The first eating disorder diagnosis, Anorexia Nervosa, was described in 1973. In the DSM-IV-TR, there are only two accepted diagnoses--anorexia and bulimia--and a grab bag classification called eating disorder not-otherwise-specified (EDNOS) for everything else. There is a lag between relevant diagnoses and the steep rise in the incidence of eating disorders and eating disordered syndromes, and this lag makes the current system essentially irrelevant for treatment. Many other diagnoses have been suggested: binge eating disorder, night eating syndrome, orthorexia, purging disorder and compulsive overeating. The psychiatric community has had difficulty codifying these symptoms into disorders largely because they are a social phenomenon or perhaps even a lifestyle choice. Due to multiple individual and societal pressures, manipulating food has become a way of life. As is evident from my previous posts, I believe these symptoms only lead to isolation and misery, but the purpose of this current post is to present an eating disorder classification system.

When it comes to treatment, only two variables really matter: the length of the illness before effective treatment and the most prominent symptom of the disorder. If effective treatment starts within the first five years, then the goals are to stabilize eating, normalize weight and return the patient to her pre-eating disorder way of life. At this point, she will more easily fall back into her natural eating patterns and her natural social patterns. Treatment is likely to be more successful and more uniform no matter the diagnosis. Her eating disorder will only be a coping strategy, not yet a lifestyle. She will be able to join her peer group relatively quickly in terms of education, friendships and relationships. Even though a significant minority of these patients will become chronic, expecting success can turn around even the most gravely ill patient early in the course of the disorder.

For people with chronic eating disorders, usually five years or longer, recovery for the patient feels more like introducing a new way of living. The eating disorder has become a buffer between herself and the world. What appears to the outsider to be liberation from the symptoms can feel oppressive, exposing and terrifying to the patient. After a lengthy illness, she can rarely fall back into pre-eating disorder living and feels as if she has fallen too far behind her peer group to ever catch up. Sadly, the benefits of remaining sick often look more appealing.

The core of successful treatment with chronic patients is personal connection. If she can break down the barrier of the eating disorder and connect in any relationship--in her life or in therapy--she can start to realize and want what she is missing. That desire and motivation is crucial to have any chance at success. The therapy relationship itself is often the critical tool that can break the hold of the disorder. The means of finding connection depends not on
diagnosis but on the primary symptom of the disorder: starving, binging and purging (vomiting, laxatives, diuretics, over-exercising etc.) or overeating.

People with chronic eating disorders almost always fall into the diagnosis EDNOS. Few people sick longer than five years are able to sustain the same symptoms. As her body adapts to the disorder, she needs to find new symptoms to survive, ie binging to compensate for long-term starvation or laxatives when she can no longer vomit. These adaptations don't change the primary symptom, and the psychological key to recovery lies in that core symptom.

People whose prominent symptom is starvation have tied up their entire identity in the ability to control hunger and remain thin. Society has lavished her with praise. She has figured it out. Everyone is incredibly jealous. Even though starvation has always curtailed any other accomplishments, nothing surpasses the ability to master food. The attachment is so powerful, she will often overlook severe medical complications to continue to starve. The key to opening the door to treatment is to unlock her isolation and sadness. By connecting in a relationship, usually in therapy, she can remember how alone she is and how much she sacrifices to continue starving. The road to
treatment is long and arduous, but sometimes the desire to survive and truly live can gradually overcome the satisfaction of the illness.

For patients who primarily binge and purge, the disorder most closely resembles an addiction. The chemical high a patient experiences from binging and the release of purging only leads to a craving for more. Often, she feels powerless to experience eating any other way. The shame leads to the need to hide so even those closest to her may not suspect she has an eating disorder. The key to treatment begins with forging a new connection with herself. Exposure of all of her eating behaviors, binging included, in therapy in a detailed food journal is essential. As the patient gains some perspective on her disorder and begins to have success with normal meals, she loses both the cravings to binge and the internal sense of shame. Reconnecting both to herself and the people in her life provides essential feedback to continue down the road to recovery.

Overeating presents the newest, least studied and most controversial group of eating disorders. Food journals can certainly help distinguish overeating from binging and expose the level of shame associated with eating. Since these patients frequently have a lot of knowledge about nutrition, education is not a critical component of treatment. What makes these patients controversial is that the illness is a national phenomenon with political, industrial and psychological causes. For now I will focus on the psychological root. These patients have disconnected on a larger, societal level, and the treatment needs to bring them back to their own daily lives. In our community, people who are obese are often ignored or even invisible. They feel disempowered, desexualized and even dehumanized, almost as if they do not deserve the same rights as others. For many patients, this isolation provides security. The isolation limits the closeness in relationships and the expectations that might be imposed on them. The public scrutiny and judgment can reinforce their extremely low self-esteem. Food itself both provides both solace and punishment. These patients need to want to be part of the world again and to believe they deserve connection, respect and love. They are usually very aware of their isolation but do not believe it could be any different. It can be a lonely life, and the goal of treatment is to provide hope again, perhaps enough to reassess her relationship with food, her life and herself.

Food journals work their way into all categories of diagnosis independent of the duration of illness and primary eating disorder symptom. I will elaborate on the utility and benefit of journals in the next post.


  1. This was a very helpful read for me, Dr. Lissak. As you know, I was in a relationship with someone who binged and purged. That is, that was the primary act. I had no idea that this could produce a sort of "high". While in this relationship I admit to being clueless about what was so seductive about this act.

  2. to get help for this disorder does one have to be hospitalized for treatment and if so how long does the treatment last? I need help for my daughter and I don't know where to turn. She is 20 and this disease is starting to consume her and she is starting to get into financial trouble because of it. Please provide me with some answers.