What eating disorders are
Eating disorders = mental illnesses with abnormal behaviors, cognitions, and emotions around food / weight as the core. DSM-5's 3 main diagnoses:
- Anorexia Nervosa (AN): ↓ weight, fear of weight gain, distorted body image
- Bulimia Nervosa (BN): binges + compensatory behaviors (vomiting, exercise, fasting)
- Binge Eating Disorder (BED): binges without compensation. Newly added to DSM-5 in 2013
Korean eating-disorder data
- Overall: ~1% (adults), 5% in adolescent / young-adult women
- Female:Male: 10:1 (AN, BN), 3:1 (BED)
- Onset: peak 12~25 years
- AN mortality: 5~10% (highest of psychiatric disorders — 20% suicide, 80% somatic)
- BN mortality: 2~3%
- BED mortality: indirectly ↑ via obesity complications
- Korean specifics: appearance society, idol thinness, idol diets, SNS comparison, plastic-surgery ads accelerate onset
1. Anorexia Nervosa (AN)
DSM-5 criteria:
- ① Weight below normal (BMI <18.5 or adolescent norms)
- ② Intense fear of weight gain (even when underweight)
- ③ Distorted weight / body image ("fat" while actually thin)
Two subtypes:
- Restricting: food restriction only
- Binge/Purge: binges followed by vomiting / exercise / diuretics
Somatic complications:
- Cardiac: arrhythmia, heart failure (#1 AN death)
- Osteoporosis: lifelong impact if adolescent onset
- Electrolytes: low K, low Na (with vomiting)
- Hormonal: amenorrhea, ↓ thyroid, ↑ cortisol
- Brain atrophy (reversible but ↓ cognition)
- Tooth erosion (vomiting)
- Hair loss, skin, muscle atrophy
2. Bulimia Nervosa (BN)
DSM-5 criteria:
- ① Binge eating (short time + large amount + sense of loss of control)
- ② Compensatory behaviors (vomiting, laxatives, fasting, excessive exercise)
- ③ At least weekly × 3+ months
- ④ Self-image determined by weight / shape
Features: unlike AN, weight may be normal — invisible externally. "Fake normal". Cycle of binge → guilt → vomiting → self-loathing.
Somatic complications:
- Electrolytes (low K endangers the heart)
- Teeth (enamel erosion from gastric acid)
- Esophagitis / esophageal rupture (emergency)
- Parotid swelling (vomiting)
- GI problems
3. Binge Eating Disorder (BED)
DSM-5 criteria (added 2013):
- ① Binge eating (same as BN)
- ② No compensation
- ③ Weekly × 3+ months
- ④ Guilt / depression about the binges
- ⑤ 3+ of the following 5:
- Eating very fast
- Eating until uncomfortable
- Eating large amounts when not hungry
- Eating alone (shame)
- Guilt / depression after
Features: most common eating disorder (50% of cases). Can co-occur with obesity — but not all obesity = BED. Strong self-loathing / depression.
Why it develops — 5 factors
① Genetics: first-degree relative with ED = 10× risk. 50~80% heritability.
② Brain circuits: reward circuit, serotonin, dopamine abnormalities.
③ Psychology: perfectionism, low self-esteem, control needs, trauma (sexual abuse 30%).
④ Sociocultural: Korean glorification of thinness, appearance society, SNS, celebrities, diet culture.
⑤ Triggers: dieting (75% develop ED after a diet), breakup, exams, bullying.
Not willpower, not vanity — a brain disease. Telling an ED patient to "just eat" is like telling a depressed patient to "just feel better".
Korean adolescent warning signs — for parents
- Refusing meals / lying "I ate"
- Rapid weight loss (5+ kg in 3 months)
- Bathroom right after meals (possible vomiting)
- Diet / exercise compulsions
- Avoiding talk of looks / weight
- Amenorrhea
- Hair loss, skin issues, cold extremities
- Avoiding friends / family, depression
- Baggy clothes (hiding weight loss)
- "Micro-controlling" food (calorie counting, weighing oneself)
2+ signs = psychiatry immediately. Faster treatment = ↑ recovery.
Integrated treatment — 5 axes
① Psychiatry / psychotherapy:
- CBT-E: first-line for BN / BED. 20 sessions.
- FBT (Family-Based Treatment, Maudsley): first-line for adolescent AN. Parents regain food-control role.
- DBT: when BPD co-occurs.
- Medication: SSRI (BN, BED) — AN responds weakly to meds.
② Nutritional rehabilitation:
- Dietitian-supervised meal plan
- Gradual ↑ calories (refeeding syndrome risk — slow at inpatient start)
- Food journal / plan
- Gradual exposure to "feared foods"
③ Internal medicine / physical care:
- Electrolyte and ECG monitoring
- Osteoporosis check (AN)
- Teeth (BN)
- Hormones (amenorrhea)
④ Family / environment:
- Normalize family meal environment
- ↓ looks / weight talk
- ↓ SNS exposure
- Family therapy
⑤ Inpatient vs. outpatient:
- Inpatient criteria: BMI <16, electrolyte abnormalities, cardiac findings, suicide risk, outpatient failure
- Inpatient duration: 4 weeks ~ 6 months
- Outpatient: 1~3 multidisciplinary visits/week
Korean treatment resources
- Specialty clinics: SNUH, Korea Univ., Samsung, Asan, Kangbuk Samsung psychiatry have ED clinics
- ED-specialty hospitals: some specialty clinics (search "식이장애 치료")
- Inpatient facilities: some general hospitals, adolescent psychiatric hospitals
- Health insurance: covers psychiatric visits / drugs
- Self-help groups: Korean ED recovery communities (online cafés)
- Family education: F.E.A.S.T. (Korean chapter)
Recovery prospects
Recovery rates with treatment:
- AN: 50% full / 30% partial / 20% chronic
- BN: 70% full / 20% partial / 10% chronic
- BED: 80% full
- Without treatment: chronic, ↑ mortality risk
Factors that ↑ recovery: ① early treatment (within 3 years) ② family support ③ integrated treatment ④ comorbidity treatment ⑤ social support.
Recovery is not just "weight normalization" but "healthy relationship with food". Can take 5~10 years; relapse is common.
Emergency signs — care now
- BMI <16 or ≥5 kg loss in 1 month
- Syncope, severe dizziness
- Palpitations, arrhythmia
- Electrolyte abnormalities (blood tests)
- Hematemesis after vomiting
- Suicidal thoughts / attempts
- Food refusal for 2+ weeks
1577-0199 or ER. Eating disorders can be emergencies — not "weak will", a medical emergency. If you notice it in your child, get specialty treatment immediately. "They'll grow out of it" is wrong — treatment determines the outcome.
