Eating disorders

Eating disorders are a class of conditions involving persistent disturbance of eating or eating-related behaviour that impairs physical health or psychosocial functioning. The DSM-5-TR class includes anorexia nervosa, bulimia nervosa, binge eating disorder, ARFID, and others. Eating disorders are serious mental illnesses with the highest mortality rates of any psychiatric diagnosis.

Overview

Eating disorders are a class of mental disorders characterized by persistent disturbance of eating or eating-related behaviour that impairs physical health or psychosocial functioning. The DSM-5-TR Feeding and Eating Disorders chapter includes Anorexia Nervosa (AN; 307.1), Bulimia Nervosa (BN; 307.51), Binge Eating Disorder (BED; 307.51), Avoidant/Restrictive Food Intake Disorder (ARFID; 307.59), Pica (307.52), Rumination Disorder (307.53), and Other Specified or Unspecified Feeding or Eating Disorder.

Eating disorders are serious mental illnesses with the highest mortality rates of any psychiatric diagnosis. Anorexia nervosa specifically has the highest mortality of any psychiatric condition (5-10% lifetime mortality from medical complications and suicide). Across all eating disorders, mortality is substantially elevated compared to general population.

Lifetime prevalence in Canadian and U.S. populations: anorexia nervosa approximately 0.5-1%, bulimia nervosa approximately 1-1.5%, binge eating disorder approximately 2-3.5% (the most common eating disorder), other specified eating disorders meaningfully higher when included. Eating disorders affect all genders, ages, racial groups, and socioeconomic groups despite stereotypical associations.

Common features across eating disorders include: persistent disturbance in eating behaviors; preoccupation with food, weight, shape, or eating; cognitive distortions about food and body; significant medical and psychological impact; and often substantial denial or minimization of symptoms. Eating disorders frequently emerge in adolescence and young adulthood but can develop at any age.

Eating disorders are highly comorbid with depression, anxiety disorders, OCD, PTSD, substance use disorders, personality disorders (particularly borderline and obsessive-compulsive features), and ADHD. Co-occurring conditions affect treatment selection and outcomes.

Treatment is highly effective for many people. Specialized eating-disorder treatment — Family-Based Treatment (Maudsley) for adolescent anorexia, Cognitive behavioural Therapy-Enhanced for adults, multidisciplinary care for severe presentations, lisdexamfetamine for binge eating disorder — produces meaningful recovery in most who engage. Early identification and intervention substantially improve outcomes. Specialized eating-disorder services exist in most Canadian provinces; residential and inpatient care is available for severe presentations.

Signs and symptoms

Restrictive eating — Persistent restriction of energy intake; rigid food rules; cutting out food groups; counting calories obsessively; avoidance of specific foods or eating contexts.
Binge eating episodes — Recurrent episodes of eating large amounts of food with sense of loss of control during the episode.
Compensatory behaviors — Self-induced vomiting, laxative misuse, diuretic misuse, fasting, excessive exercise to compensate for eating.
Body image disturbance — Persistent preoccupation with body weight, shape, or appearance; body checking or avoidance; distorted body perception; self-evaluation unduly influenced by body.
Significantly low body weight — Body weight significantly below expected for age, sex, developmental trajectory; characteristic of anorexia nervosa.
Intense fear of weight gain — Intense fear of weight gain or becoming "fat," even when underweight; persistent behaviour interfering with weight gain.
Medical complications — Cardiovascular (bradycardia, arrhythmia, low blood pressure), endocrine (amenorrhea, low bone density), gastrointestinal, dental (from purging), electrolyte abnormalities, others. Severe cases require medical hospitalization.
Psychological consequences — Cognitive impairment from malnutrition; rigid thinking; depression and anxiety; social withdrawal; identity organized around eating disorder.
Avoidance behaviors — Avoidance of social eating situations; conflict with family around food; secretive eating patterns; isolation around food.
Suicide risk — Substantially elevated across eating disorders, particularly during periods of malnutrition, after disclosure, and during early treatment.

Diagnostic context

The DSM-5-TR criteria for the principal eating disorders:

Anorexia Nervosa (AN; 307.1):

Restriction of energy intake leading to significantly low body weight in context of age, sex, developmental trajectory, and physical health.
Intense fear of gaining weight or becoming fat, or persistent behaviour that interferes with weight gain.
Disturbance in the way one’s body weight or shape is experienced; undue influence of body weight or shape on self-evaluation; or persistent lack of recognition of seriousness of low body weight.
Subtypes: restricting type; binge-eating/purging type. Severity based on BMI: mild ≥17, moderate 16-16.99, severe 15-15.99, extreme <15.

Bulimia Nervosa (BN; 307.51):

Recurrent episodes of binge eating with loss of control.
Recurrent inappropriate compensatory behaviors to prevent weight gain (vomiting, laxatives, diuretics, fasting, excessive exercise).
Binge eating and compensatory behaviors both occur, on average, at least once a week for 3 months.
Self-evaluation unduly influenced by body shape and weight.
Disturbance does not occur exclusively during episodes of anorexia nervosa.

Binge Eating Disorder (BED; 307.51):

Recurrent episodes of binge eating with loss of control.
Episodes associated with 3+ of: rapid eating, eating until uncomfortably full, eating large amounts when not hungry, eating alone due to embarrassment, feeling disgusted/depressed/guilty afterward.
Marked distress about binge eating.
Binges occur at least weekly for 3 months.
No regular compensatory behaviors (distinguishes from BN).

Avoidant/Restrictive Food Intake Disorder (ARFID; 307.59): avoidance/restriction of food without body-image disturbance — driven by sensory characteristics, fear of aversive consequences, or apparent lack of interest in food. Distinct from AN in that body-image disturbance is not the driver.

Other Specified Feeding or Eating Disorder (OSFED): includes atypical anorexia (significant weight loss without low BMI), purging disorder, night eating syndrome, and other clinically significant presentations not meeting full criteria for other diagnoses.

Validated assessment instruments include the Eating Disorder Examination (EDE-Q), SCOFF, and clinician interview.

Causes and risk factors

Eating disorders develop through complex interaction of biological, psychological, and sociocultural factors:

Genetic factors: heritability of eating disorders is approximately 50-80%. Multiple common variants of small effect contribute. Family aggregation is well-documented.

Neurobiological factors: alterations in serotonergic, dopaminergic, and reward processing systems; functional and structural brain changes (some pre-existing, some consequence of malnutrition); HPA axis dysfunction.

Developmental factors: childhood adversity (particularly sexual abuse), childhood feeding patterns, family dynamics around food and body, early dieting, perfectionism in childhood.

Psychological factors: perfectionism, harm avoidance, low self-esteem, body image disturbance, emotion regulation difficulties, certain personality features (obsessive-compulsive, borderline, avoidant).

Sociocultural factors: thin-ideal media exposure, social-media body comparison, weight stigma, cultural food norms, sport and performance contexts (aesthetic sports, weight-class sports, dance, modelling), occupational contexts.

Dieting: dieting is one of the strongest single risk factors for eating disorder onset. Adolescents who diet are 5-18x more likely to develop an eating disorder than non-dieting peers.

Trauma exposure: sexual abuse and other trauma over-represented in eating disorder populations, particularly with binge/purge presentations.

Comorbidity: mood disorders (~50-90% lifetime), anxiety disorders, OCD, PTSD, substance use disorders, personality disorders all common; ADHD increasingly recognized.

Typical treatments

Specialized eating-disorder treatment is essential for most cases. Evidence-based approaches:

For Adolescent Anorexia Nervosa:

Family-Based Treatment (FBT/Maudsley): first-line for adolescent AN. 18-20 session protocol with phases (parents take charge of refeeding, gradual transfer of control to adolescent, addressing developmental concerns).
Adolescent-Focused Therapy as alternative.

For Adult Anorexia Nervosa:

Cognitive behavioural Therapy-Enhanced (CBT-E) — Fairburn protocol; strong evidence.
Maudsley Anorexia Nervosa Treatment for Adults (MANTRA) — UK-developed protocol.
Specialist Supportive Clinical Management (SSCM).

For Bulimia Nervosa and Binge Eating Disorder:

CBT-Enhanced (Fairburn) — first-line; strong evidence.
Interpersonal Psychotherapy (IPT) — comparable long-term outcomes.
Dialectical behaviour Therapy (DBT) for BED with emotion-regulation focus.
Self-help and guided self-help for milder BN/BED presentations.

Pharmacotherapy:

SSRIs for BN (fluoxetine FDA-approved at 60 mg).
Lisdexamfetamine (Vyvanse) — FDA- and Health Canada-approved specifically for moderate-to-severe BED.
Olanzapine sometimes used for AN with severe agitation or cognitive rigidity.
SSRIs for comorbid depression and anxiety across eating disorders.
Pharmacotherapy is generally not first-line for AN itself — psychotherapy and medical management are foundational.

Levels of care: outpatient, intensive outpatient, partial hospitalization (day treatment), residential, inpatient medical hospitalization (for medical instability), inpatient psychiatric hospitalization. Matched to medical and psychiatric severity.

Multidisciplinary care: medical (physician, often specialty eating-disorder physician), nutritional (registered dietitian), psychological (therapist), psychiatric (when medication relevant), often family work.

Treatment of comorbid conditions: depression, anxiety, OCD, PTSD, substance use, personality disorders all commonly require concurrent attention.

Medical monitoring: essential for AN, BN with purging, severe restriction at any weight. Includes vital signs, weight, electrolytes, ECG, bone density, others as indicated.

Recovery is possible. Approximately 50-70% of those who engage in eating-disorder treatment achieve sustained recovery; others achieve significant improvement.

When to seek help

Professional support is indicated when:

You or a family member has restrictive eating, binge eating, purging behaviors, or other disordered eating patterns.
Body weight is significantly below expected, or has dropped significantly.
Eating patterns are interfering with health, relationships, work, or quality of life.
You experience preoccupation with food, body, or weight that is affecting your wellbeing.
You are having medical complications related to eating patterns.
Compensatory behaviors (vomiting, laxatives, excessive exercise, fasting) are occurring.
You experience comorbid depression, anxiety, suicidal thoughts, or substance use.
Family members or healthcare providers have expressed concern.

Free Canadian eating-disorder support:

1-866-NEDIC-20 (1-866-633-4220) — National Eating Disorder Information Centre (NEDIC). Free, confidential support and information; chat at nedic.ca; M-Th 9 AM-9 PM, F 9 AM-5 PM ET.
1-888-988-3275 — National Initiative for Eating Disorders (NIED).
Hopewell Eating Disorder Support Centre (Ottawa): 613-241-3428.
Provincial eating-disorder programs in BC, Alberta, Ontario, Quebec, others — pediatric and adult specialized services.
Looking Glass Foundation (BC, online) — peer support and resources.

Crisis support: if suicidal thoughts or medical emergency: 9-8-8 (Suicide Crisis Helpline, 24/7), 1-833-456-4566 (Talk Suicide Canada), 911 for medical emergency, 1-800-668-6868 (Kids Help Phone for youth).

Frequently asked questions

How serious are eating disorders?

Eating disorders are serious mental illnesses with the highest mortality rates of any psychiatric diagnosis. Anorexia nervosa specifically has 5-10% lifetime mortality. Beyond mortality, eating disorders produce substantial medical complications, psychological suffering, and functional impairment. They warrant the same seriousness as other major medical conditions.

Can men have eating disorders?

Yes. Approximately 25-30% of eating disorder cases occur in men, though the proportion may be higher given diagnostic under-recognition in men. Men may present with muscularity-focused concerns rather than thinness-focused; the underlying clinical pattern is the same.

Can someone be at "normal" weight and have an eating disorder?

Yes. Bulimia nervosa, binge eating disorder, ARFID, and atypical anorexia all occur across the weight spectrum. Body weight alone is an inadequate indicator. Eating-disorder diagnosis depends on the eating pattern and associated features, not body weight per se.

Can I recover?

Yes. Approximately 50-70% of those who engage in evidence-based eating-disorder treatment achieve sustained recovery; many more achieve significant improvement. Outcomes are best with specialized care, sustained engagement, and treatment of comorbid conditions. Recovery is the typical outcome with appropriate care.

How do I help a family member with an eating disorder?

Approach with concern and care, not blame; encourage professional evaluation; support specialized treatment; participate in family-based treatment when appropriate (particularly for adolescent AN); avoid commenting on weight or body; do not collude with eating-disorder behaviors. NEDIC and similar organizations provide family resources.

How long does treatment take?

Highly variable. Bulimia nervosa and binge eating disorder typically require 4-6 months of focused treatment. Anorexia nervosa often requires 1-3+ years of multidisciplinary care. Recovery is rarely linear; relapses are common and respond to renewed treatment. Long-term follow-up is appropriate for severe cases.

References

American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.). APA.
Lock, J., & Le Grange, D. (2013). Treatment Manual for Anorexia Nervosa: A Family-Based Approach (2nd ed.). Guilford Press.
Fairburn, C. G. (2008). Cognitive behaviour Therapy and Eating Disorders. Guilford Press.
Treasure, J., Duarte, T. A., & Schmidt, U. (2020). Eating disorders. The Lancet, 395(10227), 899–911.
National Eating Disorder Information Centre (NEDIC). (n.d.). Resources and support.

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The ShiftGrit Clinical Editorial Team combines the insight of registered psychologists, provisional psychologists, and trained writers to create accessible, evidence-informed therapy resources. All content is clinically reviewed by a Registered Psychologist.