Eating Disorders: Part I
Contents
Preface: Eating Disorders 2018: New Insights in Diagnosis, Research, and Treatment xiii
Harry A. Brandt and Steven F. Crawford
Eating Disorders Overview of Diagnostic Considerations
Diagnostic Categories for Eating Disorders: Current Status and What Lies Ahead 1
B. Timothy Walsh
The Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) for
6 feeding and eating disorders were published in 2013 and were notable
for officially recognizing binge-eating disorder and for articulating criteria
for avoidant/restrictive food intake disorder. The criteria and the rationale
for them are briefly described, and current and future challenges are
discussed.
Recent Research and Personalized Treatment of Anorexia Nervosa 11
Carol Kan and Janet Treasure
Recent advances in the understanding of aetiologic elements underlying
anorexia nervosa have provided valuable insights and are transforming
the way this illness is treated. The aim of this article is to consider how neu-
ropsychological understanding and new research can be used to develop
a more individualized and personalized approach in the management of
this serious illness.
Recent Research on Bulimia Nervosa 21
Tracey D. Wade
Estimates of lifetime bulimia nervosa (BN) range from 4% to 6.7% across
studies. There has been a decrease in the presentation of BN in primary
care but an increase in disordered eating not meeting full diagnostic
criteria. Regardless of diagnostic status, disordered eating is associated
with long-term significant impairment to both physical and mental quality
of life, and BN is associated with a significantly higher likelihood of self-
harm, suicide, and death. Assessment should adopt a motivationally
enhancing stance given the high level of ambivalence associated with
BN. Cognitive behavior therapy specific to eating disorders outperforms
other active psychological comparisons.
Binge-Eating Disorder 33
Anja Hilbert
Binge-eating disorder (BED), first included as a diagnostic entity in the
Diagnostic and Statistical Manual of Mental Disorders Fifth Edition, is char-
acterized by recurrent episodes of binge eating without regular compensa-
tory behaviors to prevent weight gain. With a complex multifactorial
etiology, BED is the most frequent eating disorder co-occuring with signif-
icant psychopathology, mental and physical comorbidity, obesity, and life
viii Contents
impairment. Despite its significance, BED is not sufficiently diagnosed or
treated. Evidence-based treatments for BED include psychotherapy and
structured self-help treatment, with cognitive-behavioral therapy as most
well-established approach, and pharmacotherapy with lisdexamfetamine
as FDA approved medication with a limitation of use.
Avoidant Restrictive Food Intake Disorder 45
Debra K. Katzman, Mark L. Norris, and Nancy Zucker
Avoidant restrictive food intake disorder (ARFID) is a rearticulated eating
disorder diagnosis in the Diagnostic and Statistical Manual of Mental Dis-
orders (fifth edition) (DSM-5), published in 2013. The purpose of this article
is to review what is known about ARFID; specifically outline the DSM-5
diagnostic criteria; review the epidemiology; describe the clinical charac-
teristics of patients with this disorder; and discuss evolving treatment ap-
proaches. Although this disorder occurs across the lifespan, the focus of
recent research has been primarily in children and adolescents with AR-
FID. Therefore, most of this article is devoted to children and adolescents
with ARFID.
Etiological Considerations
Genetics of Eating Disorders: What the Clinician Needs to Know 59
Cynthia M. Bulik, Lauren E. Blake, and Jehannine Austin
Anorexia nervosa (AN), bulimia nervosa (BN), and binge-eating disorder
(BED) are heritable conditions that are influenced by both genetic and envi-
ronmental factors. Recent genome-wide association (GWA) studies of AN
have identified specific genetic loci implicated in AN, and genetic correla-
tions have implicated both psychiatric and metabolic factors in its origin.
No GWAS have been performed for BN or BED. Genetic counseling is
an important tool and can aid families and patients in understanding risk
for these illnesses.
Cognitive Neuroscience of Eating Disorders 75
Joanna E. Steinglass, Laura A. Berner, and Evelyn Attia
Anorexia nervosa and bulimia nervosa are characterized by severely
restricted intake, binge eating, and compensatory behaviors like self-
induced vomiting. The neurobiological underpinnings of these maladaptive
behaviors are poorly understood, but the application of cognitive neurosci-
ence and neuroimaging to eating disorders has begun to elucidate their
pathophysiology. Specifically, this review focuses on 3 areas that suggest
paths forward: reward, cognitive and behavioral control, and decision
making. Understanding the brain-based mechanisms that promote and
maintain these often chronic symptoms could guide the development of
new and more effective treatments.
The Microbiome and Eating Disorders 93
Jochen Seitz, Stefanie Trinh, and Beate Herpertz-Dahlmann
Growing interest exists in the association of gut bacteria with diseases,
such as diabetes, obesity, inflammatory bowel disease, and psychiatric
Contents ix
disorders. Gut microbiota influence the fermentation of nutrients, body-
weight regulation, gut permeability, hormones, inflammation, immunology,
and behavior (gut-brain axis). Regarding anorexia nervosa (AN), altered mi-
crobial diversity and taxa abundance were found and associated with
depressive, anxious, and eating disorder symptoms. Potential mecha-
nisms involve increased gut permeability, low-grade inflammation, autoan-
tibodies, and reduced brain cell neogenesis and learning. Gut microbiome
is strongly influenced by refeeding practices. Microbiota-modulating stra-
tegies like nutritional interventions or psychobiotics application could
become relevant additions to AN treatment.
Personality Variables and Eating Pathology 105
Allison F. Wagner and Kelly M. Vitousek
Personality variables have long been implicated in the onset and mainte-
nance of eating disorders, as well as in symptom divergence between
anorexia nervosa and bulimia nervosa. Clinical observations are broadly
supported by the data, with restricting anorexia nervosa associated with
higher levels of constraint and Persistence, and binge-purge behaviors
linked to the tendency to take impulsive action when emotionally dis-
tressed. Considerable heterogeneity is found within diagnostic categories,
however, suggesting that different personality structures may predispose
individuals to develop disordered eating through alternative pathways.
The Role of Sociocultural Factors in the Etiology of Eating Disorders 121
Ruth Striegel Weissman
Most theories emphasize the role of sociocultural factors in the etiology
of eating disorders (EDs). This article uses a broad search strategy to
identify current etiologic studies. Women with an ED outnumber men
in each diagnosis, but gender differences vary by diagnosis. Men are un-
derrepresented in study samples, and information about variable risk
factors in men is sparse. Findings suggest transdiagnostic risk factors
and disorder-specific risk factors. Extracting data from population-based
registers represents a major advance. Novel analytic approaches sug-
gest complex pathways to ED. Although used in several studies, reliance
on a transdiagnostic ED category (vs diagnosis-specific groupings) is
premature.
Other Topics
Body Image in the Context of Eating Disorders 145
Siân A. McLean and Susan J. Paxton
Body dissatisfaction is a risk factor for development of eating disorders
and represents a core psychopathologic feature of eating disorders.
Prevention and treatment interventions address established risk and main-
taining factors for body dissatisfaction: appearance pressures, internaliza-
tion of appearance ideals, upward appearance comparison, avoidance
and checking, and body disparagement. It is essential to address body
dissatisfaction within eating disorders treatment to improve outcomes
and reduce risk of relapse. Future directions in research and treatment
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aim to reach populations increasingly recognized as in need, including
children, men, and individuals at higher weights, with the ultimate goal of
reducing the significant distress associated with body dissatisfaction.
Feeding and Eating Disorders in Children 157
Rachel Bryant-Waugh
This article provides an update based on recently published literature and
expert consensus on the current state of knowledge regarding feeding and
eating disorders in children aged 2 to 12 years. It covers the 6 main diag-
nostic categories—pica, rumination disorder, avoidant/restrictive food
intake disorder, anorexia nervosa, bulimia nervosa, and binge eating dis-
order—discussing issues and findings specific to this age group. It high-
lights the need for ongoing research in a number of key areas, to include
improved understanding of etiologic pathways, characterization of pre-
senting disorders, and the development of standardized evidence-based
assessment tools and treatment interventions.
