Behavioral Issues

Eating Disorders


Eating disorders include anorexia nervosa, bulimia nervosa, and binge-eating disorders.


  1. Female to male ratio of 10:1
  2. Occurs in 3% of females with bimodal peak ages of 14.5 years and 18 years. There has been an increase in the incidence in young children and adults greater than 40.
  3. The highest incidence is in industrialized countries and the higher socio-economic groups. 
  4. 50% will fully recover and 20% never improve
  5. The mortality rate in patients with eating disorders is 12x that in the general population.
  6. The mean lifetime duration of disease is 5.9 years for anorexia, 5.8 years for bulimia, and 14.4 years for binge-eating


  1. Combination of genetics, sociocultural, and neurochemical factors. 
  2. Preexisting psychiatric traits include dependency, isolation, and developmental immaturity.

Risk Factors

  1. Childhood preoccupation with thin body image
  2. History of dieting
  3. Activities that emphasize lean body types (ballet, running, wrestiling, skating, and gymnastics
    1. Female Athlete Triad: eating disordeer, amenorrhea, osteoporosis
  4. Significant family distres
  5. History of Sexual abuse
  6. Exposure to Pro-Ana Websites
    1. Click here for Social Issues Research Center article on "Pro-Ana" websites 
    2. Click here for NEDIC's (National Eating Disorders Information Center) information on "Pro-Ana" websites
      1. ​Examples of Pro-Ana Websites
        1. Here
        2. Here
        3. Here

Common Clinical Manifestations

  1. Cardiac arrythmias, CHF, hypotension, and bradycardia
  2. Sleep disturbances
  3. Hypothermia
  4. Irregular menses, amenorrhea, infertility, oligomenorrhea
  5. Constipation and rectal prolapse
  6. Bone marrow suppression with pancytopenia.
  7. Poor growth
  8. Electrolyte disturbances secondary to vomiting, use of laxatives, and diuretics, and excessive water intake. 
  9. Hair loss, lanugo hair development, dry skin, abrasions on the hands secondary to inducing vomiting. 
  10. Decrease bone density with resultant increase number of fractures.

Behavioral Changes

  1. Decrease eating in public
  2. Reluctant to be weighed
  3. Acts withdrawn
  4. Missing school and work
  5. Increased exercise
  6. Substance abuse

Diagnostic and Statistical Manual (DSM-IV) of Mental Disorders Definition of

  1. Anorexia nervosa
    1. < 85% ideal body weight or BMI of < 17.5
    2. Intense fear of weight gain
    3. Perception of body unrealistic. "Feels fat"
    4. Denial of hunger
    5. Amenorrhea
    6. High academic success and over-achievers. 
    7. Intense amount of exercise
    8. 2 subtypes:restricting and binge eating/purge
  2. Bulimia
    1. 2x/week for 3 months 
    2. Eat very rapidly and unable to control eating and stop
    3. Purging (vomiting, use of ipecac, diuretics, laxatives, enemas, caffeine, and other uppers)
    4. Increase exercise to counteract binges
  3. Binge Eating (proposed by DSM-V)
    1. Recurrent episodes of binge eating episodes characterized by an unusually large amount of food and sense of loss of control
    2. Binge-eating episodes are associaed with 3 or more of the following
      1. Eating more rapidly than normal
      2. Eating until feeling uncomfortably full
      3. Eating when not physically hungry
      4. Eating alone because of embarrassment over amount eating
      5. Feelings of disgust, depression, or guilt after overeating
      6. Presence of marked distress ove binge eating'
      7. Occurrence of binge eating, on average, > 1x/wk for 3 months
      8. Not associated with inappropriate compensatory behavior (purging)


  1. Monitor growth and weight changes. May have frequent fluctuation of weight. Has there been an arrest of pubertal development.
  2. Menstrual history, exercise history 
  3. Are there an increase number of fractures?
  4. Electrolyte levels and CBC
  5. Complete physical examination.
    1. Signs unique in bulemia: paroatid gland hypertrophy, teeth enamel erosion, skin lesion on fingers( Russell's sign)
  6. Psychiatric assessment for suicide, depression, and obsessive compulsive traits

Differential Diagnosis

  1. Hyperthyroidism
  2. Chronic disease- diabetes mellitus and inflammatory bowel disease
  3. Malignancy


  1. Discuss problem with the patient and their family
  2. Encourage improving nutritional status but may need to use enteral or parenteral means
  3. Should refer to medical and psychiatric specialist in eating disorders
  4. Pharmocotherapy often used but should obtain an ECG prior to instituting therapy because of the risk of arrythmias with some drugs. 
  5. Often require inpatient management.
  6. Monitor for refeeding syndrome, especially if severely underweight (<75% ideal body weight)
    1. Malnourishment depletes intracellular phosphate stores.  Glycolysis which occurs with refeeding can further deplet stores leading to severe hypophosphatemia
    2. Manifestations include heart failure, rhabdomyolysis, seizures, delirium
    3. Hypokalemia and hypomagnesemia can also occur

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  1. Becker, Anne E., Grinspoon, Steven, Klibanski, Anne, and Herzog, David.Eating Disorders. New England Journal of Medicine. April 8, 1999.
  2. Kreipe RE and Dukarm CP. Eating Disorders in Adolescents and Older Children. Pediatrics in Review. 1999; 20:410-421.
  3. Rome E. et al. Children and Adolescents with Eating Disorders: The State of the Art. Pediatrics Vol 111 e-98 January 2003
  4. Mehler P.S. Bulimia Nervosa. NEJM Vol 349 No. 9 Page 875
  5. Rome E , Ammerman S. Medical Complications of Eating Disorders: An Update. Journal of Adolescent Health 2003;33:418-426
  6. Golden N et al. Eating Disorders in Adolescents: Position Paper of the Society for Adolescent Medicine. Journal of Adolescent Health. 2003;33:496-503
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  8. Lawrence L Perrin E. Benjamin J.  The challenges of managing eating disorders in your office. Contemporary Pediatircs January 2006
  9. Nichols et al. Prevalence of the Female Athlete Triad Syndrome Among High School Athletes. Arch Pediatr Adolesc Med Vol 160 Feb 2006
  10. Fisher M Treatment of Eating Disordeers in Adolescents and Young Children. Pediatrics in Review January 2006
  11. American Academy of Pediatrics. Identifying and Treating Eating Disorders Jan 2003
  12. Attia E, Walsh B.T. Behavioral Management for Anorexia Nervosa.  NEJM Jan 29, 2009
  13. Pope HG Jr. et al. Binge Eating Disorder: A Stable Syndrome Am J Psychiatry 163:2181-2183. Dec 2006
  14. Mehler PS Diagnosis and Care of Patients with Anorexia Nervosa in Primary Care Settings Ann Intern Med 134 (11): 1048-1059 Jun 2001
  15. Ornstein, RM et al. Hypophosphatemia During Nutritional Rehabilitation in Anorexia Nervosa: Implications for Refeeding and Monitoring. J. Adolescent Health 32(1):83-88 Jan 2003
  16. Chen LP et al. Sexual Abuse and Lifetime Diagnosis of Psychiatric Disorders: Systematic Review and Meta-Analysis Mayo Clinic Proc 85(5) May 2010
  17. Strasburger VC, Jordan AB & Donnerstein E Health Effects of Media on Children and Adolescents Pediatrics 125; 756-767 Mar 2010
  18. Treasure J et al. Eating Disorders Lancet. 375 (9714): 583-593. Feb 2010