Eating disorders

Eating Disorders

• Anorexia Nervosa
• Binge eating disorder
• Bulimia Nervosa
• Other Specified Feeding or Eating Disorder (including EDNOS)
• Pica
• Rumination disorder

Feeding Disorders

• Avoidant/Restrictive Food Intake Disorder
• Unspecified Feeding and Eating Disorders
• Overeating associated with other psychological disturbances
• Vomiting associated with other psychological disturbances

Other food-related problems

• Obesity (not a psychiatric disorder)
• Disordered Eating

This page covers all eating and feeding disorders in the DSM-5 psychiatric manual, and describes research into the relationships between between eating disorders, trauma or stressor-related disorder, and dissociative disorder. The disorders are listed similarly described in the older ICD10 manual, which categorizes eating disorders as "behavioural syndromes associated with physiological disturbances and physical factors (F50-F59)^[1]". A significant minority of people with eating disorders also self injure or use other forms of self harm.

Discrimination and Eating Disorders

Discrimination (teasing, bullying) is associated with eating with eating disturbance, regardless of body weight.^[2] This includes discrimination which is unrelated to physical appearance or weight, for example racial or gender discrimination. ^[2]

Classifications of Eating Disorders

There are many different types of eating disorder and they may be difficult to spot in others. Eating disorders are very common in people with dissociative disorders.^[3]

While it can be useful to refer to diagnostic criteria for eating disorders it is very important to realize that all eating disorders are serious and harmful. Eating disorders can be specified as in partial or full remission, for example if all the criteria for an eating disorder are met initially, but only some of the criteria are met part way through recovery then the eating disorder will not be reclassified but will be specified as in partial remission.

Anorexia Nervosa (AN)

Anorexia Nervosa criteria has changed slightly in the DSM5 and no longer includes amenorrhea (the absence of a menstrual cycle in a woman), as a requirement and the criteria about fearing weight gain present in the DSM-IV has been broadened to include behavior that prevents the person reaching a normal weight. ^[4] Many people believe eating disorder anorexia nervosa involves only a person severely restricting their intake of good, but in fact it has two subtypes: restrictive type, and binge-eating/purging type. ^[4] Many other behaviors are common within anorexia nervosa, although these are not part of the diagnostic criteria.

Anorexia Nervosa has the highest mortality rate of any mental disorderThe DSM-5 psychiatric manual defines this as "a syndrome characterized by clinically significant disturbance in an individual's cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above."{{Rp|20}}, at 20%.^[5]

Diagnostic Criteria and Subtypes for Anorexia Nervosa

The DSM5 states that the subtype must be specified, either as restrictive type (F50.01), or binge-eating/purging type (F50.02).

A Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as weight that is less than minimally normal or, for children and adolescents, less than that minimally expected.

B Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight.

C Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight. ^[4]

The severity of the disorder is judged according to a calculation based on weight and height, using specific body mass index values (BMI). A person who has all the symptoms of anorexia nervosa but whose weight is not yet considered low enough for the diagnosis would typically be classified as having Other Specified Feeding or Eating Disorder (OSFED) or Bulimia Nervosa.^[4]

Binge eating disorder (BED)

BED is a psychiatric diagnosis, and is associated with depression and anxiety.^[6] It involves eating a large amount of food in a short period of time, at least once a week for three months or more. Binges involves feelings of being "out of control" and cause marked distress afterwards, such as shame, guilt and disgust. It was recently added to the DSM5 psychiatric manual in May 2013 and is not simply "overeating" but is concerned with significant distress.

Diagnostic Criteria for Binge Eating Disorder

DSM5 code 307.51 is used for both BED and BN

A 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 (e.g. within any 2-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.
2. A sense of lack of control over eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating).

B The binge eating episodes are associated with three (or more) of the following:

1. Eating much more rapidly than normal
2. Eating until feeling uncomfortably full
3. Eating large amounts of food when not feeling physically hungry
4. Eating alone because of feeling embarrassed by how much one is eating
5. Feeling disgusted with oneself, depressed, or very guilty afterward

C Marked distress regarding binge eating is present

D The binge eating occurs, on average, at least once a week for three months

E Binge eating not associated with the recurrent use of inappropriate compensatory behaviors as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa, or anorexia. ^[4]

Risk factors for BED

The main risk factors are:

• adverse childhood experiences^[7] including teasing^[2]
• parental depression^[7]
• vulnerability to obesity, including a genetic link ^[7][6]
• repeated negative comments about a person's shape, weight, and eating patterns/habits^[2][7]
• parental obesity/overweight parents^[2]
• childhood obesity^[7][2]
• perceived stress^[2][6]

A recent study found that

"among overweight and obese participants, 45% of the variance in eating disturbance was accounted for by interpersonal discrimination."^[2]

When the those with binge eating disorder were compared with people with other mental health disorders it was found that people with BED had both more childhood obesity and more negative comments about shape, weight, and eating. ^[7] Less than half of those with lifetime BED receive treatment. BED typically last just over 4 years and the most common age range for the condition to begin is later teens to early 20s. It affects 0.8–1.9% of the global population, varying by country. ^[8]

Binge eating is often a way of filling a "deep internal emptiness" and "existential aloneless". ^[9] In additional the guilt from binge eating and lack of self-forgiveness for normal responses to intense hunger are often striking, the powerful appetite shows powerful psychological needs which the person feels are not valid or worthy of compassion or attention. ^[9]

Interpersonal discrimination was most strongly associated with eating disturbances, even when taking into account known risks, even if the events seemed less server, for example being treated with less courtesy compared to not being given a job promotion.^[2] This could be because subtle interpersonal discrimination is more difficult to respond.^[2] More frequent experiences of discrimination were shown to lead to more frequent bulimic behaviors, binge eating episodes, and a greater tendency to overeat in response to emotions, daily discrimination could be a more significant stressor than any other in terms of impact on an eating disorders.^[2]

Durso (2012) states that

It may be important to assist overweight clients in interpreting discriminatory actions as byproducts of stereotypes and bias and not as legitimate events which the client somehow ‘deserves’^[2]

Bulimia Nervosa (BN)

This is characterized by binging on food (excessive, uncontrollable eating) and later trying to remove the excess calories. SelfThe DSM-IV uses the term identity in its definition of dissociation. (see identity) {{Rp|127}}-induced vomiting is common method of purging excess calories, but not a requirement for diagnosing bulimia nervosa since other methods of preventing weight gain may be used instead, for example excessive exercise^[5] or abusing laxatives^[5]. For diagnosis, the DSM5 diagnostic manual states that this must occur at least once a week (less frequently than in the previous DSM-IV manual). Someone who meets the criteria for bulimia nervosa but whose weight falls significantly below normal would be re-classified as having anorexia nervosa due to the weight loss alone.

Less than half of those with lifetime bulimia nervosa receive treatment, and the most common age range for the condition to begin is later teens to early 20s, or slightly younger. On average, people have bulimia nervosa for 6.5 years and it affects around 0.4-0.8% of the world population.^[8]

Diagnostic criteria for Bulimia Nervosa

DSM5 code 307.51 is used for both BED and BN

A 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 (e.g. within any 2-hour period), an amount of food that is definitely larger than most individuals would eat during a similar period of time and under similar circumstances.
2. A sense of lack of control over eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating).

B Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting, misuseNon-medical use of a prescription drug (whether obtained by prescription or other means). For example, use in a manner not prescribed, or by a person it was not prescribed to, or for a different time period or greater dose than that prescribed. {{Rp|45,48}} "Misuse" may also refer to substances used in a way which is not legal. of laxatives, diuretics, or other medications, fasting; or excessive exercise.

C The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for three months.

D Self-evaluation is unduly influenced by body shape and weight.

E The disturbance does not occur exclusively during episodes of anorexia nervosa.^[4]

Other Specified Feeding or Eating Disorder (OSFED)

DSM5 code 307.59

This was a new addition to the DSM5 and covers a range of different eating disorder behaviors which are not part of any of the other eating disorder types,^[4] many of these may previously have been described as Eating Disorder Not Otherwise Specified (EDNOS). The DSM5 has less restrictive criteria than the DSM-IV for both anorexia nervosa and bulimia nervosa, and with the inclusion of binge eating disorder it is expected that less people will have symptoms which fit into this category. ^[10] The clinician can specify the reason that another feeding or eating disorder has not been met, for example bulimia nervosa of low frequency.

Diagnostic Criteria for OSFED

To be diagnosed with the disorder the person must experience clinically significant distress or impairment in social, occupational, or other important areas of functioning as a result of the disorder but does not meet the full criteria for another feeding or eating disorders.

Examples include:

1. Atypical anorexia nervosa: All anorexia nervosa criteria are met, except despite significant weight loss, the individual’s weight is within or above the normal range.
2. Bulimia nervosa (of low frequency and/or limited duration): All of the criteria for bulimia nervosa are met, except that the binge eating and inappropriate compensatory behaviors occur, on average, less than once a week and/or for less than three months.
3. Binge-eating disorder (of low frequency and/or limited duration): All of the criteria for binge-eating disorder are met, except that the binge-eating occurs, on average, less than once a week and/or for less than three months.
4. Purging disorder: Recurrent purging behavior to influence weight or shape (e.g. self-induced vomiting; misuse of laxatives, diuretics, or other medications) in the absence of binge eating
5. Night eating syndrome: Recurrent episodes of night eating, as manifested by eating after awakening from sleep, or by excessive food consumption after the evening meal. There is awareness and recall of the eating. The night eating is not better explained by external influences such as changes in the individuals sleep-wake cycle or local social norms. The disordered pattern of eating is not better explained by binge-eating disorder or another mental disorder, including substance useHarmful Use is a pattern of psychoactive substance use that results in damage to physical or mental health, e.g. hepatitis following injecting drugs or depression which is secondary to heavy alcohol intake. Adverse social consequences normally also occur. Previously known as "non-dependent use" in the ICD manual, referred to as "substance use" in the DSM manual. {{Rp|41}}, and is not attributable to another medical disorder or to an effect of medication.

Pica

Eating non-nutritional items, which lasts at least one month. Can occur at any age, although the criteria make it clear the a person's developmental age needs to be considered, this is particularly relevant for infants and those with intellectual disabilities.

Diagnostic Criteria for Pica

A Persistent eating of nonnutritive nonfood substances for a period of at least one month.

B The eating of nonnutritive, nonfood substances is inappropriate to the developmental level of the individual.

C If the eating behavior occurs is not part of a culturally supported or socially normative practice.

D If occurring in the presence of another mental disorder (e.g. autistic spectrum disorder), or during a medical condition (e.g. pregnancy), it is severe enough to warrant independent clinical attention.^[4]

Rumination disorder

DSM5 code 307.53. This can occur at any age.

A Repeated regurgitation of food for a period of at least one month. The regurgitated food may be re-chewed, re-swallowed, or spit out.

B The repeated regurgitation is not due to another medication condition (e.g. an associated gastrointestinal condition, gastroesophageal reflux or pyloric stenosis).

C The behavior does not occur exclusively in the course of AN, BN, BED, or ARFID eating disorders.

D If it occurs in the presence of another mental disorder (e.g. intellectual developmental disorder), or another neurodevelopmental disorder, it is severe enough to warrant independent clinical attention.^[4]

Feeding Disorders

Avoidant/Restrictive Food Intake Disorder (AFRID)

DSM5 code 307.59

This disorder replaces “feeding disorder of infancy or early childhood" from the DSM-IV but has been broadened to including adults who do not meet the criteria for other eating disorders.^[10]

Diagnostic Criteria for AFRID

A An eating or feeding disturbance (e.g. apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following:

1. Significant weight loss (or failure to achieve expected weight gain or faltering growth in children).
2. Significant nutritional deficiency
3. DependenceDrug or alcohol addiction is the "repeated use of a psychoactive substance or substances, to the extent that the user (referred to as an addict) is periodically or chronically intoxicated, shows a compulsion to take the preferred substance (or substances), has great difficulty in voluntarily ceasing or modifying substance use, and exhibits a determination to obtain psychoactive substances by almost any means." Dependence is the term used to refer to addiction in the ICD diagnostic manual. {{Rp|6}} on enteral feeding or oral nutritional supplements
4. Marked interference with psychosocial functioning

B The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice.

C The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one's body weight or shape is experienced.

D The eating disturbance is not attributed to a concurrent medical condition, or better explained by another mental disorder. When the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention. ^[4]

Unspecified Feeding and Eating Disorders (UFED)

DSM5 code 307.50 This covers feeding and eating disorders which cause clinically significant distress or impaired functioning that do not meet the criteria for any other category. This is used when the clinician chooses not to specify the reason that the criteria are not met for a specific feeding and eating disorder, for example when there is insufficient information to make a more specific diagnosis (e.g. in emergency room settings). ^[4]

Overeating associated with mental health problems

This is described as psychogenic overeating within the ICD10 and coded as F50.4; and attributed to "stressful events" such, such as bereavement, accident, childbirth, etc. Obesity is an exclusion but PTSD is not. This is not a separate diagnosis within the DSM5.

Vomiting associated with mental health problems

This is described as psychogenic vomiting within the ICD10 and coded as F50.5; repeated vomiting that occurs in dissociative disorders is excluded since it is seen as a symptom of the dissociative disorder alone. Obesity is also an exclusion but PTSD is not. Vomiting associated with other psychological disturbances is not a separate diagnosis within the DSM5.

Obesity (not a mental health disorder)

The ICD differs from the DSM in it recognizes all health disorders; the DSM only refers to disorders. The ICD recognizes obesity as a diagnosis but not within the Mental or Behavioral Disorders section. The ICD10 recognizes several subtypes of obesity, including obesity due to excess calories and drug-induced obesity. ^[1]

The review process for the DSM5 considered whether obesity should be included as a mental disorder but decided against this, stating:

Obesity results from the long-term excess of energy (calorie) intake relative to energy expenditure. Genetic, physiological, behavioral, and environmental factors that vary across individuals contribute to the development of obesity; thus, obesity per se is not considered a mental disorder.^[10]

However, the strong link between obesity and a number of psychiatric disorders was mentioned during the review (including binge-eating disorder, mood disorders (for example bipolar disorder), and schizophrenia) as an associated feature of the disorder or its treatment. Obesity was recognized as is a "highly prevalent condition" which is important for psychiatrists and mental health professionals to consider. ^[10]

Disordered Eating

Disordered eating occurs where their are mild or infrequent behaviors associated with eating, but diagnostic criteria for eating disorders are not met. There are many forms of disordered eating.

Compulsive overeating (CO)

Compulsive overeating may involve overeating on a continual basis rather than in the forms of binges, which often result from emotional triggers. Compulsive overeating involves a variety of eating disorder behaviors, but is not a separate diagnosis in the DSM.^[6][4] If some binges occur but are infrequent the criteria for Other Specified Feeding and Eating Disorder may be met if significant distress or impaired functioning also results from it. ^[4]

Recovering from Eating Disorders

For binge eating disorder, Durso (2012) stated that "reducing the negative psychosocial outcomes of discrimination may not only improve an individual’s quality of life but might also remove impediments to seeking treatments".

Recovery from eating disorders which are related to trauma or dissociative disorders should be seen in the context of treating the disorder as a whole.

Links between trauma and dissociative disorders and eating disorders

In their book on Traumatic Stress, Van der Kolk et al. state that the "lack or loss of self-regulation" (emotional regulation, also known as affect regulation) "is possibly the most far-reaching effect of psychological traumaThe most fundamental effect of trauma is dissociation, so we define trauma as the event(s) that cause dissociation. {{Rp|75}} The original trauma in those with dissociative identity disorder was failure of secure attachment with a primary attachment figure in early childhood. {{Rp|83}} in both children and adults".^[11] Lemberg and Cohn's Eating Disorder Sourcebook states:

Eating disorders may represent a powerful response to and means of coping with the psychological and biological effects of trauma outlined above. When viewed as a means of coping, as well as a possible symbolic representation of the trauma, eating disturbances become more comprehensible to the patient and clinician alike.^[9]

Brewerton (2007) summarizes significant conclusions in the link between trauma and eating disorders (EDs), as follows:

1. childhood sexual abuse is a "nonspecific risk factor" for EDs
2. a spectrum of trauma is linked to EDs, including a variety of forms of abuse and neglect
3. trauma is more common in bulimic EDs compared to nonbulimic EDs
4. the link between EDs and trauma extends to children and adolescents with EDs, and to boys and men with EDs
5. multiple episodes or forms of trauma are associated with EDs
6. trauma is "not necessarily associated with greater ED severity"
7. trauma is associated with more co-existing diagnoses (including PTSD) in people with EDs
8. subthreshold (partial) PTSD may be a risk factor for bulimia nervosa and bulimic symptoms
9. the trauma and PTSD or its symptoms must be addressed in order to fully recover from the ED and co-existing diagnoses

Weight loss in eating disorders and the psychology of trauma and abuse

Lemberg (1999) goes on to explain the following links:

• dieting - avoiding needs - to need is dangerous during trauma
• dieting may be seen as a way to "purify" a damaged self
• some sexual abuse survivors deliberately starve themselves to repulse the perpetrator and any future perpetrators
• starving can bring on dissociative-like states, allowing "a level of removal from the here-and-now"
• refusing food can give the illusionIllusions are distortions of real images or sensations, however hallucinations are not based on things which are not real. Illusions have many different causes include being substance related, or caused by a disorder such as Schizophrenia or PTSD (reexperiencing the truma). {{Rp|168,260}} of power; those who have been repeatedly powerless (as occurs in cases of abuse), in this case regaining a sense of personal power in different areas of life is crucial in recovery
• many people with eating disorders lack a sense of meaning and purpose in life, and trauma survivors often experience internal chaos, confusion and pain. Westernized culture links a slender physique with control, happiness, emotional stability and calmness, and success which can lend additional importance to the pursuit of "thinness".

Ferentz (2012) also states that

• A person's quest to reduce their physical size can be a desire for invisibility, and an expression of vulnerability
• denialPsychology - Defense mechanism in which the existence of unpleasant realities is disavowed; refers to keeping out of conscious awareness any aspects of external reality that, if acknowledged, would produce anxiety {{Rp|24}}Crime - "various processes by which individual actors, social groups or states either 'block, shut out, repress or cover up certain forms of disturbing information [about wrong doing] or else evade, avoid or neutralize' its consequences (Cohen, 1995, 19)" Refers to the denial of a perpetrator of a crime, for example denying the crime or the impact of the crime, denying the victim, counter-attacks and appealing to "higher loyalties".{{Rp|125}} of food may have roots in prior neglect and lack of adequate nurturance

Binge eating and trauma

• comfort and nurturance which is not supplied by the self or others
• The negative thoughts or mood experienced as a core symptom of PTSD can involve "exaggerated negative beliefs or expectations about oneself", binge eating to the point of painful fullness may represent punishment, particularly when an abuser instilled the belief "I am bad", which later was internalized in the trauma survivor. (see also: Copy alters (introjects) Self injury, alcohol and substance misuse can also be used as punishment.
• some find binge eating a means to escape through dissociation, experiencing a trance-like state to avoid moods such as anger
• excess weight can be seen as an "armor" to repel potential abusers and/or make the person more "powerful and formidable"
• Shame and guilt are examples of negative alterations in cognitions and mood are associated with PTSD. The societal stigma and stereotyping of overweight people allows excess weight to be a public symbol of the bodily shame and self-contempt gained as a result of abuse as well as a representation of the person feeling unworthy of love

Purging and trauma

Purging can include self-induced vomiting, abusing laxatives, diuretics, excessive exercise or enemas. ^[5] Purging's psychological role includes:

• often symbolizing "a cleansing of a person's body from abuse"^[12] or removing the internal feeling of being "dirty"^[5]
• allows for the removal of rage^[5] or "anger pent up inside." ^[12]
• releasing unspoken memories^[5]
• reclaiming a sense of control over a person's own body by removing what was forced inside^[5]
• purging reenacts and perpetuates the sense of "badness" which many trauma survivors experience^[5]
• purging may be a way for trauma survivors to regain control over their emotions ^[11]

A large study of adult women with anorexia nervosa found that 13.7% met DSM-IV criteria for PTSD, with those having the restricting form of anorexia nervosa significantly less likely to have PTSD than those with purging anorexia nervosa without binge eating. Of those with PTSD the majority experienced their first traumatic event before the onset of anorexia nervosa, with the most common traumatic events reported being child sexual traumas and adult sexual trauma. ^[13]

Dissociative Disorders and Eating Disorders

Personality Disorders and Eating Disorders

Self-induced vomiting within eating disorders is significantly associated with both borderline and narcissistic personality disorders. ^[14] Avoidance is the most common personality disorder present in those with eating disorders. ^[14]

Treatment guidelines

APA practice guidelines (2006) US

National Institute of Clinical Excellence (NICE) Treatment guidelines UK

NHS information UK

NEDC treatments Australia & New Zealand

Further information about Eating Disorders and Non-profit organizations

Eating Disorders Victoria Australia

The Butterfly Foundation Eating disorder support, Australia

National Institute of Mental Health US

Academy for eating disorders Treatment information

UK

Laxatives, teeth, helping family with eating disorders

National Eating Disorders Association - information handouts

NEDC research library

American Psychological Association information on eating

References

1. ^ ^{a b} World Health Organisation, (2010). International classification of diseases.
2. ^ ^{a b c d e f g h i j k l} Durso, L.E.; Latner J.D, Hayashi K (2012). Perceived Discrimination Is Associated with Binge Eating in a Community Sample of Non-Overweight, Overweight, and Obese Adults. The Europenan Journal of Obesity, volume 5. (doi:10.1159/000345931)
3. ^ International Society for the Study of Trauma and Dissociation. Guidelines for treating dissociative identity disorder in adults, third revision. Journal of Trauma & Dissociation, volume 12.2, page 115-187.
4. ^ ^{a b c d e f g h i j k l m} Diagnostic and Statistical Manual of Mental Disorders-5.
5. ^ ^{a b c d e f g h i} Ferentz, Lisa (2012). . .
6. ^ ^{a b c d} Ross, Carolyn (2009). The Binge Eating and Compulsive Overeating Workbook: An Integrated Approach to Overcoming Disordered Eating. .
7. ^ ^{a b c d e f} Fairburn, C. G.,; Doll, H. A., Welch, S. L., Hay, P. J., Davies, B. A., & O'Connor, M. E. (1998). Risk factors for binge eating disorder: a community-based, case-control study.. Archives of general psychiatry, volume 55.5, issue 425.
8. ^ ^{a b} World Mental Health Surveys. The Prevalence and Correlates of Binge Eating Disorder in the World Health Organization. Biological Psychiatry, volume 73, issue 9, 1.
9. ^ ^{a b c} Lemberg, Raymond (Editor) (1999) (coauthors: Cohn, Leigh (Editor)). Eating Disorders: A Reference Sourcebook. .
10. ^ ^{a b c d} Attia, Evelyn; et al. (2013). Feeding and Eating Disorders in DSM-5. American Journal of Psychiatry, volume 170, page 1237-1239. (doi:10.1176)
11. ^ ^{a b} van der Kolk, Bessel A. (2012) (coauthors: McFarlane, ‎Alexander C.; Weisaeth,‎ Lars). [books.google.co.uk/books?=1462507107 Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society]. .
12. ^ ^{a b} Southard, Ashley L. (2008). Understanding Bulimia: A Qualitative Exploration of the Roles of Race, Culture, and Family. .
13. ^ Reyes-Rodríguez, Mae Lynn; Von Holle, Ann; Ulman, T. Frances; Thornton, Laura M. et al. (2011). Post traumatic stress disorder in anorexia nervosa. Psychosom Med., volume 73, issue 6, page 491-497. (doi:10.1097/PSY.0b013e31822232bb)
14. ^ ^{a b} von Lojewski, A.; Fisher, A.; Abraham, S. (2013). Have Personality Disorders Been Overdiagnosed among Eating Disorder Patients?. Psychopathology, volume 46, page 421-426. (doi:10.1159/000345856)

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