By Dr Daniel S. Cohen · Updated: 27 April 2026
Summary
Eating disorders (ED) are serious mental illnesses whose visible manifestation —weight, food, body— masks a much broader picture: disrupted emotional regulation, identity difficulties, anxiety and, in many cases, comorbidity with depression, obsessive-compulsive disorder or substance use.
They mainly affect adolescents and young adults, with a concerning clinical trend: in recent years, especially since the pandemic, anorexia nervosa is presenting at increasingly younger ages. Early detection radically changes the prognosis.
What are eating disorders
Eating disorders are mental conditions characterised by a persistent disturbance of eating behaviour that affects physical health, social functioning and emotional wellbeing. They manifest through food, but they are not disorders about food: underneath, there is difficulty regulating emotions, distortion of body image or of one’s relationship with the body, and often a search for control in a life context where other things feel uncontrollable.
That is why they are clinical disorders requiring specialised treatment, not matters of willpower or “strength of character”.
Main types
The DSM-5-TR groups several distinct conditions under the umbrella of eating disorders:
- Anorexia nervosa. Persistent food restriction, intense fear of gaining weight or of body fat, and disturbance of body image. It has two subtypes: restrictive and purging (with compensatory behaviours such as self-induced vomiting or laxative use). It is the eating disorder with the highest mortality and the greatest acute medical risk.
- Bulimia nervosa. Recurrent episodes of binge eating followed by inappropriate compensatory behaviours (self-induced vomiting, laxative or diuretic misuse, prolonged fasting, compulsive exercise) to prevent weight gain. Self-esteem is markedly influenced by weight and shape.
- Binge eating disorder. Recurrent binge episodes in which the person eats large amounts of food with a sense of loss of control, without subsequent compensatory behaviours. It is frequently associated with overweight, guilt and anxiety.
- ARFID (Avoidant/Restrictive Food Intake Disorder). Significant food restriction, but without distortion of body image or fear of gaining weight. It is associated with sensory aversion to foods, fear of choking or vomiting, or lack of interest in food. It is more common in children and shows an important clinical association with neurodevelopmental disorders —especially autism spectrum disorder, ADHD and sensory processing difficulties—, as well as with anxiety conditions.
- OSFED (Other Specified Feeding or Eating Disorder). Conditions that do not meet all the criteria of the above but cause real impairment: atypical anorexia (clear symptoms without significantly low weight), bulimia or binge eating of low frequency, night eating syndrome, etc. They are common and often underdiagnosed.
Who is affected and at what age
Eating disorders can appear at any age, but they show characteristic patterns:
- Anorexia nervosa: typical onset in adolescence, with a classic peak between 14 and 18 years.
- Bulimia nervosa: somewhat later onset, usually between 16 and 22 years.
- Binge eating disorder: later onset, usually in adulthood.
- ARFID: typically begins in childhood.
Historically they affected women more than men in an approximate ratio of 9:1 in anorexia and bulimia, but men are clearly underdiagnosed because their presentations tend to be different (more focused on muscularity and physical performance) and because the cultural bias of seeing eating disorders as “a girls’ problem” persists.
A concerning clinical trend: increasingly early onset
Since the COVID-19 pandemic, child and adolescent psychiatric services around the world have documented a consistent phenomenon: a marked increase in new cases of anorexia nervosa in young girls and boys, particularly between 8 and 14 years of age. In population registries and hospital series, hospital admissions for anorexia and atypical anorexia in children under 14 have remained 30-40 % above pre-pandemic figures, even years after lockdown.
This matters for two clinical reasons:
- Childhood-onset anorexia (before age 15) has a more severe course and a higher lifetime psychiatric comorbidity.
- Detection is usually more difficult because the child does not verbalise concerns about weight in the same way an older adolescent or adult would: the presentation is more behavioural (progressive food refusal, irritability around mealtimes, hidden hyperactivity).
This shift towards younger ages makes the role of the family, the paediatrician and the school more relevant than ever in detecting the condition in time.
Early signs
The first signs of an eating disorder are usually behavioural and emotional, not physical. The body changes late; behaviour changes earlier.
In the eating domain:
- Skipping meals, eating apart, avoiding eating outside the home.
- Restriction of entire food groups (fats, carbohydrates, proteins) under “healthy” labels.
- Rituals around food: cutting very small, moving food around the plate, excessive chewing.
- Marked increase in interest in cooking for others without eating themselves.
- Frequent trips to the bathroom after meals.
In the emotional domain:
- Marked mood swings, irritability around mealtimes or when food is mentioned.
- Anxiety or anticipatory distress at the thought of eating.
- Affective blunting, withdrawal, persistent sadness.
In the social domain:
- Progressive isolation, avoidance of social events that involve food.
- Family conflicts increasingly centred on the table.
In the academic or occupational domain:
- Increased perfectionism, academic or sporting over-demand.
- Hyperactivity or hidden compulsive exercise.
Physical signs (later):
- Weight loss or failure to gain expected weight according to development.
- Menstrual changes.
- Persistent cold sensitivity, hair loss, skin changes.
- Dizziness, fatigue, palpitations.
No single sign on its own confirms an eating disorder. What guides clinically is the clustering, persistence and, above all, change relative to the person’s previous functioning.
Frequent comorbidities
Eating disorders rarely occur in isolation. The most common comorbidities are:
- Anxiety disorders (generalised anxiety, social anxiety, specific phobias).
- Mood disorders (major depression, dysthymia).
- Obsessive-compulsive disorder, particularly associated with perfectionism in anorexia.
- ADHD, frequently associated with bulimia and binge eating disorder in adolescents and young adults. The impulsivity inherent to ADHD and the difficulty with self-regulation predict a higher risk of binge-type presentations — a clinical overlap worth keeping in mind when evaluating these patients (you can read more in the article on ADHD in children and adolescents).
- Neurodevelopmental disorders (especially autism spectrum disorder and ADHD), with a particularly strong association in ARFID.
- Problematic substance use (alcohol, cannabis, stimulants), more associated with bulimia.
- Personality disorders, particularly borderline personality disorder.
Identifying and treating these comorbidities is an essential part of eating disorder care — they are not minor conditions that resolve once eating behaviour is addressed.
Why early diagnosis is urgent
Eating disorders are serious medical conditions, not aesthetic concerns. Anorexia nervosa has the highest mortality rate of any psychiatric disorder, attributable both to medical complications (cardiac, electrolyte, organ failure) and to elevated suicide risk. Bulimia and binge eating disorder also carry significant medical risks and mortality rates higher than the general population.
In addition, eating disorders tend towards chronicity when treatment is delayed. Early diagnosis and treatment clearly improve prognosis, reduce acute medical risk and decrease the likelihood of long-term relapse.
How evaluation works in consultation
The evaluation of an eating disorder includes:
- Detailed psychiatric interview, exploring eating behaviour, body image, associated emotions, personal and family history, and the presence of comorbidity (anxiety, depression, OCD, substance use).
- Family interview, particularly with children and adolescents, to gather objective information about meals, weight, behaviour and family dynamics.
- Medical examination and screening for complications: weight, height, vital signs, general examination and, depending on the case, blood tests including electrolytes, liver and hormonal panels and an electrocardiogram.
- Nutritional assessment, fundamental for understanding the actual nutritional state and planning refeeding when needed.
- Standardised validated questionnaires, as a support for clinical assessment.
The diagnosis is clinical. Clinical severity does not always match apparent weight: there are very serious eating disorders in people with normal weight and less urgent presentations in people with visibly low weight. A comprehensive evaluation by experienced professionals is what allows risk and the necessary level of care to be calibrated.
Treatment
Eating disorder treatment is multidisciplinary by definition. No single professional covers it. The pillars are:
- Psychiatry. Diagnosis, management of comorbidities (anxiety, depression, OCD), pharmacological prescription when indicated (SSRIs, particularly fluoxetine, have demonstrated efficacy in bulimia and binge eating disorder; in anorexia the role of pharmacology is more limited and reserved for selected cases).
- Specialised psychotherapy. Cognitive-behavioural therapy adapted for eating disorders (CBT-E), evidence-based family therapy (FBT, first-line for adolescent anorexia), interpersonal therapy in some presentations.
- Clinical nutrition. Nutritional education, structured meal planning, refeeding rehabilitation and therapeutic work on the patient’s relationship with food.
- Paediatrics or internal medicine. Medical monitoring of physical state, particularly in acute phases and during refeeding.
- Art therapy and other complementary interventions. Non-verbal emotional work, particularly useful in patients who struggle to verbalise.
Levels of care
Treatment is adjusted to clinical risk:
- Outpatient treatment, when weight is stable, motivation is present and there is no acute medical risk.
- Day hospital, when outpatient care is insufficient and there is continued weight loss or frequent compensatory behaviours.
- Full inpatient hospitalisation, when there is acute medical risk, complications or suicide risk.
Transitioning between levels is part of treatment — it is not a failure, it is a clinical adjustment.
The role of the family
In children and adolescents, the family is not part of the problem; it is part of the solution. Family-Based Treatment (FBT) is the first-line treatment for adolescent anorexia nervosa, with the strongest available evidence. In its initial phases, parents take an active role in restoring adequate eating at home; that responsibility is gradually returned to the adolescent as recovery progresses.
In young adults, family involvement is more nuanced but still relevant: the close support network plays an important role in motivation, treatment adherence and relapse prevention.
Common myths
- “Eating disorders only affect very thin teenage girls.” False. They affect men, women, children, adolescents and adults; and in many eating disorders, weight may be normal or even elevated.
- “It’s vanity, a fad or a whim.” False. Eating disorders are serious mental illnesses with biological, psychological and social bases, associated with real changes in the brain and significant medical risk.
- “If they eat, it’s solved.” False. Restoring eating is necessary but not sufficient. Without psychological work and management of comorbidities, relapse is the rule.
- “It’s only diagnosed if a person loses a lot of weight.” False. There are very serious eating disorders with normal or atypical weight. The clinical criterion is not reduced to the scale.
- “It’s a voluntary decision; discipline would be enough.” False. Eating behaviour is altered by clinical mechanisms that escape the patient’s conscious control. That is why they require treatment, not just willpower.
When to consult
Some signs warrant a professional evaluation without delay:
- Significant weight loss or failure to gain expected growth in children.
- Persistent food restriction, elimination of food groups or rigid rituals around food.
- Recurrent binge episodes with a sense of loss of control.
- Compensatory behaviours: self-induced vomiting, laxative misuse, compulsive exercise.
- Marked mood changes, social isolation or drops in academic performance that coincide with changes in eating.
- Persistent comments about body, shape or weight, with concern that disrupts daily life.
If your family or the patient themselves recognise several of these signs, it is sensible to consult a team with clinical experience in eating disorders early. Early diagnosis —before the condition becomes chronic— clearly improves prognosis and reduces medical risk.
Conclusion
Eating disorders are serious, common and treatable mental illnesses, but they require early detection and a coordinated multidisciplinary approach. The current trend towards increasingly early onset of anorexia, particularly in young girls, demands attention before visible physical signs appear. When psychiatrist, psychotherapist, nutritionist, paediatrician and family work together within the same approach, prognosis improves substantially.
Clinical references
- van Eeden AE, van Hoeken D, Hoek HW. Incidence, prevalence and mortality of anorexia nervosa and bulimia nervosa. Curr Opin Psychiatry. Access
- Trends in the Observed Versus Expected Incidence of Eating Disorders Before, During, and After the COVID-19 Pandemic. 2024. Access
- Otto AK et al. Shifting age of child eating disorder hospitalizations during the Covid-19 pandemic. 2023. Access
- A meta-analysis of mortality rates in eating disorders: an update of the literature from 2010 to 2024. Clin Psychol Rev. 2025. Access
- Le Grange D, Lock J. Family-based Treatment of Eating Disorders: A Narrative Review. Pediatr Clin North Am. Access
- Benedictson C et al. Family-based treatment for adolescent anorexia nervosa: a meta-analysis. Aust N Z J Fam Ther. 2025. Access
- Thomas JJ et al. Avoidant/Restrictive Food Intake Disorder: Review and Recent Advances. Focus. 2024. Access
About the author: Dr. Daniel S. Cohen. Psychiatrist in Madrid, specialist in child and adolescent psychiatry and adult psychiatry. Medical Director of Clínica Colev. Registration No. 28/4003040 (ICOMEM). Consultations in English, French, Hebrew and Spanish. View professional profile.