in comparing anorexia nervosa to bulimia nervosa research shows that

Anorexia vs. Bulimia: The Key Differences

Anorexia nervosa (AN) and bulimia nervosa (BN) are both serious eating disorders that impact mental, physical, and emotional health.

Reviewed By | Michelle Ervin, MEd 10 sources cited

Further Reading

Diagnostic Criteria for Bulimia What is Anorexia? About Bulimia Nervosa Causes of Bulimia Anorexia Symptoms

Both conditions center around a fixation with losing or controlling weight, perpetuated by negative body image and poor self-esteem, and the two also share several negative physical and psychological consequences.

Still, when it comes to anorexia vs. bulimia, the conditions have several key differences. 

Anorexia vs. Bulimia: Similarities

Before learning more about the differences between AN and BN, it can be helpful to understand the ways these conditions are similar.

People struggling with BN and AN have many of the same signs and symptoms . A combination of biological, psychological, and social influences contribute to the development of both eating disorders.

Common signs and symptoms of bulimia nervosa and anorexia nervosa include: 7,8

• Negative or distorted body image
• Extreme preoccupation with food, eating, nutrition, and dieting
• Intense fear of gaining weight
• Sense of self-worth heavily tied to weight and appearance
• Social isolation or withdrawal
• Avoiding events or social situations that involve food

Additional physical symptoms that often overlap between AN and BN include: 7,8

• Frequent mood fluctuations
• Problems concentrating
• Gastrointestinal issues
• Trouble sleeping

Anorexia nervosa and bulimia nervosa also share many common risk factors , including: 9,10

• Family history or close relative with an eating disorder
• Certain co-occurring mental disorders , such as anxiety and depression
• Obsessive-compulsive, perfectionistic personality traits

Both conditions must be taken seriously and can have a detrimental effect on a person’s mental and physical health over time. But, as with all eating disorders, the individual dealing with the disorder may have difficulties admitting they have a problem and resist seeking help. 

Anorexia vs. Bulimia: Major Differences

The biggest difference between anorexia nervosa and bulimia nervosa is the behaviors related to food and eating that tend to manifest in each.

AN is considered a restrictive eating disorder, involving the severe limitation of food intake as its primary symptom. BN is a disorder that involves cycles of binging and purging . Someone with this condition goes through episodes where they eat large quantities of food, then use methods in an attempt to “purge” the food they consumed during the binge, such as:

• Self-induced vomiting
• Over-exercising
• Taking laxatives

Still, different “types” within each condition can blur the lines between the two. For example, there is binge-purge type anorexia nervosa. On the surface, this condition may resemble BN due to its symptoms of binging and purging. But in binge-purge AN, the primary symptom is still food restriction, with binging and purging only used as subsequent maladaptive coping mechanisms.

The nuances between the conditions can be confusing, but knowing the difference is key when it comes to treatment. (In general, anorexia nervosa is more fatal, coming second only to opioid addiction as the deadliest mental health condition. 1 ) Both disorders are treatable, and recovery is possible, but treatment recommendations vary significantly between AN and BN.

Understanding more about each condition specifically can help further illuminate their differences.

Bulimia According to the DSM-5

The Diagnostic and Statistical Manual of Mental Health Disorders, Fifth Edition (DSM-5) is a comprehensive manual that provides diagnostic criteria for mental health conditions. According to the DSM-5, bulimia nervosa has the following diagnostic criteria. 2  

A person with bulimia has recurrent episodes of binge eating. Binge eating is a pattern of behavior where a person eats significantly more food in two hours than the average person would in similar circumstances and during that same period.

Binging is also characterized by a loss of a sense of control over how much or what is eaten. Eating when not feeling physically hungry, eating past the point of feeling full, or experiencing a sense of guilt or embarrassment following an episode are also part of the diagnosis.

Compensatory behaviors are behaviors a person engages in to make up for specific actions. In the case of bulimia nervosa, these behaviors are used to compensate for binge eating.

People with bulimia engage in what are called inappropriate compensatory behaviors, which are behaviors that are destructive to overall health. These behaviors can include:

• Self-inducing vomiting
• Misusing laxatives, diuretics, or similar medications
• Excessive exercise

In contrast, appropriate compensatory behaviors include talking to a mental health professional to determine what is causing the disordered eating behaviors and develop a strategy to adopt a healthy relationship with food and eating.

Anorexia According to the DSM-5

The DSM-5’s diagnostic criteria for anorexia nervosa are as follows: 2

• Restricted energy intake
• Intense feat of weight gain
• Distorted perception of self

Restricted Energy Intake

The primary symptom of anorexia nervosa is the severe restriction of energy intake, compared to what someone requires for their specific age, gender, health status, and several other factors.

The DSM-5 still relies on body mass index (BMI) measurements to determine the severity of an AN diagnosis. However, BMI is increasingly seen as an incomplete indicator of overall health. This also confuses the fact that it is possible to experience anorexia nervosa while being in a larger body. 3

Intense Fear of Weight Gain 

An extreme fear of weight gain is a cardinal part of an anorexia nervosa diagnosis, as it is often behind much of the restrictive behavior. The diagnosis also includes frequent and intentional attempts to prevent weight gain.

Distorted Perception of Self

People with anorexia nervosa have a distorted body image . Often, this means they see themselves as larger than they actually are. Connected to this eating disorder symptom is an undue significance placed on body weight and shape, with many people struggling with AN basing their self-value on these factors.

In any case, an extreme, negative self-perception is common, along with low self-esteem. People with AN also often struggle to understand the severity of their condition or fail to recognize the damage their behaviors have on their health. 

Anorexia Subtypes

Anorexia can be characterized into one of three subtypes.

Restricting-type anorexia nervosa is the most commonly occurring type of AN. It’s characterized by significant restriction of energy intake but without recurrent binge-eating or purging behavior over the last three months.

Binge-purge-type anorexia is characterized by a person engaging in a recurrent pattern of binge eating and purging within the past three months. 4 The same maladaptive coping mechanisms are used in bulimia nervosa, but those with binge-purge type anorexia nervosa still meet the DSM-5 criteria for anorexia nervosa. Severe limitation is the primary symptom of this condition, with binging and purging occurring less frequently.

Atypical anorexia shares identical symptoms with more typical cases of anorexia, but the patient is at what is considered a “normal” or higher weight. It is often mistaken for a less severe eating disorder and misunderstood as a less dangerous attempt at weight loss. However, those views are heavily influenced by prevailing attitudes of fatphobia and weight bias. 5

In fact, atypical anorexia is not atypical at all and is far more prevalent than anorexia. 6 The condition is also dangerous and, just like AN, requires specific and appropriate care.

How to Find Treatment for Anorexia and Bulimia

Regardless of the different labels we currently have for eating disorders, all are complex mental illnesses with serious medical complications that require professional treatment. They do not go away on their own. 

Unfortunately, another shared symptom of anorexia and bulimia is that people with these conditions tend to have a hard time understanding the severity of their behavior. Many of them consider their behaviors to be a good thing, attempt to actively hide the truth of their condition, and deny there’s anything wrong.

The truth is AN, BN, and all eating disorders can have life-threatening consequences, especially if left untreated for too long. Fortunately, all of these conditions are also treatable , and no matter which eating disorder someone is struggling with, recovery is always possible.

• Edakubo S, Fushimi K. (2020). Mortality and risk assessment for anorexia nervosa in acute-care hospitals: a nationwide administrative database analysis . BMC Psychiatry; 20 (19). 
• Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) . (2013). American Psychiatric Association.
• Garber AK, Cheng J, Accurso EC, Adams SH, Buckelew SM, Kapphahn CJ, Kreiter A, Le Grange D, Machen VI, Moscicki AB, Saffran K, Sy AF, Wilson L, Golden NH. (December 2019). Weight Loss and Illness Severity in Adolescents With Atypical Anorexia Nervosa . Pediatrics; 144 (6):e20192339.
• Mustelin L, Silen Y, Raevuori A, Hoek HW, Kaprio J, & Keski-Rahkonin A. (2016). The DSM-5 diagnostic criteria for anorexia nervosa may change its population prevalence and prognostic value . Journal of Psychiatric Research; 77 :85-91.
• Meadows A. (2019). Weight stigma and physical health: an unconsidered ‘obesity’ cost: Letter to the Editor: Response to Singh et al. (2018). Is there more to the equation? Weight bias and the costs of obesity . Canadian Journal of Public Health; 110 (4):525–526. 
• Golden NH. (2022). Atypical Anorexia Nervosa is not atypical at all! Commentary on Walsh et al . The International Journal of Eating Disorders; 56 (4):826-827
• Anorexia nervosa . (n.d.). National Eating Disorders Association. Accessed February 2024.
• Bulimia nervosa . (n.d.). National Eating Disorders Association. Accessed February 2024.
• Overview – bulimia . (n.d.). National Health Service. Accessed February 2024.
• Anorexia nervosa – symptoms & causes . (n.d.). Mayo Clinic. Accessed February 2024.

Last Update | 03 - 21 - 2024

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Open Access

Peer-reviewed

Research Article

Eating disorder treatment in routine clinical care: A descriptive study examining treatment characteristics and short-term treatment outcomes among patients with anorexia nervosa and bulimia nervosa in Germany and Switzerland

Roles Data curation, Formal analysis, Investigation, Project administration, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Mental Health Research and Treatment Center, Ruhr University Bochum, Bochum, Germany

Roles Conceptualization, Funding acquisition, Supervision, Writing – review & editing

Roles Supervision, Writing – review & editing

Affiliation Department of Psychology, Clinical Psychology and Psychotherapy, University of Fribourg, Fribourg, Switzerland

Roles Data curation, Investigation, Project administration

Affiliation Praxis für Psychotherapie, Dortmund, Germany

Affiliations Department of Psychology, Clinical Psychology and Psychotherapy, University of Fribourg, Fribourg, Switzerland, Institute of Psychology, Clinical Child and Adolescent Psychology, University of Lausanne, Lausanne, Switzerland

Roles Writing – review & editing

Affiliation University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland

Affiliation Center for Eating Disorders and Obesity, Clinic Zofingen, Zofingen, Switzerland

Affiliation Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital, Zurich, Switzerland

Affiliation Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric University Hospital Zurich, University of Zurich, Zurich, Switzerland

Affiliation Privat Clinic Aadorf, Aadorf, Switzerland

Affiliation Privat Clinic Schützen Rheinfelden, Rheinfelden, Switzerland

Affiliation Department of Psychiatry, Psychotherapy and Psychosomatic Medicine, LWL-Klinik Dortmund, Dortmund, Germany

Affiliation Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital Bochum, Ruhr University Bochum, Bochum, Germany

Affiliation Christoph-Dornier-Klinik for Psychotherapy, Münster, Germany

•  [ ... ],

Roles Conceptualization, Funding acquisition, Supervision, Validation, Writing – review & editing

• [ view all ]
• [ view less ]
• Kathrin Schopf, 
• Silvia Schneider, 
• Andrea Hans Meyer, 
• Julia Lennertz, 
• Nadine Humbel, 
• Nadine-Messerli Bürgy, 
• Andrea Wyssen, 
• Esther Biedert, 
• Bettina Isenschmid, 

• Published: June 30, 2023
• https://doi.org/10.1371/journal.pone.0280402
• Peer Review
• Reader Comments

This descriptive study examined patient characteristics, treatment characteristics, and short-term outcomes among patients with Anorexia Nervosa (AN) and Bulimia Nervosa (BN) in routine clinical care. Results for patients receiving full-time treatment were contrasted with results for patients receiving ambulatory treatment. Data of a clinical trial including 116 female patients (18–35 years) diagnosed with AN or BN were subjected to secondary analyses. Patients were voluntarily admitted to one of nine treatment facilities in Germany and Switzerland. Patients received cognitive-behavioral interventions in accordance with the national clinical practice guidelines for the treatment of EDs under routine clinical care conditions, either as full-time treatment or ambulatory treatment. Assessments were conducted after admission and three months later. Assessments included a clinician-administered diagnostic interview (DIPS), body-mass-index (BMI), ED pathology (EDE-Q), depressive symptoms (BDI-II), symptoms of anxiety (BAI), and somatic symptoms (SOMS). Findings showed that treatment intensity differed largely by setting and site, partly due to national health insurance policies. Patients with AN in full-time treatment received on average 65 psychotherapeutic sessions and patients with BN in full-time treatment received on average 38 sessions within three months. In comparison, patients with AN or BN in ambulatory treatment received 8–9 sessions within the same time. Full-time treatment was associated with substantial improvements on all measured variables for both women with AN ( d = .48-.83) and BN ( d = .48-.81). Despite the relatively small amount of psychotherapeutic sessions, ambulatory treatment was associated with small increases in BMI ( d = .37) among women with AN and small improvements on all measured variables among women with BN ( d = .27-.43). For women with AN, reduction in ED pathology were positively related to the number of psychotherapeutic sessions received. Regardless of diagnosis and treatment setting, full recovery of symptoms was rarely achieved within three months (recovery rates ranged between 0 and 4.4%). The present study shows that a considerable amount of patients with EDs improved after CBT-based ED treatment in routine clinical care within three months after admission. Intensive full-time treatment may be particularly effective in quickly improving ED-related pathology, although full remission of symptoms is typically not achieved. A small amount of ambulatory sessions may already produce considerable improvements in BN pathology and weight gain among women with AN. As patient characteristics and treatment intensity differed largely between settings, results should not be interpreted as superiority of one treatment setting over another. Furthermore, this study shows that treatment intensity is quite heterogeneous, indicating the possibility for increasing effectiveness in the treatment of EDs in routine clinical care.

Citation: Schopf K, Schneider S, Meyer AH, Lennertz J, Humbel N, Bürgy N-M, et al. (2023) Eating disorder treatment in routine clinical care: A descriptive study examining treatment characteristics and short-term treatment outcomes among patients with anorexia nervosa and bulimia nervosa in Germany and Switzerland. PLoS ONE 18(6): e0280402. https://doi.org/10.1371/journal.pone.0280402

Editor: César González-Blanch, University Hospital Marques de Valdecilla, SPAIN

Received: May 16, 2022; Accepted: December 27, 2022; Published: June 30, 2023

Copyright: © 2023 Schopf et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: This work was supported by the German Research Foundation (recipient: SSc, Grant SCHN 415/4-1, www.dfg.de ) the Swiss National Science Foundation (recipient: SM, Grant 100013:149416, www.snf.ch ) and the Swiss Anorexia Nervosa Foundation (recipient: SM, Grant 22-12, www.anorexia-nervosa.ch ). We acknowledge support by the DFG Open Access Publication Funds of the Ruhr-Universität Bochum. None of the funders had a role in the study design, collection, analysis, or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Eating disorders (EDs) including Anorexia nervosa (AN) and Bulimia nervosa (BN) are severe psychosomatic disorders with lifetime prevalence among females ranging from 2–4% [ 1 , 2 ]. EDs are associated with psychological distress, functional impairment, high levels of comorbidity, poor quality of life, medical complications, and increased mortality rates [ 3 – 6 ]. Cognitive-behavioral interventions constitute an evidence-based treatment approach to EDs [ 7 – 9 ]. While clinical trials typically adhere to stringent treatment protocols, treatment programs in routine clinical care are often heterogeneous in terms of treatment components, treatment length, and treatment intensity [ 10 , 11 ]. To assist practitioners and to improve the quality of care provided to patients in clinical practice, clinical guidelines are becoming increasingly important [ 12 ]. However, research examining the implementation of clinical guidelines in routine clinical practice is scarce.

EDs can be treated in a variety of treatment settings. Different treatment settings offer varying degrees of treatment intensity and treatment structure, which may influence treatment effectiveness and costs. However, there is little empirical guidance as to what is the most appropriate treatment setting for an individual patient [ 13 ]. Treatment settings include full-time treatment (including overnight stays), which typically means admission to a medical or psychiatric hospital or a residential treatment facility with a multidisciplinary treatment program and high levels of care and restrictions. Day patient treatment (e.g., part-time hospitalization) also offers a multidisciplinary approach as well as a highly-structured treatment but without overnight stays. Ambulatory treatment typically involves one or two sessions per week with a therapist of a single discipline, preferably supported by medical monitoring, and constitutes the least restrictive and usually the least costly treatment.

Several clinical guidelines exist to guide treatment decisions for EDs [ 14 ]. According to the American Psychology Association (APA) Practice Guideline [ 7 ], hospitalization of patients with EDs is vital in case of acute medical complications. Also, severe forms of EDs, psychological comorbidity, environmental stressors, or unavailability of other treatment options may also warrant hospitalization of patients. However, it is unclear if normalization of eating behavior and weight restoration can be best achieved in a hospital setting after acute medical instabilities have been addressed. There is emerging evidence that less-intensive treatment approaches (e.g., day patient or ambulatory treatment) achieve similar outcomes as hospitalization among medically stable patients with EDs [ 15 , 16 ]. The British guideline of the National Institute for Health and Clinical Excellence (NICE) even suggests that the majority of patients with AN and BN should be treated in an ambulatory setting [ 8 ]. The German Clinical Practice Guideline [ 17 ] states that hospitalization is often necessary for patients suffering from AN, while ambulatory treatment is the treatment of choice for patients suffering from BN. The authors state that an evidence-based decision regarding the most appropriate treatment setting is limited by the small amount of empirical data and treatment decisions are often based on clinical experience and expert opinions.

As the results of randomized controlled trials (RCTs) may not always directly map the real-world situation, more outcome research in routine clinical care is needed [ 11 , 16 , 18 – 22 ]. RCTs are typically conducted under optimal conditions (e.g., selected patients, trained and supervised therapists, adherence to treatment manual), which are different from those found in routine clinical practice. Although observational studies in routine clinical practice typically lack a control group (which impedes causal conclusions regarding treatment effectiveness), they may provide valuable information regarding treatment characteristics and outcomes in public health care [ 23 ].

The present study aimed to examine patient characteristics, treatment characteristics, and short-term outcomes among women suffering from AN or BN, who were treated with CBT-based interventions according to national clinical practice treatment guidelines in nine different treatment institutions in Germany and Switzerland. The following research questions were examined: What are the differences between patients admitted to full-time treatment and patients admitted to ambulatory treatment? How much treatment and which treatment components do patients with EDs typically receive within three months after treatment initiation? Are there differences between full-time treatment and ambulatory treatment? What are short-term outcomes of guideline-based cognitive-behavioral interventions conducted in routine clinical care among patients with EDs? Which variables are associated with symptomatic improvements?

Materials and methods

Participants and procedure.

Data were drawn from a large clinical trial [ 24 , 25 ] in which behavioural, emotional, and physiological responses to mass media exposure were compared between women with EDs, women with other mental disorders, and women without mental disorders before and after guideline-oriented treatment. The study was approved by the ethical committee of the Faculty of Psychology at the Ruhr University Bochum in Germany (reference no. 142) and the local Ethics Research Committee of the canton of Fribourg in Switzerland (reference no. 023/12-CER-FR). Participation was voluntary and each participant provided informed written consent. The study was registered in the German Clinical Trials Registry (trial number: DRKS00005709). For the present study, only data of patients with a primary diagnosis of AN or BN were used. An overview of the study is provided in Fig 1 .

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https://doi.org/10.1371/journal.pone.0280402.g001

Sixty-four patients with AN and 66 patients with BN were enrolled in the study. Fifty-nine patients with AN and 57 patients with BN participated. Potentially eligible patients who were voluntarily admitted between July 2014 and April 2017 to cooperating treatment centers were approached by staff members and informed about the clinical study. Study eligibility criteria included female gender, age between 18 and 35 years, and a primary diagnosis of AN or BN. Exclusion criteria were current pregnancy, breast feeding, or intake of beta-blockers. Patients were assessed after treatment admission and three months later. Assessments included a clinician-administered diagnostic interview (60–90 minutes) and a self-report questionnaire (60 minutes).

Cooperating sites and treatment

The study sites included nine treatment sites in western Germany and northern Switzerland, which provided CBT-based interventions in accordance with the national clinical practice treatment guideline for the treatment of ED [ 17 ]. Sixty-three patients (54.3%) were recruited in Swiss treatment sites and 53 (45.7%) in German treatment sites. Three sites provided ED treatment as full-time treatment, one side provided ED treatment as either full-time or ambulatory treatment, and five sites provided ED treatment as ambulatory treatment. Sixty-one patients (52.6%) received outpatient treatment, 42 (36.2%) received inpatient treatment, and 13 (11.2%) received residential treatment.

Full-time treatment consisted of 24/7-care in a medical or psychiatric hospital or a privately governed non-hospital treatment facility, provided by a multidisciplinary team, including individual and group therapy, nutritional counselling, meal support, and occupational/recreation therapy. Ambulatory treatment typically consisted of one or two sessions of individual psychotherapy per week provided by a psychotherapist. It should be noted that the number of treatment sessions for ambulatory patients was restricted by procedural standards of the German health care system. At the time of the study, health insurance companies in Germany only reimbursed a maximum of five ambulatory treatment sessions (probatory/diagnostic sessions). To continue treatment, health insurance policies required a report, which was evaluated in a peer review process before approval of the reimbursement of treatment costs was granted. This procedure typically resulted in a treatment break of 4–6 weeks, with no contact between the patient and the therapist. Patients’ insurance companies covered the treatment costs and admission to treatment was voluntarily.

Treatments in all sites were conducted as usual. All sites confirmed that their treatment standards adhere to current clinical practice guidelines for the treatment of ED [ 17 ]. The guidelines include psychoeducation about ED, nutritional counselling, analyses of individual problem behaviors and goals, development of an individual model to understand the development and maintenance of the disorder, normalization of eating behavior and restitution of a normal body weight, stimulus control and response control, improvement of body image, improvement of interpersonal skills, reduction of interpersonal conflicts, and relapse prevention.

Diagnostic interview.

A clinician-administered, semi-structured diagnostic interview (DIPS; Diagnostic Interview for Mental Disorders) [ 26 ] was used to determine the presence or absence of any mental disorders at pre- and post-measurement. The DIPS is based on the DSM-IV-TR [ 27 ] with good psychometric properties [ 28 ]. For the purpose of our study, the DIPS EDs section was adapted according to DSM-5 [ 29 ]. In addition to clinical diagnoses, ED severity (i.e., mild, moderate, severe, extreme) based on DSM-5 [ 29 ] criteria was also specified. Furthermore, the presence or absence of a comorbid disorder was coded (no, yes). Interviews were conducted at the treatment site or by telephone (if patients were discharged). All interviewers were trained and supervised. Interviews were recorded and 10% of the interviews were additionally coded by two independent raters. Interrater reliability for primary diagnoses (Fleiss K = .85) and comorbid diagnoses (Fleiss K = .80) was good.

Self-report questionnaire.

At pre- and post-measurement, all patients completed an online questionnaire including questions regarding age, education, nationality, relationships status, use of psychopharmaceutics, and number of cigarettes smoked per day. Symptoms of ED pathology were assessed by the global score of the Eating Disorder Examination Questionnaire (EDE-Q) [ 30 ]. Internal consistency is good and convergent as well as divergent validity have been demonstrated [ 31 ]. Depressive symptoms were assessed using the 21-item Beck Depression Inventory-2 (BDI-II) [ 32 ]. Good internal consistency, test-retest reliability, sensitivity and specificity as well as clinical utility for detecting depression have been shown [ 33 ]. Symptoms of anxiety were assessed using the 21-item Beck Anxiety Inventory (BAI) [ 34 ]. The BAI has demonstrated high internal consistency, acceptable test-retest reliability, and acceptable discriminant and convergent validity [ 35 ]. Somatoform symptoms were assessed using the female 52-item version of the Screening for Somatoform Symptoms (SOMS) [ 36 ]. The scale shows high internal consistency (alpha = .92) and validity has been established [ 36 ].

Body-Mass-Index (BMI).

At pre- and post-measurement, weight and height of study participants were measured using a calibrated electronic scale (Seca 899, Basel, Switzerland) and a stadiometer (Seca 213, Basel, Switzerland). BMI was calculated as weight in kilograms divided by height in meters squared.

Remission rates.

Patients were considered fully remitted if they met the following criteria: a) Full remission based on diagnostic interview (i.e., after full criteria for AN/BN were previously met, none of the criteria have been met for a sustained period of time), b) BMI ≥ 18.5 and c) EDE-Q global score ≤ 2.77. Patients were considered partially remitted if they met the following criteria: Partial remission based on diagnostic interview (i.e., for AN: after full criteria for AN were previously met, criterion A (low body weight) has not been met for a sustained period of time, but either criterion B (intense fear of gaining weight or becoming fat or behavior that interferes with weight gain) or criterion C (disturbances in self-perception of weight and shape) is still met; for BN: after full criteria for BN were previously met, some but not all, of the criteria have been met for a sustained period of time) and b) BMI ≥ 18.5. Remission rate criteria were based on definitions of previous studies [ 37 – 39 ].

Treatment intensity and treatment characteristics.

To examine treatment intensity and treatment characteristics, brief online questionnaires were administered to therapists at post-measurement. Items assessed the number of individual and group sessions as well as treatment components and treatment goals discussed with patients (a list of response options was provided). The response rate of therapists was 67%. Patients received a similar brief online questionnaire. The response rate of patients was 77%.

Statistical analyses

Statistical analyses were conducted using SPSS 27 (IBM). To describe the total sample as well as subsamples by diagnosis (AN vs. BN) and setting (full-time treatment vs. ambulatory treatment), means, standard deviations, frequencies, and percentages of measured variables were reported. Statistical comparisons between groups on several related continuous variables were based on multivariate analyses of variance. Statistical comparisons of categorical variables were based on chi-square tests. All comparisons were made at the level of p < .05. To examine symptomatic changes on ED-related variables, Cohen’s d was calculated as the mean difference between pre- and post-measurement scores divided by the pooled standard deviation. To examine variables related to symptomatic improvements, we used a stepwise procedure. Potential correlates of symptomatic improvements (as reported in Tables 1 and 4 ) were first examined using Pearson correlations. Only statistically significant variables were then entered into multivariate regression model. Dependent variables were symptomatic improvements on primary treatment outcomes, respectively 1) weight gain defined as pre-post BMI difference and 2) ED pathology defined as pre-post EDE-Q difference. Treatment intensity was defined as the sum of individual and group sessions. Analyses were conducted for patients who provided complete data (complete-case analysis). To examine remission rates, intent-to-treat analyses were conducted (missing values were considered not remitted). A total 17 participants (14.7%) dropped out of the study. Drop-out by diagnosis and treatment setting is displayed in Table 5 . Reasons were lack of time, study burden, burden of disease, or unavailability.

https://doi.org/10.1371/journal.pone.0280402.t001

Descriptive characteristics of patients

On average, patients with EDs were 22.8 years ( SD = 4.1). A total of 54.3% of patients were Swiss and 45.7% were German. Approximately half of all patients (51.7%) displayed at least one comorbid disorders, most commonly a depressive disorder (38.8%), an anxiety disorder (25.0%), a sleep disorder (6.0%), a somatoform disorder (4.3%), or substance use disorder (2.6%). Descriptive characteristics of patients with AN and BN are displayed in Table 1 . Patients with AN differed significantly from patients with BN in BMI ( m = 17.2 vs. m = 22.7, respectively) and the use of psychopharmaceutics (23.7% vs. 38.6%, respectively).

Descriptive characteristics of patients between treatment settings are also displayed in Table 1 . For patients with AN, there were significant differences between patients receiving ambulatory treatment and patients receiving full-time treatment on age (full-time patients were significantly younger than ambulatory patients, F = 6.3, p = .02), BMI (full-time patients had a significantly lower BMI than ambulatory patients, F = 5.2, p = .03), and ED severity (full-time patients more often displayed a severe or extreme ED severity, while ambulatory patients more often displayed a mild ED severity). For patients with BN, there were significant differences between settings in the use of psychopharmaceutics (full-time patients more often reported the use of psychopharmateucis than ambulatory patients, χ 2 = 8.1, p < .01) the presence of a comorbid disorder (full-time patients were more often diagnosed with a comorbid disorder than ambulatory patients, χ 2 = 5.9, p = .01), and nationality (full-time patients were more often Swiss than ambulatory patients, χ 2 = 16.8, p < .001). Also, there was a marginal significant difference in ED severity (full-time patients more often displayed an extreme ED severity than ambulatory patients, χ 2 = 7.3, p = .06).

Treatment intensity and treatment characteristics

Table 2 displays treatment components and treatment goals reported by patients and therapists. Table 3 summarizes treatment intensity by diagnosis and treatment setting. Generally, the number of treatment sessions differed greatly between treatment settings. Patients with AN in full-time treatment received on average 28.8 individual sessions plus 36.5 group sessions and patients with BN in full-time treatment received on average 18.7 individual sessions plus 18.9 group sessions within three months after admission. Noteworthy, the range of individual and group sessions differed remarkably between treatment institutions. Patients with AN in ambulatory treatment received on average 9.4 individual sessions and patients with BN in ambulatory treatment received on average 8.1 individual sessions within three months after admission. In the present study, ambulatory patients did not receive any group sessions.

https://doi.org/10.1371/journal.pone.0280402.t002

https://doi.org/10.1371/journal.pone.0280402.t003

Symptomatic changes among patients within three months after admission

Table 4 summarizes symptomatic changes on several outcome measures from pre- to post-assessment including corresponding effect sizes (Cohen’s d ). For patients with AN, full-time treatment was associated with large improvements in BMI ( d = .83) and moderate to large improvements in somatic symptoms ( d = .77), depressive symptoms ( d = .77), and symptoms of anxiety ( d = .73). Also, moderate improvements were observed in ED pathology ( d = .48). For patients with AN, ambulatory treatment was associated with small improvements in BMI ( d = .37). For patients with BN, full-time treatment was associated with large improvements in ED pathology ( d = .81) and somatic symptoms ( d = .85). Also, moderate improvements were observed in depressive symptoms ( d = .70) and symptoms of anxiety ( d = .48). For patients with BN, ambulatory treatment was associated with small improvements in ED pathology ( d = .44), depressive symptoms ( d = .39), symptoms of anxiety ( d = .31), and somatic symptoms ( d = .27).

https://doi.org/10.1371/journal.pone.0280402.t004

Correlates of symptomatic improvements

Among women with AN, a significant correlation was found only between weight gain and ED severity ( r = .62., p < .001, R 2 = .38), indicatig that a higher AN severity (i.e., more severe underweight) at the time of admission was associated with more weight gain during the first three months of treatment. A reduction in ED pathology was significantly correlated only with treatment intensity ( r = .42., p < .01, R 2 = .20), indicating that more psychotherapeutic sessions were associated with more reduction in ED pathology among women with AN. Among women with BN, no significant correlations could be observed between reduction in ED pathology and any of the variables (all p >.05).

Remission rates among patients within three months after admission

Table 5 summarizes remission rates. Among patients with AN receiving full-time treatment, one (3.1%) was considered fully remitted and six (18.8%) were considered partially remitted within three months after admission. Among patients with AN receiving ambulatory treatment, none were considered fully remitted and four (14.8%) were considered partially remitted within three months after admission. Among patients with BN receiving full-time treatment, one (4.4%) was considered fully remitted and seven (30.4%) were considered partially remitted within three months after admission. Among patients with BN receiving ambulatory treatment, one (2.9%) was considered fully remitted and nine (26.5%) were considered partially remitted within three months after admission.

https://doi.org/10.1371/journal.pone.0280402.t005

Few empirical data examine the implementation of guideline-oriented CBT for EDs and associated outcomes in routine clinical care. In the present study, findings for full-time treatment (e.g., hospitalization) were contrasted with findings for ambulatory treatment. Across settings, patient characteristics and treatment intensity were quite heterogeneous. Due to these differences, direct comparisons of treatment outcomes between settings are not indicated and results should not be interpreted as superiority of one treatment setting over another. Generally, the present study showed that a substantial number of patients with AN and BN displayed symptomatic improvements on several indicators of mental health within three months of treatment admission, although recovery rates remained quite low.

Among women with AN receiving full-time treatment, substantial improvements were observed in body weight, depressive symptoms, symptoms of anxiety, and somatic symptoms, while improvements in ED pathology were moderate. It should be noted that, particularly for this group, the range of the number of psychotherapeutic sessions received was remarkably broad, indicating strong variations in treatment intensity. Results showed that, for women with AN, reduction in ED pathology was directly related to the number of psychotherapeutic sessions received, while weight gain was associated with higher AN severity (i.e., more severe underweight). Although nearly one fifth of patients with AN was considered partially remitted after three months of full-time treatment, the recovery rate (i.e., full remission of symptoms) was very low (3.1%). In line with this, a multi-centre study of short-term outcomes of inpatient treatment (e.g. hospitalization) similarly reported large increases in BMI and improvements in physical health, but the majority of patients remained in an underweight BMI range and continued to display clinical levels of ED symptoms at discharge [ 10 ]. Similarly, Treat and colleagues [ 40 ] reported an increase in expected body weight from 71 to 85% in inpatient care. However, one third of patients was discharged against medical advice and not included in the analyses. Among women with AN receiving ambulatory treatment, small improvements in BMI, but no further symptomatic improvements were found, which can be explained, at least in part, by the relatively low number of psychotherapeutic sessions received in the ambulatory setting compared to the full-time setting. A recent systematic review concluded that individual psychotherapy generally produces good results in patients suffering from AN and that there was no superiority of any specific treatment setting, however weight gains occurred more rapid during hospitalization compared to ambulatory treatment [ 41 ]. Another recent systematic review concluded that there were no differences in weight gain among individuals with AN treated in different settings, but patients seemed more likely to complete treatment in settings outside the hospital [ 13 ].

For women with BN receiving full-time treatment, large improvements in self-reported ED pathology and somatic symptoms were observed as well as moderate improvements in depressive symptoms and symptoms of anxiety. In line with this, research indicates that nearly half of patients with severe BN showed clinically significant symptom changes after hospitalization [ 42 ]. Among women with BN receiving ambulatory treatment, small improvements in ED pathology, depressive symptoms, symptoms of anxiety, and somatic symptoms were observed. Symptomatic changes were unrelated to any of the observed variables, indicating that improvements among BN patients were not specific for patient or treatment characteristics. Noteworthy, remission rates were quite similar for full-time BN patients (full remission: 4.4%, partial remission: 30.4%) and ambulatory BN patients (full remission: 3.1%, partial remission: 26.5%). While outcomes in full-time treatment were somewhat larger, outcomes in ambulatory treatment were achieved with far less resources and a substantially lower number of treatment sessions. The results of the present study underline treatment recommendations of clinical guidelines, which generally recommend ambulatory treatment for individuals suffering from BN and hospitalization only in case of severe forms of BN or associated medical complications [ 8 ]. Again, full recovery (i.e., full remission of symptoms) among women with BN was quite rare in both settings (4.4% in full-time treatment, 2.9% in ambulatory treatment) within three months of treatment admission, indicating the need for prolonged treatment even after intensive full-time treatment.

Several differences between the full-time setting and the ambulatory setting are noteworthy. First, as expected, patient characteristics differed between settings. Patients with AN receiving full-time treatment were younger, had a lower BMI, and more often a severe or extreme form of AN compared to ambulatory AN patients. Patients with BN receiving full-time treatment more often reported the use of psychopharmateucis, were more often diagnosed with a comorbid disorder, and more often displayed an extreme form of BN compared to ambulatory BN patients. These findings indicate that ED severity and psychiatric comorbidity are somewhat more severe among patients who voluntarily admitted to full-time treatment compared to ambulatory treatment. Yet, it is noteworthy that approximately half of all full-time AN patients displayed a mild or moderate severity form (average BMI of full-time AN patients was 16.7). This finding indicates that, in clinical practice, hospitalization of patients with AN often occurs for reasons other than very low body weight (i.e., severe form of AN).

Furthermore, treatment intensity differed largely between settings as well as treatment institutions. Full-time patients with AN received on average 65 psychotherapeutic sessions within three months after admission and full-time patients with BN received on average 38 psychotherapeutic sessions. It should be noted, that the range of the number of sessions differed largely, especially among AN patients. In this context, it should be noted that one treatment institution adminstered a highly intensive AN treatment program (including 2–5 individual sessions per day plus daily group sessions, resulting in an average of 130 psychotherapeutic sessions for AN patients in this treatment institution), thereby strongly increasing the average number of psychotherapeutic sessions for full-time AN patients in the present study. In line with this, previous studies have already noted a large variability in treatment programs and outcomes [ 11 ]. In comparison, ambulatory patients with AN or BN received 8–9 psychotherapeutic sessions within three months after treatment admission. This number was relatively low, partly due to national health insurance policies at the time of the study (as explained above), which were quite disadvantageous for German outpatients, and may have impeded fast improvements and delayed treatment results. In the light of the relatively small number of treatment sessions, the observed symptomatic improvements among ambulatory patients are particularly noteworthy. Besides large differences in treatment intensity, only small differences were observed in treatment components and treatment goals reported by therapists and patients, which probably relate to the number of treatment sessions.

The present study has several limtations. First of all, generalizability of the present findings may be limited by several factors including small sample size of subgroups, specific sample characteristics of study participants, or specific characteristics of cooperating treatment institutions. It should be acknowledged that both patients and institutions do not represent the general population. Furthermore, the present study only examined a few potential covariates. It is possible that additional patient or treatment characteristics may be associated with treatment setting as well as symptom course. In addition, the present study does not include a control group. Therefore, it cannot disentangle symptomatic improvements attributable to the treatment and naturally occurring fluctuations in symptoms. Furthermore, the short-term outcomes reported in the present study should be distinguished from long-term outcomes. As treatments may still be ongoing, remission rates after treatment termination will probably be higher. Therefore, comparisons to the remission rates of clinical trials, which typically report remission rates after treatment termination, are not feasible. Finally, it should be noted that the response rate of therapists, who provided information regarding treatment characteristics, was relatively low (67%). The strengths of the present study include the application of a thorough diagnostical procedure and well-validated measures among ED patients in nine different treatment facilities in Germany and Switzerland. It is one of the few studies evaluating outcomes of guideline-oriented ED treatment in routine clinical care.

In conclusion, the present study showed considerable symptomatic improvements among patients with AN and BN in routine clinical care. Among women with AN, full-time treatment was associated with substantial improvements in body weight, ED pathology, depressive symptoms, symptoms of anxiety, and somatic symptoms. Among women with BN, full-time treatment and ambulatory treatment were associated with considerable improvements on all measured variables, but with different treatment dosages. Results also show that full recovery of EDs is typically not achieved within three months of treatment initiation and requires prolonged treatment duration, even after initial symptomatic improvements during intensive hospitalization. Generally, results also show that treatment intensity and treatment outcomes are quite diverse, indicating the possibility for increasing effectiveness in the treatment of EDs in routine clinical care.

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Library Anorexia vs Bulimia: Whats the difference?

Anorexia vs Bulimia: Whats the difference?

Anorexia nervosa and bulimia nervosa are eating disorders characterized by distorted body image, preoccupation with food, and extreme eating habits used to control weight. [5] Commonly called simply anorexia and bulimia, these disorders have many similarities, but some critical differences in symptoms, causes, and treatment options are important to understand.

• Anorexia nervosa
• Bulimia nervosa
• Co-occurrence

How common are anorexia and bulimia?

What is anorexia nervosa.

Anorexia nervosa is characterized by an unhealthy relationship with food and a distorted body image. Individuals with this disorder try to keep their body weight down through methods such as starvation or excessive exercise. They usually maintain a body weight far below average.

The DSM-5 highlights the following criteria to be met for a diagnosis of anorexia:  

• A restriction of food intake well below what is required to maintain a healthy body weight. This leads to a significantly lower weight than expected for the individual’s height, age, and sex.
• An intense fear of becoming ‘fat’ or gaining weight, even if already at a very low body weight.
• A distorted perception of current body weight or the body weight they desire to achieve. [1]

What is bulimia nervosa?

Like anorexia, bulimia nervosa is characterized by an unhealthy relationship with food and body weight. However, individuals with bulimia also have episodes of binge eating, where they consume larger than normal quantities of food, followed by compensatory, purging behaviors. [1]

The DSM-5 highlights the following criteria to be met for a diagnosis of bulimia:  

• Recurrent episodes of binge eating.
• Repeated use of inappropriate behaviors to compensate for binge eating and avoid gaining weight. These can include vomiting, fasting, excessive exercise, or abuse of diuretics, laxatives, or other medications.
• The above two criteria occur at least once a week, on average, for at least three months.
• Sense of self-worth is overly based on body shape and weight.
• These symptoms must not occur exclusively during episodes of anorexia nervosa. [1]  

An episode of binge eating is defined by: 

• Consuming an excessive amount of food during a distinct, short period.
• Feeling a lack of control over how much one eats during that period. [1]

Anorexia vs Bulimia: Symptoms

Anorexia and bulimia share many of the same symptoms. Patients with either eating disorder may experience the following symptoms: 

• Distorted body image
• Preoccupation with food
• Preoccupation with body weight and shape
• Extreme or inappropriate behaviors to limit weight gain or control calorie intake, including excessive exercise, fasting, vomiting, and abuse of diuretics, laxatives, or enemas
• Digestive issues
• Irregular periods
• Dehydration
• Weakness or fainting
• Low self-esteem
• Unusually private eating habits
• Depressed mood
• Social withdrawal
• Fatigue [6] [1]

Those with anorexia are more likely to experience the following:

• Dramatic weight loss
• Swollen legs and arms
• Dry, yellow skin [6]  

On the other hand, those with bulimia are more likely to experience the following: 

• Binge eating episodes
• Sore throat
• Acid reflux
• Dental problems [6]

Binge eating and purging through vomiting, laxatives, enemas, or diuretics is much more common in bulimia patients. However, this can also occur in individuals with binge eating and purging-type anorexia. [1] Many in this category do not binge and will only purge after eating small amounts of food.

The main diagnostic differentiator between these two eating disorders is body weight. While those with anorexia maintain a significantly low body weight, those with bulimia maintain a normal to above-normal weight for their height, age, and sex. [1]  

Fasting is much less common with bulimia, but individuals may eat significantly less than normal in between binge eating episodes. [1]

Anorexia vs Bulimia: Causes

The exact causes of anorexia and bulimia are not yet fully understood. However, researchers believe genetic and environmental factors play a part in developing these mental health disorders.

Individuals with immediate family members who have suffered from anorexia or bulimia are more likely to develop an eating disorder themselves. [1] A family history of other mental health issues can also increase the risk.

Environmental factors that increase the risk of an eating disorder include stressors, depression, and internalizing society’s ideal of a thin body type. [1] As a result, these disorders are more commonly seen in Western cultures. 

Causes of anorexia 

Anorexia is associated with certain personality types and traits. Patients tend to be perfectionists, who are sensitive to criticism, and frequently doubt themselves. [5] They also commonly feel like they lack control in their lives.

Individuals with the disorder tend to have a history of anxiety disorders or obsessive-compulsive disorder. [1] They also have a history of dieting. Some researchers believe that positive reinforcement from dieting, such as weight loss or compliments, can contribute to the development of anorexia. [1]

Causes of bulimia

While both disorders are associated with early childhood experiences, bulimia is connected to some unique experiences. For instance, bulimia is linked to a history of sexual abuse or assault, while anorexia is not. [4] Bulimia is also more commonly connected to a past of childhood obesity. [1]

Individuals with this disorder tend to have difficulties with impulse control. [1] Additionally, bulimic patients frequently suffer from depressive disorders.

Anorexia vs Bulimia: Treatment

Treatment for anorexia and bulimia focuses on nutritional rehabilitation, family therapy, and individual psychotherapy. Medications, especially antidepressants, may also be used.

Treatment of anorexia 

The first goal of anorexia treatment is to get the individual back to a healthy weight. Depending on the severity of the patient’s condition, this may be done through hospitalization , inpatient care, or outpatient care. [2] Patients with anorexia are much more likely to require hospitalization than patients with bulimia. [4]

The Maudsley approach, a type of family therapy, is commonly used to treat anorexia in adolescents. Parents are educated on supporting their child in developing healthier eating habits. [4] This therapy also includes a cognitive component to address the patient’s distorted body weight and shape perceptions.  

Research suggests that family therapy is more effective than individual therapy for anorexia treatment. [4] However, individual psychotherapy, including cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT), can effectively reduce the chance of relapse once a healthy weight has been reached. [2] These therapies address the underlying causes of the disorder. 

While there is not enough evidence for treating anorexia with medications alone, they may help treat comorbid conditions that contribute to the severity, such as depression, OCD, and anxiety. [4]

Treatment of bulimia 

Since bulimia patients are typically not underweight, treatment is usually outpatient. Treatment focuses on improving the individual’s relationship with food and their body and reducing binging and purging cycles. 

The most common therapeutic approach for treating bulimia is CBT, which helps patients challenge unhealthy, negative beliefs. [2] It also helps them develop healthier behaviors and eating patterns.

While more evidence exists for the effectiveness of CBT, IPT is also becoming a popular treatment option. In IPT, individuals work to improve their relationships and social skills. This helps with underlying depressive symptoms and improves their support network. [2]  

Research has found that antidepressants, particularly SSRIs, are very effective for treating bulimia, even if the patient does not have a concurrent diagnosis of depression. [2] These medications help to reduce binging and purging behaviors. [4] SSRIs can also help with body image and attitudes toward food. [2]

Anorexia vs Bulimia: Treatment outcomes 

Recovery from anorexia and bulimia is a long-term process. Relapses are common, so ongoing treatment is recommended for maintenance.

Anorexia generally has a poorer prognosis than bulimia and requires a more extended recovery. It also has the highest mortality rate of any psychological condition. [4] Still, about 50% of patients fully recover, and 30% partially recover. [4]

Conversely, bulimia patients have higher recovery rates. Research has found that 80% of patients typically fully recover after treatment. [4] Relapse is still a concern, affecting up to 20% of patients. [4]

Can you have anorexia and bulimia at the same time?

Due to the nature of the symptoms, you cannot meet the criteria for a diagnosis of both anorexia nervosa and bulimia nervosa simultaneously. [1] However, many individuals diagnosed with one disorder will eventually develop the other.

Research has found that up to 50% of those diagnosed with anorexia will develop bulimia at some point in their lives. [3] On the other hand, only about 10% of those with bulimia will go on to develop anorexia. [3]

Approximately 90% of eating disorder patients are female, and the prevalence in males is not yet fully understood. [4]

Research has found that between 0.9%-2% of females will develop anorexia nervosa at some point in their lives. [7]

On the other hand, between 1.1%-4.6% of females will develop bulimia nervosa. [7]

• American Psychiatric Association. (2013). Washington, DC: Diagnostic and statistical manual of mental disorders (5th ed.).
• Chakraborty, K., & Basu, D. (2010). Management of anorexia and bulimia nervosa: An evidence-based review. Indian journal of psychiatry, 52(2), 174–186.
• https://doi.org/10.4103/0019-5545.64596  
• Eddy, K. T., Dorer, D. J., Franko, D. L., Tahilani, K., Thompson-Brenner, H., & Herzog, D. B. (2008). Diagnostic crossover in anorexia nervosa and bulimia nervosa: implications for DSM-V. The American journal of psychiatry, 165(2), 245–250. https://doi.org/10.1176/appi.ajp.2007.07060951
• Harrington, B. C., Jimerson, M., Haxton, C., & Jimerson, D. J. (2015). Initial Evaluation, Diagnosis, and Treatment of Anorexia Nervosa and Bulimia Nervosa. Am Fam Physician, 91(1), 46-52.
• John Hopkins Medicine. (n.d.). Frequently asked questions about eating disorders. Retrieved December 8, 2022 from https://www.hopkinsmedicine.org/psychiatry/specialty_areas/eating_disorders/faq.html
• MedlinePlus. (2021). Eating disorders. National Library of Medicine. Retrieved December 9, 2022 from https://medlineplus.gov/eatingdisorders.html  
• National Eating Disorders Association. (n.d.). Statistics and research on eating disorders. Retrieved December 7, 2022 from https://www.nationaleatingdisorders.org/statistics-research-eating-disorders  

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Anorexia vs. Bulimia: What’s the Difference?

Anorexia and bulimia may seem similar, but they are unique eating disorders. learn more about the difference between anorexia and bulimia and find out how to help someone you care about who you suspect has an eating disorder..

Eating disorders  are psychological conditions that distort a person’s relationship with food and their body. This distortion can influence every aspect of a person’s life and impacts their mental health, physical health and social health.

The are several types of eating disorders, but  anorexia  and  bulimia  are two of the most common disorders. Despite their differences, anorexia and bulimia share many similarities. These similarities can make it challenging for a person to quickly and accurately identify the disorder.

What’s the Difference Between Anorexia and Bulimia?

By knowing the differences anorexia vs bulimia, you put yourself and your loved ones in a better position to understand and manage the condition that affects your life.

Article at a Glance:

• Anorexia and bulimia are the most common eating disorders.
• Anorexia involves restricting food, a fear of gaining weight and distorted body image.
• Bulimia involves bingeing with large amounts of food and then purging by vomiting, laxative use, fasting or compulsive exercising.
• Both eating disorders are marked by low self-esteem, secretive food-related behaviors and intense focus on weight.
• Treatment options for anorexia and bulimia are available in inpatient and outpatient settings, as well as through online teletherapy services.

Signs & Symptoms

Every  mental health disorder  has a series of signs and symptoms that experts use to identify and treat the disorder. Anorexia and bulimia are no different. Being able to recognize their signs and symptoms allow people to better recognize the disorder in themselves, friends or family members. The sooner someone receives  treatment for their eating disorder , the faster they can resume a healthy lifestyle.

Also known as  anorexia nervosa , anorexia has several symptoms that medical professionals look for in a diagnosis. The symptoms of anorexia include:

• The restriction of energy intake (i.e., a reduced amount of food and drinks consumed) leading to a very low weight
• An intense fear of gaining weight or “being fat”
• Consistent behaviors that make weight gain impossible
• Flawed ability to accurately view their body

Professionals rate the intensity and severity of anorexia by  a person’s body mass index  (BMI), which is a calculation of their height and weight. As a person’s BMI decreases, the severity of anorexia increases.

People with anorexia may display other signs and symptoms including:

• Low self-esteem
• Poor body image
• Inconsistent or undesirable relationships
• Focusing on weight, dieting and calories
• Skipping meals
• Viewing self as much larger than reality
• Withdrawing from friends and social opportunities
• Struggling in school or work

The warning signs of anorexia can be challenging to observe, but weight loss and low BMI will are clues about the possibility of the condition.

The signs and symptoms of bulimia overlap with anorexia and involve an individual focusing on their weight and being thin.  Bulimia nervosa  is characterized by bingeing and purging behaviors.

Bingeing, or binge eating, is marked by:

• Eating an exceptionally large amount of food over a specific period
• A total lack of control during this period of binge eating

Purging is finding an extreme way to prevent weight gain from the food consumed including:

• Abusing laxatives or diuretics
• Excessive exercising

Additionally, to be diagnosed with bulimia users must binge and purge at least once per week for three months and disproportionately base their self-worth on physical appearance, weight and body shape.

Whereas anorexia grades severity based on BMI, bulimia bases severity on the number of purging episodes completed during a week. The severity is:

• Mild  with 1 – 3 episodes per week
• Moderate  with 4 – 7 episodes per week
• Severe  with 8 – 13 episodes per week
• Extreme  with 14 or more episodes per week

Like anorexia, people with bulimia may show additional signs and symptoms like:

• Being secretive or very focused on food
• Disappearing after meals

People with bulimia are more likely than those with anorexia to be at an average weight for their age group.

Relationship to Food

Eating disorders always influence a person’s relationships with eating and food. However, people with anorexia and people with bulimia have slightly different relationships with eating and the food they do or do not consume.

With  anorexia , the person’s relationship with food is based on strong and complete control. The person is methodical and meticulous when it comes to what they eat, when they eat and how much they eat. Their behavior is planned and carried out with precision.

People with anorexia sometimes build rituals and routines around eating by only eating a certain food at certain times.

People with  bulimia  will have an intense focus on food as well, but their relationship is based on a lack of control rather than maintaining full control. During a binge, the person may feel powerless to stop eating after a reasonable amount. After binging, the individual usually feels shameful and guilty about what they did, which fuels the desire to purge again.

Side Effects

Eating disorders can change a person’s mental and physical health by triggering many side effects. Some are so significant that they are irreversible.

The most common side effects of anorexia are:

• Being very thin
• Thin bones and lower bone density
• Thin hair and brittle nails
• Skin that appears dry or yellow
• New growth of fine body hairs
• Constipation
• Low body temperature
• Menstrual changes
• Slowed breathing
• Heart damage with low blood pressure and heart rate
• Brain damage
• Other organ failures

These side effects become more numerous and problematic the longer anorexia continues.

The most common bulimia side effects vary based on the methods of purging and include:

• Sore throat
• Enlarged glands in the neck and jaw
• Tooth decay
• Numerous gastrointestinal problems like acid reflux
• Dehydration
• Imbalance of electrolytes that could result in a stroke or heart attack

Side effects of bulimia may appear slowly and increase in severity as the cycle of binging and purging continues.

The precise cause of mental health conditions are often impossible to know. Medical professionals have not found a definitive connection between eating disorders and one particular cause. However, some risk factors may increase the likelihood that someone experiences anorexia or bulimia.

Although the exact  cause of anorexia  is unknown, some factors may influence the development of the eating disorder. The current understanding of anorexia is that several risk factors contribute to the development of the disorder. Anorexia risk factors include:

• A tendency to become obsessive
• Coming from an environment where thinness is valued
• Having a close family member with anorexia

Similar to anorexia, the exact cause of  bulimia  is unknown, but several risk factors are potential contributors. The risk factors of bulimia include:

• Social anxiety and childhood anxiety
• Being concerned about weight early in life
• Childhood abuse
• A belief that being thin is ideal
• Childhood obesity
• Going through puberty at a very young age
• Having family members with bulimia

Is Bulimia or Anorexia More Common?

About 30 million people in the United States will have an eating disorder, like anorexia and bulimia, at some point in their life. However, of the people who have one of the two disorders, bulimia occurs more often than anorexia.

One possible explanation is the stringent criteria for anorexia. Someone could have all the symptoms of the condition, but until their weight is low enough they will not receive the diagnosis.

According to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), every year about 0.4 percent of young females will meet the criteria for anorexia.  It’s rarer for males to have the condition, though. Research points to 10 females with anorexia for every one male. Other studies find males make up about 25 percent of those with the condition.

More people have bulimia than anorexia. The DSM-5 states that between 1 and 1.5 percent of young females have bulimia. Like with anorexia, little information exists about the condition’s prevalence in men, but women with the condition outnumber men with the condition by 10 to 1.

Age of Onset

Age of onset may refer to the time where symptoms first emerge or when a professional first diagnoses the condition. The age of onset for anorexia is very similar to the age of onset of bulimia.

Anorexia symptoms usually begin during late adolescence or early adulthood. The average age for the onset of anorexia is 18 according to the  National Institute on Mental Health .

Interestingly, the average age of onset for bulimia is also 18. Just like anorexia, symptoms of bulimia tend to appear during the late teens or early twenties.

Mortality Rate

Mortality rate is a way to identify how a disorder affects a person’s health and lifespan. A disease with a higher mortality rate signifies more danger and shorter life expectancies. Both anorexia and bulimia have a high mortality rate due to poor physical health and the increased risk of suicide.

Anorexia’s mortality rate is higher than bulimia’s, which suggests that anorexia has a more negative influence on the person’s life than bulimia does. According to the DSM-5, the mortality rate is 5 percent for anorexia and about 12 people per 100,000 with the disorder commit suicide each year.

The DSM-5 states that bulimia’s mortality rate is 2 percent, which is high enough to create concern. People with bulimia also experience a higher risk of suicide than people without the condition experience.

Effective treatment methods are available to help people with eating disorders. By utilizing a combination of individual, group and family, and  online psychotherapy  with medications, symptoms diminish and a desirable level of functioning returns.

Eating disorders may be treated in inpatient or outpatient settings, including online through  teletherapy services , depending on the disorder’s intensity and the patient’s medical status.  Treatment for eating disorders  may also involve medical care and nutritional counseling to confirm the individual is doing well physically and understands the role of healthy eating in their life.

One effective psychotherapy for anorexia is called the Maudsley approach. This style, aimed at teens with anorexia, involves the entire family. The approach places the parents in a position to ensure their child improves their eating habits and gains weight.

The Maudsley approach, combined with medications like antidepressants, mood stabilizers or antipsychotics, can shorten the duration of symptoms.

Bulimia treatment includes use of the same medication groups as anorexia while employing a different therapeutic approach.  Cognitive behavioral therapy (CBT)  helps a person identify how flawed thinking patterns affect their feelings and behaviors. When distorted thoughts are replaced with healthier ones, beliefs and actions can improve. The goal of CBT is the reduction and eventual elimination of binging and purging behaviors.

Although experts try, it is impossible to accurately predict who will respond well to treatment and who won’t. By investigating risks factors, support networks and stress levels, people can gain a better understanding of the potential prognosis.  

Some people with anorexia will have just one experience with the disorder and then make a full recovery with treatment. Others may have a challenging time with treatment and experience setbacks. According to the DSM-5, most people with anorexia achieve a full remission about five years after symptoms emerge.

Older people may have a poorer anorexia prognosis. They will have more symptoms than younger people and they exhibit their symptoms for longer periods.

Bulimia often begins during a period of high stress and continue for several years for most people. Over time, symptoms seem to diminish regardless if a person seeks treatment. Though it should be noted that professional treatment is linked to quicker recovery and longer periods without binging or purging behaviors.

Anorexia vs. Bulimia: Key Differences and Points

Because there so much information about eating disorders like  anorexia  and  bulimia , it can be easy to confuse the two. Here are some key points to remember about the difference between anorexia and bulimia:

• Anorexia and bulimia are both eating disorders that disrupt a person’s diet and body image
• Anorexia typically involves restricting food intake while bulimia involves eating large amounts of food during binges and compensating with behaviors like vomiting to reduce weight gain
• Anorexia and bulimia adversely impact a person’s mental and physical health, which may contribute to an early death
• Although males can have the disorders, bulimia and anorexia mostly affect females during adolescence and early adulthood
• Anorexia is more dangerous in terms of mortality rate, but bulimia is more common
• Treatment that combines therapy and medication works to reduce and shorten symptoms of the two disorders

Eating disorders are too serious to ignore. The long-term risks of eating disorders are too high, so seeking treatment is encouraged for anyone affected by anorexia or bulimia.

Call The Recovery Village  for information about treatment options for substance use disorders and co-occurring disorders like anorexia or bulimia. Our admissions representatives can help you start the treatment process to achieve the healthy future you deserve.

American Psychiatric Association. “Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition.” 2013.

MentalHealth.gov. “ Eating Disorders .” August 24, 2017. Accessed February 18, 2019.

National Institutes on Mental Health. “ Eating Disorders .” February 2016. Accessed February 18, 2019.

National Institutes on Mental Health. “ Eating Disorders .” November 2017. Accessed February 18, 2019.

Machado, PP, Grilo, CM, Crosby, RD. “ Evaluation of the DSM-5 Severity Indicat[…]for Anorexia Nervosa .” European Eating Disorders Review: The Journal of the Eating Disorders Association. May 25, 2017. Accessed March 18, 2019.

The Recovery Village aims to improve the quality of life for people struggling with substance use or mental health disorder with fact-based content about the nature of behavioral health conditions, treatment options and their related outcomes. We publish material that is researched, cited, edited and reviewed by licensed medical professionals. The information we provide is not intended to be a substitute for professional medical advice, diagnosis or treatment. It should not be used in place of the advice of your physician or other qualified healthcare providers.

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The differences between bulimia nervosa and anorexia nervosa

Bulimia nervosa (BN) and anorexia nervosa (AN) are two of the most well-known eating disorders, but many people may not be aware of just what those conditions entail, or the many ways they’re alike and different. 

The main difference between BN and AN are the disordered eating patterns through which the conditions are expressed. People with anorexia nervosa generally exhibit more restrictive eating behaviors, while people with bulimia nervosa experience cycles of binging and purging, though some forms of AN also present this way. 

And while people’s anxieties around food and body image tend to manifest differently in these two conditions, the underlying causes , triggers, and treatments may overlap. Learn more about the differences and similarities in these conditions below.

What is anorexia nervosa?

Anorexia nervosa is a diagnosable condition in which an individual severely restricts food intake. The cognitive reasons for restricting may vary, but are most usually a result of unhealthy thought patterns or perceptions of one’s own body or a desire to maintain control by limiting caloric intake. When AN progresses from moderate to severe, the individual can experience medical and physical consequences of starvation . 1

In many cases, the restrictive eating behaviors of anorexia nervosa will present as someone continually declining to eat, possibly by telling others they’ve already eaten or aren’t feeling hungry. It’s not uncommon for people struggling with AN to skip out on social occasions involving food all together.

The person may engage in food-related rituals and other notable eating habits, including pushing food around their plate but not taking any bites of it, eating food in certain orders, or only taking big or tiny bites of what they’re eating. Restrictive eating behaviors can also manifest as extreme control over one’s diet, through methods like keeping a strict eye on calorie counts, portions, or nutritional content in order to prevent weight gain.

And concerns over weight gain and poor self-esteem and body image can frequently look like a fixation on the topics of body weight, size, shape, or appearance, whether in general or about the person in particular. Sensitivity and visible distress around these topics is also common in people with AN.

What is bulimia nervosa?

There are actually two different medically-classified types of bulimia nervosa, but the general disordered eating pattern tying them together is a cycle of binging and purging. It can be helpful to define “binging” and “purging” separately. 

“Binging” is when a person eats, within a 2-hour window, an amount of food that is definitively larger than what most people would eat in a similar timeframe. This can be anything from eating a heavy meal to eating thousands of calories at a time, depending on severity. During these episodes, patients usually describe feeling “out of control” and they just cannot stop eating. 2

“Purging” refers to the compensatory behaviors people perform to make up for the binging episodes. This type of behavior is medically considered part of bulimia nervosa disorder when it happens at least once a week, for at least three months. 

Bulimia nervosa is defined as binging episodes with or without purging. Purging can manifest in a number of different forms, and the method(s) a person most frequently uses is what dictates the type of BN disorder they’re diagnosed with. “Purging” type of bulimia nervosa is when someone physically expels the food from their body, either through self-induced vomiting or misuse of laxatives or other diuretics, or excessive exercise . 2

The way these behaviors play out in real life can vary widely. People may utilize one or several types of purging behavior, or switch between “purging” and “nonpurging” episodes. Often, people with bulimia nervosa hide their binging episodes, declining to eat with or around others, or binging food late at night. 

Binge eating disorder

• Exercise addiction
• Compulsive overeating

Night eating syndrome

• Unspecified feeding or eating disorders

Anorexia vs. bulimia

Bulimia nervosa and anorexia nervosa share many commonalities, though the conditions ultimately present differently, may have different biological or psychological origins, or impact people in different ways.

Anorexia and bulimia: differences

Aside from the different disordered eating patterns exhibited by anorexia nervosa and bulimia nervosa, the biggest difference between the two conditions is the psychological and physiological mechanics behind those behaviors.

Most experts hypothesize that anorexia is not necessarily just about distorted body image, but is also, if not more so, a maladaptive coping mechanism to attempt to feel a sense of control. People struggling with anorexia nervosa tend to exert control over what they eat as an attempt to gain a sense of control over their life or their emotions. This is sometimes a learned response to traumatic events in their past or stressful circumstances in their present. 1

Bulimia, in contrast, is thought to be more of a coping mechanism for stress management. Patients often binge for the pleasure it provides and the way it relieves stress. 

One study on the subject found that a significant number of people with bulimia nervosa experienced disruptions in the neurological pathways responsible for motivation and reinforcement – the same neurological pathways behind the feelings of hunger and satiety. 3 Studies have found that once a person starts engaging in binging and purging behaviors, those pathways can become more dysfunctional, with the body “learning” to release floods of feel-good chemicals any time a person eats, especially when the food involved is high in fat, carbohydrates, and sucrose. 3

When this happens, it can override the reward center of the person’s brain, leading to the sensation of losing control during binging episodes . A mixture of guilt, sadness, anxiety, depression, and other negative emotions following these episodes is usually what drives the compensatory purging behaviors.

Anorexia and bulimia: similarities

Among their many similarities, bulimia nervosa and anorexia nervosa primarily share a number of common risk factors.

Both BN and AN have been found to be at least moderately hereditary . People with an immediate family member—such as a parent, sibling, or aunt or uncle—presenting with either disorder are at particularly high risk of inheriting genes that potentially make them more likely to develop bulimia nervosa or anorexia nervosa. 4

It’s also possible for someone to inherit a number of personality traits or characteristics that make them more susceptible to experiencing either condition, including perfectionism, fearfulness, pessimism, doubtfulness, shyness, a tendency to worry, and certain reactions to stress. 4

Many people with bulimia nervosa and anorexia nervosa also experience co-occurring mental disorders. Depression and anxiety disorders of many types have particularly strong connections to both anorexia nervosa and bulimia nervosa. 

Other common factors between the two conditions include poor self-esteem, a marked fear of weight gain, and overall dissatisfaction with body image. A history of childhood trauma or abuse is also common among patients with either condition. 

The two conditions also share a number of overlapping signs and eating disorder symptoms. Mood swings, weight loss, thinning hair, poor dental health, and other signs of malnutrition are common in people struggling with both conditions.

Restriction and binge eating in other disorders

There are other similar eating disorders that have been described.

Avoidant restrictive food intake disorder

Avoidant Restrictive Food Intake Disorder (ARFID) is characterized by the same restrictive eating behavior as anorexia nervosa, with the primary difference being the motivations behind that behavior. People struggling with ARFID typically refuse certain foods more out of a distaste for certain textures or smells or a fear of choking, rather than a fear of gaining weight or a desire to “control” their bodies. 

Binge eating disorder (BED) shares a number of characteristics with both anorexia nervosa and bulimia nervosa. While people struggling with BN engage in disordered eating patterns that resemble binge eating behavior, the psychological driver behind them is typically a restrictive mindset in BN: Attempts to restrict their food intake are often what leads to subsequent binging episodes.

Exercise addiction, though not technically classified as an eating disorder, hinges on the act of excessively working out, which can also present as a purging behavior.

Night eating syndrome (NES) experience some aspects of binging behavior, such as feeling a loss of control when eating, which can lead to episodes of overeating, particularly late at night. (5)

All of these conditions have a lot of overlap, and sometimes we over focus on “labeling” them instead of focusing on the individual's needs. The main reason for categorizing these various conditions is to help us identify which thoughts and fears are driving maladaptive behavior patterns so that we can best address the therapeutic needs of the individual patient.

When to seek help for an eating disorder

While eating disorders like bulimia nervosa and anorexia nervosa may seem daunting to overcome, it’s never too late to seek help . In fact, the best time to act is usually as soon as possible.

If you or a loved one is showcasing signs of restriction, binging, or purging behavior, it’s likely a good time to start a conversation about what’s going on, and to start seeking eating disorder treatment.

Your primary care physician, therapist, or another trusted medical professional may be able to help you attain an official diagnosis or determine and navigate the best next steps. A number of eating disorder hotlines are also available, offering additional information and resources on these conditions.

But no matter where you start your recovery journey, the most important thing to remember is that recovery from an eating disorder is always within reach .

Disclaimer about "overeating": Within Health hesitatingly uses the word "overeating" because it is the term currently associated with this condition in society, however, we believe it inherently overlooks the various psychological aspects of this condition which are often interconnected with internalized diet culture, and a restrictive mindset about food. For the remainder of this piece, we will therefore be putting "overeating" in quotations to recognize that the diagnosis itself pathologizes behavior that is potentially hardwired and adaptive to a restrictive mindset.

Disclaimer about weight loss drugs: Within does not endorse the use of any weight loss drug or behavior and seeks to provide education on the insidious nature of diet culture. We understand the complex nature of disordered eating and eating disorders and strongly encourage anyone engaging in these behaviors to reach out for help as soon as possible. No statement should be taken as healthcare advice. All healthcare decisions should be made with your individual healthcare provider.

• DSM-IV to DSM-5 Anorexia nervosa Nervosa Comparison . (2016, June). Substance Abuse and Mental Health Services Administration. Accessed June 2023.
• DSM-IV to DSM-5 Bulimia nervosa Nervosa Comparison . (2016, June). Substance Abuse and Mental Health Services Administration. Accessed June 2023.
• Avena, N. M., & Bocarsly, M. E. (2012). Dysregulation of brain reward systems in eating disorders: neurochemical information from animal models of binge eating, bulimia nervosa, and anorexia nervosa . Neuropharmacology, 63 (1), 87–96.
• Berrettini W. (2004). The genetics of eating disorders . Psychiatry, 1 (3), 18–25.
• Lavery, M. E., & Frum-Vassallo, D. (2022). An Updated Review of Night Eating Syndrome: An Under-Represented Eating Disorder . Current Obesity Reports, 11 (4), 395–404.

Further reading

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Challenges in bipoc eating disorders: prevalence, bias, and treatment barriers.

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The relationship between grief and eating disorders.

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Diabetes and eating disorders.

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Disordered eating vs. eating disorder

Eating disorders in the military population.

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Unpacking the fear of eating in front of others

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Anorexia Vs. Bulimia: What Is the Difference?

Author: Nicole Arzt, LMFT

Nicole Arzt LMFT

Nicole specializes in psychodynamic and humanistic therapy.  She’s  an expert in complex trauma, substance use disorder, eating disorders, anxiety, depression, imposter syndrome, narcissistic abuse, and relationships and intimacy.

Anorexia and bulimia are eating disorders characterized by preoccupations with food, weight, body image, and control. Someone with anorexia primarily relies on restricting food and avoiding eating as much as possible, while those with bulimia engage in binge/purge patterns to control their caloric intake. Both conditions can be life-threatening, and they impact people of all ages and demographics.

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Anorexia Vs. Bulimia: Key Differences

Anorexia is an eating disorder classified by disordered eating patterns, consistent food restriction, and fears of weight gain. These behaviors cause a significantly low body weight. However, the person may still perceive themselves as large, often as a result of body dysmorphia . 1 Bulimia is an eating disorder classified by recurrent patterns of binging and purging. People with bulimia can be of any weight, which can sometimes make the condition harder to detect.

While most people associate purging with self-induced vomiting, purging can also include excessive exercise, laxative abuse , misusing diet pills, and diuretic abuse. Bulimia often coincides with fatigue, acid reflux, and problems with skin and hair. Eventually, bulimia can result in tooth enamel erosion, bone damage, and heart issues.

People with anorexia primarily rely on fasting and restriction to avoid gaining weight (or boost weight loss). Many with anorexia have rituals around food, avoid entire food groups, or skip meals altogether. They must be medically underweight to have a formal anorexia diagnosis (although exceptions may be made for atypical anorexia).

People with bulimia may also use these methods to control their weight, but will engage in patterns of binging and purging, too. To be diagnosed with bulimia, a person will engage in binge eating and purging at least once a week for three months. There is no specified weight criteria for bulimia. 2

Similarities Between Bulimia & Anorexia

Bulimia and anorexia share numerous similarities. Both are eating disorders that entail a preoccupation with food and a disturbed relationship with eating. Like bulimia, some people with anorexia also engage in binging and purging. Furthermore, it’s common for people with both conditions to feel obsessed about their weight and body size.

Similarities between anorexia and bulimia include:

• Generally have a negative body image
• Typically have a fear of gaining weight
• Using compensatory eating disorder behaviors to lose weight or offset eating habits
• Secretive eating
• Co-occurring mental health conditions (i.e. depression, anxiety)
• Medical complications like dehydration, malnutrition, or gastrointestinal distress
• Food rituals or intense food rules
• Both can be life-threatening

Symptoms of Anorexia Nervosa

Anorexia impacts a person physically, emotionally, and behaviorally. At first, someone might become obsessive over food while attempting to lose weight. As a result, they may experience lethargy, poor concentration, and agitation. Over time, chronic restriction and anorexic symptoms can result in serious health consequences including malnourishment, dehydration, kidney failure, and cardiovascular problems.

Sometimes, anorexia symptoms can be obvious. But, many people attempt to hide, downplay, or deny their anorexia. They often don’t want to get into trouble, or they feel pressured to stop losing weight.

Common symptoms of anorexia include:

• Rapid and significant weight loss
• Mood swings (more agitation)
• Hair loss/dry hair
• Gray or pale skin
• Fine hair on the skin
• Avoiding meals or eating very little at mealtime
• Making frequent comments about feeling fat or wanting to lose weight
• Cutting out entire food groups

Symptoms of Bulimia

Like anorexia, people may often attempt to hide their bulimic symptoms. Loved ones should look for signs of binge eating (eating rapidly, eating secretly, or food disappearing) and purging (using the bathroom right after meals, exercising many hours a day, or evidence of laxatives or diuretics).

Common symptoms of bulimia include:

• Dehydration
• Gastrointestinal issues
• Rapid weight changes
• Dental issues
• Throat pain
• Joint or muscle injuries (from excessive exercise)
• Bowel irritation
• Skin problems

Are you or a loved one experiencing eating disorder symptoms?

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Can Someone Be Both Bulimic & Anorexic?

Even though symptoms may overlap, people cannot meet the criteria for anorexia and bulimia at the same time. However, a person with anorexia may meet the criteria for a binge-eating/purging subtype. When this is the case, they engage in binge/purge behaviors (similar to bulimia). However, they still meet all the diagnostic criteria for anorexia (significantly low body weight, intense fear of weight gain, and disturbances with shape and size).

Anorexia is also defined by a lack of recognition regarding how serious the person’s low body weight has become. 2 While many with bulimia may downplay the dangerous effects of weight loss, this is not a diagnostic feature of the condition.

What Causes Anorexia & Bulimia?

Eating disorders are caused by a variety of complex factors, and are not the result of any single variable. That said, there are several genetic and environmental factors that may increase the chance of someone developing an eating disorder.

Possible causes of anorexia and bulimia include:

• Family history of anorexia: People with first-degree relatives with anorexia are ten times more likely to have anorexia themselves. To explain this phenomenon, researchers are continuing to examine the genetic effects of serotonin, dopamine, and opioid receptors in the development of eating disorders. 3
• Childhood trauma: People with eating disorders often report histories of childhood trauma. 4 Controlling food and weight may be an attempt to cope with trauma-related distress.
• Sexual, verbal, or emotional abuse: Abuse can undoubtedly impact a person’s self-esteem. People may turn to focusing on their weight or food to cope with related trauma symptoms.
• Social pressures: Some people may be susceptible to societal messages about ideal appearances, thinness, and beauty. These messages may be the first trigger for disordered eating.
• Family patterns of disordered eating: Patterns of disordered eating (or obsessiveness about weight) can pass from parents to children. Children often mimic how their caregivers eat and take care of themselves.
• Anxiety and depression: Underlying anxiety or depression may drive disordered eating. Some people might self-medicate mental health symptoms with food.
• Athletic pressure: Certain sports or extracurricular activities emphasize leaner physiques or body weights. Pressure from coaches or teammates can unintentionally set a foundation for anorexia and other eating disorders.
• History of chronic dieting: Dieting may perpetuate and trigger ongoing disordered behavior, particularly in people who may be prone to anorexia.

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Complications of Living With an Eating Disorder

Both anorexia and bulimia can be extremely harmful, with severe cases often coinciding with substantial health issues. Unfortunately, these issues may be permanent if left untreated. It’s also estimated that 3.3 million people die each year from eating disorders. 5 That said, the right treatment can prevent and reverse some of these complications.

Complications of Anorexia Nervosa

Complications of anorexia may include:

• Hypertension
• Stomach ulcers
• Irregular heartbeat
• Disrupted or loss of menstrual cycle
• Peripheral neuropathy
• Organ failure

Complications of Bulimia Nervosa

Complications of bulimia may include:

• Enamel erosion
• Gum disease
• Bone damage
• Coronary heart disease
• Bowel obstruction and perforation
• Esophageal cancer
• Kidney damage
• Severe electrolyte imbalances

How Are Anorexia & Bulimia Diagnosed?

A healthcare provider will diagnose anorexia or bulimia with a variety of assessments. A doctor may perform a physical exam to evaluate someone’s pulse, blood pressure, and other vital signs. They might order lab tests to review liver, kidney, and thyroid functioning. A psychiatrist or therapist will evaluate the person’s eating habits and thoughts about food and body weight. They will refer to the DSM-5 to make an official diagnosis.

Diagnostic Criteria for Anorexia Nervosa

According to current diagnostic criteria, a person with anorexia will:

• Experience intense fears about gaining weight
• Severely restrict caloric intake to maintain or lose weight
• Connect their self-worth to their body size, weight, or food intake
• Present as underweight relative to their size or age

Diagnostic Criteria for Bulimia Nervosa

According to current diagnostic criteria, a person with bulimia will:

• Experience recurrent binge-eating episodes
• Engage in recurrent compensatory behaviors after binging
• Engage in patterns of binging and purging at least once a week for at least three months
• Strongly evaluate their worth based on body shape or weight (often presenting with very poor body image )

How Are Anorexia & Bulimia Treated?

Many people establish recovery from anorexia or bulimia by seeking professional treatment. Treatment tends to be multidisciplinary, and people may benefit from a combination of therapy, medication, nutritional support, and positive lifestyle changes. Moreover, there are numerous evidence-based therapy models for eating disorders .

A person with an eating disorder frequently meets the criteria for other mental health conditions, including depression, substance use disorder, and anxiety. It’s important to seek comprehensive therapy or medication to treat these conditions, as well. Treating one issue without addressing the other may increase the risk of relapse.

Therapy for Anorexia & Bulimia

Finding the right therapist is often the first step in recovery. Therapy will teach you the insight and tools needed to manage your symptoms and heal from disordered eating behaviors. It’s best to look for a therapist specializing in eating disorders. Ask about their credentials, qualifications, and experience with treatment. You can start your search with an online therapist directory .

Therapy options for anorexia and bulimia include:

• CBT-E: CBT-E is a specific therapy that blends psychoeducation along with structured treatment, directly focusing on specific eating behaviors.
• Exposure therapy: Exposure therapy is a type of CBT that can help you feel more comfortable confronting fearful situations, like eating. Over time, you will experience less worry over food triggers.
• Group therapy: Eating disorder group therapy topics may include self-esteem, body image, nutrition, and healthy living. Having peer support can help you feel more validated in your recovery.
• Family therapy: Family therapy options like the Maudsley Method can provide comprehensive support for the entire family. Each attendee will be held accountable for their own thoughts and actions relating to the member with the eating disorder.
• Interpersonal therapy: In interpersonal therapy , clients focus on addressing any interpersonal conflict. In doing so, they can strengthen their confidence and self-esteem, and reduce eating disorder symptoms.
• DBT: DBT for eating disorders includes interventions rooted in mindfulness, interpersonal effectiveness, emotional regulation, and distress tolerance. These skills can improve daily coping and reduce eating disorder behaviors.
• ACT: ACT focuses on identifying and accepting the complete spectrum of emotions and thoughts. This type of mindfulness can help people manage their urges and commit toward living a value-oriented life.
• CRT: CRT aims to strengthen cognitive flexibility, which can help improve executive functioning and working memory. This approach may be beneficial for people specifically experiencing anorexia.

Hospitalization & Residential Clinics

Sometimes eating disorder symptoms can spiral into medical emergencies. If this is the case, hospitalization for the eating disorder may be necessary. Hospitalization provides continuous monitoring and evaluation; this process may also include intravenous fluids and tube feeding. Ideally, hospitalization stabilizes the most acute symptoms to provide a safe path for recovery. 6

Inpatient/residential treatment (also known as rehab) may follow a hospitalization stay. This treatment also offers 24/7 support and monitoring. Length of programs vary, but they commonly last at least one month. After completing treatment, it’s important to stay active in recovery. Most clients will continue to work with a therapist and dietician.

Medication may also be an important part of one’s recovery treatment plan. The FDA has not approved any medications specifically for anorexia, but some evidence shows the benefits of antidepressants for helping reduce the risk of relapse. Research indicates the antidepressant fluoxetine (Prozac)  and the anticonvulsant drug, Topamax, may reduce binge frequency for those with bulimia and binge eating disorder. Additionally, healthcare providers may recommend pharmacological treatment for other presenting mental health issues, including medications for anxiety, OCD, and mood disorders. 7

Recovering From an Eating Disorder

In most cases, recovering from an eating disorder can be a lengthy and complicated process. The longer someone has had an eating disorder, the longer their treatment will typically take. Recovery tends to be a multifaceted process that includes talk therapy, support groups, psychiatric medication, nutritional counseling, and family-based support.

It’s important to remember that recovery is not a linear process. People often experience setbacks throughout their journey. Relapse does not mean that someone has failed—it simply means they are experimenting with different interventions and strategies and trying to discover what works best. That said, it’s important to maintain a positive mindset throughout this time.

How to Help a Loved One With an Eating Disorder

Loving someone with an eating disorder may feel frightening, confusing, and frustrating. However, you’re not alone in your struggles. These conditions can be challenging to comprehend. But, even if you don’t understand everything, you can still help a loved one with an eating disorder . Ideally, you want to be supportive and compassionate, without assuming you know how they’re feeling.

Here are some ways to help a loved one with an eating disorder:

• Be patient: Recovery can be a long process, so you shouldn’t expect massive changes to occur overnight.
• Offer support: Let your loved one know you are there for them, and avoid making judgments when they tell you about their feelings.
• Understand the warning signs of relapse: Ask your loved one’s treatment team how you can monitor for relapse and help intervene if needed.
• Join a support group for loved ones: Many treatment facilities and therapists offer support groups for family members. These groups can help you feel validated and grounded in challenging times.
• Keep taking care of yourself: Try not to lose yourself in your loved one’s treatment or condition. It’s still important to practice self-care and maintain your own well-being, too.
• Set boundaries: Don’t enable problematic behavior. Consider seeking therapy to establish and set reasonable boundaries with your loved one.

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In My Experience

Frequently asked questions, is bulimia or anorexia more common.

Research shows that bulimia is more common than anorexia. Approximately 2-3% of people have bulimia at some point in their lifetime, whereas about 0.5% have anorexia. 8 Eating disorders are more prevalent in women, but men account for about 10% of all eating disorder diagnoses. That said, both bulimia and anorexia are less common than binge eating disorder and other specified feeding or eating disorders (OSFED).

When is the typical age of onset for bulimia vs anorexia?

The average age of onset for anorexia peaks at 14 and then again at 18 years of age. The prevalence of bulimia tends to be slightly later (later adolescence to early adulthood). However, in recent years, there have been younger onsets for both conditions, with some eating disorders being diagnosed as early as elementary school. 9

Best Online Therapy Services

There are a number of factors to consider when trying to determine which online therapy platform is going to be the best fit for you. It’s important to be mindful of what each platform costs, the services they provide you with, their providers’ training and level of expertise, and several other important criteria.

Eating Disorders: Types, Treatments & How To Get Help

If you or a loved one are dealing with an eating disorder, know you’re not alone. Treatment can significantly help improve thought patterns and symptoms that can contribute to eating disorders, and having a robust care team can be an effective prevention strategy long-term.

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Brain networks in eating disorders: a systematic review of graph theory studies

• Open access
• Published: 23 March 2021
• Volume 27 , pages 69–83, ( 2022 )

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• Enrico Collantoni   ORCID: orcid.org/0000-0002-6730-1778 1   na1 ,
• Francesco Alberti   ORCID: orcid.org/0000-0001-5732-8224 1   na1 ,
• Valentina Meregalli   ORCID: orcid.org/0000-0003-0016-1237 1 ,
• Paolo Meneguzzo   ORCID: orcid.org/0000-0003-3323-6071 1 ,
• Elena Tenconi   ORCID: orcid.org/0000-0003-1629-9871 1 , 2 &
• Angela Favaro   ORCID: orcid.org/0000-0002-6540-5194 1 , 2  

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Recent evidence from neuroimaging research has shown that eating disorders (EDs) are characterized by alterations in interconnected neural systems, whose characteristics can be usefully described by connectomics tools. The present paper aimed to review the neuroimaging literature in EDs employing connectomic tools, and, specifically, graph theory analysis.

A systematic review of the literature was conducted to identify studies employing graph theory analysis on patients with eating disorders published before the 22nd of June 2020.

Twelve studies were included in the systematic review. Ten of them address anorexia nervosa (AN) (AN = 199; acute AN = 85, weight recovered AN with acute diagnosis = 24; fully recovered AN = 90). The remaining two articles address patients with bulimia nervosa (BN) (BN = 48). Global and regional unbalance in segregation and integration properties were described in both disorders.

The literature concerning the use of connectomics tools in EDs evidenced the presence of alterations in the topological characteristics of brain networks at a global and at a regional level. Changes in local characteristics involve areas that have been demonstrated to be crucial in the neurobiology and pathophysiology of EDs. Regional imbalances in network properties seem to reflect on global patterns.

Level of evidence

Level I, systematic review.

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Introduction

Eating disorders (EDs) are severe psychiatric conditions characterized by complex cognitive, psychopathological, and neurobiological underpinnings [ 1 , 2 ]. In recent years, many efforts have been made to describe the neurobiological correlates of these disorders through functional and structural neuroimaging. As comprehensively described in recent reviews [ 3 , 4 ], neuroimaging research in EDs indicates that their neural correlates could be better described as alterations in spatially distributed and interconnected neural systems rather than dysfunctions in single and spatially isolated areas. This evidence is consistent with the general observation that structural and functional brain alterations in psychiatric disorders can be better explained based on their covariance patterns rather than in terms of their localization [ 5 ]. A powerful tool to describe the organization of brain networks based on their covariance patterns has recently been offered by connectomic approaches, which evaluate the brain as a complex network and its alterations as modifications in the properties that govern its global or regional architecture [ 6 ]. One of the main advantages of using connectomics tools to evaluate brain structure and function is that they allow evaluating brain regions not as discrete and isolated elements but as components that interact with each other based on the topological characteristics of their connections.

The mathematical tool most commonly used in connectomics to describe the topological characteristics of brain areas within the brain is graph theory, a branch of mathematics that evaluates the properties and the interrelations between nodes and the edges connecting them [ 7 ]. Considering brain areas as nodes and their interrelations (functional or structural) as edges, graph theory can describe their topological properties employing different parameters, which can be divided according to their integration, segregation, or centrality characteristics. A correct balance between the integration and segregation properties of a network guarantees to properly couple its wiring cost with the ability to ensure communication between topologically distant areas [ 8 ]. The trade-off between integration and segregation characteristics of a network is summarized by the Small-World Index (SWI), which describes the position that a network occupies between in the continuum between regular and irregular systems [ 9 ]. Another key characteristic of the brain network is given by those nodes that are highly connected within the network, thus strongly contributing to its global structure and function, and that are generally referred to as network hubs [ 10 ]. The high connectivity of hub regions accounts for their elevated metabolic cost, which is supposed to be superior to one of more peripheric areas. However, the centrality of hubs is also hypothesized to account for a higher vulnerability to brain damages since dysfunctions in any brain region is more likely to spread through more connected nodes. Therefore, it is likely that brain disorders that implies high metabolic consequences like eating disorders could strongly impact on hubs configuration.

The segregation, integration, and centrality characteristics of a network are not stable during development and change profoundly according to the needs imposed by the different maturation phases and by the progressive recruitment of higher cognitive functions. Also, their balance varies profoundly due to the onset and progression of brain disorders, which often affects structures that require a higher functional cost, such as hubs. Eating disorders are of particular interest from this point of view since they generally emerge during adolescence or early adulthood, and are also often characterized by dramatic metabolic consequences [ 11 ]. For this reason, any alterations in the topological characteristics of the brain in these disorders must be carefully evaluated, as they can be explained both by changes that occur during neurodevelopmental trajectories and as consequences of the disorder progression. The use of multimodal imaging techniques can help in disentangling this complexity since alterations in different structural or functional indices can have different stability during developmental phases and a different sensitivity to environmental influences [ 12 ]. Moreover, longitudinal evaluation, the assessment of patients at different stages of the disorder (i.e., during acute phases or after recovery), as well as the estimation of graph properties alterations during severe and rapid weight loss, can be particularly useful for understanding how the properties that govern the network architecture vary over time and in different phases of the illness [ 13 ].

Alongside the possibility of evaluating the topological characteristics of the brain network, graph theory tools allow evaluating the strength of connectivity between nodes in case–control comparisons, through a network-based-statistics connectome approach [ 14 ]. Therefore, this approach does not measure the segregation or integration characteristics of a network but aims at identifying, in a between-group comparison, the presence of altered connectivity in subnetworks of two or more regions.

Overall, connectomics tools have been widely used in various psychiatric and neurological disorders and in eating disorders as well, allowing for deepening their neurobiological underpinnings. Therefore, in the present review, we are aimed at highlighting recent findings reported in MRI-based connectomic studies of eating disorders, which employed graph theory tools.

Literature search

A systematic review was performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement [ 15 ]. A literature search was conducted on the 22nd of June 2020 on two online digital archives, PubMed and SCOPUS, to identify fitting papers published from inception up to June 2020.

The following search key was used: “graph” AND (“anorexia nervosa” OR “bulimia nervosa” OR “eating disorders”). The reference lists of relevant articles were examined as well in order to identify further papers of interest.

Study selection

After the literature search, two authors (FA and EC) independently screened the title/abstract studies' list and then proceeded with a full-text assessment of the remaining papers.

Ultimately, in the review were only included peer-reviewed studies that respected the following inclusion criteria: (i) including patients diagnosed with EDs according to DSM-IV or DSM-5 criteria; (ii) including a control group of healthy participants; (iii) performing graph analysis on neuroimaging data. Previous reviews and meta-analyses were read in full text to identify further studies. Only studies written in English were considered.

A third author (VM) was called upon to solve any conflict that emerged in the study selection process.

Data extraction and quality assessment

During the full-text assessment, the following information was extracted into a standardized Excel sheet: (i) study population characteristics (e.g., sample size, demographics, diagnostic criteria and subtype of ED, and number of medicated participants); (ii) neuroimaging methods and additional measures (e.g., BMI, neuropsychological tests administered, and cognitive tasks performed); (iii) graph analysis characteristics (e.g., type of data used, main features of the graphs, and kinds analyses performed); (iv) main results of the analyses.

The methodological quality of the studies was assessed using the protocol proposed by Olivo et al. [ 16 ], derived from the guidelines for reliable neuroimaging research in EDs outlined by Frank et al. [ 17 ]. The protocol includes 31 items divided in 6 categories (for full list see Olivo et al. [ 16 ]): (i) development, demographic data, and illness state; (ii) effects of exercise, hydration status, binge eating and purging, and malnutrition; (iii) stage of treatment; (iv) hormonal effects; (v) comorbidity and medication; (vi) technical and statistical considerations, and study design. Items concerning longitudinal assessments (i.e., #6) and hormonal measures (i.e., #21 and #22) were excluded as they were not applicable to any of the included studies. Additionally, item #28, concerning stimuli selection for task-based fMRI, was also excluded as it was applicable to only one study. The papers were evaluated by assigning them a score between 0 and 1 for each of the remaining 27 items and multiplying it by an index of the importance of the item [ 13 ]: essential (3); strongly desirable (2); desirable (1). The sum of the obtained values represented the QA score of the publication, which is comprised between 0 and 68.5.

As summarized in Fig.  1 , the database search produced 37 results (after discarding doubles), and two articles were identified through other sources [ 18 ]. Out of these studies, 26 were excluded based on title or abstract as they either did not include an experimental group of ED patients (acute or recovered) or did not apply graph theory analyses to neuroimaging data. After the full-text examination of the studies, one more was excluded since it did not respect all inclusion criteria, while the remaining 12 were included in the systematic review. Ten of them address AN, counting 199 patients overall: 85 with acute diagnosis (AN-a), 24 weight-recovered with acute diagnosis (AN-wr), and 90 fully recovered (AN-r). The remaining two articles, instead, address Bulimia Nervosa (BN) and are based on a single sample of 48 patients with acute diagnosis (BN-a). Tables 1 and 2 summarize, respectively, the main demographic information of the participants, and the core methodological characteristics and results of all the included studies.

PRISMA flow diagram

Functional connectivity graph analysis on acute patients with AN

Most studies including AN-a participants (i.e., five) analyzed resting-state functional connectivity (FC) graphs [ 19 , 20 , 21 , 22 , 23 ]. In three instances, global topological features resulted altered. Two of these studies [ 21 , 23 ] have found higher characteristic path length (CPL) and assortativity in AN-a compared to healthy controls (HC). Among these, a study by Lord and colleagues (2016) also proved such difference in assortativity values to be consistent across two different parcellation atlases: AAL and Dosenbach [ 23 ]. A third paper [ 19 ], instead, has found a lower clustering coefficient (CC) in the AN-a group and a different hub nodes distribution between patients and controls. From this study emerged that, based on betweenness centrality, the anterior cingulate cortex (ACC) represented a hub only in AN-a and the superior frontal gyrus only in HC. Referring to degree centrality, instead, ACC and middle frontal gyrus (MFG) displayed higher values in AN-a, while left transverse frontopolar gyrus and right posterior-lateral sulcus were hubs only in HC. Additionally, the authors also compared AN-a participants based on the 5-HTTLPR polymorphisms and found that, while in HC the short variant of this gene was associated with higher modularity, in AN-a it correlated with lower SWI and modularity [ 19 ].

Furthermore, nodal topological features of AN-a graphs, instead, were altered in three studies [ 21 , 22 , 23 ]. The first study [ 21 ] found: lower CPL, strength, and degree in the insula (left middle and right posterior); lower CPL and strength in the thalamus; increased normalized local efficiency (LEGE) in the posterior occipital cortex; and increased local efficiency (LE) in the right anterior prefrontal cortex (PFC). The second study [ 22 ], instead, assessed only degree centrality, which was significantly reduced in AN-a patients in the inferior frontal gyrus (IFG). In the last study [ 23 ], Lord and colleagues (2016) reported that a consistent alteration of path length and LEGE across the two tested parcellations, albeit affecting different nodes based on the atlas (see Table 2 ). Only the path length of the right precentral gyrus was altered in both graphs.

Moreover, two studies performed a network-based analysis (NBS) of FC graphs. The first is the already-mentioned study by Lord and colleagues, who evidenced the presence of hypoconnectivity networks in AN-a patients using both parcellations [ 23 ]. These networks overlapped in the posterior insula, thalamus, and right fusiform gyrus (FFG) across atlases. The second study, by Ehrlich and collaborators, identified a similar hypoconnectivity network that also encompassed posterior insula, left thalamus, and right FFG together with putamen and left amygdala [ 20 ]. Neither of the articles has found evidence of any hyperconnectivity network in AN-a.

Structural connectivity graph analysis on acute patients with AN

Among the studies on patients with acute AN, three used structure-based graphs. The first [ 24 ] built separate graphs based on two morphological measures: cortical thickness (CT) and local gyrification index (LGI). Analyzing the CT graph, AN-a showed lower global efficiency (GE) and higher LE, CC, modularity, and small-world index (SWI). The LGI graph, instead, only displayed increased SWI in AN-a. Moreover, comparing poor- and good-outcome patients, the authors found that based on CT poor outcome was correlated with higher clustering in the left IFG, while the recovery was associated with a higher degree in this same region and, based on LGI, with higher CC and insular NPL. The remaining two studies, instead, built structural connectivity graphs based on DTI. Both are based on AN-wr patients and include a group of acute body dysmorphic disorder patients (BDD-a). One of the two [ 25 ] has found a significantly higher NPL in AN-wr than in both BDD-a and HC participants. Additionally, among other modularity metrics (see Table 2 ), the authors performed a path-length-associated community estimation (PLACE) and identified a module of nodes that varied significantly between patients and controls. In HC, this community comprised the right caudate, right accumbens, right ACC, right posterior cingulate, and right pallidum, while in AN-wr it included the right caudate, right accumbens, right rostral ACC, right medial and lateral OFC, and right frontal pole (the BDD-a module shared some elements with each of other groups, see Table 2 for details). Based on these results, the second study [ 26 ] implemented a two-step machine learning model using DTI-based NPL as a feature in conjunction with other measures (i.e. task-related FC, anxiety, depression, and insight). The model successfully discriminated AN-wr and BDD-a from HC first (89.0% accuracy), and then AN-wr from BDD-a (74.0% accuracy) with a significant association between higher NPL and anorexic participants (and between poorer insight and BDD-a).

Functional connectivity graph analysis on recovered AN patients

Of the three studies on patients that fully recovered from AN, two analyzed resting-state FC graphs and performed an NBS analysis. However, while one identified a hypoconnectivity network in AN-r that included rostral ACC, right superior occipital cortex, left paracentral lobule, left posterior insula, left medial OFC, and left lobule X of the cerebellum [ 27 ], the other did not find any altered network in AN-r [ 28 ]. The second study, however, analyzed topological graph metrics as well and has found higher assortativity and lower SWI and CC in AN-r. The Authors also implemented a machine learning model that was able to classify AN-r and HC participants with 70.4% accuracy using as features the nodal graph metrics [ 28 ].

Structural connectivity graph analysis on recovered AN patients

Only one study based on structural imaging included an AN-r group [ 19 ] which, however, did not find any evidence of topological differences between recovered patients and healthy participants neither in the CT nor in the LGI graphs. Nonetheless, this result might have been conditioned by the small numerosity of the AN-r group included by the study which may have affected the power of the analyses run on this sample.

Functional connectivity graph analysis on acute patients with BN

So far, only one study [ 29 ] has applied graph analysis to resting-state FC in BN-a patients, and its Authors found overall higher clustering and path length in BN-a and altered nodal strength in several vertices. Indeed, higher strength was found in the precuneus and in multiple nodes belonging to the primary sensorimotor and visual association cortices. Medial regions of the OFC and temporal lobe together with the insula and several subcortical structures, inversely, showed reduced strength in bulimic participants. Furthermore, from NBS analyses emerged a hyperconnectivity network encompassing the primary sensorimotor, unimodal association and polymodal association systems, and a hypoconnectivity network comprising limbic and paralimbic cortices as well as various subcortical regions.

Structural connectivity graph analysis on acute patients with BN

The only other study found in literature addressing BN [ 30 ], instead, applied graph analysis to DTI data finding an asymmetric alteration of nodal metrics in bulimic patients compared to controls. A large array of left lateralized regions belonging to the mesocorticolimbic reward system, lateral Occipito-temporal cortex, and precuneus showed higher strength, betweenness, and LE. On the contrary, right-sided nodes of the mesocorticolimbic system, somatosensory, and visuospatial networks displayed reduced GE and betweenness. Additionally, NBS analyses identified: a hyperconnectivity network within the reward circuitry with a (largely involving the OFC) and between OF and occipitotemporal regions. Hypoconnectivity, instead, was found between the IFG and the lateral temporal cortex.

From the present review emerged that connectomic research in eating disorders is somewhat limited and employs a heterogeneous array of methodological approaches, making it difficult to draw direct comparisons or give a univocal interpretation of the results. Nonetheless, certain findings show noteworthy patterns.

Most papers examined brain networks of patients with AN, both acute and recovered. Overall, the studies report fairly consistent results in the resting state and DTI networks, which diverge instead from cortical structure ones, probably reflecting different disorder-related consequences on these systems. On a global level, AN seems associated with a longer path length: the increased CPL found in FC graphs of acutely underweight patients [ 21 , 23 ] is mirrored by the increased NPL found in DTI graphs of weight recovered ones [ 25 ]. An increased path length indicates a less efficient transfer of information across the network [ 31 ], which is believed to affect integration processes [ 32 ]. The presence of reduced efficiency in brain network architecture in patients with acute AN is also supported by the evidence of a reduced clustering coefficient [ 19 , 28 ]. In fact, lower clusterization, paired with higher path length, could bolster a more random and less small-world like network organization. Nevertheless, it should be evidenced that no study to date found reduced SWI in patients with acute AN. Overall, these findings help explain the higher assortativity observed in patients with AN [ 21 , 23 ], which represents the increased nodes’ tendency to link with other nodes of a similar degree. Higher assortativity is generally a cost-efficient feature as the network is more likely to use a limited core of high-degree interconnected nodes acting as connector hubs [ 33 ] while other nodes link in specialized clusters. However, since a low clustering indicates a reduction of short-range connections, it could be speculated that the assortativity index is brought up by a decrease of low- to high-degree (or cluster to hub) links, as suggested by the increased path length and the altered hub distribution of individuals with AN [ 19 ].

This view is somewhat in line with the finding of decreased CPL, degree, and strength in the thalamus and posterior insula [ 21 , 23 ], as these areas are, respectively, a core sensory relay station and a region with high centrality values in the healthy brain [ 10 ]. Both these regions are also part of the hypoconnectivity networks detected in functional connectivity graphs of AN [ 20 , 23 ], further suggesting a disruption of the integrity of the thalamo-insular subnetwork, which was proposed to be fundamental for the internal representation of the physiological body state [ 34 ]. Moreover, the reduced integration characteristics of these two areas, which are fundamental in conveying ascending information to the rest of the cortex, could support the already proposed presence of an imbalance between top-down and bottom-up stimuli representations in the pathophysiology of AN [ 35 , 36 ].

This network disruption might be a consequence of energetic and metabolic imbalances caused by malnutrition. Nonetheless, structural NPL is high in weight-recovered patients [ 25 ], and the increase of CC and assortativity [ 19 , 28 ] persists in recovered participants, who also display reduced small-worldness. Therefore, such alterations could also be trait markers of AN or scars that persist after recovery. Longitudinal observations are needed to clarify this point.

Interestingly, the morphological graph analyses yielded partially opposite results, with acute patients displaying an increased small worldness in both CT- and LGI-based networks [ 24 ]. Moreover, CT graphs display high CC, modularity, and LE that indicate a higher level of segregation among clusters, which is probably what makes the network more small-world-like, thus theoretically more efficient. However, the decrease in GE is also a sign that the cost-efficiency of routing between distant structures is reduced at the expense of integration.

Concerning these results, however, it is important to note that although a correspondence has been established between structural covariance networks and functional/structural connectivity networks in healthy individuals [ 37 , 38 ], this notion might not hold true in acute AN due to the impact of malnourishment and dehydration on brain morphology [ 1 ]. The observed alterations in structural covariance networks may be dictated, at least partly, by transient reductions in cortical thickness and complexity rather than by connectivity alterations [ 39 ]. Reductions in thickness and gyrification indexes often emerge soon in acute AN [ 40 , 41 , 42 ] and rapidly recover with weight restoration [ 43 , 44 ]; therefore, they are unlikely to reflect changes in structural–functional connectivity. Taken together, these observations support the importance of multimodal imaging analysis on the study of brain alterations in AN, to deepen the neurobiological effects of different pathogenic mechanisms. For example, it is likely that cortical structures are more influenced by the acute effects of malnutrition, while functional and white matter connectivity patterns are more affected by other processes.

As for studies on BN, the topological characteristics of functional and structural graphs tend to diverge as many regions that had reduced strength in the first had increased strength in the second [ 29 , 30 ]. Moreover, the finding of increased CC and CPL of FC graphs was not replicated based on DTI. Results of NBS analyses vary greatly between graph types. Many of the same limbic and paralimbic regions participating in the mesocorticolimbic reward system appeared to be hypoconnected in functional networks and hyperconnected in structural ones. Additionally, the extremely limited number of studies and the fact that they all analyzed the same sample of participants make these results even harder to interpret and generalize. Thus, the relationship between the structural and functional alterations in the brain networks of BN patients is still unclear and needs further investigation.

In conclusion, the present review shows that the literature concerning the use of graph theory in the neuroimaging research of EDs is still in its infancy. Given the potentialities that these research techniques have in addressing important issues in eating disorders research, further studies that can overcome the limits imposed by low sample sizes and by the absence of longitudinal analysis are needed.

Overall, connectomic studies in EDs evidenced the presence of an imbalance between segregation and integration properties in functional and in structural networks. These alterations, detected in brain areas that showed to be crucial in AN and BN neurobiology, are likely to reflect on global patterns. Longitudinal observations are needed to better characterize the state or trait nature of topological brain alterations, and their progression in different stages of the disorder. In this regard, the possibility of recruiting experimental samples that are homogeneous in the age of onset and in illness duration could be particularly useful. Moreover, given the paucity of data on patients with BN, further evidence on this disorder should be provided.

The main limitation of the present review is the lack of homogeneity in the designs and methods of the included studies, which conducted graph theory analyses applying different methodologies for constructing and analyzing brain networks and using a heterogeneous array of topological descriptors that cannot be directly compared. These issues (partly inherent to the novelty of the methods) prevent the possibility of conducting a meta-analysis of these data. The strengths of this study lie in the fact that it provides the first systematic overview of connectomic neuroimaging analyses in EDs. Moreover, it allows identifying both points of interest and critical issues of applying these tools to date, thus helping to direct future research. Specifically, a systematic overview of the designs and analyses present in the literature could help foster the homogeneity in the employed methodologies that is now lacking, impairing proper comparability of the results.

What is already known about this topic?

The application of graph theory tools to the analysis of both structural and functional neuroimaging data in EDs is still at its infancy, but it has proven to have great potential for describing network-wise unbalances in the architecture of regional interrelations. At present, the results of connectomic analysis in EDs evidenced the presence of alterations in integration and segregation properties of the brain that take different directions based on imaging modalities (surface-based cortical analysis, DTI, fMRI) and to the stability of covariance networks to specific pathophysiological mechanisms.

What this study adds

This study highlights the importance of investigating the rules that govern the relationships between different brain structures in EDs using a connectomics approach. These tools have displayed relevant cross-methodological patterns of alterations but need more systematic investigation. Moreover, the review underlines the importance of implementing these kinds of analyses with multimodal imaging protocols and longitudinal designs.

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Enrico Collantoni, Francesco Alberti, Valentina Meregalli, Paolo Meneguzzo, Elena Tenconi & Angela Favaro

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Collantoni, E., Alberti, F., Meregalli, V. et al. Brain networks in eating disorders: a systematic review of graph theory studies. Eat Weight Disord 27 , 69–83 (2022). https://doi.org/10.1007/s40519-021-01172-x

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Anorexia vs. Bulimia

Anorexia nervosa and bulimia nervosa are the most common clinically recognized eating disorders . Those with anorexia have a tendency to skip meals, adopt highly restrictive and unhealthy diets, obsess over thinness and food, and present abnormal eating habits or rituals. Bulimia presents itself in the form of binging, or overeating, followed by purging, often either by vomiting or using laxatives. It is possible for a person to suffer from both disorders, simultaneously; one may also suffer from body dysmorphia and see herself as being "fat," even when extremely underweight. There is no clear cure for either disorder, both of which primarily affect young women, but treatment is available and can result in full recovery for some. Ongoing treatment efforts and awareness are necessary to maintain health.

Comparison chart

Signs and Symptoms

In many cases, the behavioral, psychological, and physical characteristics of anorexia are more obvious to outsiders than the characteristics of bulimia, which are often subtle. However, it is common for there to be overlapping symptoms between the two disorders.

Behavioral and Psychological Characteristics

Anorexia and bulimia share numerous psychological symptoms:

• Low self-esteem
• Obsession with food, weight, and a "thin" body image
• Fear of weight gain
• Compulsive exercise
• Tendency to use the bathroom directly after eating
• Symptoms of depression and/or anxiety
• Substance abuse
• Body dysmorphic disorder (BDD) , which affects one's ability to see the body as it truly appears; often causes one to think she is "fat" and/or oddly-shaped.

Symptoms for anorexia and bulimia differ in terms of how those with these conditions relate to food and what ritualistic behaviors they exhibit.

• Relationship to food: People with anorexia usually avoid eating, go on restrictive diets or lengthy and frequent fasts, and hesitate or delay eating even small portions of food, while people with bulimia go through periods of binge eating and periods of purging. In other words, an outsider may see evidence of excessive eating habits in the case of bulimia — e.g., buying lots of food and eating it in a very short time — but evidence of undereating in the case of anorexia — e.g., buying little food, and then not even eating that small amount. Those with bulimia are more likely to employ the frequent use of diet pills, diuretics, laxatives, and/or enemas to lose weight, but anorexia sufferers may purge in this way as well.
• Ritualistic behaviors: Except in cases where a person suffers from both disorders, someone with anorexia alone will not binge eat at all and will not necessarily go through the excessive purging stages that a person with bulimia will. In anorexia, a person tries to avoid food altogether. This usually results in a number of odd and strict rules about when, where, what, and how to eat, with many hiding their dietary habits from others and avoiding eating altogether. A common behavior seen in those with anorexia is the tendency to move food around on a plate, or cut it into small pieces, without ever actually eating. Those with bulimia will often exhibit near-normal dietary habits, but will use the bathroom directly after eating (often to force vomiting).
• It is common for those with bulimia or anorexia to be unwilling to admit they have a health condition . This can even blossom into support for anorexic or bulimic behavioral traits, as is sometimes seen in " pro-ana " communities, where there is "thinspiration" (idolizing thin, skinny, and unweight bodies) and anorexia is personified ("Ana").

Physical Characteristics

When it comes to those who suffer from one, rather than both, of these illnesses, there are markedly different associated physical characteristics.

• There is some correlation with age (though not causation). Bulimia tends to develop in older teens and young adults, whereas anorexia is generally seen in younger teens who are going through puberty. However, these are just the most common age groups affected and diagnosed; both eating disorders can occur at any age or stage of life.
• Anorexia, more than bulimia, is likely to result in an extremely underweight and unhealthy figure , but a low body weight is possible in both conditions. Bulimia is most often associated with a normal a weight, but this does not mean the disorder is less serious overall.
• While physical weakness, deterioration, and organ dysfunction are usually worse in cases where lots of weight has been lost, a number of negative physical symptoms arise, regardless of weight, due to the unhealthy habits associated with these eating disorders. In both conditions, anemia, dehydration, low blood pressure, muscle fatigue, irregular heartbeat, vitamin and mineral deficiencies, kidney problems (e.g., stones or even failure), gastrointestinal pain and/or bowel irregularity, hormonal disruption (e.g., amenorrhea , or absent periods) and reproductive problems (e.g., miscarriage), and skin conditions are all common symptoms. In anorexia, there is also hair thinning or loss, and in bulimia there are a number of oral and dental indicators related to vomiting (e.g., cavities and tooth enamel loss due to frequent exposure to stomach acid).
• Bulimia and anorexia also negatively affect brain and nervous system health , particularly in cases where an extreme amount of weight has been lost. Weight loss can exacerbate the depressive and anxious feelings that are often associated with these disorders. Experiencing memory loss, going through mood swings, and feeling faint are all common physical symptoms.

What Causes Eating Disorders?

Doctors do not yet know what causes eating disorders. However, anorexia and bulimia have known associated risk factors.

• Culture may play a significant role in the development of eating disorders, which seem to be more common in nations where media and advertising focus on beauty, "perfection," and even weight loss — usually to target a wholly different demographic: those who are obese .
• Families are an important factor in anorexia and bulimia. Many who struggle with anorexia or bulimia had a parent who also struggled with the disorder(s), or they had a parent who placed a high priority on physical beauty or criticized their physical appearance when they were younger.
• Stressful events , particularly when coupled with a "high-strung" or perfectionist personality in someone with low self-esteem , can lead to the development of eating disorders. The stress of puberty and growing up seem to be common factors in anorexia and bulimia.
• Biology , including genes and one's chemical and bacterial makeup, may ultimately be the biggest factor, but research is ongoing. In 2014, researchers discovered an bacterial protein in the intestines which can trigger or inhibit a feeling of fullness in the brain. [1] Learning how to target this protein and manage its activity may open the door to medications that can treat anorexia and bulimia.

As weight loss is common to numerous other illnesses, diagnosing anorexia and bulimia can be difficult in some cases. For this reason, doctors will often need to thoroughly examine patients and run a series of blood tests to properly diagnose these disorders and figure out a course of treatment.

Diagnosing anorexia in cases of extreme weight loss is easier than in cases where only slight weight loss has occurred. Bulimia is easier to diagnose due to the obvious oral/dental symptoms associated with the disorder.

Treating Anorexia and Bulimia

Due to bulimia being associated with average body weight, it is rare for this disorder to call for hospitalization. Anorexia, however, frequently lands sufferers in the hospital over time, as organs are prone to malfunction or fail as one loses abnormal amounts of weight.

Treating bulimia and anorexia can be difficult and, in some cases, impossible, and it appears that the age of onset and diagnosis is important. [2] Many who have an eating disorder will not acknowledge and admit that they have an eating disorder. This makes anorexia and bulimia difficult not only for those suffering from the disorder, but also for their friends and family.

In cases where a person is open to receiving treatment, there is hope to be found in a variety of outpatient and inpatient care facilities. Treatment teams consist of dietitians, doctors and psychotherapists who specialize in eating disorders, and occasionally psychiatrists who may prescribe antidepressants or anti-anxiety medications .

Cognitive-behavioral therapy is a popular method of therapy for treating these disorders, as changing how one thinks about weight and food is a primary goal. Treatment tends to also include more healthful coping mechanisms for handling stress and triggering subjects.

Long-Term Outcomes

The long-term prognosis for both disorders varies. While the majority of those who have sought treatment report moderate to complete recovery a number of years later, a significant minority (~10-30%) still struggle with symptoms and even relapses. Among those who struggle the most, suicide is common. [3]

Anorexia is harder to treat than bulimia. Roughly 20% of those who diagnosed with anorexia are dependent on social services. [4] Worse, it is a very deadly disease, with one of the highest mortality rates among mental disorders. In a 21-year follow-up study , nearly 16% of the study's participants "died from causes related to anorexia nervosa."

While both eating disorders can affect both sexes and all ages and races, they are more commonly diagnosed in young Caucasian women. At least one study has suggested racial differences have had more to do with racial prejudices affecting diagnosis, but further research is required.

90-95% of all those first diagnosed with anorexia or bulimia are young women between the ages of 15 and 24. Bulimia, affecting around 1% of young women in the U.S., is more common than anorexia, which affects 0.3%. [5]

Body dysmorphic disorder, which is sometimes coupled with one or both of these disorders, is nearly as common in men (2.2%) as it is in women (2.5%). [6]

• Anorexia nervosa fact sheet - WomensHealth.gov
• Anorexia/bulimia: bacterial protein implicated - ScienceDaily
• Body dysmorphic disorder - NIH.gov
• Bulimia nervosa - NIH.gov
• Bulimia nervosa fact sheet - WomensHealth.gov
• Epidemiology of Eating Disorders: Incidence, Prevalence and Mortality Rates - NIH.gov
• Wikipedia: Eating disorder
• Wikipedia: Anorexia nervosa
• Wikipedia: Bulimia nervosa

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Comments: Anorexia Nervosa vs Bulimia Nervosa

Anonymous comments (4).

December 29, 2013, 1:39pm Good article. Very informative. — 75.✗.✗.7

March 14, 2013, 1:41pm Why are there so few references to Black Americans and struggles with Anorexia and/or Bulimia. At 42 I struggled most of my teen years with anorexia and was hospitalized for it, at 40 I crashed after my daughters went to college and the old problem reared its head along with all of the issues that made it appear in the beginning which had nothing to do with wanting to be thin, but invisible because of human trafficking that was and continues to be ignored in my community. Isolation leads to survival and a lack of understanding leads to exorcism where everyone thinks you have demons. Therapists are fine but awed with all of the personal accomplishments that mask the pain. I can only revert back to what helped as a child. — 198.✗.✗.241

October 25, 2012, 11:20am It's devastating that our society today goes through these psychological disorders. Being thin is definitely not a sign of attractiveness. Please don't let these gruesome diseases rule your life. — 101.✗.✗.108

March 12, 2013, 8:44pm Sure, as a guy, I find smaller/thinner girls more physically attractive. But that by no means I prefer them. Just one of those things in life that'd be kinda nice. Compared to personality, physical appearance doesn't matter much. So it's not really that big a deal to me. If you think that you have to wreck your body to be attractive, then you don't understand one of the most simple facts in life; the vast majority of guys don't really care. — 71.✗.✗.171

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The Outcome of Bulimia Nervosa: Findings From One-Quarter Century of Research

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• Open access
• Published: 18 July 2024

Parent version of the Eating Disorder Examination: Reliability and validity in a treatment-seeking sample

• Lisa Hail 1 ,
• Catherine R. Drury 1 , 2 ,
• Robert E. McGrath 2 ,
• Stuart B. Murray 3 ,
• Elizabeth K. Hughes 4 , 5 ,
• Susan M. Sawyer 5 ,
• Daniel Le Grange 1 , 6 &
• Katharine L. Loeb 2 , 7  

Journal of Eating Disorders volume  12 , Article number:  101 ( 2024 ) Cite this article

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Metrics details

Assessment of eating disorders (ED) in youth relies heavily on self-report, yet persistent lack of recognition of the presence and/or seriousness of symptoms can be intrinsic to ED. This study examines the psychometric properties of a semi-structured interview, the parent version of the Eating Disorder Examination (PEDE), developed to systematically assess caregiver report of symptoms.

A multi-site, clinical sample of youth ( N  = 522; age range: 12 to 18 years) seeking treatment for anorexia nervosa (AN) and subsyndromal AN were assessed using the Eating Disorder Examination (EDE) for youth and the PEDE for collateral caregiver report.

Internal consistencies of the four PEDE subscales were on par with established ranges for the EDE. Significant medium-sized correlations and poor to moderate levels of agreement were found between the corresponding subscales on each measure. For the PEDE, confirmatory factor analysis of the EDE four-factor model provided a poor fit; an exploratory factor analysis indicated that a 3-factor model better fits the PEDE.

Conclusions

Findings suggest that the PEDE has psychometric properties on par with the original EDE. The addition of the caregiver perspective may provide incremental information that can aid in the assessment of AN in youth. Future research is warranted to establish psychometric properties of the PEDE in broader transdiagnostic ED samples.

Plain English summary

Assessments for eating disorders rely primarily on self-report; yet, the denial of symptoms or symptom severity among adolescents with anorexia nervosa can complicate assessment and delay treatment in this population. The Parent Eating Disorder Examination (PEDE) is the first semi-structured interview formally developed to improve childhood eating disorder assessment by including caregiver perspectives. In this study, a large sample of adolescents with anorexia nervosa completed a self-report interview (the Eating Disorder Examination or EDE) and their parents completed the PEDE. The PEDE appeared to measure parents’ report of their child’s eating disorder symptoms consistently. Results from both interviews were related to one another but did not completely agree. This suggests that in an eating disorder assessment, the PEDE can provide additional information from caregivers that might reduce diagnostic confusion and lead to earlier intervention for youth with anorexia nervosa.

With the publication of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders ( DSM-5 ) [ 1 ], the criteria for diagnosing eating disorders (ED) were revised to reflect greater developmental sensitivity for youth. These modifications were particularly important as the onset of ED is most common in adolescence [ 2 ]. However, there remain many challenges to diagnosing restrictive ED, such as anorexia nervosa (AN), in children and adolescents, which could delay treatment of a pernicious, often refractory disorder.

One of the most significant challenges in relying on self-report in ED assessment and case identification is the persistent lack of recognition of the seriousness of symptoms, a core diagnostic feature of AN, which renders history of illness and present symptoms vulnerable to inaccuracies [ 3 , 4 , 5 ]. However, typical assessment methods for ED rely primarily on self-report, and may therefore be insufficient, particularly for younger individuals [ 6 , 7 , 8 , 9 ]. Compared to adults, adolescents generally score lower on measures of ED pathology despite similar levels of malnutrition [ 10 ], and appear to experience ED symptoms differently [ 11 ]. Minimization might be intrinsic to a developmentally normative limitation in recognizing the potential consequences of risky behaviors such as those associated with ED [ 5 , 10 , 12 , 13 ]. Shorter duration of illness could compound this, further limiting adolescents’ appreciation of the current and future impact of what could in fact become a severe and enduring disorder [ 14 , 15 ]. Relatedly, adolescents are unlikely to independently seek help for their ED, and may even engage in strategic minimization of symptoms, to avoid the implications of symptom endorsement (e.g., intervention efforts on the part of adults).

In addition, there are cognitive and emotional obstacles to evaluating symptoms of AN in youth, as several of the criteria are psychological in nature. For example, the ability to report a fear of weight gain requires that the young person be able to recognize and label their affective state correctly, and to identify the motivation behind their behavior [ 15 , 16 ]. Other criteria are more abstract in nature (e.g., disturbance in the experience of shape and weight, undue influence of shape and weight on self-evaluation), and require the developmental maturation of abstract reasoning to recognize and endorse ED symptoms [ 2 , 17 , 18 , 19 ].

The utility of multi-informant methods of assessing child psychopathology is long-established, and approaches have advanced over time [ 6 , 20 , 21 ]. However, most measures used for youth with ED – with notable exceptions [ 3 ] – rely exclusively on direct patient report [ 7 ] despite the unique risks posed by false negatives in case identification, particularly of AN. Two studies have examined parent-child concordance on the Eating Disorder Examination (EDE) [ 22 ] by administering the interview to parents with minimal modifications to the measure [ 18 , 23 ]. For example, Couturier and colleagues [ 23 ] simply changed wording of questions from you to your child and retained items reflecting the internal experience of the child without prompting parents for data on why and how these experiences can be inferred through the child’s behavior. They found that youth with AN scored lower than their parents on two EDE subscales (Restraint and Weight Concern), while Mariano and colleagues [ 18 ] found good concordance between youth and parent scores. Mariano and colleagues [ 18 ] proposed that adolescents in their study were less likely to minimize their symptoms due to the timing of EDE administration (i.e., at the end of a two-day psychological assessment). It is also possible that more extensive adaptations to the EDE are needed to assist parents in consistently providing a comprehensive report of symptoms.

To address the need for a standardized method for including parental report in the assessment of ED, we developed a parent version of the EDE (PEDE) [ 7 , 24 , 36 ], with permission and input from the first author of the original measure [ 22 ], that mirrors the EDE but includes detailed questions to assess for observable indicators of ED. Although the EDE can be administered as young as 14 years and has been adapted for use in children aged 8 years and older [ 25 ], these assessments do not incorporate caregiver perspectives. Thus, the overall objective of the current study was to evaluate the psychometric properties of the PEDE in a large, multi-site sample of children and adolescents seeking treatment for AN and subsyndromal AN (SAN). Specifically, we examined the internal consistency of the PEDE subscales and the PEDE’s convergent and construct validity in relation to the EDE. We also aimed to compare PEDE and EDE rates of AN diagnosis. We hypothesized that:

Internal consistency of the four PEDE subscales (Restraint, Eating Concern, Weight Concern, Shape Concern) and global score as measured by Cronbach’s alpha reliability coefficients would be similar to those previously established for the EDE, which found values in the range from .44 to .85 [ 26 ].

Convergent validity would be demonstrated by small, positive correlations and low to moderate levels of agreement between the established EDE subscales and the corresponding subscales on the PEDE. These positive relationships would indicate that the subscales are tapping into similar constructs. The small effect sizes and low to moderate levels of agreement (as opposed to good or excellent) would suggest that both youth and parent perspectives offer incremental information to an ED assessment [ 23 ].

Both the EDE and PEDE would have a different factor structure than the four original subscales presented by Cooper and colleagues [ 27 ] as no studies evaluating factor structure in the EDE have confirmed this model. No specific hypotheses were possible for the expected factor structure given variations in the results of three prior studies [ 28 , 29 , 30 ], only one of which included adolescents [ 28 ].

The PEDE would yield a diagnosis of AN more frequently than the EDE among participants with both AN and SAN.

Participants

Participants were youth and guardian informants who presented to two research-based ED treatment programs in the United States (US; New York and Chicago) and one in Melbourne, Australia. Researchers at these sites received training on the EDE and PEDE, administered both interviews to youth and their caregivers presenting to clinical research centers for treatment of a suspected ED, and contributed deidentified baseline data as part of this multisite collaboration to establish the PEDE’s psychometric properties. Any larger studies [ 31 , 32 ] from which these deidentified data were derived for secondary analyses were approved by the respective institutions’ institutional review boards; the present study was designated exempt from board review.

In order to assess the reliability and validity of the PEDE in a relatively homogenous sample, this study focused specifically on youth presenting to these sites with probable AN or SAN [ 32 ], a site-specific research category that would fall under other specified feeding and eating disorder (OSFED) in DSM-5-TR nomenclature. The original inspiration for developing the PEDE was to help identify true caseness in the context of underweight ED where denial and minimization are prominent and therefore parental report may be most useful [ 23 ]. Thus, submitted cases ( n =  833) were excluded from analysis if one or more of the following were met: (a) percent expected body weight (EBW) based on median body mass index (mBMI) was greater than 100% ( n  = 232, 27.85%), (b) criteria for bulimia nervosa or binge eating disorder might be met by virtue of 12 or greater EDE objective bulimic episodes in the past three months and weight > 85% of EBW ( n  = 0), (c) age was younger than 12 years ( n  = 83, 9.96% of the full sample), or (d) there was insufficient information to accurately determine EBW ( n  = 1). Although low weight is a relative, personalized construct and population norms are not a valid benchmark against which to determine individual-level weight status, these weight criteria were used to reduce the likelihood of false positives and because not all sites recorded a more individualized measure of EBW and all reported percent of mBMI. The resulting sample included 522 youth paired with guardian informants, ranging in age from 12 to 18 years ( M  = 15.4; SD  = 1.7), 89.7% parent- or self-identified as female, who were at 54–99% of mBMI ( M  = 84.3%; SD  = 8.5). Further demographic data (including caregiver gender identity) were not reported consistently across all sites. The majority of participants were recruited from sites in Chicago ( n  = 219; 42.0%) and Melbourne ( n  = 260; 49.8%); 8.2% of participants ( n  = 43) were recruited from the New York-based site. There was a significant difference in PEDE global scores across sites ( F (2,6) = 7.49, p  = .002, η 2  = 0.03), with guardians in New York reporting higher levels of ED pathology than those in Chicago or Melbourne ( p  = .002). EDE global scores did not significantly differ across sites ( p  = .725).

Eating Disorder Examination (EDE) Version 16.0

The EDE [ 22 ] is a semi-structured clinical interview that was originally developed for use with adults but is also used, and has been found psychometrically acceptable, as a diagnostic and predictive tool with younger populations [ 33 , 34 ]. The EDE is comprised of 33 items and uses a 7-point scale to measure the frequency (0 = “absence of the feature”; 6 = “feature present every day”) and severity (0 = “absence of the feature;” 6 = “feature present to an extreme degree”) of ED attitudes and behaviors. Most of the questions capture data from the past 28 days only, with exception of the ten diagnostic items that extend to the previous three months to reflect the time frame evaluated to make the DSM ED diagnoses. The EDE includes four subscales: Restraint (5 items), Eating Concern (5 items), Shape Concern (8 items), and Weight Concern (5 items). The subscales are averaged to give a rating of global severity. Although these subscales have not been supported in a prior factor analysis, they remain widely used in both research and clinical practice [ 18 ].

Parent Eating Disorder Examination (PEDE)

The PEDE version 1.4 [ 24 ] includes items that directly mirror the content and 7-point scoring scheme of the EDE. While the term “parent” is used, this measure is appropriate to use with any adult who is in the primary caretaking role. In the parent version, endorsement or denial (depending on the item) of a stem question triggers additional queries about behavioral observations and indicators of intent that are not present in the patient-directed EDE. Two additional items were added to the PEDE to assess for refusal to maintain a normal body weight and denial of the seriousness of low body weight , diagnostic features of AN that are not explicitly asked in the EDE. The item reaction to prescribed weighing from the EDE Weight Concern subscale was excluded because the item proved confusing when piloted. In total, the PEDE has 41 scored items. A symptom is rated as present if the parent has directly observed the phenomenon; heard the child report it; or heard reports from a reliable third party such as other family members, friends, or school personnel.

The PEDE requires that parents use their best judgment, including all available sources of information, in responding to the items. For example, in assessing fear of weight gain , there is not only an item evaluating verbal expression of this fear but also subsequent items assessing for indications that the young person is refusing attempts to increase their weight “by passive resistance (e.g., refusing to eat) and/or active resistance, such as yelling, throwing a tantrum, throwing food or dishes, running away, threatening to hurt themself if made to eat,” or other means. Other examples include specific questions that evaluate evidence of purging behaviors (e.g., “Have you noticed any vomit residue or odor in the bathroom or on your child’s clothes?; “Has your child rushed to the bathroom during a meal or immediately after eating?”).

The PEDE version 1.4 was developed from the EDE version 16.0 [ 22 ] and contains diagnostic items consistent with DSM-IV-TR [ 35 ] diagnostic criteria. Additionally, the PEDE items that assess for behavioral indicators allow for the evaluation of the revised DSM-5 criteria, including those criteria that are not explicitly assessed by the EDE version 16.0 or 17.0 (i.e., refusal to maintain a normal body weight and denial of the seriousness of low body weight ). The PEDE version 2.0 has since been revised aligning the measure with DSM-5 diagnostic criteria and incorporating gender-neutral language, and is publicly available [ 36 ].

Statistical Analyses

Cronbach’s alpha coefficients were calculated to evaluate the internal consistency of the EDE and PEDE subscales and global scores using IBM SPSS Statistics v.24.0, with values less than .5 considered to be unacceptable, greater than or equal to .5 poor, greater than or equal to .6 questionable, greater than or equal to .7 acceptable, greater than or equal to .8 good, and greater than or equal to .9 excellent [ 37 ].

Convergent validity was assessed through the correlation and level of agreement between the EDE and PEDE subscales. Specifically, bivariate Pearson correlations were calculated using IBM SPSS Statistics v.24.0; as suggested by Cohen [ 38 ], .10 was considered a weak or small correlation, .30 medium, and .50 or larger strong or large. Additionally, the level of agreement between the EDE and PEDE subscales and global scores was measured using a two-way random effects model (absolute agreement, average measures) intraclass correlation coefficient (ICC). In accordance with the 95% confidence interval of the ICC estimate, values less than .50 were considered evidence of poor agreement, between .50 and .75 moderate agreement, between .75 and .90 good agreement, and greater than .90 excellent agreement [ 39 ].

To assess the goodness of fit of the original four-factor structure of the traditional EDE subscales developed by Fairburn and colleagues [ 27 ], confirmatory factor analysis (CFA) was conducted with Mplus (version 8.0) [ 40 ]. Model fit was evaluated using incremental fit tests of a “good fit” [ 41 , 42 ], including the Tucker-Lewis index (TLI) ≥ .90 and comparative fit index (CFI) ≥ .90. Two absolute measures of fit were also used: the standard root mean square residual (SRMR) ≤ .08 and root mean square error of approximation (RMSEA) ≤ .10 (< .05 preferred). The same procedure was repeated with the PEDE. Given the results of the CFA, an exploratory factor analysis (EFA) was conducted using IBM SPSS Statistics v.24.0 to determine if an alternate model was a better fit for the PEDE.

Planned analyses for diagnostic agreement between the PEDE and EDE included chi-squared tests and Cohen’s kappa to compare each measure’s diagnostic items.

Internal Consistency

The coefficient alpha values for the four established subscales and global score of the EDE in the present sample ranged from acceptable to excellent: .86 for the Restraint scale, .75 for Eating Concern, .93 for Shape Concern, .83 for Weight Concern, and .93 for the global score. While the PEDE reliability coefficients for the Shape Concern and Weight Concern subscales (.85 and .74, respectively) and the global score (.80) fell in the acceptable to good ranges, alpha coefficients were poor (.59) for the Restraint subscale and unacceptable (.44) for the Eating Concern subscale.

Construct validity

Table  1 shows the results of the Pearson correlations. There were significant medium-sized positive correlations between the corresponding subscales and global scores (all p values < .001) ranging from .36 to .49. In each case, the correlation with the corresponding scale of the other instrument was higher than that with any other scale. Estimates of inter-rater agreement between the EDE and PEDE subscale and global scores are shown in Table  2 . There was moderate agreement between the PEDE and EDE global scores and the Restraint, Shape Concern, and Weight Concern subscale scores, and poor agreement between the Eating Concern subscales.

The CFA for the EDE four-factor model, based on established subscales, approached an acceptable fit after removing the preoccupation with shape or weight item from the Weight Concern factor because of a negative loading (see Table  3 for standardized factor loadings): CFI = .90, TLI = .88, RMSEA = .09, and SRMR = .05. The CFA of the four-factor model for the PEDE provided a poor fit to the data: CFI = .70, TLI = .66, RMSEA = .11 ( SE  = .10, .11); and SRMR = .10.

For the EFA, the scree plot, parallel analysis, and Velicer’s minimum average partial (MAP) tests were conducted, with the latter two based on SPSS macros developed by O’connor [ 43 ]. All three tests supported retaining a three-factor model for the PEDE. Principal axis factoring (PAF) and promax rotation (power = 4) were used to extract the three factors. Loadings above .30 were used as evidence of a meaningful relationship between an item and a factor [ 44 ]. These three factors accounted for 47.7% of the total variance of the items; see Table  3 . One item, avoidance of eating , was not associated with any scale due to insufficient loading. Looking at the items within each factor, they could be labeled as affective preoccupation with shape , weight , and eating (10 items, α  = 0.87, 30.6% of total variance), importance of shape , weight , and restriction (7 items, α  = 0.75, 9.1% of total variance), and discomfort with eating and body display (4 items, α  = 0.58, 8.0% of total variance).

Diagnostic Agreement

We initially planned to assess diagnostic agreement between the PEDE and EDE using chi-squared tests and Cohen’s kappa to compare each measure’s diagnostic items. However, of those participants who were not missing any EDE diagnostic items ( n  = 361), only 237 had no missing PEDE diagnostic items. A t -test comparison of those with and without missing PEDE diagnostic items found that participants without missing PEDE data had significantly higher PEDE global scores ( p  = .002) and significantly lower BMIs ( p  = .013) than participants who were missing PEDE diagnostic items. As the patients who could be included in this analysis appeared to have a more severe ED presentation than the remainder of the sample, results from a PEDE-EDE diagnostic comparison would be difficult to interpret. This confound precluded our conducting the planned analyses to assess diagnostic agreement.

To our knowledge, the PEDE is the first semi-structured interview formally developed with the aim to improve ED assessment in youth through the addition of caregiver perspectives, helping to reduce Type II error rate and under-identification of symptoms in youth with ED [ 45 ]. This study investigated the psychometric properties of the PEDE in a relatively large, international, multisite sample of families seeking treatment for AN and SAN. As predicted, the internal consistency of the PEDE was within the range of what has been published for the EDE (.44 to .85) [ 26 ], though lower than the EDE’s reliability in this sample. Regarding convergent validity, effect sizes were larger than the expected small effect size based on the meta-analytic evidence for parent-child correlation for both internalizing (.26) and externalizing (.32) disorders [ 6 ]. However, the lack of strong concordance between the EDE and PEDE subscales indicates that the information captured by the PEDE is not redundant with the EDE. This finding suggests that information from parent informants complements diagnostic and clinical information over and above that obtained by youth self-report. Specifically, the behavioral indicators and examples provided by the PEDE appear to elicit diagnostically relevant information from parents that might otherwise remain unreported. In clinical practice, such questioning can also serve to educate parents that these behaviors and beliefs are part of the ED and thereby improve their capacity to clinically monitor and intervene to support their child’s recovery.

The EDE is used with four subscales, yet none of the three studies that have examined the factor structure has replicated the four-factor model [ 28 , 29 , 30 ]. In this sample, the original factor structure approached an acceptable fit with the youth self-report data, but only after removing the preoccupation with weight and shape item from the Weight Concern subscale. Given the inconsistency of factor analysis results across studies of the EDE [ 26 ], it was not surprising that another underlying structure of three subscales seemed to provide the best fit for the PEDE. Although the PEDE has an empirically derived, three-factor structure, the original four-subscale model of the PEDE was found to measure constructs similar to those measured by the corresponding EDE scales, based on significant positive associations between corresponding subscales on the youth and parent interview. As such, it is reasonable to utilize the PEDE based on the four-subscale model to maintain consistency for research purposes. When using it for exclusively clinical purposes, the three-factor model may provide more meaningful constructs. Prior research also suggests that the EDE global score is a more useful measure of ED pathology than its subscales [ 46 ]; in light of the current study’s internal consistency and construct validity results, the PEDE global score may also provide a more valid interpretation of its findings.

Limitations of this study include a predominantly female, treatment-seeking sample with specific criteria applied, including the use of population norms (i.e., %mBMI) to determine weight eligibility instead of individualized weight status based on historical growth patterns. These limitations constrained an understanding of how the PEDE interview may perform in more diverse, transdiagnostic (including atypical AN), and non-treatment-seeking samples. Resource limitations prevented duplicate assessments by multiple interviewers to establish inter-rater reliability or compare ratings from caregivers of different genders, but this is worthy of future study, as is test-retest reliability. Furthermore, missing data precluded completion of the diagnostic agreement analyses originally proposed by this study. Although the intent of developing the PEDE was to aid in the identification of AN/SAN, future research should aim to evaluate the measure’s ability to distinguish between transdiagnostic ED cases and non-cases (i.e., criterion validity) as compared to the EDE using samples of adolescents with ED, subsyndromal ED, and no ED, and sensitivity and specificity analyses such as receiver-operator characteristic (ROC) curves. Additional work is also needed to more thoroughly assess the PEDE’s validity and predictive power, including its relationships with other measures of ED and non-ED symptoms, other parent-report measures, clinician-assigned diagnosis, and clinical outcomes. Finally, by applying more sophisticated multi-informant statistical methods [ 21 ], future research could establish how clinicians and researchers systematically integrate potentially conflicting perspectives from youth and their caregivers,.

In summary, the use of parental informants is consistent with the approach to assessment of other areas of psychopathology in youth in which collateral informants frequently aid in the evaluation and diagnosis process [ 6 , 20 , 47 ]. The introduction of the PEDE allows for a standardized way to incorporate caregiver reports to aid in the assessment of AN, potentially reducing diagnostic ambiguity and compensating for the denial and minimization inherent in the self-report of symptoms within the group. Our future research will focus on differences in diagnostic rates when parents are enlisted as informants in interview-based AN case identification efforts. Enhanced assessment approaches can theoretically make identification of clinically significant presentations more efficient and accurate, and lead to earlier intervention and improved outcomes.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. The PEDE 2.0 is available at https://ccebt.com/wp-content/uploads/2024/06/PEDE-2.0_gender-neutral.pdf .

Abbreviations

Body mass index

Confirmatory factor analysis

Comparative fit index

Diagnostic and Statistical Manual of Mental Disorders

Expected body weight

Eating disorders

Eating Disorder Examination

Exploratory factor analysis

Intraclass correlation coefficient

Minimum average partial

Median body mass index

Other specified feeding and eating disorder

Principal axis factoring

Parent Eating Disorder Examination

Root mean square error of approximation

Subsyndromal anorexia nervosa

Standard root mean square residual

Tucker-Lewis index

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Acknowledgements

We gratefully acknowledge Christopher Fairburn’s ongoing mentorship and support in forwarding research-based adaptations of the Eating Disorder Examination, including the parent version discussed in this paper.

This research was supported by a grant from the National Institute of Mental Health K23 MH074506 (PI: Loeb; ClinicalTrials.gov NCT00418977, Early Identification and Treatment of Anorexia Nervosa).

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Lisa Hail, Catherine R. Drury & Daniel Le Grange

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Catherine R. Drury, Robert E. McGrath & Katharine L. Loeb

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Murdoch Children’s Research Institute, Melbourne, Australia

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Contributions

KLL developed the PEDE and conceptualized the current study with LH, REM, and SBM. EKH, SMS, DLG, and KLL provided data for the study, which was curated and analyzed by LH under the supervision of REM and KLL. CRD contributed additional analyses with guidance from KLL and LH. LH wrote the initial draft of the manuscript, to which CRD, KLL, and REM also contributed. All authors read and edited subsequent iterations of the manuscript and approved the final version.

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Correspondence to Catherine R. Drury .

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This study was determined to qualify as exempt by Fairleigh Dickinson University’s Institutional Review Board (IRB). Any parent studies from which data were derived for secondary analyses included informed consent/assent and were approved by site-specific IRBs.

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KLL receives royalties from Cambridge University Press and Routledge, and is a faculty member of and consultant for the Training Institute for Child and Adolescent Eating Disorders. DLG receives royalties from Guilford Press and Routledge, and is co-director of the Training Institute for Child and Adolescent Eating Disorders, LLC. SBM receives royalties from Oxford University Press, Routledge, and Springer.

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Hail, L., Drury, C.R., McGrath, R.E. et al. Parent version of the Eating Disorder Examination: Reliability and validity in a treatment-seeking sample. J Eat Disord 12 , 101 (2024). https://doi.org/10.1186/s40337-024-01062-4

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DOI : https://doi.org/10.1186/s40337-024-01062-4

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Clinical intervention strategies and family dynamics in adolescent eating disorders: a scoping review for enhancing early detection and outcomes.

1. Introduction

2. literature review, 2.1. anorexia nervosa [an], 2.1.1. psychotherapeutic interventions, 2.1.2. pharmacological therapy, 2.2. bulimia nervosa (bn), 2.2.1. psychotherapeutic interventions, 2.2.2. pharmacological therapy, 2.3. binge-eating disorder (bed), 2.3.1. psychotherapeutic interventions, 2.3.2. pharmacological therapy, 3. materials and methods, 3.2. sample, 3.3. inclusion criteria, 3.4. searching strategy, 3.5. searching procedure, selection, and clustering, main findings, 5. discussion, limitations, 6. conclusions, author contributions, data availability statement, conflicts of interest, abbreviation.

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Gkintoni, E.; Kourkoutas, E.; Vassilopoulos, S.P.; Mousi, M. Clinical Intervention Strategies and Family Dynamics in Adolescent Eating Disorders: A Scoping Review for Enhancing Early Detection and Outcomes. J. Clin. Med. 2024 , 13 , 4084. https://doi.org/10.3390/jcm13144084

Gkintoni E, Kourkoutas E, Vassilopoulos SP, Mousi M. Clinical Intervention Strategies and Family Dynamics in Adolescent Eating Disorders: A Scoping Review for Enhancing Early Detection and Outcomes. Journal of Clinical Medicine . 2024; 13(14):4084. https://doi.org/10.3390/jcm13144084

Gkintoni, Evgenia, Elias Kourkoutas, Stephanos P. Vassilopoulos, and Maria Mousi. 2024. "Clinical Intervention Strategies and Family Dynamics in Adolescent Eating Disorders: A Scoping Review for Enhancing Early Detection and Outcomes" Journal of Clinical Medicine 13, no. 14: 4084. https://doi.org/10.3390/jcm13144084

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• Clinical Trials

New Research Points Towards Potential Treatment for Anorexia

Medically reviewed by Carmen Pope, BPharm . Last updated on July 11, 2024.

By Dennis Thompson HealthDay Reporter

THURSDAY, July 11, 2024 -- Anorexia nervosa could be caused by lack of a specific brain chemical, reports a research team that has developed a possible cure for the eating disorder .

Mouse studies have revealed that a deficit in acetycholine, a neurotransmitter associated with the brain’s reward system, could be linked to excessive habit formation.

This deficit could be behind the compulsive self-starvation seen in people with anorexia , researchers argue in the July 7 issue of the journal Nature Communications .

The Alzheimer's drug donepezil , which increases acetylcholine, “fully reversed the anorexia-like behaviour in mice, and we believe that it could potentially offer the first mechanism-based treatment of anorexia nervosa,” said senior researcher Dr. Salah El Mestikawy , professor of psychiatry with McGill University’s Douglas Research Center in Montreal.

“In fact, we are already seeing its effects on some patients with the disease,” El Mestikawy added in a McGill news release.

Positive results have already been seen in 10 patients with severe anorexia who are being treated with low doses of donepezil, researchers said.

Three patients are in full remission from anorexia, and the other seven have shown marked improvements, results show.

Full-fledged clinical trials comparing donepezil against placebo in treating anorexia are set to start later this year at three major hospitals in the United States and France, researchers said.

However, El Mestikawy cautioned that it could take several years before a new drug targeting anorexia receives government approval and becomes available to patients.

Donazepil causes many gastrointestinal and muscle side effects, El Mestikawy said. Researchers are working to develop a new drug that boosts acetylcholine with fewer problems.

“We also suspect that other compulsive pathologies such as obsessive-compulsive disorders (OCD) and addictions can also be improved by donepezil, so we are actively looking for collaboration with other psychiatrist around the world to explore the possibilities,” El Mestikawy added.

• McGill University, news release, July 7, 2024

Disclaimer: Statistical data in medical articles provide general trends and do not pertain to individuals. Individual factors can vary greatly. Always seek personalized medical advice for individual healthcare decisions.

© 2024 HealthDay. All rights reserved.

Posted July 2024

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Study finds web-based cognitive behavioral therapy aids bulimia outcomes

by Lori Solomon

A web-based, cognitive behavioral self-help intervention effectively cuts bulimia nervosa symptoms, according to a study published online July 3 in JAMA Network Open .

Steffen Hartmann, from Heidelberg University in Germany, and colleagues evaluated the effectiveness of a web-based cognitive behavioral self-help intervention for individuals with bulimia nervosa. Adult patients with bulimia nervosa (154 participants; ages 19 to 65 years) were randomly assigned to 12 weekly modules or a wait-list control.

The researchers found that participants receiving the web-based intervention showed a significantly greater decrease in bulimic episodes versus the control group, representing a significant change in binge-eating episodes.

However, there was no significant improvement seen in compensatory behaviors. Benefits of the intervention were also seen for improvement in global eating disorder symptoms and clinical impairment. Well-being and work capacity did not show improvement with the intervention.

"These findings underscore the effectiveness of web-based cognitive behavioral treatments for bulimia nervosa and suggest that these interventions can complement face-to-face therapies," the authors write.

"Building on these results, future research should test whether more extensive interventions (i.e., blended or ecological momentary interventions) can impact compensatory behaviors, comorbid symptoms, and overall well-being more effectively."

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The Neurological Basis of Anorexia May Have Just Been Discovered

Anorexia nervosa is a gut-wrenching eating disorder that may be linked to the 'blunted' release of a particular chemical in the brain, an animal study suggests.

Male mice engineered to harbor a rare genetic variant found in some people with eating disorders (and substance use disorders too) were found to be deficient in a neurotransmitter, called acetylcholine , in a part of the brain, the striatum, involved in learned behaviors, cravings, and reward .

Although further validation and human studies are required, the work "identifies a mechanism and a potential treatment to alleviate these severe psychiatric disorders," Mathieu Favier, a neuroscientist at McGill University in Montreal, and colleagues write in their published paper .

In short, restoring acetylcholine levels – using a drug already approved for Alzheimer's disease – might help, but other kinds of therapies are probably still required.

Favier and colleagues started by confirming the link between the aforementioned genetic mutation and substance use disorders in a new cohort of patients that also included some with eating disorders. The p.T8I variant of the SLC17A8 gene is rare, found in only 9 of 793 cases in this study – so bear in mind the results may not apply to everyone with these disorders.

What these two disorders share are habits that are hard to break, and compulsive behaviors driven by restriction, in the case of eating disorders, and 'rewards', in the sense that addictive drugs activate the brain's reward system , delivering a kick of dopamine and other reward compounds in the brain.

Treating the genetically engineered mice with donepezil , an Alzheimer's drug that inhibits the enzyme that breaks down acetylcholine, had some noticeable effects: The animals began eating normally and fewer dropped weight after previously showing behaviors reminiscent of binge eating and restrictive eating.

"We found that it fully reversed the anorexia-like behavior in mice, and we believe that it could potentially offer the first mechanism-based treatment of anorexia nervosa," says McGill University neuroscientist Salah El Mestikawy, senior author of the study.

"In fact, we are already seeing its effects on some patients with the disease."

Ten patients have been treated with low doses of donepezil in a Canadian pilot study. Randomized controlled trials, testing if that treatment is any better than a placebo at alleviating anorexia nervosa, are planned .

It's handy when existing drugs can be repurposed like this to possibly treat other conditions. But until those trials are completed, we won't know how well the findings of this animal study translate into humans, and if restoring acetylcholine levels is an effective treatment strategy.

The study involved male mice when eating disorders mostly affect women so there may be some sex-based differences unaccounted for there. Donepezil also has some known and serious side effects, hence the clinical trials will test only low doses of the drug.

The results do, however, offer some cautious hope that a medication may be on the horizon to help with treating anorexia, an illness that carries one of the highest mortality rates among severe psychiatric disorders.

As with many mental illnesses, research is seemingly a tug of war between the biological factors underpinning conditions such as anorexia, or mood disorders such as depression , and the psychological aspects of each illness.

In 2019, scientists identified eight genetic markers associated with anorexia after analyzing DNA samples from almost 17,000 patients with anorexia nervosa and some 55,000 people without. Some of these genetic variants relate to the way people metabolize fats and sugars.

Finding those biological underpinnings can help reduce the stigma associated with mental health conditions. Showing they have a physiological basis helps make it clear that people may have a genetic or biological predisposition to developing a particular disorder.

However, there is always added complexity with social, psychological, and environmental factors – that people may or may not have control over – acting on those biological foundations.

Getting to grips with the intersecting contributing factors of mental health conditions has repercussions for treatment. For example, a chemical imbalance in serotonin, long thought to be the cause of depression , has driven the use of antidepressants that don't work for many people and now research suggests that theory might be somewhat off the mark.

In the case of anorexia, using acetylcholine inhibitors to treat this and other obsessive-compulsive disorders may be controversial, as Favier and colleagues themselves note , and no medication is a fix-all.

So the current standard of care, behavioral therapies , will still be part of the repertoire to help patients, even as new treatment modalities are explored.

The study has been published in Nature Communications .

• DOI: 10.3390/healthcare12141388
• Corpus ID: 271195218

Emotional Dysregulation in Anorexia Nervosa: Scoping Review of Psychological Treatments

• Enrica Cogodi , J. Ranieri , +1 author D. Di Giacomo
• Published in Healthcare 11 July 2024

38 References

Difficulties with positive emotion regulation in anorexia nervosa, associations between emotion reactivity and eating disorder symptoms in a transdiagnostic treatment-seeking sample., evaluation of the affect school as supplementary treatment of swedish women with eating disorders: a randomized clinical trial, emotion dysregulation and eating disorder outcome: prediction, change and contribution of self‐image, evaluating the use of lamotrigine to reduce mood lability and impulsive behaviors in adults with chronic and severe eating disorders, exploring changes in alexithymia throughout intensive dialectical behavior therapy for eating disorders., disordered eating as a repercussion of sexual assault: a consequence to consider, emotional processing in recovered anorexia nervosa patients: a 15 year longitudinal study., dialectical behaviour therapy improves emotion dysregulation mainly in binge eating disorder and bulimia nervosa: a systematic review and meta-analysis, implementation of mentalization-based treatment in a day hospital program for eating disorders-a pilot study., related papers.

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New Research Points Towards Potential Treatment for Anorexia

Key takeaways.

Anorexia might be caused by lack of a specific brain chemical

Mice with a deficit in acetylcholine appear to have anorexia-like symptoms

A drug to boost acetylcholine reduced anorexia symptoms in both mice and humans

THURSDAY, July 11, 2024 (HealthDay News) -- Anorexia nervosa could be caused by lack of a specific brain chemical, reports a research team that has developed a possible cure for the eating disorder .

Mouse studies have revealed that a deficit in acetylcholine, a neurotransmitter associated with the brain’s reward system, could be linked to excessive habit formation.

This deficit could be behind the compulsive self-starvation seen in people with anorexia, researchers argue in the July 7 issue of the journal Nature Communications .

The Alzheimer's drug donepezil , which increases acetylcholine, “fully reversed the anorexia-like behavior in mice, and we believe that it could potentially offer the first mechanism-based treatment of anorexia nervosa,” said senior researcher Dr. Salah El Mestikawy , professor of psychiatry with McGill University’s Douglas Research Center in Montreal.

“In fact, we are already seeing its effects on some patients with the disease,” El Mestikawy added in a McGill news release.

Positive results have already been seen in 10 patients with severe anorexia who are being treated with low doses of donepezil, researchers said.

Three patients are in full remission from anorexia, and the other seven have shown marked improvements, results show.

Full-fledged clinical trials comparing donepezil against placebo in treating anorexia are set to start later this year at three major hospitals in the United States and France, researchers said.

However, El Mestikawy cautioned that it could take several years before a new drug targeting anorexia receives government approval and becomes available to patients.

Donepezil causes many gastrointestinal and muscle side effects, El Mestikawy said. Researchers are working to develop a new drug that boosts acetylcholine with fewer problems.

“We also suspect that other compulsive pathologies such as obsessive-compulsive disorders (OCD) and addictions can also be improved by donepezil, so we are actively looking for collaboration with other psychiatrist[s] around the world to explore the possibilities,” El Mestikawy added.

More information

Johns Hopkins Medicine has more on anorexia .

SOURCE: McGill University, news release, July 7, 2024

What This Means For You

People with anorexia should talk with their doctor about upcoming clinical trials testing drug treatments for the eating disorder.

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Bulimia nervosa in adolescents: prevalence and treatment challenges

Department of Psychiatry, University of California, San Francisco, CA, USA

Daniel Le Grange

Bulimia nervosa (BN) is a serious psychiatric illness that typically develops during adolescence or young adulthood, rendering adolescents a target for early intervention. Despite the increasing research devoted to the treatment of youth with anorexia nervosa (AN) and adults with BN, there remains a dearth of evidence for treating younger individuals with BN. To date, there have been four published randomized controlled trials comparing psychosocial treatments, leaving significant room to improve treatment outcomes. Family-based treatment is the leading treatment for youth with AN, while cognitive-behavioral therapy is the leading intervention for adults with BN. Involving caregivers in treatment shows promising results, however, additional research is needed to investigate ways in which this treatment can be adapted further to achieve higher rates of recovery.

Introduction

Eating disorders (EDs) are serious psychiatric illnesses that typically develop during adolescence or young adulthood. These disorders are associated with both physical and psychological sequelae and often lead to considerable impairment and distress. 1 The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) 2 recognizes eight feeding disorders and EDs, including bulimia nervosa (BN), anorexia nervosa (AN), and subthreshold presentations that are classified under unspecified feeding or ED. While the field has advanced the understanding of treatment approaches for adolescents with AN and adults with BN in particular, evidence to guide the treatment of BN in youth lags behind.

Diagnosis of BN

BN is characterized by recurrent episodes of eating an objectively large amount of food (ie, binge) with an associated loss of control, as well as inappropriate compensatory behavior (eg, self-induced vomiting, misuse of laxatives or diuretics, fasting, or excessive exercise) and overvaluation of shape and weight. 2 In the current edition of the DSM, these episodes of binge eating and compensatory behavior must occur at a minimum frequency of once per week over the course of 3 months. In the DSM-IV-TR, the minimum frequency of these episodes of binge eating and compensatory behavior was double (ie, an average of twice per week). 3 In studies comparing full and subthreshold presentations of DSM-IV BN, those individuals who were subthreshold reported significantly more subjective binge episodes in which they experienced a loss of control but did not consume an objectively large portion of food. 4 Purge frequency across both groups was similar, suggesting that the experience of losing control may be more salient than the amount of food consumed. 4 Diagnostic crossover is relatively common, especially among youths, with many who initially present with subthreshold presentations progressing to meet full diagnostic criteria for BN or less commonly AN. 4 , 5 This diagnostic fluidity suggests that clinical management should not differ between sub- and full-threshold BN.

Traditional diagnostic approaches rely on the self-report of symptoms by the patient. While the low body weight characteristic of AN makes it more outwardly visible, AN is considered an ego-syntonic illness, such that it is consistent with the self-concept of the sufferer, making them less open to treatment. 5 Conversely, BN is considered ego-dystonic and aversive to the patient, yet shame and secrecy often inhibit disclosure of symptoms and seeking treatment. In younger populations, developmental concerns, such as the ability to endorse such conceptual symptoms as “undue influence of weight and shape” may further impact the ability to diagnose full-threshold EDs in adolescents. 4

The positively skewed distribution of age of onset of EDs, including subthreshold presentations, renders adolescents a target for screening and early intervention before symptoms become severe and enduring, 5 and research has supported that early intervention is associated with the most promising treatment outcomes. 6 Increasing research has been devoted to the treatment of AN in adolescence, with an increasing number of studies published demonstrating considerable support for family-based treatment (FBT) approaches. 7 To date, evidence to guide the treatment of BN in adolescents is limited, with only four published randomized controlled trials (RCTs) of psychological treatments and one open medication trial. 8 – 11

Many population-based studies have focused on youths who meet full-threshold criteria for an ED without reporting on the cases who may have clinically significant presentations, but fall below the diagnostic threshold. 1 In adults, the prevalence estimates of full-threshold BN are 1%–1.5%, 2 , 12 with 0.1%–2% in youth. 13 However, community studies that evaluated disordered eating behavior rather than applying strict DSM criteria found far greater prevalence (ie, 14%–22%) than those applying strict criteria. 1 , 14

In an attempt to estimate the occurrence of EDs in US adolescents better, Swanson et al utilized data from the National Comorbidity Survey replication adolescent supplement. 1 These data collected via face-to-face interviews included a representative sample of 10,123 youths aged 13–18 years. The World Health Organization Composite International Diagnostic Interview was used to assess DSM-IV psychiatric disorders, including AN, BN, and binge ED, based on the diagnostic algorithms used with adult populations. Sufficient information was gathered to assess subthreshold presentations of AN using a less stringent weight criterion (ie, less than 90% of median weight for height rather than 85%) and subthreshold binge ED. However, the survey did not include sufficient information to report on subthreshold presentations of DSM-IV BN, such as those who did not meet the duration or frequency criterion or those who experienced only subjective binge episodes. 1

In the USA, the median age of onset for DSM-IV BN is quite young: 12.4 years (interquartile range 11.1–13.5 years). 1 Within the sample, the lifetime prevalence rate of BN was 0.9% and 12-month prevalence 0.6%. Of adolescents with BN, 41.3% reported purging, while the rest met criteria based on nonpurging compensatory behaviors (ie, excessive exercise, fasting). 1 With revised diagnostic criteria reducing the frequency of binge eating and purging from twice per week over 6 months to once per week over 3 months, these numbers obviously underestimate the true prevalence of BN based on current criteria.

Comorbidity

The National Comorbidity Survey replication adolescent supplement also evaluated the presence of other DSM-IV diagnoses. The majority of respondents meeting criteria for a DSM ED also met criteria for another lifetime DSM-IV diagnosis. The highest rate of comorbidity (88%) occurred in adolescents with BN, with particularly strong associations with mood (49.9%) and anxiety (66.2%) disorders. 1

Especially concerning is the level of suicidality among this group. Adolescents with BN reported suicidality at higher rates than adults with BN and higher rates than youth with any other ED diagnosis. Of adolescents with BN, more than half (53%) endorsed suicidal ideation. Over a quarter of the sample had a plan and more than a third had had a prior attempt (17.1% with multiple past attempts). 1 , 15

Treatment for adolescent BN

A diagnosis of BN is typically associated with high rates of comorbidity and elevated mortality. 16 In addition, 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. 17 With the risk of medical complications, it is imperative to utilize a multidisciplinary team approach, including a clinician who is trained in adolescent health with expertise in EDs to ensure the medical safety of outpatient care.

In adults with BN, there is the substantial literature to support cognitive behavioral therapy (CBT) as the leading treatment approach, with relatively good outcomes for most. 18 In addition to CBT, there is evidence to support other approaches, such as interpersonal therapy, 18 and newer approaches, such as integrative cognitive-affective therapy. 19 Despite the growing evidence base for treatment of adults with BN, there remains a dearth of evidence for treating younger individuals with BN. To date, there has been one open medication trial of fluoxetine in conjunction with therapy over the course of 8 weeks. There are also four published RCTs comparing psychosocial treatments with significant room for improvement of treatment outcomes.

Psychopharmacological treatment

One open clinical trial was published investigating the feasibility and tolerability of fluoxetine (at an adult dose of 60 mg) in conjunction with psychotherapy over the course of 8 weeks. 20 Participants were female adolescents aged 12–18 (mean 16.2, SD 1) years with a DSM-IV diagnosis of BN or ED not otherwise specified (EDNOS). All participants were above the 85th percentile of median weight for height by age. 20

The medication was generally well tolerated, and no participants discontinued the trial due to side effects. Of the 13 patients who entered the study, ten received a minimum of 1 week of medication, and results were based on their outcome. Findings were comparable to studies of fluoxetine in adults with BN, with a significant decrease in both binge and purge behavior over the course of the trial. From baseline to the end of treatment (EOT), weekly binges decreased by 67% and episodes of purging by 56%. Despite improvements, three of the ten patients continued to meet criteria for a DSM-IV ED (two BN and one EDNOS) at the end of the trial. 20

These findings have not been replicated nor have there been any placebo-controlled trials in adolescents with BN. Therefore, the results remain limited in their generalizability, and additional exploration of psychopharmacological interventions is necessary.

Psychological treatment

Despite the typical onset during adolescence, there have been only four RCTs published to date evaluating psychosocial treatment for BN in youth. The first three compared FBT approaches against guided self-care CBT, CBT adapted for adolescence (CBT-A), and supportive psychotherapy (SPT). The most recently published study compared CBT and psychodynamic therapy (PDT).

Family therapy and CBT-guided self-care

Schmidt et al 10 were the first to publish findings from an RCT for the treatment of BN in adolescents. Their study, conducted in the UK, sought to compare the efficacy and cost-effectiveness of two treatments. Participants were 85 adolescents aged 13–20 years with DSM-IV BN or EDNOS. In the UK, guided self-care CBT is recommended as the first-line intervention for adults with BN. This treatment approach utilized a workbook and involved ten weekly sessions and three monthly follow-up sessions with the option of two sessions with a “close other” (eg, parent). The role of the therapist was to motivate the patients and guide them through the workbook. Similar to traditional CBT, self-monitoring was utilized, along with problem-solving and behavioral experiments. The comparison treatment was family therapy adapted from the Maudsley model of treatment for AN, as it has a growing evidence base for the treatment of young people with AN. This treatment provided psychoeducation about BN and was problem-oriented, with a focus on the role of the family in restoring regular eating patterns. In family therapy, patients were offered 13 sessions with a close other in addition to two individual sessions over the course of 6 months. 10

The primary outcome variable was abstinence from binge eating and vomiting in the month prior to assessment assessed at EOT (6 months) and follow-up (12 months). When looking at binge episodes and purging as a combined variable, there was no difference between conditions at either time point. However, CBT-guided self-care was more effective at achieving abstinence from objective binge eating (45% versus 25%) at EOT, but this advantage was not maintained at follow-up. The impact on purging did not vary by treatment. 10

FBT and SPT

In the same year, Le Grange et al 8 published another study comparing FBT and SPT. Participants were 80 youths ages 12–19 (mean 16.1, SD 1.6) years, predominantly female (98%), with a diagnosis of DSM-IV BN or partial BN (ie, binge and purge episodes averaging once per week over 6 months). The duration of treatment was 20 sessions over the course of 6 months. Both treatments involved three phases, and the frequency of sessions decreases over time. 8

FBT-BN was adapted from FBT for AN. This treatment takes an agnostic stance about the cause of the ED and assumes a significant negative impact of the illness on the family. FBT-BN also externalizes the illness as something separate from the adolescent, and empowers parents to disrupt the cycle of binge eating and purging. SPT is a nondirective treatment that does not involve specific active therapeutic approaches, such as stimulus control, psychoeducation, systematic problem-solving, or direct input about dietary modifications. SPT serves as a general treatment that might be comparable to what would be received in the community. 8 The primary outcome measure was abstinence from binge eating and purging in the month prior to assessment at 6 months (EOT) and 12 months (follow-up). At EOT, FBT-BN had significantly higher rates of abstinence (39% versus 18%). However, the rate of abstinence declined during follow-up across both groups (29% and 10%, respectively). 8

FBT and CBT

Following the comparison of FBT-BN to SPT, a control treatment similar to what youth with BN might receive in the community, Le Grange et al compared FBT-BN to CBT, which is the most efficacious approach for adults with BN. Participants were 109 youths aged 12–18 (mean 15.8, SD 1.5) years, predominantly female (94%), with DSM-IV BN or partial BN (same as previously mentioned). Both treatments involved 18 sessions over the course of 6 months. 9

FBT was comparable to the FBT-BN delivered in the previous study by Le Grange et al, 8 aside from having two fewer sessions. CBT-A was adapted from the treatment developed by Fairburn et al. 21 The treatment developed for adults was modified such that there was increased contact with the therapist in early treatment, with the goal of enhancing therapeutic alliance, collateral sessions with caregivers to provide psychoeducation about BN and elicit their support in the treatment process, the use of concrete examples to explain points, and the exploration of typical developmental issues. 9

Consistently with the prior studies, the primary outcome was abstinence from binge eating and purging for the 4 weeks prior to assessment at EOT (6 months) and follow-up (12 months). The rate of abstinence was significantly higher for FBT-BN than CBT-A (39.4% versus 19.7%), with continued improvement at 6-month follow-up (44% and 25.4% respectively). 9

CBT and PDT

In the most recently published RCT, Stefini et al 11 compared CBT and PDT. In Germany, where the study was conducted, 58.9% of psychotherapists for children and adolescents practiced PDT. This study sought to evaluate the gap in knowledge about commonly practiced PDT as a treatment for youth with BN. Participants in this sample were females aged 14–20 (mean 18.7, SD 1.9) years with a DSM-IV diagnosis of BN or partial BN (binge and purge episodes less than twice per week in previous 3 months).

The duration of the treatment was comparable to the guidelines of clinical practice in Germany, which involved substantially more treatment than the prior studies. Both CBT and PDT took place over 1 year, and participants could receive up to 60 sessions. Similar to Le Grange et al, 9 CBT was based on Fairburn et al’s model of CBT for EDs 22 with significant modifications, including tripling the number of sessions offered. PDT was manualized specifically for young people with BN. Both treatments share a symptom-focused approach that is specific to BN. However, underlying theoretical assumptions are quite different, and each approach places a different emphasis on emotions, cognitions, and behavior. 11

Rather than evaluating abstinence from binge-eating and purging behavior 1 month prior to assessment, Stefini et al evaluated what proportion of participants no longer met the criteria for an ED and found no differences between groups, with 13 participants no longer meeting diagnostic criteria for an ED (33.3% CBT and 30.2% PDT). The rates of remission improved slightly, but not significantly for CBT (38.5%) and were unchanged for PDT at follow-up 1 year after EOT. 11

Challenges in treatment

The challenges previously discussed with diagnosis will ultimately impact the ability to screen effectively for EDs and connect with treatment. Shame and secrecy may prevent the detection of BN and may inhibit treatment after symptoms are identified. The family may serve a crucial role in enhanced support to regulate eating behavior between sessions. However, in BN, it may be less obvious when binge episodes or compensatory behavior is taking place, making it difficult for parents to structure the environment fully.

In BN, the high level of comorbidity makes it probable that adolescents may present for treatment of another psychiatric disorder (eg, mood or anxiety disorder) while also struggling with binge eating and purging. Diagnostic assessment and ongoing monitoring of progress may offer opportunities to uncover clinically significant symptoms of BN. At the present time, there are limited data to guide the treatment of BN as a disorder in isolation, and there is no guidance about whether consecutive- or concurrent-treatment approaches for comorbid diagnosis are most appropriate or effective. That said, most RCTs to date have included participants with comorbid psychiatric diagnoses and provided pharmacotherapy for these diagnoses alongside psychosocial treatment for the ED. It also remains unclear why RCTs of treatments for BN within younger populations are lagging behind. Taken together, the limited systematic evaluation and concomitant advancement of treatment approaches for this patient population leaves us with a constrained scope of treatment options.

Conclusion and future directions

Despite the increasing number of RCTs for treatment of adolescents with AN and adults with BN, there continues to be few systematic studies of treatment of BN in adolescents. While FBT-BN has preliminary evidence to support the involvement of caregivers in treatment, there is considerable room for improvement to impact binge-eating and purging symptoms further among adolescent sufferers. In instances where caregivers are unable to participate in treatment or patients unwilling to assent to a high degree of parental involvement in their treatment, there is evidence that CBT approaches are helpful for some adolescents. The early study by Schmidt et al 10 suggested that a stepped-care approach beginning with guided self-care may be sufficient for some, whereas other adolescents will ultimately require a more intensive level of treatment. PDT and CBT in an extended format (ie, up to 60 session over 1 year, rather than the more typical 20 sessions over 6 months) both decreased the number of individuals meeting criteria for full-threshold BN.

Further research is necessary to enhance treatment approaches for adolescents with BN. While including caregivers in treatment shows promising results, there may be ways in which the cognitive symptoms can be more systematically addressed within the context of the family approach to treatment. It is also possible that family-based approaches might be enhanced with techniques in CBT, such as self-monitoring and behavioral experiments to challenge problematic beliefs. Further research is necessary to identify for whom which treatment approach will be most effective. In addition, adaptations of existing efficacious treatments or other heretofore unexplored treatment approaches should be examined, especially for those individuals who do not respond to the existing treatment approaches.

Dr. Le Grange receives royalties from Guilford Press and Routledge, and is co-director of the Training Institute for Child and Adolescent Eating Disorders, LLC. The authors report no other conflicts of interest in this work.