The DSM is a highly debated and controversial topic and is widely regarded as not an accurate representation of what eating disorders are and can manifest. We here at the Joy Project believe it to be incredibly flawed, however we are presenting the diagnostic criteria for eating disorders as listed currently in the Diagnostic and Statistical Manual-5th Edition (DSM-V, released in 2013) here for informational purposes. Please note that not every eating disordered individual fits neatly into one diagnostic category or another, and that is ok. In reality, few people fit precisely into one category. Eating Disorders and their diagnostic criteria are listed in alphabetical order for this post.
Anorexia Nervosa
Anorexia Nervosa is an eating disorder characterized by deliberate restriction of energy intake relative to need, and in many people, distorted body image, and denial of severity of their behaviors. People with anorexia generally restrict the types and amounts of foods they eat, and may also exercise compulsively, purge, abuse laxatives/diuretics, and/or binge eat. You cannot tell if a person is struggling with anorexia by their bodily appearance. A person does not have to appear emaciated nor underweight to be struggling. This is a potentially life-threatening illness.
Diagnostic Criteria
- 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.
- Intense fear of gaining weight, or persistent behavior that interferes with weight gain, even though at a significantly low weight.
- Disturbance in the way in which one’s body weight or shape is experienced, self-evaluation is unduly influenced by body weight and/or shape, or persistent lack of recognition of the seriousness of the current low body weight.
What is Controversial About This:
- Not all people who restrict their food have a fear of weight gain. Sometimes, some people are embarrassed by weight fluctuations and struggle to maintain their weight.
- Focusing on a low weight disproportionately hurts those who start at a high weight. This means that someone who doesn’t lose weight nor become medically compromised may struggle with disordered eating for years without seeking help. This can be extremely detrimental to the person suffering!
- The DSM lists two subtypes of anorexia, one of them being binge-purge type. This subtype is behaviorally and psychologically identical to bulimia, however, focuses on a low weight as a differentiating criterion. Weight is your relationship to gravity, NOT a psychological measure of anything!
Avoidant/Restrictive Food Intake Disorder (ARFID)
ARFID is an eating disorder characterized by a restriction in the amount and/or types of food someone consumes due to fears surrounding the food itself. This may manifest as an avoidance of food due to sensory characteristics of the food (e.g. texture, color), fear of consequences of eating food (e.g. becoming violently ill), or an apparent lack of interest for eating the food(s). This life-threatening illness can drastically affect proper development and growth in children, and in the case of adults, may result in drastic weight loss.
Diagnostic Criteria
An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on sensory characteristics of food (e.g. texture, color); concern about aversive consequences of eating (e.g. fear of becoming violently ill)) as manifested by persistent failure to meet appropriate nutritional and/or energy needs 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 enteral feeding or oral nutritional supplements.
- Marked interference with psychosocial functioning.
- The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice.
- 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.
- 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.
What’s Controversial About This:
The addition of ARFID into the DSM is a positive change as it recognizes a large portion of the population of people struggling with eating disorders that deserve a different approach to treatment that focuses on the sensory aversion to food.
Bulimia Nervosa
Bulimia is an eating disorder characterized by a cycle of behaviors in which one binge eats and then uses compensatory behaviors, such as self-induced vomiting, excessive exercise, and/or the use of laxatives in an attempt to compensate for the binge behaviors. Like all eating disorders, Bulimia is a life-threatening illness. The use of binge and purge behaviors can be extremely harmful on the body for a variety of reasons.
Diagnostic Criteria
- Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
- 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. (This may be subjective: a substantial amount of food, and/or objective: a larger amount of food than one would eat regularly in a period of time)
- A sense of lack of control over eating during the episodes (e.g., a feeling that once cannot stop eating or control what or how much one is eating).
- Recurrent inappropriate compensatory behaviors in order to counteract the food consumption, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.
- The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months.
- Self-evaluation is unduly influenced by body shape and weight.
- The disturbance does not occur exclusively during episodes of anorexia nervosa.
What is Controversial About This:
ALL purging behavior, especially self-induced vomiting, is dangerous and a sign that you deserve treatment and support. You should not have to engage in purging behaviors for three months before it’s considered a problem.
The differentiation between Anorexia Binge-Purge subtype and Bulimia is ambiguous and not clearly defined and the behaviors and thought patterns are essentially the same.
Binge Eating Disorder
Binge Eating Disorder is an eating disorder characterized by recurrent episodes of binge eating, a feeling of loss of control during the binges, and often, feelings of shame, guilt and/or disgust following the bingeing behavior. It is a life-threatening illness. BED is the most common eating disorder diagnosis in the United States.
Diagnostic Criteria
Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
- 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. (This may be subjective: a substantial amount of food, and/or objective: a larger amount of food than one would eat regularly in a period of time)
- 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).
- The binge-eating episodes are associated with three (or more) of the following:
- Eating much more rapidly than normal.
- Eating until feeling uncomfortably full.
- Eating larger amounts of food when not feeling physically hungry.
- Eating alone because of feeling embarrassed by how much one is eating.
- Feeling disgusted with oneself, depressed, or very guilty after eating.
- Marked distress regarding binge eating is present.
- The binge eating occurs, on average, at least once a week for 3 months.
- The binge eating is not associated with the recurrent use of inappropriate compensatory behavior (e.g. purging) as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa.
What is Controversial About This:
Binge Eating Disorder is the most common eating disorder in America, and it wasn’t recognized in the DSM until Edition V. This has created a belief amongst many that it is not a legitimate eating disorder, and that is false and dangerous!
Orthorexia
Orthorexia is currently not formally recognized in the DSM, but it is an eating disorder that has been recognized widely since 1998. It is an eating disorder in which the person afflicted has an obsession with self-perceived ‘healthy eating.’ There is often an extreme fixation on the purity and perceived quality of food. Often, people with orthorexia become so fixated on their concept of ‘healthy-eating’ that it damages their own well-being (e.g. not being able to get other things done due to constant rumination, not eating at certain events because of kinds of food present)
Common Symptoms and Warning Signs of Orthorexia:
- Compulsive checking of nutritional labels and ingredient lists
- An increase in concern about the health of ingredients and foods
- An increased interest in the health of foods that others are eating
- Cutting out certain food groups based on perceived health level of them
- An inability to eat anything but a narrow list of foods that are deemed ‘healthy’ or ‘pure’ by the person struggling
- Spending hours of time thinking about what kinds of food will be at upcoming events
- Showing high levels of distress when ‘safe’ or ‘healthy’ foods aren’t available
- Body image concerns may or may not be present
What is Controversial About This:
Orthorexia is not officially defined in the DSM. It’s often used colloquially as an obsession with health to the point where it starts to become unhealthy. This type of mindset can be present with any eating disorder.
Other Specified Feeding or Eating Disorders (OSFED)
This category applies to presentations of eating/feeding disorders in which symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the feeding and eating disorders 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:
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.
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.
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.
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.
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 or to an effect of medication.
This category exists in the DSM because the other eating disorder categories are limiting and exclusive in their definitions! All eating disorders are valid and deserve recognition.
A lot of people assume that this category is reserved for less serious or severe eating disorder experiences, when in actuality, these can be just as serious as any other.
Pica
Pica is an eating disorder characterized by the consumption of nonfood items that do not contain significant nutritional value (e.g. paint chips, hair, styrofoam). Due to the nonfood characteristics of things being consumed, Pica can have damaging impacts on the body. Diagnostic Criteria- Persistent eating of nonnutritive, nonfood substances over the period of at least 1 month.
- The ingestion of the substance(s) is not a part of culturally supported or socially normative practice (e.g., some cultures promote eating clay as part of a medicinal practice).
- The eating of these substances must be developmentally inappropriate. In children under two years of age, mouthing objects—or putting small objects in their mouth—is a normal part of development, allowing the child to explore their senses. Mouthing may sometimes result in ingestion. In order to exclude developmentally normal mouthing, children under two years of age should not be diagnosed with pica.
- If the eating behavior occurs in the context of another mental disorder (e.g. intellectual disability, autism spectrum disorder) or medical condition (e.g. pregnancy), it is sufficiently severe to warrant additional clinical attention.
What is Controversial About This:
PICA is a well-defined disorder and its definition is widely accepted.
Unspecified Feeding or Eating Disorders (UFED)
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 other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the feeding and eating disorders diagnostic class. The unspecified feeding and eating disorder category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for a specific feeding and eating disorder, and includes presentations in which there is insufficient information to make a more specific diagnosis (e.g., in emergency room settings).
What is Controversial About This:
This category is not well defined, and thus, is not useful for treatment purposes.
The traditional eating disorder categories too rigidly define what is and is not a certain eating disorder, leaving a lot of disorders lumped together in ambiguous groupings (ie., OSFED). Many people who struggle with disordered eating may experience a variety of symptoms and eating disorder behaviors throughout the scope of their illness. People often float from one category to another over time.