What Are Eating Disorders?

Eating disorders are psychiatric disorders characterized by severe problems with eating behavior and related thoughts and emotions. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the official guidebook to the diagnosis of psychiatric disorders used by mental health providers, recognizes eight types of eating disorders. Eating disorders included in the DSM-5 include:

Anorexia nervosa Avoidant/restrictive food intake disorder (ARFID) Binge-eating disorder Bulimia nervosa Rumination disorder Other specified feeding or eating disorder (OSFED) Pica Unspecified feeding or eating disorder (UFED)

Anorexia and Bulimia

Anorexia is marked by restrictive food consumption, a preoccupation with gaining weight, and significantly low body weight. In contrast, the central feature of bulimia nervosa is the presence of ​binge eating, followed by behaviors that attempt to compensate for the binge eating, such as self-induced vomiting, overuse of laxatives, excessive exercise, and others. There can be some overlap in symptoms between these two disorders. For example, someone may engage in binge eating and purging, but also be unwilling to maintain normal body weight.

Binge-Eating Disorder

Binge-eating disorder was officially added to the DSM as a diagnosis in 2013. The condition is characterized by binge-eating episodes where people feel that their eating is out of control. These episodes are also often accompanied by feelings of embarrassment or guilt. Unlike bulimia, there are no accompanying compensatory behaviors.

Other Eating Disorders

Pica and rumination disorder were moved from the now-eliminated DSM-IV section of disorders usually diagnosed in infancy, childhood, and adolescence into the feeding and eating disorders section of the DSM-5. Pica involves the craving and consumption of non-food substances. Rumination disorder involves regurgitating previously eaten food in order to spit or re-swallow it. Avoidant/restrictive food intake disorder is a new addition to the DSM, known previously as selective eating disorder. This disorder is characterized by restrictive food intake, but it not marked by distress over body size or weight gain.  The DSM-5 also contains umbrella diagnosis options of “other specified” and “unspecified” for conditions that do not meet the criteria of other eating disorders such as anorexia nervosa or binge-eating disorder.

Prevalence

People with borderline personality disorder have a greater prevalence of eating disorders than people in the general population. For example, a widely cited study by Dr. Mary Zanarini and her colleagues at McLean Hospital found that 53.8% of patients with BPD also met criteria for an eating disorder (compared to 24.6% of patients with other personality disorders). In this study, 21.7% of patients with BPD met criteria for anorexia nervosa and 24.1% for bulimia nervosa. Of course, this is not to say that people with eating disorders necessarily have borderline personality disorder. In fact, the overwhelming majority of people with eating disorders do not have BPD.  Some eating disorders, though, are associated with having a higher risk of BPD than others. One study found that people with bulimia nervosa, purging type may be at a greater risk for BPD (with about 11% meeting BPD criteria) than people with anorexia nervosa, binge-eating/purging type (with about 4% meeting BPD criteria).

Why do people with BPD seem to have eating disorders at a greater rate than people in the general population? Experts have noted that one possible explanation is that BPD and eating disorders (particularly bulimia nervosa) share a common risk factor. Both BPD and eating disorders are associated with histories of childhood trauma, such as physical, sexual and emotional abuse. In addition, some experts have suggested that it may be that the symptoms of BPD put one at risk for developing an eating disorder. For example, chronic impulsivity and urges to self-harm may lead one to engage in problematic eating behavior, which may over time rise to the level of an eating disorder. Conversely, engaging in eating disordered behavior may lead to experiences of stress (e.g., intense shame, hospitalization, family disruption) that may trigger BPD in someone with a genetic vulnerability for the disorder.

Treatments

What can be done about BPD and co-occurring eating disorders? The good news is that there are effective treatments available for both types of conditions. While some studies have indicated that people with BPD do not respond as well to eating disorder treatment, other studies have found no differences in treatment response between people with eating disorders with or without BPD. Which problem should be treated first? It may be that both the eating disorder and the BPD symptoms can be treated at the same time, but this may be decided on a case-by-case basis. For example, some people have eating disorder symptoms that are so severe they are immediately life-threatening. In this case, hospitalization for the eating disorder symptoms may be necessary before treatment for the BPD symptoms can begin. Alternatively, in someone with very severe BPD symptoms that are either life-threatening or threaten to reduce their ability to engage in the treatment, the BPD symptoms may be treated first.

Finding Help

If you think you (or a loved one) may have BPD and/or an eating disorder, the first step is to find a mental health provider who can make the right diagnosis and give you the right treatment.