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Eating Disorders

Clinical Pearls Video Series

Video Chapters

Click on the three lines in the upper left corner to see chapter information or reference the chapter table of contents below to navigate to specific chapters.

  • Assessment
    • What causes eating disorders? What are the risk factors we should be aware of? (00:19–01:36)
    • How do we differentiate a picky eater or normative teenage angst related to body image and the development of an eating disorder? (01:37–02:57)
    • When we suspect an eating disorder, how should we discuss this with the patient? How do we discuss it with the family? (02:58–04:26)
    • What should our initial workup entail if we suspect an eating disorder? Are there other specialists we should be contacting or involving as part of the care team? (04:27–05:49)
    • What are the different types of eating disorders and how do we distinguish them diagnostically? Does the type of eating disorder impact treatment? (05:50–08:53)
  • Management
    • Who are the principal professionals involved in the management of eating disorders once the diagnosis is made? (08:54–09:39)
    • What vitals, labs, and other assessment tools should we be using for longitudinal management of eating disorders? (09:40–10:14)
    • How do we engage the patient and family in the refeeding process? What does that refeeding look like when the patient is receiving treatment in the community? (10:15–11:53)
    • When should we suggest a referral to a higher level of care? Referral to the emergency department? (11:54–13:20)
    • What is the role of medications, including psychotropic medications, in the management of the eating disorder? (13:21–15:47)
  • Key Takeaways (15:48–16:51)
Dr. Natalie Prohaska.

Natalie Prohaska, M.D., Child & Adolescent Psychiatrist, University of Michigan

Eating disorders are psychiatric conditions characterized by persistent disturbances in eating behaviors associated with distressing thoughts and emotions. These conditions often impact physical, emotional, cognitive, and social health factors and can range from mild to severe to life-threatening. Eating disorders often co-occur with other psychiatric disorders, most commonly mood and anxiety disorders, obsessive-compulsive disorder, and alcohol and substance use disorders. A combination of genetic risk, family values, stressors related to body image or nutrition, psychiatric or psychological values that impact self-esteem or self-image, and other modeled behaviors related to eating, activity, or physical health all can play a part in elevating risk of developing an eating disorder among youth.  

There are six types of eating disorders with the more common disorders being anorexia nervosa, bulimia nervosa, binge eating disorder, and avoidant restrictive food intake disorder (ARFID). It is important to distinguish these conditions as they may involve different treatments, potential complications, and diagnostic considerations. 

Initial assessment of eating disorders involves a comprehensive patient history, review of other potential psychiatric and physical comorbidities, vitals including height, weight, and body-mass index, as well as a physical exam with particular focus on potential sequelae of restricted eating behaviors. Initial laboratory assessment includes review of electrolytes, hepatic and renal function, markers of protein loss and nutritional deficiency, as well as any additional diagnostic studies guided by history and physical examination. These assessments are often more extensive on initial examination but should be done iteratively with regular reflection and judicious evaluation as indicated with evolving symptoms.   

The most evidence-based treatment for eating disorders in adolescents is Family Based Treatment (FBT). Through FBT, the family is central in helping restore an adolescent’s weight as well as regulating eating. For more ego dystonic disorders, such as bulimia, binge eating, and sometimes ARFID, the patient may be more responsive to Cognitive Behavioral Therapy (CBT). The evidence for pharmaceutical support for eating disorders is limited and often augments management of the eating disorder symptoms or co-occurring mental health conditions and may include the use of aripiprazole, olanzapine, and SSRIs in some populations. When youth and young adults are struggling with outpatient care, higher levels of care are available, including intensive outpatient therapy, partial hospitalization, medical and psychiatric hospitalization, as well as residential care.

Couturier, J., Isserlin, L., Spettigue, W., & Norris, M. (2019). Psychotropic Medication for Children and Adolescents with Eating Disorders. Child and adolescent psychiatric clinics of North America, 28(4), 583–592. https://doi.org/10.1016/j.chc.2019.05.005

Kalm LM, Semba RD. They starved so that others be better fed: remembering Ancel Keys and the Minnesota experiment. The Journal of Nutrition. 2005; 135(6):1347–1352.

Hornberger LL, Lane MA; COMMITTEE ON ADOLESCENCE. Identification and Management of Eating Disorders in Children and Adolescents. Pediatrics. 2021 Jan;147(1):e2020040279.

Lock, J., La Via, M. C., & American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Quality Issues (CQI) (2015). Practice parameter for the assessment and treatment of children and adolescents with eating disorders. Journal of the  American Academy of Child and Adolescent Psychiatry, 54(5), 412–425.

Maguen, S., Hebenstreit, C., Li, Y., Dinh, J. V., Donalson, R., Dalton, S., Rubin, E., & Masheb, R. (2018). Screen for Disordered Eating: Improving the accuracy of eating disorder screening in primary care. General hospital psychiatry, 50, 20–25.

Morgan, J., Reid, F., & Lacey, J. (2000). The scoff questionnaire: A new screening tool for eating disorders. Western Journal of Medicine, 172, 164-165.

Peebles R, Sieke EH. Medical complications of eating disorders in youth. Child and Adolescent Psychiatric Clinics of North America. 2019; 28(4):593–615.

Test your knowledge with an optional 5-question quiz below. (Note: If you wish to receive a certificate of completion for this MC3 Clinical Pearl, you must receive a passing score of 80%.)

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Eating Disorders Quiz

1. Which of the following is an evidence-based treatment for eating disorders?

2. A 13-year-old male presents with weight loss for the past year. The patient states that it started with a reduction in foods with added sugar. He is a swimmer and during the last season, he lost about 20 pounds. His parents have explained to him that he needs to eat more if he is that active, but he continues to monitor his portions and refuses most processed foods. Despite hearing from his doctor that he needs to gain weight, he worries that he will gain too much. He feels that his current weight is fine. He becomes tearful when you encourage his parents to present him with sugary foods such as ice cream. Which of the following statements about his diagnosis is true?

3. An adolescent comes in with a several-year history of poor eating, low appetite, nausea, and low weight. The patient has been evaluated by multiple GI doctors who have not identified a cause for her nausea. The patient describes herself as a worrier and “just knows” she will be nauseous before even starting to eat. The patient has never vomited due to eating but believes it will happen if she eats too much. The patient denies any concerns about her body except significant fatigue and recognizes that this is due to her low weight. Due to fatigue and poor concentration, the patient struggled in high school last semester. The patient’s likely diagnosis is:

4. Which of the following statements is most consistent with anorexia nervosa, as compared to bulimia nervosa?

5. Which of the following statements about refeeding syndrome is true?

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