Frequently Asked Questions About Eating Disorders

What is an eating disorder?

Eating disorders include anorexia nervosa, a form of self-starvation; bulimia nervosa, in which individuals engage in repetitive cycles of binge-eating alternating with self-induced vomiting or starvation; binge-eating disorder (BED), which resembles bulimia but without compensatory behaviors to avoid weight gain (e.g. vomiting, excessive exercise, laxative abuse); avoidant restrictive food intake disorder (ARFID) in which people may have lack of interest in food, avoid certain textures or types of foods, or have fears and anxieties about consequences of eating unrelated to shape or weight concerns (e.g. fear of choking, vomiting or abdominal discomfort) and other specified feeding and eating disorders (OSFED). Eating disorders can occur in any age group, gender, ethnic or racial group.

Anorexia nervosa and bulimia are psychiatric illnesses that center on food and its consumption and are usually characterized by:

  • Excessive preoccupation with food and dissatisfaction with one’s body shape or weight
  • A compulsion to engage in extreme eating habits and unhealthy methods of weight control such as:
    o    Fasting or binge-eating
    o    Excessive exercise
    o    Self-induced vomiting
    o    Chewing and spitting or regurgitating food
    o    Excessive laxative, diuretic, or diet pill abuse.

These unhealthy behaviors and preoccupations can develop into a consuming passion and come to interfere with physical, psychological and social well-being.

Eating disorders have many causes. They may be triggered by stressful life events, including a loss or trauma; relationship difficulties; physical illness; or a life change such as entering one’s teens, starting college, marriage or pregnancy. An eating disorder may develop in association with another psychiatric illness such as a depressive disorder, obsessive-compulsive disorder, or substance abuse. Current research indicates some people are more genetically predisposed to developing an eating disorder than others.

How common are eating disorders?

The eating disorders anorexia nervosa and bulimia nervosa, respectively, affect 0.5 percent and 2-3 percent of women over their lifetime. The most common age of onset is between 12-25. Although much more common in females, 10 percent of cases detected are in males. Binge eating disorder and OSFED are more common and rates of ARFID are not yet known as this diagnosis was defined relatively recently.

What is the difference between anorexia nervosa and bulimia?

Both anorexia nervosa and bulimia are characterized by an overvalued drive for thinness and a disturbance in eating behavior. The main difference between diagnoses is that anorexia nervosa is a syndrome of self-starvation involving significant weight loss of 15 percent or more of ideal body weight, whereas patients with bulimia nervosa are, by definition, at normal weight or above.

Bulimia is characterized by a cycle of dieting, binge-eating and compensatory purging behavior to prevent weight gain. Purging behavior includes vomiting, diuretic or laxative abuse. When underweight individuals with anorexia nervosa also engage in bingeing and purging behavior the diagnosis of anorexia nervosa supercedes that of binge/purging type.

Excessive exercise aimed at weight loss or at preventing weight gain is common in both anorexia nervosa and in bulimia.

What causes an eating disorder?

Eating disorders are believed to result from a combination of biological vulnerability, environmental, and social factors. A useful way of thinking about what causes an eating disorder is to distinguish predisposing, precipitating and perpetuating factors that contribute to its onset and maintenance.

  • Predisposing factors include genetic vulnerability. Family and twin studies suggest that eating disorders run in families. Genetic studies are currently underway to isolate genes contributing to risk for an eating disorder.
  • Precipitating factors including behaviors such as dieting or exercise, or stressors including illness, trauma or loss, which can trigger the onset of the disorder.
  • Once the eating disorder takes hold however it is sustained largely by perpetuating factors that contribute to its maintenance. These maintaining factors can include physiological consequences of starvation or of binge purge behaviors, or anxiety and avoidance behaviors associated with the consumption of various foods. Starvation slows gastrointestinal transit resulting in early satiety (fullness) and constipation and it also increases preoccupation with food and the risk of eventual progression to binge-eating. Frequent self-induced vomiting can also lead to gastrointestinal dysmotility and to the development of additional symptoms and behaviors including spontaneous regurgitation, reflux and vomiting. For underweight patients, achievement of a low normal weight is essential for recovery, whilst for all patients normalizing eating and weight control behaviors and establishing healthier eating habits and coping strategies, is a priority.

Are certain personality traits more common in individuals with eating disorders?

Individuals who develop eating disorders, especially those with the restricting subtype of anorexia nervosa are often perfectionistic, eager to please others, sensitive to criticism, and self-doubting. They may have difficulty adapting to change and be routine bound. A smaller group of patients with eating disorders have a more extroverted temperament and are novelty-seeking and impulsive with difficulty maintaining stable relationships. There is no one personality associated with eating disorders, however.

What forms of treatment are effective for anorexia nervosa?

Treatment of anorexia nervosa involves nutritional rehabilitation to normalize weight and eating behavior. Psychotherapy is aimed at correcting irrational preoccupations with weight and shape, managing challenging emotions and anxieties and preventing relapse. Interventions include monitoring weight gain, prescribing an adequate diet, and admitting patients who fail to gain weight to a specialty inpatient or partial hospitalization program. Specialty programs combining close behavioral monitoring and meal support with psychological therapies are generally very effective in achieving weight gain in patients unable to gain weight in outpatient settings. The fear of fatness and body dissatisfaction characteristic of the disorder tend to extinguish gradually over several months once target weight and normal eating patterns are maintained, and 50-75% of patients eventually recover. No medications have been shown to significantly facilitate weight gain in patients with this disorder. In the case of patients under 18 years of age, family therapy aimed at helping parents support normal eating in their child has been found to be more effective than individual therapy alone.

What forms of treatment are effective for bulimia nervosa?

Most uncomplicated cases of bulimia nervosa can be treated on an outpatient basis although inpatient treatment is occasionally indicated. The best psychological treatment is cognitive-behavioral therapy, which involves self-monitoring of thoughts, feelings, and behaviors related to the eating disorder. Therapy is focused on normalizing eating behavior and identifying environmental triggers and irrational thoughts or feeling states that precipitate bingeing or purging. Patients are taught to challenge irrational beliefs about weight and self-esteem. Several medications have also been shown to be effective in decreasing bingeing and purging behaviors in bulimia.

What about the treatment of other eating disorders including BED, ARFID and OSFED?

Eating disorders are behavioral problems and the most successful modalities of treatment all focus on normalizing eating and weight control behaviors whilst managing uncomfortable thoughts and feelings. Increasingly, we understand eating disorders as not just psychological problems but as disorders of learning and habit. Changing established habits can feel challenging, however practice of healthy eating behavior under expert therapeutic guidance helps develop skills needed to manage anxieties regarding food, weight and shape -- all of which fade over time with the gradual achievement of mastery over recovery.

How do I know if I need inpatient treatment?

If you think you have an eating disorder, if your symptoms have persisted or worsened despite attempts at outpatient treatment, or if you feel constantly preoccupied by thoughts of food and weight, then a good place to start is with a comprehensive evaluation in our Consultation Clinic. To safely provide the best possible care during the COVID pandemic, we have expanded our outpatient telemedicine services to include remote clinical consultation and outpatient visits with our eating disorders doctors by videolink across multiple states. Video visits allow patients to connect face-to-face in real time without leaving their home by using their smartphone, tablet or computer. Virtual connections are secure and HIPAA compliant.

You will be seen by a psychiatrist who will perform a thorough review of your history and symptoms, medical tests and past treatment. We recommend you forward any past treatment records ahead of your appointment for the doctor to review. Whenever possible we ask that you attend the consultation with a close family member or significant other, since we believe family support and involvement is very important when you are struggling with an eating disorder. The doctor will also be interested in any medical or psychiatric problems you may have besides the eating disorder.

Common co-occuring psychiatric conditions include depression, anxiety, substance abuse and obsessive-compulsive disorder. Co-occurring medical conditions that may bring patients to treatment include gastrointestinal symptoms, infertility problems or menstrual irregularities, osteoporosis, or chronic pain conditions. At the end of your evaluation, the consulting physician will review his or her impression and diagnosis of your condition and will make suggestions regarding the best next steps for you in terms of treatment. These suggestions may include recommendations for medication, psychotherapy, further testing, or consultation with another medical specialist in The Johns Hopkins Health System.

Does our program have published treatment outcomes?

You can read about patient satisfaction with our treatment program for anorexia nervosa. Reference: Guarda AS, Cooper M, Pletch A, Laddaran L, Redgrave GW, Schreyer CC. Acceptability and tolerability of a meal-based, rapid refeeding, behavioral weight restoration protocol for anorexia nervosa. Int J Eat Disord. 2020.

You can read about our treatment outcomes for anorexia nervosa in Hopkins BrainWise: A Weighty Approach to Anorexia Nervosa. Reference: Redgrave GW, Coughlin JW, Schreyer CC, Martin LM, Leonpacher AK, Seide M, Verdi AM, Pletch A, Guarda AS. Refeeding and weight restoration outcomes in anorexia nervosa: Challenging current guidelines. Int J Eat Disord. 2015;48(7):866-73. PMID: 25625572.

You can find additional information on published treatment outcomes for ARFID and AN in this peer reviewed research article (PMID: 30779365) from our program.

Other papers:

  • Guarda AS, Schreyer CC, Fischer LK, Hansen JL, Coughlin JW, Kaminsky MJ, Attia E, Redgrave GW. Intensive treatment for adults with anorexia nervosa: The cost of weight restoration. Int J Eat Disord. 2017 Mar;50(3):302-306. PMID: 28130794.
  • Redgrave GW, Schreyer CC, Coughlin JW, Fischer LK, Pletch A, Guarda AS. Discharge Body Mass Index, Not Illness Chronicity, Predicts 6-Month Weight Outcome in Patients Hospitalized With Anorexia Nervosa. Front Psychiatry. 2021 Feb 25;12:641861. PMID: 33716836.
  • Cooper M, Guarda AS, Petterway F, Schreyer C. Change in normative eating self-efficacy is associated with sixmonth weight restoration following inpatient treatment for anorexia nervosa. Eat Behav. 2021 Aug;42:101518. PMID: 33989938.
  • Schreyer CC, Vanzhula IA, Guarda AS. Evaluating the impact of COVID-19 on severity at admission and response to inpatient treatment for adult and adolescent patients with eating disorders. Int J Eat Disord. 2023 Jan;56(1):182- 191. PMID: 36394170.

What insurance does the hospital take?

If you are being admitted to one of our hospital-based programs, both Inpatient and Partial Hospitalization, our business office will verify your benefits beforehand, and the admissions coordinator will contact you with information about your coverage. Admission to our program in the Johns Hopkins Hospital Department of Psychiatry qualifies as a mental health hospitalization and will be authorized under the mental health portion of your insurance, not the medical portion. Please see the Admissions page for more information.

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