Journal of Psychosocial Nursing and Mental Health Services

Psychopharmacology 

Treating Individuals With Eating Disorders: Part 1

Karen Jennings Mathis, PhD, CNP, PMHNP-BC; Christine Brigette Costa, DNP, APRN, PMHNP-BC; Pamela E. Xandre, DNP, WHNP-C, FNP-C

Abstract

According to the American Psychiatric Association, eating disorders (EDs) are characterized by a persistent disturbance of eating or eating-related behaviors that result in altered consumption or absorption of food and that significantly impair physical health and/or psychosocial functioning. EDs are chronic psychiatric illnesses and are notoriously difficult to treat. The etiology of eating disorders is unknown and thought to be a complex interplay among biological predisposition, environmental and sociocultural factors, neurobiological influences, and psychological factors. Moreover, prevalence of eating disorders is increasing despite variation in prevalence estimates across studies. Nurses are well-positioned to implement appropriate screening for and comprehensive assessment of EDs as well as offer patient-centered treatment options including referrals when indicated. As the first in a two-part series, this article provides an overview of the clinical characteristics of EDs and key areas for assessment and diagnostic considerations. The follow-up article in this series will focus on pharmacological treatment strategies. [Journal of Psychosocial Nursing and Mental Health Services, 58(3), 7–13.]

Abstract

According to the American Psychiatric Association, eating disorders (EDs) are characterized by a persistent disturbance of eating or eating-related behaviors that result in altered consumption or absorption of food and that significantly impair physical health and/or psychosocial functioning. EDs are chronic psychiatric illnesses and are notoriously difficult to treat. The etiology of eating disorders is unknown and thought to be a complex interplay among biological predisposition, environmental and sociocultural factors, neurobiological influences, and psychological factors. Moreover, prevalence of eating disorders is increasing despite variation in prevalence estimates across studies. Nurses are well-positioned to implement appropriate screening for and comprehensive assessment of EDs as well as offer patient-centered treatment options including referrals when indicated. As the first in a two-part series, this article provides an overview of the clinical characteristics of EDs and key areas for assessment and diagnostic considerations. The follow-up article in this series will focus on pharmacological treatment strategies. [Journal of Psychosocial Nursing and Mental Health Services, 58(3), 7–13.]

Exploring psychotherapeutic issues and agents in clinical practice

Eating disorders (EDs) are characterized by a persistent disturbance of eating or eating-related behaviors that result in altered consumption or absorption of food and that significantly impair physical health and/or psychosocial functioning (American Psychiatric Association [APA], 2013). EDs are chronic psychiatric disorders and are notoriously difficult to treat. The etiology of EDs is unknown and thought to be a complex interplay among biological predisposition, environmental and sociocultural factors, neurobiological influences, and psychological factors. Despite their high prevalence, morbidity and mortality, and potential for life-threatening medical consequences (APA, 2013; Bachmann et al., 2017; Sawyer et al., 2016; Smink et al., 2013), EDs often go undetected by health care providers (Campbell & Peebles, 2014). Nurses are well-positioned to implement appropriate screening for and comprehensive assessment of EDs as well as offer patient-centered treatment options including referrals when indicated.

As the first in a two-part series, this article provides an overview of the clinical characteristics of EDs and key areas for assessment and diagnostic considerations. The first section will briefly discuss the prevalence of EDs. The second section will present key areas for assessment and diagnostic considerations. The final section will provide a summary and clinical pearls.

How Common Are Eating Disorders?

According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), there are four primary EDs: (1) anorexia nervosa, (2) bulimia nervosa, (3) binge eating disorder (BED), and (4) avoidant/restrictive food intake disorder (ARFID) (Table A, available in the online version of this article). BED and ARFID do not require body image concerns as core diagnostic criteria and are distinguished based on eating behaviors, recurrent binge eating without regular purging, and avoidance and aversion to food and eating, respectively. Anorexia nervosa and bulimia nervosa are characterized by overvaluation on weight and shape. Anorexia nervosa includes individuals who are under-weight, engage in behaviors to lose or prevent weight gain, and may or may not binge eat or have inappropriate compensatory behaviors. Individuals with bulimia nervosa are typically not under-weight and are stuck in a cycle of binge eating and inappropriate compensatory behaviors (APA, 2013).

Criteria, Clinical Presentation, and Common Differential Diagnoses for Primary DSM-5 Eating DisordersCriteria, Clinical Presentation, and Common Differential Diagnoses for Primary DSM-5 Eating DisordersCriteria, Clinical Presentation, and Common Differential Diagnoses for Primary DSM-5 Eating Disorders

Table A:

Criteria, Clinical Presentation, and Common Differential Diagnoses for Primary DSM-5 Eating Disorders

Prevalence of EDs is increasing despite variation in prevalence estimates across studies, which are due to differences in diagnostic criteria, sampling, small sample sizes, and date of study (Galmiche et al., 2019; Hudson & Pope, 2018). In fact, researchers have postulated that BED may be the most prevalent ED yet the most underdiagnosed and undertreated (Kornstein et al., 2016). With onset typically during adolescence and early adulthood and higher prevalence in Western cultures (Kessler et al., 2013), females are more likely to be diagnosed and receive treatment for EDs (Coffino et al., 2019; Sonneville & Lipson, 2018). However, studies suggest that EDs are increasing in prevalence among males (Coelho et al., 2018; Galmiche et al., 2019); lesbian, gay, bisexual, transgender, queer, intersex, and asexual or allied (LGBTQIA) individuals (Diemer et al., 2018; Donaldson et al., 2018), older adults (Harris & Cumella, 2006; Mangweth-Matzek & Hoek, 2017), and across races and ethnicities (Dooley-Hash et al., 2019; Jennings et al., 2015; Pike et al., 2014).

Key Areas of Assessment

To better assess and treat EDs, health care providers must gain knowledge about their physiological and psychological characteristics. In fact, once EDs are identified, health care providers are more capable of providing evidence-based treatment options. Across EDs, it is essential for health care providers to execute a comprehensive assessment and have a standard practice of using screening tools and requesting laboratory tests for every patient. Table A provides information about clinical presentations and differential diagnoses. Table 1 provides resources and screening tools for EDs.

Resources and Screening Tools for Eating Disorders

Table 1:

Resources and Screening Tools for Eating Disorders

Mental Status Exam

A mental status exam provides additional information about mood and affect as well as appearance, speech, psychomotor function, and suicidal ideation and behavior. Given the high prevalence of psychiatric comorbidities, including suicidal intent and non-suicidal self-injury, the mental status exam provides essential information about the presence of symptoms related to psychiatric comorbidities.

Developmental and Social History

Developmental and social history includes developmental milestones, academic progress, occupation, interpersonal relationships, and traumatic events. Individuals with ED often experience negative social interactions that significantly impact their desire to alter body weight or shape (e.g., bullying or teasing about being under- and overweight). In time, they may also become more isolated because they are preoccupied with their shape and weight and compensatory behaviors. In fact, self-esteem for individuals with EDs is very dependent on perceptions of body shape and weight. Indications of impaired psychosocial functioning may include inability to eat with others; avoidance of social events with food; avoidance or refusal of foods based on colors, textures, smell, or temperature; avoidance of food shopping; and avoidance of eating food prepared by someone else.

Family History of Eating Disorders

Given the genetic predisposition and familial influence on EDs (APA, 2013), assessment of family history of EDs or obesity as well as family and cultural norms related to eating, perceptions of body weight and shape, and values is needed. Such information may provide insight about the individual's relationship to food, how it has contributed to the onset or severity of ED symptoms, and treatment targets.

Medical History and Current Medical Problems

Assessment of current and past medical history may provide additional information about EDs and differential diagnoses. The physical examination should include the following: weight, height, pulse, blood pressure, hydration status, and skin, neurological, dental, cardiac, abdominal, and extremity examinations (Mehler & Anderson, 2017). Medical conditions can lead to changes in appetite, weight, or food in-take that can be ruled out with a thorough history and physical examination along with laboratory studies. These illnesses include chronic infection and infectious diseases, thyroid disease, Addison's disease, inflammatory bowel disease, connective tissue disorders, cystic fibrosis, peptic ulcer disease, disease of the esophagus or small intestine, celiac disease, diarrhea, diabetes mellitus, and occult malignancies (Lock & La Via, 2015).

Regarding EDs, medical complications may include cardiovascular abnormalities, such as bradycardia, prolonged corrected QT intervals, dysrhythmias, orthostatic pulse, blood pressure instability, hypothermia, renal abnormalities (e.g., pyuria, hematuria, proteinuria), and electrolyte abnormalities (e.g., hypokalemia, hypocalcemia, hypomagnesemia, hypophosphatemia). Although most physiological disturbances associated with malnutrition are reversible by restoring healthy nutritional practices, some are not completely reversible, such as loss of bone mineral density (Mehler & Brown, 2015; Palla & Litt, 1988).

An electrocardiogram may be indicated for individuals who are very thin, complaining of palpitations, or have other signs or symptoms of cardiovascular concern. A dual-energy radiographic absorptiometry scan may be useful, particularly for individuals with irregular menses, with mood disorders, and/or who smoke cigarettes. Genetic testing may be helpful to rule in or out a deletion or translocation syndrome. Across EDs, comprehensive laboratory testing at the initial evaluation may assist in ruling out other genetic and biological diseases. Inappropriate compensatory behaviors (e.g., self-induced vomiting; misuse of laxatives, diuretics, enemas) may cause disturbances that lead to abnormal laboratory findings; however, quite often, individuals with anorexia nervosa exhibit no laboratory abnormalities until the ED has significantly progressed (Mehler & Brown, 2015). Laboratory testing should include but is not limited to: comprehensive blood chemistry with differential, serum electrolytes, calcium, magnesium, and phosphate levels; liver function tests and albumin; serum salivary amylase levels; vitamin D; serum BUN and creatinine levels; blood glucose levels; T4 and thyroid-stimulating hormone (TSH) levels; testosterone level; urinalysis; and pregnancy test (Mehler & Anderson, 2017; Miller et al., 2005).

Psychiatric History

Psychiatric history includes current and past psychotherapeutic treatment (e.g., level of care, dates, duration, location, diagnosis, treatment modality), pharmacological treatment (e.g., medication name, dose, duration, dates, response, efficacy), and adjunct therapies (e.g., family or couples, group, support, alternative, nutritional). Additional information may include illness duration for current diagnoses, and for adults, highest and lowest lifetime body mass index (BMI) or weights and age at which these occurred. Most individuals with EDs will have at least one other psychiatric disorder, and psychiatric comorbidities are predictors of health services utilization and prognosis (Keel & Brown, 2010; Weigel et al., 2019). Because nonweight-related appearance concerns occur in individuals with EDs (Kollei et al., 2013), body dysphoria disorder can be a comorbidity. The most common psychiatric comorbidities include depression, anxiety, and personality, trauma-related, and substance use disorders (Afifi et al., 2017; Bahji et al., 2019; Kimber et al., 2017; Udo & Grilo, 2019). Thus, assessments of mood, anxiety, substance use, trauma, and suicidal thoughts and behavior are useful.

Eating Patterns and Compensatory Behaviors

Assessment of eating patterns includes frequency, amount, type, and location of food intake (Wolfe et al., 2016). Considerations of existing guidelines (e.g., dietary, BMI) and the individual's weight history, body type, and physiological disturbances are helpful. Individuals with ARFID tend to lack interest in eating or food, which leads to food restriction or avoidance and eventually weight loss or malnutrition. Diagnostic markers of ARFID may include malnutrition, low weight, growth delay, and a need for artificial nutrition (APA, 2013). However, for anorexia nervosa, individuals tend to restrict intake and have low weight because of significant weight loss or failure to meet expected weight gain or maintain normal developmental trajectories. Diagnostic features of anorexia nervosa may include: fasting or excessive physical activity to lose or maintain low weight; manipulation of medication dosage to lose or maintain low weight; preoccupation with thoughts of food; binge eating episodes and inappropriate compensatory behaviors; and purging behaviors after consumption of small amounts of food to maintain low weight (APA, 2013).

For binge eating episodes, information to gather includes frequency, duration, time of day, types and amount of food, and associated feelings and events. Individuals who engage in binge eating may be hesitant to disclose details because they often develop a sense of guilt and shame about binge eating episodes and tend to secretly engage in the behavior. For BED, binge eating episodes are not accompanied by compensatory behaviors, but quite often, individuals experience embarrassment, guilt, and/or feeling of disgust after the episodes, which may lead to more food consumption. For bulimia and anorexia nervosa, the fear of gaining weight leads to inappropriate compensatory behaviors to counter the size and/or frequency of binge eating episodes. In fact, individuals with bulimia nervosa tend to restrict caloric intake or fast between binge eating episodes. Thus, assessing types and frequency of inappropriate compensatory behaviors is useful. Although self-induced vomiting is the most common, other inappropriate compensatory behaviors include, but are not limited to, misuse of laxatives, diuretics, and enemas and/or excessive exercise

Cognitive distortions about food and weight are commonplace in EDs. For example, individuals may have dichotomous thinking about foods as “good” or “bad,” or body image concerns may manifest as complaints about body parts (e.g., thighs, hips, stomach). However, ARFID and BED do not require body image concerns as core diagnostic criteria and are based primarily on eating behaviors. Overall, assessment of psychosocial environment, psychiatric comorbidities, and life stressors are needed because these factors can negatively influence self-esteem, body image, and cognitive distortions, which contribute to ED symptoms.

Special Populations

Other Specified or Unspecified Eating Disorders. For these diagnoses, individuals do not meet the full criteria for one of the primary EDs. For example, with BED or bulimia nervosa, individuals do not meet the required frequency or duration of binge eating and/or compensatory behaviors. Atypical anorexia nervosa is characterized by having the same key features of anorexia nervosa except being under-weight (APA, 2013). In fact, individuals with atypical anorexia nervosa may have significant weight loss and are within or above normal weight ranges. The key characteristic of purging disorder is engaging in recurrent weight control behaviors to influence weight or shape in the absence of binge eating. Finally, night eating syndrome is characterized by recurrent episodes of night eating (after evening meal or waking to eat) associated with significant distress or impairment in functioning.

Pediatrics. Most pediatric patients with EDs require medical intervention and need to receive ongoing medical monitoring in concert with psychiatric treatment. Although minimal scientific evidence exists for using weight as a marker of illness severity in children and adolescents, pediatric weight is based on age and gender norms according to BMI percentiles, with BMI below the 10th percentile being consistent with the degree of malnutrition associated with anorexia nervosa (APA, 2013). Signs and symptoms of EDs may present differently in children and adolescents compared to adults. Developmental stage should be considered and often information from primary caregivers is critical because self-report can be unreliable (e.g., lack insight, minimization, more likely to deny seriousness). For example, verbalizing abstract thoughts may not be possible for children and they may use ED behaviors, such as food refusal, as nonverbal representations of emotional experiences. Other examples include variations in maladaptive behaviors, such as constant compulsive movements, change in appearance (e.g., loose-fitting clothing or heavier clothing for warmth), and fluid restriction. In addition, primary caregivers can provide information about behavioral changes, such as changes in being withdrawn, depressed, and anxious (Lock & La Via, 2015).

Psychosis. Undernutrition or malnutrition can produce clinical presentation that resembles psychosis but is usually transient. However, clinical phenomena include EDs serving as a prodrome or early stage of psychosis and EDs emerging as a result of the treatment of psychosis (Seeman, 2014). Although there is no established connection between eating and psychotic disorders, a subset of individuals may have both an ED and a psychotic disorder (Alves Pereira et al., 2016). Individuals with a psychotic disorder may have delusions that lead to food aversions and dangerous eating behavior, but this is not an ED. Research in the common dimensions of illness for both disorders is accelerating.

Pregnant Women. Estimated occurrence of EDs among pregnant women is 7.5% (Dörsam et al., 2019), and places the woman and fetus in jeopardy. Pregnant women with EDs have increased risk of antepartum hemorrhage and hyperemesis gravidarum, and higher rates of spontaneous abortion, cesarean sections, and postpartum depression (Mantel et al., 2019). Detrimental fetal outcomes can include presence of lower or higher birth weights, intrauterine growth restriction, small head circumferences, neurobehavioral dysregulations early after birth, premature deliveries, and increased perinatal mortality (Ward, 2008). Clinical presentation varies and may be influenced by whether the pregnancy was intended/anticipated; social, emotional, and financial supports; and age. Indeed, EDs may be linked to lack of acceptance of the pregnancy, a way to inhibit body disfigurement, or an attempt to keep the pregnancy secret. Despite inconsistencies in optimal approaches to treating EDs during pregnancy, pregnant women with EDs require medical intervention and ongoing surveillance along with psychiatric treatment. Balanced nutrition is critical to ensure positive obstetrical outcomes, whereas lack of balanced nutrition may lead to negative consequences. Moreover, early intervention strategies and a multidisciplinary approach are preferential especially because pregnant women require significantly more nutrients typically starting in the 4th month of gestation. Although, pregnancy may be a trigger for the continuation or even deterioration of symptoms, especially for BED, evidence suggests an improvement of eating behaviors during pregnancy (Dörsam et al., 2019).

Summary

EDs often go undetected by health care providers. Nurses are well-positioned to implement appropriate screening for and comprehensive assessment of EDs to determine ED diagnosis. Indeed, a comprehensive evaluation is essential to guide optimal treatment options. Table 2 presents clinical pearls for assessing and diagnosing EDs.

Clinical Pearls for Assessing and Diagnosing Eating Disorders (EDs)

Table 2:

Clinical Pearls for Assessing and Diagnosing Eating Disorders (EDs)

As the first in a two-part series, this article provided an overview of the clinical characteristics of EDs and key areas for assessment and diagnostic considerations.

References

  • Afifi, T. O., Sareen, J., Fortier, J., Taillieu, T., Turner, S., Cheung, K. & Henriksen, C. A. (2017). Child maltreatment and eating disorders among men and women in adulthood: Results from a nationally representative United States sample. International Journal of Eating Disorders, 50(11), 1281–1296 doi:10.1002/eat.22783 [CrossRef] PMID:28990206
  • Alves Pereira, C., Silva, J. R., Cajão, R., Lourenço, J. P. & Casanova, T. (2016). The co-occurrence of eating disorders and psychosis. European Psychiatry, 33, S425 doi:10.1016/j.eurpsy.2016.01.1540 [CrossRef]
  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Author.
  • Bachmann, K. N., Schorr, M., Bruno, A. G., Bredella, M. A., Lawson, E. A., Gill, C. M., Singhal, V., Meenaghan, E., Gerweck, A.V., Slattery, M., Eddy, K. T., Ebrahimi, S., Koman, S. L., Greenblatt, J. M., Keane, R. J., Weigel, T., Misra, M., Bouxesein, M. L., Klibanski, A. & Miller, K. K. (2017). Vertebral volumetric bone density and strength are impaired in women with low-weight and atypical anorexia nervosa. The Journal of Clinical Endocrinology and Metabolism, 102(1), 57–68 doi:10.1210/jc.2016-2099 [CrossRef] PMID:27732336
  • Bahji, A., Mazhar, M. N., Hudson, C. C., Nadkarni, P., MacNeil, B. A. & Hawken, E. (2019). Prevalence of substance use disorder comorbidity among individuals with eating disorders: A systematic review and meta-analysis. Psychiatry Research, 273, 58–66 doi:10.1016/j.psychres.2019.01.007 [CrossRef] PMID:30640052
  • Campbell, K. & Peebles, R. (2014). Eating disorders in children and adolescents: State of the art review. Pediatrics, 134(3), 582–592 doi:10.1542/peds.2014-0194 [CrossRef] PMID:25157017
  • Coelho, J. S., Lee, T., Karnabi, P., Burns, A., Marshall, S., Geller, J. & Lam, P.-Y. (2018). Eating disorders in biological males: Clinical presentation and consideration of sex differences in a pediatric sample. Journal of Eating Disorders, 6(1), 40 doi:10.1186/s40337-018-0226-y [CrossRef] PMID:30534377
  • Coffino, J. A., Udo, T. & Grilo, C. M. (2019). Rates of help-seeking in US adults with lifetime DSM-5 eating disorders: Prevalence across diagnoses and differences by sex and ethnicity/race. Mayo Clinic Proceedings, 94(8), 1415–1426 doi:10.1016/j.mayocp.2019.02.030 [CrossRef] PMID:31324401
  • Diemer, E. W., White Hughto, J. M., Gordon, A. R., Guss, C., Austin, S. B. & Reisner, S. L. (2018). Beyond the binary: Differences in eating disorder prevalence by gender identity in a transgender sample. Transgender Health, 3(1), 17–23 doi:10.1089/trgh.2017.0043 [CrossRef] PMID:29359198
  • Donaldson, A. A., Hall, A., Neukirch, J., Kasper, V., Simones, S., Gagnon, S., Reich, S. & Forcier, M. (2018). Multidisciplinary care considerations for gender nonconforming adolescents with eating disorders: A case series. International Journal of Eating Disorders, 51(5), 475–479 doi:10.1002/eat.22868 [CrossRef] PMID:29740834
  • Dooley-Hash, S., Adams, M., Walton, M. A., Blow, F. C. & Cunningham, R. M. (2019). The prevalence and correlates of eating disorders in adult emergency department patients. International Journal of Eating Disorders, 52(11), 1281–1290 doi:10.1002/eat.23140 [CrossRef] PMID:31322755
  • Dörsam, A. F., Preißl, H., Micali, N., Lörcher, S. B., Zipfel, S. & Giel, K. E. (2019). The impact of maternal eating disorders on dietary intake and eating patterns during pregnancy: A systematic review. Nutrients, 11(4), 840 doi:10.3390/nu11040840 [CrossRef] PMID:31013875
  • Galmiche, M., Déchelotte, P., Lambert, G. & Tavolacci, M. P. (2019). Prevalence of eating disorders over the 2000–2018 period: A systematic literature review. The American Journal of Clinical Nutrition, 109(5), 1402–1413 doi:10.1093/ajcn/nqy342 [CrossRef] PMID:31051507
  • Harris, M. & Cumella, E. J. (2006). Eating disorders across the life span. Journal of Psychosocial Nursing and Mental Health Services, 44(4), 20–26 doi:10.3928/02793695-20060401-06 [CrossRef] PMID:16640239
  • Hudson, J. I. & Pope, H. G. Jr. . (2018). Evolving perspectives on the public health burden of eating disorders. Biological Psychiatry, 84(5), 318–319 doi:10.1016/j.biopsych.2018.06.011 [CrossRef] PMID:30115240
  • Jennings, K. M., Kelly-Weeder, S. & Wolfe, B. E. (2015). Binge eating among racial minority groups in the United States: An integrative review. Journal of the American Psychiatric Nurses Association, 21(2), 117–125 doi:10.1177/1078390315581923 [CrossRef] PMID:25979879
  • Keel, P. K. & Brown, T. A. (2010). Update on course and outcome in eating disorders. International Journal of Eating Disorders, 43(3), 195–204 doi:10.1002/eat.20810 [CrossRef] PMID:20186717
  • Kessler, R. C., Berglund, P. A., Chiu, W. T., Deitz, A. C., Hudson, J. I., Shahly, V., Aguilar-Gaxiola, S., Alonso, J., Angermeyer, M. C., Benjet, C., Bruffaerts, R., de Girolamo, G., de Graaf, R., Maria Haro, J., Kovess-Masfety, V., O'Neill, S., Posada-Villa, J., Sasu, C., Scott, K. & Xavier, M. (2013). The prevalence and correlates of binge eating disorder in the World Health Organization World Mental Health Surveys. Biological Psychiatry, 73(9), 904–914 doi:10.1016/j.biopsych.2012.11.020 [CrossRef] PMID:23290497
  • Kimber, M., McTavish, J. R., Couturier, J., Boven, A., Gill, S., Dimitropoulos, G. & MacMillan, H. L. (2017). Consequences of child emotional abuse, emotional neglect and exposure to intimate partner violence for eating disorders: A systematic critical review. BMC Psychology, 5(1), 33 doi:10.1186/s40359-017-0202-3 [CrossRef] PMID:28938897
  • Kollei, I., Schieber, K., de Zwaan, M., Svitak, M. & Martin, A. (2013). Body dysmorphic disorder and nonweight-related body image concerns in individuals with eating disorders. International Journal of Eating Disorders, 46(1), 52–59 doi:10.1002/eat.22067 [CrossRef] PMID:23044508
  • Kornstein, S. G., Kunovac, J. L., Herman, B. K. & Culpepper, L. (2016). Recognizing binge-eating disorder in the clinical setting: A review of the literature. The Primary Care Companion for CNS Disorders, 18(3). doi:10.4088/PCC.15r01905 [CrossRef] PMID:27733955
  • Lock, J. & La Via, M. C. (2015). Practice parameter for the assessment and treatment of children and adolescents with eating disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 54(5), 412–425 doi:10.1016/j.jaac.2015.01.018 [CrossRef] PMID:25901778
  • Mangweth-Matzek, B. & Hoek, H. W. (2017). Epidemiology and treatment of eating disorders in men and women of middle and older age. Current Opinion in Psychiatry, 30(6), 446–451 doi:10.1097/YCO.0000000000000356 [CrossRef] PMID:28825955
  • Mantel, Ä., Lindén Hirschberg, A. & Stephansson, O. (2019). Association of maternal eating disorders with pregnancy and neonatal outcomes. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2019.3664 [CrossRef] PMID:31746972
  • Mehler, P. S. & Anderson, A. E. (2017). Eating disorders: A guide to medical care and complications (3rd ed.). Johns Hopkins University Press.
  • Mehler, P. S. & Brown, C. (2015). Anorexia nervosa: Medical complications. Journal of Eating Disorders, 3(1), 11 doi:10.1186/s40337-015-0040-8 [CrossRef] PMID:25834735
  • Miller, K. K., Grinspoon, S. K., Ciampa, J., Hier, J., Herzog, D. & Klibanski, A. (2005). Medical findings in outpatients with anorexia nervosa. Archives of Internal Medicine, 165(5), 561–566 doi:10.1001/archinte.165.5.561 [CrossRef] PMID:15767533
  • Palla, B. & Litt, I. F. (1988). Medical complications of eating disorders in adolescents. Pediatrics, 81(5), 613–623 PMID:3162764
  • Pike, K. M., Hoek, H. W. & Dunne, P. E. (2014). Cultural trends and eating disorders. Current Opinion in Psychiatry, 27(6), 436–442 doi:10.1097/YCO.0000000000000100 [CrossRef] PMID:25211499
  • Sawyer, S. M., Whitelaw, M., Le Grange, D., Yeo, M. & Hughes, E. K. (2016). Physical and psychological morbidity in adolescents with atypical anorexia nervosa. Pediatrics, 137(4), e20154080 doi:10.1542/peds.2015-4080 [CrossRef] PMID:27025958
  • Seeman, M. V. (2014). Eating disorders and psychosis: Seven hypotheses. World Journal of Psychiatry, 4(4), 112–119 doi:10.5498/wjp.v4.i4.112 [CrossRef] PMID:25540726
  • Smink, F. R., van Hoeken, D. & Hoek, H. W. (2013). Epidemiology, course, and outcome of eating disorders. Current Opinion in Psychiatry, 26(6), 543–548 doi:10.1097/YCO.0b013e328365a24f [CrossRef] PMID:24060914
  • Sonneville, K. R. & Lipson, S. K. (2018). Disparities in eating disorder diagnosis and treatment according to weight status, race/ethnicity, socioeconomic background, and sex among college students. International Journal of Eating Disorders, 51(6), 518–526 doi:10.1002/eat.22846 [CrossRef] PMID:29500865
  • Udo, T. & Grilo, C. M. (2019). Psychiatric and medical correlates of DSM-5 eating disorders in a nationally representative sample of adults in the United States. International Journal of Eating Disorders, 52(1), 42–50 doi:10.1002/eat.23004 [CrossRef] PMID:30756422
  • Ward, V. B. (2008). Eating disorders in pregnancy. BMJ (Clinical Research Ed.), 336(7635), 93–96 doi:10.1136/bmj.39393.689595.BE [CrossRef] PMID:18187726
  • Weigel, T. J., Wang, S. B., Thomas, J. J., Eddy, K. T., Pierce, C., Zanarini, M. C., Fitzmaurice, G. & Busch, A. (2019). Residential eating disorder outcomes associated with screening positive for substance use disorder and borderline personality disorder. International Journal of Eating Disorders, 52(3), 309–313 doi:10.1002/eat.23028 [CrossRef] PMID:30746736
  • Wolfe, B. E., Dunne, J. P. & Kells, M. R. (2016). Nursing care considerations for the hospitalized patient with an eating disorder. The Nursing Clinics of North America, 51(2), 213–235 doi:10.1016/j.cnur.2016.01.006 [CrossRef] PMID:27229277

Resources and Screening Tools for Eating Disorders

Resource/URLSelf-Report Screening Tools
Academy for Eating Disorders https://www.aedweb.org/homeEating Attitudes Test (EAT): 26 items
Alliance for Eating Disorders Awareness https://www.allianceforeatingdisorders.comEating Disorder Diagnostic Scale (EDDS): 22 items
Eating Disorders Anonymous http://eatingdisordersanonymous.orgEating Disorder Examination-Questionnaire (EDE-Q): 28 items
Eating Disorders Coalition https://www.eatingdisorderscoalition.orgEating Disorder Inventory 3 (EDI-3): 91 items
Eating Disorders Hope https://www.eatingdisorderhope.com
International Association of Eating Disorders Professionals http://www.iaedp.com
Maudsley Parents http://www.maudsleyparents.org
Multiservice Eating Disorders Association https://www.medainc.org
National Eating Disorders Association https://www.nationaleatingdisorders.org
National Eating Disorder Information Centre https://nedic.ca

Clinical Pearls for Assessing and Diagnosing Eating Disorders (EDs)

Primary care can gain competency in treating most individuals with EDs, especially the more commonplace earlier onset and less severe clinical presentations.
Males tend to be undiagnosed or avoid diagnosis and treatment.
EDs can and do occur across the lifespan. However, EDs are most common in adolescents and young adults; and binge eating disorder (BED) tends to occur at older ages.
Pre-conceptional care and the first prenatal visit are excellent opportunities to screen for EDs because women are more motivated to receive advice and help at these times.
BED and avoidant/restrictive food intake disorder do not require body image concerns as core diagnostic criteria and are distinguished based on eating behaviors.
Assessing eating patterns includes frequency, amount, type, and location of food intake.
Existing guidelines (e.g., dietary, body mass index), weight history, body type, and physiological disturbances should also be considered.
Assessing binge eating episodes includes frequency, duration, time of day, types and amount of food, and associated feelings and events.
Abnormal laboratory findings may be indicative of inappropriate compensatory behaviors (e.g., self-induced vomiting; misuse of laxatives, diuretics, enemas).
Individuals with anorexia nervosa tend to have normal laboratory findings until the ED has significantly progressed.
Most individuals with EDs will have at least one other psychiatric disorder, and psychiatric comorbidities are predictors of health services utilization and prognosis. Most common psychiatric comorbidities include depression, anxiety, and personality, trauma-related, and substance use disorders.
Most physiological disturbances associated with malnutrition are reversible with nutritional rehabilitation, but not all, such as loss of bone mineral density.

Criteria, Clinical Presentation, and Common Differential Diagnoses for Primary DSM-5 Eating Disorders

DSM 5 Eating DisorderDSM 5 criteria (adapted)Clinical presentationCommon differential diagnosis
Anorexia NervosaRestriction of needed energy intake leading to significantly low body weight Intense fear of gaining weight or persistent behavior that interferes with weight gain Undue influence of body shape or weight on self–evaluation Disturbance in the way that one experiences body weight or shape Persistent lack of recognition of the seriousness of low weight Subtypes: (1) restricting or (2) binge eating and/or purging based on the absence or presence of recurrent binge–eating or purging behaviorsEating and weightSevere restriction of food intake Underweight Significant weight loss or failure to make appropriate weight gains Unwillingness to maintain normal or healthy weight Intense fear of gaining weightCognitivePursuit of thinness Distorted body image Self-esteem heavily influenced by perceptions of body weight and shape Denial of the seriousness of low body weight Lethargy, sluggishness, or feeling tired Worsening mood and/or anxiety PhysiologicalOsteopenia/osteoporosis Mild anemia Muscle wasting and weakness Brittle hair and nails Dry and yellowish skin Growth of fine hair all over the body (lanugo) Severe constipation Hypothermia Low blood pressure Slowed breathing and pulse Heart damage (structural, functional) Brain damage Multiorgan failure InfertilityAchalasia Addison's disease Avoidant/restrictive food intake disorder Celiac disease (Sprue) Chronic infection Superior mesenteric artery syndrome Diabetes mellitus Hyperthyroidism Inflammatory bowel syndrome Malabsorption Malignancy Panhypopituitaris Parasitic intestinal infection Protein-losing enteropathy Psychiatric disorders associated with weight loss
Bulimia NervosaRecurrent binge eating and inappropriate compensatory behaviors Binge eating. defined as eating an objectively larger amount of food than most people would eat in a similar setting with an associated sense of loss of control overeating Inappropriate compensatory behaviors to prevent weight gain such as self–induced vomiting, misuse of laxatives, diuretics, enemas, other medications, fasting, or excessive exercise Undue influence of body shape or weight on self–evaluationEating and weightIrregular, skipping meals Restriction of food intake outside of binge eating Normal or above normal weight CognitiveDistorted body image Self-esteem heavily influenced by perceptions of body weight and shape PhysiologicalChronically inflamed and sore throat Swollen salivary glands Worn tooth enamel Increasingly sensitive and decaying teeth as a result of exposure to stomach acid Acid reflux disorder and other gastrointestinal problems Intestinal distress and irritation from laxative abuse Severe dehydration from purging of fluids Electrolyte imbalance which can lead to stroke or heart attackBrain tumor Bowel obstruction Connective tissue disorders with GI involvement Depression Diabetes Gastric outlet obstruction Gastroesophageal disorder Insulinoma Infections Inflammatory bowel disease Kleine-Levin syndrome Kluver-Bucy syndrome Malabsorptive states Parasitic intestinal infection
Binge Eating DisorderRecurrent binge eating withoutassociatedinappropriate compensatory weightcontrol behaviors Distress about binge eating which areassociated with eating rapidly, eatinguntil uncomfortably full, eating largeamounts when not hungry, eating alonedue to embarrassment, and feelingdisgusted, depressed, or very guiltyafter eatingEating and weightIrregular food intake No extreme restriction of intake Normal or above normal weight CognitiveBinge eating episodes associated with anacute feeling of loss of control andmarked distress Night eating Self-esteem heavily influenced by perceptions of body weight and shapeMood disordersTumor of ventromedialhypothalamus orparaventricular nucleus Nutritional deficiency states Obesity
Avoidant and Restrictive Food Intake DisorderAvoidance of specific foods or restriction of food intake because of a lack of interest, sensory characteristics of food, or adverse consequences of eating Must include one or more: significant weight loss (or failure to gain); significant nutritional deficiency; dependence on enteral feeding or oral nutritional supplements; marked interference with psychosocial functioning, or no evidence of body dysmorphismFood and weightSevere restriction of all or selected foods Underweight and/or nutrition deficiency Significant weight loss or failure to make appropriate weight gains Food avoidance based on food texture and smell Lack of appetite Absolute food refusal CognitiveGeneral dislike of foods Fear of vomiting Generalized anxiety with eating PhysiologicalAbdominal pain Nausea Feelings of fullness Unpleasant sensory experiences while eatingAnorexia nervosa Bulimia nervosa Dysphagia Food avoidance Emotional disorder Selective eating
Authors

Dr. Mathis is Assistant Professor, College of Nursing University of Rhode Island, Nursing Education Center, Providence, Rhode Island; and Dr. Costa is Assistant Professor and Dr. Xandre is Associate Professor, College of Health and Human Services/School of Nursing, California State University, Long Beach, Long Beach, California.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Karen Jennings Mathis, PhD, CNP, PMHNP-BC, Assistant Professor, College of Nursing University of Rhode Island, Nursing Education Center, 350 Eddy Street, Providence, RI 02903; e-mail: k_jennings@uri.edu.

10.3928/02793695-20200217-02

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