Eating Disorders

Facts About Eating Disorders and the Search for Solutions 

DEPA RT MENT OF HEALTH AND HUMAN SERVICES HEALTH SERVICE TIONAL I NSTITUTES O F HEALTH 

of Mental Health 

National Institute 

I •I

I

PUBLIC NA NIM
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E

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. 
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 self-


evaluation, 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. 
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


Harvard Eating Disorders Center


c/o Massachusetts General Hospital 


15 Parkman Street


Boston, MA 02114


Phone: (617) 726-8470 

Web site: http://www.hedc.org


National Association of Anorexia Nervosa and Associated Disorder

P.O. Box 7


Highland Park, IL 60035


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


National Eating Disorders Association


603 Stewart Street, Suite 803


Seattle, WA 98101


Phone: (206) 382-3587: Web site: http://www.nationaleatingdisorde

1

American Psychiatric Association Work Group on Eating Diso

Practice guideline for the treatment of patients with eating disorde

(revision). American Journal of Psychiatry, 2000; 157(1 Suppl): 1-3

2

American Psychiatric Association. Diagnostic and Statistical M

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

Psychiatric Press, 1994. 3

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

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

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

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

Guilford Press, 1995; 177-87. 5

Spitzer RL, Yanovski S, Wadden T, Wing R, Marcus MD, Stunk

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

validation in a multisite study. International Journal of Eating Diso

1993; 13(2): 137-53. 

For More Information

References
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-base

investigation. International Journal of Eating Disorders, 1992; 12: 3

8

Agras WS. Pharmacotherapy of bulimia nervosa and binge eat

disorder: longer-term outcomes. Psychopharmacology Bulletin, 1997

433-6. 9

Wilfley DE, Cohen LR. Psychological treatment of bulimia nerv

binge eating disorder. Psychopharmacology Bulletin, 1997; 33(3): 43

10Apple RF, Agras WS. Overcoming eating disorders. A cognitive

behavioral treatment for bulimia and binge-eating disorder. San Ant

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

family study of anorexia nervosa and bulimia nervosa: evidence of 

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 Jou

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

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

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

susceptibility loci for anorexia nervosa: methods and sample descrip

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, Elm

Chemical characterization of leptin-activated neurons in the rat brai

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

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

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

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 

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

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

Cuthbert, Ph.D., Regina Dolan-Sewell, Ph.D., Benedetto Vitiello, Ph.D., Claris

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

Strock and Lisa D. Alberts, also NIMH staff members. 
NIH Publication No. 01-4901


Printed 2001

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