Eating Disorders

The most common eating disorders are Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder. Even though they are different, they are often related.

Anorexia Nervosa is an eating disorder that can cause children and teens to starve themselves. Kids with anorexia think they are too fat, even though others see them as too thin. To keep a very low weight, they eat very little and do things like vomiting on purpose or exercising a lot. They do not understand that their body image is not accurate and that their choices are dangerous.

Anorexia usually starts during the teen years. Because kids with anorexia often do well in school and look like they have the ideal body, it can be hard for caregivers and other adults to notice there’s a problem. Girls are diagnosed much more often than boys, but that could be partly because anorexia is harder to spot in boys.

Anorexia is very serious. The sooner it is treated, the better. If it is not treated, it can lead to serious medical problems or even suicide.

Bulimia Nervosa is an eating disorder where a child or teen has episodes of out-of-control eating called “binging.” After eating too much, the child tries to undo their binging by “purging,” or vomiting on purpose, using laxatives, not eating, or exercising too much. Unlike kids with Anorexia Nervosa, who are usually very thin, kids with only Bulimia Nervosa are usually normal weight or somewhat overweight, but maintaining their weight is very unhealthy.

Binge Eating Disorder, like Bulimia Nervosa, involves episodes of bingeing, during which a child or teen feels they have lost control and cannot stop eating. This is not always a conscious loss of control. Many kids say they were not planning to binge eat; instead, they eat large amounts when they get the chance, like when they are home alone, and “zone out” while eating. Because of this behaviour, kids tend to gain weight. If they realise they are binge eating, they may feel upset because they can’t control their eating and gain weight. But Binge Eating Disorder is sometimes diagnosed in teens seeking weight loss help who do not even know they have an eating disorder.

What are the symptoms of Eating Disorders?

The main sign that a child or teen has Anorexia Nervosa is that they look in the mirror and see themselves as too fat when everyone else sees them as too thin.

Core Symptoms of Anorexia Nervosa

  • Restricted food intake leading to very low body weight
  • Strong fear of gaining weight or becoming fat
  • A disturbance in how the person sees their body weight or shape
  • Body weight or shape has too much influence on self-evaluation
  • Consistent lack of understanding of the seriousness of low body weight

Associated Symptoms of Anorexia Nervosa

  • Extreme dieting or exercising
  • Making themselves vomit or using laxatives (this is called purging)
  • Weak nails or hair loss
  • Constipation
  • Low self-esteem or negative views about oneself
  • Fatigue
  • Mood swings
  • Disturbed menstrual cycle (for girls)

The main signs for Bulimia Nervosa are bingeing and purging behaviours, which kids and teens often hide well, making them hard to spot.

Core Symptoms of Bulimia Nervosa

  • Repeated binge-eating episodes*
  • Repeated inappropriate behaviours to avoid or prevent weight gain, like self-induced vomiting, fasting, or excessive exercise, or using medications (e.g., laxatives, diuretics)
  • Body weight or shape has too much influence on self-evaluation

Associated Symptoms of Bulimia Nervosa

  • Having a self-image that is mostly focused on body weight
  • Missing a lot of meals
  • Rushing to the bathroom right after eating
  • Long periods of not eating
  • Being secretive about eating
  • Physical effects of vomiting, like sore throat, swollen glands, acid reflux, and teeth damaged by stomach acid
  • Low self-esteem or negative views about oneself
  • Mood swings

Binge eating involves consuming large amounts of food very quickly in a short time, even when not hungry, and to the point of being uncomfortable. During the episode of binge eating, there is a sense of lack of control over eating.

Binge Eating Disorder is different from Bulimia Nervosa because the child or teen does not try to counter their binge eating with purging behaviours. The binge eating must happen at least once a week for three months and cause marked distress.

Core Symptoms of Binge Eating Disorder

  • Recurrent binge-eating episodes* with three (or more) of the following:
  • Eating much more quickly than normal
  • Eating until uncomfortably full
  • Eating large amounts when not physically hungry
  • Feeling embarrassed about eating, or eating alone
  • Feeling guilty, depressed, or disgusted with oneself after eating

Associated Symptoms of Binge Eating Disorder

  • Finding certain foods particularly rewarding
  • Hiding food wrappers and containers in the bedroom or other places at home
  • Noticeable weight changes
  • Eating alone
  • Eating at unusual times (often at night)
  • Skipping meals
  • Having a history of eating in response to stress

How are Eating Disorders diagnosed?

Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder are diagnosed by a medical professional and an appropriately trained and experienced child and adolescent mental health professional (psychiatrist or psychologist).

They look at the child’s or teen’s weight and compare it to what is average for their age and gender. They also check the child’s or teen’s behaviours to see if symptoms, like restricted food intake, binging, and/or purging behaviours, are happening.

The doctor may also interview and/or assess both the child or teen and a caregiver to figure out the specific nature of the current eating behaviours. The practitioner will also try to determine that the child’s or teen’s symptoms are not related to something unexpected.

Eating Disorder Facts

Worldwide frequency of the condition:
Eating Disorders, altogether, are estimated to be present in between 0.72% and 1.69% of the world’s population, although the estimates per disorder vary: Anorexia Nervosa ranging from 0.6% to 0.8%, Bulimia Nervosa ranging from 0.28% to 1%, and Binge Eating Disorder from 0.85% to 2.8%. There is no recent, specific data for Greece.

Gender ratio:
Gender comparative data for Eating Disorders varies based on the type of disorder. Generally, females are more likely to be diagnosed than males, at a ratio of about 8:1 for Anorexia Nervosa, 3:1 for Bulimia Nervosa, and 2:1 for Binge Eating Disorder.

Peak age of onset:
The peak age of onset for Eating Disorders, in general, is estimated to be 15.5 years, while the estimates for Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder are 15.5, 15.5, and 19.5 years, respectively.

Proportion of the condition that emerges before age 18:
According to recent data, 48.1% of individuals with an Eating Disorder will have been diagnosed by the time they are 18 years old. Specifically, 55.2% with Anorexia Nervosa, 45.3% with Bulimia Nervosa, and 34.5% with Binge Eating Disorder will have been diagnosed by the time they are 18 years old.
Burden of the condition in South Africa:*

One recent study reporting on the prevalence of Tic Disorder among children and adolescents in South Africa, sampling children between 6 and 16 at a local clinic in one of the South African provinces, reported an incidence of 15.8%.

What are the associated factors for Eating Disorders?

Some common factors linked with Anorexia Nervosa are:

  • Genetic and Familial factors: Having a parent or sibling with the disorder.
  • Emotional factors: These include anxiety, depression, and low self-esteem.
  • Environmental factors: These include doing activities that focus on being thin, such as modelling and sports; excessive use of social media; and high parental demands.
  • Other factors: These include perfectionism, obsessive thinking, and excessive focus on physical appearance.

Some common factors linked with Bulimia Nervosa are:

  • Genetic and Familial factors: Having a parent or sibling with the disorder.
  • Emotional factors: These include anxiety, depression, and low self-esteem.
  • Environmental factors: These include childhood physical or sexual abuse and excessive use of social media.
  • Other factors: These include internalisation of a thin body ideal, weight concerns, and excessive focus on physical appearance.

Some common factors linked with Binge Eating Disorder are:

  • Emotional factors: Experiencing depression, anxiety, stress, or interpersonal difficulties.
  • Responsiveness to food: Being particularly responsive to certain foods as rewards.
  • Executive functioning difficulties: These include poor impulse control and self-regulation skills.

What other disorders co-occur with Eating Disorders?

Even though each child and teen is different, multiple mental health disorders, including bipolar, depressive, and anxiety disorders, might often happen with either Anorexia Nervosa, Bulimia Nervosa, or Binge Eating Disorder. OCD sometimes occurs with individuals with Anorexia Nervosa.

How are Eating Disorders treated?

The first goal for treating Anorexia Nervosa is to get the child or teen to a healthy weight. This may require hospitalisation or a residential program if their health is in danger. Treatment works best when the disorder is caught early.

The most successful therapy for kids and teens with anorexia is family-based therapy (FBT). When the whole family joins in therapy, they learn how to support healthier eating habits at home. The longer a child or teen stays at a healthy weight, the less likely they are to experience Anorexia Nervosa again. Some studies show that individual cognitive-behavioural therapy (CBT), interpersonal therapy (IPT), or group therapy may help, but the evidence for kids is limited.

There are no medications for Anorexia Nervosa. However, a child may be prescribed antidepressants if they also have another disorder like OCD, anxiety, or depression. Treating these disorders with medication can make the therapy for anorexia more successful.

All psychiatric medication needs to be prescribed by a psychiatrist, a medical officer or a psychiatric nurse.

Please refer to the SAHPRA (South African Health Products Regulatory Authority) for up-to-date professional and patient information leaflets on psychiatric or other medication.

For Bulimia Nervosa, psychotherapy is the main treatment. CBT is often used to help reduce the child’s or teen’s concerns about body image, help them understand what triggers binge eating, and change unhealthy eating habits. IPT, which focuses on how the child’s or teen’s relationship with others affects feelings and actions, is also helpful. Lastly, there is some evidence that group psychotherapy may be helpful for kids and teens, but the evidence is limited.

Some antidepressants, especially selective serotonin reuptake inhibitors (SSRIs), can help treat Bulimia Nervosa. Medications can have side effects, but they are safe for kids to use with proper care from their doctor. A child or teen taking one of these medications should see their doctor regularly, especially if their dosage has recently changed.

All psychiatric medication needs to be prescribed by a psychiatrist, a medical officer or a psychiatric nurse.

Please refer to the SAHPRA (South African Health Products Regulatory Authority) for up-to-date professional and patient information leaflets on psychiatric or other medication.

There is evidence that CBT, IPT, and dialectical behaviour therapy (DBT) are effective for treating Binge Eating Disorder, although these treatments have been studied in adults more than kids and teens. In general, these treatments focus on a child’s or a teen’s self-control around eating and strengthening self-control in general.

Some stimulant medications may reduce impulsive behaviours linked with binge eating in Binge Eating Disorder, and some antidepressant SSRIs may reduce binge eating by improving mood.

All psychiatric medication needs to be prescribed by a psychiatrist, a medical officer or a psychiatric nurse.

Please refer to the SAHPRA (South African Health Products Regulatory Authority) for up-to-date professional and patient information leaflets on psychiatric or other medication.

Where to find more information

For more details on eating behaviour and reasons for concerns, visit our guides for caregivers, educators and adolescents.

To learn more about the technical work behind this guide, please see our reference list below.

References

Clinical description, symptoms, and diagnostic information

Facts

  • American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition Text Revision DSM-5-TR. American Psychiatric Association Publishing, Washington, DC.
  • Bourne, L., Bryant-Waugh, R., Cook, J., & Mandy, W. (2020). Avoidant/restrictive food intake disorder: A systematic scoping review of the current literature. Psychiatry Research, 288, 112961. https://doi.org/10.1016/j.psychres.2020.112961
  • Institute for Health Metrics and Evaluation (IHME). (2019). GBD Compare Data Visualization. Seattle, WA: IHME, University of Washington. Available from http://vizhub.healthdata.org/gbd-compare. (Accessed 11/15/2022)
  • Qian, J., Wu, Y., Liu, F., Zhu, Y., Jin, H., Zhang, H., Wan, Y., Li, C., & Yu, D. (2022). An update on the prevalence of eating disorders in the general population: A systematic review and meta-analysis. Eating and Weight Disorders – Studies on Anorexia, Bulimia and Obesity, 27(2), 415–428. https://doi.org/10.1007/s40519-021-01162-z
  • Sanchez‐Cerezo, J., Nagularaj, L., Gledhill, J., & Nicholls, D. (2023). What do we know about the epidemiology of avoidant/restrictive food intake disorder in children and adolescents? A systematic review of the literature. European Eating Disorders Review, 31(2), 226–246. https://doi.org/10.1002/erv.2964
    Robertson, B.A., et al., Prevalence and detection of psychiatric disorders among children and adolescents attending a primary health care clinic. Southern African Journal of Child and Adolescent Mental Health, 2001. 13(1): p. 30-40.+A4:L9
  • Solmi, M., Radua, J., Olivola, M., Croce, E., Soardo, L., Salazar de Pablo, G., Il Shin, J., Kirkbride, J. B., Jones, P., Kim, J. H., Kim, J. Y., Carvalho, A. F., Seeman, M. V., Correll, C. U., & Fusar-Poli, P. (2022). Age at onset of mental disorders worldwide: Large-scale meta-analysis of 192 epidemiological studies. Molecular Psychiatry, 27(1), 281–295. https://doi.org/10.1038/s41380-021-01161-7
  • Van Buuren, L., Fleming, C. A. K., Hay, P., Bussey, K., Trompeter, N., Lonergan, A., & Mitchison, D. (2023). The prevalence and burden of avoidant/restrictive food intake disorder (ARFID) in a general adolescent population. Journal of Eating Disorders, 11(1), 104. https://doi.org/10.1186/s40337-023-00831-x
  • Tanofsky-Kraff, M., Schvey, N. A., & Grilo, C. M. (2020). A developmental framework of binge-eating disorder based on pediatric loss of control eating. American Psychologist, 75(2), 189–203. https://doi.org/10.1037/amp0000592

Associated factors

  • American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition Text Revision DSM-5-TR. American Psychiatric Association Publishing, Washington, DC.
  • Arango, C., Dragioti, E., Solmi, M., Cortese, S., Domschke, K., Murray, R. M., Jones, P. B., Uher, R., Carvalho, A. F., Reichenberg, A., Shin J. I., Andreassen, O. A., Correll, C. U., & Fusar‐Poli, P. (2021). Risk and protective factors for mental disorders beyond genetics: An evidence‐based atlas. World Psychiatry, 20(3), 417–436. https://doi.org/10.1002/wps.20894
  • Bohon, C. (2019). Binge Eating Disorder in Children and Adolescents. Child and Adolescent Psychiatric Clinics of North America, 28(4), 549–555. https://doi.org/10.1016/j.chc.2019.05.003
  • Caslini, M., Bartoli, F., Crocamo, C., Dakanalis, A., Clerici, M., & Carrà, G. (2016). Disentangling the Association Between Child Abuse and Eating Disorders: A Systematic Review and Meta-Analysis. Psychosomatic Medicine, 78(1), 79–90. https://doi.org/10.1097/PSY.0000000000000233
  • Grogan, K., MacGarry, D., Bramham, J., Scriven, M., Maher, C., & Fitzgerald, A. (2020). Family-related non-abuse adverse life experiences occurring for adults diagnosed with eating disorders: A systematic review. Journal of Eating Disorders, 8(1), 36. https://doi.org/10.1186/s40337-020-00311-6
  • Kendler, K. S. (2013). What psychiatric genetics has taught us about the nature of psychiatric illness and what is left to learn. Molecular Psychiatry, 18(10), 1058–1066. https://doi.org/10.1038/mp.2013.50
  • Padín, P. F., González-Rodríguez, R., Verde-Diego, C., & Vázquez-Pérez, R. (2021). Social media and eating disorder psychopathology: A systematic review. Cyberpsychology: Journal of Psychosocial Research on Cyberspace, 15(3). https://doi.org/10.5817/CP2021-3-6
  • Tanofsky-Kraff, M., Schvey, N. A., & Grilo, C. M. (2020). A developmental framework of binge-eating disorder based on pediatric loss of control eating. American Psychologist, 75(2), 189–203. https://doi.org/10.1037/amp0000592

Co-occurring disorders

  • American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition Text Revision DSM-5-TR. American Psychiatric Association Publishing, Washington, DC.
  • Hambleton, A., Pepin, G., Le, A., Maloney, D., National Eating Disorder Research Consortium, Aouad, P., Barakat, S., Boakes, R., Brennan, L., Bryant, E., Byrne, S., Caldwell, B., Calvert, S., Carroll, B., Castle, D., Caterson, I., Chelius, B., Chiem, L., Clarke, S., … Maguire, S. (2022). Psychiatric and medical comorbidities of eating disorders: Findings from a rapid review of the literature. Journal of Eating Disorders, 10(1), 132. https://doi.org/10.1186/s40337-022-00654-2
  • Mandelli, L., Draghetti, S., Albert, U., De Ronchi, D., & Atti, A.-R. (2020). Rates of comorbid obsessive-compulsive disorder in eating disorders: A meta-analysis of the literature. Journal of Affective Disorders, 277, 927–939. https://doi.org/10.1016/j.jad.2020.09.003
  • Filipponi, C., Visentini, C., Filippini, T., Cutino, A., Ferri, P., Rovesti, S., Latella, E., & Di Lorenzo, R. (2022). The Follow-Up of Eating Disorders from Adolescence to Early Adulthood: A Systematic Review. International Journal of Environmental Research and Public Health, 19(23), 16237. https://doi.org/10.3390/ijerph192316237

Interventions

  • Berg, E., Houtzager, L., Vos, J., Daemen, I., Katsaragaki, G., Karyotaki, E., Cuijpers, P., & Dekker, J. (2019). Meta‐analysis on the efficacy of psychological treatments for anorexia nervosa. European Eating Disorders Review, 27(4), 331–351. https://doi.org/10.1002/erv.2683
  • Bohon, C. (2019). Binge Eating Disorder in Children and Adolescents. Child and Adolescent Psychiatric Clinics of North America, 28(4), 549–555. https://doi.org/10.1016/j.chc.2019.05.003
  • Buerger, A., Vloet, T. D., Haber, L., & Geissler, J. M. (2021). Third-wave interventions for eating disorders in adolescence: Systematic review with meta-analysis. Borderline Personality Disorder and Emotion Dysregulation, 8(1), 20. https://doi.org/10.1186/s40479-021-00158-6
  • Chang, P. G. R. Y., Delgadillo, J., & Waller, G. (2021). Early response to psychological treatment for eating disorders: A systematic review and meta-analysis. Clinical Psychology Review, 86, 102032. https://doi.org/10.1016/j.cpr.2021.102032
  • Child Mind Institute. (2024, May 28). What Is ARFID? https://childmind.org/article/what-is-arfid/
  • Correll, C. U., Cortese, S., Croatto, G., Monaco, F., Krinitski, D., Arrondo, G., Ostinelli, E. G., Zangani, C., Fornaro, M., Estradé, A., Fusar‐Poli, P., Carvalho, A. F., & Solmi, M. (2021). Efficacy and acceptability of pharmacological, psychosocial, and brain stimulation interventions in children and adolescents with mental disorders: An umbrella review. World Psychiatry, 20(2), 244–275. https://doi.org/10.1002/wps.20881
  • Linardon, J., Kothe, E. J., & Fuller-Tyszkiewicz, M. (2019). Efficacy of psychotherapy for bulimia nervosa and binge-eating disorder on self-esteem improvement: Meta-analysis. European Eating Disorders Review, 27(2), 109–123. https://doi.org/10.1002/erv.2662
  • Murray, S. B., Quintana, D. S., Loeb, K. L., Griffiths, S., & Le Grange, D. (2019). Treatment outcomes for anorexia nervosa: A systematic review and meta-analysis of randomized controlled trials. Psychological Medicine, 49(4), 535–544. https://doi.org/10.1017/S0033291718002088
  • Slade, E., Keeney, E., Mavranezouli, I., Dias, S., Fou, L., Stockton, S., Saxon, L., Waller, G., Turner, H., Serpell, L., Fairburn, C. G., & Kendall, T. (2018). Treatments for bulimia nervosa: A network meta-analysis. Psychological Medicine, 48(16), 2629–2636. https://doi.org/10.1017/S0033291718001071
  • Thomas, J. J., Wons, O. B., & Eddy, K. T. (2018). Cognitive–behavioural treatment of avoidant/restrictive food intake disorder. Current Opinion in Psychiatry, 31(6), 425–430. https://doi.org/10.1097/YCO.0000000000000454
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