Patient information: See related handout on eating disorders , written by the authors of this article.

Eating disorders are life-threatening conditions that are challenging to address; however, the primary care setting provides an important opportunity for critical medical and psychosocial intervention. The recently published Diagnostic and Statistical Manual of Mental Disorders, 5th ed., includes updated diagnostic criteria for anorexia nervosa (e.g., elimination of amenorrhea as a diagnostic criterion) and for bulimia nervosa (e.g., criterion for frequency of binge episodes decreased to an average of once per week). In addition to the role of environmental triggers and societal expectations of body size and shape, research has suggested that genes and discrete biochemical signals contribute to the development of eating disorders. Anorexia nervosa and bulimia nervosa occur most often in adolescent females and are often accompanied by depression and other comorbid psychiatric disorders. For low-weight patients with anorexia nervosa, virtually all physiologic systems are affected, ranging from hypotension and osteopenia to life-threatening arrhythmias, often requiring emergent assessment and hospitalization for metabolic stabilization. In patients with frequent purging or laxative abuse, the presence of electrolyte abnormalities requires prompt intervention. Family-based treatment is helpful for adolescents with anorexia nervosa, whereas short-term psychotherapy, such as cognitive behavior therapy, is effective for most patients with bulimia nervosa. The use of psychotropic medications is limited for anorexia nervosa, whereas treatment studies have shown a benefit of antidepressant medications for patients with bulimia nervosa. Treatment is most effective when it includes a multidisciplinary, team-based approach.

Eating disorders have traditionally been classified into two well-established categories. They are anorexia nervosa and bulimia nervosa.1 Additionally, many patients have been classified as having the residual category of eating disorder not otherwise specified.2 Revisions in the recently published Diagnostic and Statistical Manual of Mental Disorders, 5th ed., (DSM-5) may facilitate more specific eating disorder diagnoses.3,4 The DSM-5 includes a diagnostic category for binge-eating disorder, which is characterized by a loss of control and the feelings of guilt, shame, and embarrassment. The disorder is not associated with self-induced vomiting or other compensatory behaviors; hence, patients are typically overweight or obese. Other feeding and eating disorders in the DSM-5 include pica, rumination disorder, and avoidant/restrictive food intake disorder.3 This article focuses on anorexia nervosa and bulimia nervosa.

Enlarge Print SORT: KEY RECOMMENDATIONS FOR PRACTICE Clinical recommendation Evidence rating References Initial evaluation of patients with eating disorders requires assessing medical stability and whether hospitalization is required. C 3, 11, 12, 35, 37, 38 In patients with eating disorders, assess for psychiatric comorbidities, including depression and suicide risk, anxiety disorders, and substance use disorders. C 3, 11, 12, 38–40 An interdisciplinary team approach is needed for the treatment of eating disorders, and often includes a family physician, a psychotherapist or psychiatrist, a dietitian, an eating disorder specialist, and school personnel. C 11, 12, 21–26, 35, 36 A minimum weight restoration target for patients with anorexia nervosa is 90% of the average weight expected for the patient's age, height, and sex. C 12, 22 Family-based treatment (the Maudsley method) is effective for treating anorexia nervosa in adolescents. B 23, 24 Most patients with bulimia nervosa benefit from psychotherapy such as cognitive behavior therapy and/or treatment with a selective serotonin reuptake inhibitor. B 11, 12, 26, 27, 35–37 Antipsychotic medications are generally not effective in the treatment of eating disorders. B 11, 32–35 SORT: KEY RECOMMENDATIONS FOR PRACTICE Clinical recommendation Evidence rating References Initial evaluation of patients with eating disorders requires assessing medical stability and whether hospitalization is required. C 3, 11, 12, 35, 37, 38 In patients with eating disorders, assess for psychiatric comorbidities, including depression and suicide risk, anxiety disorders, and substance use disorders. C 3, 11, 12, 38–40 An interdisciplinary team approach is needed for the treatment of eating disorders, and often includes a family physician, a psychotherapist or psychiatrist, a dietitian, an eating disorder specialist, and school personnel. C 11, 12, 21–26, 35, 36 A minimum weight restoration target for patients with anorexia nervosa is 90% of the average weight expected for the patient's age, height, and sex. C 12, 22 Family-based treatment (the Maudsley method) is effective for treating anorexia nervosa in adolescents. B 23, 24 Most patients with bulimia nervosa benefit from psychotherapy such as cognitive behavior therapy and/or treatment with a selective serotonin reuptake inhibitor. B 11, 12, 26, 27, 35–37 Antipsychotic medications are generally not effective in the treatment of eating disorders. B 11, 32–35

Definition Jump to section + Abstract

Definition

Prevalence and Etiology

Clinical Presentation

Screening for Eating Disorders

Initial Evaluation

Treatment

Prognosis

References The DSM-5 diagnostic criteria for anorexia nervosa (Table 13) are similar to the previous DSM-IV criteria with respect to behavioral and psychological characteristics involving restriction of food intake resulting in low body weight, intense fear of gaining weight or becoming fat, and disturbance of body image.1,3 Notably, the DSM-5 criteria do not refer to a specific degree of weight loss required for the diagnosis, but instead provide guidelines for specifying the severity of weight loss. As in the DSM-IV, the new criteria specify two diagnostic types of anorexia nervosa (restricting type and binge eating/purging type). In a significant revision to previous criteria, diagnosis of anorexia nervosa no longer requires the presence of amenorrhea. Enlarge Print Table 1. DSM-5 Diagnostic Criteria for Anorexia Nervosa A. Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected. B. Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight. C. 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 persistent lack of recognition of the seriousness of the current low body weight. Coding note: The ICD-9-CM code for anorexia nervosa is 307.1, which is assigned regardless of the subtype. The ICD-10-CM code depends on the subtype (see below). Specify whether: (F50.01): Restricting type: During the last 3 months, the individual has not engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise. (F50.02): Binge-eating/purging type: During the last 3 months, the individual has engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). Specify if: In partial remission: After full criteria for anorexia nervosa were previously met, Criterion A (low body weight) has not been met for a sustained period, but either Criterion B (intense fear of gaining weight or becoming fat or behavior that interferes with weight gain) or Criterion C (disturbances in self-perception of weight and shape) is still met. In full remission: After full criteria for anorexia nervosa were previously met, none of the criteria have been met for a sustained period of time. Specify current severity: The minimum level of severity is based, for adults, on current body mass index (BMI) (see below) or, for children and adolescents, on BMI percentile. The ranges below are derived from World Health Organization categories for thinness in adults; for children and adolescents, corresponding BMI percentiles should be used. The level of severity may be increased to reflect clinical symptoms, the degree of functional disability, and the need for supervision. Mild: BMI ≥ 17 kg/m2 Moderate: BMI 16–16.99 kg/m2 Severe: BMI 15–15.99 kg/m2 Extreme: BMI < 15 kg/m2 Table 1. DSM-5 Diagnostic Criteria for Anorexia Nervosa A. Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected. B. Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight. C. 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 persistent lack of recognition of the seriousness of the current low body weight. Coding note: The ICD-9-CM code for anorexia nervosa is 307.1, which is assigned regardless of the subtype. The ICD-10-CM code depends on the subtype (see below). Specify whether: (F50.01): Restricting type: During the last 3 months, the individual has not engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise. (F50.02): Binge-eating/purging type: During the last 3 months, the individual has engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). Specify if: In partial remission: After full criteria for anorexia nervosa were previously met, Criterion A (low body weight) has not been met for a sustained period, but either Criterion B (intense fear of gaining weight or becoming fat or behavior that interferes with weight gain) or Criterion C (disturbances in self-perception of weight and shape) is still met. In full remission: After full criteria for anorexia nervosa were previously met, none of the criteria have been met for a sustained period of time. Specify current severity: The minimum level of severity is based, for adults, on current body mass index (BMI) (see below) or, for children and adolescents, on BMI percentile. The ranges below are derived from World Health Organization categories for thinness in adults; for children and adolescents, corresponding BMI percentiles should be used. The level of severity may be increased to reflect clinical symptoms, the degree of functional disability, and the need for supervision. Mild: BMI ≥ 17 kg/m2 Moderate: BMI 16–16.99 kg/m2 Severe: BMI 15–15.99 kg/m2 Extreme: BMI < 15 kg/m2 Bulimia nervosa involves the uncontrolled eating of an abnormally large amount of food in a short period, followed by compensatory behaviors, such as self-induced vomiting, laxative abuse, or excessive exercise. The main update in the DSM-5 criteria for bulimia nervosa (Table 23) is a decrease in the average frequency of bingeing and purging from twice to once a week.4 Enlarge Print TABLE 2. DSM-5 Diagnostic Criteria for Bulimia Nervosa A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: 1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances. 2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or howmuch one is eating). B. Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse oflaxatives, diuretics, or other medications; fasting; or excessive exercise. C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months. D. Self-evaluation is unduly influenced by body shape and weight. E. The disturbance does not occur exclusively during episodes of anorexia nervosa. Specify if: In partial remission: After full criteria for bulimia nervosa were previously met, some, but not all, of the criteria have been met for a sustained period of time. In full remission: After full criteria for bulimia nervosa were previously met, none of the criteria have been met for a sustained period of time. Specify current severity: The minimum level of severity is based on the frequency of inappropriate compensatory behaviors (see below). The level of severity may be increased to reflect other symptoms and the degree of functional disability. Mild: An average of 1–3 episodes of inappropriate compensatory behaviors per week. Moderate: An average of 4–7 episodes of inappropriate compensatory behaviors per week. Severe: An average of 8–13 episodes of inappropriate compensatory behaviors per week. Extreme: An average of 14 or more episodes of inappropriate compensatory behaviors per week. TABLE 2. DSM-5 Diagnostic Criteria for Bulimia Nervosa A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: 1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances. 2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or howmuch one is eating). B. Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse oflaxatives, diuretics, or other medications; fasting; or excessive exercise. C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months. D. Self-evaluation is unduly influenced by body shape and weight. E. The disturbance does not occur exclusively during episodes of anorexia nervosa. Specify if: In partial remission: After full criteria for bulimia nervosa were previously met, some, but not all, of the criteria have been met for a sustained period of time. In full remission: After full criteria for bulimia nervosa were previously met, none of the criteria have been met for a sustained period of time. Specify current severity: The minimum level of severity is based on the frequency of inappropriate compensatory behaviors (see below). The level of severity may be increased to reflect other symptoms and the degree of functional disability. Mild: An average of 1–3 episodes of inappropriate compensatory behaviors per week. Moderate: An average of 4–7 episodes of inappropriate compensatory behaviors per week. Severe: An average of 8–13 episodes of inappropriate compensatory behaviors per week. Extreme: An average of 14 or more episodes of inappropriate compensatory behaviors per week.

Prevalence and Etiology Jump to section + Abstract

Definition

Prevalence and Etiology

Clinical Presentation

Screening for Eating Disorders

Initial Evaluation

Treatment

Prognosis

References Bulimia nervosa affects four to six out of 200 females in the United States. Anorexia nervosa is much less common, with a lifetime prevalence of one out of 200 females in the United States. Approximately 95% of persons with an eating disorder are 12 to 25 years of age. Although 90% of patients with an eating disorder are female, the incidence of diagnosed eating disorders in males appears to be increasing.5 The etiology of eating disorders is unknown and probably multifactorial. Environmental influences include societal idealizations about weight and body shape. Parenting style has been discounted as a primary cause of eating disorders. However, parenting style, household stress, and parental discord may contribute to anxiety and personality traits that are risk factors for an eating disorder. An emphasis on success and external rewards may lead to overly high expectations. Children may then try to be successful with something they can control: regulating what they eat and how they look. Sexual assault or abuse has not been associated with anorexia nervosa but may be a risk factor for bulimia nervosa.6 There is increasing evidence of biologic risk factors for eating disorders. Twin studies and other research suggest a genetic link.7 Eating disorders have been associated with abnormal neurotransmitter systems involving serotonin and dopamine.8,9 The role of hormones such as ghrelin, leptin, and oxytocin has also been investigated.10

Clinical Presentation Jump to section + Abstract

Definition

Prevalence and Etiology

Clinical Presentation

Screening for Eating Disorders

Initial Evaluation

Treatment

Prognosis

References Table 3 includes clinical signs of eating disorders.11–13 Patients with eating disorders may often comment about being “fat” or not liking their body shape. Weight loss with anorexia nervosa may go unnoticed for some time, particularly when patients wear baggy clothes or extra layers. Patients with anorexia nervosa commonly restrict their diet to vegetables, fruit, and diet products, and often skip meals altogether. They develop mealtime rituals, such as cutting food into tiny pieces, patting liquid off with napkins, or picking food apart. Although anorexia nervosa has been associated with some cognitive deficits as demonstrated on neuropsychological tests, many patients maintain good cognitive function and verbal fluency even when malnourished.14 Enlarge Print Table 3. Selected Clinical Signs of Eating Disorders Sign Underlying pathophysiology Anorexia nervosa Amenorrhea Hypothalamic dysfunction, low fat stores, malnutrition Arrhythmia Electrolyte disorders, heart failure, prolonged corrected QT interval Bradycardia Heart muscle wasting, associated with arrhythmias and sudden death (common in anorexia nervosa) Brittle hair and nails Malnutrition Edema Heart muscle wasting, associated with arrhythmias and sudden death (common in anorexia nervosa) Hyperkeratosis Malnutrition, vitamin and mineral deficiencies Hypotension Malnutrition, dehydration Hypothermia Thermoregulatory dysfunction, hypoglycemia, reduced fat tissue Lanugo (fine, white hairs on the body) Response to fat loss and hypothermia Marked weight loss Self starvation, low caloric intake Osteoporosis at a young age Malnutrition Bulimia nervosa Dental enamel erosions and gum disease Recurrent vomiting washes mouth with acid and stomach enzymes; mineral deficiencies Edema Laxative abuse, hypoproteinuria, electrolyte imbalances Parotid gland enlargement Gastric acid and enzymes from vomiting cause parotid inflammation Scars or calluses on fingers or hands (Russell sign [knuckle calluses]) Self-induced vomiting Weight fluctuations; not underweight Alternating between bingeing and purging Table 3. Selected Clinical Signs of Eating Disorders Sign Underlying pathophysiology Anorexia nervosa Amenorrhea Hypothalamic dysfunction, low fat stores, malnutrition Arrhythmia Electrolyte disorders, heart failure, prolonged corrected QT interval Bradycardia Heart muscle wasting, associated with arrhythmias and sudden death (common in anorexia nervosa) Brittle hair and nails Malnutrition Edema Heart muscle wasting, associated with arrhythmias and sudden death (common in anorexia nervosa) Hyperkeratosis Malnutrition, vitamin and mineral deficiencies Hypotension Malnutrition, dehydration Hypothermia Thermoregulatory dysfunction, hypoglycemia, reduced fat tissue Lanugo (fine, white hairs on the body) Response to fat loss and hypothermia Marked weight loss Self starvation, low caloric intake Osteoporosis at a young age Malnutrition Bulimia nervosa Dental enamel erosions and gum disease Recurrent vomiting washes mouth with acid and stomach enzymes; mineral deficiencies Edema Laxative abuse, hypoproteinuria, electrolyte imbalances Parotid gland enlargement Gastric acid and enzymes from vomiting cause parotid inflammation Scars or calluses on fingers or hands (Russell sign [knuckle calluses]) Self-induced vomiting Weight fluctuations; not underweight Alternating between bingeing and purging Patients with eating disorders often engage in excessive physical activity despite bad weather, illness, or injury. A study found that approximately one-third of patients hospitalized for anorexia nervosa reported excessive (i.e., obligatory, obsessive, or driven) exercise during the three months before admission.15 Patients with bulimia nervosa may arrange complex schedules to accommodate episodes of binge eating and purging, often accompanied by frequent trips to the bathroom. In addition to excessive exercise, other methods of weight control include abuse of laxatives or diuretics. Frequent self-induced vomiting can contribute to parotitis, stained teeth or enamel erosions, and hand calluses. As cachexia progresses, patients with anorexia nervosa lose strength and endurance, move more slowly, and demonstrate decreased performance in sports. Overuse injuries and stress fractures can occur. Bradycardia, orthostatic hypotension, and palpitations may progress to potentially fatal arrhythmias. Epigastric pain and a bloating sensation are common. Laxative abuse causes hemorrhoids and rectal prolapse. Severe hypoglycemia may lead to seizures. Wounds heal poorly. Endocrine symptoms in anorexia nervosa include hypothermia (feeling cold), delayed onset of menses or secondary amenorrhea, and osteopenia progressing to osteoporosis.11,12 More than one-half of patients with eating disorders meet criteria for a current or past episode of major depression.16 Anorexia nervosa is associated with an increased risk of suicide, with the suicide standardized mortality ratio estimated to be as high as 31 in one meta-analysis.17 Other associated psychiatric disorders include obsessive-compulsive disorder, obsessive-compulsive personality disorder, social phobia, anxiety disorders, substance use disorders, and personality disorders. Psychological symptoms include heightened emotional arousal, reduced tolerance of stress, emotional dysregulation, social withdrawal, and self-critical perfectionistic traits.3

Screening for Eating Disorders Jump to section + Abstract

Definition

Prevalence and Etiology

Clinical Presentation

Screening for Eating Disorders

Initial Evaluation

Treatment

Prognosis

References Annual health supervision examinations and preparticipation sports physicals are ideal screening opportunities. In addition to weight, height, and body mass index measurements, a screening tool such as the SCOFF questionnaire (Table 418) can be used.11,12,18 The SCOFF questionnaire has been validated only in adults but suggests an approach that can also be used with children.12 Enlarge Print Table 4. The SCOFF Questionnaire: Screening for Eating Disorders in Adults Do you make yourself sick because you feel uncomfortably full? Do you worry you have lost control over how much you eat? Have you recently lost more than one stone (14 lb) in a three-month period? Do you believe yourself to be fat when others say you are too thin? Would you say that food dominates your life? Table 4. The SCOFF Questionnaire: Screening for Eating Disorders in Adults Do you make yourself sick because you feel uncomfortably full? Do you worry you have lost control over how much you eat? Have you recently lost more than one stone (14 lb) in a three-month period? Do you believe yourself to be fat when others say you are too thin? Would you say that food dominates your life?

Initial Evaluation Jump to section + Abstract

Definition

Prevalence and Etiology

Clinical Presentation

Screening for Eating Disorders

Initial Evaluation

Treatment

Prognosis

References The first priority in the evaluation of patients with eating disorders is to identify emergency medical conditions that require hospitalization and stabilization. Before the patient is weighed, a urine sample should be obtained to assess specific gravity for hydration status, pH level, ketone level, and signs of kidney damage. Weight, height, body mass index, and body temperature should be recorded. Because patients may wear extra clothes or hide heavy items to exaggerate their weight, they should be weighed wearing only underwear and a hospital gown. An attendant or parent may have to be present while they change. Clinicians may consider having patients face away from the scale so that they do not know their weight. Blood pressure should be recorded with orthostatic vital signs. Electrocardiography and laboratory studies such as urinalysis with specific gravity, complete blood count, complete metabolic panel, amylase and lipase measurement, phosphorous and magnesium measurement, and thyroid function tests (thyroid-stimulating hormone, thyroxine, free triiodothyronine) should be performed promptly.11,12 Less urgent testing, such as bone density testing, can be deferred.