Skip to main content
Log in

Deconstructing “Atypical” Eating Disorders: an Overview of Emerging Eating Disorder Phenotypes

  • Eating Disorders (C Grilo, Section Editor)
  • Published:
Current Psychiatry Reports Aims and scope Submit manuscript

Abstract

Recent changes to the diagnostic framework of eating disorders (ED’s) in DSM-5 were introduced to reduce the large preponderance of cases falling within the residual and undifferentiated category. However, current reports continue to illustrate overrepresentation of cases in this residual category, suggesting that clinical reality comprises more diverse ED psychopathology than is accounted for in the current diagnostic spectrum. However, with emerging evidence preliminarily delineating several additional distinct phenotypes, we aim to provide a narrative overview of emerging ED phenotypes which (i) are not currently located as a specific diagnostic category in diagnostic criteria for ED’s, (ii) centrally feature ED psychopathology, and (iii) have emerging empirical evidence suggesting the distinct nature of the syndrome. A greater awareness of these emerging phenotypes will likely facilitate accurate diagnostic practice and may also serve to facilitate further empirical efforts.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Russell GFM, Treasure J. The modern history of anorexia nervosa: an interpretation of why the illness has changed. Ann N Y Acad Sci. 1989;575:13–30.

    Article  CAS  PubMed  Google Scholar 

  2. Gull WW. Anorexia nervosa (apepsia hysterica, anorexia hysterica). Trans Clin Soc Lond. 1874;7:22–8.

    Google Scholar 

  3. Lasegue C. De l’anorexie hysterique. Arch Generales Med. 1873;21:385–403.

    Google Scholar 

  4. Russell GFM. Bulimia nervosa: an ominous variant of anorexia nervosa. Psychol Med. 1979;9:429–48.

    Article  CAS  PubMed  Google Scholar 

  5. Steinhaussen HC, Weber S. The outcome of bulimia nervosa: findings from one-quarter century of research. Am J Psychiatr. 2009;166:1331–41.

    Article  Google Scholar 

  6. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Washington: American Psychiatric Association; 2013.

    Google Scholar 

  7. Machado PPP, Machado BC, Concalves S, Hoek HW. The prevalence of eating disorders not otherwise specified. Int J Eat Disord. 2007;41:212–7.

    Article  Google Scholar 

  8. Dalle-Grave R, Calugi S. Eating disorder not otherwise specified in an inpatient unit: the impact of altering the DSM-IV criteria for anorexia and bulimia nervosa. Eur Eat Disord Rev. 2007;15:340–9.

    Article  PubMed  Google Scholar 

  9. Zimmerman M, Francoice-Witt C, Chelminski I, Yound D, Tortolani C. Problems applying the DSM-IV eating disorders diagnostic criteria in a general psychiatric outpatient practice. J Clin Psychiatry. 2008;69:381–4.

    Article  PubMed  Google Scholar 

  10. Fairburn CG, Bohn K. Eating disorder NOS (EDNOS): an example of the troublesome “not otherwise specified” (NOS) category in DSM-IV. Behav Res Ther. 2005;43:691–701.

    Article  PubMed Central  PubMed  Google Scholar 

  11. Crow SJ, Agras WS, Halmi K, Mitchell JE, Kraemer HC. Full syndromal versus subthreshold anorexia nervosa, bulimia nervosa, and binge eating disorder: a multicenter study. Int J Eat Disord. 2002;32:309–18.

    Article  PubMed  Google Scholar 

  12. Machado PPP, Goncalves S, Hoek HW. DSM-5 reduces the proportion of EDNOS cases: evidence from community samples. Int J Eat Disord. 2013;46:60–5.

    Article  PubMed  Google Scholar 

  13. Keel PK, Brown TA, Holm-Denoma J, Bodell LP. Comparison of DSM-IV versus proposed DSM-5 diagnostic criteria for eating disorders: reduction of eating disorder not otherwise specified and validity. Int J Eat Disord. 2011;44:553–60. An important analysis of the prevalence of atypical undifferentiated eating disorder cases according to both DSM-IV and DSM-5 criteria.

    Article  PubMed  Google Scholar 

  14. Hudson JI, Coit CE, Lalonde JK, Pope HG. By how much will the proposed new DSM-5 criteria increase the prevalence of binge eating disorder? Int J Eat Disord. 2012;45:139–41.

    Article  PubMed  Google Scholar 

  15. Skysko R, Roberto CA, Barnes RD, Grilo CM, Attia E, Walsh BT. Test-retest reliability o the proposed DSM-5 eating disorder diagnostic criteria. Psychiatry Res. 2012;196:302–8.

    Article  Google Scholar 

  16. Thomas JJ, Eddy KT, Murray HB, Trompt M, Hartmann AS et al. The impact of revised DSM-5 criteria on the relative distribution and inter-rater reliability of eating disorder diagnoses in a residential treatment setting. Psych Res. 2015.

  17. Keel PK, Haedt A, Edler C. Purging disorder: an ominous variant of bulimia nervosa? Int J Eat Disord. 2005;38:191–9. This important study examined the distinctiveness and clinical significant of purging disorder, supporting its conceptualization as a distinct eating disorder.

    Article  PubMed  Google Scholar 

  18. Keel PK. Purging disorder: subthreshold variant of full-threshold eating disorder? Int J Eat Disord. 2007;40:s89–94.

    Article  PubMed  Google Scholar 

  19. Franko DL, Keel PK. Suicidality in eating disorders: occurrence, correlates, and clinical implications. Clin Psychol Rev. 2006;26:769–82.

    Article  PubMed  Google Scholar 

  20. Pomeroy C. Medical evaluation and medical management. In: Mitchell JE, editor. The outpatient treatment of eating disorders. Minneapolis: University of Minnesota Press; 2001. p. 306–48.

    Google Scholar 

  21. Keel PK, Wolfe BE, Gravener JA, Jimerson DC. Co-morbidity and disorder-related distress and impairment in purging disorder. Psychol Med. 2008;38:1435–42.

    Article  CAS  PubMed  Google Scholar 

  22. Tobin DL, Griffing A, Griffing S. An examination of subtype criteria for bulimia nervosa. Int J Eat Disord. 1997;22:179–86.

    Article  CAS  PubMed  Google Scholar 

  23. Keel PK, Wolfe BE, Liddle RA, De Young KP, Jimerson DC. Clinical features and physiological response to a test meal in purging disorder and bulimia nervosa. Arch Gen Psychiatry. 2007;64:1058–66. This study illustrated the nature of eating abnormalities of those with purging disorder, and was the first paper to note aberrant psychobiology amongst those with purging disorder.

    Article  PubMed  Google Scholar 

  24. Wade TD, Crosby R, Martin NG. Use of latent profile analysis to identify eating disorder phenotypes in an adult Australian twin cohort. Arch Gen Psychiatry. 2006;63:1377–84.

    Article  PubMed  Google Scholar 

  25. Favaro A, Ferrara S, Santonastoso P. The spectrum of eating disorders in young women: a prevalence study in a general population sample. Psychosom Med. 2003;65:701–8.

    Article  PubMed  Google Scholar 

  26. Fairburn CG, Cooper Z, Bohn K, O’Connor ME, Doll HA, Palmer RL. The severity and status of eating disorder NOS: implications for DSM-V. Behav Res Ther. 2007;45:1705–15.

    Article  PubMed Central  PubMed  Google Scholar 

  27. Binford RB, Le Grange D. Adolescents with bulimia nervosa and eating disorder not otherwise specified-purging only. Int J Eat Disord. 2005;38:157–61.

    Article  PubMed  Google Scholar 

  28. Rockert W, Kaplan AS, Olmsted M. Eating disorder not otherwise specified: the view from a tertiary care treatment center. Int J Eat Disord. 2007;40:s99–103.

    Article  PubMed  Google Scholar 

  29. Stice E, Marti NC, Shaw H, Jaconis M. An 8-year longitudinal study of the natural history of threshold, subthreshold, and partial eating disorders from a community sample of adolescents. J Abnorm Psychol. 2009;118:587–97.

    Article  PubMed Central  PubMed  Google Scholar 

  30. Haedt AA, Keel PK. Comparing definitions of purging disorder on point prevalence and associations with external validators. Int J Eat Disord. 2010;43:433–9.

    PubMed Central  PubMed  Google Scholar 

  31. Sancho C, Arija MV, Asorey O, Canals J. Epidemiology of eating disorders: a two year follow-up in an early adolescent school population. Eur Child Adolesc Psych. 2007;16:495–504.

    Article  CAS  Google Scholar 

  32. Pope HG, Katz DL, Hudson JI. Anorexia nervosa and “reverse anorexia” among 108 male bodybuilders. Compr Psychiatry. 1993;34:406–9.

    Article  PubMed  Google Scholar 

  33. Pope HG, Gruber AJ, Choi P, Olivardia R, Phillips KA. Muscle dysmorphia: an underrecognized form of body dysmorphic disorder. Psychosomatics. 1997;38:548–57. This paper was the first empirical investigation specifically targeted at muscle dysmorphia, illustrating the core clinical features.

    Article  PubMed  Google Scholar 

  34. Griffiths S, Murray SB, Touyz SW. Disordered eating and the muscular body ideal. J Eat Disord. 2013;1:15.

    Article  PubMed Central  PubMed  Google Scholar 

  35. Murray SB, Rieger E, Touyz SW, De la Garza García Y. Muscle dysmorphia and the DSM-V conundrum: where does it belong? A review paper. Int J Eat Disord. 2010;43:483–91. This review paper was the first to comprehensively review the potential placement of muscle dysmorphia as an eating disorder phenotype.

    Article  PubMed  Google Scholar 

  36. Murray SB, Rieger E, Touyz SW. Muscle dysmorphia symptomatology during a period of religious fasting: a case report. Eur Eat Disord Rev. 2011;19(2):162–8.

    Article  PubMed  Google Scholar 

  37. Murray SB, Maguire S, Russell J, Touyz SW. The emotional regulatory features of bulimic episodes and compulsive exercise in muscle dysmorphia: a case report. Eur Eat Disord Rev. 2012;20(1):68–73.

    Article  PubMed  Google Scholar 

  38. Murray SB, Rieger E, Hildebrandt T, Karlov L, Russell J, et al. A comparison of eating, exercise, shape, and weight related symptomatology in males with muscle dysmorphia and anorexia nervosa. Body Image. 2012;9:193–200. This cross sectional investigation revealed comparable eating disorder pathology amongst men with anorexia nervosa and men with muscle dysmorphia, although expressed in polar opposite directions.

    Article  PubMed  Google Scholar 

  39. Murray SB, Rieger E, Karlov L, Touyz SW. An investigation of the transdiagnostic model of eating disorders in the context of muscle dysmorphia. Eur Eat Disord Rev. 2013;21:160–4.

    Article  PubMed  Google Scholar 

  40. Murray SB, Touyz SW. Muscle dysmorphia: towards a diagnostic consensus. Aust N Z J Psych. 2013;47:206–7.

    Article  Google Scholar 

  41. Murray SB, Touyz SW. How do clinicians in the field conceptualize muscle dysmorphia? Adv Eat Disord: Theory Res Pract. 2013;1:207–12.

    Article  Google Scholar 

  42. Grieve FG. A conceptual model of factors contributing to the development of muscle dysmorphia. Eat Disord: J Treat Prev. 2009;15:63–80.

    Article  Google Scholar 

  43. Leone JE. Muscle dysmorphia symptomatology and extreme drive for muscularity in a 23-year-old woman: a case study. J Strength Cond Res. 2009;23:988–95.

    Article  PubMed  Google Scholar 

  44. Olivardia R, Pope HG, Hudson JI. Muscle dysmorphia in male weightlifters: a case control study. Am J Psychiatr. 2000;157:1291–6.

    Article  CAS  PubMed  Google Scholar 

  45. Field AE, Sonnenville KR, Crosby RD, Swanson SA, Eddy KT, et al. Prospective associations of concerns about physique and the development of obesity, binge drinking, and drug use among adolescent boys and young adult men. JAMA Pediatr. 2014;168:34–9.

    Article  PubMed Central  PubMed  Google Scholar 

  46. Griffiths S, Mond JM, Murray SB, Touyz SW. Positive beliefs about anorexia nervosa and muscle dysmorphia are associated with eating disorder symptomatology. Aust N Z J Psychiatr. 2015.

  47. Murray SB, Griffiths S. Muscle dysmorphia and family-based treatment: a preliminary case report. Clin Child Psychol Psych. 2015;20:324–30.

    Article  Google Scholar 

  48. Fairburn CG, Cooper Z, Shafran R. Cognitive behaviour therapy for eating disorders: a “transdiagnostic” theory and treatment. Behav Res Ther. 2003;41:509–28.

    Article  PubMed  Google Scholar 

  49. Peveler RC, Bryden KS, Neil HA, Fairburn CG, Mayou RA, et al. The relationship of disordered eating habits and attitudes to clinical outcomes in young adult females with type 1 diabetes. Diabetes Care. 2005;28:84–8. Novel paper reporting the longitudinal outcome of disordered eating attitudes and behaviors in females with type 1 diabetes.

    Article  PubMed  Google Scholar 

  50. Bryden KS, Neil A, Mayou RA, Peveler RC, Fairburn CG, Dunger DB. Eating habits, body weight, and insulin misuse. A longitudinal study of teenagers and young adults with type 1 diabetes. Diabetes Care. 1999;22:1956–60.

    Article  CAS  PubMed  Google Scholar 

  51. Verrotti A, Catino M, De Luca FA, Morgese G, Chiarelli F. Eating disorders in adolescents with type 1 diabetes mellitus. Acta Diabetol. 1999;36:21–5.

    Article  CAS  PubMed  Google Scholar 

  52. Goebel-Fabbri AE, Fikkan J, Franko DL, Pearson K, Anderson BJ, Weinger K. Insulin restriction and associated morbidity and mortality in women with type 1 diabetes. Diabetes Care. 2008;31:415–9.

    Article  PubMed  Google Scholar 

  53. Colton P, Olmsted M, Daneman D, Rydall A, Rodin G. Disturbed eating behavior and eating disorders in preteen and early teenage girls with type 1 diabetes: a case-controlled study. Diabetes Care. 2004;27:1654–9.

    Article  PubMed  Google Scholar 

  54. Neumark-Sztainer D, Patterson J, Mellin A, Ackard DM, Utter J, et al. Weight control practices and disordered eating behaviors among adolescent females and males with type 1 diabetes. Diabetes Care. 2002;25:1289–96. This study reported the prevalence of specific weight control- and disordered eating practices in patients with type 1 diabetes.

    Article  PubMed  Google Scholar 

  55. Custal N, Arcelus J, Agüera Z, Bove FI, Wales J, et al. Treatment outcome of patients with comorbid type 1 diabetes and eating disorders. BMC Psychiatry. 2014;14:140.

    Article  PubMed Central  PubMed  Google Scholar 

  56. Olmsted MP, Colton PA, Daneman D, Rydall AC, Rodin GM. Prediction of the onset of disturbed eating behavior in adolescent girls with type 1 diabetes. Diabetes Care. 2008;31:1978–82.

    Article  PubMed Central  PubMed  Google Scholar 

  57. Larranaga A, Docet M, Garcia-Mayor RV. Disordered eating behaviors in type 1 diabetic patients. World J Diab. 2011;2:189–95.

    Google Scholar 

  58. Goebel-Fabbri AE. Disturbed eating behaviors and eating disorders in type 1 diabetes: clinical significance and treatment recommendations. Curr Diab Rep. 2009;9:133–9.

    Article  PubMed  Google Scholar 

  59. Nansel TR, Anderson BJ, Laffel LM, Simons-Morton BG, Weissberg-Benchell J, et al. A multisite trial of a clinic-integrated intervention for promoting family management of pediatric type 1 diabetes: feasibility and design. Pediatr Diabetes. 2008;10:105–15.

    Article  PubMed Central  PubMed  Google Scholar 

  60. Stunkard AJ, Grace WJ, Wolff HG. The night-eating syndrome; a pattern of food intake among certain obese patients. Am J Med. 1955;19:78–86.

    Article  CAS  PubMed  Google Scholar 

  61. Lundgren JD, Allison KC, Stunkard AJ. Night eating syndrome: research, assessment, and treatment. New York: Guilford Press; 2012. This book comprehensively overviews the clinical features of night eating syndrome, in addition to outlining available treatment options.

    Google Scholar 

  62. Allison KC, Grilo CM, Masheb RM, Stunkard A. Binge eating disorder and night eating syndrome: a comparative study of disordered eating. J Consult Clin Psychol. 2005;73:1107–15.

    Article  PubMed  Google Scholar 

  63. Fischer S, Meyer A H, Hermann E, Tuch A, Munsch S. Night eating syndrome in young adults: Delineation from other eating disorders and clinical significance. Psychiatr Res 2012;200:494–501. This paper summarizes delineates night eating syndrome from healthy controls, noting greater eating disorder pathology, greater general psychopathology, and greater distress in those with night eating syndrome.

  64. Stunkard AJ, Allison KC, Lundgren JD, O’Reardon JP. A biobehavioural model of the night eating syndrome. Obes Rev. 2009;10:69–77. This neuroimaging study examined the role of serotonin transporters in night eating syndrome, noting increased binding in the midbrain, which underpins the dysregulated circadian rhythm in both food intake and neuroendocrine function.

    Article  PubMed  Google Scholar 

  65. Kucukgoncu S, Midura M, Tek C. Optimal management of night eating syndrome: challenges and solutions. Neuropsychiatr Dis Treat. 2015;11:751–60.

    Article  PubMed Central  PubMed  Google Scholar 

  66. Allison KC, Lundgren JD, Moore RH, O’Reardon JP, Stunkard AJ. Cognitive behavior therapy for night eating syndrome: a pilot study. Am J Psychother. 2010;64:91–106.

    PubMed  Google Scholar 

  67. Veale D, Costa A, Murphy P, Ellison N. Abnormal eating behaviour in people with a specific phobia of vomiting (emetophobia). Eur Eat Disord Rev. 2012;20:414–8. This study reported the eating behaviors of those with emetophobia, further noting that those with lower body mass index and greater food restriction report a greater degree of psychopathology.

    Article  PubMed  Google Scholar 

  68. Veale D. Cognitive behaviour therapy for a specific phobia of vomiting. Cogn Behav Ther. 2009;2:272–88. This paper summarizes current knowledge pertaining to the clinical profile, and treatment options, for those with a specific phobia of vomiting.

    Google Scholar 

  69. Van Hout WJ, Bouman TK. Clinical features, prevalence and psychiatric complaints in subjects with fear of vomiting. Clin Psychol Psychother. 2012;19:531–9.

    Article  PubMed  Google Scholar 

  70. Vandereycken W. Media hype, diagnostic fad or genuine disorder? Professionals’ opinions about night eating syndrome, orthorexia, muscle dysmorphia, and emetophobia. Eat Disord. 2011;19:145–55.

    Article  PubMed  Google Scholar 

  71. Kupfer D. DSM-5: new opportunities and challenges for teaching and training. Acad Psychiatry. 2014;38:58–60.

    Article  PubMed  Google Scholar 

  72. Kupfer DJ, Rieger DA. Neuroscience, clinical evidence, and the future of psychiatric classification in DSM-5. Am J Psychiatr. 2011;168:672–4.

    Article  PubMed  Google Scholar 

Download references

Compliance with Ethics Guidelines

Conflict of Interest

Stuart B. Murray and Leslie K. Anderson declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Stuart B. Murray.

Additional information

This article is part of the Topical Collection on Eating Disorders

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Murray, S.B., Anderson, L.K. Deconstructing “Atypical” Eating Disorders: an Overview of Emerging Eating Disorder Phenotypes. Curr Psychiatry Rep 17, 86 (2015). https://doi.org/10.1007/s11920-015-0624-7

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11920-015-0624-7

Keywords

Navigation