Elsevier

The Lancet

Volume 361, Issue 9355, 1 February 2003, Pages 407-416
The Lancet

Seminar
Eating disorders

https://doi.org/10.1016/S0140-6736(03)12378-1Get rights and content

Summary

Eating disorders are an important cause of physical and psychosocial morbidity in adolescent girls and young adult women. They are much less frequent in men. Eating disorders are divided into three diagnostic categories: anorexia nervosa, bulimia nervosa, and the atypical eating disorders. However, the disorders have many features in common and patients frequently move between them, so for the purposes of this Seminar we have adopted a transdiagnostic perspective. The cause of eating disorders is complex and badly understood. There is a genetic predisposition, and certain specific environmental risk factors have been implicated. Research into treatment has focused on bulimia nervosa, and evidence-based management of this disorder is possible. A specific form of cognitive behaviour therapy is the most effective treatment, although few patients seem to receive it in practice. Treatment of anorexia nervosa and atypical eating disorders has received remarkably little research attention.

Section snippets

Classification and diagnosis

The classification of the eating disorders and their principal diagnostic criteria are shown in panel 1.1, 2, 3, 4, 5, 6 Note that in addition to anorexia nervosa and bulimia nervosa, there is a third diagnostic category, atypical eating disorders,3 the equivalent American term being “eating disorders not otherwise specified”.1 A further eating disorder has also been proposed, termed binge eating disorder.1 Since this condition is somewhat different in nature to the other three diagnostic

General clinical features

Anorexia nervosa and bulimia nervosa are united by a distinctive core psychopathology, which is essentially the same in female and male individuals; patients overevaluate their shape and weight. Whereas most of us assess ourselves on the basis of our perceived performance in various domains—eg, relationships, work, parenting, sporting prowess—patients with anorexia nervosa or bulimia nervosa judge their self-worth largely, or even exclusively, in terms of their shape and weight and their

Distribution

panel 217-21 gives a summary of what is known about the distribution of eating disorders. The general belief is that eating disorders have become more frequent over recent decades. In the instance of bulimia nervosa, this notion could well be true,22, 23, 24, 25 but alternative explanations for the apparent increase in anorexia nervosa26, 27 are plausible, including greater help-seeking and better detection than in the past, and changes in diagnostic practice.18, 28 The fact that many instances

Development and subsequent course

Anorexia nervosa typically starts in midteenage years with the onset of dietary restriction, which proceeds to get out of control. In some instances the disorder is short-lived and self-limiting, or only requires a brief intervention. These instances are most typical of young individuals with a brief history. In others, the disorder becomes entrenched and necessitates more intensive treatment. In 10–20% of individuals, the disorder proves intractable and unremitting.32, 33 This heterogeneity in

Pathogenesis

Research into the pathogenesis of the eating disorders has focused almost exclusively on anorexia nervosa and bulimia nervosa. There is undoubtedly a genetic predisposition and a range of environmental risk factors, and there is some information with respect to the identity and relative importance of these contributions. However, virtually nothing is known about the individual causal processes involved, or about how they interact and vary across the development and maintenance of the disorders.

Binge eating disorder

By comparison with anorexia nervosa and bulimia nervosa, little is known about binge eating disorder. Although it shares with bulimia nervosa the symptom of binge eating, its overlap with the other eating disorders is limited. For example, the condition seems to primarily affect an older age group, its sex ratio is less uneven, the binge eating occurs against the background of a general tendency to overeat rather than dietary restraint (which probably accounts for its strong association with

Medical complications and their management

The physical abnormalities seen in anorexia nervosa seem to be largely secondary to these patients' disturbed eating habits and their compromised nutritional state. Hence most are reversed by restoration of healthy eating habits and sound nutrition, with the possible exception of reduced bone density. The main physical features are listed in panel 5.91, 92 The physical abnormalities seen in bulimia nervosa are usually minor unless vomiting, or laxative or diuretic misuse are frequent, in which

Management of eating disorders

Over the past 20 years the treatment of bulimia nervosa has attracted considerable research attention, and evidence-based management is now possible. There have been few randomised controlled studies into the treatment of anorexia nervosa or the atypical eating disorders, with the result that in their instance treatment recommendations have to be tentative. In the absence of satisfactory systematic reviews of the full range of the research that has been done, table 2 is intended to convey the

Clinical and research priorities

Several research themes and priorities emerge from this Seminar. First, the existing scheme for classifying eating disorders is unsatisfactory and anomalous, in that about half the cases seen in clinical practice are relegated to an atypical or not otherwise specified group (figure 1). This system is a historical accident that needs to be rectified, since far more unites the three categories of eating disorder than separates them.48 A classificatory scheme that reflects clinical reality would

Search strategy

We searched the Medline and PsycINFO databases for articles on eating disorders published since 1980. The key words used were eating disorders, anorexia nervosa, bulimia nervosa, bulimia, and binge eating. Only articles written in English were reviewed. Additionally, we reviewed professional books (written in English) on eating disorders published during this period. The references listed at the end of this article were chosen on the basis of their importance, accessibility, and

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