Eating Disorders

Facts About Eating Disorders and the Search for Solutions

DEPARTMENT OF HEALTH AND HUMAN SERVICES PUBLIC HEALTH SERVICE NATIONAL INSTITUTES OF HEALTH NIMI

I•I

National Institute

of Mental Health 
For more information on research into the brain, behavior, and

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ating is controlled by

many factors, including

appetite, food

availability, family, peer,

and cultural practices,

and attempts at 

voluntary control. Dieting to a body weight leaner than

needed for health is highly promoted by current fashion

trends, sales campaigns for special foods, and in some

activities and professions. Eating disorders involve

serious disturbances in eating behavior, such as extreme

and unhealthy reduction of food intake or severe

overeating, as well as feelings of distress or extreme

concern about body shape or weight. Researchers are

investigating how and why initially voluntary behaviors,

such as eating smaller or larger amounts of food than

usual, at some point move beyond control in some people

and develop into an eating disorder. Studies on the basic

biology of appetite control and its alteration by prolonged

overeating or starvation have uncovered enormous

complexity, but in the long run have the potential to lead

to new pharmacologic treatments for eating disorders.

E
Eating disorders are not due to a failure of will or behavior;

rather, they are real, treatable medical illnesses in which certain

maladaptive patterns of eating take on a life of their own. The main

types of eating disorders are anorexia nervosa and bulimia nervosa.1

A third type, binge-eating disorder, has been suggested but has not

yet been approved as a formal psychiatric diagnosis.2 Eating

disorders frequently develop during adolescence or early adulthood,

but some reports indicate their onset can occur during childhood or

later in adulthood.3

Eating disorders frequently co-occur with other psychiatric

disorders such as depression, substance abuse, and anxiety

disorders.1 In addition, people who suffer from eating disorders can

experience a wide range of physical health complications, including

serious heart conditions and kidney failure which may lead to death.

Recognition of eating disorders as real and treatable diseases,

therefore, is critically important. 

Females are much more likely than males to develop an eating

disorder. Only an estimated 5 to 15 percent of people with anorexia

or bulimia4 and an estimated 35 percent of those with binge-eating

disorder5 are male. 

Anorexia Nervosa

An estimated 0.5 to 3.7 percent of females suffer from anorexia

nervosa in their lifetime.1 Symptoms of anorexia nervosa include:

■ Resistance to maintaining body weight at or above a minimally

normal weight for age and height

■ Intense fear of gaining weight or becoming fat, even though

underweight

■ Disturbance in the way in which one’s body weight or shape is

experienced, undue influence of body weight or shape on selfevaluation, or denial of the seriousness of the current low body

weight
■ Infrequent or absent menstrual periods (in females who have

reached puberty)

People with this disorder see themselves as overweight even

though they are dangerously thin. The process of eating becomes an

obsession. Unusual eating habits develop, such as avoiding food and

meals, picking out a few foods and eating these in small quantities,

or carefully weighing and portioning food. People with anorexia may

repeatedly check their body weight, and many engage in other

techniques to control their weight, such as intense and compulsive

exercise, or purging by means of vomiting and abuse of laxatives,

enemas, and diuretics. Girls with anorexia often experience a

delayed onset of their first menstrual period.

The course and outcome of anorexia nervosa vary across

individuals: some fully recover after a single episode; some have a

fluctuating pattern of weight gain and relapse; and others experience a chronically deteriorating course of illness over many years.

The mortality rate among people with anorexia has been estimated

at 0.56 percent per year, or approximately 5.6 percent per decade,

which is about 12 times higher than the annual death rate due to all

causes of death among females ages 15-24 in the general population.6 The most common causes of death are complications of the

disorder, such as cardiac arrest or electrolyte imbalance, and suicide. 

Bulimia Nervosa

An estimated 1.1 percent to 4.2 percent of females have bulimia

nervosa in their lifetime.1 Symptoms of bulimia nervosa include:

■ Recurrent episodes of binge eating, characterized by eating an

excessive amount of food within a discrete period of time and by a

sense of lack of control over eating during the episode

■ Recurrent inappropriate compensatory behavior in order to

prevent weight gain, such as self-induced vomiting or misuse of

laxatives, diuretics, enemas, or other medications (purging); fasting;

or excessive exercise
■ The binge eating and inappropriate compensatory behaviors

both occur, on average, at least twice a week for 3 months

■ Self-evaluation is unduly influenced by body shape and weight

Because purging or other compensatory behavior follows the

binge-eating episodes, people with bulimia usually weigh within the

normal range for their age and height. However, like individuals with

anorexia, they may fear gaining weight, desire to lose weight, and

feel intensely dissatisfied with their bodies. People with bulimia

often perform the behaviors in secrecy, feeling disgusted and

ashamed when they binge, yet relieved once they purge. 

Binge-Eating Disorder

Community surveys have estimated that between 2 percent and 5

percent of Americans experience binge-eating disorder in a 6-month

period.5,7 Symptoms of binge-eating disorder include:

■ Recurrent episodes of binge eating, characterized by eating an

excessive amount of food within a discrete period of time and by a

sense of lack of control over eating during the episode

■ The binge-eating episodes are associated with at least 3 of the

following: eating much more rapidly than normal; eating until

feeling uncomfortably full; eating large amounts of food when not

feeling physically hungry; eating alone because of being

embarrassed by how much one is eating; feeling disgusted with

oneself, depressed, or very guilty after overeating

■ Marked distress about the binge-eating behavior

■ The binge eating occurs, on average, at least 2 days a week for

6 months

■ The binge eating is not associated with the regular use of

inappropriate compensatory behaviors (e.g., purging, fasting,

excessive exercise)

People with binge-eating disorder experience frequent episodes

of out-of-control eating, with the same binge-eating symptoms as
those with bulimia. The main difference is that individuals with

binge-eating disorder do not purge their bodies of excess calories.

Therefore, many with the disorder are overweight for their age and

height. Feelings of self-disgust and shame associated with this

illness can lead to bingeing again, creating a cycle of binge eating. 

Treatment Strategies1

Eating disorders can be treated and a healthy weight restored. The

sooner these disorders are diagnosed and treated, the better the

outcomes are likely to be. Because of their complexity, eating

disorders require a comprehensive treatment plan involving medical

care and monitoring, psychosocial interventions, nutritional

counseling and, when appropriate, medication management. At the

time of diagnosis, the clinician must determine whether the person

is in immediate danger and requires hospitalization. 

Treatment of anorexia calls for a specific program that involves

three main phases: (1) restoring weight lost to severe dieting and

purging; (2) treating psychological disturbances such as distortion of

body image, low self-esteem, and interpersonal conflicts; and

(3) achieving long-term remission and rehabilitation, or full recovery.

Early diagnosis and treatment increase the treatment success rate.

Use of psychotropic medication in people with anorexia should be

considered only after weight gain has been established. Certain

selective serotonin reuptake inhibitors (SSRIs) have been shown to

be helpful for weight maintenance and for resolving mood and

anxiety symptoms associated with anorexia.

The acute management of severe weight loss is usually

provided in an inpatient hospital setting, where feeding plans

address the person’s medical and nutritional needs. In some cases,

intravenous feeding is recommended. Once malnutrition has been

corrected and weight gain has begun, psychotherapy (often

cognitive-behavioral or interpersonal psychotherapy) can help people
with anorexia overcome low self-esteem and address distorted

thought and behavior patterns. Families are sometimes included in

the therapeutic process.

The primary goal of treatment for bulimia is to reduce or

eliminate binge eating and purging behavior. To this end, nutritional

rehabilitation, psychosocial intervention, and medication

management strategies are often employed. Establishment of a

pattern of regular, non-binge meals, improvement of attitudes related

to the eating disorder, encouragement of healthy but not excessive

exercise, and resolution of co-occurring conditions such as mood or

anxiety disorders are among the specific aims of these strategies.

Individual psychotherapy (especially cognitive-behavioral or

interpersonal psychotherapy), group psychotherapy that uses a

cognitive-behavioral approach, and family or marital therapy have

been reported to be effective. Psychotropic medications, primarily

antidepressants such as the selective serotonin reuptake inhibitors

(SSRIs), have been found helpful for people with bulimia,

particularly those with significant symptoms of depression or

anxiety, or those who have not responded adequately to psychosocial

treatment alone. These medications also may help prevent relapse.

The treatment goals and strategies for binge-eating disorder are

similar to those for bulimia, and studies are currently evaluating the

effectiveness of various interventions. 

People with eating disorders often do not recognize or admit

that they are ill. As a result, they may strongly resist getting and

staying in treatment. Family members or other trusted individuals

can be helpful in ensuring that the person with an eating disorder

receives needed care and rehabilitation. For some people, treatment

may be long term. 
Research Findings and Directions

Research is contributing to advances in the understanding and

treatment of eating disorders. 

■ NIMH-funded scientists and others continue to investigate the

effectiveness of psychosocial interventions, medications, and the

combination of these treatments with the goal of improving

outcomes for people with eating disorders.8,9

■ Research on interrupting the binge-eating cycle has shown that

once a structured pattern of eating is established, the person

experiences less hunger, less deprivation, and a reduction in negative

feelings about food and eating. The two factors that increase the

likelihood of bingeing—hunger and negative feelings—are reduced,

which decreases the frequency of binges.10

■ Several family and twin studies are suggestive of a high

heritability of anorexia and bulimia,11,12 and researchers are

searching for genes that confer susceptibility to these disorders.13

Scientists suspect that multiple genes may interact with

environmental and other factors to increase the risk of developing

these illnesses. Identification of susceptibility genes will permit the

development of improved treatments for eating disorders. 

■ Other studies are investigating the neurobiology of emotional

and social behavior relevant to eating disorders and the

neuroscience of feeding behavior. 

■ Scientists have learned that both appetite and energy

expenditure are regulated by a highly complex network of nerve cells

and molecular messengers called neuropeptides.14,15 These and future

discoveries will provide potential targets for the development of new

pharmacologic treatments for eating disorders. 

■ Further insight is likely to come from studying the role of

gonadal steroids.16,17 Their relevance to eating disorders is suggested

by the clear gender effect in the risk for these disorders, their

emergence at puberty or soon after, and the increased risk for eating

disorders among girls with early onset of menstruation. 
For More Information

National Institute of Mental Health (NIMH)

Office of Communications and Public Liaison

Public Inquiries: (301) 443-4513

Media Inquiries: (301) 443-4536

E-mail: nimhinfo@nih.gov; Web site: http://www.nimh.nih.gov

American Anorexia Bulimia Association, Inc.

Phone: (212) 575-6200; Web site: http://www.aabainc.org

Eating Disorders Awareness and Prevention, Inc.

Phone: 1 (800) 931-2237; Web site: http://www.edap.org

Harvard Eating Disorders Center

Phone: 1 (888) 236-1188 ext. 100; Web site: http://www.hedc.org

National Association of Anorexia Nervosa and Associated Disorders

Phone: (847) 831-3438; Web site: http://www.anad.org

References 1

American Psychiatric Association Work Group on Eating Disorders.

Practice guideline for the treatment of patients with eating disorders

(revision). American Journal of Psychiatry, 2000; 157(1 Suppl): 1-39. 2

American Psychiatric Association. Diagnostic and Statistical Manual

for Mental Disorders, fourth edition (DSM-IV). Washington, DC: American

Psychiatric Press, 1994. 3

Becker AE, Grinspoon SK, Klibanski A, Herzog DB. Eating disorders.

New England Journal of Medicine, 1999; 340(14): 1092-8. 4

Andersen AE. Eating disorders in males. In: Brownell KD, Fairburn CG,

eds. Eating disorders and obesity: a comprehensive handbook. New York:

Guilford Press, 1995; 177-87. 5

Spitzer RL, Yanovski S, Wadden T, Wing R, Marcus MD, Stunkard A,

Devlin M, Mitchell J, Hasin D, Horne RL. Binge eating disorder: its further

validation in a multisite study. International Journal of Eating Disorders,

1993; 13(2): 137-53. 6

Sullivan PF. Mortality in anorexia nervosa. American Journal of

Psychiatry, 1995; 152(7): 1073-4. 7

Bruce B, Agras WS. Binge eating in females: a population-based

investigation. International Journal of Eating Disorders, 1992; 12: 365-73.
8

Agras WS. Pharmacotherapy of bulimia nervosa and binge eating

disorder: longer-term outcomes. Psychopharmacology Bulletin, 1997; 33(3):

433-6. 9

Wilfley DE, Cohen LR. Psychological treatment of bulimia nervosa and

binge eating disorder. Psychopharmacology Bulletin, 1997; 33(3): 437-54. 10Apple RF, Agras WS. Overcoming eating disorders. A cognitivebehavioral treatment for bulimia and binge-eating disorder. San Antonio:

Harcourt Brace & Company, 1997. 11Strober M, Freeman R, Lampert C, Diamond J, Kaye W. Controlled

family study of anorexia nervosa and bulimia nervosa: evidence of shared

liability and transmission of partial syndromes. American Journal of

Psychiatry, 2000; 157(3): 393-401. 12Walters EE, Kendler KS. Anorexia nervosa and anorexic-like

syndromes in a population-based female twin sample. American Journal of

Psychiatry, 1995; 152(1): 64-71. 13Kaye WH, Lilenfeld LR, Berrettini WH, Strober M, Devlin B, Klump KL,

Goldman D, Bulik CM, Halmi KA, Fichter MM, Kaplan A, Woodside DB,

Treasure J, Plotnicov KH, Pollice C, Rao R, McConaha CW. A search for

susceptibility loci for anorexia nervosa: methods and sample description.

Biological Psychiatry, 2000; 47(9): 794-803. 14Frank GK, Kaye WH, Altemus M, Greeno CG. CSF oxytocin and

vasopressin levels after recovery from bulimia nervosa and anorexia

nervosa, bulimic subtype. Biological Psychiatry, 2000; 48(4): 315-8. 15Elias CF, Kelly JF, Lee CE, Ahima RS, Drucker DJ, Saper CB, Elmquist JK.

Chemical characterization of leptin-activated neurons in the rat brain.

Journal of Comparative Neurology, 2000; 423(2): 261-81. 16Devlin MJ, Walsh BT, Katz JL, Roose SP, Linkei DM, Wright L, Vande

Wiele R, Glassman AH. Hypothalamic-pituitary-gonadal function in anorexia

nervosa and bulimia. Psychiatry Research, 1989; 28(1): 11-24. 17Flanagan-Cato LM, King JF, Blechman JG, O’Brien MP. Estrogen reduces

cholecystokinin-induced c-Fos expression in the rat brain.

Neuroendrocrinology, 1998; 67(6): 384-91.

This publication was written by Melissa Spearing, Office of Communications and

Public Liaison, National Institute of Mental Health (NIMH). Expert assistance was

provided by NIMH Director Steven E. Hyman, M.D., and staff members Bruce N.

Cuthbert, Ph.D., Regina Dolan-Sewell, Ph.D., Benedetto Vitiello, Ph.D., Clarissa K.

Wittenberg, and Constance Burr. Editorial assistance was provided by Margaret

Strock and Lisa D. Alberts, also NIMH staff members.

All material in this publication is in the public domain and may be copied or

reproduced without permission of the Institute. Citation of the source is

appreciated.
NIH Publication No. 01-4901

Printed 2001