Teenage girl at psychotherapy session talking with therapist about eating disorder.

Eating Disorders: Signs and How to Address Them

Teenage girl at psychotherapy session talking with therapist about eating disorder.

Eating disorders can be deadly and are seen as a common morbidity in adolescent and young adult females. Too often, diagnosis in men goes overlooked and treatment may be neglected.  

Eating disorders negatively impact the whole person, from physical to mental health. Experts estimate that 20 million women and 10 million men in the United States Of America will have or have had an eating disorder at some point in their life. Sexual abuse also plays a large role in eating disorders, with 30% of patients having had a positive history of sexual abuse. 

Related: Body Image and Dissatisfaction: Theories and Cultural Considerations

Anorexia: Fear of losing self control

Anorexia has a slightly higher morbidity than any eating disorder. Onset of anorexia in teenage girls is seen at age 15; 80-90% of patients with anorexia are female. Roughly 25% of men are diagnosed with anorexia nervosa.

Many things can cause anorexia. Some patients may have a genetic predisposition to the disease. In others, it can be seen as a coping mechanism against developmental challenges, transitions, family conflicts, and academic pressures. Those struggling with anorexia often believe “If you can control what you eat, you can control your life.” Controlling the amount of food they eat gives them control over their bodies. 

Signs of anorexia

Common signs of anorexia include:

  • Over-exercise and over-activity
  • Depressed mood
  • Obsessive compulsive disorder related to food
  • Family history of anorexia nervosa or affective disorder
  • Emaciation
  • Hypotension
  • Heart arrhythmia
  • Constipation
  • If anorexia occurs before puberty, puberty can be delayed
  • Loss of sexual interest
  • Amenorrhea
  • Cold intolerance
  • Dry skin
  • Dental enamel erosion

Men who are diagnosed with anorexia may have been mildly to moderately obese at one point in their lives. Sexual abuse may have gone unreported due to shame and stigmatization.

Laboratory findings in both men and women with anorexia include leukopenia and mild anemia, elevated BUN, hypercholesterolemia, elevated LFTs, metabolic acidosis, decreased thyroid levels, low estrogen in females, low testosterone in males, EKG sinus bradycardia, dysrhythmia, hypotension, and syncope. 


Developing healthy eating behaviors is the main focus of treatment. Comprehensive in-patient treatment with NG (Naso Gastric Feedings) or IV (Intravenous) feedings, may be needed, as well as psychotherapy and nutritional counseling. Patients may receive treatment with SSRI’s (Selective serotonin reuptake inhibitors) after weight gain. Family therapy and cognitive behavioral therapy are also suggested treatment regimens. 

Bulimia nervosa

Bulimia nervosa typically shows signs in adolescence or early adulthood. The disorder is characterized by eating large amounts of food (binging) with a loss of self-control and compensatory behavior which involve self-induced vomiting (purging).

The causal factors underpinning eating disorders have been clarified by understanding about the central control of appetite. Cultural, social, and interpersonal elements can trigger onset, and changes in neural networks can sustain the illness. Overall, apart from studies reporting pharmacological treatments for binge eating disorder, advances in treatment for adults have been scarce, other than interest in new forms of treatment delivery.

Binging and vomiting occur in 80-90% of people with bulimia. Binge-eating and purging behaviors can lead to a range of medical complications, such as electrolyte imbalance, which can lead to arrhythmia or death, esophageal tears, gastric disruption, problems with fertility, and dental decay. People suffering from BN typically have a normal weight or are slightly overweight. They are extremely critical of themselves and have a depressed mood. Adolescents suffering from BN often have a high risk for suicidal behavior. 

Signs of bulimia nervosa

Common signs of bulimia nervosa include:

  • Diarrhea (laxatives)
  • Erosion of enamel noted at the back of their teeth
  • Dental carries
  • Esophagus tears
  • Menstrual irregularities or amenorrhea
  • Mood disturbances
  • Family history of obesity

Labs may show fluid and electrolyte imbalances which include hypokalemia, hypochloremia, and metabolic acidosis. 


Treatment for bulimia includes comprehensive medical care and monitoring, psychotherapy and nutritional counseling. The focus is on establishing a pattern of regular eating without purging. Healthy exercise SSRI’s for depression, individual, family therapy and cognitive behavioral therapy. 

Men may go under-diagnosed since many don’t consider themselves to have a problem. They also may have a misconception that eating disorders contribute to other health issues. This denial behavior is common in men with bulimia. 

Binge eating disorder

Binge eating disorder is the most common disorder affecting 3% of American adults. Typically, people experience a lack of control and consume larger amounts of food than the average person would. It emerges in adolescence and early adulthood and can continue on in midlife. In the beginning, a person can eat a little more or little less food than usual. The urge to eat more becomes compelling until it consumes the person’s whole life. 

The following are common warning signs of a binge eater:

  • Eats at discreet times
  • Uncomfortable eating around others
  • Fear of eating in public
  • Frequently diets
  • Withdraws from friends
  • Shows extreme concern with body weight and shape
  • Eating large amounts of food when not feeling physically hungry
  • Eating much more rapidly than normal
  • Feeling disgusted with oneself
  • Stomach cramps (constipation, acid reflux)
  • Noticeable fluctuations in weight
  • Difficulties concentrating

Obesity and weight stigma are all serious concerns that can arise from BED. These can lead to more serious health concerns and comorbidities such as diabetes, heart disease, and several others. Notably, however, most people experiencing this disorder will present at a normal weight. 


Pica is described as the persistent eating of non-nutritive non-food substances for a period of at least one month. The term pica comes from the Latin word meaning magpie bird, because of the bird’s tendency to gather various objects for consumption out of sheer curiosity. Most commonly seen in children, pica can also be a disorder seen in mentally impaired adults. In women, it is also occasionally seen during pregnancy.

People suffering from pica have a tendency to eat earth, raw starches, ice, charcoal, ash, paper, chalk, cloth, baby powder, coffee grounds, and eggshells. While it can be an isolated disorder, it can also manifest with schizophrenia, trichotillomania, and OCD. 

Risk factors for pica

Risk factors related to pica include:

  • Stress
  • Cultural issues
  • Nutritional deficiencies
  • Pregnancy
  • Epilepsy
  • Family psychopathology
  • Child neglect
  • Underlying mental health disorder
  • Learned behavior

Assessment of pica

Exams can be normal but healthcare professionals need to be on the alert for signs of poisoning. Certain objects that are ingested can cause toxicity as well as complications that can lead to obstruction and bezoar formation, along with ulceration and perforation. Lead poisoning can also occur which can further cause seizures, headaches, lethargy, and cranial nerve palsy.

Labs and GI studies

Iron studies, lead levels, and zinc studies should be considered in all people suspected of having pica. Metabolic studies are especially important when a person has been ingesting clay since it can cause metabolic disturbances and hypokalemia. Plain abdominal x-rays, barium studies, and endoscopy may also be beneficial. In many cases, serial studies are needed to ensure that the substance has passed.

Pica is not a life-threatening disease and is categorized as being benign. In pregnant women and in children, the disease can spontaneously resolve.

Rumination disorder

Rumination disorder (RD) is the repeated regurgitation of food after chewing and swallowing without the use of medication ingestion. Spitting out of the regurgitated material can also be placed in this category. As it is often under-reported, RD is difficult to diagnose and treat. RD does not occur in conjunction with anorexia, bulimia, binge eating, or avoidant-restrictive disorders. 

A physical cause for RD must be ruled out. Treatment includes diaphragmatic breathing exercises and habit reversal. The person experiencing RD is taught the signs and situations along with how to reverse them. Deep breathing techniques replace the rumination habit. 

Avoidant and Restrictive Food Disorder (ARFD)

 First described in 2013,  avoidant and restrictive food disorder (ARFD) is a complex eating disorder that stems from genetic, psychological, and social ramifications that affects mostly children and adolescents. It is categorized as a persistent failure to meet appropriate nutritional and energy needs. Typical patients with ARFD present as having significant weight loss or nutritional deficiency, dependence on enteral feeding or nutritional supplements, and/or a marked interference in psychosocial functioning.

Signs of ARFD

The major signs presenting in ARFD patients are:

  • Fear of negative consequences of eating
  • Low appetite or disinterest in food
  • Avoidant of food based sensory characteristics
  • Falling off growth curve in the pediatric population


The focus of treatment is on weight gain and family-based therapy. Family-based therapy focuses on lifting blame, raising the family’s anxiety about the dangers of low weight and malnutrition in young people, and empowering parents to take charge of nutrition and to focus on the goal of weight gain. Cognitive behavioral therapy may lift anxiety as well. 

Almost anyone can suffer from an eating disorder. Eating disorders occur more frequently in affluent countries. Although, it does not mean that all people suffering from this disease process are well-off financially. Pressures from mainstream media and social media contribute to current-day body image issues in both males and females.

Healthcare and behavioral health professionals should pay special attention to the psychosocial aspects of eating disorders, specifically on repeated behaviors that cause cyclic incidences.