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Eating Disorders (FL INITIAL Autonomous Practice- Differential Diagnosis)

2 Contact Hours including 2 Advanced Pharmacology Hours
Only FL APRNs will receive credit for this course
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This course is only applicable for Florida nurse practitioners who need to meet the autonomous practice initial licensure requirement.
This peer reviewed course is applicable for the following professions:
Advanced Practice Registered Nurse (APRN)
This course will be updated or discontinued on or before Saturday, July 5, 2025

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.

Outcomes

≥ 92% of participants will understand the six forms, screening tools, and available treatment options for eating disorders.

Objectives

After completing this continuing education course, the participant will be able to:

  1. Differentiate between each of the eating disorder diagnoses.
  2. Explain the possible causes for eating disorders.
  3. Identify the screening tools for assessment for eating disorders.
  4. Interpret the clinical features often found with eating disorders.
  5. Determine various medical complications associated with eating disorders.
  6. Outline the treatment options available for eating disorders.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.
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Author:    Heather Rhodes (APRN-BC)

Introduction

Eating disorders are disabling and costly mental health disorders that significantly impair both physical and psychosocial functioning in adults and children. Eating disorders are defined by a persistent disturbance of eating that impairs health or psychosocial functioning (American Psychological Association [APA], 2013).

There are six specific disorders identified (APA, 2013):

  1. Anorexia nervosa
  2. Avoidant/restrictive food intake disorder
  3. Binge eating disorder
  4. Bulimia nervosa
  5. Pica
  6. Rumination disorder

Diagnoses are based upon the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), which divides eating disorders into mutually exclusive categories that are based upon observed symptoms (APA, 2013). “As eating disorders are under-researched, there is a great deal of uncertainty as to their pathophysiology, treatment and management” within both the medical and mental health care communities (Treasure et al., 2020, p. 899).

Attitudes towards weight, body shape, and eating within American culture greatly impacts the obsession with weight, weight loss, and dieting. The incidence of eating disorders has increased over the last 50 years (Treasure et al., 2020). The weight loss industry is 3.8 billion dollars in the United States, targeting people of all races, ages, and income levels. Magazines and popular television shows display thin models who are airbrushed to unattainable perfectionism. Athletes pursue a lean body mass to improve performance, and young adolescents, strongly influenced by social media platforms, emulate peers and role models through food manipulation. People at high risk for eating disorders include those with a history of trauma, transgender individuals, athletes, females, young adults, and patients who present anxiety and depressive disorders, rigidity and perfectionism, or symptoms of rapid weight loss, bradycardia, amenorrhea, or a preoccupation with eating and appearance (National Institute of Health [NIH], 2023; Yager, Roy-Byrne & Solomon, 2022).

Case Study Part 1: Carrie

Carrie is a 22-year-old female who just graduated from college and landed a new job as an account manager in a large corporation. She is recently engaged and is planning a destination wedding to occur in six months. Her body mass index is 16.2 and she would like to lose another fifteen pounds to fit into the wedding dress she just purchased. She makes an appointment with her primary care physician because she has been experiencing a rapid, irregular heartbeat, shortness of breath and dizziness with light exercise. Her friends from her running club have mentioned that she is looking terrific but that she should probably stop trying to lose weight. She checks in at the front desk of her primary physician’s office and is handed a form to complete prior to her appointment.

Screening

High-Risk Individuals

Eating disorders are often undetected and untreated; thus, screening is vital to identify those who are at risk and may be experiencing an eating disorder. As briefly mentioned above, people at high risk for eating disorders include the following:

  • Those who have experienced trauma
  • Young adults
  • Females
  • Transgender individuals
  • Athletes
  • Individuals who experience anxiety or depressive disorders
  • Those who exhibit signs of rapid weight loss, preoccupation with eating and appearance, bradycardia or amenorrhea
  • Those with general rigidity in thinking and perfectionism

Screening Tools

If a patient is found to be at risk, four screening tools are available for use. These include:

  1. The SCOFF questionnaire
  2. The Eating Disorder Screen for Primary Care (ESP) 
  3. The Eating Attitudes Test (EAT)
  4. The Primary Care Evaluation of Mental Disorders Patient Health Questionnaire

The SCOFF Questionnaire

The SCOFF questionnaire is the most used instrument and is recommended by the U.S. Preventative Service Task Force (2022). It consists of five questions. A positive response to two or more questions is indicative of either anorexia nervosa or bulimia nervosa. The SCOFF fails, however, to detect other eating disorders (e.g., binge eating disorder), but does have an 84% sensitivity and an 80% specificity for these two eating disorders.

SCOFF clinician-administered questions (Cotton et al., 2003):

  1. Do you make yourself Sick because you feel uncomfortably full?
  2. Do you worry you have lost Control over how much you eat?
  3. Have you recently lost more than One stone (14 pounds or 6.35 kg) in a three-month period?
  4. Do you believe yourself to be Fat when others say you are too thin?
  5. Would you say that Food dominates your life?

The Eating Disorder Screen for Primary Care (ESP)

The Eating Disorder Screen for Primary Care (ESP) is an alternative to the SCOFF Screening tool and has a sensitivity range from 97 to 100% with a specificity range from 40 to 71% (Attia & Guarda, 2022; U.S. Preventative Task Force, 2022). Three or more “abnormal” responses are indicative of a positive screen for eating disorders.

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

  1. Are you satisfied with your eating patterns (No is abnormal)
  2. Do you ever eat in secret? (Yes is abnormal)
  3. Does your weight affect the way you feel about yourself (Yes is abnormal)
  4. Have any members of your family suffered from an eating disorder (Yes is abnormal)
  5. Do you currently suffer from or have you ever suffered in the past with an eating disorder? (Yes is abnormal)

The Eating Attitudes Test (EAT)

The Eating Attitudes Test (EAT) is a 26-item screening tool. It has an accuracy rate of 90% with a cut off score of 20. It is a self-reporting instrument and is widely used due to its accuracy and ease of administration.

The Primary Care Evaluation of Mental Disorders Patient Health Questionnaire

The Primary Care Evaluation of Mental Disorders Patient Health Questionnaire is a brief instrument that screens for depression, anxiety, alcohol, and somatoform disorders. It also screens for bulimia nervosa and is specifically designed for use in the primary care setting. It is fully self-administered by the client with a sensitivity of 75%  and a specificity of 90%.

Types of Eating Disorders & Clinical Features

Anorexia Nervosa

The term “anorexia nervosa” is derived from the Greek and Latin words for “loss of appetite” and “nervous”. Clients with anorexia do not actually lose appetite until very late in the disorder. The prevalence of anorexia nervosa in the United States is 0.6% in adults and 0.3% for adolescents (aged 10 to 18 years), impacting both females and males at a ratio of 20:1 (Hudson et al., 2007; Pedersen et al., 2014; Sadock et al., 2017).The median age of onset in the general population is 14 to 18 years (Hudson et al., 2007; Sadock et al., 2017).

Diagnostic criteria for anorexia nervosa, as defined by the American Psychiatric Association (2013), is as follows (APA, 2013, p. 338):

  • Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected.
  • Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight.
  • Disturbances 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.

Diagnostic criteria specify between restricting type and binge-eating/purging type and then further specify the severity of symptoms based on body mass index. “Crossover between subtypes is not uncommon” (APA, 2013, p 339). In the restrictive subtype of anorexia nervosa, people severely limit the amount of food they ingest. In the binge-purge subtype of anorexia nervosa, people severely restrict the amount of food ingested. They may then have episodes of binge eating (consuming large amounts of food in a very short time) followed by self-induced vomiting or the use of laxatives or diuretics to rid the body of what was just consumed (NIH, 2023). Severity of anorexia nervosa is graded based on the patient’s BMI (APA, 2013):

  • Mild (BMI ≥ 17 kg/m2)
  • Moderate (BMI 16-16.99 kg/m2)
  • Severe (BMI 15-15.99 kg/m2)
  • Extreme (BMI < 15 kg/m2)

Pathogenesis and Neurobiology

It is common to see eating disorders in families, and thus, it is suggested that there is a genetic component and/or environmental factors that contribute to the development of the disorder (Steinhausen et al., 2015). One research study found that chromosome 12 (rs4622308) was associated with anorexia nervosa (Duncan et al., 2017). It was also found that there is a strong correlation between eating disorders and other significant mental health disorders (e.g., neuroticism, schizophrenia, educational attainment, etc.) (Duncan et al., 2017). Magnetic resonance imaging studies have shown abnormal functioning of the corticolimbic circuits (which control appetite) in clients who have an eating disorder which suggests that hunger signals are not accurately recognized (Oberndorfer et al., 2013; Yager, Roy-Byrne & Solomon, 2022).

According to Yager et al. (2022), “Neurotransmitter systems are also disrupted in anorexia nervosa. Deficits have been found in dopaminergic function (involved with motivation, reward and eating behavior) and serotonergic function (involved with mood, impulse control, and obsessional behavior)” (Yager et al., 2022, p. 25).

Clinical Features

Aside from the core clinical features outlined by the American Psychological Association (2013), other signs and symptoms often seen with anorexia nervosa include:

  • A relentless pursuit of thinness
  • An obsessional preoccupation with food (e.g., hoarding food, collecting recipes)
  • Fear of certain foods
  • Overestimating number of calories consumed
  • Social withdrawal
  • Exercise-related rituals (e.g., running a set number of miles every day, doing aerobics for a specific number of minutes)
  • Feelings of ineffectiveness
  • Poor sleep
  • Low libido
  • Perfectionism
  • A need to control one’s environment

Common medical complications include (Sadock et al., 2017; Weider et al., 2015):

  • Amenorrhea (typically seen with a weight loss of 15% or more of normal weight)
  • Peripheral (starvation) edema
  • Muscle atrophy
  • Bradycardia
  • Hypotension
  • Arrhythmia
  • Electrolyte imbalances
  • Delayed gastric emptying
  • Irritable bowel syndrome
  • Hypoglycemia
  • Elevated liver enzymes
  • Acute and chronic renal failure
  • Elevated cortisol 

These and other medical complications are a direct result of weight loss and malnutrition. Anorexia nervosa is also associated with impaired learning and memory, poor executive functioning (planning, decision-making, response inhibition), and slower motor function.

Avoidant/Restrictive Food Intake Disorder

Clinical Features

There are no body dysmorphic symptoms present with this disorder. Patients are often under-weight for their age with diminished bone mineral density. This disorder cannot be caused by a lack of available food, but rather is caused by a behavior in which the client either avoids or restricts food intake, which may be based on either (APA, 2013):

  • A lack of interest in food
  • The sensory aspects of food (e.g., slimy, crunchy, etc.)
  • A conditioned negative response associated with food intake following a traumatic experience (e.g., anaphylactic reactions, choking, etc.)

One or more of the following must also be present (APA, 2013):

  1. Significant weight loss
  2. Significant nutritional deficiency
  3. Dependence on enteral feeds or supplements
  4. A marked interference towards eating

Bulimia Nervosa

Clinical Features

There is a distorted body image with this eating disorder. Binging, defined as consuming large amounts of food and feeling unable to stop eating, is followed by recurrent, inappropriate compensatory behaviors (purging, excessive exercising, use of laxatives, etc.). The compulsion to overeat and then purge occurs more than one week at a time for a duration of a minimum of three consecutive months (APA, 2013). The number of episodes per week of inappropriate compensatory behaviors is what helps to determine the level of severity (APA, 2013):

  • Mild (1-3)
  • Moderate (4-7)
  • Severe (8-13)
  • Extreme (14+)

Binge-Eating Disorder

Clinical Features

This disorder is very similar to Bulimia Nervosa, except that there are no compensatory behaviors involved. The patient will binge eat and have a lack of control when bingeing. Three or more of the following features will also be present (APA, 2013):

  • Eating rapidly
  • Eating until uncomfortable
  • Eating large amounts of food when not hungry
  • Eating alone out of embarrassment
  • Having feelings of being disgusted with self or depressed afterward

This behavior occurs more than one week at a time for a duration of a minimum of three consecutive months (APA, 2013). The level of severity is based on the number of binge-eating episodes that occur per week (APA, 2013; Yager et al., 2022):

  • Mild (1-3)
  • Moderate (4-7)
  • Severe (8-13)
  • Extreme (14 or more)

Pica

Clinical Features

In the case of Pica, a client will eat non-nutritive items (e.g., paper, pens, nails, paper clips, thread, tacks, etc.) that are inappropriate to the client’s developmental level and the behavior lasts for more than one month (APA, 2013).

Rumination Disorder

Clinical Features

The client with Rumination Disorder will repeatedly regurgitate food and either re-swallow the food or spit it out. This does not occur in congruence with another eating disorder and is not due to a medical condition. This behavior must last for more than one month to meet diagnostic criteria (APA, 2013).

Physical Findings

Medical complications from eating disorders are often the reason a client initiates contact with a healthcare professional. According to Voderholzer et al. (2020), “Medical complications of anorexia nervosa generally occur due to starvation, malnutrition and their associated physiological effects, whereas medical complications of bulimia nervosa are generally due to purging behaviors” (Voderholzer et al., 2020, p. 542).

Treatment begins with a full assessment of vital signs, a full medical history, and a physical examination. Common physical findings are detailed in Table 1.Laboratory assessment should include:

  • Serum electrolytes
  • Blood urea nitrogen
  • Serum creatinine
  • Serum glucose
  • Serum calcium
  • Phosphorous level
  • Magnesium level
  • Serum albumin and prealbumin
  • Liver function tests (aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase)
  • International Normalized Ratio (INR)
  • Complete blood count including differential
  • Thyroid stimulating hormone
  • 25-hydroxyvitamin D
  • Pregnancy test (females)
  • Testosterone (males)
  • Electrocardiogram
Table 1: Physical Examination Findings for Eating Disorders (Mehler, Yager & Solomon, 2022)
Vital SignsBradycardia, hypotension (systolic blood pressure <90 mmHg and/or a diastolic blood pressure <50 mmHg), orthostatic hypotension, hypothermia
Weight and GrowthLow body mass index, emaciation (body weight less than 85 percent of ideal body weight)
HeadParotid gland swelling, enamel erosion, dental caries
ChestArrhythmia, heart murmur from mitral valve prolapse
AbdomenPalpable stool, bloating, abdominal distention and pain, hypoactive bowel sounds
ExtremitiesEdema, muscle atrophy, weakness
SkinDry skin, hair loss, lanugo, acrocyanosis, pressure sores, yellow skin

Differential Diagnosis

Other possible causes for significantly low body weight or significant weight loss should be considered, especially when the age of onset is atypical (e.g., after age 40). Acute weight loss can occasionally be associated with a medical condition that initially presents as an eating disorder but is masked by a comorbid metabolic illness or other mental illness. Medical conditions that can contribute include (APA, 2013; Mehler et al., 2022):

  • Uncontrolled diabetes
  • Hyperthyroidism
  • Acquired immunodeficiency syndrome (AIDS)
  • Nutritional malabsorption (e.g., bariatric surgery, genetic deficiency, etc.) syndrome
  • Cancer
  • Irritable bowel syndrome
  • Crohn’s Disease

Case Study Part 2: Carrie

Carrie’s BMI of 16.2 and a positive Eating Disorder Screen for Primary Care indicates that she has moderately severe (severity judged based on BMI) eating disorder. Her primary care provider orders a full laboratory work up with and EKG. She is also referred to an in-house psychiatric provider for a mental health assessment.

Treatment

The goal is to provide treatment in the least restrictive environment possible, with hospitalization utilized only for patients at risk of medical or psychological compromise (Hay et al., 2014; Wagner et al., 2013).

The least restrictive environment is outpatient. Treating the underlying cause of anorexia nervosa is vital to ongoing recovery. Along with a medical workup and focused laboratory testing, the patient should also undergo a psychiatric evaluation to address any comorbid mental health issues. Most patients with an eating disorder have a lifetime history of at least one comorbid mental disorder. While eating disorders are very uncommon in patients with schizophrenia, comorbid psychological disorders can generally include (APA, 2013):

  • Unipolar major depression
  • Persistent depressive disorder
  • Bipolar I or II disorder
  • Panic disorder
  • Generalized anxiety disorder
  • Social anxiety disorder
  • Specific phobias
  • Obsessive compulsive disorder
  • Oppositional-defiant disorder
  • Conduct disorder
  • Intermittent explosive disorder
  • PTSD
  • Attention-deficit/hyperactivity disorder
  • Drug and alcohol abuse
  • Personality disorders

Cognitive behavioral therapy (CBT) has been found to be effective in helping patients reframe abnormal thinking patterns, identify and regulate emotions, and improve interpersonal relationships (Hay et al., 2014). The vulnerability to rely on anorexic behavior as a coping mechanism can decrease through cognitive behavioral therapy techniques. Group and family therapy has also shown, in combination with individual therapy, to be effective.

Olanzapine is an atypical antipsychotic that is FDA-approved for ages 13 and older for nausea and vomiting prevention, to improve weight restoration, and to help stabilize mood and is better than a placebo in clients who are in starvation (Lexicomp, 2018; Stahl et al., 2018; Voderholzer, et al., 2020). Atypical antipsychotics are FDA-approved to treat mood disorders, but not every drug in this category is FDA approved for pediatric use, so caution must be taken when deciding on which drug to trial.

The use of selective serotonin reuptake inhibitors (SSRIs) has been shown to be effective in the management of underlying anxiety and depressive symptoms. Tricyclic antidepressants (TCAs) are generally avoided due to the vulnerability of hypotension, cardiac arrhythmias, and dehydration status in this population.

Criteria for Hospitalization

The level of care a patient should be admitted to depends on the severity of presenting symptoms upon initial assessment. Generally, a body mass index (BMI) of less than or equal to 14 kg/m2 or less than 70% of the ideal body weight will require inpatient treatment.

Medical instability is characterized by one or more of the following (Mehler et al., 2022; Saddock et al., 2017):

  • Pulse < 40 beats per minute (bpm)
  • Blood pressure < 80/60 mmHg
  • Orthostatic increase in pulse (> 20 beats/minute)
  • Decrease in systolic blood pressure (> 20 mmHg)
  • Cardiac dysrhythmia (e.g., QTc > 0.499 msec)
  • Any rhythm other than normal sinus rhythm or sinus bradycardia
  • Cardiovascular, hepatic, or renal compromise requiring medical stabilization
  • Marked dehydration
  • Serious medical complications of malnutrition (e.g., electrolyte imbalance, hypoglycemia, or syncope)

Refeeding syndrome is defined as the “clinical complications that can occur as a result of fluid and electrolyte shifts during aggressive nutritional rehabilitation of malnourished clients” and can be fatal when not detected or treated early during nutritional rehabilitation (Mehanna et al., 2008, p. 1496). These fluid and electrolyte shifts result from hormonal and metabolic changes and can result in the hallmark biochemical feature of the refeeding syndrome: hypophosphatemia (Hearing, 2004). Other abnormal shifts include changes in fat metabolism, thiamine deficiency, hypokalemia, hypomagnesemia, and glucose levels. Many clinicians are not aware of the seriousness and potential for death that refeeding syndrome poses, and thus, it still occurs.

Case Study Part 3: Carrie

Carrie meets with the in-house mental health provider and is diagnosed with anorexia nervosa, generalized anxiety, post-traumatic stress disorder, and unipolar depression. She discusses with the provider that she has been struggling with the stress of a new job and planning a destination wedding and has not been sleeping well either. The provider utilizes cognitive behavioral therapy (CBT) to help her identify triggers for anxiety and begins to teach her coping mechanisms that will improve her emotional regulation. She is started on a low-dose antidepressant to help increase serotonin use in the brain and is scheduled with a therapist to continue outpatient treatment for her mental health disorders.

Due to Carrie’s low body-mass index (16.2 kg/m2), her anorexia nervosa is classified as moderate. Her blood workup showed elevated liver enzymes, anemia, leukopenia hypoglycemia, and elevated cortisol. Her electrocardiogram (EKG) showed a decreased response to exercise along with bradycardia. Her primary care physician consulted with cardiology, and due to the abnormal EKG and lab, she was admitted for observation and fluids.

Conclusion

American culture greatly impacts the obsession with weight, weight loss, and dieting, creating a culture where eating disorders emerge. People across all demographics are at risk for eating disorders, including those with a history of mental illness or trauma, transgender individuals, athletes (both male and female), and young adults (NIH, 2023; Yager et al., 2022). Eating disorders are often undetected and untreated; thus, screening is vital to identify those who are at risk and may be experiencing an eating disorder. Treatment options occur in the least restrictive milieu allowing for the severity of symptoms and patient needs.

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Implicit Bias Statement

CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.

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