TW: eating disorders
Anti-obesity medications are gaining popularity, but less discussed is the simultaneous rise in eating disorders. They’re more severe than ever, too, and many people seem to shift between disorders. This crossover could be because of how we diagnose and treat them.
Described broadly as disturbances in eating behaviors that can affect a person’s overall function, eating disorders affect over 28 million Americans, or 9% of the population. And lately, emergency department visits for young people struggling with one have doubled.
Interestingly, some people seem to experience multiple types of eating disorders over their lifetimes. This crossover receives little attention, but the research that is available suggests that it may actually be relatively common.
A study from the late 1990s found that more than half of participants with Anorexia Nervosa developed Bulimia Nervosa at some point during 15 years of follow up. This was supported by later research, too. In the late 2010s, another study found that migration between eating disorder diagnoses occurred in over 60% of cases. Only a third of participants retained their original diagnosis at the end of follow up. Most recently in 2023, a review of 79 studies found that nearly a quarter of individuals with Bulimia crossed over to other diagnostic groups at follow up.
An eating disorder is difficult to manage by itself, but dealing with several over time may make it harder for patients to get the support they need.
First, the shame of switching to diagnoses can be a barrier to treatment. Some people with eating disorders attach their identity to their diagnosis. One study found that participants with Anorexia believe their diagnosis is the “golden tier” diagnosis because it correlates with having the most desirous physical appearance (by Eurocentric beauty standards). So, someone with Anorexia who gains weight and now experiences Binge Eating Disorder behaviors may be embarrassed to get help.
Clinicians may also be unaware that an individual is still struggling with an eating disorder at all. This is particularly true for patients with Anorexia who may appear to be recovering after gaining weight over a period of time. But the weight gain could actually be due to symptoms of another eating disorder.
So, how can we help clinicians detect a shift in eating disorder diagnosis and help patients feel comfortable disclosing these changes?
There needs to be greater awareness that diagnostic crossover even occurs. This is crucial to challenge the existing stigma people with eating disorders face and to destabilize the diagnostic hierarchy many patients perceive.
There’s also a need for more research. Questions remain about the causes of crossover, risk factors, and effective methods of support. (One study suggests comorbid affective disorders, like major depressive disorder, may be part of the answer.)
Lastly, there could be improvements made to the clinical manual used to diagnose eating disorders. For example, measures like body mass index and frequency of symptomatic episodes currently used to analyze the severity of disorders do not offer reliable information on the course of illness or outcomes. Also, diagnoses are usually made over three-month periods so minor fluctuations in weight and eating behaviors can lead to a completely different diagnosis. To avoid recurrent crossovers, some suggest viewing eating disorders as a single entity within which an individual may experience different symptoms at different points in time.
There’s still a lot to be learned about diagnostic crossover in eating disorders, but what we do know is patients experience it more than we think. With more awareness, research, and revisions to existing diagnostic assessments, hope remains that patients will receive better treatment in the future.
