Introduction to Eating Disorders

{This is the first in a monthly series on Eating Disorders. Future topics to be discussed will include, diagnosis & assessment, treatment approaches and best practices, eating disorders in special populations (including the Military), and training and education opportunities. If you have requests for specific topics to be addressed related to eating disorders, please contact the author.}

Eating Disorders are life threatening mental illnesses, whose behaviors offer short term and relatively quick relief from distress. Eating Disorders are often mischaracterized, misunderstood, and can be easily missed by clinicians due to lack of appropriate training and education. Eating disorders are illnesses associated with severe disturbances in eating behaviors, as well as related thoughts and emotions. There may also be symptoms of preoccupation with food, and body weight and shape.

The DSM-5 classifies six distinct types of Feeding and Eating disorders, plus an additional two types of unspecified feeding and eating disorders that include symptomatology that do not neatly fit in the predominating categories. While many people likely have heard about Anorexia Nervosa, and Bulimia Nervosa, less information has been shared about a third and significant diagnosis, Binge Eating Disorder. Binge Eating Disorder, or BED, is more prevalent than Anorexia Nervosa and Bulimia Nervosa combined, but is often unreported to primary care providers (Hudson et al, 2007, Kessler et al., 2013, Marques et al., 2011, Zerbe, 2016).

With over 50 years of research (Stunkard, 1959; Zerbe, 2016),  Binge Eating Disorder (BED) was finally differentiated from other conditions including obesity, anorexia, and bulimia.  Binge Eating Disorder was only recently added to the DSM-5 edition of the American Psychiatric Association Diagnostic and Statistical Manual (2013).  Binge eating is a symptom that can occur within or outside the context of a formal eating disorder. A binge episode is classified by the DSM-5 as consuming a large amount of food (more than what would be considered typical consumption) in a period of two hours or less, and must include feeling out of control over the behavior (they can’t stop eating or control what they are eating). In Bulimia Nervosa, the primary symptoms are binge/purge episodes where the patient consumes large quantities of food, and then purges it either through vomiting, laxatives, or over-exercise. While Anorexia Nervosa is most typically known as an eating disorder, which focuses on restriction of food intake, the DSM-5 does include a subtype of Anorexia Nervosa, “binge/purge type” wherein the restrictive phases are punctuated by either episodes of purging or binging behaviors.

Healthcare and mental health professionals struggle to understand why patients develop a fear of eating food (Walker & Lloyd, 2011).  There is an underlying belief that anorexics and bulimics are vain, even though the professionals intellectually understand the issue is more complex and multifactorial (Walker & Lloyd, 2011). There are some common misconceptions about Eating Disorders, including the false trope that eating disorders primarily affect White upper class women and girls. In fact, eating disorders present across the gender spectrum (and occur in higher rates in the LGBTQ+ community), as well as across ages (children as young as seven years old have presented with symptoms consistent with an eating disorder diagnosis, and we have seen eating disorders present in both chronic and acute presentations in middle aged and late stage life adults), and across cultures, races and ethnicities.

When eating disorders were first “discovered”, there were limited treatment options and poor understanding of what exactly an eating disorder was and what it wasn’t. Over time, as society became more sophisticated and our means for understanding the mind and body changed, treatments moved away from more supernatural based beliefs and related treatments (bloodletting in the era of the 4 humors; trephination in the 16th century). Treatment approaches within the mid-19th century through the mid-20th century, were rooted in the psychological constructs of the time and were primarily psychoanalytic. Beginning in the mid-20th century there was a social and academic shift toward cognitive and behavioral therapies, with an increasing push toward the end of 20th century and into the 21st century for “evidence-based treatments.” This trend was driven by many factors including the influence of managed healthcare organizations and a desire to limit payment for treatment, focus on cessation of symptoms/behaviors versus total wellness, and a general social trend toward fast quick fixes.

Eating Disorders are best treated by clinicians who have expertise and specific advanced training in the treatment of eating disorders. A team approach to treatment is generally required with at least an eating disorder therapist, nutritionist, and primary care physician. Depending on the severity and acuity of the symptoms, eating disorders will require different levels of care including outpatient treatment, residential treatment or hospitalization. Best practices typically indicate medical stabilization first, followed by symptom relief as the individual works toward longer-term goals of behavioral change and understanding of the function of the eating disorder in their life.

Since eating disorders can affect a person’s cognition, emotions, behaviors, physical body, and relationships, it is critical that they are treated with an integrated approach, by a team of experts who are knowledgeable about what works. In the coming months, please join me, as I will continue to share additional information about eating disorders, including, diagnosis & assessment, treatment approaches and best practices, eating disorders in special populations (including the Military), and training and education opportunities.


About the author:

Marissa Sappho, LCSW, BCD, CEDS-S, is the Founder & Clinical Director at Aurora Center NYC, an outpatient clinic for Eating Disorder Treatment and Mental Health Services. In addition to overseeing the Clinical Programs at Aurora, she maintains a full time patient caseload. Ms. Sappho is a certified eating disorder specialist, certified eating disorder supervisor and Board certified psychoanalyst. She is a passionate educator, holding the title of Adjunct Professor at New York University in their graduate school of social work, as well as being Faculty and Supervisor at the Center for the Study of Anorexia and Bulimia (CSAB), where she also serves on the Advisory Board and the Executive Committee.

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