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:
- a person of average weight who does
not have binge eating episodes, but
frequently engages in self-induced
vomiting for fear of gaining weight
- all of the features of Anorexia
Nervosa in a female except absence of
menses
- all of the features of Bulimia
Nervosa except the frequency of binge
eating episodes
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