Clinical Eating Disorders versus Disordered Eating: A Wide Spectrum of Dangerous Behaviors

By Terry Zeigler, EdD, ATC

Eating disorders and subclinical disordered eating behaviors are serious problems that can negatively affect both the health and performance of young athletes. The incidence of young women struggling with eating disorders or disordered eating behaviors may be higher in some sports. For example, in sports like gymnastics, cross country, swimming, cheerleading these disorders need to be better understood by both athletes and those working closely with athletes in all sports so that intervention and treatment can be provided early.

The terms “eating disorders” and “disordered eating” are frequently used interchangeably, but they are distinct and should be recognized as such. With that being said, it may be easier to understand the differences if they are placed on a continuum.

Anorexia nervosa can be placed on the far left end of the continuum with subclinical anorexia just to the right of anorexia nervosa, bulimia nervosa on the far right end of the continuum with subclinical bulimia just to the left of bulimia nervosa and normal eating behaviors in the middle. All across the continuum (somewhere between the far ends and normal eating behavior in the middle) lies a host of abnormal eating behaviors.

The definition of eating disorders is that they are “psychiatric disorders that affect individuals’ psychological, physical, nutritional, interpersonal, and emotional functioning and are characterized by dysfunctional eating patterns and disturbances or distortions about body size and shape” (Ray, R. & Wise-Bjornstal, D.M., 1999).

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), there are three clinical eating disorders (Beals, K.A., 2004). The three include anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified (EDNOS). The category of EDNOS was designed to describe conditions that meet some but not all of the criteria for anorexia nervosa and bulimia nervosa.

While there are three distinct categories of clinical eating disorders, there is another grouping of disordered eating syndromes that are classified as subclinical eating disorders. This category is used to describe individuals with considerable eating behavior pathology, but who do not meet the clinical criteria for the three identified clinical eating disorders.

Recognizing and Understanding Anorexia Nervosa

It is interesting to note that the term anorexia nervosa originated from the Greek word “anorexia” which means “lack of appetite” (Beals, K.A., 2004). Perhaps early on it was thought that these individuals actually had a lack of appetite, but that is not really the case.

In actuality, the individual is always hungry. However hungry, the individual denies her hunger and in the process is starving herself. The criteria for diagnosing anorexia nervosa include the following (Ray, R. & Wise-Bjornstal, D.M., 1999):

• Refusal to maintain body weight at or above a minimally normal weight for age and height (i.e., at least 85% of expected body weight).
• Intense fear of gaining weight or becoming fat, even though underweight.
• Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight of shape on self-evaluation, or denial of the seriousness of the current low body weight.
• In postmenarcheal females, amenorrhea (i.e., the absence of at least three consecutive menstrual cycles).

Within the category of anorexia nervosa are two subtypes: the restricting type and the binge-eating/purging type. An individual with the restricting type of anorexia nervosa severely restricts her caloric intake and indulges in excessive exercise to burn the calories that are consumed. An individual with the binge-eating/purging type also restricts her caloric intake and participate in excessive exercise, but may also be involved with binge eating and purging either through self-induced vomiting or laxative/diuretic use to control weight (Beals, K.A., 2004).

Although the appearance of an individual with anorexia nervosa is one of physiological starvation, one has to understand that the disorder is a complex interplay of psychological, physiological, social, and physical systems. The psychological obsession is the focus on losing weight and being thin, but regardless of how much weight the individual loses, the individual still perceives herself as overweight.

Characteristics of an individual with anorexia nervosa may include the following:

• High-achieving
• Goal-oriented
• Perfectionist
• Low self-esteem
• Need for control
• Body dissatisfaction
• Depression
• Lack of assertiveness
• Obsessive-compulsive tendencies
• Anxiety

The characteristics are important to understand because the low self-esteem is what drives these individuals towards achieving their goal of losing weight with the belief that if only the weight is lost, the individual will be successful. The need for control also plays a critical role because controlling the amount of food intake is something that makes this individual feel successful.

The disorder manifests itself in a host of both physiological and psychological problems including decreased cardiac functioning, iron deficiencies, fatigue, increased rate of infection and illness, increased rate of injuries, gastrointestinal complications, endocrine abnormalities, decreased bone density, and psychological stress (Beals, K.A., 2004). Unfortunately, this disorder has an increased fatality rate with individuals dying from cardiac arrest due to weakening of the heart muscle.

Recognizing and Understanding Bulimia Nervosa

Whereas anorexia nervosa is characterized by starvation, bulimia nervosa is characterized by repeated cycles of uncontrollable food consumption followed by behavior to rid the body of the excessive calories including self-induced vomiting, excessive exercise, or laxative or diuretic abuse (Beals, K.A., 2004).

The criteria for diagnosing bulimia nervosa include (Ray, R. & Wise-Bjornstal, D.M., 1999):

• Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
1. Eating, in a discrete period of time (i.e., within a two hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances, and
2. A sense of lack of control over eating during the episode.
• Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise.
• The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for three months.
• Self-evaluation is unduly influenced by body shape and weight.
• The disturbance does not occur exclusively during episodes of anorexia nervosa.

Bulimia nervosa is also further divided into subtypes including the purging type and the nonpurging type. An individual with the purging type of bulimia nervosa engages in purging types of behavior including self-induced vomiting, and the misuse of laxatives, diuretics, and other medication to purge her body of the excessive calories.

The non-purging type of bulimic individual uses methods that do not immediately rid the body of the excess calories but does so over time including excessive exercise and fasting. This individual may be involved in an episode of binge eating and then exercise for four or five hours followed by a fast for the next several days.

Unfortunately, the extended starvation period only makes the individual want food more. Instead of being able to eat normal portion sizes, the individual will eventually lose control of their appetite and gorge on food once again. This cycle is repeated over and over as the individual tries to gain control of their food obsession while not gaining weight.

The individual with bulimia nervosa tends to have cyclical variations in weight depending on where the person is in the binge-purge cycle. However, this individual’s body weight stays in a neutral range unlike the individual suffering from anorexia nervosa. This up and down weight gain can be easily hidden with loose clothes so the condition may be more difficult to spot in athletes.

Along with the somewhat normal body weight of the individual, these individuals are adept at hiding their condition which makes this condition really difficult to identify. These individuals go to great lengths to binge and purge in private so as not to be caught. The fear of being discovered is a constant fear in the life of an individual with bulimia nervosa.

Some of the psychological characteristics or effects of bulimia nervosa include the following (Thompson, R.A. & Trattner Sherman, R., 1993):

• Preoccupation with food
• Relentless pursuit of thinness
• Unusual eating habits and behaviors
• Low self-esteem
• Impulsivity or low sense of self-control
• Affective instability (depression, anger, anxiety)
• Difficulty expressing emotion in a direct manner
• Low frustration tolerance
• Absolute thinking
• Significant body dissatisfaction
• High need for approval (fear of disapproval)

Along with psychological characteristics, the individual suffering from bulimia nervosa may experience specific medical problems including menstrual irregularities, dental and gum disease, swollen parotid glands, gastrointestinal problems, and electrolyte abnormalities due to dehydration (Thompson, R.A. & Trattner Sherman, R., 1993).

Whereas the individual with anorexia nervosa may suffer physiological effects directly related to starvation, the individual with bulimia nervosa may suffer from a number of physiological effects from purging. For example, dental cavities and tooth erosion are one side effect due to the gastric acid in the mouth from repeated vomiting.

Gastrointestinal problems may also occur including abdominal cramping, bloating, constipation, diarrhea, esophagitis, gastric and duodenal ulcers, slowed gastric emptying, spontaneous or reflex regurgitation, and even stomach rupture (Thompson, R.A. & Trattner Sherman, R., 1993).

Last, cardiovascular complications may occur from electrolyte abnormalities and dehydration including water retention, low blood pressure, dizziness, light-headedness, and fainting. Damage to the heart muscle may also occur as a result of the use of emetics to induce vomiting.

Recognizing and Understanding Eating Disorders Not Otherwise Specified (EDNOS)

This fairly new clinical diagnosis was recently added to the DMS-IV to describe conditions that don’t quite meet the criteria for either anorexia nervosa or bulimia nervosa but are clinically significant. The criteria for the diagnosis of EDNOS include the following (Beals, K.A., 2004):

• All of the criteria for anorexia nervosa are met except amenorrhea.
• All of the criteria for anorexia nervosa are met except that, despite significant weight loss, the individual’s current weight is within the normal range.
• All of the criteria for bulimia nervosa are met except that the binge and purge cycles occur at a frequency of less than twice a week for a duration of less than three months.
• An individual of normal body weight regularly uses purging behaviors after eating small amounts of food.
• An individual repeatedly chews and spits out, but does not swallow, large amounts of food.

Recognizing and Understanding Subclinical Eating Disorders

Across the continuum from behaviors of an individual with anorexia nervosa to behaviors of an individual suffering from bulimia nervosa lie a large range of disordered eating behaviors that fall short of the established DSM-IV criteria for one of the three clinical conditions. These conditions may include individuals with considerable unhealthy eating behaviors and body weight concerns, but who may not manifest all of the clinical criteria.

The difficulty with individuals who may fall in to the category of subclinical eating disorders is that they may move along the continuum from unhealthy to healthy eating behaviors and back over time. Unhealthy eating behaviors may include the following:

• Excessive dieting
• Fasting
• Extreme body dissatisfaction
• Binge eating
• Compulsive exercising
• Purging

Regardless of where an individual may fall on the continuum of disordered eating behaviors, the behaviors associated with eating disorders and disordered eating are dangerous. The focus of those working with athletes is to be able to recognize that an athlete may be at risk for an eating disorder and to be able to refer the athlete to a team of appropriate medical professionals for intervention and treatment.

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Beals, K.A. (2004). Disordered Eating Among Athletes: A Comprehensive Guide for Health Professionals. Human Kinetics: Champaign, IL.

Ray, R. & Wiese-Bjornstal, D.M. (1999). Counseling in Sports Medicine. Human Kinetics: Champaign, IL.

Thompson, R.A. & Trattner Sherman, R. (1993). Helping Athletes with Eating Disorders. Human Kinetics: Champaign, IL.