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An eating disorder is characterized by abnormal eating habits that may involve either insufficient or excessive food intake to the detriment of an individual's physical and emotional health. The causes of eating disorders are complex and not yet fully understood. Eating disorders are estimated to affect 5-10 million females and 1 million males in the United States.^[1] Although not yet classified as separate disorder, binge eating disorder^[2] is the most common eating disorder in the United States affecting 3.5% of females and 2% of males according to a study by Harvard affiliated McLean Hospital. Bulimia nervosa was the second most common followed by Anorexia nervosa.^[3]

Statistics-Facts

• Eating disorders affect all socioeconomic levels.^[4]
• 40% of 9- and 10-year-old girls are already trying to lose weight.^[5]
• Girls with ADHD are 5.6 times more likely to develop bulimia and 2.7 times more likely to develop anorexia nervosa^[6][7]
• Women who were raised in foster care are 7 times more likely to develop bulimia nervosa.^[8]
• Binge eating is the most common eating disorder in the United States affecting 3.5% of females and 2% of males, followed by bulimia nervosa then anorexia nervosa.^[9]
• Females with anorexia nervosa have a higher suicide rate than those with any other mental health disorder and the general population^[10] up to 60 times higher according to one study^[11]
• Anorexia nervosa has the highest mortality rate of any psychiatric disorder.^[12]
• Anorexia nervosa although usually reported in white adolescent females affects all races and ages groups^[13][14]
• The mortality rate for anorexia nervosa is 4.0%, bulimia nervosa is 3.9% and 'eating disorder not otherwise specified' (EDNOS) which includes binge eating disorder is placed at 5.2%^[15]
• Males account for 5%-10% of anorexia nervosa cases^[16] and 10%-15% of bulimia nervosa cases.^[17]
• An optimum healthy weight is calculated using the Body Mass Index

Causes

It is not known with certainty what causes eating disorders. It can be due to a combination of biological, psychological or environmental causes.

Biological

DNA ligase (shown here in color), encircles the double helix to repair a broken strand of human DNA.

• Genetic: Numerous studies have been undertaken that show a possible genetic predisposition toward eating disorders.^[18][19][20]
• Biochemical:Eating behavior is a complex process controlled by the neuroendocrine system of which the Hypothalamus-pituitary-adrenal-axis (HPA axis) is a major component. Dysregulation of the HPA-axis has been associated with eating disorders,^[21][22] such as irregularities in the manufacture, amount or transmission of certain neurotransmitters, hormones^[23] or neuropeptides^[24].
  • serotonin: a neurotransmitter involved in depression also has an inhibitory affect on eating behavior^{[25][26][27][28][29]}
  • norepinephrine is both a neurotransmitter and a hormone; abnormalities in either capacity may affect eating behavior^[30][31]
  • dopamine:which in addition to being a precursor of norepinephrine and epinephrine is also a neurotransmitter which regulates the rewarding property of food^[32][33]
• leptin and ghrelin; leptin is a hormone produced primarily by the fat cells in the body it has an inhibitory effect on appetite by inducing a feeling of saiety. Ghrelin is an appetite inducing hormone produced in the stomach and the upper portion of the small intestine. Circulating levels of both hormones are an important factor in weight control. While often associated with obesity both hormones and their respective effects have been implicated in the pathophysiology of anorexia nervosa and bulimia nervosa.^[34]
• immune system:studies have shown that a majority of patients with anorexia and bulimia nervosa have elevated levels of autoantibodies that affect hormones and neuropeptides that regulate appetite control and the stress response. There may be a direct correlation between autoantibody levels and associated psychological traits.^[35][36]

Cerebral cortex of the human brain showing the 4 major lobes, below which are the cerebellum, pons, olive, and medulla oblongata

• infection:PANDAS, is an abbreviation for Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections. Children with PANDAS "have Obsessive Compulsive Disorder (OCD) and/or tic disorders such as Tourette's Syndrome, and in whom symptoms worsen following infections such as "Strep throat" and Scarlet Fever." (NIMH) There is a possibility that PANDAS may be a precipitating factor in the development of Anorexia nervosa in some cases, (PANDAS AN).^[37]
• lesions:studies have shown that lesions to the right frontal lobe or temporal lobe can cause the pathological symptoms of an eating disorder^[38][39][40]
• tumors:tumors in various regions of the brain have been implicated in the development of abnormal eating patterns.^{[41][42][43][44][45]}
• brain calcification: a study highlights a case in which prior calcification of the right thalumus may have contributed to development of anorexia nervosa.^[46]

• somatosensory homunculus; is the representation of the body located in the somatosensory cortex, first described by renowned neurosurgeon Wilder Penfield. The illustration was originally termed "Penfield's Homunculus", homunculus meaning little man. "In normal development this representation should adapt as the body goes through its pubertal growth spurt. However, in AN it is hypothesized that there is a lack of plasticity in this area, which may result in impairments of sensory processing and distortion of body image". (Bryan Lask, also proposed by VS Ramachandran)
• Obstetric complications. There have been studies done which show maternal smoking, obstetric and perinatal complications such as maternal anemia, very pre-term birth (32<wks.), being born small for gestational age, neonatal cardiac problems, preeclampsia, placental infarction and sustaining a cephalhematoma at birth increase the risk factor for developing either anorexia nervosa or bulimia nervosa. Some of this developmental risk as in the case of placental infarction, maternal anemia and cardiac problems may cause intrauterine hypoxia, umbilical cord occlusion or cord prolapse may cause ischemia, resulting in cerebral injury, the prefrontal cortex in the fetus and neonate is highly susceptible to damage as a result of oxygen deprivation this has been shown to contribute to executive dysfunction, ADHD, and may affect personality traits associated with both eating disorders and comorbid disorders such as impulsivity, mental rigidity and obsessionality. The problem of perinatal brain injury, in terms of the costs to society and to the affected individuals and their families, is extraordinary." (Yafeng Dong, PhD) ^{[47][48][49][50][51][52][53][54][55][56][57]}

Psychological

Eating disorders are classified as Axis I^[58] disorders in the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-IV). Published by The American Psychiatric Association. There are various other psychological issues that may factor into eating disorders, some fulfill the criteria for a separate Axis I diagnosis or a personality disorder which is coded Axis II and thus are considered comorbid to the diagnosed eating disorder. Axis II disorders are subtyped into 3 "clusters", A, B and C.The causality between personality disorders and eating disorders has yet to be fully established.^[59] Some people have a previous disorder which may increase their vulnerability to developing an eating disorder.^[60][61][62] Some develop them afterwards.^[63] The severity and type of eating disorder symptoms have been shown to affect comorbidity.^[64] The DSM-IV should not be used by laypersons to diagnose themselves, even when used by professionals there has been considerable controversy over the diagnostic criteria used for various diagnoses, including eating disorders. There has been controversy over various editions of the DSM including the latest edition DSM-V due in May 2013.^{[65][66][67][68][69]}

Personality traits

There are various childhood personality traits associated with the development of eating disorders.^[84] During adolescence these traits may become intensified due to a variety of physiological and cultural influences such as the hormonal changes associated with puberty, stress related to the approaching demands of maturity and socio-cultural influences and perceived expectations, especially in areas that concern body image. Many personality traits have a genetic component and are highly heritable. Maladaptive levels of certain traits may be acquired as a result of anoxic or traumatic brain injury, neurodegenerative diseases such as Parkinson's disease, neurotoxicity such as lead exposure, bacterial infection such as Lyme disease or viral infection such as Toxoplasma gondii as well as hormonal influences. While studies are still continuing via the use of various imaging techniques such as fMRI; these traits have been shown to originate in various regions of the brain^[85] such as the amygdala^[86][87] and the prefrontal cortex^[88] Disorders in the prefrontal cortex and the executive functioning system have have been shown to affect eating behavior.^[89][90]

Personality Traits
The Big Five personality traits	The "Big Five" also referred to as the "Five-Factor Model" are five broad factors (dimensions) of personality, that are based upon empirical research. A mnemonic device to remember them is the acronym "OCEAN". Two of the tests to measure the Big Five are the "Big Five Inventory" and the IPIP (International Personality Item Pool ) an abbreviated form is the "IPIP-NEO". The BFI and the IPIP-NEO are available free online for noncommercial purposes. see; external links [91]
1.Openness to Experience/Intellect	Composed of two related but seperable traits, Openness to Experience and Intellect. Behavioral aspects include having wide interests, and being imaginative and insightful, correlated with activity in the dorsolateral prefrontal cortex. Considered primarily a cognitive trait.[92]
2.conscientiousness	Scrupulous, meticulous, principaled behavior guided or conforming to one's own conscience. Associated with the dorsolateral prefrontal cortex. Anorexics are noted to have higher levels of conscientiousness.[93][94][95]
3.extroversion amygdala	Gregarious, outgoing, sociable, projecting one's personality outward. The opposite of extroversion is introversion. Extroversion has shown to share certain genetic markers with substance abuse. Extroversion is associated with various regions of the prefrontal cortex and the amygdala.[96][97][98]
4.agreeableness	Refers to a compliant, trusting, empathic, sympathetic, friendly and cooperative nature.[99][100][101]
5.neuroticism thalamus	"Refers to an individual’s tendency to become upset or emotional" (Hans Eysenck) "Neuroticism is the major factor of personality pathology" (Eysenck & Eysenck, 1969). Neuroticism has a been linked to serotonin transporter (5-HTT) binding sites in the thalamus: as well as activity in the insular cortex.[102][103][104]
self esteem (low)	A "favorable or unfavorable attitude toward the self (Rosenberg, 1965)."An individual's sense of his or her value or worth, or the extent to which a person values, approves of, appreciates, prizes, or likes him or herself" (Blascovich & Tomaka, 1991).[105][106][107]
harm avoidance	A tendency towards shyness, being fearful and uncertain, tendency to worry. Neonatal complications such as preterm birth have been shown to affect harm avoidance. Those with BED, AN, and BN exhibit high levels of harm avoidance. The volume of the left amygdala in girls was correlated to levels of HA, in separate studies HA was correlated with reduced grey matter volume in the orbito-frontal, occipital and parietal regions.[108][109][110][111]
novelty seeking	Impulsive, exploratory, fickle, excitable, quick-tempered, and extravagant. Associated with addictive behavior.
perfectionism	"I don't think needing to be perfect is in any way adaptive" (Paul Hewitt, PhD) Socially prescribed perfectionism-"believing that others will value you only if you are perfect." Self-oriented perfectionism-"an internally motivated desire to be perfect. Perfectionism is one of the traits associated with obsessional behavior and like obsessionality is also believed to be regulated by the basal ganglia.[112][113][114].
Alexithymia insular cortex	The inability to express emotions."To have no words for one's inner experience"(Rený J. Muller Ph. D).In studies done with stroke patients, alekithymia was found to be more prevalent in those who developed lesions in the right hemisphere following a cerebral infarction. There is a positive association with Post Traumatic Stress Disorder (PTSD), childhood abuse and neglect and alekithymia. Utilizing psychometric testing and fMRI, studies showed positive response in the insula, posterior cingulate cortex (PCC), and thalamus.[115][116][117]
rigidity frontal lobe	Inflexibility, difficulty making transitions, adherence to set patterns. Mental rigidity arises out of a deficit of the executive functions. Originally termed frontal lobe syndrome it is also referred to as dysexecutive syndrome and usually occurs as a result of damage to the frontal lobe. This may be due to physical damage as in the famous case of Phineas Gage, or due to the effects of a disease such as Huntington's disease or an hypoxic or anoxic insult[118][119] [120][121]
impulsivity inferior frontal gyrus	Risk taking, lack of planning, and making up one’s mind quickly (Eysenck and Eysenck). A component of disinhibition. Abnormal patterns of impulsivity have been linked to lesions in the right inferior frontal gyrus and in studies done by Antonio Damasio author of Descartes Error, damage to the ventromedial prefrontal cortex has been shown to cause a defect in real-life decision making in individuals with otherwise normal intellect. Those who sustain this type of damage are oblivious to the future consequences of their actions and live in the here and now.[122][123].[124][125]:[126][127]
disinhibition orbitofrontal cortex	Behavioral disinhibition is an inability or unwillingness to constrain impulses, it is key component of executive functioning. Researchers have emphasized poor behavioural inhibition as the central impairment of ADHD. May symptomatic of orbitofrontal lobe syndrome a subtype of frontal lobe syndrome which may be an acquired disorder as a result of traumatic brain injury, Hypoxic Ischaemic Encephalopathy (HIE), anoxic encephalopathy, degenerative diseases such as Parkinson's, bacterial or viral infection such as Lyme disease and neurosyphilis. Disinhibition has been consistently associated with substance abuse disorders, obesity, higher BMI, excessive eating, an increased rate of eating, and perceived hunger.[128][129][130][131][132][133][134][135]
obsessionality basal ganglia	Persistent often unwelcome and frequently disturbing ideas, thoughts, images or emotions, rumination, often inducing an anxious state. Obsessionality may result as a dysfunction of the basal ganglia [136][137][138]

Environmental

Child maltreatment

Child abuse which encompasses physical, psychological and sexual abuse, as well as neglect has been shown by innumerable studies to be a precipitating factor in a wide variety of psychiatric disorders including eating disorders. Children who are subjugated to abuse may develop a disordered eating pattern in an effort to gain some sense of control or for a sense of comfort. Or they may be in an environment where the diet is unhealthful or insufficient.

Child abuse and neglect can cause profound changes in both the physiological structure and the neurochemistry of the developing brain. Children who as wards of the state were placed in orphanages or foster homes are especially susceptible to developing a disordered eating pattern. In a study done in New Zealand 25% of the study subjects in foster care exhibited an eating disorder. (Tarren-Sweeney M. 2006) An unstable home environment is detrimental to the emotional well-being of children, even in the absence of blatant abuse or neglect the stress of an unstable home can contribute to the development of an eating disorder.^{[139][140][141] [142][143][144][145][146][147]}

Social isolation

Social isolation has been shown to have a deleterious effect on an individuals' physical and emotional well-being. Those that are socially isolated have a higher mortality rate in general as compared to individuals that have established social relationships. This effect on mortality is markedly increased in those with pre-existing medical or psychiatric conditions, this has been especially noted in cases of coronary heart disease. "The magnitude of risk associated with social isolation is comparable with that of cigarette smoking and other major biomedical and psychosocial risk factors." ( Brummett et al.)

Social isolation can be inherently stressful, depressing and anxiety provoking. In an attempt to ameliorate these distressful feelings an individual may engage in emotional eating in which food serves as a source of comfort. The loneliness of social isolation and the inherent stressors thus associated have been implicated as triggering factors in binge eating as well.^{[148][149][150][151]}

Parental influence

Parental influence has been shown to be an intrinsic component in developing the eating behaviors of children. This influence is manifested and shaped by a variety of diverse factors such as familial genetic predisposition, dietary choices as dictated by cultural or ethnic preferences, the parents' own body shape and eating patterns, the degree of involvement and expectations of their children's eating behavior as well as the interpersonal relationship of parent and child. This is in addition to the general psychosocial climate of the home and the presence or absence of a nurturing stable environment. It has been shown that maladaptive parental behavior has an important role in the development of eating disorders. As to the more subtle aspects of parental influence it has been shown that eating patterns are established in early childhood and that children should be allowed to decide when their appetite is satisfied as early as the age of two. A direct link has been proven between obesity and parental pressure to eat more.

Coercive tactics in regard to diet have not been proven to be efficacious in controlling a child's eating behavior. Affection and attention have been shown to affect the degree of a childs' finickiness and their acceptance of a more varied diet.^{[152] [153] [154][155][156][157]}

Peer pressure

In various studies such as one conducted by The McKnight Investigators, peer pressure was shown to be a significant contributor to body image concerns and attitudes toward eating among subjects in their teens and early twenties.

Eleanor Mackey and co-author, Annette M. La Greca of the University of Miami, studied 236 teen girls from public high schools in southeast Florida. "Teen girls' concerns about their own weight, about how they appear to others and their perceptions that their peers want them to be thin are significantly related to weight-control behavior," says psychologist Eleanor Mackey of the Children's National Medical Center in Washington and lead author of the study. "Those are really important."

Dieting among adolescents was also reported to being influenced by peer behavior. With many of those individuals on a diet reporting that their friends also were dieting. The number of friends dieting and the number of friends who pressured them to diet also played a significant role in their own choices.^{[158] [159] [160][161]}

Cultural pressure

There is a cultural emphasis on thinness which is especially pervasive in western society. There is an unrealistic stereotype of what constitutes beauty and the ideal body type as portrayed by the media, fashion and entertainment industries."The cultural pressure on women to be thin is an important predisposing factor for the development of eating disorders" (Bryan Lask, PhD) ^{[162] [163]}

Eating disorders in men

There has been an increasing rate of males suffering from various eating disorders including anorexia nervosa. There is a perceived stigma attached, as eating disorders are generally viewed as primarily affecting women. Among men the rates of eating disorders are higher in the gay and bi-sexual communities (Feldman & Meyer, 2007), yet it also affects heterosexual men. Despite the perceived stigma, some high profile male celebrities have publicised their struggles with eating disorders such as actor Dennis Quaid, who struggled with what he called "manorexia" for which he sought treatment. Quaid said his problems began when he went on a diet to lose forty pounds to play Doc Holliday in the movie "Wyatt Earp" in 1994. Billy Bob Thornton has also struggled with anorexia, once losing 59 lbs.Thomas Holbrook, M.D., is Clinical Director of the Eating Disorders Program at Rogers Memorial Hospital in Oconomowoc, Wisconsin despite being a psychiatrist specializing in eating disorders, he suffered from anorexia nervosa with compulsive exercising. At one time the 6-ft.-tall psychiatrist weighed just 135 lbs. "I was terrified," he says, "of being fat." His story has been chronicled in various publications including USA Today and People Magazine.

Signs

Anorexia-Bulimia

Anorexia nervosa (AN) is divided into two subtypes restrictive, which doesn't enage in purging behavior and purging type which does. Bulimia nervosa is divided into two subtypes purging and the less common; non purging. There is a tendency for diagnostic "crossover" in which symptoms change over time between the restricting and binge eating/purging anorexia nervosa subtypes and bulimia nervosa.^[164][165] While anorexics are often underweight or below average body weight, bulimics range from a normal weight to even slightly above average weight.

Binge eating

Both bulimics and those with binge eating disorder (BED) engage in binge eating. Those with BED do not engage in any compensatory behavior e.g. they do not purge, use laxatives or engage in compulsive exercise. The binge eating is caused by emotional upset and not by hunger. During these episodes, those affected with BED will consume thousands of calories at once, often in one sitting. Because of the lack of purging, those with BED tend to be overweight or obese, even though persons of normal or average weight can be affected.

Polycystic Ovary Syndrome (PCOS) is the most common endocrine disorder to affect women. Though often associated with obesity it can occur in normal weight individuals. PCOS has been associated with binge eating and bulimic behavior.^{[168][169][170][171][172][173]}

Other eating disorders

Rumination Syndrome

Rumination Syndrome, is characterized by the repeated painless regurgitation of food following a meal which is then either re-chewed, re-swallowed or discarded. It is an under-diagnosed disorder possibly due to the fact that most physicians do not recognize the symptoms of the disorder. While often diagnosed in infants and developmently individuals it also occurs in adults of normal intelligence. An accurate clinical diagnosis is critical in making an accurate diagnosis. The Rome III Consensus Criteria for Rumination Syndrome varies for infants, adolescents and adults. ^{[174][175][176]}

Diabulimia

Diabulimia; not currently a recognized medical condition, is the deliberate manipulation of insulin including withholding shots, by individuals with Type 1 diabetes in an effort to control their weight.^[177] Insulin is an anabolic hormone^[178] that is involved in the metabolism of carbohydrates and lipids (fats).^[179] It helps the body maintain muscle mass, it also encourages fat retention.^[180]

The effects of withholding insulin can lead to severe complications^[181] such as diabetic ketoacidosis. The long term effects can lead to the acceleration of diabetes related complications such as diabetic vasculopathy which may lead to limb amputation.^[182][183]

Food Maintenance Syndrome

Food Maintenance Syndrome is characterized by a set of aberrant eating behaviors of children in foster care it is "a pattern of excessive eating and food acquisition and maintenance behaviors without concurrent obesity", it resembles "the behavioral correlates of Hyperphagic Short Stature". (Tarren-Sweeney M. 2006)^[184] It is hypothesised that this syndrome is triggered by the stress and maltreatment these children are subjected to.

Female Athlete Triad

Female Athlete Triad is a syndrome in which eating disorders/disordered eating behavior, amenorrhoea/oligomenorrhoea and decreased bone mineral density (osteoporosis and osteoenia) are present. Not all patients exhibit all three components of the triad according to recent studies some may have only one or two which increases the difficulty of proper diagnosis and long-term morbidity. The full impact of this disorder may not be realized until menopause when the resultant bone loss is accelerated. The strict criteria for diagnosis have been amended by the American College of Sports Medicine in 2007. The diagnostic criteria are now ascertained on a continuous spectrum instead of the most severe presentation. Disordered eating has been replaced by "optimal energy availability" to "low energy availability with or without an eating disorder". Amenorrhea has been replaced by a spectrum ranging from normal menstruation (eumenorrhea) to "functional hypothalmic amenorrhea", in younger patients delayed primary menstruation may occur. Osteoporosis has been replaced by a spectrum ranging from optimal bone health to osteoporosis.^{[185][186][187]}

Additional eating disorders

• EDNOS
• Pica
• Orthorexia
• Night Eating Syndrome
• Nocturnal Sleep Related Eating Disorder
• Hyperphagia

Symptoms-complications

Symptoms and complications vary according to the nature and severity of the eating disorder^[188]

Diagnosis

The initial diagnosis should be made by a competent medical professional."The medical history is the most powerful tool for diagnosing eating disorders"( American Family Physician).^[196] There are many medical disorders that mimic eating disorders and comorbid psychiatric disorders. All organic causes should be ruled out prior to a diagnosis of an eating disorder or any other psychiatric disorder is made. According to an in depth study conducted by psychiatrist Richard Hall as published in The Archives of General Psychiatry:

• Medical illness often presents with psychiatric symptoms.
• It is difficult to distinguish physical disorders from functional psychiatric disorders on the basis of psychiatric symptoms alone.
• Detailed physical examination and laboratory screening are indicated as a routine procedure in the initial evaluation of psychiatric patients.
• Most patients are unaware of the medical illness that is causative of their psychiatric symptoms.
• The conditions of patients with medically induced symptoms are often initially misdiagnosed as a functional psychosis.^[197]

Medical

PET scan of the human brain.

A consultation with a reputable medical professional who specializes in eating disorders is an indispensable part of both the diagnostic process and treatment. A complete medical and psychosocial history should be provided and a rational and formulaic approach to the diagnosis should be used. Neuroimaging using fMRI, MRI, PET and SPECT scans have been used to detect cases in which a lesion, tumor or other organic condition has been either the sole causative or contributory factor in an eating disorder."Right frontal intracerebral lesions with their close relationship to the limbic system could be causative for eating disorders,we therefore recommend performing a cranial MRI in all patients with suspected eating disorders"(Trummer M et.al.2002)","intracranial pathology should also be considered however certain is the diagnosis of early-onset anorexia nervosa. Second, neuroimaging plays an important part in diagnosing early-onset anorexia nervosa, both from a clinical and a research prospective".(O'Brien et.al.2001).^[198][199]

Without visible images of neuropathology, psychiatric disorders have been a fertile ground for stigma and bizarre propositions, as evidenced by etiologic theories involving “schizophrenogenic”^[200] and “refrigerator mothers". Neuroimaging will clearly establish psychiatric disorders as being “medical”, thereby bringing these disorders into the mainstream in terms of public attitude and, perhaps more importantly, funding for treating these problems.(Derryck H Smith, MD, Canadian Psychiatric Association) In addition to neuroimaging there are a variety of tests that may be performed to diagnosis and assess the effects of an eating disorder.

Psychological

After ruling out organic causes and the initial diagnosis of an eating disorder being made by a medical professional a trained mental health professional aids in the assessment and treatment of the underlying psychological components of the eating disorder and any comorbid psychological conditions. The clinician conducts a clinical interview and may employ various psychometric tests. Some are general in nature while others were devised specifically for use in the assessment of eating disorders. Some of the general tests that may be used are the Hamilton Depression Rating Scale^[233] and the Beck Depression Inventory.^{[234] [235]}

Differential diagnoses

Medical

According to a recent report issued in The Journal of the American Medical Association (JAMA), anywhere from 40,000 to 80,000 deaths in the U.S. are attributable to misdiagnosis in the hospital setting per year. Also in the U.S., deaths due to medical errors are higher than the numbers attributable to the 8th-leading cause of death. More people die in a given year as a result of medical errors than from motor vehicle accidents (43,458), breast cancer (42,297), or AIDS (16,516).^[236]

^[237] These figures do not factor in those misdiagnosed outside the hospital setting or for individuals who present with psychiatric symptoms and receive contraindicated i.e. wrong, mental health care predicated upon poor diagnostic procedure. On average, 32,000 Americans commit suicide per year. 77% had seen a physician and 30% had received mental health counseling in the year prior. In England alone independent of the rest of the United Kingdom an average of four psychiatric patients die, many from suicide and another three suffer serious physical harm each day while under the care of the National Health Service.^{[238][239][240]}

• acute pandysautonomia is one form of an autonomic neuropathy, which are a collection of various syndromes and diseases which affect the autonomic neurons of the autonomic nervous system (ANS). Autonomic neuropathies may be the result of an inherited condition or they may be acquired due to various premorbid conditions such as diabetes and alcoholism, bacterial infection such as Lyme disease or a viral illness. Some of the symptoms of ANS which may be associated with an ED include nausea, dysphagia, constipation, pain in the salivary glands early saiety. It also affects peristalsis in the stomach. ANS may cause emotional instability and has been misdiagnosed as various psychiatric disorders including hysterical neurosis and anorexia nervosa.^[241]
• Mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) is a rare genetic disorder characterized by gastrointestinal dysmotility, severe cachexia progressive external ophthalmoplegia, post-prandial emesis (vomiting after eating), peripheral neuropathy, and diffuse leukoencephalopathy. Onset is prior to age 20 in 60% of cases. ""Miss A" was a 21-year-old Indian woman diagnosed as having treatment-resistant anorexia nervosa." It was subsequently proven to be MNGIE^{[242][243][244]}
• achalasia; There have been cases where achalasia, a disorder of the esophagus which affects peristalsis, has been misdiagnosed as various eating disorders including anorexia nervosa, bulimia nervosa, compulsive eating disorder and obesity related problems. It has been reported in cases where there is sub-clinical manifestation of anorexia nervosa and also in cases where the full diagnostic criteria AN has been met.^[245]
• superior mesenteric artery syndrome: (SMA) syndrome; "is a gastrointestinal disorder characterized by the compression of the third or transverse portion of the duodenum against the aorta by the superior mesenteric artery resulting in chronic partial, incomplete, acute or intermittent duodenal obstruction". It may occur as a complication of AN or as a differential diagnosis. There have been reported cases of a tentative diagnosis of AN, where upon treatment for SMA syndrome the patient is asymptomatic.^[246][247]
  

  

  Borrelia burgdorferi
• Lyme Disease is known as the "great imitator", as it may present as a variety of psychiatric or neurologic disorders including anorexia nervosa. "A 12 year old boy with confirmed Lyme arthritis treated with oral antibiotics subsequently became depressed and anorectic. After being admitted to a psychiatric hospital with the diagnosis of anorexia nervosa, he was noted to have positive serologic tests for Borrelia burgdorferi. Treatment with a 14 day course of intravenous antibiotics led to a resolution of his depression and anorexia; this improvement was sustained on 3 year follow-up."^[248][249] Serologic testing can be helpful but should not be the sole basis for diagnosis. The Centers for Disease Control (CDC) issued a cautionary statement (MMWR 54;125) regarding the use of several commercial tests. Clinical diagnostic criteria has been issued by the CDC (CDC, MMWR 1997; 46: 531-535).
• Addison's Disease; is a disorder of the adrenal cortex which results in decreased hormonal production. Addison's disease, even in subclinical form may mimic many of the symptoms of anorexia nervosa.^[250]
• Simmond's disease (organic hypopituitarism) – "A 20-year-old Japanese man with a hypothalamic tumor which caused hypopituitarism and diabetes insipidus was mistakenly diagnosed as anorexia nervosa because of anorexia, weight loss, denial of being ill, changes in personality, and abnormal behavior resembling the clinical characteristics of anorexia nervosa"(Hotta, M. 1999)
• Celiac Disease is an inflammatory disorder triggered by peptides from wheat and similar grains which cause an immune reaction in the small intestine."information on the role of the gastrointestinal system in causing or mimicking eating disorders is scarce."(Leffler DA et.al.)^[251]
• Gastric adenocarcinoma is one of the most common forms of cancer in the world. Complications due to this condition have been misdiagnosed as an eating disorder.^[252]
• helicobacter pylori is a bacteria which causes stomach ulcers and gastritis and has been shown to be a precipitating factor in the development of gastric carcinomas. It also has an affect on circulating levels of leptin and ghrelin, two hormones which help regulate appetite. Upon successful treatment of helicobacter pylori associated gastritis in pre-pubertal children they showed "significant increase in BMI, lean and fat mass along with a significant decrease in circulating ghrelin levels and an increase in leptin levels" (Pacifico, L)."SUMMARY: H. pylori has an influence on the release of gastric hormones and therefore plays a role in the regulation of body weight, hunger and satiety,"(Weigt J, Malfertheiner P).^[253][254]
• Gall bladder disease which may be caused by inflammation, infection, gallstones, obstruction of the gallbladder or torsion of the gall bladder. Many of the symptoms of gall bladder disease may mimic anorexia nervosa (AN). Laura Daly, a woman from Missouri, suffered from an inherited disorder in which the gall bladder was not properly attached; the resultant complications led to multiple erroneous diagnoses of AN. Upon performance of a CCK test, standard imaging techniques are done with the patient lying prone, in this instance it was done with the patient in an upright position. The gall bladder was shown to be in an abnormal position having flipped over the liver. The gallbladder was removed and the patient has since recovered. The treatment was performed by William P. Smedley, M.D., F.A.C.S.in Pennsylvania.
• colonic tuberculosis misdiagnosed as anorexia nervosa in a physician at the hospital where she worked. "This patient, who had severe wasting, was misdiagnosed as having anorexia nervosa despite the presence of other symptoms suggestive of an organic disease, namely, fever and diarrhea"(Madani, A 2002).^[255]
• Crohn's Disease: "We report three cases of young 18 to 25 year-old girls, initially treated for anorexia nervosa in a psychiatric department. Diagnosis of Crohn's disease was made within 5 to 13 years."(Blanchet C, Luton JP. 2002)"This disease should be diagnostically excluded before accepting anorexia nervosa as final diagnosis". (Wellmann W et al.)^{[256][257][258][259]}
• Insulinomas, are (pancreatic tumors) that cause an overproduction of insulin causing hypoglycemia. Various neurological deficits have been ascribed to this condition including misdiagnosis as an eating disorder.^{[260][261][262][263][264]}
• hypothyroidism, hyperthyroidism, hypoparathyroidism and hyperparathyroidism may mimic some of the symptoms of, can occur concurrently with, be masked by or exacerbate an eating disorder.^{[265][266][267][268][269][270][271][272]}
• Multiple sclerosis (Encephalomyelitis disseminata) is a progressive autoimmune disorder in which the protective covering (myelin sheath) of nerve cells is damaged as a result of inflammation and resultant attack by the bodies own immune system. In its initial presentation MS has been misdiagnosed as an eating disorder.^[273]
• cestodes (tapeworm) infestations can affect various regions of the human body including the gastrointestinal and neuroendocrine systems. While most of those infected are asymptomatic, infestations can cause psychiatric symptoms, epilepsy, megoblastic anemia, weight gain or loss.
  • Cysticercosis is an infection caused by the larval stage of the pork tapeworm (Taenia solium). The larval stage of T. solium can create cysts in various regions of the body including the brain (neurocysticercosis). Hypothalimic cysticercosis has been associated with obesity. Cysts may form in the bile and pancreatic ducts causing full or partial obstruction some of the symptoms may include weight loss, anorexia, or increased appetite.^[274][275]

Differential diagnoses/ Comorbid medical disorders

There are multiple medical conditions which may misdiagnosed as a primary psychiatric disorder. These may have have a synergistic effect on conditions which mimic an eating disorder or on a properly diagnosed ED. They also may make it more difficult to diagnose and treat an ED.

• Lupus: 19 psychiatric conditions have been associated with systemic lupus erythematosus (SLE), including depression and bipolar disorder.^[276]
• Toxoplasma seropositivity even in the absence of symptomatic toxoplasmosis has been linked to changes in human behavior and psychiatric disorders including those comorbid with eating disorders such as depression. In reported case studies the response to antidepressant treatment improved only after adequate treatment for toxoplasma.^[277]
• neurosyphilis;It is estimated that their may be up to one million cases of untreated syphyilis in the U.S. alone. "the disease can present with psychiatric symptoms alone, psychiatric symptoms that can mimic any other psychiatric illness". Many of the manifestations may appear atypical. Up to 1.3% of short term psychiatric admissions may be attributable to neurosyphilis, with a much higher rate in the general psychiatric population. Neurosyphilis like Lyme Disease has been given the appellation the "great imitator" for it may present in various ways such as depression and chronic alcoholism. (Ritchie, M Perdigao J,)^[278]
• dysautonomia a term used to describe a wide variety of autonomic nervous system (ANS) disorders may cause a wide variety of psychiatric symptoms including anxiety, panic attacks and depression. Dysautonomia usually involves failure of sympathetic or parasympathetic components of the ANS system but may also include excessive ANS activity. Dysautonomia can occur in conditions such as diabetes and alcoholism.

Differential diagnoses/Comorbid psychological disorders

There are separate psychological disorders which may be misdiagnosed as an eating disorder.

• Emetophobia is an anxiety disorder characterized by an intense fear of vomiting. A person so afflicted may develop rigorous standards of food hygiene, such as not touching food with their hands. They may become socially withdrawn to avoid situations which in their perception may make them vomit. Many who suffer from emetophobia are diagnosed with anorexia or self-starvation. In severe cases of emetophobia they may drastically reduce their food intake.^[279][280]
• phagophobia is an anxiety disorder characterized by a fear of eating, it is usually initiated by an adverse experience while eating such as choking or vomiting. persons with this disorder may present with complaints of pain while swallowing.^[281]
• Body dysmorphic disorder (BDD) is listed as a somatoform disorder that affects up to 2% of the population. BDD is characterized by excessive rumination over an actual or perceived physical flaw. BDD has been diagnosed equally among men and women. While BDD has been misdiagnosed as anorexia nervosa, it also occurs comorbidly in 39% of eating disorder cases. BDD is a chronic and debilitating condition which may lead to social isolation, major depression and suicidal ideation and attempts. Neuroimaging studies to measure response to facial recognition have shown activity predominately in the left hemisphere in the left lateral prefrontal cortex, lateral temporal lobe and left parietal lobe showing hemispheric imbalance in information processing. There is a reported case of the development of BDD in a 21 year old male following an inflammatory brain process. Neuroimaging showed the presence of new atrophy in the frontotemporal region.^{[282][283][284][285][286]}

Treatment

Treatment varies according to type and severity of eating disorder. Usually more than one treatment option is utilized.^[287] Some of the treatment methods are:

• Cognitive Behavioral Therapy(CBT)^{[288][289][290]} is an evidence based approach. The basic premise is that a person's thoughts cause their feelings and behaviors not external stimulus like other people, situations or events in a persons life. The rational is to change how a person thinks and reacts to a situation even if the situation itself does not change. CBT has been shown to be efficacious in the treatment of bulimia nervosa.
  • Dialectical Behavior Therapy is a form of CBT developed by Marsha M. Linehan, PhD.^[291]
• Family Therapy^[292]
  • Maudsley Family Therapy; The Maudsley model of family-based treatment for anorexia nervosa, was developed in the 1980s (Dare, 1985), it utilizes a variety of family therapy models and is designed for use with adolescents 18 and under who are living with their families. It is an evidence based approach designed as an aggressive intervention within three years of the onset of anorexia nervosa and bulimia nervosa.^[293][294]
• Behavioral Therapy; focuses on gaining control and changing unwanted behaviors.^[295]
• Interpersonal Psychotherapy (IPT); "The current treatment of IPT was developed by the late Gerald Klerman and Myrna Weissman in the 1980s as a means of operationalising the interpersonal approach to psychotherapy for a series of treatment studies in depression conducted in the United States. Since that time it has been modified for a variety of other indications including Dysthymia, Bulimia Nervosa, Substance Misuse ,Somatization and depression in a variety of clinical settings. Preliminary studies in Anorexia Nervosa, Bipolar Disorder, PTSD and some anxiety disorders are underway. In each adaptation the fundamentals of the treatment manual are adhered to, however different components are emphasized." (International Society for Interpersonal Psychotherapy)^[296]
• Art Therapy; is the therapeutic use of art. The American Art Therapy Association describes art therapy "as a belief that individuals can resolve conflicts, develop interpersonal skills, and gain self-esteem and insight through the creative process of artistic self-expression".^[297]
• Nutrition counseling^[298]
• Medical Nutrition Therapy; Medical nutrition therapy (MNT) also referred to as Nutrition Therapy is the development and provision of a nutritional treatment or therapy based on a detailed assessment of a person's medical history, psychosocial history, physical examination, and dietary history.^{[299][300][301]}
• Medication; there are currently medications developed for use in obesity treatment such as Orlistat. To date there are none specifically designed for use in either anorexia or bulimia nervosa although olanzapine has shown promise in various studies for its' propensity to promote weight gain as well as the ability to ameliorate obsessional behaviors concerning weight gain. The Endocrine Research Project has conducted studies with cortisol supplements. Zinc supplements have been shown to be helpful as well.^{[302][303][304][305][306][307]}
• Self help and guided self help have been shown in various studies to be helpful in varying degrees including cost reduction for treatment in An, BN and BED.^{[308][309][310][311]}
  • Self Help Groups; there are various support and self-help groups for eating disorders which may be helpful and can be used in conjunction with professional treatment. Both Eating Disorders Anonymous and Overeaters Anonymous are based on the traditional 12-step program pioneered in Alcoholics Anonymous. In some instances such as with BED, self help groups alone have been shown to be on par with individual therapy.^[312][313]
• Psychoanalysis is a non evidence based approach. While the psychoanalyst Hilde Bruch, the author of "The Golden Cage" helped bring anorexa nervosa to the public consciousness, the discipline has fallen into disrepute. "Alice Eagly, the chairwoman of the psychology department at Northwestern University, explained why: Psychoanalysis is “not the mainstream anymore” and so “we give it less weight.”".

  Psychoanalysis has been accused of having iatrogenic, i.e. harmful tendencies."Psychoanalysis is a great idea in personality, just as long as one is a male, who grew up in a two parent house, who had either a sister or female playmate at a very young age, with a great memory, and who has lots of money and no specific time frame in which one would like one's psychological problems cured." (Popkin, Nathan. NWU)."Psychoanalysis is a spurious, ineffective pseudoscience, Freud's legacy continues to inform a "therapeutic" tradition that destroys people's lives." (Frederick Crews).^[314] In 2004 The French Institute of Health and Medical Research (INSERM) issued an official government funded report on three separate therapeutic approaches. The report was highly critical of the efficacy of psychoanalysis.^[315][316]

Paying for treatment

Unfortunately getting the proper diagnosis and treatment for an eating disorder is expensive.^[317][318] There are few studies on cost effectiveness of various treatment modalities and none on how a patients socioeconomic status affects treatment.^[319] Patients with anorexia nervosa are often discharged early while still underweight due to limitations in health care coverage, which results in relapse and rehospitalization.^[320]

• In the United Kingdom there are about two dozen NHS eating disorders clinics. But quality and access to care depend upon the region the patient lives in. They are also subject to the NICE:guidelines There are several private clinics in the U.K., the average cost is £300 to £500 per day. Occasionally the NHS will cover this cost. The best source of information is the non-profit organization beat.^[321][322]
• In the United States the cost of in treatment is not always fully covered by private insurance. The National Eating Disorders Association provides information on how deal with insurance companies more effectively. Medicaid and Medicare do cover the cost of eating disorder treatment and they are accepted at various hospitals and some private clinics. Quality and accessibility to services vary by state. Some organizations such as The Manna Fund also offer private "scholarships" to help defray the cost.
• In Canada the national health insurance program, often referred to as "Medicare", is composed of 13 provincial and territorial health insurance plans they share certain common features but not all, access and quality of care may be better in certain provinces and not all services are covered. The National Eating Disorder Information Centre (NEDIC) is a non-profit entity that provides information on resources.

Prognosis

There are varying estimates as to the prognosis of individual eating disorders as the criteria used to arrive at the respective conclusions vary. With increasing knowledge as to the causes of individual eating disorders and which treatment options prove to be the most efficacious, the remission rates and ultimately full recovery rates rise.

• anorexia nervosa (AN);for AN the remission rate has been placed between 75%-83%, with varying estimates as to the full recovery rate. Dr. Walter Vandereycken a noted expert in the field chooses to be optimistic in his prognostic assessment and places the potential recovery rate at 70%.^[323]
• bulimia nervosa (BN); for BN the remission rate has been placed as high as 75%^[324] In a 7.5 year follow-up study done by Herzog et al. at the Harvard Medical School the full recovery rate for BN was 74%, 99% of those with BN achieved at least partial recovery.^[325]
• binge eating disorder (BED); the outcomes of studies on BED treatment were predicated on the absence of binge eating episodes at 6mo. and 12mo. followup, the rate in this study was 51.7%. The reduction of binge eating episodes was 88.3%.^[326]

Bibliography

• Anorexia Misdiagnosed Publisher:Laura A. Daly; 1st edition (December 15, 2006) Language:English ISBN 0938279076 ISBN 978-0938279075
• Wasted: A Memoir of Anorexia and Bulimia Marya Hornbacher. Publisher: Harper Perennial; 1 edition (January 15, 1999) Language: English ISBN 0060930934 ISBN 978-0060930936
• Anorexia Nervosa and Related Eating Disorders in Childhood and Adolescence By Bryan Lask, Rachel Bryant-Waugh Publisher: Psychology Press; 2 edition (October 12, 2000) ISBN 0863778046 ISBN 978-0863778049
• Too Fat or Too Thin?: A Reference Guide to Eating Disorders; Cynthia R. Kalodner. Publisher: Greenwood Press; 1 edition (August 30, 2003) Language: English ISBN 0313315817 ISBN 978-0313315817
• Overcoming Binge Eating; Christopher Fairburn. Publisher: The Guilford Press; Reissue edition (March 10, 1995) Language:English ISBN 0898621798 ISBN 978-0898621792
• The Great Starvation Experiment: Ancel Keys and the Men Who Starved for Science. By Todd Tucker. (Minneapolis: University of Minnesota Press, 2006. ISBN 9780816651610.)
• The Golden Cage: The Enigma of Anorexia Nervosa: Hilde Bruch. Publisher: Vintage (March 12, 1979) Language: English ISBN 039472688X ISBN 978-0394726885
• Phantoms in the Brain : Probing the Mysteries of the Human Mind, VS Ramachandran, Sandra Blakeslee, Publisher: Harper Perennial (August 18, 1999) Language:English ISBN 0688172172 ISBN 978-0688172176
• Psychiatric Aspects of ImpulsivityF. Gerard Moeller, M.D., Ernest S. Barratt, Ph.D., Donald M. Dougherty Am J Psychiatry 158:1783-1793, November © 2001 American Psychiatric Association
• Blascovich, J., & Tomaka, J. (1991). Measures of self-esteem. In J. P. Robinson, P. R. Shaver, & L. S. Wrightsman (Eds.) Measures of personality and social psychological attitudes, Volume I. San Diego, CA: Academic Press.
• Rosenberg, M. (1965). Society and the adolescent self-image. Princeton, NJ: Princeton University Press.Abstract
• The many faces of perfectionism, The need for perfection comes in different flavors, each associated with its own set of problems, researchers say. By ETIENNE BENSON. Monitor Staff, November 2003, Vol 34, No. 10 Print version: page 18Article
• Psychiatric Times. July 1, 2000 Vol. 17 No. 7 When a Patient Has No Story To Tell: Alexithymia Rený J. Muller, Ph.D. Article
• A test of behavioral rigidity. Schaie, K. Warner The Journal of Abnormal and Social Psychology. Vol 51(3), Nov 1955, 604-610.Article
• Stewin, L (September 1983). "The concept of rigidity: An enigma". Advancement of Counselling 6 (3): 227–232. doi:10.1007B/F00124273. 
• Waniek C; Prohovnik I; Kaufman MA; Dwork AJ Rapidly progressive frontal-type dementia associated with Lyme disease. New York State Psychiatric Institute, NY 10032, USA.J Neuropsychiatry Clin Neurosci 1995 Summer;7(3):345-7 Abstract
• William Sheehan, Steven Thurber. Anorexia Nervosa: A Suggestion for an Altruistic Paradigm from an Evolutionary Perspective. Article
• Forman-Hoffman VL, Cunningham CL Geographical clustering of eating disordered behaviors in U.S. high school students Int J Eat Disord. 2008 Apr;41(3):209-14.PMID 18027858 U.S. Govt. Funded
• Decline and Fall of the Freudian Empire by Hans Eyesneck Publisher:Transaction Publishers; Revised edition (August 13, 2004) Language: English ISBN 0765809451 ISBN 978-0765809452
• The lengthening hour: Time and the demise of psychoanalysis as therapy. Social Science & Medicine, Volume 20, Issue 9, 1985, Pages 939-943 Kenneth P. Starkey
• Madness on the couch: blaming the victim in the heyday of psychoanalysis By Edward Dolnick Publisher: Simon & Schuster; 1 edition (October 7, 1998) Language: English ISBN 0684824973 ISBN 978-0684824970

See also

• Marya Hornbacher
• Minnesota Starvation Experiment
• Adi Barkan
• Obesity

References

External links

• Dying to Be Thin on PBS
• The Big Five Inventory Online Test
• The IPIP-NEO Online Test
• Body Mass Index Calculator
• National Association of Anorexia Nervosa and Associated Disorders
• National Eating Disorders Association
• Overeaters Anonymous
• Academy for Eating Disorders
• Eating disorders at the Open Directory Project

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