Elephant in the Room: There Are More Than Three

Elephant in the Room: There Are More Than Three

You are sitting in a room filled with people. Your next door neighbor Kevin, best friend Melissa, and your cousins from down South even decided to stop by. Everyone is playing a friendly game of Taboo until your mother calls everyone in for dinner in the next room over. You are the last one to go in because you do not want anyone to know. You are afraid that everyone, even Melissa, will never look at you the same way again.

Because you do not eat at all. Not because you cannot, but because you will not. And if you do, you might eat more than you can control. Not because you want to, but because you cannot stop once it is happening. You are inherently afraid of the elephant always lurking behind you. Why introduce it into the room now, at the dinner table, when everyone is enjoying their meals? Sometimes the elephant unexpectedly introduces itself, mostly because your frame has become thin enough for the elephant to extend itself. Or maybe, your frame has stayed the same, and the elephant has stayed alongside to accompany you.

Telling friends and family about a constant struggle with food is not an easy topic of discussion, but many people realize that a support system exists for their distressed relationship with eating; however, several other people are still left behind tumbling in the dust, stranded away from guidance or intervention. As a society, I think time has come for the elephant in the room to be identified.

Anorexia nervosa, bulimia nervosa, and binge eating disorder are the three elephants in the room that have been discussed and addressed extensively, but there exists a bigger elephant in the room than you might think. While all three are serious disorders, many others on the wide spectrum of eating disorders are not being given the attention they deserve. The media covers mainly anorexia, followed by bulimia and then binge eating disorder; however, according to the 2008-2012 Mental Health Surveillance Study conducted by the Center for Behavioral Health Statistics and Quality, anorexia is less common than bulimia and binge eating disorder in individuals aged 18 and over, occurring in less than 0.1% of the adult population.

An article published by Smink and Hoeken (2012) in the peer-reviewed medical journal known as Current Psychiatric Reports revealed that when younger women aged 15-19 years are included in the data and statistical analysis, the “lifetime prevalence of anorexia increases to 0.9 percent of women in the population…” and “…0.3 percent of men exhibit the disorder at some point in their lives.” Smink and Hoeken (2012) also suggested that the prevalence rates of anorexia, bulimia, and binge eating disorder are 1.2%, 1.6%, and 5.7%, respectively, in the population aged 15 and older.

Unlike many eating disorders studies, this study also included a comprehensive meta-analysis of 125 other studies to collect the epidemiological data of all eating disorders, and found that eating disorder not otherwise specified (EDNOS), which has most recently been termed other specified eating or feeding disorder (OSFED), had the highest population prevalence and is associated with psychological and physiological risks comparable to specified eating disorders, such as anorexia, bulimia, and binge eating disorder. While this group of researchers’ goal was to reduce the size of the EDNOS/OSFED category, what about the rest? You may not have even known they existed.

“Sweetheart, eat your peas, Al. They are not going to eat themselves.” This theoretical exchange between a mother and her “picky” child Al is not enough to represent avoidant/restrictive food intake disorder (ARFID), when a person is conflicted by food or foods, resulting in inadequate nutrition (“Avoidant/Restrictive Food Intake Disorder,” 2013). What Al’s mother does not know is that he is choosing not to eat the peas because he fears eating green-colored foods in the shape of spheres. Two doors down from Al’s house, Jane takes her plate of dinner to her room to “eat,” but what her family does not know is that she goes to the backyard and empties her plate into the trash can, pretending she ate everything. The truth? She is afraid of eating any food as a result of her growing fear of vomiting or choking.

“Teacher, Tim is chewing on his pencil again.” This theoretical situation in which a young student alerts her teacher about her classmate’s “weird” habit of eating the wood of pencils may be an understatement of pica, an eating disorder usually defined by a persistent ingestion of non-nutritive substances (e.g. rocks, wood, or even glass) “for at least one month at an age for which this behavior is developmentally inappropriate” (“Pica,” 2013). Consuming these substances over the course of a long period of time can potentially cause unwarranted physiological consequences (e.g. digestive issues), and especially in individuals who have autism spectrum disorder or schizophrenia where pica can manifest itself more seriously.

“Just a midnight snack, that’s all.” Meanwhile, Charlie consistently does not feel hungry until the very peak of the night around 4 A.M., which may be the result of night eating syndrome (NES) disorder characterized by a “delayed circadian pattern of food intake” (“Other Specified Eating or Feeding Disorders,” 2013). Charlie may be consuming a lot of food during unusual times of the evening or night, which is typically uncontrollable and causes individuals to become physically and mentally distressed by both the disturbed sleep cycle episodes of late-night feeding.

Before reading this article, you may have known about only three of the six, seven, or eight plus eating disorders that have been officially recognized on the spectrum of eating disorders. When people think eating disorders they usually assume a discussion of anorexia or bulimia, and sometimes acknowledge binge eating. By introducing EDNOS/OFSED, ARFID, pica, and NES into the playing field we can begin to understand that eating disorders can affect anyone and in a multitude of ways, and not necessarily the ways in which we have been taught in school and the media to accept.

With the elephant in the room that there are more than three, we need to create a society that is open to discussion about and accepting of these many other disordered relationships with eating. The elephant that was once invisible is now ready to be painted with perspective about these once hidden, invisible eating disorders.


American Psychiatric Association. (2013). Feeding and Eating Disorders. Avoidant/Restrictive Intake Disorder. http://dx.doi.org/10.1176/appi.books.9780890425596.dsm10

American Psychiatric Association. (2013). Feeding and Eating Disorders. Other Specified Eating or Feeding Disorders. http://dx.doi.org/10.1176/appi.books.9780890425596.dsm10

American Psychiatric Association. (2013). Feeding and Eating Disorders. Pica. http://dx.doi.org/10.1176/appi.books.9780890425596.dsm10

Karg, R.S., Jonaki, B., Batts, K.R., Forman-Hoffman, V.L., Liao D., Hirsch E., Pemberton, M.R., Colpe, L.J., & Hedden S.L. (2014). Past Year Mental Disorders Among Adults in the United States: Results from the 2008–2012 Mental Health Surveillance Study. CBHSQ Data Review.

Smink, F. R. E., van Hoeken, D., & Hoek, H. W. (2012). Epidemiology of Eating Disorders: Incidence, Prevalence and Mortality Rates. Current Psychiatry Reports, 14(4), 406–414.

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