Eating disorders are serious medical conditions involving severe and often persistent disturbances in eating behaviors and associated distressing thoughts and emotions that impair psychosocial functioning. Types of eating disorders include anorexia nervosa, bulimia nervosa, binge eating disorder, avoidant restrictive food intake disorder, other specified feeding and eating disorder, pica and rumination disorder.

Eating disorders affect up to 5% of the population, and most often develop in adolescence and young adulthood. Eating disorders are more common among girls and women. However, they affect people of all genders, body sizes, ages, socio-economic statuses and racial/ethnic identities. You can’t tell by a person’s appearance whether they have an eating disorder.

Eating disorders involve a disordered relationship with food and/or body shape and weight that drives compulsive behaviors such as restrictive eating, avoiding certain foods, binge eating, self-induced vomiting/laxative misuse, or excessive exercise. These behaviors can become driven in ways that appear similar to an addiction.

Causes and Treatments

Our current understanding of what causes an eating disorder includes many factors — biological, psychological, and social factors, and emerging research showing strong genetic contributions. Eating disorders often co-occur with other mental disorders, most commonly mood and anxiety disorders, obsessive-compulsive disorder, and alcohol and substance use disorders. Eating disorders are among the most fatal of psychiatric disorders, due to high rates of suicide and medical complications, especially heart issues.

Early identification and treatment are important for lasting recovery. Initial treatment focuses on addressing malnutrition and restoring weight, if needed. Treatment also addresses disordered thoughts, behaviors, and feelings and encourages healthy eating patterns. Many individuals are hesitant about treatment. With proper medical care, physical and emotional recovery is possible. Affirming that recovery is always possible helps empower individuals and instill hope.

Warning Signs of an Eating Disorder

While none of these items alone indicates an eating disorder, if several of the items are seen, it may be cause for concern.

Changes in eating and diet

• Avoiding previously enjoyed foods
• Avoiding entire food groups - carbohydrates, protein
• Abrupt changes in diet/new diets
• Eating large portions of food rapidly
• Cooking calorie-rich foods for others but not eating them
• Needing to control the exact ingredients in meals
• Using child-sized bowls or cutlery

Changes in exercise and movement

• Having to exercise in order to “earn” food
• Significant guilt or anxiety if unable to exercise
• Inability to sit still, always standing
• Exercising despite injuries

Changes in behavior

• Avoiding eating in front of others
• Using the bathroom immediately after eating
• Social withdrawal - avoiding social situations where food is involved
• Wearing baggy clothing
• Weighing oneself daily

Changes in mood

• Increased irritability without a clear cause
• Increased anxiety and depression

Common physical symptoms

• Fainting or lightheadedness
• Gastrointestinal symptoms (i.e., abdominal pain, nausea)
• Loss of menses in females
• Unexplained weight loss

Types of Eating Disorders

Anorexia nervosa involves concerns about body shape and an intense fear of weight gain that drive extreme food restriction. This results in low body weight for age and height. Body mass index or BMI, a measure of weight for height, is typically under 18.5 in an adult individual with anorexia nervosa.

It is not uncommon for people with anorexia nervosa to minimize or hide symptoms. For example, individuals with anorexia may say they want and are trying to gain weight. However, their behaviors, such as eating small amounts of low-calorie foods or excessively exercising, are not consistent with this intent. Anorexia nervosa is among the most lethal psychiatric diagnoses, with suicide accounting for up to 44% of deaths.

There are two subtypes of anorexia nervosa:

• Restricting type, in which individuals lose weight primarily by restrictive eating and/or excessively exercising.
• Binge-eating/purging type in which individuals also engage in binge eating and/or purging behaviors (i.e., self-induced vomiting or laxative misuse).

Because malnutrition affects multiple organ symptoms, potential symptoms from starvation are broad and may include:

• Cessation of menstrual periods
• Dizziness or fainting from dehydration
• Brittle hair/nails
• Cold intolerance
• Muscle weakness and wasting
• Heartburn and reflux (in those who vomit)
• Severe constipation, bloating and fullness after meals
• Stress fractures from compulsive exercise, as well as bone loss resulting in osteopenia or osteoporosis (thinning of the bones)
• Depression, irritability, anxiety, poor concentration and fatigue
• Sudden cardiac arrest
• Abdominal pain, nausea, bloating

Purging behaviors (i.e., self-induced vomiting or laxative/diuretic misuse) are especially dangerous. They can lead to potentially life-threatening complications of electrolyte imbalances, including heart rhythm abnormalities, and other serious medical complications such as esophageal or gastric tears.

Treatment for anorexia nervosa involves helping those affected normalize their eating and weight control behaviors and restore their weight. Evaluation and treatment of any co-occurring psychiatric or medical condition is an important component of the treatment plan. The nutritional plan should focus on helping individuals counter anxiety about eating and practice consuming a wide, balanced range of foods of different calorie densities across regularly spaced meals. For adolescents and emerging adults, the most effective treatments involve helping parents to support and monitor their children’s meals. Addressing body dissatisfaction is also important, but it often takes longer to correct than weight and eating behavior.

If anorexia nervosa is severe or if outpatient treatment is not effective, an individual may be admitted to an inpatient or residential behavioral specialty program. Most specialty programs are effective in restoring weight and normalizing eating behavior. However, there is a risk of relapse in the first year after program completion.

 

 

Bulimia nervosa also involves body image concerns. The individual alternates between eating only low-calorie “safe foods” and binge eating on “forbidden” high-calorie foods. People with bulimia are excessively preoccupied with thoughts of food, weight, or shape, which impact their self-worth.

Binge eating is defined as eating a large amount of food in a short period of time, associated with a sense of loss of control over what or how much one is eating. Binge behavior is usually secretive and associated with feelings of shame or embarrassment. Binges may be very large, and food is often consumed rapidly, beyond fullness to the point of nausea and discomfort.

Binges occur at least weekly and are typically followed by what are called "compensatory behaviors" to prevent weight gain. These can include fasting, vomiting, compulsive exercise, and/or misuse of medications, including GLP-1 agonists, laxatives, and diuretics. As noted above, purging behavior can lead to potentially life-threatening complications of electrolyte imbalances and other serious medical complications.

Possible signs of purging behavior include:

• Frequent trips to the bathroom right after meals
• Large amounts of food disappearing or unexplained empty wrappers and food containers
• Chronic sore throat
• Swelling of the salivary glands in the cheeks
• Dental decay resulting from erosion of tooth enamel by stomach acid
• Heartburn and gastroesophageal reflux
• Laxative or diet pill misuse
• Recurrent unexplained diarrhea
• Misuse of diuretics (water pills)
• Feeling dizzy or fainting from excessive purging behaviors resulting in dehydration
• Cuts and callouses on the knuckles can sometimes result from self-induced vomiting

Individuals with bulimia can be slightly underweight, normal weight or overweight. Family members or friends may not know that a person has bulimia because they do not appear underweight and because their behaviors are hidden and may go unnoticed.

Outpatient cognitive behavioral therapy is regarded as the best treatment for bulimia nervosa. It helps patients establish healthy eating behavior and manage thoughts and feelings that perpetuate the disorder. Antidepressants (e.g., fluoxetine) can also be helpful in decreasing urges to binge and vomit. Eating disorder-focused family-based treatment, which involves providing caregivers with information on how to assist an adolescent or young adult to normalize their eating pattern, may also be helpful in the treatment of young people with bulimia nervosa.

Binge eating disorder, like bulimia nervosa, involves episodes of binge eating. However, there are no compensatory behaviors to control weight, such as vomiting, fasting, exercising or laxative misuse. Binges occur once a week for three months, are associated with a sense of loss of control, and are defined by at least three of the following:

• Eating more rapidly than normal
• Eating until uncomfortably full
• Eating large amounts of food when not feeling hungry
• Eating alone because of feeling embarrassed by how much one is eating
• Feeling disgusted with oneself, depressed or very guilty after a binge

While body image concerns are not part of the diagnostic criteria, it is not uncommon for individuals with binge eating disorder to also experience excessive preoccupation with weight and shape.

Binge eating disorder can lead to serious health complications, including obesity and metabolic syndrome, which increases the risk for diabetes, hypertension and cardiovascular diseases.

Treatment of binge eating disorder is focused on normalizing eating patterns and emotional regulation. Weight loss is not a primary goal of treatment, and diets that restrict calories may make bingeing worse. Outpatient treatment is often most appropriate. The most effective treatment for binge eating disorder is cognitive behavioral therapy, individual or group-based. Interpersonal therapy has also been shown to be effective. Antidepressant medications, including lisdexamfetamine and topiramate, may also be helpful.

ARFID involves an ongoing severe pattern of avoiding foods or selective eating that results in not meeting nutritional needs. The food avoidance is generally one of three types:

1. Lack of interest in eating: Low appetite and lack of interest in eating or food.
2. Sensory-based avoidance: Avoiding foods based on sensory factors, such as texture, appearance, color, or smell.
3. Fear of consequences: Anxiety or concern about consequences of eating, such as fear of choking, nausea, vomiting, constipation, an allergic reaction, etc. The disorder may develop in response to a specific event, such as an episode of choking or food poisoning.

The diagnosis of ARFID requires one or more of the following:

• Significant weight loss (or failure to achieve expected weight gain in children).
• Significant nutritional deficiency.
• The need to rely on a feeding tube or oral nutritional supplements to maintain sufficient nutrition intake.
• Problems with social functioning (such as inability to eat with others).

The impact on physical and mental health and the degree of malnutrition can be similar to the impact of anorexia nervosa. However, people with ARFID do not have excessive concerns about their body weight or shape. Also, while individuals with autism spectrum disorder often have rigid eating behaviors and sensory sensitivities, these do not necessarily lead to the level of impairment required for a diagnosis of AFRID.

ARFID does not include food restrictions related to lack of access to food; normal dieting; cultural practices, such as religious fasting; or developmentally normal behaviors, such as toddlers who are picky eaters.

Food avoidance or restriction often develops in infancy or early childhood and may continue in adulthood. However, it can start at any age. ARFID can impact families, causing increased stress at mealtimes and in other social eating situations. It often occurs along with other conditions, including anxiety disorders, particularly panic disorders.

Treatment for ARFID involves an individualized plan and may involve several specialists, including a mental health professional, a registered dietitian nutritionist, and others. A key intervention includes reversing the negative associations with feared foods by pairing them with positive experiences. Food chaining is another method to systemically and slowly introduce new foods by making small changes from “safe foods” to new foods.

Pica is an eating disorder in which a person repeatedly eats things that are not food with no nutritional value. The behavior persists for at least one month and is severe enough to warrant clinical attention.

The substances typically ingested vary with age and availability. They may include paper, paint chips, soap, cloth, hair, string, chalk, metal, pebbles, charcoal or coal, or clay. Individuals with pica do not typically have an aversion to food in general.

The behavior is inappropriate for the individual’s developmental level and is not part of a cultural practice. Pica may first occur in childhood, adolescence, or adulthood, although childhood onset is most common. It is not diagnosed in children under age 2. Putting small objects into their mouth is a normal part of development for children under 2. Pica often occurs along with autism spectrum disorder and intellectual disability but can occur in otherwise typically developing children.

A person with pica is at risk of intestinal blockages or toxic effects of substances consumed, such as lead in paint chips.

Treatment for pica involves testing for nutritional deficiencies and addressing them if needed. Behavioral interventions may include redirecting the individual away from nonfood items and rewarding them for setting aside or avoiding them.

Rumination disorder involves the repeated regurgitation and re-chewing of food after eating where swallowed food is brought back up into the mouth voluntarily and is re-chewed and re-swallowed or spat out. Rumination disorder can occur in infancy, childhood and adolescence or in adulthood. To meet the diagnosis the behavior must:

• Occur repeatedly over at least a 1-month period
• Not be due to a gastrointestinal or medical problem
• Not occur as part of one of the other eating disorders listed above

This diagnostic category includes eating disorders or disturbances of eating behavior that cause distress and impair family, social or work function but do not fit the other categories listed here. In some cases, this is because the frequency of the behavior does not meet the diagnostic threshold (e.g., the frequency of binges in bulimia or binge eating disorder) or the weight criteria for the diagnosis of anorexia nervosa are not met.

An example of other specified feeding and eating disorder is "atypical anorexia nervosa". This category includes individuals who may have lost a lot of weight and whose behaviors and preoccupation with weight or shape concerns and fear of fatness is consistent with anorexia nervosa, but who are not yet considered underweight based on their BMI because their baseline weight was above average.

Since speed of weight loss is related to medical complications, individuals with atypical anorexia nervosa who lose a lot of weight rapidly by engaging in extreme weight control behaviors can be at high risk of medical complications, despite appearing normal or above average weight.

Physician Review

Jean Wu, M.D.
Psychiatry resident Physcian at VCU Health

January 2026

 

Angela Guarda, M.D.
Professor of PSychiatry and Behavioral Sciences
Director, Johns Hopkins Eating Disorders Program
The Johns Hopkins University

February 2023