Eating disorders: anorexia nervosa, bulimia nervosa, binge eating disorder and eating disorders in children

Eating disorders (ICD-10: F50) are mental health conditions in which eating behaviour has changed permanently and no longer serves to satisfy hunger, but is increasingly used as a means of coping with internal conflicts. Those affected are almost constantly preoccupied with food, body weight and their own figure. Eating is often associated with compulsive behaviours that are very difficult to break free from on one’s own.

Depending on the symptoms, three main types of eating disorder are generally distinguished: anorexia nervosa, bulimia and binge-eating disorder. In addition, there are mixed forms in which those affected exhibit characteristics of different clinical pictures, such as atypical bulimia or atypical anorexia.

Another, rarer form is pica syndrome, which occurs primarily in people with developmental delays, intellectual disabilities or dementia and is characterised by the ingestion of non-edible substances such as soil or paper.

The central feature of anorexia is a pathological need to continually reduce one’s body weight, combined with a pronounced fear of weight gain. In bulimia nervosa, colloquially known as binge-purge disorder, sufferers are usually of normal weight but tend to experience weight fluctuations and recurrent binge-eating episodes followed by vomiting. Binge-eating disorder is also characterised by recurrent binge eating episodes, without those affected subsequently resorting to compensatory behaviours such as vomiting or the use of laxatives, which can contribute to overweight and obesity in the long term.

Eating disorders usually arise from a combination of several factors. Psychological stress, low self-esteem, family conflicts and social pressure stemming from a particular ideal of beauty often play a role in the development of eating disorders. Biological and genetic factors are also under discussion.

Adolescents and young adults are particularly at risk, as body image and identity play a central role during this stage of life.

However, the problem is also increasingly being observed in younger children, which is why eating disorders in children are receiving greater attention from experts.

The symptoms vary depending on the type of eating disorder, but they share common features: disordered eating behaviour, a distorted perception of one’s own body and, frequently, accompanying psychosomatic symptoms.

Depending on the symptoms, three main types of eating disorder can be distinguished:

• Anorexia
• Bulimia and
• Binge-eating disorder

The most important characteristic of anorexia (anorexia nervosa) is a pathological need to lose weight. Those affected experience an almost panic-like fear of gaining weight.

Consequently, they try to consume as little food as possible. They also ensure that the food they eat contains very few calories. Many patients also engage in frequent and intense physical activity to increase their energy expenditure.

Anorexia is accompanied by a distorted body image. This means that those affected still perceive themselves as being too fat, even when they are extremely underweight.

In the case of bulimia nervosa, on the other hand, those affected are usually of normal weight but tend to experience weight fluctuations. A key characteristic is binge eating followed by self-induced vomiting. Furthermore, patients with eating disorders frequently resort to the uncontrolled use of laxatives.

In binge-eating disorder (episodes of uncontrolled overeating), patients suffer from recurrent binge-eating episodes. However, in this behavioural disorder, those affected do not resort to weight-loss measures. They lose their sense of satiety and control over their food intake. Even if the binge-eating episodes are of short duration, their frequency can lead to obesity.

Furthermore, mixed forms of eating disorders may occur. In such cases, those affected exhibit characteristics of different clinical pictures.

The term used to describe this is, for example:

• atypical bulimia or
• atypical anorexia

Another eating disorder is pica syndrome. It occurs in patients with developmental disorders, intellectual disabilities or dementia. These people ingest non-edible substances, such as soil, scraps of paper or faeces.

Eating disorders affect people of all ages and genders, although girls and women continue to be disproportionately affected.

Signs of disordered eating behaviour are relatively common amongst children and adolescents: more than 20 per cent of 11- to 17-year-olds show noticeable symptoms, such as extreme dissatisfaction with their figure and weight or bouts of ravenous hunger. Girls are affected almost twice as often as boys. However, an abnormal screening result does not automatically mean that a clinically diagnosable eating disorder is present

Eating disorders in children are still frequently overlooked in clinical practice, as disturbed eating behaviour in young people is not necessarily perceived as a distinct condition at first. Yet the first signs can already be seen as early as primary school age, such as increasingly fussy or restrictive eating habits, concerns about one’s own body weight, or a noticeable avoidance of certain meals. As children are unable to clearly articulate their thoughts and fears regarding food and their bodies, parents and carers often do not notice the relevant signs until it is too late.

An early onset of the condition, particularly before the age of 11, is considered a poor prognostic factor for its subsequent course. At the same time, a child’s body is still in the midst of growth, which is why nutritional deficiencies and persistent underweight can have particularly serious consequences for physical development. Paediatricians and specialist centres for child and adolescent psychiatry therefore play a key role in recognising eating disorders in children at an early stage and initiating age-appropriate treatment, which usually involves the family closely.

The doctor makes the diagnosis based on the patient’s medical history and a physical examination.

They assess underweight, overweight and obesity using the Body Mass Index (BMI). The BMI indicates the relationship between a person’s body weight and height.

In the case of anorexia, body weight is at least 15 per cent below normal weight. In girls or women, menstruation often ceases, and hair loss and damage to the teeth may occur.

For a diagnosis of bulimia, binge-eating episodes must occur at least twice a week for a period of at least three months. In addition, cardiac and circulatory disorders, kidney disease and gastrointestinal disorders may occur. 

For binge-eating disorder, at least three of the following five criteria must be met:

• Eating without feeling hungry
• eating excessively quickly
• Eating until a feeling of fullness sets in
• eating alone due to feelings of guilt
• Emotions such as depression, disgust or shame following binge episodes

The Munich-based organisation ANAD e.V. Eating Disorders Support Centre offers a self-assessment test for eating behaviour. Please note: A self-assessment test provides only a rough guide. It is by no means a substitute for seeing a doctor.

The treatment of eating disorders is based on two pillars:

• Psychotherapy and
• nutritional therapy

This can be provided on an outpatient or inpatient basis. In particularly severe cases, there is the option of longer-term treatment in therapeutic residential groups.

Main aims of the treatment:

• Learning normal eating behaviour
• Stabilising body weight
• Restoring a positive body image
• Developing a normal sense of hunger and satiety
• Regaining a sense of joy and pleasure in eating

Psychotherapy focuses primarily on treating the symptoms of abnormal eating behaviour. These include, first and foremost, starvation, vomiting, binge eating and low self-esteem.

As far as possible, the therapist and patient should identify the causes of the disordered behaviour and restore psychological balance.

In addition to cognitive behavioural therapy, systemic family therapy is also used. This enables those affected to take responsibility for their own eating behaviour and body weight.

Family-centred treatment is particularly suitable for young people who still live at home. In this context, it is helpful to involve the whole family in resolving the problems caused by the eating disorder.

Nutritional therapy aims to educate those affected about the symptoms and consequences of disordered eating behaviour.

In addition, experts provide guidance on:

• a structured meal plan
• optimal portion sizes and
• healthy foods

Outpatient therapy

Outpatient treatment takes place several times a week with a practising psychotherapist.

The following criteria should be met:

• a BMI above 15
• regular weight gain in cases of underweight
• no significant bulimic symptoms (such as severe binge eating, frequent vomiting, heavy misuse of laxatives)
• Evidence of insight and motivation to change eating behaviour
• no risk of suicide
• A stable social support network

Regional self-help groups offer additional support for those affected. It is essential to ensure that a suitable person facilitates the meetings.

Qualified group leaders may be people affected by the condition who have dealt extensively with their illness and are stable. There are also professionally facilitated groups, led by social workers or psychotherapists.

Inpatient treatment

Inpatient treatment is indicated for very severe or particularly long-standing eating disorders and may be considered under the following conditions:

• a BMI below 15
• rapid weight loss that also persists over a longer period
• significant bulimic symptoms (for example, severe binge eating and frequent vomiting, or heavy misuse of laxatives)
• Risk of suicide
• no stable social support network
• outpatient therapy that has proved unsuccessful

In-patient treatment is often necessary for patients with anorexia, as weight loss is associated with an increased risk of death.

Digital technology in therapy

Leading experts from the scientific community have come together to form the German Society for Eating Disorders (DGESS e.V.). Among other things, they are researching internet-based therapy programmes.

These are used, amongst other things, for aftercare following an inpatient stay. You can find information on the current state of research on the association’s website.

Particularly for younger patients, there is a good chance of recovery if treatment begins at an early stage. If you or a member of your family has an eating disorder, it is important to seek medical advice as soon as possible.

The earlier treatment begins, the more likely it is that weight will return to normal and those affected will regain a normal life expectancy.

In some cases, however, eating disorders remain chronic even with treatment, or relapses may occur.

The prospects of recovery decrease with:

• the onset of the condition before the age of 11
• a low initial weight; and
• a long duration of the eating disorder

Patients with anorexia, in particular, are at risk of dehydration or acute organ failure, which can be fatal.

Family members should therefore recognise the signs of eating disorders as early as possible and arrange for appropriate treatment.