According to the most recently accepted definitions by the American Psychiatric Association (1994), anorexia nervosa (AN) and bulimia nervosa (BN) are defined as high-severity emotional disorders and interference in many of the vital areas of the individual who suffers from it.

The data suggest that the confluence of biological, psychological and social factors interact with the personality of the individual, favouring the development of this type of eating pathology.

Among the first group of factors, the type of temperament of the individual as well as his or her level of emotional stability can be decisive; as for the socio-cultural components, the idealization of society for maintaining a slim body by associating it with success and superiority over others should be highlighted; as for the psychological factors, this type of patient presents phenomena such as low self-esteem, feelings of inefficiency in problem solving and coping, or a high desire for perfectionism that make daily functioning extremely difficult.

Symptoms in eating disorders

On the other hand, it is frequent the presence of anxious and depressive symptomatology , characterized by the continuous sadness and the thought of dichotomic type (of “everything or nothing”).

A large proportion of people with anorexia present traits of obsession and compulsion with regard to the maintenance of strict regulation and rigidity in the control of eating, extreme physical exercise, image and body weight. Finally, it is also characteristic the difficulty in expressing themselves emotionally externally in spite of being very intelligent, so they tend to isolate themselves from the circles of close relationships.


In the case of anorexia nervosa, it is characterized by a predominance of body weight rejection , usually accompanied by a distortion of body image and an inordinate fear of becoming fat. In anorexia nervosa, two subtypes are distinguished, depending on whether or not binge eating or compensatory behaviors occur (AN-Purgative vs. AN-Restrictive, respectively).


The second nosology, bulimia nervosa, is characterized by the maintenance of cyclical episodes of binge eating and compensatory behaviors of those through vomiting , the use or abuse of laxatives, excessive physical exercise, or restriction in subsequent intakes. Here again, a distinction is made between the categories BN-Purgative, if the individual uses vomiting as a compensatory behavior, and BN-Non-Purgative, if he or she resorts to fasting or excessive physical activity.

Many of the people who present an Eating Disorder do not meet all the criteria that allow one of the two previous diagnoses to be made. Therefore, a third category called Unspecified Eating Disorder can be distinguished, where all these subjects of difficult classification can be included.

Characterization of bulimia nervosa and anorexia nervosa

Anorexia nervosa usually stems from family histories of eating disorders, especially obesity. It is more easily detected than bulimia nervosa, due to the high weight loss and the numerous medical complications that accompany the condition, such as metabolic, cardiovascular, renal, dermatological, etc. In extreme cases of malnutrition, anorexia nervosa can lead to death, with the mortality rate being between 8 and 18%.

Unlike anorexia, bulimia is consulted much less frequently. In this case the weight loss is not so evident since the binge-compensation cycles cause the weight to remain, more or less, at similar values.

People with bulimia are characterized by an exaggerated concern for their body image , although they manifest it in a different way than in anorexia: in this case, intake becomes the method to cover their unsatisfied emotional needs through adequate means.

Analogous to anorexia, alterations are also observed at the psychological and social level. Normally these people show a marked isolation, so that family and social interactions are usually poor and unsatisfactory. Self-esteem is usually low. Comorbidity between bulimia, anxiety and depression has also been observed; the latter usually occurs as a result of the former.

As for the level of anxiety, there is usually a parallel between this and the frequency of binges carried out by the subject. Later, feelings of guilt and impulsivity motivate the compensatory behavior of the binge. It is for this reason that a certain relationship of bulimia with other impulsive disorders such as substance abuse, pathological gambling, or personality disorders where behavioral impulsivity predominates has also been indicated.

The thoughts that characterize bulimia are also often defined as dichotomous and irrational . They spend a lot of time each day on cognitions about not getting fat and feeding the distortions of the body shape.

Finally, medical pathologies are also common, due to the maintenance in time of the binge-compensation cycles. The alterations are observed at a metabolic, renal, pancreatic, dental, endocrine or dermatological level, among others.

Causes of Eating Disorders

There are three factors that have been demonstrated by the majority of expert authors in this field of knowledge: the predisposing, the precipitating and the perpetuating factors. Thus, there seems to be agreement in granting the causality of ACTs a multicausal character where both physiological and evolutionary , psychological and cultural elements are combined as intervening in the appearance of the pathology.

Among the predisposing aspects, reference is made to individual factors (overweight, perfectionism, level of self-esteem, etc.), genetic factors (higher prevalence in the subject whose relatives present such psychopathology) and socio-cultural factors (fashion ideals, eating habits, prejudices derived from body image, parental overprotection, etc.).

Precipitating factors are the age of the subject (greater vulnerability in adolescence and early youth), inadequate body assessment, excessive physical exercise, stressful environment, interpersonal problems, presence of other psychopathologies, etc.

The perpetuating factors differ in terms of their psychopathology . While it is true that negative beliefs about body image, social pressure and stressful experiences are common, in the case of anorexia the most important factors are related to complications derived from malnutrition, social isolation and the development of fears and obsessive ideas about food or body shape.

In the case of bulimia, the central elements that maintain the problem are linked to the binge-compensation cycle, the level of anxiety experienced, and the presence of other maladaptive behaviors such as substance abuse or self-injury.

Main behavioral, emotional and cognitive manifestations

As it has been commented in previous lines, Eating Disorders derive in a long list of manifestations both physical (at endocrine, nutritional, gastrointestinal, cardiovascular, renal, bone and immunological levels) and psychological, emotional and behavioral.

By way of summary, about this second set of symptoms, can be given :

At the behavioural level

  • Restrictive diets or binge eating.
  • Compensation of intake by vomiting, laxatives and diuretics.
  • Alterations in the mode of intake and rejection of some specific foods
  • Obsessive-compulsive behaviors.
  • Self-harm and other displays of impulsiveness.
  • Social isolation.

On the psychological level

  • Terrible fear of getting fat.
  • Wrong thoughts about food, weight and body image.
  • Alteration in the perception of body image.
  • Impoverishment of the creative capacity.
  • Confusion in the feeling of satiety.
  • Difficulties in the ability to concentrate.
  • Cognitive distortions: polarized and dichotomous thinking, selective abstractions, thought attribution, personalization, overgeneralization, catastrophism and magical thinking.

On an emotional level

  • Emotional readiness.
  • Depressive symptomatology and suicidal ideation.
  • Anxious symptomatology, development of specific phobias or generalized phobia

Intervention in ACT: objectives of the first personalized attention

In a generic approach to ATD intervention, the following guidance points may be useful in providing an initial individualized attention to the case at hand:

1. An approach to the problem . In this first contact, a questionnaire is completed to acquire the greatest volume of information regarding the history and course of the disorder.

2. Awareness . To allow the patient to gain an adequate insight into the deviant behaviours related to the disorder so that he or she can become aware of the vital risk derived from them.

3. Motivation towards treatment . Awareness of the importance of using a professional in psychology and specialized clinical psychiatry is a fundamental step to ensure greater probability of therapeutic success, as well as early detection of incipient symptoms can be a great predictor of positive evolution of the disease.

4. Information on intervention resources . Offering useful addresses may be useful to increase the perception of social support received, such as associations of ATD patients attending group therapy groups.

5. Bibliographic recommendation . The reading of certain self-help manuals may be indicated, both for the patients themselves and for their closest relatives.

By way of conclusion

Given the very complex nature of this type of psychopathology and the powerful maintaining factors that make a favourable evolution of these disorders very difficult, it seems essential to detect the first manifestations early and to guarantee a multi-component and multidisciplinary intervention that covers all the altered components (physical, cognitive, emotional and behavioural) as well as the extensive set of vital areas affected.

Bibliographic references:

  • Cervera, Montserrat. “Risk and prevention of anorexia and bulimia”. Martínez Roca. Barcelona, 1996.
  • Fernandez, A. and Turon Gil. “Eating disorders.” Masson. 2002.
  • Raich, Rosa Maria. “Anorexia and Bulimia: Eating Disorders.” Pyramid. Madrid, 2001.