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
SeminarEating disorders
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
References (140)
- et al.
A slimming program for eating disorders not otherwise specified: reconceptualizing a confusing, residual diagnostic category
Psychiatr Clin North Am
(2001) - et al.
Enhancing motivation for change in treatment-resistant eating disorders
Clin Psychol Rev
(1998) Epidemiology and mortality of eating disorders
Psychiatr Clin North Am
(2001)- et al.
Standardized mortality in eating disorders: a quantitative summary of previously published and new evidence
J Psychosom Res
(1998) - et al.
Recovery and relapse in anorexia and bulimia nervosa: A 7.5-year follow-up study
J Am Acad Child Adolesc Psychiatry
(1999) - et al.
Predictors of 1-year treatment outcome in bulimia nervosa
Compr Psychiatry
(1998) - et al.
Heritability of binge-eating and broadly defined bulimia nervosa
Biol Psychiatry
(1998) - et al.
Association between 5-HT2A gene promoter polymorphism and anorexia nervosa
Lancet
(1997) - et al.
Candidate gene polymorphisms in eating disorders
Eur J Pharmacol
(2000) - et al.
Evidence for a susceptibility gene for anorexia nervosa on chromosome 1
Am J Hum Genet
(2002)
Reduced 5-HT2A receptor binding after recovery from anorexia nervosa
Biol Psychiatry
A cognitive behavioural theory of anorexia nervosa
Behav Res Ther
Food selection and intake of obese women with binge eating disorder
Am J Clin Nutrition
Guided and unguided self-help for binge eating
Behav Res Ther
Osteopenia in anorexia nervosa: specific mechanisms of bone loss
J Psychiatr Res
Diagnostic and statistical manual of mental disorders
Diagnostic issues
Atypical eating disorders (eating disorder not otherwise specified)
Childhood-onset eating disorders
Should amenorrhoea be necessary for the diagnosis of anorexia nervosa? Evidence from a Canadian community sample
Br J Psychiatry
Clinical presentation of anorexia nervosa and bulimia nervosa
Binge-eating episodes in bulimia nervosa: the amount and type of food consumed
Int J Eat Disord
An empirical test of the DSM-III-R definition of binge
Int J Eat Disord
Self-injurious behavior in women with eating disorders
Am J Psychiatry
Comorbidity of bulimia nervosa and alcohol use disorders: results from the national women's study
Int J Eat Disord
Co-morbidity of eating disorders and substance abuse: review of the literature
Int J Eat Disord
Impulsivity or comorbidity in bulimia nervosa: a controlled study of deliberate self-harm and alcohol and drug misuse in a community sample
Br J Psychiatry
Psychopathological and clinical features of outpatients with an eating disorder not otherwise specified
Eat Weight Disord
Review of the epidemiological studies of eating disorders
Int Rev Psychiatry
Epidemiology
Secular trends in the incidence of anorexia nervosa: integrative review of population-based studies
Int J Eat Disord
Anorexia nervosa in a Swedish urban region: a population-based study
Br J Psychiatry
Prevalence of 3 bulimia syndromes in the general population
Psychol Med
The genetic epidemiology of bulimia nervosa
Am J Psychiatry
Bulimia nervosa in Rochester, Minnesota from 1980 to 1990
Psychol Med
The demand for eating disorder care: an epidemiological study using the general practice research database
Br J Psychiatry
50-year trends in the incidence of anorexia nervosa in Rochester, MN: a population-based study
Am J Psychiatry
The ups and downs of anorexia nervosa
Int J Eat Disord
Anorexia nervosa: no evidence for an increase
Br J Psychiatry
Self-induced vomiting and bulimia nervosa: an undetected problem
BMJ
Bias and bulimia nervosa: how typical are clinic cases?
Am J Psychiatry
New eating disorder service
Psychiatr Bull
Outcome of anorexia nervosa: a case-control study
Am J Psychiatry
The outcome of anorexia nervosa in the 20th century
Am J Psychiatry
Longitudinal comparison of anorexia nervosa subtypes
Int J Eat Disord
Predictors of the development of bulimia nervosa in women with anorexia nervosa
J Nerv Ment Dis
Characteristics of 275 patients with bulimia
Am J Psychiatry
The significance of a prior history of anorexia in bulimia nervosa
Int J Eat Disord
The natural course of bulimia nervosa and binge eating disorder in young women
Arch Gen Psychiatry
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