Somerset and Wessex Eating Disorders Association
"Supporting those affected by eating disorders"
As you will see from our Definitions section, technically speaking there exist only a small number of 'official' eating disorders (plus their atypical variants), Anorexia Nervosa, Bulimia Nervosa and Eating Disorders Not Otherwise Specified (EDNOS) as defined in the two diagnostic manuals DSM-IV and ICD-10. The latter category - EDNOS - provides a convenient, generic place to stow away a variety of eating disordered behaviour that does not conform to the diagnostic criteria for Anorexia and Bulimia Nervosa. Currently Binge Eating Disorder, although recognised as possibly being a distinct eating disorder in its own right, would constitute an Eating Disorder Not Otherwise Specified.
There are a number of other conditions in which disordered eating or body image/weight play a significant part. A number of them may be considered by some to be eating disorders in their own right but which, by lacking a formal diagnosis and definition, are to be consigned to the Eating Disorders Not Otherwise Specified (EDNOS - DSM-IV) category, or Eating Disorders Unspecified (ICD-10). Others may be distinct disorders in themselves and have diagnostic criteria and classification in the diagnostic manuals but not being considered eating disorders (DSM-IV ~ 307, ICD ~ F50) despite having a disordered eating or distorted body image component.
We have given some examples below along with a brief description. Please note that the groups that these conditions have been ordered in are for illustrative purposes only and may vary between different organisations. This information is by no means complete or authoritative and provided only to give an illustration of other conditions with food, eating or body image distortion elements.
Unofficial Eating Disorders is a 'homemade' catagory we have created in order to include 'disorders' created by third parties such as authors, the media etc. to describe certain patterns of eating or body image related behaviour. They are not 'official' in the sense that they do not appear in the diagnostic systems either as recognised disorders or, as in the case of Binge Eating Disorder, as research criteria. It should be noted that experts in the field of eating disorders may themselves label eating disordered behaviour which may then be adopted by some quarters of the medical profession.
• Anorexia Athletica
The term has since come to be used, rather loosely, in some quarters to simply refer to compulsive exercising. There is much information and research available on the internet for anyone wishing to look into anorexia athletica further, for example the 1994 paper by Sundgot-Borgen - "Risk and trigger factors for the development of eating disorders in female elite athletes" .
• Bigorexia (Muscle Dysmporphia)
Although unrecognised some members of the scientific community do consider it to be link to eating disorders (in particular anorexia nervosa) in that similar body image distortions and extreme preoccupations to remedy the situation occur (albeit in a reverse direction). The use of steriods and anabolic agents and the associated health risks to achieve the desired goal may be seen to be strikingly similar to the use of laxative, diueretics and slimming pill with anorexia nervosa and bulimia nervosa. They are also likely to have self-esteem and 'coping' issues in common. Bigorexia is considered to affect more men than women and there may be connections between Bigorexia and anorexia nervosa in terms of percieved gender ideals.
• Ortharexia Nervosa
Ortharexia Nervosa is not a recognised condition and lacks the 'clarity' of diagnostic criteria when it comes to defining whether an individual has Ortharexia Nervosa. Individuals with obsessive and/or dangerous behaviour around 'proper' food might be considered to fit Dr. Bratman's label but equally may not. Lacking diagnostic criteria and therefore differential diagnosis it is unclear whether individuals following extreme dietary practices for religous or moral reasons would be considered. Any connections with Obsessive Compulsive Disorder are also unclear.
Most people would not consider Ortharexia Nervosa an eating disorder on the grounds that the emphasis and concern relates to the quality or purity of food rather than on a desire to be thin and/or any body distortion issues. However if one considers 'eating disorders' to be mechanisms of coping with underlying distress the definition 'may' fit.
• Multi-Impulsive Bulimia
Multi-impulsive bulimia is not a formal diagnosis and has been challenged but is recognised by some agencies and clinics. It should be noted that both DSM-IV and ICD-10 consider eating disorders to be a catagory in their own right and not impulse control disorders. It may also be worth noting that it is not unkown for additional self-harming behaviours to be used by individuals suffering from bulimia nervosa as a way of copy with the distress of their bulimic condition.
Multi-impulsive bulimia is a complex area and much information (for and against) can be found on the internet.
Eating Problems in Children
There are a number of eating problems found in children which are not generally considered to be eating disorders and lack formal diagnostic criteria and classification. It is argued that these childhood eating problems are not eating disorders because it is felt that they have different causes and symptoms and require different treatment. This view is, however, not universally accepted and some do considered certain of them to be eating disorders in themselves. Things can be further complicated as, due to the lack of formal diagnostic criteria, different professionals may choose to apply different names to the same problem. In some instances some professionals may consider a pattern of disordered eating in a child to be simply an extreme manifestation of 'picky eating' behaviour which often occurs normally in children; it is not unheard of for childhood eating problems to be dismissed as faddy eating which the child will "grow out of".
Which ever view is subscribed to these childhood disordered eating problems can be very distressing and, in some cases, have serious consequences.
Below are some examples of childhood eating problems, this list is by no means complete nor does the inclusion of a condition necessarily mean that that condition is restricted on to children.
• Food Avoidance Emotional Disorder
This can be mistaken for child onset anorexia nervosa but there are a number of differences. Notably it is considered that the avoidance of food results from symptoms of emotional difficulties (such as depression or worry) which affect appetite and is not an attempt to use food to suppress these difficulties. The sufferer will often be aware of their eating difficulties and thinness (unlike the distorted body image that can occur in anorexia) and express a desire to eat more. Food Avoidance Emotional Disorder sufferers are also not considered to have preoccupations with weight or aspirations to be thin.
• Food Refusal
Despite appearing to be manipulative it is often felt that some form of stress, sadness or upset may underlie the behaviour.
• Restrictive Eating
A child with Restrictive Eating may be below normal height/weight norms for their age but, due to their generally balanced diet, are often considered to be healthy. As with Selective Eating there appears to be no preoccupation with weight or aspirations to be thin.
• Selective Eating [Disorder]
There does not seem to be a group of foods common to selective eating and consequently the the consequences of the problem can be dependant on the type and range of foods taken but malnutrition must be considered. Body weight may be high, low or normal and as such is not a good indication of the condition. Dental problems may occur is the child's acceptable range of food contains sugary foods. Selective Eating does not seem to have the preoccupation with weight and desire to be thin components of anorexia nervosa.
Other [related?] Disorders
There are a number of other disorders which are sometimes considered to be related in some way to 'eating disorders' in that they posses a symptomatic component which can be seen to be similar to symptoms existing with 'eating disorders'. These disorders are often conditions in their own right with their own diagnostic criteria. Some examples are shown below.
• Body Dysmorphic Disorder
Body Dysmorphic Disorder is sometime considered to have associations with Social Phobia and Obsessive Compulsive Disorder. It is sometimes associated with eating disorders in that the 'body dysmorphia' can be seen to have similarities with the dissatisfaction with, and distorted view of, body shape and size seen in anorexia nervosa. Interestingly Body Dysmorphic Disorder cannot be diagnosed in the presence of a dissatisfaction with, or distorted image of, body size/shape cause by anorexia nervosa (differential diagnosis).
• Food Phobia
Where the phobia is related to food (Sitophobia) or the process of eating, the fear and avoidance of eating can show 'eating disorder' like symptoms. There are a number of Specific Phobias that can fall into this category.
• Night Eating
It is unclear exactly what Night Eating Syndrome is, it is variously considered to be a form of eating disorder, a dysfunction in the body clock, that it may be stress induced, physiological rather than psychological (possibly hormonal) and others.
Obsessional behaviour around food/dieting may present 'eating disorder' like symptoms. It is also thought by some the OCD and eating disorders 'may' be related in some way. It is not uncommon for someone to suffer both an eating disorder and OCD.
Pica is not generally considered a serious condition, however depending on the substances consumed intestinal blockages can occur and the ingestion of toxic non-food substances is possible as is contracting parasitic or bacterial infections.
There is an obvious 'food' connection between Pica and eating disorders and one of the reasons often cited for Pica, the eating of non-calorie non-food items to ease hunger (when dieting), is often mirrored in eating disorders.
Pica in adults is included is ICD-10's 'Other Eating Disorders' (F50.8) catagory and as such is an eating disorder under this diagnostic system.
• Pervasive Refusal
Pervasive Refusal Syndrome is a very serious, non-organic, condition in which a child may present an overwhelming refusal to eat, drink, engage in activities (e.g. walking) or generally care for themselves in any way (including washing, toileting etc.). This is obviously a life threatening condition and since the refusal to eat and drink is likely to elicit concern first, it may be that the condition is seen to an eating disorder.
In some quarters Pervasive Refusal Syndrome is considered to be a child form of 'catatonia'. The condition is often linked to a previous, severe trauma.
One symptom of Prader-Willi Syndrome, thought to be caused by hypothalamic dysfunction, is appetite and satiation dysfunction in which there is an overwhelming physiological urge to eat and an obsession with food. This is compounded by the fact that individuals with Prader-Willi Syndrome have lower than normal calorie requirements. Whilst this is clearly not an 'eating disorder', Prader-Willi Syndrome does have a food/weight component.
The Prader-Willi Syndrome Association UK can provide information and support.
• Sleep Eating
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