In recent years, it's become clear that there are many people with eating disorders who don't fit the classic profile of someone with anorexia or bulimia.
What are the different types of eating disorder?
One eating disorder called orthorexia was only described for the first time in the 1990s. As a result, there have been several changes in how eating disorders are grouped together, or classified.
The World Health Organization uses a classification called ICD-10, which splits eating disorders up into Anorexia Nervosa; Bulimia Nervosa; Overeating Associated with Other Psychological Disturbances; and Other Eating Disorders.
The DSM classification, from the American Psychiatric Association, was updated to its fifth version (DSM-5) in 2013. DSM-5 breaks eating disorders down into:
- Anorexia nervosa (often just called anorexia, which is the medical term for anyone who is off their food).
- Bulimia nervosa (often just called bulimia).
- Binge eating disorder.
- Other specified feeding or eating disorder (OSFED).
- Avoidant/restrictive food intake disorder (ARFID).
- Rumination disorder.
- Unspecified feeding or eating disorder.
The two most common eating disorders are anorexia and bulimia. People with anorexia restrict the amount they eat and often lose so much weight they put their health, and even their lives, at risk. However, if you have anorexia, you'll often be obsessed with thinking about food.
In some respects this isn't surprising. If you have anorexia, you are starving yourself and, as a result of evolution, we're primed to think about food all the time if we don't have enough of it. This basic instinct drove our ancestors to keep searching for food when famine was just around the corner, and those who had the strongest drive were most likely to survive long enough to have children.
If you have bulimia, you go through phases of bingeing on food and then 'purging', either by making yourself sick or taking laxatives. Most people with bulimia are of normal weight or even overweight.
Physical problems with bulimia are not as common as they are with anorexia, but the emotional distress is often every bit as great.
Binge eating disorder
You can be diagnosed with binge eating disorder if you both:
- Go through episodes of eating much more than most people would in a short period of time (usually defined as two hours); and
- Feel out of control during these eating episodes.
These episodes happen at least once a week for three months for a diagnosis of binge eating disorder. During these episodes, you may:
- Eat much faster than normal.
- Eat until you feel uncomfortably full.
- Keep eating, even when you're not hungry.
- Feel ashamed of yourself afterwards.
- Hide yourself away to eat because you don't want anyone to know you're doing it.
As with other eating disorders, the emotional distress is every bit as difficult to cope with as the eating issue itself.
Other specified feeding or eating disorder (OSFED)
These are eating disorders that don't tick all the boxes needed to make a diagnosis such as anorexia, bulimia or binge eating disorder. It doesn't mean they're not as serious, or that they don't need treatment. The mental distress they cause, and the underlying psychological problems that lead to them, are very similar. However, they show themselves in slightly different ways.
For instance, to be diagnosed with 'classic' bulimia or binge eating disorder, you need to binge and/or purge with a certain frequency for a set minimum length of time. Someone who binges or binges and purges in exactly the same way as someone with binge eating disorder or bulimia, but does it less often, might be diagnosed with OSFED. Likewise, someone with the same abnormal body image and fears about gaining weight as someone with anorexia, but whose weight is not low enough for a diagnosis of anorexia, might be diagnosed with OSFED.
Conditions that can be labelled as OSFED include:
- Night eating disorder (repeated episodes of eating large quantities between supper and bed, or in the middle of the night).
- Purging disorder (similar to the purging in bulimia, but without the bingeing).
- Atypical anorexia nervosa (that doesn't fit all the DSM-5 criteria for bulimia).
- Atypical bulimia nervosa (that doesn't fit all the DSM-5 criteria for anorexia).
- Binge eating disorder that doesn't fit all the DSM-5 criteria.
Pica is a very specific eating disorder which involves a compulsion to eat 'non-nutritive substances' such as coal or chalk repeatedly. It must not be explained because of your age or level of development (for instance, babies are very unfussy about what they put in their mouths) or to do with cultural or social practices.
People who have rumination disorder will repeatedly regurgitate food before swallowing it again, chewing it once more or spitting it out. Some people regurgitate food because they have problems with their digestive tract: this is not counted as a rumination disorder.
Avoidant/restrictive food intake disorder (ARFID)
A person with this disorder will persistently fail to eat enough to maintain their energy requirements. It is diagnosed if as a result they:
- Lose significant amounts of weight; and/or
- Become deficient in vitamins, minerals or other vital nutrients; and/or
- Are dependent on oral or tube feeding to get the nutrients they need; and/or
- Have their lives majorly affected as a result.
Orthorexia is not included as an eating disorder in its own right under the DSM-5 criteria. It's a relatively 'new' eating disorder, first defined in 1997. People with orthorexia are obsessed with eating 'pure' food and often start with a desire to become generally healthier. Many psychiatrists see clear links between 'clean eating' and orthorexia, and have also seen many patients with orthorexia progress to develop anorexia.
As with other eating disorders, you don't have orthorexia unless your eating is having a significant impact on your emotional well-being. You may feel unable to eat out, or to socialise with friends where food is involved. You may find yourself being judgemental about other people's eating habits, and guilty or 'unclean' if you don't follow your own, self-imposed eating rules.
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Do I have an eating disorder?
The kind of questions you can ask yourself include:
- Does food dominate my life?
- Do I worry that something bad will happen if I lose control of my eating?
- Do I have episodes where I feel I have lost control of my eating, then feel disgusted with myself afterwards?
- Have I lost more than a stone in the last three months?
- Do people tell me I'm thin, even though I think I'm fat?
- Do I hide myself away to eat large quantities, because I'm embarrassed to let anyone know what I'm eating?
- Have I taken laxatives or made myself sick because I'm uncomfortably full?
Spotting an eating disorder in a loved one
Different eating disorders have some different features - for instance, to be diagnosed with anorexia you must be underweight. However, it's absolutely possible to have an eating disorder without being grossly underweight. In fact, people with orthorexia are often also obsessed with being in perfect physical shape, so may be extremely fit and look very healthy.
Warning signs include:
- Losing lots of weight.
- Making excuses not to eat in company.
- Wearing baggy clothes to hide their shape.
- Secret stashes of unhealthy food or laxatives.
- Locking themselves in the bathroom after meals or at other times.
- Becoming distressed if you try to talk to them about eating.
- Being very concerned that others in the family eat lots.
- Being very fussy about their food.
- Cutting out whole food groups - gluten, lactose, any form of processed foods, animal products, etc.
- Insisting on doing the food shopping, and spending long periods looking at he food nutritional labels.
- Being short-tempered or irritable.
How to help someone with an eating disorder
Treatment for any eating disorder involves admitting there's a problem, addressing the physical issues and getting intensive, often long-term, treatment for the psychological disorder that has caused it and keeps it going.
If you think someone you love has an eating disorder, being supportive is key. You need to help them to recognise that they have a serious medical condition which goes much further than food and needs medical help. People with eating disorders are often secretive and they're likely to be sensitive if you broach the subject. You may want to talk to their GP in confidence and get ideas on how to persuade them to seek help. Reassure them you're 'on their side' - you could be their salvation.
Further reading and references
The International Statistical Classification of Diseases and Related Health Problems, tenth revision - ICD-10; Eating Disorders Victoria, 2015
Classifying eating disorders - DSM-5: Diagnostic and Statistical Manual of Mental Disorders; Eating Disorders Victoria, 2016
The Authorized Bratman Orthorexia Self-Test; Orthorexia.com, 2017
Body Mass Index (BMI) charts for girls and boys age 2-18; Royal College of Paediatrics and Child Health and Dept of Health.