3.5 Problem 1: Eating Disorders
Arlington: Diagnostic & Statistical Manual of Mental Disorders
Pica
A) Persistent eating of nonnutritive, nonfood substances over a period of at least 1 month
B) The eating of these substances is inappropriate to the developmental level of the
individual
C) Eating behaviour is not part of a culturally supported/socially normative practice
D) If the eating behaviour occurs in the context of another mental disorder (e.g.,
intellectual disability/intellectual developmental disorder, autism spectrum disorder,
schizophrenia) or medical condition (including pregnancy), it is sufficiently severe to
warrant additional clinical attention
Rumination
A) Repeated regurgitation of food over a period of at least 1 month. Regurgitated food
may be rechewed, re-swallowed, or spit out
B) Repeated regurgitation is not attributable to an associated gastrointestinal or other
medical condition
C) The eating disturbance does not occur exclusively during the course of anorexia
nervosa, bulimia nervosa, binge-eating disorder, or avoidant/restrictive food intake
disorder
D) If symptoms occur in the context of another mental disorder (e.g., intellectual
disability or another neurodevelopmental disorder), they are sufficiently severe to
warrant additional clinical attention
Specify if:
In remission: after full criteria for rumination were previously met, the criteria have
not been met for a sustained period of time
Avoidant/Restrictive Food Intake Disorder
A) An eating/feeding disturbance (e.g., apparent lack of interest in eating/food, avoidance
based on sensory characteristics of food, concern about aversive consequences of
eating) associated with one (or more) of the following:
Significant weight loss (or failure to achieve expected weight gain or faltering
growth in children)
Significant nutritional deficiency
Dependence on eternal feeding (tube feeding) or oral nutritional supplements
Marked interference with psychosocial functioning
B) The disturbance is not better explained by lack of available food or by an associated
culturally sanctioned practice
C) The eating disturbance does not occur exclusively during the course of anorexia
nervosa/bulimia nervosa, and there is no evidence of a disturbance in the way in
which one’s body weight/shape is experienced
D) The eating disturbance is not attributable to a concurrent medical condition or not
better explained by another mental disorder. When the eating disturbance occurs in
, the context of another condition or disorder, the severity of the eating disorder
exceeds that routinely associated with the condition/disorder and warrants additional
clinical attention
Anorexia Nervosa
A) Restriction of energy intake relative to requirements, leading to a significantly low
body weight in the context of age, sex, developmental trajectory, and physical health.
Significantly low weight is defined as a weight that is less than minimally normal or,
for children and adolescents, less than that minimally expected
B) Intense fear of gaining weight or of becoming fat, or persistent behaviour that
interferes with weight gain, even though at a significantly low weight
C) Disturbance in the way in which one’s body weight/shape is experienced, undue
influence of body weight/shape on self-evaluation, or persistent lack of recognition of
the seriousness of the current low body weight
Subtypes:
Restricting type: during the last 3 months, the individual has not engaged in recurrent
episodes of binge-eating/purging behaviour. This subtype describes presentations in
which weight loss is accomplished mostly through dieting, fasting and/or excessive
exercise
Binge-eating/purging type: during the last 3 months, the individual has engaged in
recurrent episodes of binge-eating/purging behaviour
Specify current severity:
The minimum level of severity is based, for adults, on current body mass index (BMI)
or, for children & adolescents, on BMI percentile
Mild = BMI ≥ 17kg/m2
Moderate = BMI 16-16.99kg/m2
Severe = BMI 15-15.99 kg/m2
Extreme = BMI ¿ 15kg/m2
Subtypes
Most people with binge-eating/purging type of AN binge eat & also purge, some do
not binge eat but do regularly purge after the consumption of small amounts of food
Crossover between the subtypes over the course of the disorder is not uncommon;
therefore, subtype description should be used to describe current symptoms rather
than longitudinal course
Diagnostic Features
Criterion A requires that individual’s weight be significantly low – BMI. Adults who
are not underweight should not be assigned diagnosis of AN
Criterion B: intense fear of gaining weight/becoming fat. This fear is not alleviated
by weight loss, concern about weight gain may actually increase even as weight falls
Criterion C: experience & significance of body weight/shape are distorted. Some feel
overweight, others realize they are thin, but still concerned certain body parts are ‘too
fat’. Frequent weighing, obsessive measuring of body parts, persistent use of mirror to
check for perceived areas of ‘fat’. Self-esteem is highly dependent on their
, perceptions of body shape & weight. Weight loss is viewed as impressive
achievement and sign of self-discipline, weight gain is seen as unacceptable failure of
self-control. Some may acknowledge being thin, but they don’t recognize serious
medical implications of their malnourished state
Associated Features
Semistarvation & purging behaviours sometimes associated with AN
Nutritional compromise affects most major organ systems
Most physiological disturbances associated with malnutrition are reversible with
nutritional rehabilitation. But some, like loss of bone mineral density, are not
completely reversible
When seriously underweight, patients can have depressive signs: depressed mood,
social withdrawal, irritability, insomnia, diminished interest in sex
Obsessive-compulsive features, both related & unrelated to food. Most people with
AN are preoccupied with thoughts of food. Some collect recipes or hoard food.
Obsessions & compulsions related to food may be exacerbated by undernutrition.
Concerns about eating in public, feelings of ineffectiveness, strong desire to control
one’s environment, inflexible thinking, limited social spontaneity and overly
restrained emotional expression
Compared to AN restricting type, those with binge-eating/purging type have higher
rates of impulsivity and are more likely to abuse alcohol & drugs
Some show excessive levels of physical activity, accelerates weight loss. During
treatment, excessive activity may be difficult to control, thereby jeopardizing weight
recovery
May misuse medications, e.g., manipulating dosage, to achieve weight loss/avoid
weight gain
Prevalence
Higher rates in women than in men
Most prevalent in post industrialized, high-income countries
Development & Course
AN usually begins during adolescence/young adulthood. Rarely begins before puberty
or after age 40
Onset is associated with stressful life event, e.g., leaving home for college
Younger individuals may manifest atypical features, including denying ‘fear of fat’
Older individuals more likely to have a longer duration of illness, and their clinical
presentation may include more signs & symptoms of long-standing disorders
Most experience remission within 5 years
Death most commonly results from medical complications from the disorder or from
suicide
Risk & Prognostic Factors
Temperamental: those who develop anxiety disorders/display obsessional traits in
childhood are at increased risk for developing anorexia nervosa
Environmental: occupations that encourage thinness, like modeling & elite athletics,
associated with increased risk
Genetic & Physiological: increased risk among biological relatives
Association with suicidal thoughts/behaviour:
Arlington: Diagnostic & Statistical Manual of Mental Disorders
Pica
A) Persistent eating of nonnutritive, nonfood substances over a period of at least 1 month
B) The eating of these substances is inappropriate to the developmental level of the
individual
C) Eating behaviour is not part of a culturally supported/socially normative practice
D) If the eating behaviour occurs in the context of another mental disorder (e.g.,
intellectual disability/intellectual developmental disorder, autism spectrum disorder,
schizophrenia) or medical condition (including pregnancy), it is sufficiently severe to
warrant additional clinical attention
Rumination
A) Repeated regurgitation of food over a period of at least 1 month. Regurgitated food
may be rechewed, re-swallowed, or spit out
B) Repeated regurgitation is not attributable to an associated gastrointestinal or other
medical condition
C) The eating disturbance does not occur exclusively during the course of anorexia
nervosa, bulimia nervosa, binge-eating disorder, or avoidant/restrictive food intake
disorder
D) If symptoms occur in the context of another mental disorder (e.g., intellectual
disability or another neurodevelopmental disorder), they are sufficiently severe to
warrant additional clinical attention
Specify if:
In remission: after full criteria for rumination were previously met, the criteria have
not been met for a sustained period of time
Avoidant/Restrictive Food Intake Disorder
A) An eating/feeding disturbance (e.g., apparent lack of interest in eating/food, avoidance
based on sensory characteristics of food, concern about aversive consequences of
eating) associated with one (or more) of the following:
Significant weight loss (or failure to achieve expected weight gain or faltering
growth in children)
Significant nutritional deficiency
Dependence on eternal feeding (tube feeding) or oral nutritional supplements
Marked interference with psychosocial functioning
B) The disturbance is not better explained by lack of available food or by an associated
culturally sanctioned practice
C) The eating disturbance does not occur exclusively during the course of anorexia
nervosa/bulimia nervosa, and there is no evidence of a disturbance in the way in
which one’s body weight/shape is experienced
D) The eating disturbance is not attributable to a concurrent medical condition or not
better explained by another mental disorder. When the eating disturbance occurs in
, the context of another condition or disorder, the severity of the eating disorder
exceeds that routinely associated with the condition/disorder and warrants additional
clinical attention
Anorexia Nervosa
A) Restriction of energy intake relative to requirements, leading to a significantly low
body weight in the context of age, sex, developmental trajectory, and physical health.
Significantly low weight is defined as a weight that is less than minimally normal or,
for children and adolescents, less than that minimally expected
B) Intense fear of gaining weight or of becoming fat, or persistent behaviour that
interferes with weight gain, even though at a significantly low weight
C) Disturbance in the way in which one’s body weight/shape is experienced, undue
influence of body weight/shape on self-evaluation, or persistent lack of recognition of
the seriousness of the current low body weight
Subtypes:
Restricting type: during the last 3 months, the individual has not engaged in recurrent
episodes of binge-eating/purging behaviour. This subtype describes presentations in
which weight loss is accomplished mostly through dieting, fasting and/or excessive
exercise
Binge-eating/purging type: during the last 3 months, the individual has engaged in
recurrent episodes of binge-eating/purging behaviour
Specify current severity:
The minimum level of severity is based, for adults, on current body mass index (BMI)
or, for children & adolescents, on BMI percentile
Mild = BMI ≥ 17kg/m2
Moderate = BMI 16-16.99kg/m2
Severe = BMI 15-15.99 kg/m2
Extreme = BMI ¿ 15kg/m2
Subtypes
Most people with binge-eating/purging type of AN binge eat & also purge, some do
not binge eat but do regularly purge after the consumption of small amounts of food
Crossover between the subtypes over the course of the disorder is not uncommon;
therefore, subtype description should be used to describe current symptoms rather
than longitudinal course
Diagnostic Features
Criterion A requires that individual’s weight be significantly low – BMI. Adults who
are not underweight should not be assigned diagnosis of AN
Criterion B: intense fear of gaining weight/becoming fat. This fear is not alleviated
by weight loss, concern about weight gain may actually increase even as weight falls
Criterion C: experience & significance of body weight/shape are distorted. Some feel
overweight, others realize they are thin, but still concerned certain body parts are ‘too
fat’. Frequent weighing, obsessive measuring of body parts, persistent use of mirror to
check for perceived areas of ‘fat’. Self-esteem is highly dependent on their
, perceptions of body shape & weight. Weight loss is viewed as impressive
achievement and sign of self-discipline, weight gain is seen as unacceptable failure of
self-control. Some may acknowledge being thin, but they don’t recognize serious
medical implications of their malnourished state
Associated Features
Semistarvation & purging behaviours sometimes associated with AN
Nutritional compromise affects most major organ systems
Most physiological disturbances associated with malnutrition are reversible with
nutritional rehabilitation. But some, like loss of bone mineral density, are not
completely reversible
When seriously underweight, patients can have depressive signs: depressed mood,
social withdrawal, irritability, insomnia, diminished interest in sex
Obsessive-compulsive features, both related & unrelated to food. Most people with
AN are preoccupied with thoughts of food. Some collect recipes or hoard food.
Obsessions & compulsions related to food may be exacerbated by undernutrition.
Concerns about eating in public, feelings of ineffectiveness, strong desire to control
one’s environment, inflexible thinking, limited social spontaneity and overly
restrained emotional expression
Compared to AN restricting type, those with binge-eating/purging type have higher
rates of impulsivity and are more likely to abuse alcohol & drugs
Some show excessive levels of physical activity, accelerates weight loss. During
treatment, excessive activity may be difficult to control, thereby jeopardizing weight
recovery
May misuse medications, e.g., manipulating dosage, to achieve weight loss/avoid
weight gain
Prevalence
Higher rates in women than in men
Most prevalent in post industrialized, high-income countries
Development & Course
AN usually begins during adolescence/young adulthood. Rarely begins before puberty
or after age 40
Onset is associated with stressful life event, e.g., leaving home for college
Younger individuals may manifest atypical features, including denying ‘fear of fat’
Older individuals more likely to have a longer duration of illness, and their clinical
presentation may include more signs & symptoms of long-standing disorders
Most experience remission within 5 years
Death most commonly results from medical complications from the disorder or from
suicide
Risk & Prognostic Factors
Temperamental: those who develop anxiety disorders/display obsessional traits in
childhood are at increased risk for developing anorexia nervosa
Environmental: occupations that encourage thinness, like modeling & elite athletics,
associated with increased risk
Genetic & Physiological: increased risk among biological relatives
Association with suicidal thoughts/behaviour:
