INTRODUCTION TO EATING DISORDERS

Ukraine ECHO

26 June 2025

Suki Conrad, MD

CASE REVIEW

CASE

• 20 year old female
• Difficulty with food intake and fear of eating (likely fear of gaining weight)
• Restricts food types and quantities
• Lack of energy, feeling weak, disrupted bowel movements, skin rashes
• Isolation, self-hatred, guilt
• Sister described as “slim bodied” and aspirational; childhood nickname of “little dumpling;” food as a gesture of love/caring from grandmother
• Family without understanding of the disordered eating behaviors

MY INITIAL QUESTIONS

• When did she first start engaging in disordered eating behaviors?
• Is she engaging in any other behaviors besides restriction – binging, purging, excessive exercise, use of caffeine for diuresis or to suppress appetite, other substances to suppress appetite
• Is she afraid of gaining weight? Of being a certain size? Does she have concerns about specific areas of her body or about her body in general?
• How many hours a day does she spend thinking about food and her body?
• What have her weight trends been over the past 10 years?

WHAT IS AN EATING DISORDER

DISORDERED EATING VERSUS� EATING DISORDER

• Disordered eating describes a range of eating behaviors that may or may not warrant diagnosis of a specific eating disorder
• Frequent dieting, including following “fad” diets
• Rigid routines around food and/or activity
• Focus on “health” benefits or consequences of foods
• Behaviors used to “make up” for “bad” foods consumed
• Compulsive eating or emotional eating
• Lack of food variety
• Fluid loading or fluid restriction
• Excessive or unexpected use of condiments

WHAT IS AN EATING DISORDER

• Brain-based illness causing difficulties in the ability to nourish oneself with or without abnormalities in the way one views/experiences one’s body shape/weight/size
• Eating disorders are not habits, choices, or volitional behaviors
• Eating disorders are highly comorbid with other psychiatric conditions: substance use, depression, anxiety, PTSD, OCD, neurodevelopmental disorders

​

WHAT IS AN EATING DISORDER

• Sociocultural idealization of thinness is the best known environmental contributor to the development of eating disorders
• Eating disorders are highly genetic
• First degree relatives of patient with anorexia nervosa are 11.3x more likely to have anorexia nervosa than controls
• Eating disorders are very common
• A 2023 global study of children and adolescents showed disordered eating as assessed by the SCOFF screening tool to be 22%
• Further elevations were seen in females, older adolescents, and individuals with higher BMI

TEMPERAMENT AND PERSONALITY

• Anxiety, intolerance of uncertainty
• Harm avoidance
• Achievement orientated, perfectionism
• Cognitive rigidity/inflexibility
• Impaired set-shifting

​

• Criticism/rejection sensitivity
• Impulsivity, emotional dysregulation
• Sensation seeking
• Lack of planning
• Poor persistence
• Malnutrition exaggerates traits

POTENTIAL PHYSICAL SIGNS

• Noticeable fluctuations in weight, both up and down
• Stomach cramps, other non-specific gastrointestinal complaints (constipation, acid reflux, etc.)
• Menstrual irregularities
• Difficulties concentrating
• Abnormal laboratory findings (anemia, low thyroid and hormone levels, low potassium, low white and red blood cell counts)
• Dizziness, especially upon standing
• Fainting/syncope
• Sleep problems

​

​

• Cuts and calluses across the top of finger joints
• Dental problems, such as enamel erosion, cavities, and tooth sensitivity
• Dry skin and hair, and brittle nails
• Swelling around area of salivary glands
• Fine hair on body (lanugo)
• Muscle weakness
• Feeling cold and cold, mottled hands and feet or swelling of feet
• Poor wound healing
• Impaired immune functioning

​

POTENTIAL EMOTIONAL AND BEHAVIORAL SIGNS

• Behaviors and attitudes that indicate that weight loss, dieting, and control of food are becoming primary concerns
• Preoccupation with weight, food, calories, carbohydrates, fat grams, and dieting
• Refusal to eat certain foods, progressing to restrictions against whole categories of food
• Appears uncomfortable eating around others
• Food rituals (e.g. eats only a particular food or food group [e.g. condiments], excessive chewing, doesn’t allow foods to touch)

• Skipping meals or taking small portions of food at regular meals
• Any new practices with food or fad diets, including cutting out entire food groups (no sugar, no carbs, no dairy, vegetarianism/veganism)
• Withdrawal from usual friends and activities
• Frequent dieting
• Extreme concern with body size and shape 
• Frequent checking in the mirror for perceived flaws in appearance
• Extreme mood swings

​

NEUROBIOLOGY OF EATING DISORDERS

NEUROLOGICAL CHANGES

Altered insula activity leads to disturbed interoceptive awareness

• Decreased hunger sensation
• Distorted body image
• Lack of recognition of malnutrition
• Diminished motivation to change
• Numbed emotions
• Altered sense of self

​

Altered reward processing

Thought Rumination

• Repetitive thinking pattern that has been found to predict anxiety, binge eating, binge drinking, self-injury, and depression
• Mode of responding to distress that involves repetitively and passively focusing on symptoms of distress and the possible causes and consequences of these symptoms

SCREENING AND INITIAL ASSESSMENT

15

QUICK SCREENING ASSESSMENT

INITIAL EVALUATION

• The patient’s height and weight history (e.g., maximum and minimum weight, recent weight changes)
• Presence of, patterns in, and changes in restrictive eating, food avoidance, binge eating, and other eating-related behaviors (e.g., rumination, regurgitation, chewing and spitting)
• Patterns and changes in food repertoire (e.g., breadth of food variety, narrowing or elimination of food groups)
• Presence of, patterns in, and changes in compensatory and other weight control behaviors, including dietary restriction, compulsive or driven exercise, purging behaviors (e.g., laxative use, self-induced vomiting), and use of medication to manipulate weight
• Percentage of time preoccupied with food, weight, and body shape
• Prior treatment and response to treatment for an eating disorder
• Psychosocial impairment secondary to eating or body image concerns or behaviors; and family history of eating disorder, other psychiatric illnesses, and other medical conditions (e.g., obesity, inflammatory bowel disease, diabetes mellitus)

TREATMENT

FIRST STEP – STABILIZE NUTRITION

• All eating disorders have some component of restriction
• Food types, volumes/quantities, consumption patterns
• MUST weight restore before brain can start engaging in deeper process work!
• A starved brain is a regressed, irritable, depressed, anxious, ruminative brain!

TREATMENT PROGRESSION

• Stabilize nutrition
• As nutritional status improves, cognition and distress tolerance improves
• Reduce compensatory behaviors
• Address food judgements/fears, normalize relationship with food and body (neutrality before acceptance)
• Concurrent psychotherapy
• Expect symptom substitution
• Relapse prevention

PSYCHOTHERAPEUTIC MODALITIES

• Family Based Treatment
• Adolescent Focused Therapy
• Cognitive Behavioral Therapy for eating disorders

• Acceptance and Commitment Therapy
• Dialectical Behavioral Therapy
• Trauma processing therapies
• Motivational interviewing

Exposure and Response Prevention

TREATMENT IN PRACTICE

• Involve families!
• Families need education and coaching – they can be your greatest allies
• Change language around food
• No “good” or “bad” foods – only “bad” food is a food that you are allergic to or a food that is spoilt
• Refrain from labeling foods as “health” vs “unhealthy”
• Eating carrots at every meal is equally unhelpful as eating chocolate at every meal!
• Food can feed the body and the soul
• Praise food variety and flexibility, eating to hunger and fullness cues
• Help to separate appearance from self-worth

CHALLENGES IN PRACTICE

• Talking about behavior does not change behavior
• Harder before easier
• Anxiety = eating disorder being challenged
• Putting things off does not make them easier
• Eating disorders are not educatable illnesses
• Not requesting, requiring
• Begging, pleading, cajoling - unhelpful
• Don’t sanction ending treatment at 90%

THANK YOU