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Eating disorders, including anorexia nervosa and bulimia nervosa, are especially challenging diagnoses for clinicians. Psychological manifestations of these diseases, such as guilt or denial, may interfere with patient communication. Physical presentations are often subtle and complications are delayed. Signs and symptoms of eating disorders have broad differential diagnoses. Although eating disorders are pervasive diseases, with many psychosocial consequences, it is the recognition and treatment of medical complications that is essential for emergency physicians.


Although epidemiologic studies have had many limitations, eating disorders are thought to be increasing in overall prevalence. For anorexia nervosa, lifetime prevalence is estimated at 0.9% for women and 0.3% for men. Lifetime prevalence for bulemia is estimated at 1.5% for women and 0.5% for men.1 Additionally, eating disorder not otherwise specified, indicating eating or weight management patterns that diverge significantly from societal norms, but do not meet specific criteria for anorexia or bulemia, affects 3% to 5% of women between the ages of 15 and 30 years old. Eating disorder not otherwise specified is an imprecise classification, and patients in this category may exhibit psychopathology as serious as those with anorexia or bulemia.2 The prevalence data noted has been gathered primarily in clinical settings and likely underestimates the true degree of disordered eating in the general population. Cultural fixation on weight loss has been implicated in increasing rates of eating disorders. The 2005 Youth Risk Behavior Survey found that approximately 60% of adolescent females and 30% of adolescent males were attempting to lose weight. Furthermore, 13% of adolescent females had gone without eating for more than 24 hours, 6% had used diet pills or aids, and 5% had vomited or used laxatives in an attempt to control their weight within the past 30 days.3


Eating disorders have been described in all age groups, racial groups, and socioeconomic classes. Anorexia generally begins in late childhood to early adulthood with bimodal peaks at ages 14 and 18 years old. The onset of bulimia most commonly occurs between ages 17 and 25 years old.


Eating disorders have been associated with various dysfunctions of neurotransmission. Serotonin is a neurotransmitter that is known to regulate mood and satiety, and the onset and maintenance of eating disorders are thought to be related to serotonin dysfunction. Bulimia represents a hyposerotonergic state, presumably self treated with binge-eating, whereas serotonin dysfunction in anorexia is more complex. Decreased noradrenergic activity is thought to be secondary to malnourishment and may contribute to cardiovascular complications of eating disorders. Dopaminergic abnormalities have been related to disordered eating as well. Further studies are required to better characterize neuroendocrine states as they relate to eating disorders to facilitate treatment.


Complex biologic, psychological, and social factors determine onset and severity of eating disorders. Women with first-degree relatives with eating disorders have a significantly higher risk of developing an eating disorder. Biologic predisposition to eating disorders is supported by monozygotic twin studies, and ...

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