to engage in risky behavior such as the abuse of alcohol and drugs.

When considering personality and eating disorders, some tools can be helpful in the task of pinning down an eating disorder. Remember that the medical history is the most powerful tool for diagnosing eating disorders, and that physical examination and laboratory findings might be normal, especially early in the course of eating disorders. That is why a comprehensive psychiatric interview can be helpful for the diagnoses of eating disorders. Unfortunately, due to the necessity of arranging an appropriate setting these are impractical in an acute or primary care environment.

One promising psychiatric screening tool is the SCOFF questionnaire. Due to its moderate rate of false positives (12.5 percent) this abbreviated test is not sufficiently accurate for diagnosing eating disorders on its own, but it can be an appropriate, and useful, screening tool.

SCOFF Questions, with other helpful questions
(Pritts, 2003)

  1. Do you make yourself Sick (induce vomiting) because you feel uncomfortably full?
  2. Do you worry that you have lost Control over how much you eat?
  3. Have you recently lost more than one stone (14 lb. [6.4 kg]) in a three-month period?
  4. Do you think you are too fat, even though others say you are too thin?
  5. Would you say that Food dominates your life?

One point for every yes answer.

A score >= 2 Indicates a likely case of anorexia or bulimia.

Sensitivity: 100 percent.

Specificity: 87.5 percent.

Suggested Screening Questions for Anorexia Nervosa and Bulimia

  1. How many diets have you been on in the past year?
  2. Do you think you should be dieting?
  3. Are you dissatisfied with your body size?
  4. Does your weight affect the way you think about yourself?

A positive response to any of these questions warrants further evaluation.


Genetic and environmental factors

The tendency toward developing an eating disorder appears to run in families with female relatives of a sufferer being most often affected. This type of pattern suggests that genetic factors may predispose some people to eating disorders, but do not jump to conclusions as other influences of both behavioral and environmental nature probably play important roles. One example of these factors is a recent study that found that mothers who are overly concerned about their daughters' weight and physical attractiveness could put the girls at an increased risk of developing an eating disorder. Studies have also shown that girls with eating disorders often have a father and/or brothers who have been overly critical of their weight.

Although most victims of anorexia and bulimia are adolescent and young adult women, these illnesses can also strike men and older women. It is also true that anorexia and bulimia are found most often in caucasians, but these illnesses also affect African americans and other racial ethnic groups. People pursuing professions or activities that emphasize thinness such as modeling, dancing, gymnastics, wrestling, or long-distance running seem to be more susceptible to these conditions. In contrast to the other two major eating disorders, one-third to one-fourth of those with binge eating disorders are men. Preliminary studies also show that this condition seems to occur equally among African americans and caucasians.


In an attempt to learn more about the nature of eating disorders, researchers have studied the effects of various biochemicals on the neuroendocrine system. The neuroendocrine system refers to the co-relationship of the central nervous and hormonal systems. Through complex but carefully balanced feedback mechanisms, the neuroendocrine system regulates sexual function, physical growth and development, appetite and digestion, sleep, heart and kidney function, emotions, thinking, and memory. Many of these regulatory mechanisms are seriously disturbed in people with eating disorders.

Key chemicals in the central nervous system, particularly the brain, serve as messengers known as neurotransmitters and control hormone production. Researchers have found that the neurotransmitters serotonin and norepinephrine function abnormally in people affected by depression. Recently, researchers funded by NIMH have learned that these neurotransmitters are also decreased in acutely ill anorexia and bulimia patients as well as long-term recovered anorexia patients. This seems to validate the suspicion that many people with eating disorders also suffer from depression, a theory of disease linkage that some psychologists have believed possible for some time. This confirmation does not positively link the two disorders, what it does is help focus research. In fact, one new research study has suggested that, at least with some patients possessing anorexia, a good response can occur to the antidepressant medication fluoxetine that has positive affects on the serotonin function in the body.

Another interesting finding is that individuals afflicted with either anorexia or certain forms of severe depression also tend to have higher than normal levels of cortisol, a brain hormone released in response to stress. Researchers have been able to show that the excessive levels of cortisol present in both anorexia and depression seem to be caused by a problem that occurs in or near a region of the brain called the hypothalamus.

Depression is not the only neurohormonally influenced disorder with uncanny links to the eating disorders. Researchers have found biochemical similarities between people with eating disorders and those possessing obsessive-compulsive disorder (OCD). Again it is serotonin levels that are abnormal. Due to a recent shift in focus, NIMH researchers have found that many patients with bulimia have obsessive-compulsive behavior as severe as that seen in those who are actually diagnosed with OCD. Conversely, when looked for it was noted that those individuals diagnosed exclusively with OCD frequently had abnormal eating behaviors.

The hormone vasopressin has been found to be abnormal in people with either eating disorders or OCD. NIMH researchers have shown that levels of this hormone are elevated in clients with OCD, anorexia, and bulimia. Normally released in response to physical and possibly emotional stress, vasopressin may contribute to the obsessive behavior seen in some patients with eating disorders. (NIDDK, 2001)


The early recognition and diagnosis of eating disorders is essential as they are most successfully treated when diagnosed early. It is all to common that when family members confront the ill person about his or her behavior, or even when physicians make an objective diagnosis, those individuals with an eating disorder will vehemently deny that they have a problem. This means that people with anorexia may not receive essential medical or psychological attention until they have already become dangerously thin and malnourished. Those who have bulimia are often normal weight and are able to hide their illness from others for years. Eating disorders in males may be even more frequently missed because anorexia and bulimia are relatively rare in boys and men. The result of these factors is a battle for treatment, one that is often lost by friends and the family that love the afflicted person. It simply cannot be overemphasized how important treatment is. The sooner, the better. The longer abnormal eating behaviors persist, the more difficult it is to overcome the disorder and its effects on the body. In many cases, long-term treatment may be required. Families and friends offering support and encouragement can play an important role in the success of the treatment program.

When an eating disorder is suspected, particularly if it involves weight loss, the first step is a complete physical examination to rule out any other illnesses. Should an eating disorder be diagnosed, the clinician must determine whether that person is in immediate medical danger and requires hospitalization. While most patients can be treated as outpatients, some need hospital care.

Indications for immediate medical hospitalization.
(APA, 2003)

  • Marked orthostatic hypotension with an increase in pulse of >20 bpm or a drop in blood pressure of >20 mm Hg/minute standing.
  • Bradycardia below 40 bpm, tachycardia over 110 bpm.
  • Inability to sustain body core temperature (e.g., temperatures are below 97.0°F).
  • Loss of consciousness.


Conditions warranting hospitalization include, but are not limited to, excessive and rapid weight loss, serious metabolic disturbances, clinical depression or risk of suicide, severe binge eating and purging, or indications of an active psychosis. Weight, cardiac and metabolic status are typically the most important physical parameters for determining choice of setting. Generally, patients who weigh less than approximately 85% of their individually estimated healthy weights have considerable difficulty gaining weight in the absence of a highly structured program. While those weighing less than 75% of their individually estimated healthy weights are likely to require a 24-hour hospital program. Be aware that once weight loss is severe enough to cause the indications for immediate medical hospitalization, treatment of the underlying eating disorder may be less effective, refeeding may entail greater risks, and prognosis may be more problematic than when intervention is provided earlier (APA, 2003).

Nutritional rehabilitation for patients who are significantly underweight
(APA, 2003)

  • Healthy target weights and expected rates of controlled weight gain (e.g., 2-3 lbs/week for most inpatient and 0.5-1 lbs/week for most outpatient programs)
  • Intake levels should usually start at 30-40 kcal/kg per day (approximately 1000-1600 kcal/day)
  • Levels may be increased to as high as 70-100 kcal/kg per day during the weight gain phase.
  • Intake levels should be 40-60 kcal/kg per day during weight maintenance and for ongoing growth and development in children and adolescents.
  • Vitamin and mineral supplements may also be beneficial for patients (e.g., phosphorus supplementation may be particularly useful to prevent serum hypophosphatemia).
  • It is essential to monitor patients medically during refeeding
  • Monitoring should include assessment of vital signs as well as food and fluid intake and output; electrolytes (including phosphorus); and the presence of edema, rapid weight gain (associated primarily with fluid overload), congestive heart failure, and gastrointestinal symptoms, particularly constipation and bloating.


The very nature of the complex interaction of emotional and physiological problems in eating disorders calls for a comprehensive treatment plan, involving a variety of experts and approaches. When putting the team together, the treatment team should include an internist, nursing staff, a nutritionist, an individual psychotherapist, and a psychopharmacologist. It is always important to have a resource person who is knowledgeable about the psychoactive medications useful in treating these complex disorders.

Goals in the treatment of anorexia nervosa
(APA, 2003)

  • Restoring healthy weight (i.e., weight at which menses and ovulation in females, normal sexual drive and hormone levels in males, and normal physical and sexual growth and development in children and adolescents are restored)
  • Treating physical complications
  • Enhancing patients' motivations to cooperate in the restoration of healthy eating patterns and to participate in treatment
  • Providing education regarding healthy nutrition and eating patterns
  • Correcting core maladaptive thoughts, attitudes, and feelings related to the eating disorder
  • Treating associated psychiatric conditions, including defects in mood regulation, self-esteem, and behavior
  • Enlisting family support and providing family counseling and therapy where appropriate
  • Preventing relapse


Experience has shown that in order to help those with eating disorders deal with their illness and underlying emotional issues, some form of psychotherapy is typically beneficial. A psychiatrist, psychologist, or other mental health professional meets with the patient individually and provides ongoing emotional support, while the patient begins to understand and cope with the illness. Group therapy, in which people share their experiences with others who have similar problems, has been especially effective for individuals with bulimia.

Use of individual psychotherapy, family therapy, and cognitive-behavioral therapy appears to be the most productive combination. Cognitive-behavioral therapy is a form of psychotherapy that teaches patients how to change abnormal thoughts and behavior. Cognitive-behavior therapists focus on changing eating behaviors usually by rewarding or modeling wanted behavior. These therapists can also help patients work to change the distorted and rigid thinking patterns associated with eating disorders.

The efforts of mental health professionals need to be combined with those of other health professionals to obtain the best treatment. Physicians treat any medical complications, and nutritionists advise on diet and eating regimens. The challenge of treating eating disorders is made more difficult by the metabolic changes associated with them. Just to maintain a stable weight, individuals with anorexia may actually have to consume more calories than someone of similar weight and age without an eating disorder.

This information is important for patients and the clinicians who treat them. Consuming calories is exactly what the person with anorexia wishes to avoid, yet must do to regain the weight necessary for recovery. In contrast, some normal weight people with bulimia may gain excess weight if they consume the number of calories required to maintain normal weight in others of similar size and age.

In Hospital Care Considerations for Bulimia
(Monero, 2003)

  • Inpatient care is warranted if patient is suicidal, has abnormal ECG findings or electrolyte levels, is dehydrated, or has had no response to outpatient therapy.
  • Inpatient care should include the following:
    • Supervised meals
    • Supervised bathroom privileges
    • No access to bathroom for 2 hours after eating
    • Monitoring of weight and physical activity
    • Assessment of nutritional state
    • Identifications of precipitants to binge and purge
    • Frequent assessment of electrolytes
    • Individual psychotherapy
    • Frequent doctor visits


Medications are also an essential component to successful treatment. It is important to stress the effectiveness of combining psychotherapy and medications. In a recent study of bulimia, researchers found that intensive group therapy and antidepressant medications either combined or alone, benefited patients. However, studies have consistently shown that it is the combined use of cognitive-behavioral therapy and antidepressant medications that is most beneficial. The combination treatment is particularly effective in preventing relapse once medications are discontinued.

For patients with binge eating disorder studies are only now looking for the best form of treatment. It is believed that cognitive-behavioral therapy and antidepressant medications may prove to be useful.

Antidepressant medications commonly used to treat bulimia include desipramine, imipramine, and fluoxetine. For anorexia, preliminary evidence shows that some antidepressant medications may be effective when combined with other forms of treatment. Fluoxetine has also been useful in treating some patients with binge eating disorder. These antidepressants may also treat any co-occurring depression (NIDDK, 2001).

Indications for hospitalization in bulimia.
(APA, 2003)

  • Severe disabling symptoms that have not responded to adequate trials of competent outpatient treatment
  • Serious concurrent general medical problems (e.g., metabolic abnormalities, hematemesis, vital sign changes, or the appearance of uncontrolled vomiting)
  • Suicidality
  • Psychiatric disturbances that would warrant the patient's hospitalization independent of the eating disorders diagnosis
  • Severe concurrent alcohol or drug abuse


An act of loving intervention leading to treatment can save the life of someone with an eating disorder. Friends, relatives, teachers, and physicians all play an important role in helping the ill person start and stay with a treatment program. Encouragement, caring, and persistence, as well as information about eating disorders and their dangers, may be needed to convince the ill person to get help, stick with treatment, or try again.

Information about eating disorders is available to family members and friends who can call local hospitals or university medical centers to find out about eating disorder clinics and clinicians experienced in treating the illnesses. For many employees or college students, treatment programs may be available in workplace or school counseling centers. Many local mental health organizations and the self-help groups also provide free literature on eating disorders. Some of these groups will provide treatment program referrals and information on local self-help resources. Once the person gets help, he or she will continue to need lots of understanding and encouragement to stay in treatment.

Following Up

Eating disorders are one of the toughest self-harm conditions to treat. The individual who is suffering from an eating disorder is going through their own form of personal hell due to a broken self-view and a maladaptive means of coping. The family, friends, and treatment providers involved in bringing that person up out of the pit of their own making can also suffer tremendously during the process.

It all comes down to the fact that many individuals with eating disorders do not want to change! Some refuse to acknowledge that there is any problem at all; others are able to say they want things to be better, but simply are invested in the maladaptive behaviors to be able to abandon them.

It is up to others, who can view the problem from outside the pit, to encourage, exhort, and continue to follow up with our care and concern. The treatment of an eating disorder is really a treatment of an entire community. Rarely does the individual afflicted have the inner strength to fight the bad behaviors on a long-term basis without assistance. Inpatient treatment is a common starting point in the journey towards health. Continuing out patient treatment combined with both individual and group therapies follow this in-patient treatment. At the time when it seems most advantageous to the treatment team that should be following the progress of each client, family therapy should be added in.

From that point community support is encouraged. Individual therapy should continue, and provide guidance to the world of larger resources such as self-help groups, and local support chapters of other individuals who are lending their strength to one another to help overcome eating disorders. Plugging into a good active church or citizens group is always helpful, as is finding activities to participate in with healthy friends and family.

Be aware of local crises call-in numbers and ensure that your client has them for when they face a difficult time. Warn each person that is in treatment for an eating disorder that the occasional relapse or backslide is inevitable, but that does not mean that treatment has failed. Coach them on honesty to themselves and others when those things happen. After all, they are not alone in their struggle towards health.


Eating disorders are a mix of distorted body image and poor coping skills. The individuals who have these conditions are tortured souls in need of comfort, acceptance, and a firm hand leading them towards healthy behaviors. Early recognition and intervention are the keys to recovery of their feelings of self-worth and the healing of their overwrought bodies.

The recovery rates for eating disorder clients have been recorded at greater then 80%. Together, health professionals of all disciplines, with the aid of caring families, friends and communities, can lead those who are afflicted to better health. Good treatment planning includes all of the stakeholders and combines medication with cognitive and family therapies has been proven to turn things around for those with eating disorders (Murray, 2002).


“Binge Eating Disorder.” NIH Publication No. 99-3589. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). National Institute of Health. (NIH). February 2001.

“BMI for Adults – What is BMI?” Centers for Disease Control (CDC). National Center for Chronic Disease Prevention and Health Promotion. April 2003.

“Practice Guidelines for the Treatment of Patients with Eating Disorders.” American Psychiatric Association (APA). Workgroup on Eating Disorders. December 2003.

Moreno et al. “Eating Disorder: Bulimia.” E-Medicine. December 2003.

Murray, B. “Partners in Illness – Patients Trading Thinness Tips.” Monitor on Psychology. March 2002.

Myers, M. “Eating Disorders.” August 2001.

Pritts et al. “Diagnosis of Eating Disorders in Primary Care.” American Family Physician. January 2003.