EATING

DISORDERS

NATIONAL INSTITUTE OF MENTAL HEALTH

eating 

Disorders

National Institute of mental health

Table

of

contents

TWO what are eating disorders ?

FIVE anorexia nervosa

nine bulimia nervosa

twelve binge-eating disorder

fourteen how are men and boys affected ?

fifteen how are we working to better understand 

and treat eating disorders ?
 

two

What are eating 

Disorders?

an eating disorder

is marked by extremes. It is present when a person experiences 

severe disturbances in eating 

behavior, such as extreme reduction of food intake or extreme 

overeating, or feelings of extreme 

distress or concern about body 

weight or shape.

A person with an eating disorder 

may have started out just eating 

smaller or larger amounts of 

food than usual, but at some 

point, the urge to eat less or 

more spirals out of control. 

Eating disorders are very 

complex, and despite scientific 

research to understand them, 

the biological, behavioral and 

social underpinnings of these 

illnesses remain elusive.
The two main types of eating 

disorders are anorexia nervosa 

and bulimia nervosa. A third 

category is “eating disorders not 

otherwise specified (EDNOS),” 

which includes several variations 

of eating disorders. Most of these 

disorders are similar to anorexia 

or bulimia but with slightly 

different characteristics. Bingeeating disorder, which has received increasing research and 

media attention in recent years, 

is one type of EDNOS.

Eating disorders frequently 

appear during adolescence or 

young adulthood, but some 

reports indicate that they can 

develop during childhood or later 

in adulthood. Women and girls 

are much more likely than males 

to develop an eating disorder. 

Men and boys account for an 

estimated 5 to 15 percent of 

patients with anorexia or bulimia 

and an estimated 35 percent of 

those with binge-eating disorder.

Eating disorders are real, treatable medical illnesses with 

complex underlying psychological 

and biological causes. They 

frequently co-exist with other 

psychiatric disorders such as 

depression, substance abuse, or 

anxiety disorders. People with 

eating disorders also can suffer 

from numerous other physical 

health complications, such as 

heart conditions or kidney 

failure, which can lead to death. 
Eating disorders are treatable 

diseases. 

Psychological and medicinal 

treatments are effective for many 

eating disorders. However, in 

more chronic cases, specific 

treatments have not yet been 

identified. 

In these cases, treatment plans 

often are tailored to the 

patient’s individual needs that 

may include medical care 

and monitoring; medications; 

nutritional counseling; and 

individual, group and/or family 

psychotherapy. Some patients 

may also need to be hospitalized 

to treat malnutrition or to gain 

weight, or for other reasons. 

FOUR
Anorexia 

nervosa

anorexia nervosa is 

characterized by emaciation, 

a relentless pursuit of thinness 

and unwillingness to maintain 

a normal or healthy weight, a 

distortion of body image and 

intense fear of gaining weight, 

a lack of menstruation among 

girls and women, and extremely 

disturbed eating behavior. Some 

people with anorexia lose weight 

by dieting and exercising excessively; others lose weight by 

self-induced vomiting, or misusing 

laxatives, diuretics or enemas.

Many people with anorexia see 

themselves as overweight, even 

when they are starved or are 

clearly malnourished. Eating, food 

and weight control become obsessions. A person with anorexia 

typically weighs herself or himself 

repeatedly, portions food carefully, and eats only very small 

quantities of only certain foods. 

Some who have anorexia recover with treatment after only 

one episode. Others get well but 

have relapses. Still others have a 

more chronic form of anorexia, 

in which their health deteriorates 

over many years as they battle 

the illness.
six

According to some studies, 

people with anorexia are up 

to ten times more likely to 

die as a result of their illness 

compared to those without 

the disorder. The most common 

complications that lead to death 

are cardiac arrest, and electrolyte and fluid imbalances. 

Suicide also can result. 

Many people with anorexia 

also have coexisting psychiatric 

and physical illnesses, including 

depression, anxiety, obsessive 

behavior, substance abuse, 

cardiovascular and neurological 

complications, and impaired 

physical development.

Other symptoms may develop over time, including:

• thinning of the bones (osteopenia or osteoporosis)

• brittle hair and nails

• dry and yellowish skin 

• growth of fine hair over body (e.g., lanugo)

• mild anemia, and muscle weakness and loss

• severe constipation

• low blood pressure, slowed breathing and pulse

• drop in internal body temperature, causing a person 

to feel cold all the time

• lethargy
MTreating anorexia

involves three components :

1. restoring the person to a healthy weight; 

2. treating the psychological issues related to the eating 

disorder; and 

3. reducing or eliminating behaviors or thoughts that lead

to disordered eating, and preventing relapse. 

Some research suggests that 

the use of medications, such as 

antidepressants, antipsychotics 

or mood stabilizers, may be 

modestly effective in treating 

patients with anorexia by helping 

to resolve mood and anxiety 

symptoms that often co-exist 

with anorexia. Recent studies, 

however, have suggested that 

antidepressants may not be 

effective in preventing some 

patients with anorexia from 

relapsing. In addition, no medication has shown to be effective 

during the critical first phase 

of restoring a patient to healthy 

weight. Overall, it is unclear if 

and how medications can help 

patients conquer anorexia, but 

research is ongoing.

Different forms of psychotherapy, 

including individual, group and 

family-based, can help address 

the psychological reasons for the

illness. Some studies suggest that 

family-based therapies in which 

parents assume responsibility 

for feeding their afflicted adolescent are the most effective in 

helping a person with anorexia 

gain weight and improve eating 

habits and moods. Shown to 

be effective in case studies and 

clinical trials, this particular 

approach is discussed in some 

guidelines and studies for treating eating disorders in younger, 

nonchronic patients. 
eight

Others have noted that a 

combined approach of medical 

attention and supportive 

psychotherapy designed specifically for anorexia patients 

is more effective than just 

psychotherapy. But the effectiveness of a treatment depends 

on the person involved and his 

or her situation. Unfortunately, 

no specific psychotherapy appears to be consistently effective 

for treating adults with anorexia. 

However, research into novel 

treatment and prevention 

approaches is showing some 

promise. One study suggests 

that an online intervention 

program may prevent some 

at-risk women from developing 

an eating disorder. 
Bulimia 

nervosa

bulimia nervosa is characterized by recurrent and frequent 

episodes of eating unusually 

large amounts of food (e.g., 

binge-eating), and feeling a lack 

of control over the eating. This 

binge-eating is followed by a type 

of behavior that compensates 

for the binge, such as purging 

(e.g., vomiting, excessive use of 

laxatives or diuretics), fasting 

and/or excessive exercise. 

Unlike anorexia, people with 

bulimia can fall within the normal 

range for their age and weight. 

But like people with anorexia, 

they often fear gaining weight, 

want desperately to lose weight, 

and are intensely unhappy with 

their body size and shape. 

Usually, bulimic behavior is done 

secretly, because it is often 

accompanied by feelings of 

disgust or shame. The binging 

and purging cycle usually repeats 

several times a week.

Similar to anorexia, people with 

bulimia often have coexisting 

psychological illnesses, such as 

depression, anxiety and/or 

substance abuse problems. Many 

physical conditions result from 

the purging aspect of the illness, 

including electrolyte imbalances, 

gastrointestinal problems, and 

oral and tooth-related problems.
ten

Other symptoms include:

• chronically inflamed and sore throat

• swollen glands in the neck and below the jaw

• worn tooth enamel and increasingly sensitive and decaying 

teeth as a result of exposure to stomach acids 

• gastroesophageal reflux disorder

• intestinal distress and irritation from laxative abuse

• kidney problems from diuretic abuse

• severe dehydration from purging of fluids
As with anorexia,

TREATMENT FOR BULIMIA

often involves a combination of options and

depends on the needs of the individual. 

To reduce or eliminate binge 

and purge behavior, a patient 

may undergo nutritional counseling and psychotherapy, especially 

cognitive behavioral therapy 

(CBT), or be prescribed medication. Some antidepressants, such 

as fluoxetine (Prozac), which is 

the only medication approved 

by the U.S. Food and Drug 

Administration for treating 

bulimia, may help patients who 

also have depression and/or 

anxiety. It also appears to help 

reduce binge-eating and purging 

behavior, reduces the chance 

of relapse, and improves eating 

attitudes. 

CBT that has been tailored 

to treat bulimia also has shown 

to be effective in changing 

binging and purging behavior, 

and eating attitudes. Therapy 

may be individually oriented 

or group-based.
twelve

binge-eating 

disorder

Binge-eating disorder

is characterized by recurrent 

binge-eating episodes during 

which a person feels a loss of 

control over his or her eating. 

Unlike bulimia, binge-eating 

episodes are not followed by 

purging, excessive exercise 

or fasting. As a result, people 

with binge-eating disorder often 

are overweight or obese. They 

also experience guilt, shame 

and/or distress about the bingeeating, which can lead to more 

binge-eating.

Obese people with binge-eating 

disorder often have coexisting 

psychological illnesses including 

anxiety, depression, and personality disorders. In addition, links 

between obesity and cardiovascular disease and hypertension 

are well documented.

TReatment options for 

Binge-eating Disorder 

are similar to those used to treat bulimia.

Fluoxetine and other antidepressants may reduce binge-eating 

episodes and help alleviate

depression in some patients. 

Patients with binge-eating 

disorder also may be prescribed 

appetite suppressants. 
Psychotherapy, especially CBT, is 

also used to treat the underlying 

psychological issues associated 

with binge-eating, in an individual 

or group environment. 

FDA WARNINGS ON 

ANTIDEPRESSANTS:

Despite the relative safety and 

popularity of selective serotonin 

reuptake inhibitors (SSRIs) and 

other antidepressants, some 

studies have suggested that they 

may have unintentional effects on 

some people, especially adolescents and young adults. In 2004, 

after a thorough review of data, 

the Food and Drug Administration (FDA) adopted a “black box” 

warning label on all antidepressant medications to alert the 

public about the potential increased risk of suicidal thinking 

or attempts in children and 

adolescents taking antidepressants. In 2007, the FDA proposed 

that makers of all antidepressant 

medications extend the warning 

to include young adults up 

through age 24. A “black box” 

warning is the most serious type 

of warning on prescription drug 

labeling. The warning emphasizes 

that children, adolescents and 

young adults taking antidepressants should be closely monitored, 

especially during the initial weeks 

of treatment, for any worsening 

depression, suicidal thinking or 

behavior, or any unusual changes in 

behavior such as sleeplessness, 

agitation, or withdrawal from 

normal social situations. However, 

results of a comprehensive review 

of pediatric trials conducted 

between 1988 and 2006 suggested 

that the benefits of antidepressant 

medications likely outweigh their 

risks to children and adolescents 

with major depression and anxiety 

disorders. The study was partially 

funded by the National Institute 

of Mental Health.
fourteen

How are men AND 

BOYS AFFECTED?

Although eating disorders 

primarily affect women and 

girls, boys and men are also 

vulnerable. One in four preadolescent cases of anorexia 

occurs in boys, and binge-eating 

disorder affects females 

and males about equally. 

Like females who have eating 

disorders, males with the illness 

have a warped sense of body 

image and often have muscle 

dysmorphia, a type of disorder 

that is characterized by an 

extreme concern with becoming 

more muscular. Some boys 

with the disorder want to lose 

weight, while others want to 

gain weight or “bulk up.” Boys 

who think they are too small 

are at a greater risk for using 

steroids or other dangerous 

drugs to increase muscle mass.

Boys with eating disorders 

exhibit the same types of emotional, physical and behavioral 

signs and symptoms as girls, but 

for a variety of reasons, boys 

are less likely to be diagnosed 

with what is often considered a 

stereotypically “female” disorder.
How are we working to 

better understand and

treat eating disorders?

Researchers are unsure of 

the underlying causes and 

nature of eating disorders. 

Unlike a neurological disorder, 

which generally can be pinpointed to a specific lesion on the 

brain, an eating disorder likely 

involves abnormal activity distributed across brain systems. 

With increased recognition 

that mental disorders are brain 

disorders, more researchers 

are using tools from both modern neuroscience and modern 

psychology to better understand 

eating disorders. 

One approach involves the study 

of the human genes. With the 

publication of the human genome sequence in 2003, mental 

health researchers are studying 

the various combinations of 

genes to determine if any DNA

variations are associated with 

the risk of developing a mental 

disorder. Neuroimaging, such as 

the use of magnetic resonance 

imaging (MRI), may also lead 

to a better understanding of 

eating disorders.

Neuroimaging already is used 

to identify abnormal brain activity in patients with schizophrenia, 

obsessive-compulsive disorder 

and depression. It may also help 

researchers better understand 

how people with eating disorders 

process information, regardless 

of whether they have recovered 

or are still in the throes of 

their illness. 

Conducting behavioral or psychological research on eating 

disorders is even more complex 

and challenging. As a result, 

few studies of treatments for 

eating disorders have been 

conducted in the past. New 

studies currently underway, 

however, are aiming to remedy 

the lack of information available 

about treatment.
SIXTEEN

Researchers also are working 

to define the basic processes of 

the disorders, which should help 

identify better treatments. 

For example, is anorexia the 

result of skewed body image, 

self esteem problems, obsessive 

thoughts, compulsive behavior, 

or a combination of these? 

Can it be predicted or identified 

as a risk factor before drastic 

weight loss occurs, and therefore avoided? 

These and other questions may 

be answered in the future as 

scientists and doctors think of 

eating disorders as medical 

illnesses with certain biological 

causes. Researchers are studying 

behavioral questions, along with 

genetic and brain systems 

information, to understand risk 

factors, identify biological markers and develop medications 

that can target specific pathways 

that control eating behavior. 

Finally, neuroimaging and genetic 

studies may also provide clues 

for how each person may respond 

to specific treatments.

references

Agency for Healthcare Research and Quality 

(AHRQ). Management of Eating Disorders, 

Evidence Report/Technology Assessment, Number 

135, 2006; AHRQ publication number 06-E010, 

www.ahrq.gov.

American Psychiatric Association. Diagnostic and 

Statistical Manual for Mental Disorders, fourth edition 

(DSM-IV). Washington, DC: American Psychiatric 

Press, 1994.

American Psychiatric Association (APA). Let’s Talk 

Facts About Eating Disorders. 2005. Available online 

at http://www.healthyminds.org/letstalkfacts.cfm

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.

Andersen AE. Eating disorders in males. In: Brownell 

KD, Fairburn CG, eds. Eating disorders and obesity: a 

comprehensive handbook. New York: Guilford Press, 

1995; 177-187.

Anderson AE. Eating disorders in males: Critical 

questions. In R Lemberg (ed), Controlling Eating 

Disorders with Facts, Advice and Resources. Phoenix, 

AZ: Oryx Press, 1992, pp.20-28.

Arnold LM, McElroy SL, Hudson JI, Wegele JA, 

Bennet AJ, Kreck PE Jr. A placebo-controlled 

randomized trial of fluoxetine in the treatment of 

binge-eating disorder. Journal of Clinical Psychiatry,

2002; 63:1028-1033.

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

Eating Disorders. New England Journal of Medicine,

1999; 340(14): 1092-1098.

Birmingham CL, Su J, Hlynsky JA, Goldner EM, Gao M. 

The mortality rate of anorexia nervosa. International 

Journal of Eating Disorders. 2005 Sep; 38(2):143-146.

Bridge JA, Iyengar S, Salary CB, Barbe RP, Birmaher B, 

Pincus HA, Ren L, Brent DA. Clinical response and risk 

for reported suicidal ideation and suicide attempts in 

pediatric antidepressant treatment, a meta-analysis of 

randomized controlled trials. Journal of the American 

Medical Association, 2007; 297(15): 1683-1696.

Bryant-Waugh R, Lask B. Childhood-onset eating 

disorders. In CG Fairburn, KD Brownell (eds.), Eating 

disorders and obesity: A comprehensive handbook, 

2nd ed. New York: Guilford Press, 2002, pp. 210-214.

Bulik CM, Sullivan PF, Kendler KS. Medical and 

psychiatric comorbidity in obese women with and 

without binge eating disorder. International Journal 

of Eating Disorders, 2002; 32: 72-78.

Eisler I, Dare C, Hodes M, Russel G, Dodge, and Le 

Grange D. Family therapy for adolescent anorexia 

nervosa: The results of a controlled comparison of 

two family interventions. Journal of Child Psychology 

and Psychiatry, 2000; 1: 727-736.

Fitzgerald KD, Welsh RC, Gehring WJ, Abelson 

JL, Himle JA, Liberzon I, Taylor SF. Error-related 

hyperactivity of the anterior cingulated cortex in 

obsessive-compulsive disorder. Biological Psychiatry,

February 1, 2005; 57 (3): 287-294.

Halmi CA, Agras WS, Crow S, Mitchell J, Wilson 

GT, Bryson S, Kraemer HC. Predictors of treatment 

acceptance and completion in anorexia nervosa: 

implications for future study designs. Archives of 

General Psychiatry; 2005; 62: 776-781.

Insel TR and Quirion R. Psychiatry as a clinical 

neuroscience discipline. Journal of the American 

Medical Association, November 2, 2005; 294 (17): 

2221-2224.

Lasater L, Mehler P. Medical complications of bulimia 

nervosa. Eating Behavior, 2001; 2:279-292.

eighteen
Lock J, Agras WS, Bryson S, Kraemer, HC. A

comparison of short-and long-term family therapy

for adolescent anorexia nervosa, Journal of the 

American Academy of Child and Adolescent Psychiatry, 

2005; 44: 632-639.

Lock J, Couturier J, Agras WS. Comparison of 

long-term outcomes in adolescents with anorexia 

nervosa treated with family therapy. Journal of the 

American Academy of Child and Adolescent Psychiatry, 

2006; 45: 666-672.

Lock J, Le Grange D, Agras WS, Dare C. Treatment 

Manual for Anorexia Nervosa: A Family-based 

Approach. New York: Guilford Press, 2001. 

McIntosh VW, Jordan J, Carter FA, Luty SE, et al. 

Three psychotherapies for anorexia nervosa: a 

randomized controlled trial. The American Journal 

of Psychiatry, Apr. 2005; 162: 741-747.

Meyer-Lindenberg AS, Olsen RK, Kohn PD, Brown 

T, Egan MF, Weinberger DR, et al. Regionally 

specific disturbance of dorsolateral prefrontalhippocampal functional connectivity in 

schizophrenia. Archives of General Psychiatry, 

April 2005; 62(4). 

National Institute for Clinical Excellence (NICE). 

Core interventions in the treatment and 

management of anorexia nervosa, bulimia nervosa, 

and binge eating disorder, 2004: London: British 

Psychological Society.

Pezawas L, Meyer-Lindenberg A, Drabant EM, 

Verchinski BA, Munoz KE, Kolachana BS, et al. 5-

HTTLPR polymorphism impacts human cingulatedamygdala interactions: a genetic susceptibility 

mechanism for depression. Nature Neuroscience,

June 2005; 8 (6): 828-834.

Pope HG, Gruber AJ, Choi P, Olivardi R, Phillips KA. 

Muscle dysmorphia: an underrecognized form of 

body dysmorphic disorder. Psychosomatics, 1997; 

38: 548-557.

Romano SJ, Halmi KJ, Sarkar NP, Koke SC, Lee JS. 

A placebo-controlled study of fluoxetine in 

continued treatment of bulimia nervosa after 

successful acute fluoxetine treatment. American 

Journal of Psychiatry, Jan. 2002; 151(9): 96-102.

Russell GF, Szmuckler GI, Dare C, Eisler I. An 

evaluation of family therapy in anorexia nervosa 

and bulimia nervosa. Archives of General Psychiatry,

1987; 44: 1047-1056.

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): 137-153.

Steiner H, Lock J. Anorexia nervosa and bulimia 

nervosa in children and adolescents: a review of the 

past ten years. Journal of the American Academy of 

Child and Adolescent Psychiatry, 1998; 37: 352-359.

Streigel-Moore RH, Franko DL. Epidemiology of 

Binge Eating Disorder. International Journal of Eating 

Disorders, 2003; 21: 11-27.

Taylor CB, Bryson S, Luce KH, Cunning D, Doyle 

AC, Abascal LB, Rockwell R, Dev P, Winzelberg AJ, 

Wilfley DE. Prevention of Eating Disorders in 

At-risk College-age Women. Archives of General 

Psychiatry; 2006 Aug; 63(8):881-888.

Walsh et al. Fluoxetine after weight restoration in 

anorexia nervosa: a randomized controlled trial. 

Journal of the American Medical Association. 2006 

Jun 14; 295(22): 2605-2612.

Wilson GT and Shafran R. Eating disorders 

guidelines from NICE. Lancet, 2005; 365: 79-81.

Wonderlich SA, Lilenfield LR, Riso LP, Engel S, Mitchell 

JE. Personality and anorexia nervosa. International 

Journal of Eating Disorders, 2005; 37: S68-S71.
Visit the National Library of Medicine’s:

MedlinePlus:

www.nlm.nih.gov/medlineplus

En Espanol:

http://medlineplus.gov/spanish

For information on Clinical Trials for Eating Disorders:

www.nimh.nih.gov/studies/index.cfm

National Library of Medicine Clinical Trials Database:

www.clinicaltrials.gov

Information from NIMH is available in multiple formats. You can browse 

online, download documents in PDF, and order paper brochures through 

the mail. If you would like to have NIMH publications, you can order them 

online at: 

www.nimh.nih.gov

for the most up-to-date information on this 

topic, Please check the NIMH website at: 

http://www.nimh.nih.gov

If you do not have Internet access and wish to have information that 

supplements this publication, please contact the NIMH Information 

Center at the following numbers.

National Institute of Mental Health (NIMH)

Science Writing, Press & Dissemination Branch

6001 Executive Boulevard

Room 8184. MSC 9663

Bethesda, MD 20892-9663

for more information on eating disorders...

twenty
Phone............................................................................................301.443.4513 

Toll-free .....................................................................1.866.615.NIMH (6464) 

TTY ...............................................................................................301.443.8431

TTY Toll-free ...............................................................................866.415.8051

Fax .................................................................................................301.443.4279

Email..................................................................................... nimhinfo@nih.gov

Reprints:

This publication is in the public domain and may be reproduced or 

copied without permission from NIMH. We encourage you to reproduce 

it and use it in your efforts to improve public health. Citation of the 

National Institute of Mental Health as a source is appreciated. However, 

using government materials inappropriately can raise legal or ethical 

concerns, so we ask you to use these guidelines:

• NIMH does not endorse or recommend any commercial products, 

processes, or services, and our publications may not be used for 

advertising or endorsement purposes.

• NIMH does not provide specific medical advice or treatment 

recommendations or referrals; our materials may not be used in a 

manner that has the appearance of such information.

• NIMH does not endorse or recommend any commercial products, 

NIMH requests that non-Federal organizations not alter our publications in ways that will jeopardize the integrity and “brand” when 

using the publication.

• Addition of non-Federal Government logos and Web site links may 

not have the appearance of NIMH endorsement of any specific 

commercial products or services or medical treatments or services.

If you have questions regarding these guidelines and use of NIMH publications, please contact the NIMH Information Center at 1.866.615.6464 

or email at nimhinfo@nih.gov.
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

National Institutes of Health

NIH Publication No. 07-4901

Revised 2007