EATING DISORDERS
This subclass of disorders is characterized by gross disturbances in eating
behavior; it includes Anorexia Nervosa, Bulimia Nervosa, Pica, and Rumination
Disorder of Infancy. Anorexia Nervosa and Bulimia Nervosa are apparently
related disorders, typically beginning in adolescence or early adult life. Pica and
Rumination Disorder of Infancy are primarily disorders of young children and are
probably unrelated to Anorexia Nervosa and Bulimia Nervosa.
Simple obesity is a physical disorder, and is not in this section since it is not
generally associated with any distinctly psychological or behavioral syndrome.
However, when there is evidence that psychological factors are of importance in
the etiology or course of a particular case of obesity, this can be indicated by
noting Psychological Factors Affecting Physical Condition.
Anorexia Nervosa
The essential features of this disorder are: refusal to maintain body weight over a
minimal normal weight for age and height; intense fear of gaining weight or
becoming fat, even though underweight; a distorted body image; and
amenorrhea (in females). (The term anorexia is a misnomer since loss of
appetite is rare.)
The disturbance in body image is manifested by the way in which the
person's body weight, size, or shape is experienced. People with this disorder
may they "feel fat," or that parts of their body are fat, when they are obviously
underweight or even emaciated. They are preoccupied with their body size and
usually dissatisfied with some feature of their physical appearance.
The weight loss is usually accomplished by a reduction in total food intake,
often with extensive exercising. Frequently there is also self-induced vomiting or
use of laxatives or diuretics. (In such cases Bulimia Nervosa may also be
present.)
The person usually comes to professional attention when weight loss (or
failure to gain expected weight) is marked. An example is weighing less than
85% of expected weight (85% is provided as an arbitrary but useful guide). By
the time the person is profoundly underweight, there are other signs, such as
hypothermia, bradycardia, hypotension, edema, lanugo (neonatal-like hair), and
a variety of metabolic changes. In most cases amenorrhea follows weight loss,
but it is not unusual for amenorrhea to appear before noticeable weight loss has
occurred.
Associated features. Some people with this disorder cannot exert continuous
control over their intended voluntary restriction of food intake and have bulimic
episodes (eating binges), often followed by vomiting. Many of these people also
have Bulimia Nervosa.
Other peculiar behaviors concerning food are common. For example, people
with Anorexia Nervosa often prepare elaborate meals for others, but tend to limit
themselves to a narrow selection of low-calorie foods. In addition, they may
hoard, conceal, crumble, or throw away food.
Most people with this disorder steadfastly deny or minimize the severity of
their illness and are uninterested in, or resistant to, therapy. Many of the
adolescents have delayed psychosexual development, and adults have a
markedly decreased interest in sex. Compulsive behavior, such as
hand-washing, may be present during the illness and may justify the additional
diagnosis of Obsessive Compulsive Disorder.
Age at onset. Age at onset is usually early to late adolescence, although it
can range from prepuberty to the early 30s (rare).
Sex ratio. This disorder occurs predominantly in females (95%).
Prevalence. Studies of samples from different populations have reported a
range of from I in 800 to as many as 1 in 100 females between the ages of 12
and 18.
Course. The course may be unremitting until death, episodic, or, most
commonly, consist of a single episode, with return to normal weight.
Impairment. The severe weight loss often necessitates hospitalization to
prevent death by starvation.
Complications. Follow-up studies indicate mortality rates of between 5% and
18%.
Familial pattern. The disorder is more common among sisters and mothers of
those with the disorder than among the general population. Several studies have
reported a higher than expected frequency of Major Depression and Bipolar
Disorder among first degree biologic relatives of people with Anorexia
Nervosa.
Predisposing factors. In some people the onset of illness is associated with a
stressful life situation. Many of these people are described as having been overly
perfectionist, "model children." About one-third of them are mildly overweight
before onset of the illness.
Differential diagnosis. In Depressive Disorders and certain physical
disorders, weight loss can occur, but there is no disturbance of body image or
intense fear of obesity.
In Schizophrenia there may he bizarre eating patterns; however, the full
syndrome of Anorexia Nervosa is rarely present; when it is, both diagnoses
should be given.
In Bulimia Nervosa (without associated Anorexia Nervosa) there may be a
fear of fatness, and weight loss may be substantial, but the weight does not fall
below a minimal normal weight. In some instances Anorexia Nervosa occurs in a
person with Bulimia Nervosa, in which case both diagnoses are given.
(Diagnostic Criteria for Anorexia Nervosa)
A. Refusal to maintain body weight over a minimal normal weight for age and
height, e.g., weight loss leading to maintenance of body weight 15% below
that expected; or failure to make expected weight gain during period of
growth, leading to body weight 15% below that expected.
B. Intense fear of gaining weight or becoming fat, even though
underweight.
C. Disturbance in the way in which one's body weight, size, or shape is
experienced, e.g., the person claims to "feel fat" even when emaciated,
believes that one area of the body is "too fat" even when obviously
underweight.
D. In females, absence of at least three consecutive menstrual cycles when
otherwise expected to occur (primary or secondary amenorrhea). (A woman
is considered to have amenorrhea if her periods occur only following
hormone, e.g., estrogen, administration.)
Bulimia Nervosa
The essential features of this disorder are: recurrent episodes of binge eating
(rapid consumption of a large amount of food in a discrete period of time); a
feeling of lack of control over eating behavior during the eating binges;
self-induced vomiting, use of laxatives or diuretics, strict dieting or fasting, or
vigorous exercise in order to prevent weight gain; and persistent overconcern
with body shape and weight. In order to qualify for the diagnosis, the person must
have had, on average, a minimum of two binge eating episodes a week for at
least three months.
Eating binges may be planned. The food consumed during a binge often has
a high caloric content, a sweet taste, and a texture that facilitates rapid eating.
The food is usually eaten as inconspicuously as possible, or secretly. The food is
usually gobbled down quite rapidly, with little chewing. Once eating has begun,
additional food may be sought to continue the binge. A binge is usually
terminated by abdominal discomfort, sleep, social interruption, or induced
vomiting. Vomiting decreases the physical pail) of abdominal distention, allowing
either continued eating or termination of the binge, and often reduces post-binge
anguish. In some cases vomiting may itself be desired, so that the person will
binge in order to vomit, or will vomit after eating a small amount of food. Although
eating binges may be pleasurable, disparaging self-criticism and a depressed
mood often follow.
People with Bulimia Nervosa invariably exhibit great concern about their
weight and make repeated attempts to control it by dieting, vomiting, or the use of
cathartics or diuretics. Frequent weight fluctuations due to alternating binges and
fasts are common. Often these people feel that their life is dominated by conflicts
about eating.
Associated features. Although most people with Bulimia Nervosa are within a
normal weight range, some may be slightly underweight, and others may be
overweight. A depressed mood that may be part of a Depressive Disorder is
commonly observed. Some people with this disorder are subject to Psychoactive
Substance Abuse or Dependence, most frequently involving sedatives,
amphetamines, cocaine, or alcohol.
Age at onset. The disorder usually begins in adolescence or early adult
life.
Course. The usual course, in clinic samples, is chronic and intermittent over
a period of many years. Usually the binges alternate with periods of normal
eating, or with periods of normal eating and fasts. In extreme cases, however,
there may be alternate binges and fasts, with no periods of normal eating.
Familial pattern. Frequently the parents of people with this disorder are
obese. Several studies have reported a higher than expected frequency of Major
Depression in first-degree biologic relatives of people with Bulimia Nervosa.
Impairment and complications. Bulimia Nervosa is seldom incapacitating,
except in a few people who spend their entire day in binge eating and vomiting.
Dental erosion is a common complication of the vomiting. Electrolyte imbalance
and dehydration can occur, and may cause serious physical complications, such
as cardiac arrhythmia�s and, occasionally, sudden death. Rare complications
include esophageal tears and gastric ruptures.
Prevalence and sex ratio. A recent study of college freshman indicated that
4.5% of the females and 0.4% of the males had a history of Bulimia.
Predisposing factors. There is some evidence that obesity in adolescence
predisposes to the development of the disorder in adulthood.
Differential diagnosis. In Anorexia Nervosa there is severe weight loss, but in
Bulimia Nervosa (without associated Anorexia Nervosa) the weight fluctuations
are rarely so extreme as to be life-threatening. In some instances Anorexia
Nervosa occurs in a person with Bulimia Nervosa, in which case both diagnoses
are given... In Schizophrenia there may be unusual eating behavior, but the full
syndrome of Bulimia Nervosa is rarely present; when it is, both diagnoses should
be given. In certain neuralgic diseases, such as epileptic equivalent seizures,
central nervous system tumors, KIuver-Bucy-like syndromes, and KIeme-Levin
syndrome, there are abnormal eating patterns, but the diagnosis of Bulimia
Nervosa is rarely warranted; when it is, both diagnoses should be given. Binge
eating is often a feature of Borderline Personality Disorder in females. If the full
criteria for Bulimia Nervosa are met, both diagnoses should be given.
(Diagnostic Criteria for Bulimia Nervosa)
A. Recurrent episodes of binge eating (rapid consumption of a large amount
of food in a discrete period of time).
B. A feeling of lack of control over eating behavior during the eating
binges.
C. The person regularly engages in either self-induced vomiting, use of
laxatives or diuretics, strict dieting or fasting, or vigorous exercise in order
to prevent weight gain.
D. A minimum average of two binge eating episodes a week for at least three
months.
E. Persistent overconcern with body shape and weight.
Pica
The essential feature is the persistent eating of a nonnutritive substance. Infants
with the disorder typically eat paint, plaster, string, hair, or cloth. Older children
may eat animal droppings, sand, insects, leaves, or pebbles. There is no
aversion to food.
Associated features. There are no regularly associated features.
Age at onset. Age at onset is usually from 12 to 24 months, but may be
earlier.
Course. Pica usually remits in early childhood, but may persist into
adolescence or, rarely, continue through adulthood.
Impairment. None.
Complications. Lead poisoning may result from the ingestion of paint or
paint-soaked plaster; hairball tumors may cause intestinal obstruction.
Toxoplasma or toxocara infections may follow ingestion of feces or dirt.
Predisposing factors. Mental Retardation, neglect, and poor supervision may
be predisposing factors.
Prevalence and sex ratio. Pica is rare in normal adults, but is occasionally
seen in young children, in persons with Mental Retardation, and in pregnant
females.
Familial pattern. No information.
Differential diagnosis. In Autistic Disorder, Schizophrenia, and certain physical
disorders, such as Kieme-Levin syndrome, nonnutritive substances may be
eaten. In such instances Pica should not be noted as an additional
diagnosis.
(Diagnostic Criteria for Pica)
A. Repeated eating of a nonnutritive substance for at least one month.
B. Does not meet the criteria for either Autistic Disorder, Schizophrenia, or
KIeme-Levin syndrome.
Rumination Disorder of Infancy
The essential feature of this disorder is repeated regurgitation of food, with
weight loss or failure to gain expected weight, developing after a period of normal
functioning. Partially digested food is brought up into the mouth without nausea,
retching, disgust, or associated gastrointestinal disorder. The food is then ejected
from the mouth or chewed and reswallowed. A characteristic position of straining
and arching the back, with the head held back, is observed. The infant makes
sucking movements with his or her tongue and gives the impression of gaining
considerable satisfaction from the activity.
Associated features. The infant is generally irritable and hungry between
episodes of regurgitation.
Age at onset. The disorder usually appears between 3 and 12 months of age.
In children with Mental Retardation, it occasionally begins later.
Course. The disorder is potentially fatal. A mortality rate from malnutrition as
high as 25% has been reported. In severe cases, although the infant is
apparently hungry and ingests large amounts of food, progressive malnutrition
occurs because regurgitation immediately follows the feedings spontaneous
remissions are thought to be common.
Impairment. If failure to gain expected weight or severe malnutrition
develops, developmental delays in all spheres often occur, and impairment can
be severe.
Complications. A frequent complication of this disorder is that the caretaker
becomes discouraged by failure to feed the infant successfully, and then
becomes alienated from the child. The noxious odor of the regurgitated material
may cause the caretaker to avoid the infant, which results in
understimulation.
Predisposing factors and familial pattern. No information.
Prevalence. The disorder is apparently very rare.
Sex ratio. The disorder is equally common in males and in females.
Differential diagnosis. Congenital anomalies, such as pyloric stenosis, or
infections of the gastrointestinal system, can cause regurgitation of food, and
need to be ruled out by appropriate physical examinations and laboratory
tests.
(Diagnostic Criteria for Rumination Disorder in Infancy)
A. Repeated regurgitation, without nausea or associated gastrointestinal
illness, for at least one month following a period of normal functioning.
B. Weight loss or failure to make expected weight gain.
Eating Disorder Not Otherwise Specified
Disorders of eating that do not meet the criteria for a specific Eating
Disorder.
Examples:
(1) a person of average weight who does not have binge eating
episodes, but frequently engages in self-induced vomiting for fear of
gaining weight
(2) all of the features of Anorexia Nervosa in a female except absence
of menses
(3) all of the features of Bulimia Nervosa except the frequency of binge
eating episodes
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This subclass of disorders is characterized by gross disturbances in eating behavior; it includes Anorexia Nervosa, Bulimia Nervosa, Pica, and Rumination Disorder of Infancy. Anorexia Nervosa and Bulimia Nervosa are apparently related disorders, typically beginning in adolescence or early adult life. Pica and Rumination Disorder of Infancy are primarily disorders of young children and are probably unrelated to Anorexia Nervosa and Bulimia Nervosa.
Simple obesity is a physical disorder, and is not in this section since it is not generally associated with any distinctly psychological or behavioral syndrome. However, when there is evidence that psychological factors are of importance in the etiology or course of a particular case of obesity, this can be indicated by noting Psychological Factors Affecting Physical Condition.
Anorexia Nervosa
The essential features of this disorder are: refusal to maintain body weight over a minimal normal weight for age and height; intense fear of gaining weight or becoming fat, even though underweight; a distorted body image; and amenorrhea (in females). (The term anorexia is a misnomer since loss of appetite is rare.)
The disturbance in body image is manifested by the way in which the person's body weight, size, or shape is experienced. People with this disorder may they "feel fat," or that parts of their body are fat, when they are obviously underweight or even emaciated. They are preoccupied with their body size and usually dissatisfied with some feature of their physical appearance.
The weight loss is usually accomplished by a reduction in total food intake, often with extensive exercising. Frequently there is also self-induced vomiting or use of laxatives or diuretics. (In such cases Bulimia Nervosa may also be present.)
The person usually comes to professional attention when weight loss (or failure to gain expected weight) is marked. An example is weighing less than 85% of expected weight (85% is provided as an arbitrary but useful guide). By the time the person is profoundly underweight, there are other signs, such as hypothermia, bradycardia, hypotension, edema, lanugo (neonatal-like hair), and a variety of metabolic changes. In most cases amenorrhea follows weight loss, but it is not unusual for amenorrhea to appear before noticeable weight loss has occurred.
Associated features. Some people with this disorder cannot exert continuous control over their intended voluntary restriction of food intake and have bulimic episodes (eating binges), often followed by vomiting. Many of these people also have Bulimia Nervosa.
Other peculiar behaviors concerning food are common. For example, people with Anorexia Nervosa often prepare elaborate meals for others, but tend to limit themselves to a narrow selection of low-calorie foods. In addition, they may hoard, conceal, crumble, or throw away food.
Most people with this disorder steadfastly deny or minimize the severity of their illness and are uninterested in, or resistant to, therapy. Many of the adolescents have delayed psychosexual development, and adults have a markedly decreased interest in sex. Compulsive behavior, such as hand-washing, may be present during the illness and may justify the additional diagnosis of Obsessive Compulsive Disorder.
Age at onset. Age at onset is usually early to late adolescence, although it can range from prepuberty to the early 30s (rare).
Sex ratio. This disorder occurs predominantly in females (95%).
Prevalence. Studies of samples from different populations have reported a range of from I in 800 to as many as 1 in 100 females between the ages of 12 and 18.
Course. The course may be unremitting until death, episodic, or, most commonly, consist of a single episode, with return to normal weight.
Impairment. The severe weight loss often necessitates hospitalization to prevent death by starvation.
Complications. Follow-up studies indicate mortality rates of between 5% and 18%.
Familial pattern. The disorder is more common among sisters and mothers of those with the disorder than among the general population. Several studies have reported a higher than expected frequency of Major Depression and Bipolar Disorder among first degree biologic relatives of people with Anorexia Nervosa.
Predisposing factors. In some people the onset of illness is associated with a stressful life situation. Many of these people are described as having been overly perfectionist, "model children." About one-third of them are mildly overweight before onset of the illness.
Differential diagnosis. In Depressive Disorders and certain physical disorders, weight loss can occur, but there is no disturbance of body image or intense fear of obesity.
In Schizophrenia there may he bizarre eating patterns; however, the full syndrome of Anorexia Nervosa is rarely present; when it is, both diagnoses should be given.
In Bulimia Nervosa (without associated Anorexia Nervosa) there may be a fear of fatness, and weight loss may be substantial, but the weight does not fall below a minimal normal weight. In some instances Anorexia Nervosa occurs in a person with Bulimia Nervosa, in which case both diagnoses are given.
(Diagnostic Criteria for Anorexia Nervosa)
A. Refusal to maintain body weight over a minimal normal weight for age and height, e.g., weight loss leading to maintenance of body weight 15% below that expected; or failure to make expected weight gain during period of growth, leading to body weight 15% below that expected.
B. Intense fear of gaining weight or becoming fat, even though underweight.
C. Disturbance in the way in which one's body weight, size, or shape is experienced, e.g., the person claims to "feel fat" even when emaciated, believes that one area of the body is "too fat" even when obviously underweight.
D. In females, absence of at least three consecutive menstrual cycles when otherwise expected to occur (primary or secondary amenorrhea). (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen, administration.)
Bulimia Nervosa
The essential features of this disorder are: recurrent episodes of binge eating (rapid consumption of a large amount of food in a discrete period of time); a feeling of lack of control over eating behavior during the eating binges; self-induced vomiting, use of laxatives or diuretics, strict dieting or fasting, or vigorous exercise in order to prevent weight gain; and persistent overconcern with body shape and weight. In order to qualify for the diagnosis, the person must have had, on average, a minimum of two binge eating episodes a week for at least three months.
Eating binges may be planned. The food consumed during a binge often has a high caloric content, a sweet taste, and a texture that facilitates rapid eating. The food is usually eaten as inconspicuously as possible, or secretly. The food is usually gobbled down quite rapidly, with little chewing. Once eating has begun, additional food may be sought to continue the binge. A binge is usually terminated by abdominal discomfort, sleep, social interruption, or induced vomiting. Vomiting decreases the physical pail) of abdominal distention, allowing either continued eating or termination of the binge, and often reduces post-binge anguish. In some cases vomiting may itself be desired, so that the person will binge in order to vomit, or will vomit after eating a small amount of food. Although eating binges may be pleasurable, disparaging self-criticism and a depressed mood often follow.
People with Bulimia Nervosa invariably exhibit great concern about their weight and make repeated attempts to control it by dieting, vomiting, or the use of cathartics or diuretics. Frequent weight fluctuations due to alternating binges and fasts are common. Often these people feel that their life is dominated by conflicts about eating.
Associated features. Although most people with Bulimia Nervosa are within a normal weight range, some may be slightly underweight, and others may be overweight. A depressed mood that may be part of a Depressive Disorder is commonly observed. Some people with this disorder are subject to Psychoactive Substance Abuse or Dependence, most frequently involving sedatives, amphetamines, cocaine, or alcohol.
Age at onset. The disorder usually begins in adolescence or early adult life.
Course. The usual course, in clinic samples, is chronic and intermittent over a period of many years. Usually the binges alternate with periods of normal eating, or with periods of normal eating and fasts. In extreme cases, however, there may be alternate binges and fasts, with no periods of normal eating.
Familial pattern. Frequently the parents of people with this disorder are obese. Several studies have reported a higher than expected frequency of Major Depression in first-degree biologic relatives of people with Bulimia Nervosa.
Impairment and complications. Bulimia Nervosa is seldom incapacitating, except in a few people who spend their entire day in binge eating and vomiting. Dental erosion is a common complication of the vomiting. Electrolyte imbalance and dehydration can occur, and may cause serious physical complications, such as cardiac arrhythmia�s and, occasionally, sudden death. Rare complications include esophageal tears and gastric ruptures.
Prevalence and sex ratio. A recent study of college freshman indicated that 4.5% of the females and 0.4% of the males had a history of Bulimia.
Predisposing factors. There is some evidence that obesity in adolescence predisposes to the development of the disorder in adulthood.
(Diagnostic Criteria for Bulimia Nervosa)
A. Recurrent episodes of binge eating (rapid consumption of a large amount of food in a discrete period of time).
B. A feeling of lack of control over eating behavior during the eating binges.
C. The person regularly engages in either self-induced vomiting, use of laxatives or diuretics, strict dieting or fasting, or vigorous exercise in order to prevent weight gain.
D. A minimum average of two binge eating episodes a week for at least three months.
E. Persistent overconcern with body shape and weight.
Pica
The essential feature is the persistent eating of a nonnutritive substance. Infants with the disorder typically eat paint, plaster, string, hair, or cloth. Older children may eat animal droppings, sand, insects, leaves, or pebbles. There is no aversion to food.
Associated features. There are no regularly associated features.
Age at onset. Age at onset is usually from 12 to 24 months, but may be earlier.
Course. Pica usually remits in early childhood, but may persist into adolescence or, rarely, continue through adulthood.
Impairment. None.
Complications. Lead poisoning may result from the ingestion of paint or paint-soaked plaster; hairball tumors may cause intestinal obstruction.
Toxoplasma or toxocara infections may follow ingestion of feces or dirt.
Predisposing factors. Mental Retardation, neglect, and poor supervision may be predisposing factors.
Prevalence and sex ratio. Pica is rare in normal adults, but is occasionally seen in young children, in persons with Mental Retardation, and in pregnant females.
Familial pattern. No information.
Differential diagnosis. In Autistic Disorder, Schizophrenia, and certain physical disorders, such as Kieme-Levin syndrome, nonnutritive substances may be eaten. In such instances Pica should not be noted as an additional diagnosis.
(Diagnostic Criteria for Pica)
A. Repeated eating of a nonnutritive substance for at least one month.
B. Does not meet the criteria for either Autistic Disorder, Schizophrenia, or KIeme-Levin syndrome.
Rumination Disorder of Infancy
The essential feature of this disorder is repeated regurgitation of food, with weight loss or failure to gain expected weight, developing after a period of normal functioning. Partially digested food is brought up into the mouth without nausea, retching, disgust, or associated gastrointestinal disorder. The food is then ejected from the mouth or chewed and reswallowed. A characteristic position of straining and arching the back, with the head held back, is observed. The infant makes sucking movements with his or her tongue and gives the impression of gaining considerable satisfaction from the activity.
Associated features. The infant is generally irritable and hungry between episodes of regurgitation.
Age at onset. The disorder usually appears between 3 and 12 months of age. In children with Mental Retardation, it occasionally begins later.
Course. The disorder is potentially fatal. A mortality rate from malnutrition as high as 25% has been reported. In severe cases, although the infant is apparently hungry and ingests large amounts of food, progressive malnutrition occurs because regurgitation immediately follows the feedings spontaneous remissions are thought to be common.
Impairment. If failure to gain expected weight or severe malnutrition develops, developmental delays in all spheres often occur, and impairment can be severe.
Complications. A frequent complication of this disorder is that the caretaker becomes discouraged by failure to feed the infant successfully, and then becomes alienated from the child. The noxious odor of the regurgitated material may cause the caretaker to avoid the infant, which results in understimulation.
Predisposing factors and familial pattern. No information.
Prevalence. The disorder is apparently very rare.
Sex ratio. The disorder is equally common in males and in females.
Differential diagnosis. Congenital anomalies, such as pyloric stenosis, or infections of the gastrointestinal system, can cause regurgitation of food, and need to be ruled out by appropriate physical examinations and laboratory tests.
(Diagnostic Criteria for Rumination Disorder in Infancy)
A. Repeated regurgitation, without nausea or associated gastrointestinal illness, for at least one month following a period of normal functioning.
B. Weight loss or failure to make expected weight gain.
Eating Disorder Not Otherwise Specified
Disorders of eating that do not meet the criteria for a specific Eating Disorder.
Examples:
(1) a person of average weight who does not have binge eating episodes, but frequently engages in self-induced vomiting for fear of gaining weight
(2) all of the features of Anorexia Nervosa in a female except absence of menses
(3) all of the features of Bulimia Nervosa except the frequency of binge eating episodes