National Eating Disorders Association

For more information, please contact [email protected].

ANOREXIA

  • At any given point in time between 0.3-0.4% of young women and 0.1% of young men will suffer from anorexia nervosa
  • Several more recent studies in the US have used broader definitions of eating disorders that more accurately reflect the range of disorders that occur, resulting in a higher prevalence of eating disorders.
  • A 2007 study asked 9,282 English-speaking Americans about a variety of mental health conditions, including eating disorders. The results, published in Biological Psychiatry, found that 0.9% of women and 0.3% of men had anorexia during their life.

Keski-Rahkonen A, Hoek HW, Susser ES, Linna MS, Sihvola E, Raevuori A, …, and Rissanen A. (2007). Epidemiology and course of anorexia nervosa in the community. American Journal of Psychiatry, 164(8):1259-65. doi: 10.1176/appi. ajp.2007.06081388.

  • When researchers followed a group of 496 adolescent girls for 8 years, until they were 20, they found: 
    • 5.2% of the girls met criteria for DSM5 anorexia, bulimia, or binge eating disorder. 
    • When the researchers included nonspecific eating disorder symptoms, a total of 13.2% of the girls had suffered from a DSM-5 eating disorder by age 20.

Stice E, Marti CN, Shaw H, and Jaconis M. (2010). An 8-year longitudinal study of the natural history of threshold, subthreshold, and partial eating disorders from a community sample of adolescents. Journal of Abnormal Psychology, 118(3):587-97. doi: 10.1037/a0016481.

  • Combining information from several sources, Eric Stice and Cara Bohon (2012) found that 
    • Between 0.9% and 2.0% of females and 0.1% to 0.3% of males will develop anorexia 
    • Subthreshold anorexia occurs in 1.1% to 3.0% of adolescent females

Stice E & Bohon C. (2012). Eating Disorders. In Child and Adolescent Psychopathology, 2nd Edition, Theodore Beauchaine & Stephen Linshaw, eds. New York: Wiley.

  • Anorexia is the third most common chronic disease among young people, after asthma and type 1 diabetes.

Whitaker AH. An epidemiological study of anorectic and bulimic symptoms in adolescent girls: Implications for pediatricians. Pediatr Ann. 1992;21:752–9.

  • Young people between the ages of 15 and 24 with anorexia have 10 times the risk of dying compared to their same-aged peers.

Smink, F. E., van Hoeken, D., & Hoek, H. W. (2012). Epidemiology of eating disorders: Incidence, prevalence and mortality rates. Current Psychiatry Reports, 14(4), 406-414.

Fichter, M. M., & Quadflieg, N. (2016). Mortality in eating disorders – Results of a large prospective clinical longitudinal study. International Journal of Eating Disorders, Epub ahead of print. 

  • Males represent 25% of individuals with anorexia nervosa, and they are at a higher risk of dying, in part because they are often diagnosed later since many people assume males don’t have eating disorders.

Mond, J.M., Mitchison, D., & Hay, P. (2014) “Prevalence and implications of eating disordered behavior in men” in Cohn, L., Lemberg, R. (2014) Current Findings on Males with Eating Disorders. Philadelphia, PA: Routledge. 

  • Subclinical eating disordered behaviors (including binge eating, purging, laxative abuse, and fasting for weight loss) are nearly as common among males as they are among females.

Mond, J.M., Mitchison, D., & Hay, P. (2014) “Prevalence and implications of eating disordered behavior in men” in Cohn, L., Lemberg, R. (2014) Current Findings on Males with Eating Disorders. Philadelphia, PA: Routledge. 

  • An ongoing study in Minnesota has found incidence of anorexia increasing over the last 50 years only in females aged 15 to 24. Incidence remained stable in other age groups and in males.

Lai, K. Y. (2000). Anorexia nervosa in Chinese adolescents—does culture make a Lucas AR, Crowson CS, O’Fallon WM, Melton LJ 3rd. (1999). The ups and downs of anorexia nervosa. International Journal of Eating Disorders, 26(4):397-405. DOI: 10.1002/(SICI)1098108X(199912)26:4<397::AID-EAT5>3.0.CO;2-0.difference?. Journal of Adolescence, 23(5), 561-568.

ARFID

  • In a group of adolescents with eating disorders receiving treatment at a specialist clinic, 14% met criteria for ARFID. Those with ARFID were more likely to be
    • Younger, and
    • Male
  • Many children with ARFID reported the following symptoms:
    • food avoidance 
    • decreased appetite
    • abdominal pain
    • emetophobia (fear of vomiting)
  • Nearly half of children with ARFID report fear of vomiting or choking, and one-fifth say they avoid certain foods because of sensory issues.
    • The same study found that one-third of children with ARFID have a mood disorder, three-quarters have an anxiety disorder, and nearly 20 percent have an autism spectrum condition

Fisher, M. M., Rosen, D. S., Ornstein, R. M., Mammel, K. A., Katzman, D. K., Rome, E. S., ... & Walsh, B. T. (2014). Characteristics of avoidant/restrictive food intake disorder in children and adolescents: a “new disorder” in DSM-5. Journal of Adolescent Health, 55(1), 49-52.

Nicely, T. A., Lane-Loney, S., Masciulli, E., Hollenbeak, C. S., & Ornstein, R. M. (2014). Prevalence and characteristics of avoidant/restrictive food intake disorder in a cohort of young patients in day treatment for eating disorders. Journal of eating disorders, 2(1), 1.

ATHLETES

  • In a study of Division 1 NCAA athletes, over one-third of female athletes reported attitudes and symptoms placing them at risk for anorexia nervosa.

Johnson, C. Powers, P.S., and Dick, R. Athletes and Eating Disorders: The National Collegiate Athletic Association Study, Int J Eat Disord 1999; 6:179.

  • Though most athletes with eating disorders are female, male athletes are also at risk—especially those competing in sports that tend to emphasize diet, appearance, size and weight. In weight-class sports (wrestling, rowing, horseracing) and aesthetic sports (bodybuilding, gymnastics, swimming, diving) about 33% of male athletes are affected. In female athletes in weight class and aesthetic sports, disordered eating occurs at estimates of up to 62%.

Sport Nutrition for Coaches by Leslie Bonci, MPH, RD, CSSD, 2009, Human Kinetics. Byrne et al. 2001; Sundot - Borgen & Torstviet 2004

  • Among female high school athletes in aesthetic sports, 41.5% reported disordered eating. They were eight times more likely to incur an injury than athletes in aesthetic sports who did not report disordered eating.

Jankowski, C. (2012). Associations Between Disordered Eating, Menstrual Dysfunction, and Musculoskeletal Injury Among High School Athletes. Yearbook of Sports Medicine, 2012, 394-395. doi:10.1016/j.yspm.2011.08.003

  • One study found that 35% of female and 10% of male college athletes were at risk for anorexia nervosa and 58% of female and 38% of male college athletes were at risk for bulimia nervosa.

The National Center on Addiction and Substance Abuse (CASA) at Columbia University. Food for Thought: Substance Abuse and Eating Disorders. The National Center on Addiction and Substance Abuse (CASA) Columbia University; New York: 2003.

  • The prevalence of eating disorders in college athletes is higher among dancers and the most elite college athletes, particularly those involved with sports that emphasize a lean physique or weight restriction (e.g., figure skating, wrestling, rowing).

The National Center on Addiction and Substance Abuse (CASA) at Columbia University. Food for Thought: Substance Abuse and Eating Disorders. The National Center on Addiction and Substance Abuse (CASA) Columbia University; New York: 2003.

  • Among female college athletes surveyed, 25.5% had subclinical eating disorder symptoms.

Greenleaf, C., Petrie, T. A., Carter, J., & Reel, J. J. (2009). Female Collegiate Athletes: Prevalence of Eating Disorders and Disordered Eating Behaviors. Journal of American College Health, 57(5), 489-496. doi:10.3200/jach.57.5.489-496

  • In a survey of athletic trainers working with female collegiate athletes, only 27% felt confident identifying an athlete with an eating disorder. Despite this, 91% of athletic trainers reported dealing with an athlete with an eating disorder. 93% of trainers felt that increased attention needs to be paid to preventing eating disorders among collegiate female athletes. 25% worked at an institution without a policy on managing eating disorders.

Greenleaf, C., Petrie, T. A., Carter, J., & Reel, J. J. (2009). Female Collegiate Athletes: Prevalence of Eating Disorders and Disordered Eating Behaviors. Journal of American College Health, 57(5), 489-496. doi:10.3200/jach.57.5.489-496

  • A study of female Division II college athletes found that 25% had disordered eating, 26% reported menstrual dysfunction, 10% had low bone mineral density, and 2.6% had all three symptoms.

Beals KA, Hill AK. The prevalence of disordered eating, menstrual dysfunction, and low bone mineral density among US collegiate

  • Female high school athletes reporting disordered eating were twice as likely to incur a musculoskeletal injury as athletes who did not report disordered eating.

Jankowski, C. (2012). Associations Between Disordered Eating, Menstrual Dysfunction, and Musculoskeletal Injury Among High School Athletes. Yearbook of Sports Medicine, 2012, 394-395. doi:10.1016/j.yspm.2011.08.003

BINGE EATING DISORDER

NEDA has gathered data on the prevalence of eating disorders from the US, UK, and Europe to get a better idea of exactly how common eating disorders are. Although BED is not a new disorder, its new formal recognition in the research community has left far more gaps in the data on the incidence and prevalence of BED than for anorexia and bulimia.

  • A 2007 study asked 9,282 English-speaking Americans about a variety of mental health conditions, including eating disorders. The results, published in Biological Psychiatry, found that 3.5% of women and 2.0% of men had binge eating disorder during their life
    • o This makes BED more than three times more common than anorexia and bulimia combined.
    • o BED is also more common than breast cancer, HIV, and schizophrenia.

Hudson JI, Hiripi E, Pope HG Jr, and Kessler RC. (2007). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 61(3):348-58. doi:10.1016/j.biopsych.2006.03.040.

  • When researchers followed a group of 496 adolescent girls for 8 years until they were 20, they found: 
    • o 5.2% of the girls met criteria for DSM5 anorexia, bulimia, or binge eating disorder. 
    • o When the researchers included nonspecific eating disorder symptoms, a total of 13.2% of the girls had suffered from a DSM-5 eating disorder by age 20.

Stice E, Marti CN, Shaw H, and Jaconis M. (2010). An 8-year longitudinal study of the natural history of threshold, subthreshold, and partial eating disorders from a community sample of adolescents. Journal of Abnormal Psychology, 118(3):587-97. doi: 10.1037/a0016481. 

  • Combining information from several sources, Eric Stice and Cara Bohon found that
    • o Between 0.2% and 3.5% of females and 0.9% and 2.0% of males will develop binge eating disorder
    • o Subthreshold binge eating disorder occurs in 1.6% of adolescent females

Stice E & Bohon C. (2012). Eating Disorders. In Child and Adolescent Psychopathology, 2nd Edition, Theodore Beauchaine & Stephen Linshaw, eds. New York: Wiley. 

  • Research estimates that
    • o 28.4% of people with current BED are receiving treatment for their disorder
    • o 43.6% of people with BED at some point in their lives will receive treatment
  • BED often begins in the late teens or early 20s, although it has been reported in both young children and older adults.
  • Approximately 40% of those with binge eating disorder are male.
  • Three out of ten individuals looking for weight loss treatments show signs of BED.

For further reading:

Westerberg, D. P., & Waitz, M. (2013). Binge-eating disorder. Osteopathic Family Physician, 5(6), 230-233.

BULIMIA 

NEDA has gathered data on the prevalence of eating disorders from the US, UK, and Europe to get a better idea of exactly how common eating disorders are. Older data from other countries that use more strict definitions of anorexia and bulimia give lower prevalence estimates. Several more recent studies in the US have used broader definitions of eating disorders that more accurately reflect the range of disorders that occur, resulting in a higher prevalence of eating disorders:

  • At any given point in time, 1.0% of young women and 0.1% of young men will meet diagnostic criteria for bulimia nervosa.
  • A 2007 study asked 9,282 English-speaking Americans about a variety of mental health conditions, including eating disorders. The results, published in Biological Psychiatry, found that 1.5% of women and 0.5% of men had bulimia during their life
  • When researchers followed a group of 496 adolescent girls for 8 years until they were 20, they found: 
    • o 5.2% of the girls met criteria for DSM5 anorexia, bulimia, or binge eating disorder. 
    • o When the researchers included nonspecific eating disorder symptoms, a total of 13.2% of the girls had suffered from a DSM-5 eating disorder by age 20.
  • Combining information from several sources, Eric Stice and Cara Bohon found that
    • o Between 1.1% and 4.6% of females and 0.1% to 0.5% of males will develop bulimia 
    • o Subthreshold bulimia occurs in 2.0% to 5.4% of adolescent females

Have these numbers changed over time? The answer isn’t clear. It does appear that, at least for the last two decades, the rates of new diagnoses of anorexia and bulimia have remained relatively stable.

  • A Dutch study published in the International Journal of Eating Disorders found that new diagnoses of anorexia and bulimia remained relatively steady in the Netherlands from 1985-1989 to 1995-1999.
  • Rates of bulimia increased during the 1980s and early 1990s, and they have since remained the same or decreased slightly 
  • A British study also found stability in new anorexia and bulimia diagnoses in both males and females, although rates of EDNOS diagnoses increased in both groups. (Please note that in the new DSM-5, EDNOS is no longer recognized and a new term of OSFED has been added, meaning Other Specified Feeding or Eating Disorder). 
  • Eating disorder symptoms are beginning earlier in both males and females, which agrees with both formal research and clinical reports.

Favaro A, Caregaro L, Tenconi E, Bosello R, and Santonastaso P. (2009). Time trends in age at onset of anorexia nervosa and bulimia nervosa. Journal of Clinical Psychiatry, 70(12):1715-21. doi: 10.4088/JCP.09m05176blu.

Hoek HW and van Hoeken D. (2003). Review of the prevalence and incidence of eating disorders. International Journal of Eating Disorders, 34(4):383-96. doi: 10.1002/eat.10222. 

Hudson JI, Hiripi E, Pope HG Jr, and Kessler RC. (2007). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 61(3):348-58. doi:10.1016/j.biopsych.2006.03.040.

Micali N, Hagberg KW, Petersen I, and Treasure JL. (2013). The incidence of eating disorders in the UK in 2000–2009: findings from the General Practice Research Database. BMJ Open, 3(5): e002646. doi: 10.1136/bmjopen-2013-002646.

Smink FR, van Hoeken D, and Hoek HW. (2012). Epidemiology of eating disorders: incidence, prevalence and mortality rates. Current Psychiatry Reports, 14(4):406-14. doi: 10.1007/ s11920-012-0282-y. 

Stice E & Bohon C. (2012). Eating Disorders. In Child and Adolescent Psychopathology, 2nd Edition, Theodore Beauchaine & Stephen Linshaw, eds. New York: Wiley. 

Stice E, Marti CN, Shaw H, and Jaconis M. (2010). An 8-year longitudinal study of the natural history of threshold, subthreshold, and partial eating disorders from a community sample of adolescents. Journal of Abnormal Psychology, 118(3):587-97. doi: 10.1037/a0016481. 

van Son GE, van Hoeken D, Bartelds AI, van Furth EF, and Hoek HW. (2012). Time trends in the incidence of eating disorders: a primary care study in the Netherlands. International Journal of Eating Disorders, 39(7):565-9. doi: 10.1002/eat.20316.

BULLYING/WEIGHT SHAMING

  • The best-known environmental contributor to the development of eating disorders is the sociocultural idealization of thinness.

Culbert, K. M., Racine, S. E., & Klump, K. L. (2015). Research Review: What we have learned about the causes of eating disorders - a synthesis of sociocultural, psychological, and biological research. J Child Psychol Psychiatry, 56(11), 1141-1164. 

  • By age 6, girls especially start to express concerns about their own weight or shape. 40-60% of elementary school girls (ages 6-12) are concerned about their weight or about becoming too fat. This concern endures through life.

Smolak, L. (2011). Body image development in childhood. In T. Cash & L. Smolak (Eds.),  Body Image: A Handbook of Science, Practice, and Prevention (2nd ed.).New York: Guilford. 

  • 79% of weight-loss program participants reported coping with weight stigma by eating more food.

Andreyeva, T., Puhl, R. M. and Brownell, K. D. (2008), Changes in Perceived Weight Discrimination Among Americans, 1995–1996 Through 2004–2006. Obesity, 16: 1129–1134. doi:10.1038/oby.2008.35

  • Of American elementary school girls who read magazines, 69% say that the pictures influence their concept of the ideal body shape. 47% say the pictures make them want to lose weight.

Martin, J. B. (2010). The Development of Ideal Body Image Perceptions in the United States.Nutrition Today, 45(3), 98-100. Retrieved from nursingcenter.com/pdf.asp?AID=1023485 

  • Up to 40% of overweight girls and 37% of overweight boys are teased about their weight by peers or family members. Weight teasing predicts weight gain, binge eating, and extreme weight control measures.

Golden, N. H., Schneider, M., & Wood, C. (2016). Preventing Obesity and Eating Disorders in Adolescents. Pediatrics, 138(3). doi:10.1542/peds.2016-1649

  • Weight-based victimization among overweight youths has been linked to lower levels of physical activity, negative attitudes about sports, and lower participation in physical activity among overweight students. Among overweight and obese adults, those who experience weight-based stigmatization engage in more frequent binge eating, are at increased risk for eating disorder symptoms, and are more likely to have a diagnosis of binge eating disorder.

Andreyeva, T., Puhl, R. M. and Brownell, K. D. (2008), Changes in Perceived Weight Discrimination Among Americans, 1995–1996 Through 2004–2006. Obesity, 16: 1129–1134. doi:10.1038/oby.2008.35

  • Children of mothers who are overly concerned about their weight are at increased risk for modeling their unhealthy attitudes and behaviors.

Andreyeva, T., Puhl, R. M. and Brownell, K. D. (2008), Changes in Perceived Weight Discrimination Among Americans, 1995–1996 Through 2004–2006. Obesity, 16: 1129–1134. doi:10.1038/oby.2008.35

  • Weight stigma poses a significant threat to psychological and physical health. It has been documented as a significant risk factor for depression, low self-esteem, and body dissatisfaction.

Andreyeva, T., Puhl, R. M. and Brownell, K. D. (2008), Changes in Perceived Weight Discrimination Among Americans, 1995–1996 Through 2004–2006. Obesity, 16: 1129–1134. doi:10.1038/oby.2008.35

  • Low self-esteem is a common characteristic of individuals who have eating disorders.

The National Center on Addiction and Substance Abuse (CASA) at Columbia University. Food for Thought: Substance Abuse and Eating Disorders. The National Center on Addiction and Substance Abuse (CASA) Columbia University; New York: 2003.

  • Perceived weight discrimination is significantly associated with a current diagnosis of mood and anxiety disorders and mental health services use.

Hatzenbuehler ML, Keyes KM, Hasin DS. Associations between perceived weight discrimination and the prevalence of psychiatric disorders in the general population. Obesity 2009;17(11)2033–2039 

CO-OCCURRING DISORDERS

  • Two-thirds of people with anorexia also showed signs of an anxiety disorder several years before the start of their eating disorder.
  • Childhood obsessive-compulsive traits, such as perfectionism, having to follow the rules, and concern about mistakes, were much more common in women who developed eating disorders than women who didn’t.
  • A study of more than 2400 individuals hospitalized for an eating disorder found that 97% had one or more co-occurring conditions, including:
    • 94% had co-occurring mood disorders, mostly major depression
    • 56% were diagnosed with anxiety disorders
      • 20% had obsessive-compulsive disorder
      • 22% had post-traumatic stress disorder
      • 22% had an alcohol or substance use disorder
  • Approximately one in four people with an eating disorder has symptoms of post-traumatic stress disorder (PTSD).

Tagay, S., Schlottbohm, E., Reyes-Rodriguez, M. L., Repic, N., & Senf, W. (2014). Eating disorders, trauma, PTSD, and psychosocial resources. Eating disorders, 22(1), 33-49.

  • In women hospitalized for an eating disorder, 36.8% regularly self-harmed
  • A 2009 study in the International Journal of Eating Disorders found that one in five women seeking treatment for an eating disorder had six or more signs of attention-deficit hyperactivity disorder (ADHD).
  • Personality disorders also commonly occur in individuals with eating disorders. 
  • Among those with anorexia,
    • Restricting type: 20% had obsessive-compulsive personality disorder, 10% had borderline personality disorder
    • Binge-purge type:12% had obsessive-compulsive personality disorder, 25% had borderline personality disorder
    • Among those with bulimia:11% had obsessive-compulsive personality disorder, 28% had borderline personality disorder
  • A 2014 study found that combined and analyzed data from 20 previous studies found signs of personality disorders in 
    • 38% of people with EDNOS/OSFED
      • 11% had obsessive-compulsive personality disorder
      • 12% had borderline personality disorder
    • 30% of people with binge eating disorder
      • 10% had obsessive-compulsive personality disorder
      • 10% had borderline personality disorder
  • Depression and other mood disorders co-occur with eating disorders quite frequently.

Mangweth, B., Hudson, J. I., Pope, H. G. Jr., Hausmagn, A., DeCol, C., Laird, N. M., …Tsuang, M.T. (2003). Family study of the aggregation of eating disorders and mood disorders.Psychological Medicine, 33, 1319-1323.

McElroy, S. L. O., Kotwal, R., & Keck, P. E. Jr. (2006). Comorbidity of eating disorders with bipolar disorder and treatment implications. Bipolar Disorders, 8, 686-695. 

  • There is a markedly elevated risk for obsessive-compulsive disorder among those with eating disorders.

Altman, S. E., & Shankman, S. A. (2009). What is the association between obsessive-compulsive disorder and eating disorders? Clinical Psychology Review, 29, 638-646. 

  • One study found that 73.8% of patients with binge eating disorder had at least one additional lifetime psychiatric disorder, and 43.1% had at least one current psychiatric disorder. Among lifetime disorders, mood, anxiety, and substance use disorders were most common. Among current comorbidities, mood and anxiety were most common.

Grilo, C. M., White, M. A. and Masheb, R. M. (2009), DSM-IV psychiatric disorder comorbidity and its correlates in binge eating disorder. Int. J. Eat. Disord., 42: 228–234. doi:10.1002/eat.20599 

  • Up to 69% of patients with anorexia nervosa and 33% of patients with bulimia nervosa have a coexisting diagnosis of OCD.

The National Center on Addiction and Substance Abuse (CASA) at Columbia University. Food for Thought: Substance Abuse and Eating Disorders. The National Center on Addiction and Substance Abuse (CASA) Columbia University; New York: 2003.

  • Binge eating disorder patients with a co-occurring psychiatric disorder also had significantly higher levels of current eating disorder psychopathology, negative affect, and lower self-esteem than did patients with binge eating disorder without a co-occurring condition.

Grilo, C. M., White, M. A. and Masheb, R. M. (2009), DSM-IV psychiatric disorder comorbidity and its correlates in binge eating disorder. Int. J. Eat. Disord., 42: 228–234. doi:10.1002/eat.20599 

  • Certain psychiatric disorders, particularly obsessive-compulsive disorder, mood disorders and personality disorders, frequently are found among those with eating disorders, with estimates ranging from 42-75%.

The National Center on Addiction and Substance Abuse (CASA) at Columbia University. Food for Thought: Substance Abuse and Eating Disorders. The National Center on Addiction and Substance Abuse (CASA) Columbia University; New York: 2003.

  • In a nationally representative survey, 95% of respondents with bulimia nervosa, 79% with binge eating disorder, and 56% with anorexia nervosa met criteria for at least one other psychiatric disorder. 64% of those with bulimia nervosa met criteria for three or more co-occurring psychiatric disorders.

Hudson JI, Hiripi E, Pope HG Jr, and Kessler RC. (2007). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 61(3):348-58.

  • In a study of women with eating disorders, 94% of the participants had a co-occurring mood disorder. 92% of those in the sample were struggling with a depressive disorder.

Blinder, B. J., Cumella, E. J., & Sanathara, V. A. (2006). Psychiatric Comorbidities of Female Inpatients With Eating Disorders. Psychosomatic Medicine, 68(3), 454-462. doi:10.1097/01.psy.0000221254.77675.f5

  • 32-39% of people with anorexia nervosa, 36-50% of people with bulimia nervosa, and 33% of people with binge eating disorder are also diagnosed with major depressive disorder.

Hudson JI, Hiripi E, Pope HG Jr, and Kessler RC. (2007). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 61(3):348-58.

"NIH Categorical Spending -NIH Research Portfolio Online Reporting Tools (RePORT)." U.S National Library of Medicine. U.S. National Library of Medicine, 3 Jul. 2017. Web. 11 Jan. 2018.

Milos, G., Spindler, A., Buddeberg, C., & Crameri, A. (2003). Axes I and II comorbidity and treatment experiences in eating disorder subjects. Psychother and Psychosom, 72(5), 276-285.

  • 48-51% of people with anorexia nervosa, 54-81% of people with bulimia nervosa, and 55-65% of people with binge eating disorder are also diagnosed with anxiety disorder.

Hudson JI, Hiripi E, Pope HG Jr, and Kessler RC. (2007). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 61(3):348-58.

NIH Categorical Spending -NIH Research Portfolio Online Reporting Tools (RePORT)." U.S National Library of Medicine. U.S. National Library of Medicine, 3 Jul. 2017. Web. 11 Jan. 2018.

Ulfvebrand, S., Birgegard, A., Norring, C., Hogdahl, L., & von Hausswolff-Juhlin, Y. (2015). Psychiatric comorbidity in women and men with eating disorders results from a large clinical database. Psychiatry Res, 230(2), 294-299.

For further reading:

Anderluh, M. B., Tchanturia, K., Rabe-Hesketh, S., & Treasure, J. (2003). Childhood obsessive-compulsive personality traits in adult women with eating disorders: defining a broader eating disorder phenotype. American Journal of Psychiatry, 160(2), 242-247.

Eddy, K. T., Dorer, D. J., Franko, D. L., Tahilani, K., Thompson-Brenner, H., & Herzog, D. B. (2008). Diagnostic crossover in anorexia nervosa and bulimia nervosa: implications for DSM-V. American Journal of Psychiatry, 165(2), 245-250.

Friborg, O., Martinussen, M., Kaiser, S., Øvergård, K. T., Martinsen, E. W., Schmierer, P., & Rosenvinge, J. H. (2014). Personality disorders in eating disorder not otherwise specified and binge eating disorder: a meta-analysis of comorbidity studies. The Journal of nervous and mental disease, 202(2), 119-125.

Kaye, W. H., Bulik, C. M., Thornton, L., Barbarich, N., & Masters, K. (2004). Comorbidity of anxiety disorders with anorexia and bulimia nervosa. American Journal of Psychiatry, 161(12), 2215-2221.

Kostro, K., Lerman, J. B., & Attia, E. (2014). The current status of suicide and self-injury in eating disorders: a narrative review. Journal of eating disorders, 2(1), 1.

Sansone, R. A., Levitt, J. L., & Sansone, L. A. (2004). The prevalence of personality disorders among those with eating disorders. Eating Disorders, 13(1), 7-21.

COMPULSIVE EXERCISE

  • An estimated 90-95% of college students diagnosed with an eating disorder also belong to a fitness facility. 
  • An estimated 3% of gym-goers have a destructive relationship with exercise. Some studies have found that number may be even higher, including a 2008 Paris study that found that up to 42% of gym-goers have a destructive relationship with exercise.
  • A study involving fitness professionals revealed that 100% of the participants believed that they would benefit from further education and guidelines for identifying and addressing eating disorders.
  • There is a strong link between exercise compulsion and various forms of eating disorders. 
  • Between 40% and 80% of anorexia nervosa patients are prone to excessive exercise in their efforts to avoid putting on weight.

Jodi Rubin, ACSW, LCSW, CEDS, Destructively Fit®, Private Practice

Berczik, K., Szabo, A., Griffiths, M., Kurimay, T., Kun, B., Urban R., & Demetrovics, Z. (2012). Exercise Addiction: Symptoms, Diagnosis, Epidemiology, and Etiology. Substance Use & Misuse, 47, 403-417.

Holtkamp, K., Hebebrand, J., Herpetz-Dahlmann, B. (2004). The Contribution of Anxiety and Food Restriction on Physical Activity Levels in Acute Anorexia Nervosa. The International Journal of Eating Disorders, 36(2):163-71.1

Lejoyeux, M., Avril, M., Richoux, C., Embouazza, H. & Nivoli, F. (2008). Prevalence of exercise dependence and other behavioral addictions among clients of a Parisian fitness room. Comprehensive Psychiatry, 49, 353-358.

Manley, R. O’Brien, K. & Samuels, S. (2008) Fitness instructors’ recognition of eating disorders and attendant ethical/liability issues. Eating Disorders: The Journal of Treatment & Prevention, 16(2), 103-116.

McLean Hospital: http://www.nutrition411.com/wp-content/uploads/2013/11/fitnessmanage0704.

Thompson, R. A., & Sherman, R. T. (2010). Eating disorders in sport. New York: Rutledge.

DIABULIMIA

  •  A review of studies published over the last 25 years on the prevalence of eating disorders and insulin restriction among people with diabetes shows that 30%-35% of women restrict insulin in order to lose weight at some point in their life. This number has remained relatively constant over the decades. 
  • A study of adolescents in 2000 across three Canadian cities found that young women with type 1 diabetes were 2.4 times more likely to have a diagnosable eating disorder and 1.9 times more likely to have sub-threshold eating disorder.
  • In a more recent study, 1/3 of female patients and 1/6 of male patients with Type 1 diabetes reported disordered eating and frequent insulin restriction.
  • People with diabetes often experience uncontrolled eating when they experience a low blood sugar. In Duke University’s study of 276 individuals with type 1 diabetes the frequency of uninhibited eating contributed to 31.3% of insulin omission for weight management. 
  • A study of adolescents from Norway revealed that in addition to age, negative attitude toward diabetes and negative beliefs about insulin had the highest association with insulin restriction and eating disorder behavior.
  • People with diabetes also have a higher risk for emotional states often associated with eating disorders. For example, an analysis of 42 studies found that diabetes doubles the likelihood of having clinical depression (1.7 – 2.9 times greater). 
  • While the majority of studies have been conducted within the type 1 diabetes population, there is case study and anecdotal evidence that the same prevalence and risk exists in any person with insulin dependence whether type 1 diabetes, type 2 diabetes or LADA (latent autoimmune diabetes of adults).

Polonsky WH, et al. Insulin omission in women with IDDM. Diabetes Care. 1994;(17):1178–1185.

Affenito SG, et al. Subclinical and Clinical Eating Disorders in IDDM Negatively Affect Metabolic Control. Diabetes Care. 1997; 20(2):182-184.

Goebel-Fabbri AE FJ, et al. Insulin restriction and associated morbidity and mortality in women with type 1 diabetes. Diabetes Care. 2008;31:415–419.

Jones JM, et al. Eating disorders in adolescent females with and without type 1 diabetes: cross sectional study. BMJ. 2000;2000(320):1563–1566.

Doyle EA, et al. Disordered Eating Behaviors in Emerging Adults with Type 1 Diabetes: A Common Problem for both Men and Women. J Pediatric Health Care. 2017;31(3):327-333.

Custal, Nuria, et al. Treatment Outcome of Patients with Comorbid Type 1 Diabetes and Eating Disorders. BMC Psychiatry. 2014;14:140.

Lee-Akers, Dawn. Biological and Psychological Risk Factors for Eating Disorders in Type 1 Diabetes. Poster presented at: Annual Conference of American Association of Diabetes Educators; 2017 Aug 4-7; Indianapolis, IN.

Merwin RM, et al. Disinhibited eating and weight-related insulin mismanagement among individuals with T1D. Appetite. 2014;81:123-130.

Wisting, Line, et al. Adolescents with T1D – The impact of gender, age, and health-related functioning on eating disorder psychopathology. PLoS ONE. 2015;10(11):e0141386.

Anderson RJ, et. al. The Prevalence of Comorbid Depression in Adults with Diabetes. Diabetes Care. 2001;24(6):1069-1078.

Bächle C, Stahl-Pehe A, Rosenbauer J. Disordered eating and insulin restriction in youths receiving intensified insulin treatment: Results from a nationwide population-based study. Int J Eat Disord. 2016 Feb;49(2):191-6

Bermudez, Ovidio, et al. Inpatient Management of Eating Disorders in Type 1 Diabetes. Diabetes Spectrum. 2009;22(3):153-158.

DIETING/”CLEAN EATING”

  • In a large study of 14– and 15-year-olds, dieting was the most important predictor of a developing eating disorder. Those who dieted moderately were 5x more likely to develop an eating disorder, and those who practiced extreme restriction were 18x more likely to develop an eating disorder than those who did not diet.

Golden, N. H., Schneider, M., & Wood, C. (2016). Preventing Obesity and Eating Disorders in Adolescents. Pediatrics, 138(3). doi:10.1542/peds.2016-1649 

  • 62.3% of teenage girls and 28.8% of teenage boys report trying to lose weight. 58.6% of girls and 28.2% of boys are actively dieting. 68.4% of girls and 51% of boys exercise with the goal of losing weight or to avoid gaining weight.

The National Center on Addiction and Substance Abuse (CASA) at Columbia University. Food for Thought: Substance Abuse and Eating Disorders. The National Center on Addiction and Substance Abuse (CASA) Columbia University; New York: 2003.

  • Over one-half of teenage girls and nearly one-third of teenage boys use unhealthy weight control behaviors such as skipping meals, fasting, smoking cigarettes, vomiting, and taking laxatives.

Neumark-Sztainer, D. (2005). I’m, Like, SO Fat!.New York: Guilford.

  • 35-57% of adolescent girls engage in crash dieting, fasting, self-induced vomiting, diet pills, or laxatives. Overweight girls are more likely than normal weight girls to engage in such extreme dieting.

Boutelle, K., Neumark-Sztainer, D.,Story, M., &Resnick, M. (2002).Weight control behaviors  among obese, overweight, and nonoverweight adolescents. Journal of Pediatric Psychology,27, 531-540. 

Neumark-Sztainer, D., &Hannan, P. (2001). Weight-related behaviors among adolescent girls and boys: A national survey. Archives of Pediatric and Adolescent Medicine, 154, 569-577.

Wertheim, E., Paxton, S., &Blaney, S. (2009).Body image in girls.In L. Smolak & J. K. Thompson (Eds.), Body image, eating disorders, and obesity in youth: Assessment, prevention, and treatment (2nd ed.) (pp. 47-76). Washington, D.C.: American Psychological Association. 

  • Girls who diet frequently are 12 times as likely to binge as girls who don’t diet.

 Neumark-Sztainer, D. (2005). I’m, Like, SO Fat!.New York: Guilford.

  • Even among clearly non-overweight girls, over 1/3 report dieting.

Wertheim, E., Paxton, S., &Blaney, S. (2009).Body image in girls.In L. Smolak & J. K. Thompson (Eds.), Body image, eating disorders, and obesity in youth: Assessment, prevention, and treatment (2nd ed.) (pp. 47-76). Washington, D.C.: American Psychological Association. 

  • 95% of all dieters will regain their lost weight in 1-5 years.

Grodstein, F., Levine, R., Spencer, T., Colditz, G. A., &Stampfer, M. J. (1996). Three-year follow-up of participants in a commercial weight loss program: Can you keep it off? Archives of Internal Medicine 156(12), 1302.

Neumark-Sztainer D., Haines, J., Wall, M., & Eisenberg, M. ( 2007). Why does dieting predict weight gain in adolescents? Findings from project EAT-II: a 5-year longitudinal study. Journal of the American Dietetic Associatio, 107(3), 448-55

  • 19.1% of teenage girls and 7.6% of teenage boys fast for 24 hours or more, 12.6% of girls and 5.5% of boys use diet pills, powders or liquids, and 7.8% of girls and 2.9% of boys vomit or take laxatives to lose weight or to avoid gaining weight.

The National Center on Addiction and Substance Abuse (CASA) at Columbia University. Food for Thought: Substance Abuse and Eating Disorders. The National Center on Addiction and Substance Abuse (CASA) Columbia University; New York: 2003.

  • 12.6% of female high school students took diet pills, powders or liquids to control their weight without a doctor’s advice.

The National Center on Addiction and Substance Abuse (CASA) at Columbia University. Food for Thought: Substance Abuse and Eating Disorders. The National Center on Addiction and Substance Abuse (CASA) Columbia University; New York: 2003.

  • Multiple studies have found that dieting was associated with greater weight gain and increased rates of binge eating in both boys and girls.

Golden, N. H., Schneider, M., & Wood, C. (2016). Preventing Obesity and Eating Disorders in Adolescents. Pediatrics, 138(3). doi:10.1542/peds.2016-1649 

  • In elementary school fewer than 25% of girls diet regularly. Yet those who do know what dieting involves and can talk about calorie restriction and food choices for weight loss fairly effectively.

Smolak, L. (2011). Body image development in childhood. In T. Cash & L. Smolak (Eds.), Body Image: A Handbook of Science, Practice, and Prevention (2nd ed.).New York: Guilford. 

  • Middle school girls who dieted more than once a week were nearly four times as likely to become smokers, compared to non-dieters. 

The National Center on Addiction and Substance Abuse (CASA) at Columbia University. Food for Thought: Substance Abuse and Eating Disorders. The National Center on Addiction and Substance Abuse (CASA) Columbia University; New York: 2003.

  • A content analysis of weight-loss advertising in 2001 found that more than half of all advertising for weight-loss product made use of false, unsubstantiated claims. 

Wertheim, E., Paxton, S., &Blaney, S. (2009).Body image in girls.In L. Smolak & J. K. Thompson (Eds.), Body image, eating disorders, and obesity in youth: Assessment, prevention, and treatment (2nd ed.) (pp. 47-76). Washington, D.C.: American Psychological Association. 

  • Americans spend over $60 billion on dieting and diet products each year.

Hobbs, R., Broder, S., Pope, H., & Rowe, J. (2006). “How adolescent girls interpret weight-loss advertising.” Health Education Research, 21(5) 719-730.

INSURANCE/LEGAL ISSUES

  • Eating disorders are associated with some of the highest levels of medical and social disability of any psychiatric disorder.

Klump KL, Bulik CK, Kaye W, Treasure J, Tyson E. Academy for Eating Disorders Position Paper: Eating Disorders are Serious Mental Illnesses. Int J Eat Disord. 2009 Mar;42(2):97-103. doi: 10.1002/eat.20589.

  • APA Practice Guidelines (2000 & 1993) reports these medical findings:
    • Physical consequences of eating disorders include all serious disorders caused by malnutrition, especially cardiovascular compromise.
    • Prepubertal patients may have arrested sexual maturity and growth failure.
    • Even those who “look and feel deceptively well,” with normal EKGs may have cardiac irregularities, variations with pulse and blood pressure, and are at risk for sudden death.
    • Prolonged amenorrhea (>6 months) may result in irreversible osteopenia and a high rate of fractures.
    • Abnormal CT scans of the brain are found in >50% of patients with anorexia nervosa.
  • In 1996, Congress passed the Mental Health Parity Act, a law that requires plans to provide the same annual and lifetime overall limits for mental health benefits as for other health conditions. Eating disorders ought to receive health care coverage and research funding that is equal to that of medical disorders as well as psychiatric conditions categorized as serious forms of mental illness.

Klump KL, Bulik CK, Kaye W, Treasure J, Tyson E. Academy for Eating Disorders Position Paper: Eating Disorders are Serious Mental Illnesses. Int J Eat Disord. 2009 Mar;42(2):97-103. doi: 10.1002/eat.20589.

JEWISH COMMUNITY

  • In one study of ultra-Orthodox and Syrian Jewish communities in Brooklyn, 1 out of 19 girls was diagnosed with an eating disorder, which is a rate about 50 percent higher than the general U.S. population (Sacker, 1996).

LGBTQ+ COMMUNITY

  • Transgender individuals experience eating disorders at rates significantly higher than cisgender individuals. 
  • Research is limited and conflicting on eating disorders among lesbian and bisexual women.
  • While research indicates that lesbian women experience less body dissatisfaction overall, research shows that beginning as early as 12, gay, lesbian, and bisexual teens may be at higher risk of binge-eating and purging than heterosexual peers.
  • In one study, gay and bisexual boys reported being significantly more likely to have fasted, vomited, or taken laxatives or diet pills to control their weight in the last 30 days. Gay males were 7 times more likely to report binging and 12 times more likely to report purging than heterosexual males.
  • Females identified as lesbian, bisexual, or mostly heterosexual were about twice as likely to report binge-eating at least once per month in the last year.
  • Elevated rates of binge-eating and purging by vomiting or laxative abuse was found for both males and females who identified as gay, lesbian, bisexual, or “mostly heterosexual” in comparison to their heterosexual peers.
  • Compared to other populations, gay men are disproportionately found to have body image disturbances and eating disordered behavior. Gay men are thought to only represent 5% of the total male population but among men who have eating disorders, 42% identify as gay.
  • In a 2007 study of Lesbian, Gay and Bisexual (LGB)-identified participants, which was the first to assess DSM diagnostic categories, rather than use measures that may be indicative of eating disorders (e.g., eating disorder symptoms), in community-based (versus those recruited from clinical or academic settings) ethnically/racially diverse populations. Researchers found:
  • Compared with heterosexual men, gay and bisexual men had a significantly higher prevalence of lifetime full syndrome bulimia, subclinical bulimia, and any subclinical eating disorder.
  • There were no significant differences between heterosexual women and lesbians and bisexual women in the prevalence of any of the eating disorders.
  • Respondents aged 18–29 were significantly more likely than those aged 30–59 to have subclinical bulimia.
  • Black and Latino LGBs have at least as high a prevalence of eating disorders as white LGBs
  • A sense of connectedness to the gay community was related to fewer current eating disorders, which suggests that feeling connected to the gay community may have a protective effect against eating disorders

Austin, S. Bryn, Sc.D.. 2004. Sexual Orientation, Weight Concerns, and Eating- Disordered  Behaviors in Adolescent Girls and Boys. Journal of the American Academy of Child &  Adolescent Psychiatry, V43.

Carlat, D.J., Camargo, CA, & Herzog, DB, 1991. Eating disorders in males: a report of 135 patients. American Journal of Psychiatry, 148, 1991.

Center for Disease Control and Massachusetts Department of Education. 1999. Massachusetts State  Youth Risk Behavior Survey. National Gay and Lesbian Task Force (with National Coalition for the Homeless)

Ray, Nicholas. 2007. Gay, Lesbian, Bisexual and Transgender Youth: An Epidemic of  Homelessness. National Gay and Lesbian Task Force and National Coalition for the Homeless.

Waldron, Jennifer J., Semerjian, Tamar Z., Kauer, Kerrie. 2009. Doing ‘Drag’: Applying Queer- Feminist Theory to the Body Image and Eating Disorders across Sexual Orientation and  Gender Identity. In The Hidden Faces of Eating Disorders, Edited by Justine J. Reel &  Katherine A. Beals, (63-81).

MARGINALIZED VOICES

  • Despite similar rates of eating disorders among non-Hispanic Whites, Hispanics, African-Americans, and Asians in the United States, people of color are significantly less likely to receive help for their eating issues.

Marques, L., Alegria, M., Becker, A. E., Chen, C., Fang, A., Chosak, A., & Diniz, J. B. (2011). Comparative Prevalence, Correlates of Impairment, and Service Utilization for Eating Disorders across U.S. Ethnic Groups: Implications for Reducing Ethnic Disparities in Health Care Access for Eating Disorders. The International Journal of Eating Disorders, 44(5), 412–420. http://doi.org/10.1002/eat.20787 

Becker, A. E., Franko, D. L., Speck, A., & Herzog, D. B. (2003). Ethnicity and differential access to care for eating disorder symptoms. International Journal of Eating Disorders, 33(2), 205-212. doi:10.1002/eat.10129 

Wade, T. D., Keski-Rahkonen A., & Hudson J. (2011).Epidemiology of eating disorders. In M. Tsuang and M. Tohen (Eds.), Textbook in Psychiatric Epidemiology (3rd ed.) (pp. 343-360). New York: Wiley.

  • Although eating disorders affect a higher proportion of males who identify as gay or bisexual than females, the majority of males with eating disorders are heterosexual.

Strother, E., Lemberg, R., Stanford, S. C., & Turberville, D. (2012). Eating Disorders in Men: Underdiagnosed, Undertreated, and Misunderstood. Eating Disorders, 20(5), 346-355. doi:10.1080/10640266.2012.715512

  • 15% of gay and bisexual men and 4.6% of heterosexual men had a full or subthreshold eating disorder at some point in their lives.

Feldman, M. B. and Meyer, I. H. (2007), Eating disorders in diverse lesbian, gay, and bisexual populations. Int. J. Eat. Disord., 40: 218–226.

  • Black teenagers are 50% more likely than white teenagers to exhibit bulimic behavior, such as binging and purging.

Goeree, Michelle Sovinsky, Ham, John C., &  Iorio, Daniela. (2011). Race, Social Class, and Bulimia Nervosa. IZA Discussion Paper No. 5823. Retrieved from http://ftp.iza.org/dp5823.pdf. 

  • In a study of adolescents, researchers found that Hispanics were significantly more likely to suffer from bulimia nervosa than their non-Hispanic peers. The researchers also reported a trend towards a higher prevalence of binge eating disorder in all minority groups.

Swanson SA, Crow SJ, Le Grange D, Swendsen J, and Merikangas KR. (2011). Prevalence and correlates of eating disorders in adolescents. Results from the national comorbidity survey replication adolescent supplement. Archives of General Psychiatry, 68(7):714-23.

  • From 1999 to 2009, hospitalizations involving eating disorders increased for all age groups, but hospitalizations for patients aged 45-65 increased the most, by 88 percent. In 2009, people over the age of 45 accounted for 25% of eating disorder-related hospitalizations.

Zhao, Y., Encinosa, W. Update on Hospitalizations for Eating Disorders, 1999 to 2009. HCUP Statistical Brief #120. September, 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb120.pdf

  • Teenage girls from low-income families are 153% more likely to be bulimic than girls from wealthy families.

Goeree, Michelle Sovinsky, Ham, John C., &  Iorio, Daniela. (2011). Race, Social Class, and Bulimia Nervosa. IZA Discussion Paper No. 5823. Retrieved from http://ftp.iza.org/dp5823.pdf. 

  • From 1999 to 2009, the number of men hospitalized for an eating disorder-related cause increased by 53%.

Zhao, Y., Encinosa, W. Update on Hospitalizations for Eating Disorders, 1999 to 2009. HCUP Statistical Brief #120. September, 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb120.pdf

  • A 2014 study found that rates of disordered eating have increased across all demographic sectors, but at a faster rate in male, lower socioeconomic, and older participants.

Mitchison, D., Hay, P., Slewa-Younan, S., & Mond, J. (2014). The changing demographic profile of eating disorder behaviors in the community. BMC Public Health, 14(1). doi:10.1186/1471-2458-14-943

  • In a survey of college students, transgender students were significantly more likely than members of any other group to report an eating disorder diagnosis in the past year.

Diemer, E. W., Grant, J. D., Munn-Chernoff, M. A., Patterson, D. A., & Duncan, A. E. (2015). Gender Identity, Sexual Orientation, and Eating-Related Pathology in a National Sample of College Students. Journal of Adolescent Health, 57(2), 144-149. doi:10.1016/j.jadohealth.2015.03.003

  • A study of 2,822 students on a large university campus found that 3.6% of males had positive screens for eating disorders. The female-to-male ratio was 3-to-1.

Eisenberg, D., Nicklett, E. J., Roeder, K., & Kirz, N. E. (2011). Eating Disorder Symptoms Among College Students: Prevalence, Persistence, Correlates, and Treatment-Seeking. Journal of American College Health, 59(8), 700-707. doi:10.1080/07448481.2010.546461 

  • Subclinical eating disordered behaviors are nearly as common among males as they are among females.

Mond, J.M., Mitchison, D., & Hay, P. (2014) “Prevalence and implications of eating disordered behavior in men” in Cohn, L., Lemberg, R. (2014) Current Findings on Males with Eating Disorders. Philadelphia, PA: Routledge. 

  • There were no significant differences between heterosexual women and lesbians and bisexual women in the prevalence of any of the eating disorders.

Ray, Nicholas. 2007. Gay, Lesbian, Bisexual and Transgender Youth: An Epidemic of  Homelessness. National Gay and Lesbian Task Force and National Coalition for the Homeless.

  • When presented with identical case studies demonstrating disordered eating symptoms in white, Hispanic and African-American women, clinicians were asked to identify if the woman’s eating behavior was problematic. 44% identified the white woman’s behavior as problematic; 41% identified the Hispanic woman’s behavior as problematic, and only 17% identified the black woman’s behavior as problematic. The clinicians were also less likely to recommend that the African-American woman should receive professional help.

Gordon, K. H., Brattole, M. M., Wingate, L. R., & Joiner, T. E. (2006). The Impact of Client Race on Clinician Detection of Eating Disorders. Behavior Therapy, 37(4), 319-325. doi:10.1016/j.beth.2005.12.002.

MEDIA

  • According to The Nielsen Company, a U.S.-based global marketing and research firm that tracks media habits and trends worldwide, the average American spends more than 11 hours a day using media—that is more than the average time spent sleeping or working each day.
  • Among American youth ages 8-18, media are an ever-increasingly large part of their daily routines, fueled by the growing availability of internet-enabled mobile devices, which accounts for almost half of all their screen time. Teens ages 13-18 spend an average of 9 hours a day and tweens ages 8-12 average 6 hours a day using entertainment media. These amounts vary by race, income, and gender, and do not include using media in school or doing homework. 
  • Teens and tweens use media for a variety of activities and have different favorites depending on their gender – boys like to play video games, and girls prefer using social media.
  • 10,500 women and girls in 13 countries and found that beauty and appearance anxiety continue to be critical global issues and media are a key factor driving their concerns. 
    • Approximately 7 in 10 women and girls report a decline in body confidence and increase in beauty and appearance anxiety, which they say is driven by the pressure for perfection from media and advertising’s unrealistic standard of beauty.  
    • Almost 8 in 10 girls (79%) and even more women (85%) admit to opting out of important events in their lives when they don’t feel they look their best.
    • Nine out of 10 women say they will actually not eat and risk putting their health at stake when they feel bad about their body image. And 7 in 10 girls said they're more likely to be less assertive in their decisions when they're feeling insecure.
    • To counteract these unreal messages, a majority of women and girls around the globe are challenging media to portray more diverse physical appearances, age, race, body shapes, and sizes. 
  • In a study on social media, nearly all girls (95%) say they see the onslaught of negative beauty critiques on social media posts, comments, photos, and videos, and a majority see them at least once a week (72%) and wish social media were a space that empowered body positivity (62%).
  • According to Common Sense Media, 41% of teen girls say the use social media to “make themselves look cooler.” Teens feel pressure to look good and cool online, but also feel social media helps their friendships and connections.
  • One study of teen girls found that social media users were significantly more likely than non-social media users to have internalized a drive for thinness and to engage in body surveillance. 
  • Another study found social media use is linked to self-objectification, and using social media for merely 30 minutes a day can change the way you view your own body.

Statista, 2015

CommonSense Media, 2015

Perloff, R. M. 2014.  Social Media Effects on Young Women’s Body Image Concerns: Theoretical Perspectives and an Agenda for Research. Sex Roles,  DOI 10.1007/s11199-014-0384-6.

Tiggemann, M., & Slater, A. (2013). NetGirls: The Internet, Facebook, and body image concern in adolescent girls. International Journal of Eating Disorders, 46, 630–633. doi:10.1002/eat.22141.  

Fardouly, J., Diedrichs, P. C., Vartanian, L. R., & Halliwell, E. (2015). Social comparisons on social media: The impact of Facebook on young women’s body image concerns and mood. Body Image, 13, 38–45. doi:10.1016/j.bodyim.2014.12. 002 

Fardouly, J., & Vartanian, L. R. (2015). Negative comparisons about one’s appearance mediate the relationship between Facebook usage and body image concerns. Body Image, 12, 82–88. doi: 10.1016/j.bodyim.2014.10.004 

MEN

  • From 1999 to 2009, the number of men hospitalized for an eating disorder-related cause increased by 53%.

Zhao, Y., Encinosa, W. Update on Hospitalizations for Eating Disorders, 1999 to 2009. HCUP Statistical Brief #120. September, 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb120.pdf

  • The most widely-quoted study estimates that males have a lifetime prevalence of .3% for anorexia nervosa (AN), .5% for bulimia nervosa (BN) and 2% for binge eating disorder (BED). These figures correspond to males representing 25% of individuals with AN and BN and 36% of those with BED. They are based on DSM-IV criteria.

Hudson, J., Hiripi, E., Pope, H., & Kessler, R. (2007) “The prevalence and correlates of eating disorders in the national comorbidity survey replication.” Biological Psychiatry, 61, 348–358.

  • In a study of 1,383 adolescents, the prevalence of any DSM-5 ED in males was reported to be 1.2% at 14 years, 2.6% at 17 years, and 2.9% at 20 years.

Allen, K., Byme, S., Oddy, W., & Crosby, R. (2013) “DSM-IV-TR and DSM5 eating disorders in adolescents: prevalence, stability, and psychosocial correlates in a population-based sample of male and female adolescents.” Journal of Abnormal Psychology, 122, 720-732.

  • A study of 2,822 students on a large university campus found that 3.6% of males had positive screens for ED. The female-to-male ratio was 3-to-1.

Eisenberg, D., Nicklett, E., Roeder, K., & Kirz, N. (2011) “Eating disorders Symptoms Among College Students: Prevalence, Persistence, Correlates, and Treatment-Seeking.” Journal of American College Health, 59-8, 700-707.

  • In looking at male sexuality and eating disorders, higher percentage of gay (15%) than heterosexual males (5%) had diagnoses of ED but when these percentages are applied to population figures, the majority of males with ED are heterosexual.

Feldman, M., Meyer, I. (2007) “Eating disorders in diverse, lesbian, gay, and bisexual populations.” International Journal of Eating Disorders, 40-3, 218-226.

  • Subclinical eating disordered behaviors (including binge eating, purging, laxative abuse and fasting for weight loss) are nearly as common among males as they are among females.

Mitchison, D., Hay, P., Slewa-Younan, S., & Mond, J. (2014). The changing demographic profile of eating disorder behaviors in the community. BMC Public Health, 14(1). doi:10.1186/1471-2458-14-943

  • Various studies suggest that risk of mortality for males with ED is higher than it is for females.

Raevuoni, A., Keski-Rahkonen, Hoek, H. (2014) “A review of eating disorders in males.” Current Opinions on Psychiatry, 27-6, 426-430.

  • Men with eating disorders often suffer from comorbid conditions such as depression, excessive exercise, substance disorders, and anxiety.

Weltzin, T. Carlson, T., et al. (2014) “Treatment Issues and Outcomes for Males with Eating Disorders” in Cohn, Lemberg.

  • A gender-sensitive approach with recognition of different needs and dynamics for males is critical in effective treatment. Males in treatment can feel out of place when predominantly surrounded by females, and an all-male treatment environment is recommended—when possible.

Weltzin, T. Carlson, T., et al. (2014) “Treatment Issues and Outcomes for Males with Eating Disorders” in Cohn, Lemberg.

Bunnell, D. & Maine, M. (2014) “Understanding and treating males with eating disorders” in Cohn, Lemberg.

MORTALITY

  • Eating disorders are serious conditions that can have a profound mental and physical impact, including death. This should not discourage anyone struggling—recovery is real, and treatment is available. Statistics on mortality and eating disorders underscore the impact of these disorders and the importance of treatment.
  • A review of nearly fifty years of research confirms that anorexia nervosa has the highest mortality rate of any psychiatric disorder. 

Arcelus, J., Mitchell, A. J., Wales, J., & Nielsen, S. (2011). Mortality rates in patients with Anorexia Nervosa and other eating disorders. Archives of General Psychiatry, 68(7), 724-731.

  • Anorexia has an estimated mortality rate of around 10%.

Arcelus, J., Mitchell, A. J., Wales, J., & Nielsen, S. (2011). Mortality rates in patients with Anorexia Nervosa and other eating disorders. Archives of General Psychiatry, 68(7), 724-731.

  • Among those who struggle with anorexia, 1 in 5 deaths is by suicide
  • A Swedish study of 6,000 women who were treated for anorexia nervosa found that, over 30 years, women with anorexia nervosa had a six-fold increase in mortality compared to the general population. The researchers also found an increased mortality rate from ‘natural’ causes, such as cancer, compared to the general population. Younger age and longer initial hospitalizations were associated with improved outcomes, while comorbid conditions (e.g., alcohol addiction) worsened the outcome. 

Papadopoulos, F. C., A. Ekbom, L. Brandt, and L. Ekselius. "Excess Mortality, Causes of Death and Prognostic Factors in Anorexia Nervosa." The British Journal of Psychiatry 194.1 (2008): 10-17.

  • Researchers studied records of 1,885 individuals evaluated for anorexia nervosa, bulimia nervosa, and EDNOS at the University of Minnesota outpatient clinic, over 8-25 years. Researchers found an increased risk of suicide for all eating disorders studied. Crude mortality rates were 4% for anorexia nervosa; 3.9% for bulimia nervosa; and 5.2% for EDNOS, now recognized as OSFED.

Crow, S. J., Peterson, C. B., Swanson, S. A., Raymond, N. C., Specker, S., Eckert, E. D., & Mitchell, J. E. (2009). Increased mortality in bulimia nervosa and other eating disorders. American Journal of Psychiatry, 166(12), 1342-1346. DOI: 10.1176/appi.ajp.2009.09020247

For further reading:

Brown, CA and Mehler, PS. Medical complications of self-induced vomiting. Eating Disorders. 2013;21(4):287-94.

Brown, CA and Mehler, PS. Successful “Detoxing” From Commonly Utilized Modes of Purging in Bulimia Nervosa. Eating Disorders. 2012; 20(4): 312-20.

Insel, Thomas. "Post by Former NIMH Director Thomas Insel: Spotlight on Eating Disorders."National Institute of Mental Health. U.S. Department of Health and Human Services, 24 Feb. 2012. 

Mehler, PS and AE Anderson. Eating Disorders. Baltimore: Johns Hopkins UP, 2010. Print.

Mitchell, J. E., & Crow, S. (2006). Medical complications of anorexia nervosa and bulimia nervosa. Current Opinion in Psychiatry, 19(4), 438-443.

PICA

  • Between 4%-26% of institutionalized individuals are believed to have Pica. 

Walke. C. E., Michael C. R.( 2001), Handbook of Clinical Child Psychology, John Wiley and sons, 3ed edition 692-713.

SUBSTANCE ABUSE

  • According to the National Center on Addiction and Substance Abuse, up to 50% of individuals with eating disorders abused alcohol or illicit drugs, a rate five times higher than the general population.

The National Center on Addiction and Substance Abuse (CASA) at Columbia University. Food for Thought: Substance Abuse and Eating Disorders. The National Center on Addiction and Substance Abuse (CASA) Columbia University; New York: 2003.

  • Up to 35% of individuals who abused or were dependent on alcohol or other drugs have also had eating disorders, a rate 11 times greater than the general population.

The National Center on Addiction and Substance Abuse (CASA) at Columbia University. Food for Thought: Substance Abuse and Eating Disorders. The National Center on Addiction and Substance Abuse (CASA) Columbia University; New York: 2003.

  • The substances most frequently abused by individuals with eating disorders or with sub-clinical symptoms of these disorders include: caffeine, tobacco, alcohol, laxatives, emetics, diuretics, appetite suppressants (amphetamines), heroin, and cocaine.

The National Center on Addiction and Substance Abuse (CASA) at Columbia University. Food for Thought: Substance Abuse and Eating Disorders. The National Center on Addiction and Substance Abuse (CASA) Columbia University; New York: 2003.

  • In a study looking at calorie restriction prior to alcohol consumption in college freshmen, 14% of the subjects reported restriction calories, with 6% reporting the behavior to avoid weight gain and 10% to enhance alcohol’s effect.

Burke, S. C., Cremeens, J., Vail-Smith, K., & Woolsey, C. L. (2010). Drunkorexia: Calorie restriction prior to alcohol consumption among college freshman. Journal of Alcohol and Drug Education, 54(2), 17-35.

  • Women with bulimia who were alcohol-dependent reported a higher rate of suicide attempts, anxiety, personality and conduct disorders and other drug dependence than women with bulimia who were not alcohol-dependent.

The National Center on Addiction and Substance Abuse (CASA) at Columbia University. Food for Thought: Substance Abuse and Eating Disorders. The National Center on Addiction and Substance Abuse (CASA) Columbia University; New York: 2003.

  • Eating disorders and substance abuse share a number of common risk factors, including brain chemistry, family history, low self-esteem, depression, anxiety, and social pressures.  Other shared characteristics include compulsive behavior, social isolation, and risk for suicide.

The National Center on Addiction and Substance Abuse (CASA) at Columbia University. Food for Thought: Substance Abuse and Eating Disorders. The National Center on Addiction and Substance Abuse (CASA) Columbia University; New York: 2003.

  • Roughly 20% of men and women being treated for substance use disorders reported binge eating.

Grilo CM, Sinha R, O’Malley SS. Eating disorders and alcohol use disorders. Alc Res Health.2002;26:151–160. 

  • 24.8% of binge eating disorder sufferers have also struggled with a substance use disorder. Of men with BED, 40.4% report having struggled with a substance use disorder.

Schreiber, L. R., Odlaug, B. L., & Grant, J. E. (2013). The overlap between binge eating disorder and substance use disorders: Diagnosis and neurobiology. Journal of Behavioral Addictions, 2(4), 191-198. doi:10.1556/jba.2.2013.015

  • In a study of women with bulimia nervosa, 31% had a history of alcohol abuse and 13% had a history of alcohol dependence.

Gregorowski, C., Seedat, S., & Jordaan, G. P. (2013). A clinical approach to the assessment and management of co-morbid eating disorders and substance use disorders. BMC Psychiatry, 13(1). doi:10.1186/1471-244x-13-289

  • 25% of people with anorexia, 34% of people with bulimia, and 21% of people with binge eating disorder abuse or are dependent on alcohol. 

Hudson J.I., Hiripi E., Pope H.G., Kessler R.C. (2007). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatry, 61(3), 348-358.

Milos, G., Spindler, A., Buddeberg, C., & Crameri, A. (2003). Axes I and II comorbidity and treatment experiences in eating disorder subjects. Psychother and Psychosom, 72(5), 276-285.

Ulfvebrand, S., Birgegard, A., Norring, C., Hogdahl, L., & von Hausswolff-Juhlin, Y. (2015). Psychiatric comorbidity in women and men with eating disorders results from a large clinical database. Psychiatry Res, 230(2), 294-299.

  • 27% of people with anorexia, 37% of people with bulimia, and 23% of people with binge eating disorder abuse or are dependent on other substances.

Hudson J.I., Hiripi E., Pope H.G., Kessler R.C. (2007). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatry, 61(3), 348-358.

Milos, G., Spindler, A., Buddeberg, C., & Crameri, A. (2003). Axes I and II comorbidity and treatment experiences in eating disorder subjects. Psychother and Psychosom, 72(5), 276-285.

Ulfvebrand, S., Birgegard, A., Norring, C., Hogdahl, L., & von Hausswolff-Juhlin, Y. (2015). Psychiatric comorbidity in women and men with eating disorders results from a large clinical database. Psychiatry Res, 230(2), 294-299.

TRAUMA/PTSD

  • What is “traumatic” to any given individual is best understood in light of the “three E’s,” i.e., Event, Experience, and Effects
  • Available evidence suggests that eating disorder patients may be particularly sensitive or vulnerable to stress and its consequences.
  • PTSD symptoms include (American Psychiatric Association, 2013): Re-experiencing symptoms (e.g., flashbacks, nightmares, intrusive imagery)
    • Hyperarousal symptoms (e.g., irritability or angry outbursts, exaggerated startle, problems concentrating, insomnia, being overly watchful and anxious)
    • Avoidance symptoms (e.g., numbing, forgetting and avoiding trauma-related material)
    • Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred (e.g., partial amnesia, negative beliefs about oneself, others, or the world, self-blame, constantly expecting the worst)
  • Over one-third of individuals with an index episode of PTSD still had the full syndrome 10 years later.
  • Unresolved trauma and/or PTSD can be an important perpetuating factor in the maintenance of symptoms.

Brewerton, T. D., & Dennis, A. B. (2015). Perpetuating factors in severe and enduring anorexia nervosa. In S. Touyz, P. Hay, D. Le Grange, & J. H. Lacey (Eds.), Managing Severe and Enduring Anorexia Nervosa: A Clinician's Handbook. New York: Routledge.

  • Two major national representative studies have shown that individuals with bulimia nervosa, binge eating disorder or any binge eating have significantly higher rates of PTSD than individuals without an eating disorder. The highest rates of lifetime PTSD were 38% and 44% respectively in the BN groups. When partial or subclinical forms of PTSD are considered, then well over half of individuals with bulimic symptoms have PTSD or significant PTSD symptoms. In addition, traumatized people with eating disorders demonstrate high levels of dissociative symptoms, such as amnesia of traumatic material (being unable to remember the traumatic event), which are also factors that contribute to a negative medical. 
  • When partial or subclinical forms of PTSD are considered, then well over half of individuals with bulimic symptoms have PTSD or significant PTSD symptoms.
  • In much the same way abuse of certain substances is used to self-medicate, binge eating and/or purging appear to be behaviors that facilitate: 
    • Reducing the hyperarousal or anxiety associated with trauma
    • The numbing, avoidance, and even forgetting of traumatic experiences

These behaviors are reinforcing, making it difficult to break the cycle. As a result, traumatic experiences and their destructive effects are not effectively processed and continue to cause problems.

  • Individuals with an eating disorder complicated by trauma and PTSD require treatment for both conditions using a trauma-informed, integrated approach.
  • Although the best approach to address PTSD in the context of an eating disorder remains elusive, work so far has focused primarily on cognitive processing therapy (CPT) integrated with traditional treatment for the eating disorder.
  • Future research is likely to shed light on how best to treat this comorbid combination.
  • Unresolved trauma and/or posttraumatic stress disorder (PTSD) can be an important perpetuating factor in the maintenance of eating disorders symptoms.
  • Binge eating and/or purging appear to be behaviors that facilitate reducing the hyperarousal or anxiety associated with trauma, and the numbing, avoidance, and even forgetting of traumatic experiences. These behaviors are reinforcing, making it difficult to break the cycle. As a result, traumatic experiences and their destructive effects are not effectively processed and continue to cause problems.

Brewerton, T. D. (2007). Eating disorders, trauma, and comorbidity: focus on PTSD. Eat Disord, 15(4), 285-304. doi:10.1080/10640260701454311

  • Individuals with bulimia nervosa, binge eating disorder, or any binge eating have significantly higher rates of PTSD than individuals without an eating disorder. Two major national representative studies found high rates of lifetime PTSD—38% and 44%—in those with bulimia nervosa.

Dansky, B. S., Brewerton, T. D., O'Neil, P. M., & Kilpatrick, D. G. (1997). The National Womens Study: Relationship of victimization and posttraumatic stress disorder to bulimia nervosa. International Journal of Eating Disorders, 21, 213-228. 

Hudson, J. I., Hiripi, E., Pope, H. G., Jr., & Kessler, R. C. (2007). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatry, 61(3), 348-358. doi:10.1016/j.biopsych.2006.03.040

  • When partial or subclinical forms of PTSD are considered, well over half of individuals with bulimic symptoms have PTSD or significant PTSD symptoms.

Brewerton, T. D. (2007). Eating disorders, trauma, and comorbidity: focus on PTSD. Eat Disord, 15(4), 285-304. doi:10.1080/10640260701454311

Mitchell, K. S., Mazzeo, S. E., Schlesinger, M. R., Brewerton, T. D., & Smith, B. N. (2012). Comorbidity of partial and subthreshold ptsd among men and women with eating disorders in the national comorbidity survey-replication study. Int J Eat Disord, 45(3), 307-315. doi:10.1002/eat.20965

  • Traumatized people with eating disorders demonstrate high levels of dissociative symptoms, such as being unable to remember the traumatic event.

Brewerton, T. D. (2004). Eating disorders, victimization, and comorbidity: Principles of treatment. In T. D. Brewerton (Ed.), Clinical Handbook of Eating Disorders: An Integrated Approach (pp. 509-545). New York: Marcel Decker.

Brewerton, T. D., Dansky, B. S., Kilpatrick, D. G., & O'Neil, P. M. (1999). Bulimia nervosa, PTSD, and forgetting results from the National Women's Study. In L. M. Williams & V. L. Banyard (Eds.), Trauma and Memory (pp. 127-138). Durham: Sage.

  • Individuals with an eating disorder complicated by trauma and PTSD require treatment for both conditions using a trauma-informed, integrated approach. Although the best approach to address PTSD in the context of an eating disorder remains elusive, work so far has focused primarily on cognitive processing therapy (CPT) integrated with traditional treatment for the eating disorder.

Brewerton, T. D. (2007). Eating disorders, trauma, and comorbidity: focus on PTSD. Eat Disord, 15(4), 285-304. doi:10.1080/10640260701454311

Mitchell, K. S., Mazzeo, S. E., Schlesinger, M. R., Brewerton, T. D., & Smith, B. N. (2012). Comorbidity of partial and subthreshold ptsd among men and women with eating disorders in the national comorbidity survey-replication study. Int J Eat Disord, 45(3), 307-315. doi:10.1002/eat.20965

Brewerton, T. D. (2004). Eating disorders, victimization, and comorbidity: Principles of treatment. In T. D. Brewerton (Ed.), Clinical Handbook of Eating Disorders: An Integrated Approach (pp. 509-545). New York: Marcel Decker.

SAMHSA. (2014). SAMHSA's Concept of Trauma and Guidance for a Trauma-Informed Approach. (14-4884). Rockville, MD: U.S. Department of Health and Human Services.

  • Researchers found that women who were victims of assault were 1.86x more likely  to develop bulimia than those who had not been victimized (26% v. 13.3%).

Mitchell, K. S., Mazzeo, S. E., Schlesinger, M. R., Brewerton, T. D., & Smith, B. N. (2012). Comorbidity of partial and subthreshold ptsd among men and women with eating disorders in the national comorbidity survey-replication study. Int J Eat Disord, 45(3), 307-315. doi:10.1002/eat.20965

Brewerton, T. D., Dansky, B. S., Kilpatrick, D. G., & O'Neil, P. M. (1999). Bulimia nervosa, PTSD, and forgetting results from the National Women's Study. In L. M. Williams & V. L. Banyard (Eds.), Trauma and Memory (pp. 127-138). Durham: Sage.

  • One study of veterans showed that military sexual trauma lead to nearly a two-fold increased likelihood of eating disorder diagnoses, especially amongst male veterans. 

Blais RK, Brignone E, Maguen S, Carter ME, Fargo JD, Gundlapalli AV. Military sexual trauma is associated with post-deployment eating disorders among Afghanistan and Iraq veterans. Int J Eat Disord. 2017; 50:808-816. https://doi.org/10.1002/eat.22705

  • According to one study, the majority of individuals with anorexia nervosa, bulimia nervosa, and binge eating disorder reported a history of interpersonal trauma. Rates of PTSD were significantly higher among women and men with bulimia nervosa and binge eating disorder. Subthreshold PTSD was more prevalent than threshold PTSD among women with bulimia nervosa and men with binge eating disorder. 

Mitchell, K. S., Mazzeo, S. E., Schlesinger, M. R., Brewerton, T. D., & Smith, B. N. (2012). Comorbidity of partial and subthreshold PTSD among men and women with eating disorders in the national comorbidity survey - replication study. International Journal of Eating Disorders, 45(3), 307-315.

  • The National Institutes  of Health (NIH) 2017 budget for PTSD research was $93 million, compared to $30 million for all eating disorders research.

NIH Categorical Spending -NIH Research Portfolio Online Reporting Tools (RePORT)." U.S National Library of Medicine. U.S. National Library of Medicine, 3 Jul. 2017. Web. 11 Jan. 2018.

  • According to one study, rates of sexual violence were up to 48% of females & 68% of males with anorexia nervosa, up to 41% of females & 24% of males with bulimia nervosa, and up to 35% of females & 16% of males with binge eating disorder.

Mitchell, K. S., Mazzeo, S. E., Schlesinger, M. R., Brewerton, T. D., & Smith, B. N. (2012). Comorbidity of partial and subthreshold PTSD among men and women with eating disorders in the national comorbidity survey - replication study. International Journal of Eating Disorders, 45(3), 307-315.

For further reading: 

Timothy D. Brewerton, MD, DFAPA, FAED, DFAACPA, HEDS

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, D.C. : American Psychiatric Press.

Brewerton, T. D. (2004). Eating disorders, victimization, and comorbidity: Principles of treatment. In T. D. Brewerton (Ed.), Clinical Handbook of Eating Disorders: An Integrated Approach (pp. 509-545). New York: Marcel Decker.

Brewerton, T. D. (2007). Eating disorders, trauma, and comorbidity: focus on PTSD. Eat Disord, 15(4), 285-304. doi:10.1080/10640260701454311

Brewerton, T. D. (2011). Posttraumatic stress disorder and disordered eating: food addiction as self-medication. J Womens Health (Larchmt), 20(8), 1133-1134. doi:10.1089/jwh.2011.3050

Brewerton, T. D. (2015). Stress, trauma, and adversity as risk factors in the development of eating disorders. In L. Smolak & M. Levine (Eds.), Wiley Handbook of Eating Disorders (pp. 445-460). New York: Guilford.

Brewerton, T. D., Dansky, B. S., Kilpatrick, D. G., & O'Neil, P. M. (1999). Bulimia nervosa, PTSD, and forgetting results from the National Women's Study. In L. M. Williams & V. L. Banyard (Eds.), Trauma and Memory (pp. 127-138). Durham: Sage.

Brewerton, T. D., & Dennis, A. B. (2015). Perpetuating factors in severe and enduring anorexia nervosa. In S. Touyz, P. Hay, D. Le Grange, & J. H. Lacey (Eds.), Managing Severe and Enduring Anorexia Nervosa: A Clinician's Handbook. New York: Routledge.

Dansky, B. S., Brewerton, T. D., O'Neil, P. M., & Kilpatrick, D. G. (1997). The National Womens Study: Relationship of victimization and posttraumatic stress disorder to bulimia nervosa. International Journal of Eating Disorders, 21, 213-228. 

Hudson, J. I., Hiripi, E., Pope, H. G., Jr., & Kessler, R. C. (2007). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatry, 61(3), 348-358. doi:10.1016/j.biopsych.2006.03.040

Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry, 52(12), 1048-1060. 

Mitchell, K. S., Mazzeo, S. E., Schlesinger, M. R., Brewerton, T. D., & Smith, B. N. (2012). Comorbidity of partial and subthreshold ptsd among men and women with eating disorders in the national comorbidity survey-replication study. Int J Eat Disord, 45(3), 307-315. doi:10.1002/eat.20965

SAMHSA. (2014). SAMHSA's Concept of Trauma and Guidance for a Trauma-Informed Approach. (14-4884). Rockville, MD: U.S. Department of Health and Human Services.

Trottier, K., Wonderlich, S. A., Monson, C. M., Crosby, R. D., & Olmsted, M. P. (2016). Investigating posttraumatic stress disorder as a psychological maintaining factor of eating disorders. Int J Eat Disord, 49(5), 455-457. doi:10.1002/eat.22516

 

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