# Eating disorder

An eating disorder is a mental disorder defined by abnormal eating habits that negatively affect a person's physical or mental health. They include binge eating disorder where people eat a large amount in a short period of time, anorexia nervosa where people eat very little and thus have a low body weight, bulimia nervosa where people eat a lot and then try to rid themselves of the food, pica where people eat non-food items, rumination disorder where people regurgitate food, avoidant/restrictive food intake disorder where people have a lack of interest in food, and a group of other specified feeding or eating disorders.
Arranged alphabetically by author or source: A · B · C · D · E · F · G · H · I · J · K · L · M · N · O · P · Q · R · S · T · U · V · W · X · Y · Z · See also · External links

## A

* Because eating disorders (EDs) and obsessive compulsive disorder (OCD) co-occur at high rates and can have functionally similar clinical presentations, it has been suggested that both constructs might be part of a common spectrum of disorders. Identifying the relationship between EDs and OCD may lead to the discovery of important shared core disease processes and/or mechanisms for maintenance. The objective of this paper is to understand the relationship between EDs and OCD by systematically reviewing epidemiological, longitudinal and family studies guided by five models of comorbidity posited by Klein and Riso (1993) and others. Though this literature is relatively small, the preponderance of evidence from these studies largely suggests that OCD/ED co-occur because of a shared etiological relationship.
** Altman SE, Shankman SA, "What is the association between obsessive-compulsive disorder and eating disorders?", Clin Psychol Rev. 2009 Nov;29(7):638-46. doi: 10.1016/j.cpr.2009.08.001.
* There is a commonly held view that eating disorders are a lifestyle choice. Eating disorders are actually serious and often fatal illnesses that cause severe disturbances to a person’s eating behaviors. Obsessions with food, body weight, and shape may also signal an eating disorder.
** American Psychiatry Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington: American Psychiatric Publishing. pp. 329–354. ISBN 978-0-89042-555-8.
* Eating disorders frequently appear during the teen years or young adulthood but may also develop during childhood or later in life. These disorders affect both genders, although rates among women are higher than among men. Like women who have eating disorders, men also have a distorted sense of body image. For example, men may have muscle dysmorphia, a type of disorder marked by an extreme concern with becoming more muscular.
** American Psychiatry Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington: American Psychiatric Publishing. pp. 329–354. ISBN 978-0-89042-555-8.
* The results of this study confirm our hypothesis that women with eating disorders show high levels of obsessive-compulsive personality traits in childhood, relative to healthy comparison subjects. There was a strong increasing relationship between the number of reported childhood traits and the odds of developing an eating disorder, with each extra reported trait increasing the odds of developing an eating disorder nearly sevenfold. We also confirmed our subsidiary hypothesis of developmental continuity in that the presence of childhood perfectionism and rigidity identified a subgroup of people with eating disorders with a significantly higher prevalence of obsessive-compulsive personality disorder later in life.
** Anderluh, MB; Tchanturia, K; Rabe-Hesketh, S; Treasure, J (2003). "Childhood obsessive-compulsive personality traits in adult women with eating disorders: defining a broader eating disorder phenotype". The American Journal of Psychiatry. 160(2): 242–7. doi:10.1176/appi.ajp.160.2.242. PMID 12562569.
* Our results confirm and extend findings from previous studies. Fairburn et al. assessed perfectionism in childhood with a single item (high personal standards) and identified it as a risk factor for anorexia and bulimia in eating disorder patients, compared with healthy subjects (odds ratio=3.9, 95% CI=2.1–7.4, and odds ratio=2.6, 95% CI=1.5–4.6, respectively). The instrument we developed retrospectively examined a broader spectrum of obsessive-compulsive personality traits, including perfectionism, by using a range of behavioral examples. Approximately two-thirds of the subjects with anorexia nervosa reported perfectionism and rigidity in childhood. This prevalence is consistent with that reported by Rastam (22) for premorbid obsessive-compulsive (or anankastic) personality disorder in anorexia nervosa. We are not aware of any similar studies conducted for patients with bulimia nervosa. However, previous findings that perfectionism, obsessionality, excessive concern about mistakes, and doubt about actions persist after recovery from both disorders suggest that they represent persistent traits (10, 13, 16).
** Anderluh, MB; Tchanturia, K; Rabe-Hesketh, S; Treasure, J (2003). "Childhood obsessive-compulsive personality traits in adult women with eating disorders: defining a broader eating disorder phenotype". The American Journal of Psychiatry. 160(2): 242–7. doi:10.1176/appi.ajp.160.2.242. PMID 12562569.
* The findings suggest that childhood obsessive-compulsive personality traits are important risk factors for later development of eating disorders, particularly anorexia nervosa. Furthermore, the findings suggest that childhood perfectionism and rigidity may offer a more specific and homogenous phenotypic determination for genetic studies. Further studies are needed to determine whether these traits are specific for eating disorders or are also linked to other psychiatric disorders, such as depression or OCD. Personality traits may also act as maintaining factors and as such may have an important influence on the prognosis of the disorder. Studies of people who have recovered from an eating disorder would be needed to explore the influence of childhood obsessive-compulsive-personality traits on the length of illness and its severity. Female subjects were included in this study because the prevalence of eating disorders is approximately nine times higher in women than in men. However, further studies that include male subjects are needed to better understand the role of the assessed traits. To our knowledge, the interview scale described here is the first to measure these personality trait risk factors in a broad and comprehensive way. The finding that perfectionism and rigidity represent strong risk factors suggests that these items might also be also used to identify people at high risk for developing an eating disorder later in life. Prospective studies are needed to replicate these findings.
** Anderluh, MB; Tchanturia, K; Rabe-Hesketh, S; Treasure, J (2003). "Childhood obsessive-compulsive personality traits in adult women with eating disorders: defining a broader eating disorder phenotype". The American Journal of Psychiatry. 160(2): 242–7. doi:10.1176/appi.ajp.160.2.242. PMID 12562569.
* Dancers, in general, had a higher risk of suffering from eating disorders in general, anorexia nervosa and EDNOS, but no higher risk of suffering from bulimia nervosa. The study concluded that as dancers had a three times higher risk of suffering from eating disorders, particularly anorexia nervosa and EDNOS, speciﬁcally designed services for this population should be considered
** Arcelus, J; Witcomb, GL; Mitchell, A (March 2014). "Prevalence of eating disorders amongst dancers: a systemic review and meta-analysis". European Eating Disorders Review. 22 (2): 92–101. doi:10.1002/erv.2271. PMID 24277724.
* At follow-up in girls, 3.6% (15 of 422) in control schools compared with 1.2% (4 of 327) in intervention schools reported engaging in disordered weight-control behaviors (P = .04). Multivariate analyses indicated that the odds of these behaviors in girls in intervention schools were reduced by two thirds compared with girls in control schools (odds ratio, 0.33; 95% confidence interval, 0.11-0.97). No intervention effect was observed in boys.
** Austin SB, Kim J, Wiecha J, Troped PJ, Feldman HA, Peterson KE, “School-based overweight preventive intervention lowers incidence of disordered weight-control behaviors in early adolescent girls.“, Arch Pediatr Adolesc Med. 2007 Sep;161(9):865-9.
* Results add compelling support for the effectiveness of an interdisciplinary, school-based obesity prevention intervention to prevent disordered weight-control behaviors in early adolescent girls.
** Austin SB, Kim J, Wiecha J, Troped PJ, Feldman HA, Peterson KE, “School-based overweight preventive intervention lowers incidence of disordered weight-control behaviors in early adolescent girls.“, Arch Pediatr Adolesc Med. 2007 Sep;161(9):865-9.

## B

* This review first identifies diseases with which eating disorders are often confused and then explores features in the history, physical examination, and laboratory studies, which can provide clues to the cause of the patient's symptoms. In addition, it discusses the recommended evaluation and treatments for the gastrointestinal diseases that most commonly mimic the presentation of eating disorders including Crohn disease (CrD), celiac disease, gastroesophageal reflux disease (GERD), and eosinophilic esophagitis (EoE).
** Bern EM, O'Brien RF (Aug 2013). "Is it an eating disorder, gastrointestinal disorder, or both?". Curr Opin Pediatr (Review). 25 (4): 463–70. doi:10.1097/MOP.0b013e328362d1ad. PMID 23838835
* The ubiquitous nature of the gastrointestinal complaints requires the clinician to consider a broad differential diagnosis when evaluating a patient for an eating disorder.
** Bern EM, O'Brien RF (Aug 2013). "Is it an eating disorder, gastrointestinal disorder, or both?". Curr Opin Pediatr (Review). 25 (4): 463–70. doi:10.1097/MOP.0b013e328362d1ad. PMID 23838835
* ADHD girls were 3.6 times more likely to meet criteria for an eating disorder throughout the follow-up period compared to control females. Girls with eating disorders had significantly higher rates of major depression, anxiety disorders, and disruptive behavior disorder compared to ADHD girls without eating disorders. Girls with ADHD and eating disorders had a significantly earlier mean age at menarche than other ADHD girls. No other differences in correlates of ADHD were detected between ADHD girls with and without eating disorders.
** Biederman, J; Ball, SW; Monuteaux, MC; Surman, CB; Johnson, JL; Zeitlin, S (2007). "Are girls with ADHD at risk for eating disorders? Results from a controlled, five-year prospective study". Journal of Developmental and Behavioral Pediatrics: JDBP. 28(4): 302–7. doi:10.1097/DBP.0b013e3180327917. PMID 17700082.
* Social cognitive theory would warn that the high prevalence of interaction opportunities in the pro–eating disorder community has the potential to be extremely harmful if viewers are learning dangerous behaviors from one another, particularly if they are similar in age and gender. Other studies suggest that discussing techniques and perceived benefits may also have contagious effects on those not yet committed to the behaviors.5 The disclaimers included on pro–eating disorder Web sites may warn unsuspecting readers away from distressing content but also may entice vulnerable individuals to read further. Although there is no evidence as to the impact of warnings or disclaimers on pro–eating disorder sites, research on other media such as movies and video games with adult ratings suggests that labels might entice young viewers to want to see media that are not appropriate for them. Behavioral and communication theories, such as the social cognitive and cultivation theories mentioned earlier,8,9 would also suggest that the most deleterious components of these sites are the evocative images depicted coupled with constant social support encouraging extreme behaviors. On these Web sites, striving to be underweight is deemed not only as normative but as a signal of success. Only 13% of site maintainers offered an overt statement indicating that their own eating disorder was a problem. In addition, the Internet's easy accessibility allows users to tap into a site's features at any time of day or night. Social interaction is the most common reason young people use the Internet. This may be particularly relevant to the eating disorder online community, as research shows that individuals suffering from eating disorders have difficulty relating with same-age peers, attempt to hide their eating disorder behaviors, and often experience shame and isolation. Online venues for interaction with friends or strangers may seem like a safer and even appropriate place to disclose personal information. Furthermore, the Internet allows one to not only maintain relative anonymity but also easily retreat from criticism or uncomfortable situations.
** Borzekowski, D; Schenk, S; Wilson, J; Peebles, R (2010). "E-Ana and e-mia: A content analysis of pro-eating disorder web sites". American Journal of Public Health. 100 (8): 1526–1534. doi:10.2105/AJPH.2009.172700. PMC 2901299. PMID 20558807.
* The Structured Clinical Interview for DSM-III-R (SCID and SCID II) was administered to 105 eating disorder in-patients in order to examine rates of comorbid psychiatric disorders and the chronological sequence in which these disorders developed. Eighty-six patients, 81.9% of the sample, had Axis I diagnoses in addition to their eating disorder. Depression, anxiety and substance dependence were the most common comorbid diagnoses. Anorexic restrictors were significantly more likely than bulimics (all subtypes) to develop their eating disorder before other Axis I comorbid conditions. Personality disorders were common among the subjects; 69% met criteria for at least one personality disorder diagnosis. Of the 72 patients with personality disorders, 93% also had Axis I comorbidity. Patients with at least one personality disorder were significantly more likely to have an affective disorder or substance dependence than those with no personality disorder.
** Braun, DL; Sunday, SR; Halmi, KA (1994). "Psychiatric comorbidity in patients with eating disorders". Psychological Medicine. 24 (4): 859–67. doi:10.1017/S0033291700028956. PMID 7892354.
* Alcohol use disorders were significantly more prevalent in women with ANBN and bulimia nervosa than in women with anorexia nervosa (p =.0001). The majority of individuals reported primary onset of the eating disorder, with only one third reporting the onset of the AUD first. After eating disorder subtype was controlled for, AUDs were associated with the presence of major depressive disorder, a range of anxiety disorders, and cluster B personality disorder symptoms. In addition, individuals with AUDs presented with personality profiles marked by impulsivity and perfectionism.
** Bulik, CM; Klump, KL; Thornton, L; Kaplan, AS; Devlin, B (2004). "Alcohol use disorder comorbidity in eating disorders: a multicenter study". The Journal of Clinical Psychiatry. 65 (7): 1000–6. doi:10.4088/JCP.v65n0718. PMID 15291691.
* Individuals with eating disorders and AUDs exhibit phenotypic profiles characterized by both anxious, perfectionistic traits and impulsive, dramatic dispositions. These traits mirror the pattern of control and dyscontrol seen in individuals with this comorbid profile and suggest that anxiety modulation may be related to alcohol use in this group.
** Bulik, CM; Klump, KL; Thornton, L; Kaplan, AS; Devlin, B (2004). "Alcohol use disorder comorbidity in eating disorders: a multicenter study". The Journal of Clinical Psychiatry. 65 (7): 1000–6. doi:10.4088/JCP.v65n0718. PMID 15291691.
* Eating disorders and alcohol use disorders (AUDs) commonly co-occur, although the patterns of comorbidity differ by eating disorder subtype. Our aim was to explore the nature of the co-morbid relation between AUDs and eating disorders in a large and phenotypically well-characterized group of individuals.
** Bulik CM, Klump KL, Thornton L, Kaplan AS, Devlin B, Fichter MM, Halmi KA, Strober M, Woodside DB, Crow S, Mitchell JE, Rotondo A, Mauri M, Cassano GB, Keel PK, Berrettini WH, Kaye WH, “Alcohol use disorder comorbidity in eating disorders: a multicenter study.”, J Clin Psychiatry, 2004 Jul;65(7):1000-6.
* Alcohol use disorders were significantly more prevalent in women with ANBN and bulimia nervosa than in women with anorexia nervosa (p =.0001). The majority of individuals reported primary onset of the eating disorder, with only one third reporting the onset of the AUD first. After eating disorder subtype was controlled for, AUDs were associated with the presence of major depressive disorder, a range of anxiety disorders, and cluster B personality disorder symptoms. In addition, individuals with AUDs presented with personality profiles marked by impulsivity and perfectionism.
** Bulik CM, Klump KL, Thornton L, Kaplan AS, Devlin B, Fichter MM, Halmi KA, Strober M, Woodside DB, Crow S, Mitchell JE, Rotondo A, Mauri M, Cassano GB, Keel PK, Berrettini WH, Kaye WH, “Alcohol use disorder comorbidity in eating disorders: a multicenter study.”, J Clin Psychiatry, 2004 Jul;65(7):1000-6.
* Individuals with eating disorders and AUDs exhibit phenotypic profiles characterized by both anxious, perfectionistic traits and impulsive, dramatic dispositions. These traits mirror the pattern of control and dyscontrol seen in individuals with this comorbid profile and suggest that anxiety modulation may be related to alcohol use in this group.
** Bulik CM, Klump KL, Thornton L, Kaplan AS, Devlin B, Fichter MM, Halmi KA, Strober M, Woodside DB, Crow S, Mitchell JE, Rotondo A, Mauri M, Cassano GB, Keel PK, Berrettini WH, Kaye WH, “Alcohol use disorder comorbidity in eating disorders: a multicenter study.”, J Clin Psychiatry, 2004 Jul;65(7):1000-6.
* In a large study of psychiatric outpatients, their eating disorders were mainly classed as "not otherwise specified" (NOS) — rather than as bulimia, anorexia, or binge eating — and most patients failed to meet the full diagnostic criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition ( DSM-IV). This suggests that DSM-IV diagnostic thresholds for eating disorders are too restrictive, the researchers, led by Mark Zimmerman, MD, from Brown University School of Medicine, in Providence, Rhode Island, write. Dr. Zimmerman told Medscape that their findings "strongly suggest that there are problems with the diagnostic criteria in the DSM category for eating disorders, because most individuals with an eating disorder don't meet the formal diagnostic criteria." He added that this contrasts with other categories of diagnosis — such as anxiety, personality, and depressive disorders — where "the overwhelming majority" of individuals meet the formal diagnostic criteria. "The conclusion is that there are significant problems with the eating-disorder diagnostic category in the DSM," he said.
** Busko, Marlene. "DSM-IV Diagnostic Criteria for Eating Disorders May Be Too Stringent". Medscape. Archived from the original on 2012-05-13.

## C

* Personality traits have been implicated in the onset, symptomatic expression, and maintenance of eating disorders (EDs). The present article reviews literature examining the link between personality and EDs published within the past decade, and presents a meta-analysis evaluating the prevalence of personality disorders (PDs) in anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED) as assessed by self-report instruments versus diagnostic interviews. AN and BN are both consistently characterized by perfectionism, obsessive-compulsiveness, neuroticism, negative emotionality, harm avoidance, low self-directedness, low cooperativeness, and traits associated with avoidant PD. Consistent differences that emerge between ED groups are high constraint and persistence and low novelty seeking in AN and high impulsivity, sensation seeking, novelty seeking, and traits associated with borderline PD in BN. The meta-analysis, which found PD rates of 0 to 58% among individuals with AN and BN, documented that self-report instruments greatly overestimate the prevalence of every PD.
** Cassin SE, von Ranson KM, "Personality and eating disorders: a decade in review.", Clin Psychol Rev. 2005 Nov;25(7):895-916.
* BN and BED are associated with childhood abuse, whereas AN shows mixed results. Individuals with similar trauma should be monitored for early recognition of EDs.
** Caslini, M; Bartoli, F; Crocamo, C; Dakanalis, A; Clerici, M; Carrà, G (January 2016). "Disentangling the Association Between Child Abuse and Eating Disorders: A Systematic Review and Meta-Analysis". Psychosomatic Medicine. 78 (1): 79–90. doi:10.1097/psy.0000000000000233. PMID 26461853.
* Both depressive disorders and eating disorders are multidimensional and heterogeneous disorders. This paper examines the nature of their relationship by reviewing clinical descriptive, family-genetic, treatment, and biological studies that relate to the issue. The studies confirm the prominence of depressive symptoms and depressive disorders in eating disorders. Other psychiatric syndromes which occur with less frequency, such as anxiety disorders and obsessive-compulsive disorders in anorexia nervosa, or personality disorders, anxiety disorders, and substance abuse in bulimia nervosa, also play an important role in the development and maintenance of eating disorders. Since few studies have controlled for starvation-induced physical, endocrine, or psychological changes which mimic the symptoms considered diagnostic for depression, further research will be needed. The evidence for a shared etiology is not compelling for anorexia nervosa and is at most suggestive for bulimia nervosa. Since in contemporary cases dieting-induced weight loss is the principal trigger, women with self-critical or depressive features will be disproportionately recruited into eating disorders. The model that fits the data best would accommodate a relationship between eating disorders and the full spectrum of depressive disorders from no depression to severe depression, with somewhat higher rates of depression in bulimic anorectic and bulimia nervosa patients than in restricting anorexia nervosa patients, but the model would admit a specific pathophysiology and psychopathology in each eating disorder.
** Casper, Regina C (1998). "Depression and eating disorders". Depression and Anxiety. 8 (Suppl 1): 96–104. doi:10.1002/(SICI)1520-6394(1998)8:1+<96::AID-DA15>3.0.CO;2-4. PMID 9809221. https://www.ncbi.nlm.nih.gov/pubmed/9809221

## D

* The Stroop task has been adapted from cognitive psychology to be able to examine attentional biases in various forms of psychopathology, including the eating disorders. This paper reviews the research on the Stroop task in the eating disorders research area in both descriptive and meta-analytic fashions. Twenty-eight empirical studies are identified, which predominantly examine food and body/weight stimuli in bulimic, anorexic, or dieting/food-restricted samples. It is concluded that there is evidence of an attentional bias in bulimia for a range of stimuli but that the effect seems to be limited to body/weight stimuli in anorexia. The evidence to date is that there is no attentional bias in dieting samples.
** Dobson KS1, Dozois DJ; "Attentional biases in eating disorders: a meta-analytic review of Stroop performance", Clin Psychol Rev. 2004 Jan;23(8):1001-22.

## E

* Dieting is common among adolescent girls and may place them at risk of using unhealthy weight-control behaviors (UWCBs), such as self-induced vomiting, laxatives, diet pills, or fasting. Research has suggested that social factors, including friends and broader cultural norms, may be associated with UWCBs. The present study examines the relationship between the school-wide prevalence of current weight loss efforts among adolescent girls, friends' dieting behavior, and UWCBs, and investigates differences in these associations across weight categories. Survey data were collected in 31 middle and high schools in ethnically and socio-economically diverse communities in Minnesota, USA. The response rate was 81.5%. Rates of UWCBs were compared across the spectrum of prevalence of trying to lose weight and friends' involvement with dieting, using chi(2) analysis and multivariate logistic regression, controlling for demographic factors and clustering by school. Girls with higher body mass index (BMI) were more likely to engage in UWCBs than those of lower BMI. Multivariate models indicated that friends' dieting behavior was significantly associated with UWCBs for average weight girls (OR = 1.57, CI = 1.40-1.77) and moderately overweight girls (OR = 1.47, CI = 1.19-1.82). The school-wide prevalence of trying to lose weight was significantly, albeit modestly, related to UWCBs for average weight girls (15th-85th percentile; OR = 1.17, CI = 1.01-1.36), and marginally associated for modestly overweight girls (85th-95th percentile; OR = 1.21, CI = .97-1.50), even after controlling for friends' dieting behaviors. The social influences examined here were not associated with UWCBs among underweight ( < 15th percentile) or overweight ( > 95th percentile) girls. Findings suggest that social norms, particularly from within one's peer group, but also at the larger school level may influence UWCBs, particularly for average weight girls. Implications for school-based interventions to reduce UWCBs are discussed.
** Eisenberg, ME; Neumark-Sztainer, D; Story, M; Perry, C (2005). "The role of social norms and friends' influences on unhealthy weight-control behaviors among adolescent girls". Social Science & Medicine. 60 (6): 1165–73. doi:10.1016/j.socscimed.2004.06.055. PMID 15626514.
* The similarities between the mentalities of anorexia nervosa, bulimia, and sexual repression among young women are undeniable. Young women starve their bodies until they can no longer resist both physical and sexual hungers. But the guilt associated with indulging becomes overwhelming and purging and punishment ensues. Both biological and sexual hungers are natural. However the messages sent to young women by their culture are that neither of these hungers are normal and, in fact, are immoral and inexcusable.
** Essick, Ellen (2006). "Eating Disorders and Sexuality". In Steinberg, Shirley R.; Parmar, Priya; Richard, Birgit. Contemporary Youth Culture: An International Encyclopedia. Greenwood. p.276

## F

* Among the whole sample, the factor most strongly associated with suicide attempt or suicidal ideation was the diagnostic category, with the highest odds ratio for bulimia nervosa followed by anorexia nervosa of the binging/purging subtype. Among diagnostic subgroups, the strongest factors were drug use, alcohol use, and tobacco use.
** Fedorowicz VJ, Falissard B, Foulon C, Dardennes R, Divac SM, Guelfi JD, Rouillon F., "Factors associated with suicidal behaviors in a large French sample of inpatients with eating disorders." Int J Eat Disord. 2007 Nov;40(7):589-95.
* Parental influence has been shown to be an intrinsic component in the development of eating behaviors of children. This influence is manifested and shaped by a variety of diverse factors such as familial genetic predisposition, dietary choices as dictated by cultural or ethnic preferences, the parents' own body shape and eating patterns, the degree of involvement and expectations of their children's eating behavior as well as the interpersonal relationship of parent and child. This is in addition to the general psychosocial climate of the home and the presence or absence of a nurturing stable environment. It has been shown that maladaptive parental behavior has an important role in the development of eating disorders.
** Fox, John (July 2009). "Eating Disorders and Emotions". Clinical Psychology & Psychotherapy. 16 (237–239): 237–239. doi:10.1002/cpp.625. PMID 19639648.
* Adams and Crane (1980), have shown that parents are influenced by stereotypes that influence their perception of their child's body. The conveyance of these negative stereotypes also affects the child's own body image and satisfaction. Hilde Bruch, a pioneer in the field of studying eating disorders, asserts that anorexia nervosa often occurs in girls who are high achievers, obedient, and always trying to please their parents. Their parents have a tendency to be over-controlling and fail to encourage the expression of emotions, inhibiting daughters from accepting their own feelings and desires. Adolescent females in these overbearing families lack the ability to be independent from their families, yet realize the need to, often resulting in rebellion. Controlling their food intake may make them feel better, as it provides them with a sense of control.
** Fox, John (July 2009). "Eating Disorders and Emotions". Clinical Psychology & Psychotherapy. 16 (237–239): 237–239. doi:10.1002/cpp.625. PMID 19639648.
* Body dissatisfaction, disordered eating and depression differentially affect adolescent girls (compared to boys); however, these variables have not been examined in relation to ethnicity. A review of the literature finds that Black adolescent girls are more satisfied with their bodies than White adolescent girls and engage much less frequently in dieting or disordered eating than do White girls in the US. A central question raised by this review is whether body dissatisfaction and pubertal timing are as relevant to our understanding of the etiology of depression in Black girls as they appear to be in White girls. Based on the available data, it does not seem that a risk factor model supporting the role of early pubertal timing, weight increases and body dissatisfaction in the development of depression applies to Black adolescent girls. This review underscores the need for future research with a variety of ethnic minority groups to better understand the etiology of adolescent depression.
** Franko DL, Striegel-Moore RH, “The role of body dissatisfaction as a risk factor for depression in adolescent girls: are the differences Black and White?”, J Psychosom Res. 2002 Nov;53(5):975-83.
* Suicide is the third most frequent cause of death among teenagers and young adults. Reviews and meta-analyses have shown that suicidal behaviour is more frequent among people with eating disorders than in the general population. The course of illness and the follow up period is of great importance for the correct evaluation of suicidality in this class of patients.5 Suicide may occur not only in the late phases of the illness but in periods of symptomatic remission. Franko et al assessed suicidality every 6–12 months over 8.6 years. This is a most important and innovative contribution to the international literature. This approach should be implemented in everyday clinical practice, as it provides a greater opportunity to predict and prevent suicidal behaviour. However, such an approach may work only with certain resources and with increased staff motivation. We agree with the scales employed by the authors; however scales specifically designed for suicide risk assessment should be used in future studies. The evaluation of suicidality using tools that aim to recognise the possibility of committing suicide may contribute to the definition of a suicidal spectrum among people with eating disorders. Franko et al’s results are also very interesting as they found that suicide attempts were more frequent among people with anorexia than among people with bulimia. This finding may have implications for clinical practice, both for treatment and for seeking confirmation of this evidence. The generalisability of Franko et al’s results will depend on further longitudinal studies with similar features. One of the authors’ aims was to identify predictors of suicide and suicide attempts. This should also be the aim of all mental health professionals involved in the treatment of people with eating disorders. However, future studies would benefit from a careful consideration of the diagnostic tools used, the evaluation of suicide risk and the recognition of comorbid Axis I disorders or personality disorders that may increase suicide risk dramatically.
** Franko, DL; Keel, PK; Dorer, DJ; Blais, MA; Delinsky, SS (2004). "What predicts suicide attempts in women with eating disorders?". Psychological Medicine. 34 (5): 843–53.
* Disturbances of volume-regulating mechanisms have already been implicated in the pathophysiology of eating disorders like anorexia or bulimia nervosa with the peptide hormones vasopressin and atrial natriuretic peptide (ANP) being of special interest. Aim of the present study was to investigate, whether the expression of the corresponding genes was altered and if so, if these changes could be explained by epigenetic mechanisms such as DNA methylation. We analyzed blood samples of 46 women suffering from anorexia (n=22) or bulimia nervosa (n=24) as well as of 30 healthy controls. Peripheral mRNA expression and DNA methylation of the vasopressin and the ANP precursor genes were assessed using real-time PCR. We found significantly lower levels of ANP mRNA in patients with eating disorders. This downregulation was accompanied by a hypermethylation of the ANP gene promoter in the bulimic subgroup. We did not find differences regarding expression or methylation of the vasopressin gene. ANP mRNA expression was inversely associated with impaired impulse regulation. We conclude that epigenetic mechanisms may contribute to the known alterations of ANP homeostasis in women with eating disorders.
** Frieling H1, Bleich S, Otten J, Römer KD, Kornhuber J, de Zwaan M, Jacoby GE, Wilhelm J, Hillemacher T., “Epigenetic downregulation of atrial natriuretic peptide but not vasopressin mRNA expression in females with eating disorders is related to impulsivity.” Neuropsychopharmacology. 2008 Oct;33(11):2605-9. doi: 10.1038/sj.npp.1301662. Epub 2008 Jan 2.
* The pathophysiology of eating disorders such as anorexia nervosa (AN) and bulimia nervosa (BN) has been linked to an impaired dopaminergic neurotransmission, still the origin of this disturbance remains unknown. The aim of the present study was, therefore, to evaluate whether the expression of dopaminergic genes is altered in the blood of patients suffering from eating disorders and if these alterations can be explained by changes in the promoter specific DNA methylation of the genes.
** Frieling, H; Römer, KD; Scholz, S; Mittelbach, F; Wilhelm, J; De Zwaan, M; Jacoby, GE; Kornhuber, J; Hillemacher, T; Bleich, S (2010). "Epigenetic dysregulation of dopaminergic genes in eating disorders". The International Journal of Eating Disorders. 43 (7): 577–83. doi:10.1002/eat.20745. PMID 19728374.
* Our study shows a disturbed expression of dopaminergic genes that is accompanied by a dysregulation of the epigenetic DNA methylation. Further studies are necessary to provide more insight into the epigenetic dysregulation of the dopaminergic neurotransmission in the pathophysiology of eating disorders.
** Frieling, H; Römer, KD; Scholz, S; Mittelbach, F; Wilhelm, J; De Zwaan, M; Jacoby, GE; Kornhuber, J; Hillemacher, T; Bleich, S (2010). "Epigenetic dysregulation of dopaminergic genes in eating disorders". The International Journal of Eating Disorders. 43 (7): 577–83. doi:10.1002/eat.20745. PMID 19728374.

## G

* There is no one sign of an eating disorder, however there are red flags. These can include excessive “fat, weight or calorie talk,” a pattern of eating a limited choice of low-calorie food or a pattern of occasional binge eating of calorie-dense foods. People with anorexia nervosa may excessively exercise or excessively stand, pace or fidget. Affected individuals may severely limit the amount of calories they consume or may avoid weight gain following meals by inducing vomiting or abusing laxative, diuretic and diet pills. Feeling self-conscious about one’s eating behavior is common. Affected individuals often avoid social eating settings and eat alone.
** Angela Guarda, M.D. "Eating Disorders". American Psychiatric Association. Archived from the original on 21 December 2014. Retrieved 4 December 2014.
* There is no single cause of an eating disorder. We know that genetics play a large role, but genetic vulnerability is only part of the story. Environment plays a role too, especially in triggering onset, which often occurs in adolescence. Pressure to diet or weight loss related to a medical condition can be the gateway to anorexia nervosa or bulimia. For those who are genetically vulnerable to anorexia nervosa, once they lose the first five to 10 lbs, dieting becomes increasingly compelling and rewarding. Looked at another way, if eating disorders were the result solely of social pressure for thinness we would expect eating disorder rates to have increased as obesity has in the past few decades, yet anorexia nervosa and bulimia remain relatively rare and often cluster in families.
** Angela Guarda, M.D. "Eating Disorders". American Psychiatric Association. Archived from the original on 21 December 2014. Retrieved 4 December 2014.
* Treatment for an eating disorder is challenging. It involves interrupting behaviors that have become driven and compelling. Recovery takes a team, which includes family, friends and other social supports, as well as medical and mental health professionals. Be empathic, but clear. List signs or behaviors you have noticed and are concerned about. Help locate a treatment provider and offer to go with your friend or relative to an evaluation. Be prepared that the affected individual may be uncertain about seeking treatment. Treatment is effective, many are able to achieve full recovery and the vast majority will improve with expert care. Treatment assists affected individuals to change what they do. It helps them normalize their eating and reframe the irrational thoughts that sustain eating disordered behaviors. Food is central to many social activities and the practice of eating meals with supportive friends and family is an important step in recovery.
** Angela Guarda, M.D. "Eating Disorders". American Psychiatric Association. Archived from the original on 21 December 2014. Retrieved 4 December 2014.
* Eating disorders do not discriminate and can affect anyone. Although they are most common in young women, it is not unusual for older women to have an eating disorder. Some have had one all their life, others were only mildly affected until some life event triggers clinical worsening – a stressor, physical illness or a co-occurring psychiatric illness, such as depression or anxiety. Recent evidence strongly suggests that anxiety disorders, especially social anxiety disorder, and obsessive compulsive personality traits increase individual vulnerability to an eating disorder. Eating disorders occur in men too. An estimated 10 percent of people with anorexia nervosa and bulimia and a third or more of people with binge eating disorder are male. More
** Angela Guarda, M.D. "Eating Disorders". American Psychiatric Association. Archived from the original on 21 December 2014. Retrieved 4 December 2014.

## H

* Eating disorders have morbidity and mortality rates that are among the highest of any mental disorders and are associated with significant functional impairment. This article provides an up-to-date review on recent developments and expanding knowledge in adolescent anorexia nervosa, bulimia nervosa, and related disorders. It covers diagnoses and assessment, recognition of typical symptoms, medical and psychiatric comorbidities, and current trends in epidemiology.
** Herpertz-Dahlmann B, “Adolescent eating disorders: definitions, symptomatology, epidemiology and comorbidity”, Child Adolesc Psychiatr Clin N Am. 2009 Jan;18(1):31-47. doi: 10.1016/j.chc.2008.07.005.

## J

* A wide range of childhood adversities were associated with elevated risk for eating disorders and problems with eating or weight during adolescence and early adulthood after the effects of age, childhood eating problems, difficult childhood temperament, parental psychopathology, and co-occurring childhood adversities were controlled statistically. Numerous unique associations were found between specific childhood adversities and specific types of problems with eating or weight, and different patterns of association were obtained among the male and female subjects. Maladaptive paternal behavior was uniquely associated with risk for eating disorders in offspring after the effects of maladaptive maternal behavior, childhood maltreatment, and other co-occurring childhood adversities were controlled statistically. Childhood adversities may contribute to greater risk for the development of eating disorders and problems with eating and weight that persist into early adulthood. Maladaptive paternal behavior may play a particularly important role in the development of eating disorders in offspring.
** Johnson, JG; Cohen, P; Kasen, S; Brook, JS (2002). "Childhood adversities associated with risk for eating disorders or weight problems during adolescence or early adulthood", The American Journal of Psychiatry. 159 (3): 394–400. doi:10.1176/appi.ajp.159.3.394. PMID 11870002.
* Three core beliefs were found to moderate the relationship between paternal rejection and aspects of eating psychopathology. The predictive validity of paternal rejection on aspects of eating symptomatology was found to decrease as dysfunctional core beliefs increased. When levels of social isolation, vulnerability to harm, and self-sacrifice core beliefs were high, recalled parental relationships were no longer relevant to current eating psychopathology. The findings provide further evidence that core beliefs are important factors in eating disorder psychopathology and may be clinically useful in identifying targets for treatment.
** Jones, C; Harris, G; Leung, N (2005). "Parental rearing behaviours and eating disorders: the moderating role of core beliefs". Eating Behaviors. 6 (4): 355–64. doi:10.1016/j.eatbeh.2005.05.002. PMID 16257809.
* Osteoporosis has been reported in anorexia nervosa (AN), but not in other eating disorders. Thirty-three patients, 8 AN, 17 bulimia nervosa (BN), and 8 eating disorder not otherwise specified (EDNOS), were evaluated by bone densitometry (radius, spine, femur) to determine the prevalence and distribution of osteoporosis and the role of physical parameters, exercise and estrogen. All three diagnostic subgroups had evidence of decreased bone density, worst in the EDNOS subgroup and least in the BN subgroup. The most affected site was the femur, least the spine; the radius was intermediate. Age, body surface area, age of onset, and length of illness weakly correlated with the femur and spine density in the BN and EDNOS subgroups. Exercise was related to bone density in the AN subgroup in the femur, moderate exercise having a protective effect and strenuous exercise being detrimental. No significant correlation of bone density measurements with estradiol levels and/or history of amenorrhea was identified. Eating disorder patients are at risk for osteoporosis, which has multiple contributing factors including physical parameters and exercise. Estrogen deficiency by itself may not be a major causative factor.
** Joyce, JM; Warren, DL; Humphries, LL; Smith, AJ; Coon, JS (1990), "Osteoporosis in women with eating disorders: comparison of physical parameters, exercise, and menstrual status with SPA and DPA evaluation", Journal of Nuclear Medicine. 31 (3): p. 325.

## K

* About 60% of eating disorder cases are attributable to biological and genetic components. Other cases are due to external reasons or developmental problems.
** Kadison, Richard (2004). College of the Overwhelmed: The Campus Mental Health Crisis and What to Do About It. San Francisco: Jossey-Bass. p. 132. ISBN 9780787981143.
* Anxiety disorders commonly had their onset in childhood before the onset of an eating disorder, supporting the possibility they are a vulnerability factor for developing anorexia nervosa or bulimia nervosa.
* Kaye, WH; Bulik, CM; Thornton, L; Barbarich, N; Masters, K (2004). "Comorbidity of anxiety disorders with anorexia and bulimia nervosa". The American Journal of Psychiatry. 161 (12): 2215–21. doi:10.1176/appi.ajp.161.12.2215. PMID 15569892.
* The authors explore the extent to which eating disorders, specifically anorexia nervosa (AN) and bulimia nervosa (BN), represent culture-bound syndromes and discuss implications for conceptualizing the role genes play in their etiology. The examination is divided into 3 sections: a quantitative meta-analysis of changes in incidence rates since the formal recognition of AN and BN, a qualitative summary of historical evidence of eating disorders before their formal recognition, and an evaluation of the presence of these disorders in non-Western cultures. Findings suggest that BN is a culture-bound syndrome and AN is not. Thus, heritability estimates for BN may show greater variability cross-culturally than heritability estimates for AN, and the genetic bases of these disorders may be associated with differential pathoplasticity.
** Keel, PK; Klump, KL (2003). "Are eating disorders culture-bound syndromes? Implications for conceptualizing their etiology". Psychological Bulletin. 129 (5): 747–69. CiteSeerX 10.1.1.524.4493. doi:10.1037/0033-2909.129.5.747. PMID 12956542.
* Epidemiological, cross-cultural, and longitudinal studies underscore the importance of the idealization of thinness and resulting weight concerns as psychosocial risk factors for eating disorders. Personality factors such as negative emotionality and perfectionism contribute to the development of eating disorders but may do so indirectly by increasing susceptibility to internalize the thin ideal or by influencing selection of peer environment. During adolescence, peers represent self-selected environments that influence risk.
** Keel PK1, Forney KJ., “Psychosocial risk factors for eating disorders”, Int J Eat Disord. 2013 Jul;46(5):433-9. doi: 10.1002/eat.22094.
* Peer context may represent a key opportunity for intervention, as peer groups represent the nexus in which individual differences in psychological risk factors shape the social environment and social environment shapes psychological risk factors. Thus, peer-based interventions that challenge internalization of the thin ideal can protect against the development of eating pathology.
** Keel PK1, Forney KJ., “Psychosocial risk factors for eating disorders”, Int J Eat Disord. 2013 Jul;46(5):433-9. doi: 10.1002/eat.22094.
* Data described earlier are clear in establishing a role for genes in the development of eating abnormalities. Estimates from the most rigorous studies suggest that more than 50% of the variance in eating disorders and disordered eating behaviors can be accounted for by genetic effects. These high estimates indicate a need for studies identifying the specific genes contributing to this large proportion of variance. Twin and family studies suggest that several heritable characteristics that are commonly comorbid with AN and BN may share genetic transmission with these disorders, including anxiety disorders or traits, body weight, and possibly major depression. Moreover, some developmental research suggests that the genes involved in ovarian hormones or the genes that these steroids affect also may be genetically linked to eating abnormalities. Molecular genetic research of these disorders is in its infant stages. However, promising areas for future research have already been identified (e.g., 5-HT2A receptor gene, UCP-2/UCP-3 gene, and estrogen receptor beta gene), and several large-scale linkage and association studies are underway. These studies likely will provide invaluable information regarding the appropriate phenotypes to be included in genetic studies and the genes with the most influence on the development of these disorders.
** Klump, KL; Kaye, WH; Strober, M (2001). "The evolving genetic foundations of eating disorders". The Psychiatric Clinics of North America. 24 (2): 215–25. doi:10.1016/S0193-953X(05)70218-5. PMID 11416922.

## L

* The aim of this study was to describe patterns of personality disorders (PDs) in women with chronic eating disorders (EDs). An index group of nineteen women who have had EDs for an average of 8.5 years was compared with a control group of same-aged women from the general population. At the time of the study the index group received treatment at a tertiary treatment center in Stockholm. The PDs were assessed using the DSM-IV part of the DSM-IV and ICD-10 Personality Questionnaire (DIP-Q). In the index group, eighteen of nineteen fulfilled the criteria for one or more PD. The number of PD diagnoses for each women ranged from zero (n = 1) to eight (n = 2) with a median of three. Among the controls, only one woman fulfilled the criteria for one or more PD. The most prevalent disorders in the index group were Borderline, Avoidant, and Obsessive-Compulsive. The index group had significantly higher DIP-Q dimensional scores than the controls in the Paranoid, Schizoid, Schizotypal, Borderline, Histrionic, Avoidant, and Dependent scales. Although the assessment of PD symptoms was limited to self-reports, the high prevalence of PD diagnoses and PD symptoms most probably reflects the severe psychiatric impairments in patients suffering from chronic ED.
** Larsson, JO; Hellzén, M (2004). "Patterns of personality disorders in women with chronic eating disorders", Eating and Weight Disorders : EWD. 9 (3): 200–5. doi:10.1007/bf03325067. PMID 15656014.

## M

* Thin body preoccupation and social pressure are important risk factors for the development of eating disorders in adolescents. Some Hispanic groups are at risk of developing eating disorders. Efforts to reduce peer, cultural, and other sources of thin body preoccupation may be necessary to prevent eating disorders.
** McKnight, Investigators (2003). "Risk factors for the onset of eating disorders in adolescent girls: results of the McKnight longitudinal risk factor study". The American Journal of Psychiatry. 160 (2): 248–54. doi:10.1176/ajp.160.2.248. PMID 12562570.
* The spectrum of eating disorders varies widely, ranging from mildly abnormal eating habits to life-threatening chronic disease. Given the many different cultural food norms and individual preferences, along with the fact that dieting behavior is extremely common, it can be challenging to differentiate unusual eating behaviors from clinically significant eating disorders.
** Miller CA, Golden NH, “An introduction to eating disorders: clinical presentation, epidemiology, and prognosis”, Nutr Clin Pract. 2010 Apr;25(2):110-5. doi: 10.1177/0884533609357566.
* Approximately two-thirds of adolescent girls at any age are dissatisfied with their weight, the proportion increasing with actual weight. Slightly more than half of all girls are dissatisfied with the shape of their bodies, an attitude which also is positively correlated with body weight. Girls are most likely to be distressed about excess size of their thighs, hips, waist and buttocks, and inadequate size of their breasts. Those who are dissatisfied with their bodies are more likely to engage in potentially harmful weight control behaviors, such as dieting, fasting, self-induced vomiting, diuretic use, laxative use and diet pill use. Those who diet are more likely to begin in early adolescence, to be white than black, to be of higher socioeconomic status, to engage in other eating-related practices and to have a poor body image and self esteem. Boys who are underweight are most likely to be dissatisfied with their weight and many with normal weight wish to weigh more. Approximately one-third of boys are dissatisfied with their body shape, desiring larger upper arms, chest and shoulders. Dieting and purging are less likely than exercise to be chosen by boys as methods of weight control. Dieting among boys is more likely to be associated with increased body weight and some sports, such as wrestling. Body consciousness and altered body image are widespread among adolescents, and may be associated with potentially harmful eating practices in both sexes, but more so in girls.
** Moore DC, “Body image and eating behavior in adolescents”, J Am Coll Nutr. 1993 Oct;12(5):505-10.

## N

* Gynecological problems are one of the most frequent somatic complications of eating disorders. The purpose of the present study was to assess the role of improper eating habits in the aetiology of menstrual disturbances, anovulation and hormonal related changes. Bulimia nervosa is the focus of attention since amenorrhea is considered a diagnostic criterium in anorexia nervosa. Subjects of the BITE (Bulimia Investigation Test, Edinburgh) test who were infertile were studied (n = 58) In the studied population there were 6 cases of clinical and 8 cases of subclinical bulimia nervosa. Symptoms and severity subscales of the BITE test significantly correlated with body mass index (p = 0.003). All 14 patients suffering from clinical and subclinical bulimia nervosa had pathologically low FSH and LH hormone levels. In those with clinical bulimia nervosa (n = 6) we diagnosed 4 cases of multicystic ovary (MCO) and in the eating disorder not otherwise specified (EDNOS) group (n = 22) there were 2 cases of MCO and 5 cases of polycystic ovary syndrome (PCOS). The results suggest that unsatisfactory nutrition (binges and "crash diet") in bulimia nervosa results in hormonal dysfunction, menstrual disturbances and infertility. The authors question the necessity for immediately estrogen replacement: they consider the reversibility of the hormonal status by early treatment of eating disorders is more appropriate. Excessive use of hormonal contraceptives in therapy has to be questioned.
** Naessén, S; Carlström, K; Garoff, L; Glant, R; Hirschberg, AL (2006). "Polycystic ovary syndrome in bulimic women—an evaluation based on the new diagnostic criteria". Gynecological Endocrinology. 22 (7): 388–94.
* In recent years, anorexia and bulimia nervosa, whether combined into a single clinical picture or considered as distinct syndromes, have reached epidemic proportions among adolescents. Professionals in the educational and physical and mental health care fields need to be aware of the influence of social pressures on teenagers' perceptions of body image and appearance. This article reviews the sociocultural, socioeconomic, and sex-related factors which contribute to the development of eating disorders. It is recommended that professionals help adolescents resist societal pressure to conform to unrealistic standards of appearance, and provide guidance on nutrition, realistic body ideals, and achievement of self-esteem, self-efficacy, interpersonal relations and coping skills.
** Nagel KL, Jones KH, “Sociological factors in the development of eating disorders”, Adolescence. 1992 Spring;27(105):107-13.
* Prior research on non-clinical samples has lent support to the sexual competition hypothesis for eating disorders (SCH) where the drive for thinness can be seen as an originally adaptive strategy for women to preserve a nubile female shape, which, when driven to an extreme, may cause eating disorders. Restrictive versus impulsive eating behavior may also be relevant for individual differences in allocation of resources to either mating effort or somatic growth, reflected in an evolutionary concept called "Life History Theory" (LHT). In this study, we aimed to test the SCH and predictions from LHT in female patients with clinically manifest eating disorders. Accordingly, 20 women diagnosed with anorexia nervosa (AN), 20 with bulimia nervosa (BN), and 29 age-matched controls completed a package of questionnaires comprising measures for behavioral features and attitudes related to eating behavior, intrasexual competition, life history strategy, executive functioning and mating effort. In line with predictions, we found that relatively faster life history strategies were associated with poorer executive functioning, lower perceived own mate value, greater intrasexual competition for mates but not for status, and, in part, with greater disordered eating behavior. Comparisons between AN and BN revealed that individuals with BN tended to pursue a "fast" life history strategy, whereas people with AN were more similar to controls in pursuing a "slow" life history strategy. Moreover, intrasexual competition for mates was significantly predicted by the severity of disordered eating behavior. Together, our findings lend partial support to the SCH for eating disorders. We discuss the implications and limitations of our study findings.
** Nettersheim J, Gerlach G, Herpertz S, Abed R, Figueredo AJ, Brüne M. "Evolutionary Psychology of Eating Disorders: An Explorative Study in Patients With Anorexia Nervosa and Bulimia Nervosa", Front Psychol. 2018 Oct 31;9:2122. doi: 10.3389/fpsyg.2018.02122. eCollection 2018.
* Previous research demonstrates that the relationship between socio-economic status (SES) and eating disorders is not consistent. The present study compares SES and demographic factors among Swedish women, randomly drawn from the population register and female patients seen for treatment.
** Nevonen, L; Norring, C (2004). "Socio-economic variables and eating disorders: A comparison between patients and normal controls". Eating and Weight Disorders. 9 (4): 279–84. doi:10.1007/BF03325082. PMID 15844400.
* ED's have a higher SES background and live in more privileged socio-demographic areas than CONT. ED's have lower social status, have more separations, and are more often single than CONT.
** Nevonen, L; Norring, C (2004). "Socio-economic variables and eating disorders: A comparison between patients and normal controls". Eating and Weight Disorders. 9 (4): 279–84. doi:10.1007/BF03325082. PMID 15844400.
* These data demonstrate a connection between high socio-economic and demographic data, low social status and eating disorder patients compared to normal controls.
** Nevonen, L; Norring, C (2004). "Socio-economic variables and eating disorders: A comparison between patients and normal controls". Eating and Weight Disorders. 9 (4): 279–84. doi:10.1007/BF03325082. PMID 15844400.
* Interest in all forms of eating disorder in children, adolescents and adults continues to grow steadily across the world. The number of publications grows from day to day but, despite the increasing body of knowledge, the causes and origins of eating disorders are as abffling and obscure as ever. Death from anorexia nervosa (AN) was recorded by both Lasegue (1873a,b) and Gull (1874), who first described it. In 1895, both Stephens and Marshall published postmortem finding in the Lancet for a 16-year-old and an 11-year-old patient respectively. In the last five decades there have been several reports of cases of AN with fatal outcomes and subsequent ausopsies (Siebenmann, 1955; Martin, 1955, 1958; Hack, 1959; Mosli, 1967; Chikasue et al., 1988). Gradually work began to be published which covered long observation periods and produced yet more mortality figures. In 1988 in Britain, Patton presented a study of a group of 460 consecutive patients with eating disorders covering the years from 1971-1981. These were divided into two groups for AN and bulimia nervosa (BN) with resulting crude mortality rates of 3.3 percent for the former and 3.1 percent for tha latter. He also carried out a critical evaluation of the methodological problems and the results obtained from earlier studies. Hsu et al. (1979) reported that more than 2 percent had died during an average follow-up period of 5.9 years; Isafer et al. (1985) gave a crude mortality rate of 8.2 percent with an average follow-up period of 12.5 years; and Theander (1985) a crude morality rate of 18 percent over 33 years. Even allowing for the differences in these data, it is clear that AN has the highest mortality rate of all the psychiatric illnesses (Licht et al., 1993). However these differences in crude mortality rates are unsatisfactory from a methodological point of view for a number of reasons. These include the way cases were selected and the differing lengths of the observation periods.
** Neumaker, K.J. (2000). "Morality rates and causes of death". European Eating Disorders Review. 8(2): 181–187. doi:10.1002/(SICI)1099-0968(200003)8:2<181::AID-ERV336>3.0.CO;2-#.
* The severity and type of eating disorder symptoms have been shown to affect comorbidity. The DSM-IV should not be used by laypersons to diagnose themselves even when used by professionals there has been considerable controversy over the diagnostic criteria used for various diagnoses, including eating disorders.
** Nicholls D, Bryant-Waugh R, “Eating disorders of infancy and childhood: definition, symptomatology, epidemiology, and comorbidity.”, Child Adolesc Psychiatr Clin N Am. 2009 Jan;18(1):17-30. doi: 10.1016/j.chc.2008.07.008.

## P

* The speculation about whether there may be a positive association between sexual abuse in childhood and the later development of clinical eating disorder has been widely considered over the past 15 years. It has sometimes been accepted uncritically as established truth. It is certainly plausible. After all, bulimia and anorexia nervosa differentially affect girls and seem to involve complex feelings about the body which might well have originated in adverse early sexual experience. Furthermore, many patients disclose such experiences in the clinic. The evidence from early research studies, however, does not consistently support all of the clinical speculation. More than one review reached broadly negative conclusions.1,2 The study by Wonderlich et al systematically re-examines publications up to the end of 1994. The authors of this review had to grapple with studies employing a wide variety of methods and samples. They used predetermined criteria of quality but not meta-analysis to sort out which studies could contribute to their conclusions. They were appropriately strict in applying their criteria. This review supports the position of clinicians who consider that a history of childhood sexual abuse is worth seeking and may be an important consideration in their patients with eating disorders, but no more important than in many other patients. It may be especially relevant for those who have bulimia nervosa with comorbidity. Patients with such complex problems require careful thought. Finding a background of sexual abuse may prove to be important but should not lead to the conclusion that “all is now explained”. Furthermore, most studies show that only a minority of patients with eating disorders report abuse and inferring past abuse from the fact of present eating disorder is unjustified.
** Robert L Palmer, Aetiology, "Review: childhood sexual abuse is associated with bulimia nervosa especially when there is psychiatric comorbidity", vol. 1, issue 2; Wonderlich SA, Brewerton TD, Jocic Z , et al. "Relationship of childhood sexual abuse and eating disorders". J Am Acad Child Adolesc Psychiatry, 1997 Aug; 36 : 1107 –15 CrossRefPubMedWeb of Science
* There is good evidence that children of parents with psychological disorders are themselves at increased risk of disturbances in their development. Although there has been considerable research on a variety of disorders such as depression and alcohol, research on the children of parents with eating disorders has been relatively recent. This paper aims to review the evidence and covers a number of areas, including genetic factors, pregnancy, the perinatal and postpartum period, infancy, and the early years of life, focusing on feeding and mealtimes, general parenting functions, and growth. This is followed by a consideration of psychopathology in the children, parental attitudes to children's weight and shape, and adolescence. What is clear is that although there are numerous case reports and case series, the number of systematic controlled studies is relatively small, and almost nothing has been written about the children of fathers with eating disorders. What is evident from the available evidence is that children of mothers with eating disorders are at increased risk of disturbance, but that the risk depends on a variety of factors, and that difficulties in the children are far from invariable. The paper concludes by summarizing five broad categories of putative mechanisms, based on the evidence to date, by which eating disturbance in parents can influence child development.
** Patel, P; Wheatcroft, R; Park, R; Stein, A (2002). "The Children of Mothers With Eating Disorders". Clinical Child and Family Psychology Review. 5 (1): 1–19. doi:10.1023/A:1014524207660. PMID 11993543.
* This study explored friendship variables in relation to body image, dietary restraint, extreme weight-loss behaviors (EWEBs), and binge eating in adolescent girls. From 523 girls, 79 friendship cliques were identified using social network analysis. Participants completed questionnaires that assessed body image concerns, eating, friendship relations, and psychological family, and media variables. Similarity was greater for within than for between friendship cliques for body image concerns, dietary restraint, and EWLBs, but not for binge eating. Cliques high in body image concerns and dieting manifested these concerns in ways consistent with a high weight/shape-preoccupied subculture. Friendship attitudes contributed significantly to the prediction of individual body image concern and eating behaviors. Use of EWLBs by friends predicted an individual's own level of use.
** Paxton, SJ; Schutz, HK; Wertheim, EH; Muir, SL (1999). "Friendship clique and peer influences on body image concerns, dietary restraint, extreme weight-loss behaviors, and binge eating in adolescent girls". Journal of Abnormal Psychology. 108 (2): 255–66. doi:10.1037/0021-843X.108.2.255. PMID 10369035.
* While historically, eating disorders were conceptualized as primarily afflicting Caucasian adolescent or young adult women within high-income, industrialized Western Europe and North America, eating disorders are increasingly documented in diverse countries and cultures worldwide. This study highlights recent trends that reflect the changing landscape of culture and eating disorders: stabilization of the incidence of anorexia nervosa and possibly lower incidence rates of bulimia nervosa in Caucasian North American and Northern European groups; increasing rates of eating disorders in Asia; increasing rates of eating disorders in the Arab region; and increasing rates of binge eating and bulimia nervosa in Hispanic and Black American minority groups in North America.
** Pike, KM; Hoek, HW; Dunne, PE (November 2014). "Cultural trends and eating disorders". Current Opinion in Psychiatry. 27 (6): 436–42.
* The purpose of this study was to assess the relative contribution of personality and emotional experience to self-reported eating attitudes in a group of patients with clinically diagnosed eating disorders, a weight-reduction training group (Weight Watchers), and a control group without body weight problems. Participants in this study (N = 114) completed Estonian versions of the Eating Disorder Inventory-2 (EDI-2; Garner, 1991), NEO Personality Inventory (Costa & McCrae, 1989), and Positive Affect and Negative Affect Schedule, Expanded Form (Watson & Clark, 1994). Data demonstrated validity of the Estonian version of EDI-2 in its ability to identify problems on a continuum of disordered eating behavior. Among the Big Five personality dimensions, Neuroticism made the largest contribution to EDI-2 subscales. Two other dimensions, Openness to Experience and Conscientiousness, also predispose individuals to eating problems. Personality traits made a larger contribution to the self-reported eating pathology than the self-rated effects experienced during the last few weeks. It was argued that personality dispositions have a larger relevancy in the etiology of eating disorders than emotional state.
** Podar, I; Hannus, A; Allik, J (1999). "Personality and affectivity characteristics associated with eating disorders: a comparison of eating disordered, weight-preoccupied, and normal samples". Journal of Personality Assessment. 73 (1): 133–47. doi:10.1207/S15327752JPA730109. PMID 10497805.
* Some contributory factors appear to be necessary for the appearance of eating disorders, but none is sufficient. Eating disorders may represent a way of coping with problems of identity and personal control.
** Polivy, J; Herman, CP (2002). "Causes of eating disorders". Annual Review of Psychology. 53: 187–213. doi:10.1146/annurev.psych.53.100901.135103. PMID 11752484.

## Q

* Although it remains unclear whether the prevalence of eating disorders is higher in those with DRCHCs compared with the general population, overall findings suggest that young people with DRCHCs may be at risk of endorsing disordered eating behaviors that may lead to diagnosis of an eating disorder and other health problems over the course of their treatment. Thus, health care providers should be aware that young people with DRCHCs may be at risk of eating disorders and carefully monitor psychological changes and the use of unhealthy weight control methods. It is also important to develop and evaluate theory-based interventions and disease-specific eating disorder risk screening tools that are effective in halting the progression of eating disorders and negative health outcomes in young people with chronic health conditions.
** Quick VM, Byrd-Bredbenner C, Neumark-Sztainer D (May 1, 2013). "Chronic illness and disordered eating: a discussion of the literature". Adv Nutr (Review). 4 (3): 277–86. doi:10.3945/an.112.003608. PMC 3650496. PMID 23674793.

## R

* The development of eating disorders including anorexia nervosa, bulimia nervosa, binge eating disorder, and atypical eating disorders that affect many young women and even men in the productive period of their lives is complex and varied. While numbers of presumed risk factors contributing to the development of eating disorders are increasing, previous evidence for biological, psychological, developmental, and sociocultural effects on the development of eating disorders have not been conclusive. Despite the fact that a huge body of research has carefully examined the possible risk factors associated with the eating disorders, they have failed not only to uncover the exact etiology of eating disorders, but also to understand the interaction between different causes of eating disorders. This failure may be due complexities of eating disorders, limitations of the studies or combination of two factors. In this review, some risk factors including biological, psychological, developmental, and sociocultural are discussed.
** Rikani, AA; Choudhry, Z; Choudhry, AM; Ikram, H; Asghar, MW; Kajal, D; Waheed, A; Mobassarah, NJ (October 2013). "A critique of the literature on etiology of eating disorders". Annals of Neurosciences. 20 (4): 157–61. doi:10.5214/ans.0972.7531.200409. PMC 4117136. PMID 25206042.
* It has been hypothesized that eating disorders have multiple and often shared etiologies including biological, psychological, developmental, and sociocultural. A tightly woven network of causes, symptoms, and outcomes of eating disorders makes the study of etiology of these disorders very challenging. Some suggested risk factors for eating disorders require to be defined as either integral parts of eating disorders syndrome such as body dissatisfaction, and perfectionism or outcome of prolonged disordered eating such as functional alterations in serotonin, and some mood disturbances. Researchers should structure their thought processes around this concept that some of currently well-known risk factors for eating disorders are concurrent symptoms of eating disorders. Hence paying special attention to the new and evolved concepts is highly recommended while studying the etiology of eating disorders.
** Rikani, AA; Choudhry, Z; Choudhry, AM; Ikram, H; Asghar, MW; Kajal, D; Waheed, A; Mobassarah, NJ (October 2013). "A critique of the literature on etiology of eating disorders". Annals of Neurosciences. 20 (4): 157–61. doi:10.5214/ans.0972.7531.200409. PMC 4117136. PMID 25206042.
* Studies have reported that the oral health status is jeopardized in patients with eating disorders. The aim was to review the oro-facial manifestations in patients with eating disorders. The address the focused question was "What is the oro-dental health status in patients with eating disorders?" MEDLINE/PubMed and Google Scholar databases were searched from 1948 to March 2012 using the following terms in various combinations: "Anorexia nervosa", "bulimia nervosa", "eating disorders", "dental", "oral health status". Letters to the editor, unpublished data and articles published in languages other than English were excluded. Dry lips, burning tongue and parotid gland swelling are common manifestations in patients with eating disorders as compared to medically healthy controls. The association of dental caries and periodontal disease in patients with eating disorders remains debatable. Temporomandibular disorders have also been reported to be more prevalent in patients with eating disorders as compared to healthy controls. A critical oral-dental examination during routine dental check-ups may reveal valuable information regarding the presence or absence of eating disorders in routine dental patients. This may be important information, updating the medical history, supporting the role of the physician.
** Romanos, GE; Javed, F; Romanos, EB; Williams, RC (October 2012). "Oro-facial manifestations in patients with eating disorders". Appetite. 59 (2): 499–504. doi:10.1016/j.appet.2012.06.016. PMID 22750232.
* Comorbid personality disorders in eating disordered patients may seriously affect the treatment and course of their illness. Several studies show such a comorbidity, though with inconsistent findings. Qualitative reviews attribute this to methodological shortcomings, but the qualitative method may itself create new shortcomings. To circumvent this, the present, more extensive review applies a meta-analytic approach. Using the databases MEDLINE and PSYCHLIT, the 28 articles published between 1983 and 1998 that presented empirical evidence for an eating disorder and personality disorder comorbidity suitable for meta-analysis were included. We found a higher proportion of eating disordered patients with any personality disorder (average proportion = 0.58) related to comparison groups (average proportion = 0.28). Compared with anorexia nervosa patients, a higher proportion of patients with bulimia nervosa had a concurrent cluster B personality (average proportion = 0.44) and a borderline personality disorder (average proportion = 0.31). However, no differences between anorexia nervosa and bulimia nervosa patients in proportions of cluster C were found (average proportion = 0.45 and 0.44 respectively). Patients with eating disorders and patients with bulimia nervosa in particular, should be routinely assessed for a concurrent personality disorder using structured clinical interviews. In future research, more stringent assessment procedures are highly recommended to address the question of causality between eating disorders and personality disorders, and how eating disorder symptoms and personality disorder symptoms are related to treatment effects.
** Rosenvinge, JH; Martinussen, M; Ostensen, E (2000). "The comorbidity of eating disorders and personality disorders: a meta-analytic review of studies published between 1983 and 1998". Eating and Weight Disorders. 5 (2): 52–61. doi:10.1007/bf03327480. PMID 10941603.

## S

* The cognitive model of eating disorders (EDs) states that the processing of external and internal stimuli might be biased in mental disorders. These biases, or cognitive errors, systematically distort the individual's experiences and, in that way, maintains the eating disorder. This chapter presents an updated literature review of experimental studies investigating these cognitive biases. Results indicate that ED patients show biases in attention, interpretation, and memory when it comes to the processing of food-, weight-, and body shape-related cues. Some recent studies show that they also demonstrate errors in general cognitive abilities such as set shifting, central coherence, and decision making. A future challenge is whether cognitive biases and processes can be manipulated. Few preliminary studies suggest that an attention retraining and training in the cognitive modulation of food reward processing might be effective strategies to change body satisfaction, food cravings, and eating behavior.
* An individual who is a first degree relative of someone who has had or currently has an eating disorder is seven to twelve times more likely to have an eating disorder themselves. Twin studies also show that at least a portion of the vulnerability to develop eating disorders can be inherited, and there is evidence to show that there is a genetic locus that shows susceptibility for developing anorexia nervosa.
** Siep 1, Jansen A, Havermans R, Roefs A. “Cognitions and emotions in eating disorders.”, Curr Top Behav Neurosci. 2011;6:17-33. doi: 10.1007/7854_2010_82.
* Of the empirical studies undertaken, few investigated a cultural group's eating pathology in both its country of origin and a Western country using the same methodology. To date, the research findings are mixed and it is still unclear if the presentation of an eating disorder differs across cultures. Acculturation has not been consistently taken into consideration and psychological control has not been examined in relation to eating disturbances in non‐Western groups.
** Soh, NL; Touyz, SW; Surgenor, LJ (2006). "Eating and body image disturbances across cultures: A review". European Eating Disorders Review. 14 (1): 54–65. doi:10.1002/erv.678.
* Patients with eating disorders (ED) frequently exhibit additional psychiatric disorders. This study aimed to examine whether psychiatric comorbidity in ED patients is associated with increased severity of ED symptoms in a sample of 277 women with a current ED (84 anorexia nervosa, 152 bulimia nervosa, 41 eating disorders not otherwise specified). Psychiatric comorbidity of Axes I and II was determined using the Structured Clinical Interview (SCID) for DSM-IV. Severity of ED-related symptoms was assessed using interviewer-rated scales from the Structured Interview for Anorexia and Bulimia Nervosa (SIAB). Affective and anxiety-related disorders of both axes were linked with increased intensity of weight- and appearance-related fears and concerns. Frequency of binge-eating and frequency of purging both were associated with Axis I anxiety disorders, substance-related disorders, and Cluster B personality disorders. Frequency of dieting was related to anxiety disorders on both axes. Multivariate analyses revealed that Axis I anxiety disorders were more closely linked with severity of ED symptoms than affective or substance-related disorders. The results showed that psychiatric comorbidity of both axes is linked with increased severity of ED symptoms and that there are associations between specific ED symptoms and specific forms of comorbidity.
** Spindler, A; Milos, G (2007). "Links between eating disorder symptom severity and psychiatric comorbidity". Eating Behaviors. 8 (3): 364–73. doi:10.1016/j.eatbeh.2006.11.012. PMID 17606234.
* Eating disorders, such as anorexia, bulimia, and binge eating disorder, commonly involve a dysregulation of behavior (e.g., a lack or excess of inhibition and impulsive eating patterns) that is suggestive of prefrontal dysfunction. Functional neuro-imaging studies show that prefrontal-subcortical systems play a role in eating behavior and appetite in healthy individuals, and that people with eating disorders have altered activity in these systems. Eating behavior is often disturbed by illnesses and injuries that impinge upon prefrontal-subcortical systems. This study examined relationships between executive functioning and eating behavior in healthy individuals using validated behavioral rating scales (Frontal Systems Behavior Scale and Eating Inventory). Correlations demonstrated that increased dysexecutive traits were associated with disinhibited eating and greater food cravings. There was also a positive association with cognitive restraint of eating, suggesting that increased compensatory behaviors follow disinhibited eating. These psychometric findings reinforce those of other methodologies, supporting a role for prefrontal systems in eating.
** Spinella, M; Lyke, J (2004). "Executive personality traits and eating behavior". The International Journal of Neuroscience. 114 (1): 83–93. doi:10.1080/00207450490249356. PMID 14660070.
* Eating disorders are significant causes of morbidity and mortality in adolescent females and young women. They are associated with severe medical and psychological consequences, including death, osteoporosis, growth delay and developmental delay. Dermatologic symptoms are almost always detectable in patients with severe anorexia nervosa (AN) and bulimia nervosa (BN), and awareness of these may help in the early diagnosis of hidden AN or BN.
** Strumia, R (2005). "Dermatologic signs in patients with eating disorders". American Journal of Clinical Dermatology. 6 (3): 165–73. doi:10.2165/00128071-200506030-00003. PMID 15943493.
* Of the empirical studies undertaken, it is clear that anxiety disorders are significantly more frequent in subjects with eating disorders than the general community. Researchers have shown that often anxiety disorders pre-date eating disorders, leading to a suggestion that early onset anxiety may predispose individuals to developing an eating disorder. To date however, the research presents strikingly inconsistent findings, thus complicating our understanding of eating disorder and anxiety co-morbidity. Furthermore, despite indications that eating disorder prevalence amongst individuals presenting for anxiety treatment may be high, there is a distinct lack of research in this area.
** Swinbourne, JM; Touyz, SW (2007). "The co-morbidity of eating disorders and anxiety disorders: a review". European Eating Disorders Review. 15 (4): 253–74. doi:10.1002/erv.784. PMID 17676696.

## T

* Substance abuse has been shown to predict poor outcome in eating disorder (ED) samples, and prior cross-sectional data on personality subtypes of EDs suggest that substance abuse is associated with dysregulated and possibly avoidant-insecure subtypes.
** Thompson-Brenner H, Eddy KT, Franko DL, Dorer D, Vashchenko M, Herzog DB. "Personality pathology and substance abuse in eating disorders: a longitudinal study.", Int J Eat Disord. 2008 Apr;41(3):203-8.
* The present review focused on the personality profiles of patients with eating disorders. Studies using the Structured Clinical Interview for DSM-III-R Personality Disorder showed high rates of diagnostic co-occurrence between eating disorders and personality disorders. The most commonly observed were histrionic, obsessive-compulsive, avoidant, dependent and borderline personality disorders. Studies using the Cloninger's personality theory suggested that high Harm Avoidance might be relevant to the pathology of anorexia nervosa and high Novelty Seeking and Harm Avoidance to bulimia nervosa. Moreover, high Self-Directedness was suggested to be associated with favorable outcome in bulimia nervosa. The assessment of personality in a cross-sectional study, however, might be influenced by the various states of the illness. Therefore, a sophisticated longitudinal study will be required to advance this area of research.
** Tomotake M, Ohmori T, "Personality profiles in patients with eating disorders.", J Med Invest. 2002 Aug;49(3-4):87-96.
* One out of four subjects showed a significant risk of an eating disorder and 6-7% probably already had one. No significant differences were found between the two samples. Significant differences were found in risk behaviors: more Spanish girls reported body dissatisfaction and binging; more Mexican girls had a history of psychiatric and psychological treatment, pressure from parents and friends to lose weight, dieting, physical activity and vomiting to lose weight, and a history of greater weight loss. In both the groups around 50% of subjects wanted to increase the size of their breasts. However, significantly more Mexican girls desired thinner arms and narrower shoulders and back, and more Spanish girls wanted thinner hips, buttocks, and legs, parts of the body that many Mexicans wanted to increase.
** Toro J, Gomez-Peresmitré G, Sentis J, Vallés A, Casulà V, Castro J, Pineda G, Leon R, Platas S, Rodriguez R, “Eating disorders and body image in Spanish and Mexican female adolescents”, Soc Psychiatry Psychiatr Epidemiol. 2006 Jul;41(7):556-65. Epub 2006 May 9.
* Risk behaviors and the ideal body models of these Spanish and Mexican adolescent girls varied significantly, indicating major socio-cultural differences. However, the prevalence of ED was similar. Further research should aim to clarify whether the similarities found between this Spanish sample and a Mexican sample taken from an upper-middle class urban environment, a minority that is unrepresentative of the general population, are also observed in samples from other sectors of Mexican society.
** Toro J, Gomez-Peresmitré G, Sentis J, Vallés A, Casulà V, Castro J, Pineda G, Leon R, Platas S, Rodriguez R, “Eating disorders and body image in Spanish and Mexican female adolescents”, Soc Psychiatry Psychiatr Epidemiol. 2006 Jul;41(7):556-65. Epub 2006 May 9.
* This Seminar adds to the previous Lancet Seminar about eating disorders, published in 2003, with an emphasis on the biological contributions to illness onset and maintenance. The diagnostic criteria are in the process of review, and the probable four new categories are: anorexia nervosa, bulimia nervosa, binge eating disorder, and eating disorder not otherwise specified. These categories will also be broader than they were previously, which will affect the population prevalence; the present lifetime prevalence of all eating disorders is about 5%. Eating disorders can be associated with profound and protracted physical and psychosocial morbidity. The causal factors underpinning eating disorders have been clarified by understanding about the central control of appetite. Cultural, social, and interpersonal elements can trigger onset, and changes in neural networks can sustain the illness. Overall, apart from studies reporting pharmacological treatments for binge eating disorder, advances in treatment for adults have been scarce, other than interest in new forms of treatment delivery.
** Treasure, J; Claudino, AM; Zucker, N (2010). "Eating disorders". The Lancet. 375 (9714): 583–93. doi:10.1016/S0140-6736(09)61748-7. PMID 19931176.
* There are a number of differences in the aetiology of subtypes of eating disorder. The present results suggest that cognitive styles pertaining to the social arena in adolescence, and prior to the onset of any eating disorders, may play a causal role in the development of anorexia nervosa of the binge/purge subtype, but not anorexia nervosa of the restricting subtype.
** Troop, NA; Bifulco, A (2002). "Childhood social arena and cognitive sets in eating disorders". The British Journal of Clinical Psychology. 41 (Pt 2): 205–11. doi:10.1348/014466502163976. PMID 12034006.

## U

* Eating disorders, including anorexia and bulimia nervosa, are characterised by abnormal eating behaviour and typical psychopathological features, including fear of fatness, drive for thinness, and body image disturbance. In most patients, there is no detectable focal brain abnormality. Nonetheless, associations of anorexia and bulimia nervosa with history of perinatal complications and head injuries suggest a role of cerebral pathology in some cases. A number of case studies describe eating disorders with intracranial tumours, injuries, or epileptogenic foci. However, many clinical descriptions are limited to changes in appetite and lack psychopathological features characteristic of eating disorders. A previous review of 21 anorexia cases associated with brain tumours found that only three of them fulfilled formal diagnostic criteria. In the present paper, we provide a systematic review of published case reports and highlight those relatively rare cases where typical eating disorders appear to be causally associated with localised brain damage.
** Uher R, Treasure J, "Brain lesions and eating disorders", J Neurol Neurosurg Psychiatry. 2005 Jun; 76(6):852-7.
* This review of published case reports challenges the traditional view that hypothalamic disturbance underlies eating disorders. Although hypothalamic lesions are the most commonly reported neural causes of anorexia-like syndrome, most of them lack the typical psychopathology. Of the eight cases with characteristic psychopathological presentation and suggestive evidence for a causal association, four had frontal and temporal cortical lesions, two brain stem tumours, one hypothalamic tumour, and one hydrocephalus. Implication of frontotemporal circuits is consistent with functional neuroimaging research in eating disorders and with benign changes in eating, such as the gourmand syndrome.49 Therefore, we conclude that evidence favours cortical mechanisms in the genesis of eating disorders over hypothalamic ones. An association of disordered eating with epilepsy was reported in 12 cases. In six of these, remission after a surgical removal of an epileptogenic focus or anticonvulsant treatment suggests that eating disorder may be actively maintained by an epileptogenic focus rather than being a deficit syndrome due to missing normal brain tissue. In five of the reviewed cases, disturbed eating occurred alongside obsessive compulsive psychopathology. This finding parallels the comorbidity and familial cooccurrence of eating disorders and obsessive compulsive disorder50 51 and suggests a common or overlapping neural substrate of the two.
** Uher R, Treasure J, "Brain lesions and eating disorders", J Neurol Neurosurg Psychiatry. 2005 Jun; 76(6):852-7.

## V

* All dominant models of the eating disorders implicate personality variables in the emergence of weight concerns and the development of specific symptoms such as bingeing and purging. Standardized measures of personality traits and disorders generally confirm clinical descriptions of restricting anorexics as constricted, conforming, and obsessional individuals. A less consistent picture suggesting affective instability and impulsivity has emerged from the assessment of subjects with bulimia nervosa. Considerable heterogeneity exists within eating disorder subtypes, however, and a number of special problems complicate the interpretation of personality data in this population. These include young age at onset, the influence of state variables such as depression and starvation sequelae, denial and distortion in self-report, the instability of subtype diagnoses, and the persistence of residual problems following symptom control.
** Vitousek, K; Manke, F (1994). "Personality variables and disorders in anorexia nervosa and bulimia nervosa". Journal of Abnormal Psychology. 103(1): 137–47. doi:10.1037/0021-843X.103.1.137. PMID 8040475.

## W

* Social media have become a significant means for peer-related communication, self-presentation, and identity management. So-called eating disorder websites that propagate a drastic thin ideal and unhealthy eating behaviors have triggered a debate about the harmful facets of social Internet activity. Little research has addressed the language that is used by the authors of these websites. The present study focuses on personal weblogs, a popular form of mostly text-based, diary-like, online journals. We compared 31 pro–eating disorder blogs, 29 recovery blogs, and 27 control blogs by the means of computerized quantitative text analyses. The language of pro–eating disorder blogs featured lower cognitive processing, a more closed-minded writing style, was less emotionally expressive, contained fewer social references, and focused more on eating-related contents than recovery blogs. A subset of 12 language indicators correctly classified the blogs in 84% of the cases. The distinct language patterns appear to reflect the psychological conditions of the blog authors and provide insight into their various stages of coping.
** Wolf, M; Theis, F; Kordy, H (2013). "Language Use in Eating Disorder Blogs: Psychological Implications of Social Online Activity". Journal of Language and Social Psychology. 32 (2): 212–226.

### "Unbearable Weight” (2003)

Susan Bordo, “Unbearable Weight: Feminism, Western Culture and the Body”, Berkeley and Los Angeles, CA: University of California Press, 2003
* I was intrigued when my articles on eating disorders began to be translated, over the past few years, into Japanese and Chinese. Among the members of audiences at my talks, Asian women had been among the most insistent that eating and body image weren’t problems for their people, and indeed, my initial research showed that eating disorders were virtually unknown in Asia. But when, this year, a Korean translation of Unbearable Weight was published, I felt I needed to revisit the situation. I discovered multiple reports on dramatic increases in eating disorders in China, South Korea, and Japan. “As many Asian countries become Westernized and infused with the Western aesthetic of a tall, thin, lean body, a virtual tsunami of eating disorders has swamped Asian countries,” writes Eunice Park in “Asian Week” magazine. Older people can still remember when it was very different. In China, for example, where revolutionary ideals once condemned any focus on appearance and there have been several disastrous famines, “little fatty” was a term of endearment for children. Now, with fast good on every corner, childhood obesity is on the rise, and the cultural meaning of fat and thin has changed. “When I was young,” says Li Xiaojing, who manages a fitness center in Bejing, “people admired and were even jealous of fat people since they thought they ahd a better life. . . . But now, most of us see a far person and think ‘He looks awful’”
** p.xv
* Because of their remote location, the Fiji islands did not access to television until 1995, when a single station was introduced. It broadcasts programs from the United States, Great Britain, and Australia. Until that time, Fiji had no reported cases of eating disorders, and a study conducted by anthropologist Anne Becker showed that most Fijian girls and women, no matter how large, were comfortable with their bodies. In 1998, just three years after the station began broadcasting, 11 percent of girls reported vomiting to control weight, and 62 percent of girls surveyed reported dieting during the previous months. Becker was surprised by the change; she had though that Fijian cultural traditions, which celebrate eating and favor voluptous bodies, would “withstand” the influence of media images. Her explanation for the Fijian’s vulnerability? They were not sophisticated enough about media to recognize that the television images were not “real.”
** pp.xv-xvi
* In their world, there is a size zero, and it’s a status symbol. The chronic dieters have been as it since they were eight and nine years old. “Epidemic of eating disorders” is old stuff; being preached to about it turns them right off. Their world is one in which the anorexics swap starvation diet tips on the Internet, participate in group fasts, offer advice on how to hide your “ana” from family members, and share inspirational photos of emaciated models. But full-blown anorexia has never been the norm among teenage girls; the real epidemic is among the girls with seemingly healthy eating habits, seemingly health bodies, who commit or work their butts off as a result form of anti-fat maintenance. These girls not only look “normal” but consider themselves normal. The new criterion circulating among teenage girls: If you get rid of it through exercise rather than purging or laxatives, you don’t have a problem. Theirs is a world in which groups of dorm girls will plough voraciously through pizzas, chewing and then spitting out each mouthful. Do they have a disorder? Of course not-look, they’re eating pizza.
** pp.xxvi-xxviii
* When I wrote Unbearable Weight, it was widely believed that privileged white girls had the monopoly on eating and body-image problems. The presumption was a relic of the old medical models, which accepted the “profile” presented by the typical recipient of therapy-who was indeed largely white and upper middle class- as definitive, and which failed to recognize the central role of media imagery in “spreading” eating and body-image problems across race and class (and sexual orientation). Like the Black Africans and the Fijians and the Russians (and lesbians and [Latins]] and every other “subculture” boasting a history of regard for fleshy women), African Americans were believed “protected” by their alternative cultural values. And so, many young girls were left feeling stranded and alone, dealing with feelings about their bodies that they weren’t “supposed” to have, as they struggled, along with their white peers, with unprecedented pressure to achieve, and watched Janet Jackson and Halle Berry shrink before their eyes. Many medical professionals, too, were trapped in what I’d call the “anorexic paradigm.” They hadn’t yet understood that eating problems take many different forms and inhabit bodies of many different sizes and shapes. Binge eating-a chronic problem among many African American women-is no less a disordered relation to good than habitual purging, and large women who don’t or won’t diet are not necessarily comfortable with their bodies. Exercise addiction is rarely listed among the criteria for eating problems, but it has become the weight control of choice among an generation emulating Jennifer Lopez’s round tight buns rather than Kate Moss’s skeletal collarbones. Just because e a teenager looks healthy and fit does not mean that she is not living her life on a treadmill-metaphorically as well as literally-which she dare not step off lest food and fat overtake her body. Until recently, most clinicians were not receptive to the arguments of feminists like Susie Ohrbach (and later, myself) that “body image disturbance syndrome,” binge/purge cycling, bulimic thinking,” and all the rest needed to be understood as much more culturally normative than generally recognized. They wanted to draw a sharp dividing line between pathology and normality-a line that can be very blurry when it comes to eating and body-image problems in this culture. And while they acknowledged that images “play a role,” they clung to the notion that only girls with a “predisposing vulnerability” get into trouble. Trained in a medical model which seeks the ause of disorder in individual and family pathology, they hadn’t yet understood just how powerful, ubiquitous, and invasive the demands of culture are on our bodies and souls.
** pp.xviii-xix
* Families matter, of course, and so do racial and ethnic traditions. But families exist in cultural time and space-and so do racial groups. Thus, no one lives in a bubble of self-generated dysfunction” or permanent immunity-especially today, as mass media culture increasingly has provided the dominant “public education” in our children’s lives. The “profile” of girls with eating problems is dynamic, not static; heterogenous, nut uniform. Therapists now report treating the anorexic daughters of anorexics, and are coming to realize the role parents play, not just in being “over-controlling” or overly demanding of their children, but in modeling and obedience to cultural norms. And the old generalizations about race and “fat acceptance” while perhaps valid for older generations of Black Americans, do not begin to adequately describe the complex and often conflicted attitudes of younger people, many of whom are aware of traditional values but constantly feel the pull of contemporary demands. While working on Unbearable Weight”, I called up organizations devoted to Black women’s health issues, asking for statistics and clinical anecdotes, and was told: “That’s a white girl’s thing. African American women are comfortable with their bodies.” For twenty-something Tenisha Williamson, who suffers from anorexia, such notions are almost as oppressive as her eating disorder: “From an African American standpoint,” she writes, “we as a people are encouraged to ‘embrace our big, voluptuous bodies,’ This makes me feel terrible because I don’t want a big voluptuous body! I don’t ever want to be fat-ever, and I don’t ever want to gain weight. I would rather die from starvation than gain a single pound. [This makes me feel like] the proverbial Judas of my race. . . and so incredibly shallow.” In fact, the starving white girls were just the forward guard, the miners’ canaries warning of how poisonous the air was becoming for everyone. I could see it in the magazines the videos, and in my students’ journals. I could see it, as I write in “Material Girl,” in the transformations of Madonna and other performers of Italian, Jewish, and African American descent who seemed at the start of their careers, to represent resistance to the waifs and willows but who just couldn't hold out against what, indeed, had begun to look like a tsunami, a cultural tidal wave of obsession with achieving a disciplined, normalized body.
** p.xx
* At the 1983 meetings of the New York Center for the Study of Anorexia and Bulimia, Steven Levenkron charged feminism with sacrificing the care of “helpless, chaotic, and floundering” children in the interests of a “rational” political agenda. Is he right? Does maintaining a continuity between eating disorders and “normal” female behavior entail a denial of the fact that anorexia and bulimia are extreme and debilitating disorders? I think not. The feminist perspective has never questioned the reality of the anoretic’s disorder or the severity of her suffering. Rather, what is at stake is the conception of the pathological as the indicator of a special “profile” (psychological or biological) that distinguishes the eating-disordered woman from the women who “escape” disorder. Feminist analysts see no firm boundary on one side of which a state of psychological comfort and stability may be said to exist. They see, rather, only varying degrees of disorder, some more “functional” than others, but all undermining women’s full potential. At one end of this continuum we find anorexia and bulimia, extremes which set into play physiological and psychological dynamics that lead the sufferer into addictive patterns and medical and emotional problems outside the “norms” of behavior and experience. But it is not only anoretics and bulimics whose lives are led into “disorder.” This is a culture in which rigorous dieting and exercise are being engaged in by more and younger girls all the time-girls as young as seven or eight, according to some studies. These little girls live in constant fear- a fear reinforced by the attitudes of the boys in their classes-of gaining a pound and thus ceasing to be “attractive.” They jog daily, count their calories obsessively, and risk serious vitamin deficiencies and delayed reproductive maturation. We may be producing a generation of young, privileged women with severely impaired menstrual, nutritional, and intellectual functioning.
** pp.60-61
* But how can a cultural analysis account for the fact that only “some” girls and women develop full-blown eating disorders, despite the fact that we are all subject to the same sociocultural pressures? Don’t you require the postulation of a distinctive underlying pathology (familial or psychological) to explain why some individuals are more vulnerable than others? The first of these questions is frequently presented by medical professionals as though it dealt a decisive blow to the cultural argument, and it is extraordinary how often it is indeed accepted as a devastating critique. It is based, however, on an important and common misunderstanding (or misrepresentation) of the feminist position as involving the positing of an “identical” cultural situation for all “women” rather than the description of ideological and institutional parameters governing the construction of “gender” in our culture. The difference is crucial, yet even such a sophisticated thinker as Joan Brumberg misses it completely. “Current cultural models,” Brumberg argues, “fail to explain why so many individuals “do not” develop the disease, even though they have been exposed to the same cultural environment.” But of course we are “not” all exposed to “the same cultural environment.” What we “are” all exposed to, rather, are homogenizing and normalizing images and ideologies concerning “femininity” and female beauty. Those images and ideology press for conformity to dominant cultural norms. But people’s identities are not formed “only” through interaction with such images, powerful as they are. The unique configurations (of ethnicity, social class, sexual orientation, religion, genetics, education, family, age, and so forth) that make up each person’s life will determine how each “actual” woman is affected by our culture. The search for distinctive patterns, profiles, and abnormalities underlying anorexia nervosa and bulimia is thus not, as man researchers claim, “conceptually” demanded; a myriad of heterogeneous factors, “family resemblances” rather than essential features, unpredictable combinations of elements, may be at work in determining who turns out to be most susceptible. It may be, too, that patterns and profiles could one be assembled but are now breaking apart under the pressure of an increasingly coercive mass culture with its compelling, fabricated images of beauty and success.
** pp.61-62
* The shallow and unanalyzed conception of slenderness as merely “an external body configuration “rather than” an internal spiritual state,” an ideal without psychological or moral depth, still predominates in the literature on anorexia and bulimia. Why? One explanation is that so long as eating disorders remain situated within a medical model, those who are entrusted with the conceptualization of anorexia and bulimia will be medical professionals who have little experience in or inclination toward cultural interpretation and criticism. But more important is the fact that to begin to incorporate such interpretation and criticism within the medical model would be to transform that model itself. Susceptibility to “images” can still be conceptualized in terms of a passive subject and a mechanical process. To acknowledge, however, that meaning is continually being produced at all levels-by the culture, by the subject, by the clinician as well-and that in a fundamental sense there “is” no body that exists neutrally, outside this process of making meaning, no body that passively awaits the objective deciphering of trained experts, is to question the presuppositions on which much of modern science is built and around which our highly specialized, professionalized, and compartmentalized culture revolves. Or, to put this another way: it is to suggest that the study of the disordered body is as much the proper province of cultural critics in every field and of nonspecialists, ordinary but critically questioning citizens, as it is o the “experts.” This audacious challenge is the legacy of the feminist reconceptualization of eating disorders.
** p.69

### "Environmental and genetic risk factors for eating disorders: What the clinician needs to know" (2009)

Mazzeo, SE; Bulik, CM (2009). "Environmental and genetic risk factors for eating disorders: What the clinician needs to know". Child and Adolescent Psychiatric Clinics of North America. 18 (1): 67–82. doi:10.1016/j.chc.2008.07.003. PMC 2719561. PMID 19014858
* Although genetic research in eating disorders is frankly in its infancy, patients, families, and clinicians are aware of this research and face challenges in incorporating this knowledge into either their personal conceptions of their (or their family member’s) illness, or in the case of clinicians, helping patients and their families to understand the implications of this knowledge. Simplistic nature versus nurture dichotomies are easy to understand, yet rarely capture the complexity of reality, and definitely fail to do so in the case of eating disorders. Clinicians and researchers must become educated in the nuances of gene x environment interplay and avoid perpetuating purely environmental or purely genetic conceptualizations of eating disorder etiology.
* By definition, eating disorders are complex traits. That means that their inheritance pattern in families does not follow traditional Mendelian patterns, and that they are influenced by multiple genetic and environmental factors of small to moderate effect. There is not one gene for anorexia nervosa or one gene for bulimia nervosa. More likely there are a number of genes that code for proteins that influence traits that index vulnerability to these disorders. Complicating the risk picture even further, these genes exist in concert with other genetic factors that may confer protection against eating disorders, along with main effects of risk and protective environments, as well as gene x environment interplay as we discuss in the following section.
* For decades, parenting styles have been unrightfully blamed for causing eating disorders. Considerable care must be taken when discussing gene x environment interplay not to convey the message that somehow parenting is to blame for these pernicious illnesses. Conversely, a purely genetic explanation should not be taken to mean that parents need not examine their parenting style and the influence that might have on their children.
* In addition to having concerns about their own shape and weight, women with eating disorders may similarly be over-concerned about their children’s weight, even when it is well within normal limits. One study found that 15% of mothers with a history of bulimia nervosa had attempted to “slim down” their normal weight infants. Similarly, Waugh and Bulik found that 20% of the mothers with eating disorder histories in their sample tried to change their children’s appearance. Maternal restriction of children’s eating is a concern, as previous research suggests that maternal control of children’s eating interferes with the development of dietary self-regulation. These effects have been found among children as young as two years of age.
* The influence of maternal perceptions on daughters’ eating disordered behavior appears to continue into adolescence and young adulthood. For example, mothers whose daughters engaged in eating disordered behavior were more likely to view their daughters as overweight than were mothers of non-eating disordered daughters (controlling for weight differences between groups). Further, this appearance pressure is not necessarily limited to weight, as mothers of daughters with eating disorder symptomatology also rated their daughters as less attractive than the daughters rated themselves. These results are concerning, as they suggest that daughters who engage in eating disordered behaviors may not only lack a maternal role model of healthy eating, but also feel maternal pressure to lose weight and enhance their appearance. This of course could reflect several complex intergenerational processes. On one hand, mothers may harbor threshold or subthreshold eating disturbances themselves, and their comments or behaviors could reflect their underlying pathology. Alternatively or complementarily, the daughters’ pathology could render them more sensitive to maternal comments that in other situations may be perceived as culturally normative. These environmental experiences could facilitate the expression of an existing genetic predisposition for eating disorder symptomatology.
* One potential pitfall of genetic research on eating disorders is the misinterpretation that environmental factors such as the media do not matter. Western media’s idealization of an ultra-thin female body type has long been viewed as an important sociocultural risk factor for eating disorders. However, given the ubiquity of this influence in Western cultures, other factors must influence vulnerability to the thin cultural ideal. As Bulik suggests, genetically vulnerable individuals might seek out experiences, such as exposure to thin-ideal media images, which reinforce their negative body image. This hypothesis is supported by a longitudinal study which found that adolescent girls whose eating disorder symptomatology increased over a 16 month period also reported significantly greater fashion magazine reading at Time 2, compared with Time.
* Similarly, individuals genetically predisposed to eating disorder symptomatology such as thin-ideal internalization might also actively choose to affiliate with peers who place a similar high value on weight and appearance. One potential example of this form of active selection could be the decision to join a sorority (particularly for European-American women). European-American sorority members report high levels of eating disorder symptomatology, including weight preoccupation, drive for thinness, and body dissatisfaction. A longitudinal study found that sorority and non-sorority members did not differ on three measures of disordered eating (EDI Drive for Thinness, Body Dissatisfaction, and Bulimia) at Time 1 and Time 2 (first and second year of undergraduate, respectively). However, by Time 3 (third year of undergraduate), non-members’ drive for thinness scores had decreased, while members’ scores on this measure remained roughly the same, and this difference was statistically significant. Thus, the authors concluded that characteristics of the sorority environment could contribute to the persistence of a higher degree of drive for thinness. Although this study did not include a measure of actual or putative genetic vulnerability to eating disorders, it is plausible to speculate that an environment that promotes the maintenance of eating disordered characteristics would be particularly problematic for a genetically vulnerable individual.
* One fascinating and modifiable environmental factor that has emerged as a possible buffer against the development of eating disorders in adolescent girls is family meals. Likewise, breakfast eating may also play a role in preventing the development of eating problems. For example, Fernández-Aranda and colleagues found that women with eating disorders were less likely to have eaten breakfast regularly during childhood compared to non-eating disordered controls. Although retrospective, these findings are consistent with those of a large (n = 2216), longitudinal study which found that breakfast eating frequency was inversely associated with dieting and weight-control behaviors, and positively related to dietary quality and physical activity in adolescents. Overall, these studies offer preliminary insight into potential buffers against eating disorders; however, research in this area has not yet progressed to assess the differential effect of these protective factors in individuals at high-risk for eating disorders versus the general population.
* Another factor that offers promise as a potential buffer against the development of eating disorders is the enhancement of emotion regulation skills. As noted above, individuals with eating disorders experience relatively high levels of perceived stress and difficulties regulating emotion. Thus, interventions aimed at enhancing emotion regulation skills might be of particular benefit to high-risk groups. However, research incorporating mindfulness techniques has not specifically targeted high-risk groups. For example, a recent study investigated the effectiveness of a primary prevention program incorporating elements of mindfulness (e.g., yoga), targeting fifth-grade girls. This program integrated mindfulness into an empirically-based curriculum, which also included other elements, such as media literacy, and the promotion of dissonance regarding idealization of an ultra-slim body type. Compared to a control group, girls in the intervention reported lower body dissatisfaction and uncontrolled eating, and higher social self-concept at post-testing. However, there were no significant changes on other variables assessed including drive for thinness, perceived stress, physical self-concept and perceived competence. Nonetheless, these outcomes do provide some support for the inclusion of mindfulness-based activities in prevention. In contrast, a study with undergraduate women did not find any differences between participants in a yoga program and a control group on eating disorder symptoms at post-testing. Future studies should target high-risk groups, to evaluate the efficacy of mindfulness-based techniques within this specific sample.
* Results from focus groups and clinical case studies suggest that mothers with eating disorders are eager to learn about how best to care for their children, especially with respect to feeding. However, they report that the level of assistance they desire is not routinely offered by their health care providers. In one of the only published interventions conducted with this population, Stein et al. studied 80 mothers with eating disorders and their four to six month old infants to test whether a 13 session intervention of video-feedback treatment in conjunction with cognitive behavioral self-help was more effective than cognitive behavioral self-help alone in reducing mealtime conflict and other aspects of maternal-child interaction. Those mothers in the video-feedback group exhibited significantly less conflict than control mothers as well as significant improvements in infant autonomy and several other interaction measures. In addition, maternal eating psychopathology was reduced across both groups. Such interventions could help break the “cycle of risk” associated with eating disorders, by providing parents with useful buffering strategies.
* Patients read enormous amounts about their illness and are often aware of the genetic research on eating disorders yet they struggle to understand what the data mean for them and the challenges they face every day during recovery. Helping patients to understand the genetic literature is a first step. Although they might not initially see its relevance to their situation, helping them map how disordered eating and temperamental traits track in their families by using techniques such as labeling family trees can provide a useful context for understanding genetic and environmental contributions to their current situation. An understanding of genetic and environmental interplay can provide them with an explanatory model for not only their illness, but also for understanding their sensitivity to the environment. It can help provide them with the motivation to acquire skills that may help buffer them from the environment and combat their biology most effectively.

### "Personality profiles in eating disorders: rethinking the distinction between axis I and axis II" (2001)

Westen, D; Harnden-Fischer, J (2001). "Personality profiles in eating disorders: rethinking the distinction between axis I and axis II". The American Journal of Psychiatry. 158 (4): 547–62. doi:10.1176/appi.ajp.158.4.547. PMID 11282688.
* Clinical observation has long suggested a link between personality and eating disorders. Research has consistently linked anorexia (particularly when the patient does not also have bulimic symptoms) to personality traits such as introversion, conformity, perfectionism, rigidity, and obsessive-compulsive features. The picture for bulimia is more mixed. Traits such as perfectionism, shyness, and compliance have consistently emerged in studies of individuals with bulimia or with anorexia, although research has often found bulimic patients to be extroverted, histrionic, and affectively unstable. Research on personality disorders has also examined the relation between eating disorders and personality and has documented considerable, but highly variable, rates of comorbidity, ranging from 21% to 97% for the presence of any personality disorder in patients with various eating disorder diagnoses. Conversely, patients with personality disorders have a higher than normal prevalence rate for eating disorders. The situation is similar for many axis I disorders, such as mood and anxiety disorders, for which comorbidity with axis II disorders hovers around 50%.
* The findings of this study raise questions about the concept of comorbidity as applied to eating disorders and suggest the likely utility for both research and clinical practice of considering eating-disordered symptoms in their characterological context (e.g., references 12, 34). The data from this study suggest that individuals who develop eating disorders who are constricted in most areas of their lives—e.g., who are passive and unassertive, emotionally constricted, and interpersonally avoidant—are likely to express this pattern with anorexic, rather than bulimic behavior. Clinically, these patients tend to be just as constricted in their sexual lives as they are with food, denying themselves pleasure, avoiding sexual relationships, feeling too ashamed or guilty to indicate to their partners what feels good, and so forth. Conversely, individuals with eating disorders whose ability to regulate their impulses and affects is tenuous—as expressed in spiraling emotions, tantrums, clinging to others for soothing, self-mutilation, and other impulsive acts—are likely to lose control over their eating in binges and to use self-destructive compensatory measures such as vomiting that momentarily help them regulate their affects. From this point of view, the question of whether bulimic symptoms should be regarded as impulsive behavior may be misplaced. The answer is probably that it depends on the personality configuration within which bulimic symptoms are contextualized. In low-functioning, emotionally dysregulated, type II bulimic patients, binge eating and purging may be functional equivalents of substance abuse, self-mutilation, and promiscuity. For these patients, bulimic symptoms may represent desperate efforts to regulate intense negative affects that call for immediate, and often maladaptive, responses. In contrast, high-functioning, perfectionistic, type I bulimic patients do not struggle with affects of the same intensity, and they have more adaptive coping strategies at their disposal for dealing with their distress. For these patients, binge eating is not equivalent to impulsive behaviors such as drinking or self-mutilation. More broadly, the data suggest that eating-disordered symptoms can be one expression, albeit a highly visible and sometimes life-threatening one, of a more general pattern of impulse and affect regulation. Thus, treating eating disorders primarily as disorders of food intake—and hence focusing primarily on altering the behavior, providing nutritional information (to patients who often know more about calories than the nutritionists who work with them), and so forth—may be taking the symptoms too literally. As in the treatment of trauma survivors, safety must be the clinician’s primary concern in treating patients with eating disorders when their symptoms are life-threatening or pose serious consequences for their current or future health. Particularly at those times, pharmacological and cognitive behavioral interventions can be essential components of a treatment plan, as they may be at various other points in the treatment.
* At the same time, however, symptom-focused treatment strategies may fail to address the personality structure that provides a context for understanding disordered eating. Patients whose personality profiles match the overcontrolled, constricted prototype, for example, rarely recognize their stance toward their own impulses and relationships as a problem. What brings them into treatment is typically someone else’s concern about their weight. If their attitudes toward their needs and feelings in general (and not just toward food) do not become the object of therapeutic attention, they are likely to change with treatment from being starving, unhappy, isolated, and emotionally constricted people to being relatively well fed, unhappy, isolated, and emotionally constricted people. The data also raise questions about the extent to which axis II is adequate for describing clinically meaningful patterns of personality pathology, at least for women with eating disorders. Patients in the high-functioning/perfectionistic cluster generally lacked diagnosable axis II pathology; indeed, in our study (as in the other studies that have isolated a similar cluster), they were defined by the absence of such pathology. These patients are articulate, conscientious, and empathic, and they tend to elicit liking in others. Yet they clearly have personality pathology—that is, enduring, problematic patterns of thought, feeling, motivation, and behavior. They are self-critical, perfectionistic, competitive, anxious, and guilt-ridden, and these aspects of their personality require clinical attention. The data reported here make sense in light of other findings that roughly 60% of patients treated for clinically significant personality pathology do not have problems severe enough to be diagnosable on axis II and that their personality problems (e.g., perfectionism and chronic feelings of guilt) generally are not reducible to any axis I syndrome (21, 22). Available data suggest that these patients represent the majority of patients treated in clinical practice and are not simply the “worried well.” Either axis II needs to be expanded from a personality disorderaxis to a personalityaxis that includes the range of functioning (from relatively healthy to relatively impaired), or subtypes such as those uncovered here need to be built into axis I. From a methodological standpoint, the results of this study suggest that we should routinely test for subtypes in our data sets rather than assuming homogeneity of categories. Group means may not be very meaningful when substantial intracategory heterogeneity exists, particularly if this heterogeneity is ordered, not random. The problem is particularly pronounced if pathology can be expressed in phenotypically opposite directions, leading to means that cancel out patterned within-group variability. Thus, although the etiological data on sexual abuse reported here are correlational and preliminary, they suggest that the same risk factor—sexual abuse—may manifest in opposite personality and behavioral styles—constriction and inhibition on the one hand, and dyscontrol and promiscuity on the other. Whether this is true of other etiologically significant psychosocial variables, such as harsh parental criticism (which, from a clinical point of view, appears sometimes to lead to self-criticism, sometimes to hostility and criticism toward others, and sometimes to both in adulthood), is an important question for future research.

## See also

* Anorexia nervosa
* Bulimia nervosa
* Binge eating
* Body
* Diet
* Exercise
* Food
* Force-feeding
* Gluttony
* Hunger
* Obesity
* Starvation