Have you heard the term eating disorder? Have you lived through this disease yourself or know someone currently working through recovery? Whatever the situation is that brought you to this blog, I’m happy to explain to you the basics on what an eating disorder is and the different types listed in the “Feeding and Eating Disorders” section of the Diagnostic Statistical Manual, 5th Edition (DSM-V, 2013) and it’s newest version, the Text Revisition (DSM-V-TR, 2022).
First let me define what an eating disorder (ED) is: it’s a condition psychological, social, and biological in nature characterized by eating behaviors that affect physical and mental wellbeing. Untreated, they can cause serious harm. Health consequences include, but not limited to, gastrointestinal tract disturbances such as gastroparesis, constipation, diarrhea, nausea and bloating, tooth decay, exacerbated co-occurring mental health conditions like anxiety and depression, disturbances in hormone health, poor blood sugar regulation, weight changes, and negative changes in hair, skin and nails. Someone may have disordered eating and not quite meet criteria for a specific eating disorder or have great enough physical effects to qualify. (However, sometimes this can be a barrier to treatment where early detection and treatment greatly increases the success of recovery, so ruling in an ED is an important practice.) EDs can present one at a time, morph one into another over time, or can occur in multiples. It’s very common for EDs to present in tandem with other mental health conditions like anxiety, depression, obsessive compulsive disorder (OCD), substance use disorder (SUD), or personality disorder.
Anorexia Nervosa
Anorexia Nervosa (AN) is characterized by an obsession with food restrictions and body image disturbances generally resulting in weight loss and other health consequences congruent with malnourishment. AN ranks in severity by BMI: mild > 17 kg/m2, moderate 16-16.99 kg/m2, severe 15-15.99 kg/m2, and extreme < 15 kg/m2. ANYONE at ANY SIZE can be experiencing signs/symptoms and using behaviors associated with AN, the diagnosis may just be a bit different if BMI criteria is not met. I personally dislike the diagnosis of atypical anorexia, a type of Other Specified Feeding or Eating Disorder (OSFED), which I’ll explain later in this blog, that rules in AN for folks that do not meet the BMI criteria of AN. Identifying AN as atypical can create bias around what should be considered appropriate for AN and pushes for BMI to be an accurate marker of health, where in reality it is not for various reasons– I could write a whole blog post on BMI itself.
The two subtypes of AN are restricting type and binge eating/purging type. The first is categorized by the presence of weight loss in the last three months through means of exercise and food restriction via dieting, limiting types and amount of food consumed, and fasting. The second subtype includes individuals that over the last three months have engaged in purging and/or binging with resulting weight loss or meeting a low BMI.
Bulimia Nervosa
Bulimia Nervosa (BN) involves binging then using compensatory behaviors (purging) to get rid of consumed calories and also includes body image disturbances and preoccupation with weight. Levels of severity for BN range from mild to extreme, varying in frequency of binge/purge episodes per week over at least a three month time frame. The DSM-V-TR defines a binge as (a) “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” and (b) feeling “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)”. It’s important as practitioners and patients to recognize that the way bingeing is defined is very objective, and everyone’s experience is unique and there are many layers to binging that make it subjective, so in out the possibility of BN will help someone find the right care and treatment.
Binge Eating Disorder
Binge Eating Disorder, or BED, is the most common ED. It’s categorized by binging, the same criteria for binging as in BN, along with three or more of the following being met: taking large bites and/or pacing quickly, eating until uncomfortably full, eating even when physically full, hiding or eating alone (types and amount of food) out of shame, and feeling “disgusted”, “guilty”, or “depressed” after episodes. There is also a level of severity with this disorder, ranging from mild (1-3 binges per week) to extreme (14 or more binges per week), over a period of three months. From my clinical observation, weight changes may or may not be associated with BED, but negative body image and preoccupation with weight are more often than not present.
Avoidant Restrictive Food Intake Disorder
Avoidant Restrictive Food Intake Disorder, well known as ARFID, is a new diagnosis to the DSM-V and DSM-V-TR. This disorder may present with similar signs/symptoms and health consequences as AN, and sometimes is misdiagnosed, but restrictions are related to texture, taste, and/or adverse consequences such as choking, gagging, nausea or vomiting. ARFID does not have the same body image distress association as AN, but sometimes discomfort with one's body occurs because weight restoration is typically necessary to achieve full recovery. ARFID may be diagnosed in early childhood or go undetected and found later in life.
Pica and Rumination Disorder
I’ve decided to chunk these two together as they are less common disorders than the first three and their characteristics are quite straight forward. Left untreated, these conditions could still result in health consequences similar to any other ED.
Pica refers to the consumption of nonnutritive substances at a level that is not normal for the individual’s age and intellectual level, occurring for one month or more, and is not a normal eating practice.
Rumination disorder refers to the regurgitation of food, either swallowed, rechewed, or spit out, over a period of one month, and is not due to a gastrointestinal disorder such as acid reflux.
Other Specified Feeding or Eating Disorder
Well known as OSFED, this disorder is sort of a catch all for folks that meet criteria for an ED but their behaviors, health consequences, duration and frequency are not meeting one specific ED as listed above. The different subtypes of OSFED include:
Atypical Anorexia Nervosa - all criteria for AN is met except low BMI
Bulimia Nervosa (of low frequency and/or limited duration)
Purging Disorder
Night Eating Syndrome
Unspecified Feeding or Eating Disorder
This diagnosis (UFED) can be given to individuals that do not meet criteria for any of the above specific EDs. It allows a clinician to diagnose an individual with an ED without providing specific reasons for it, and lacks clear evidence. Per the DSM-V-TR, an accurate use of this diagnosis could be in the emergency room.
Other: Body Dysmorphic Disorder and Orthorexia Nervosa
These two disorders were formally recognized in the DSM-V (ON was not identified in the TR edition) under Other. Hopefully in future additions they will have their own sections, as they warrant the same attention as the above disorders.
Body Dysmorphic Disorder includes body checking behaviors and hyper fixation on specific body parts through the use of mirrors, pictures, excessive grooming, and/or pinching skin as an individual sees certain flaws that are not rational or perceived by another. Body image disturbances may have nothing to do with weight or BMI, but rather specific physique. Muscle dysmorphia is a subcategory of this that requires specification when present.
Orthorexia Nervosa (ON) is categorized by “healthy” eating, met through a set of food rules defined by the individual, that interferes with everyday life as hyper fixation on food choices causes emotional distress if “healthy” food choices are not met and/or “unhealthy” food choices are consumed. Weight loss may occur due to restrictions but is not the primary focus like in AN. ON was identified in the DSM-V, but not listed in the DSM-5-TR edition. However, awareness of ON affecting day-to-day life similar to the above ED diagnoses is growing and allowing practitioners to identify this in their patients’ relationship with food.
Have questions after reading this blog? Are you, or someone you know, ready to start treatment for their eating disorder or disordered eating? Reach out to us today at Enhance Nutrition to get started in healing your relationship with food, weight, body, and movement.
Resources
https://www.mredscircleoftrust.com/storage/app/media/DSM%205%20TR.pdf
https://insideoutinstitute.org.au/assets/dsm-5%20criteria.pdf
https://www.sciencedirect.com/science/article/abs/pii/S1471015315300362?via%3Dihub