EATING DISORDERS

Anorexia Nervosa

People with anorexia nervosa experience physical, emotional, and behavioral symptoms. Physically, they are exceedingly underweight, and are not at the expected weight for their age and height. They may have abnormal blood counts, irregular heart rhythms and low blood pressure, which can lead to fatigue, dizziness, or sometimes fainting. Due to the irregularities in their body, the individual may experience thinning of their hair, bluish discoloration in fingers, dry and yellowish skin, intolerance of the cold, dehydration, swelling of arms and legs, eroded teeth, constipation, and loss of menstruation in women. Behaviorally, people with anorexia nervosa will restrict their food in different ways. Some diet and cut out specific foods, while others completely fast for some time. Other individuals might exercise excessively, whether it is along with dieting or not. Lastly, some people with anorexia nervosa may binge or purge which means that they might use laxative, enemas, diet aids, herbal products, or self induced vomiting. Further, people with anorexia are preoccupied with food. They may make elaborate meals for others, but then not eat it themselves. They might deny hunger or make excuses such as they have already eaten, or their stomach hurts. People with anorexia tend to eat only their “safe foods,” which are foods that are typically low in fat and calories. Individuals with anorexia also have certain rituals. They might have rituals surrounding meals, meaning they spit food out after it's chewed, or they might have certain body checks to make sure they have not gained any weight. Emotionally, many individuals with anorexia have a lack of emotion, and they are withdrawn, irritable, and have a reduced interest in sex. In order to diagnose an individual with anorexia nervosa, a medical professional must perform many tests and exams, so that other disorders can be ruled out. For example, a doctor would probably perform a physical exam, which would look at the individual’s height, weight, heart rate, blood pressure, temperature, nails, skin, heart, lungs, and abdomen. Once this is done, multiple lab tests are completed. One for a complete blood count (CBC), another for electrolyte and protein levels, and more for liver, kidney, and thyroid function. Next, a doctor will complete a psychological evaluation to determine the individual’s thoughts, feelings, and eating habits. The doctor may ask the individual to fill out a self-assessment questionnaire. Depending on the severity, other tests such as x-rays (for bone density, pneumonia, and heart problems) and electrocardiograms (for heart irregularities) may be done.

Bulimia Nervosa 

Some symptoms of bulimia nervosa are similar to anorexia nervosa in the sense that the individual is very preoccupied with their body shape and weight, and they have a very intense fear of gaining weight. Though similar, an individual who has bulimia nervosa will include some different symptoms. For example, there might be repeated times when the individual eats abnormally large amounts of food in a sitting. They also don't feel in control over what and how much they eat while they are bingeing. Because of this, after a bingeing episode, the individual might feel uncomfortably full and potentially guilty or shameful. The individual then forces themselves to vomit or exercise too much. People with bulimia might also use laxatives, herbal supplements, diuretics or enemas after eating, even though they do not need them. The reason people with bulimia might use these different medications is because they believe it to be a compensation for the amount of food they may have eaten during a binge. Most of the time, people who are bulimic fast and restrict their food intake in between binges. In order to be diagnosed with bulimia, a medical professional needs to conduct a variety of tests. Similarly to the way someone is texted for anorexia, a medical professional would conduct a physical exam, blood and urine test, an electrocardiogram, and a psychological exam.

Binge-Eating Disorder 

There are many behavioral and emotional signs and symptoms that an individual with binge eating disorder may have. For instance, someone with binge eating disorder might eat abnormally large amounts of food, at a quick pace, even if they are full. They might also feel depressed, ashamed or guilty after bingeing, and eat alone. Sometimes people with binge eating disorder will attempt to diet in between bingeing episodes, even though sometimes there is no weight loss. Similarly to the way someone is texted for anorexia or bulimia, a medical professional would conduct a physical exam, blood and urine test, an electrocardiogram, and a psychological exam. For people with binge eating disorder, a doctor may also conduct a sleep disorder consultation. This is because people with sleep disorders experience sleep deprivation, which hinders hormones that control appetite. If hormones that control appetite are not working properly, then an individual’s impulse control and food choice is also affected. 

Other Specified Feeding or Eating Disorder (OSFED) 

People with other specified feeding or eating disorders have many different physical, psychological, and behavioral symptoms. Some physical symptoms that someone has OSFED is that there is a fluctuation in their body weight, they are getting sick more than usual, they have swelling in their cheeks and jaw, bad breath, and they often feel faint or dizzy. Psychologically, many people are exceedingly preoccupied with eating, dieting, exercising, and/or their body image. Someone with OSFED might also be highly sensitive to comments surrounding food, eating, dieting, and body image. They might feel guilty after eating, have low self-esteem, and feel more depressed, anxious, and irritable. Behaviorally, individuals with OSFED spend a lot of time dieting and counting calories. They are also very secretive about food. For instance, people with OSFED tend to eat alone, hide food for bingeing, and say they’ve eaten when they have not. They might also make themselves vomit, but less than someone with bulimia. Lastly, someone with OSFED might have rituals, similar to other eating disorders, like checking the mirror, doing “body checks,” and weighing themselves. While these symptoms may sound similar to other eating disorders, individual's with OSFED experience less severe, and less overall, symptoms than individuals with anorexia nervosa , bulimia nervosa, and bing-eating disorder. Though this is true, someone is tested for OSFED pretty much the same way as other eating disorders. The same tests and exams are conducted order to determine this individual's overall health, but especially to ensure that the individual should not be diagnosed with a more severe eating disorder. 

Avoidant/Restrictive Food Intake Disorder

Individuals who have avoidant/restrictive food intake disorder tend to be a really picky eater. They may refuse to eat certain foods, or lack appetite. Physically, people with avoidant/restrictive food intake disorder might experience a delay in their growth or loss in their weight. 

Rumination Disorder

Individuals who have rumination disorder experience repeated regurgitation of their food. Physically, they may have lost weight, although it is unintentional. 

DSM-5 Criteria for Anorexia Nervosa

A) Restriction of energy intake relative to requirements, leading to a significant low body weight in the context of the 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 becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight.

C) Disturbance in one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight. 

Coding note: The ICD-9-CM code for anorexia nervosa is 307.1, which is assigned regardless of the subtype. The ICD-10-CM code depends on the subtype (see below). 

(F50.01) Restricting type: During the last 3 months, the individual has not engages in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise. 

(F50.02) Binge-eating/purging type: During the last 3 months, the individual has engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). 

Specify if: 

In partial remission: After a full criteria for anorexia nervosa were previously met, Criterion A (low body weight) has not been met for a sustained period, but either Criterion B (intense fear of gaining weight or becoming fat or behavior that interferes with weight gain) or Criterion C (disturbances in self-perception of weight and shape) is still met. 

In full remission: After full criteria for anorexia nervosa were previously met, none of the criteria have been met for a sustained period of time. 

Specify current severity: 

The minimum level of severity is based, for adults, on current body mass index (BMI) (see below) or, for children and adolescents, on BMI percentile. The ranges below are derived from World Health Organization categories for thinness in adults; for children and adolescents, corresponding BMI percentiles should be used. The level of severity may be increased to reflect clinical symptoms, the degree of functional disability and the need for supervision. 

Mild: BMI ≥ 17 kg/m^2

Moderate: BMI 16-16.99 kg/m^2

Severe: BMI 15-15.99 kg/m^2

Extreme: BMI < 15 kg/m^2

DSM-5 Criteria for Bulimia Nervosa 

A) Recurrent episodes of binge eating, as characterized by both:

1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances. 
2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).

B) Recurrent inappropriate compensatory behaviors in order to prevent weight gain such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting or excessive exercise.

C) The binge eating and inappropriate compensatory behaviors occur, on average, at least once a week for 3 months.

D) Self-evaluation is unjustifiably influenced by body shape and weight.

E) The disturbance does not occur exclusively during episodes of anorexia nervosa.

Specify if: 

Partial remission: After full criteria were previously met, some but not all of the criteria have been met for a sustained period of time.

Full remission: After full criteria were previously met, none of the criteria have been met for a sustained period of time.

Specify current severity: 

The minimum level of severity is based on the frequency of inappropriate compensatory behaviors (see below). The level of severity may be increased to reflect other symptoms and the degree of functional disability. 

Mild: An average of 1–3 episodes of inappropriate compensatory behaviors per week.

Moderate: An average of 4–7 episodes of inappropriate compensatory behaviors per week.

Severe: An average of 8–13 episodes of inappropriate compensatory behaviors per week.

Extreme: An average of 14 or more episodes of inappropriate compensatory behaviors per week.

DSM-5 Criteria for Binge-Eating Disorder 

A) Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: 

1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most people would eat in a similar period of time under similar circumstances. 
2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).

B) The binge-eating episodes are associated with three (or more) of the following: 

1. Eating much more rapidly than normal. 
2. Eating until uncomfortably full. 
3. Eating large amounts of food when not feeling physically hungry. 
4. Eating alone because of feeling embarrassed by how much one is eating. 
5. Feeling disgusted with oneself, depressed, or very guilty afterward. 

C) Marked distress regarding binge eating is present. 

D) The binge eating occurs, on average, at least once a week for 3 months. 

E) The binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa. 

Specify if: 

In partial remission: After full criteria for binge-eating disorder were previously met, binge eating occurs at an average frequency of less than one episode per week for a sustained period of time. 

In full remission: After full criteria for binge-eating disorder were previously met, none of the criteria have been met for a sustained period of time. 

Specify current severity: 

The minimum level of severity is based on the frequency of episodes of binge eating (see below). The level of severity may be increased to reflect other symptoms and the degree of functional disability. 

Mild: 1-3 binge-eating episodes per week. 

Moderate: 4-7 binge-eating episodes per week. 

Severe: 8-13 binge-eating episodes per week.

Extreme: 14 or more binge-eating episodes per week. 

DSM-5 Criteria for OSFED

This category applies to presentations in which symptoms characteristic of a feeding and eating disorder that cause clinically significant distress or impairment in social, occupational, or any of the disorders in the feeding and eating disorder diagnostic class. The other specified feeding or eating disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific feeding and eating disorder. This is done by recording “other specified feeding or eating disorder” followed by the specific reason (e.g., “bulimia nervosa of low frequency”). 

Examples of presentations that can be specified using the “other specified” designation include the following: 

1. Atypical anorexia nervosa: All of the criteria for anorexia nervosa are met, except that despite significant weight loss, the individual’s weight is within or above the normal range.
2. Bulimia nervosa (of low frequency and/or limited duration): All of the criteria for bulimia nervosa are met, except that the binge eating and inappropriate compensatory behaviors occur, on average, less than once a week and/or for less than 3 months. 
3. Binge-eating disorder (of low frequency and/or limited duration): all of the criteria for binge-eating disorder are met, except that the binge eating occurs, on average, less than once a week and/or for less than 3 months. 
4. Purging disorder: recurrent purging behavior to influence weight or shape (e.g., self-induced vomiting; misuse of laxatives, diuretics, or other medications) in the absence of binge eating. 
5. Night eating syndrome: recurrent episodes of night eating, as manifested by eating after awakening from sleep or by excessive food consumption after the evening meal. There is awareness and recall of the eating. The night eating is not better explained by external influences such as changes in the individual’s sleep-wake cycle or by local social norms. The night eating causes significant distress and/or impairment in functioning. The disordered pattern of eating is not better explained by binge-eating disorder or another mental disorder, including substance use, and is not attributable to another medical disorder to an effect of medication.

DSM-5 for Avoidant/Restrictive Food Intake Disorder: 

A) An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following: 

1. Significant weight loss (or failure to achieve expected weight gain or faltering growth in children). 
2. Significant nutritional deficiency. 
3. Dependence on enteral feeding or oral nutritional supplements. 
4. 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 or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or 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 disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention. 

Specify if: 

In remission: After full criteria for avoidant/restrictive food intake disorder were previously met, the criteria have not been met for a sustained period of time. 

DSM-5 for Rumination Disorder: 

A) Repeated regurgitation of food over a period of at least 1 month. Regurgitated food may be re-chewed, re-swallowed, or spit out. 

B) The repeated regurgitation is not attributed to an associated gastrointestinal or other medical condition (e.g., gastroesophageal reflux, pyloric stenosis). 

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 the symptoms occur in the context of another mental disorder (e.g., intellectual disability [intellectual developmental disorder] or another neurodevelopmental disorder), they are sufficiently severe to warrant additional clinical attention. 

Specify if: 

In remission: After a full criteria for rumination disorder were previously met, the criteria have not been met for a sustained period of time.