Anorexia Nervosa: Symptoms and ICD Diagnostic Criteria

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The formal diagnosis of anorexia nervosa is defined by this set of symptoms, which can be evaluated by psychiatrists and other mental health professionals.

Diagnostic Guidelines

Differential diagnosis, anorexia nervosa according to the icd-10.

The following information is reproduced verbatim from the ICD-10 Classification of Mental and Behavioural Disorders, World Health Organization, Geneva, 1992. (Since the WHO updates the overall ICD on a regular basis, individual classifications within it may or may not change from year to year; therefore, you should always check directly with the WHO to be sure of obtaining the latest revision for any particular individual classification.) Also see the related diagnostic criteria for bulimia nervosa.

F50.0 Anorexia Nervosa

Anorexia nervosa is a disorder characterized by deliberate weight loss, induced and/or sustained by the patient. The disorder occurs most commonly in adolescent girls and young women, but adolescent boys and young men may be affected more rarely, as may children approaching puberty and older women up to the menopause. Anorexia nervosa constitutes an independent syndrome in the following sense:

  • the clinical features of the syndrome are easily recognized, so that diagnosis is reliable with a high level of agreement between clinicians;
  • follow-up studies have shown that, among patients who do not recover, a considerable number continue to show the same main features of anorexia nervosa, in a chronic form.

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Although the fundamental causes of anorexia nervosa remain elusive, there is growing evidence that interacting sociocultural and biological factors contribute to its causation, as do less specific psychological mechanism and a vulnerability of personality. The disorder is associated with undernutrition of varying severity, with resulting secondary endocrine and metabolic changes and disturbances of bodily function. There remains some doubt as to whether the characteristic endocrine disorder is entirely due to the undernutrition and the direct effect of various behaviours that have brought it about (e.g. restricted dietary choice, excessive exercise and alterations in body composition, induced vomiting and purgation and the consequent electrolyte disturbances), or whether uncertain factors are also involved.

For a definite diagnosis, all the following are required:

  • Body weight is maintained at least 15% below that expected (either lost or never achieved), or Quetelet’s body-mass index is 17.5 or less. Prepubertal patients may show failure to make the expected weight gain during the period of growth.
  • The weight loss is self-induced by avoidance of “fattening foods” and one or more of the following: self-induced vomiting; self-induced purging; excessive exercise; use of appetite suppressants and/or diuretics.
  • There is body-image distortion in the form of a specific psychopathology whereby a dread of fatness persists as an intrusive, overvalued idea and the patient imposes a low weight threshold on himself or herself.
  • A widespread endocrine disorder involving the hypothalamic-pituitary-gonadal axis is manifest in women as amenorrhoea and in men as a loss of sexual interest and potency. (An apparent exception is the persistence of vaginal bleeds in anorexic women who are receiving replacement hormonal therapy, most commonly taken as a contraceptive pill.) There may also be elevated levels of growth hormone, raised levels of cortisol, changes in the peripheral metabolism of the thyroid hormone, and abnormalities of insulin secretion.
  • If onset is prepubertal, the sequence of pubertal events is delayed or even arrested (growth ceases; in girls the breasts do not develop and there is a primary amenorrhoea; in boys the genitals remain juvenile). With recovery, puberty is often completed normally, but the menarche is late.

There may be associated depressive or obsessional symptoms, as well as features of a personality disorder, which may make differentiation difficult and/or require the use of more than one diagnostic code. Somatic causes of weight loss in young patients that must be distinguished include chronic debilitating diseases, brain tumors, and intestinal disorders such as Crohn’s disease or a malabsorption syndrome.

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All clinical material on this site is peer reviewed by one or more qualified mental health professionals. This specific article was originally published by MH Resource Research Staff on March 30, 2011 and was last reviewed or updated by Dr Greg Mulhauser, Managing Editor on February 15, 2016 .

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What Is Anorexia Nervosa?

Rachel Goldman, PhD FTOS, is a licensed psychologist, clinical assistant professor, speaker, wellness expert specializing in eating behaviors, stress management, and health behavior change.

anorexia nervosa icd 10 criteria

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Anorexia nervosa is an eating disorder that causes a person to restrict their food intake. They might try to avoid eating altogether, eat very small portions, and/or cut out certain foods and eat only a select few. A common feature of anorexia is an extreme fear of being overweight (even if they are underweight).

Anorexia typically begins in adolescents 15 years old or younger. The condition primarily affects girls and women. However, like other eating disorders, anorexia can affect people of all ages, genders, and racial/ethnic backgrounds. Worldwide, it's estimated that up to 4% of females and 0.3% of males experience anorexia.

It's important to recognize all of the warning signs and symptoms associated with anorexia . However, the symptoms often appear differently from person to person.

It should be noted that not all of these symptoms will be indicative of anorexia. Some people with anorexia may not display all, or even any, of these signs.

Symptoms may include:

  • Being underweight (sometimes severely)
  • Bingeing and purging (by vomiting or taking laxatives)
  • Constipation, bloating, and stomach pains
  • Dehydration
  • Distorted body image
  • Dizzy spells and faintness
  • Extreme tiredness (fatigue)
  • Extremely restrictive eating
  • Intense fear of gaining weight
  • Loss of periods or failure to begin a menstrual cycle
  • Loss or fluctuation of body fat and muscle
  • Poor circulation (constantly feeling cold)
  • Skin that is yellowed, dry, or covered in soft hair (lanugo)
  • Taking diet pills or aids
  • Talking about weight or food all the time
  • Suicidal thoughts or actions

If you are having suicidal thoughts, contact the  National Suicide Prevention Lifeline  at  988  for support and assistance from a trained counselor. If you or a loved one are in immediate danger, call 911.

For more mental health resources, see our  National Helpline Database .

People with anorexia may display specific behavioral symptoms, like refusing to eat in front of others, over-exercising to burn calories , or hiding their bodies in loose clothing. Some people also develop food rituals, such as cutting food into tiny pieces or rearranging food on a plate (to make it look like they've eaten more than they have).

Serious medical complications are associated with anorexia. It can cause malnutrition, low blood pressure, slowed breathing and pulse, and damage to the heart and heart function. It can also cause severe dehydration and electrolyte imbalances. In some cases, these symptoms are life-threatening.

One of the most harmful misconceptions about anorexia is that all people who struggle with it are severely underweight. While this may be true for some, many people with anorexia can appear to be in good health, when in actuality they are malnourished (deficient in important nutrients). Atypical anorexia is a term used to describe anorexia in people who aren't underweight.

According to the current edition of the "Diagnostic and Statistical Manual of Mental Disorders" (DSM-5), diagnostic criteria for anorexia includes:

  • Intense fear of gaining weight : People with anorexia typically fear weight gain and dread becoming "fat." This fear often manifests itself through depriving the body of food.
  • Food intake restriction : People with anorexia tend to eat less food than the body needs to function correctly. This may lead to significantly low body weight for the person's age and height.
  • Distorted body image : This has to do with a person's perception of their body size. People with anorexia often have exaggerated views of their bodies. They generally view themselves as overweight, even if they're dangerously underweight.

There are two subtypes of anorexia: the restricting type and the binge-eating/purging type.

People with the restricting subtype place severe restrictions on the amount and type of food they eat. Restrictive behaviors include counting calories, skipping meals, or eliminating certain foods (such as carbohydrates). These behaviors are sometimes coupled with excessive exercise.

Those with the binge-eating and/or purging subtype also restrict their food intake. In addition, they also regularly engage in binge eating or purging behaviors, such as self-induced vomiting or misuse of laxatives or diuretics, or both binge eating and purging.

Differential Diagnosis

Restricted food intake and subsequent weight loss can also be a sign of another mental health condition. Before diagnosing anorexia, a healthcare provider must also rule out the following conditions:

  • Avoidant/restrictive food intake disorder
  • Bulimia nervosa
  • Major depressive disorder
  • Schizophrenia
  • Social anxiety disorder or social phobia
  • Substance use disorder

There can also be medical causes for unexpected weight loss. Possible medical conditions to rule out include gastrointestinal disease and hyperthyroidism.

Some conditions, however, may also occur alongside anorexia. A healthcare provider will do a thorough review of both physical and mental health symptoms before making a diagnosis.

There isn't a definite cause of anorexia identified by experts, but research indicates a number of risk factors that people with anorexia often share.

Risk Factors

There are certain temperamental, environmental, and genetic factors that may play a role in the development of anorexia.

People with eating disorders may be perfectionists or high achievers. One study found that participants who were diagnosed with eating disorders tended to have emotional problems, distress, stress, unhappiness with their appearance, high expectations of themselves, and felt a lack of control.

People with anorexia may struggle with self-esteem . They may have other mental health conditions that contribute to their anorexia symptoms, such as obsessive-compulsive disorder (OCD) or social anxiety.

Environmental or cultural stressors may also play a role in the development of anorexia. For instance, people who play sports or do physical activities might feel more pressure to have a thin body. Societal pressure and weight stigma , especially as it's portrayed in the media when thin bodies are idealized, can also play a role in someone's fixation with having a thin body.

Environmental triggers combined with other risk factors can contribute to the development of anorexia and other eating disorders.

Research suggests that the development of anorexia is influenced by genetics as well. You may be more likely to have anorexia if someone in your family has it.

Treatment for anorexia nervosa can occur in a variety of settings. Though it can be extremely difficult for someone with anorexia to seek help (and difficult for loved ones to intervene), encouraging them to speak to a doctor is key. This could be the first step in eventual treatment and recovery.

Hospitalization

If a person with anorexia is in severe and life-threatening danger, immediate hospitalization may be required. Hospitalization is necessary to treat anorexia-related complications like disturbance to the heart rhythm, electrolyte imbalances, dehydration, or malnourishment.

A person with anorexia may also require psychiatric hospitalization if they are refusing to eat.

In some cases, people with anorexia are fed through a tube inserted through the nose (nasogastric tube) so they can receive the nutrients they need.

There are clinics available to people with eating disorders as well. There are inpatient programs (where a person stays in the hospital for a period of time) as well as outpatient programs (where patients can go for the day).

There aren't any medications specifically approved to treat anorexia. However, if symptoms don't improve with psychotherapy or nutritional rehabilitation, healthcare practitioners might prescribe an antidepressant such as Prozac (fluoxetine), Celexa (citalopram), or Zoloft (sertraline) to treat any underlying symptoms of depression or anxiety in people with anorexia.

Psychotherapy

Cognitive behavioral therapy (CBT) is often recommended for people with eating disorders. Using CBT strategies, a therapist can help a person with anorexia recognize their maladaptive thought patterns surrounding food, eating, and body image. The goal of CBT is to learn new and healthy coping mechanisms instead of reverting to eating disordered behavior.

For adolescents with anorexia, family-based treatment (FBT) may be recommended. With help from a qualified therapist, FBT teaches parents or caregivers how to support a child or teen during mealtimes and encourage them to eat. The goal of FBT is to provide additional support to families coping with anorexia.

Group therapy is also effective for the treatment of eating disorders. Group sessions allow a person with anorexia to share their experiences and listen to others, which may help improve their self-awareness and insight into their own behaviors as well as develop strong interpersonal relationships.

Nutritional counseling may be provided by an inpatient or outpatient program, or a person with anorexia may see a nutritional counselor who has experience treating eating disorders. A counselor will help them understand what their basic nutritional needs are and how to fulfill them each day. The counselor may also review bodily functions like hunger, satiety, and fullness.

History of Anorexia Nervosa

The criteria in the previous edition of the diagnostic manual, the DSM-IV (published in 1994), was problematic because as many as three-quarters of patients diagnosed with an eating disorder fell into the catch-all category of  eating disorder not otherwise specified (EDNOS). The broad ambiguity of the category made it hard for researchers and clinicians to adequately define and treat the condition.

The DSM-5, published in 2013, attempted to relax some of the criteria for various eating disorders and broaden the categories in order to reduce the number of patients in the EDNOS group (now called other specified feeding and eating disorder, or OSFED ).

For anorexia nervosa, there were two primary changes in criteria from the DSM-IV to the DSM-5:

  • Amenorrhea (loss of a menstrual period) was eliminated as a criterion. This is important because it allows males or those who don't menstruate to meet the criteria for anorexia nervosa.  It also allows the official inclusion of the small minority of females who continue menstruating despite extreme weight loss and malnutrition.
  • The low weight criterion was revised to allow more subjectivity and clinical judgment. This is also an important revision because anorexia nervosa can occur in individuals who are not what would be considered objectively low weight on a BMI chart. The new criteria allows professionals to take into account an individual's unique growth trajectory and weight history

Related Conditions

For patients who do not meet the full criteria for anorexia nervosa, other specified feeding and eating disorder (OSFED) may be an appropriate diagnosis. Being diagnosed with OSFED as opposed to anorexia nervosa does not make a person's condition any less serious.

It is important to note that people may meet the criteria for different eating disorders at different times, as symptoms can change. There is not a distinct line between healthy and disordered eating, but many shades of gray in the middle.

While it can be overwhelming to experience anorexia (or to have a loved one experience it), there are ways of coping that can help support mental health. Research has found that social support positively contributes to recovery from eating disorders. If you have anorexia, you shouldn't have to go through it alone.

It can be tough to ask for help or to let someone else know you have an eating disorder, but you can start by simply asking to meet up with a friend or catching up over the phone.

It's OK if you're not ready to provide loved ones with all the details of your diagnosis. But letting a loved one know you're going through a difficult time and would appreciate their support can go a long way.

Make sure you're doing things that you enjoy as much as possible. Make time to watch your favorite movies, or to take a road trip to your favorite place.

If you feel yourself becoming stressed and you're concerned your disordered eating behavior will be triggered , try to disrupt the behavior with an activity like going for a quick walk. Doing anything that takes you out of your thoughts, even for a second, can help calm your nervous system and relax the urgency you feel to act on something like skipping a meal.

It's important that you are kind to yourself. People with eating disorders tend to have perfectionist tendencies, so try to notice when your negative self-talk happens and try not to engage with it for too long.

Research shows that people with eating disorders who show themselves compassion—particularly when it comes to body image—may lessen their eating disordered behavior compared to people who don't show themselves the same self-compassion .

Anorexia Discussion Guide

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If you or a loved one are coping with an eating disorder, contact the  National Eating Disorders Association (NEDA) Helpline  for support at 1-800-931-2237. 

A Word From Verywell

Remember that anorexia looks different in everyone. Symptoms of this condition can be relieved with adequate treatment. Getting help early improves the chance of a complete and lasting recovery. If you or someone you know is suffering from some or all of the above criteria, it is important they see a physician, dietician, and/or a mental health professional for an assessment.

National Institute of Mental Health. Eating disorders .

Walsh BT. The enigmatic persistence of anorexia nervosa .  Am J Psychiatry . 2013;170(5):477-484. doi:10.1176/appi.ajp.2012.12081074

van Eeden AE, van Hoeken D, Hoek HW. Incidence, prevalence and mortality of anorexia nervosa and bulimia nervosa .  Curr Opin Psychiatry . 2021;34(6):515-524. doi:10.1097/YCO.0000000000000739

National Institute of Mental Health. Eating disorders: About more than food .

Dimitropoulos, G., Kimber, M., Singh, M.  et al.   Stay the course: practitioner reflections on implementing family-based treatment with adolescents with atypical anorexia .  J Eat Disord.  2019;7(10). doi:10.1186/s40337-019-0240-8

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th edition . American Psychiatric Association.

Blodgett Salafia EH, Jones ME, Haugen EC, Schaefer MK. Perceptions of the causes of eating disorders: a comparison of individuals with and without eating disorders .  J Eat Disord. 2015;3(1):32. doi:10.1186/s40337-015-0069-8

Steinglass JE, Lempert KM, Choo TH, et al. Temporal discounting across three psychiatric disorders: Anorexia nervosa, obsessive compulsive disorder, and social anxiety disorder .  Depress Anxiety . 2017;34(5):463-470. doi:10.1002/da.22586

Rodgers, R.F., Melioli, T. The relationship between body image concerns, eating disorders and internet use, Part I: A review of empirical support .  Adolescent Res Rev  2016;1:95–119. doi:10.1007/s40894-015-0016-6

Himmerich H, Bentley J, Kan C, Treasure J. Genetic risk factors for eating disorders: an update and insights into pathophysiology .  Ther Adv Psychopharmacol . 2019;9:2045125318814734. doi:10.1177/2045125318814734

Khalifa I, Goldman RD. Anorexia nervosa requiring admission in adolescents .  Can Fam Physician . 2019;65(2):107-108.

Hindley K, Fenton C, McIntosh J. A systematic review of enteral feeding by nasogastric tube in young people with eating disorders .  J Eat Disord. 2021;9:90. doi:10.1186/s40337-021-00445-1

Marvanova M, Gramith K. Role of antidepressants in the treatment of adults with anorexia nervosa .  Ment Health Clin . 2018;8(3):127-137. doi:10.9740/mhc.2018.05.127

Kass AE, Kolko RP, Wilfley DE. Psychological treatments for eating disorders .  Curr Opin Psychiatry . 2013;26(6):549-555. doi:10.1097/YCO.0b013e328365a30e

Rienecke RD. Family-based treatment of eating disorders in adolescents: current insights .  Adolesc Health Med Ther . 2017;8:69-79. doi:10.2147/AHMT.S115775

Okamoto Y, Miyake Y, Nagasawa I, Shishida K. A 10-year follow-up study of completers versus dropouts following treatment with an integrated cognitive-behavioral group therapy for eating disorders .  J Eat Disord . 2017;5:52. doi:10.1186/s40337-017-0182-y

Marzola, E., Nasser, J.A., Hashim, S.A.  et al.   Nutritional rehabilitation in anorexia nervosa: review of the literature and implications for treatment .  BMC Psychiatry  2013;13:290. doi:10.1186/1471-244X-13-290

Vo M, Accurso EC, Goldschmidt AB, Le Grange D. The impact of DSM-5 on eating disorder diagnoses .  International Journal of Eating Disorders. 2017;50(5):578–581. doi:10.1002/eat.22628

Zayas LV, Wang SB, Coniglio K, et al. Gender differences in eating disorder psychopathology across DSM-5 severity categories of anorexia nervosa and bulimia nervosa .  Int J Eat Disord . 2018;51(9):1098–1102. doi:10.1002/eat.22941

Estour B, Marouani N, Sigaud T, et al. Differentiating constitutional thinness from anorexia nervosa in DSM 5 era .  Psychoneuroendocrinology . 2017;84:94–100. doi:10.1016/j.psyneuen.2017.06.015

Fitzsimmons EE, Bardone-Cone AM. Differences in coping across stages of recovery from an eating disorder .  Int J Eat Disord . 2010;43(8):689-693. doi:10.1002/eat.20781

Braun TD, Park CL, Gorin A. Self-compassion, body image, and disordered eating: A review of the literature . Body Image. 2016;17:117-131. doi:10.1016/j.bodyim.2016.03.003

By Susan Cowden, MS Susan Cowden is a licensed marriage and family therapist and a member of the Academy for Eating Disorders.

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Diagnosis and Assessment Issues in Eating Disorders

You must assess the presenting problem and identify the appropriate diagnostic code needed for insurance billing. But diagnosis is complicated. Help here.

Summary of eating disorder diagnostic criteria

TABLE. Summary of eating disorder diagnostic criteria

anorexia nervosa icd 10 criteria

It is essential to detect the presence of an eating disorder because of high associated mortality. Clinicians are faced with the difficulty of determining the presenting problem and identifying the appropriate diagnostic code needed for insurance billing. Although efforts have been made to improve the diagnostic criteria, not all presentations fit perfectly into the established criteria. Moreover, diagnosis is further complicated by the differences in criteria outlined in DSM-5 and ICD-10 ( Table ). Many applaud the recognition of binge eating disorder in DSM-5 as a major improvement in the field, but it does not have its own code in ICD-10.

Anorexia nervosa

Anorexia nervosa was first included in DSM-III and ICD-9. The key clinical criterion in anorexia nervosa is a significantly low body weight. However, the level at which body weight is considered “significantly low” has evolved. DSM-5 criteria for low weight consider what is “normal” for one’s age, sex, physical health, and developmental trajectory. Severity level may be assigned based on specified BMI. Previously, the weight criteria were criticized for being arbitrary because the criterion of 15% below ideal body weight was not empirically derived. ICD-10 (F50.0) quantifies low weight as at least 15% below what is expected or a BMI of 17.5 or lower.

Criteria from DSM-5 and ICD-10 recognize a fear of gaining weight and significant body image disturbance as essential features. One major change in DSM-5 is the removal of the amenorrhea criterion, which was criticized for not being applicable to males or prepubescent females. Moreover, the presence of amenorrhea does not differentiate severity of psychopathology. 1 ICD-10, however, still acknowledges that amenorrhea may be present in females with anorexia nervosa. Anorexia nervosa is divided into 2 subtypes:

• Restricting type (F50.01): the patient has refrained from binge eating and/or purging in the past 3 months

• Binge-eating/purging type (F50.02): characterized by recurrent episodes of bingeing and/or purging over the past 3 months

Bulimia nervosa

Bulimia nervosa first appeared in DSM-III-R and ICD-9 and is characterized by recurrent episodes of binge eating followed by compensatory behaviors. Binge eating is defined as eating what would be considered an objectively large amount of food in a relatively short period. DSM specifies the presence of a feeling of “loss of control” of one’s eating in addition to the large amount consumed. Both criteria include the presence of compensatory behaviors (eg, self-induced vomiting, laxatives, diuretics, excessive exercise, or fasting) and recognize similar concern about shape and weight as found in anorexia nervosa. DSM-5 specifies a frequency threshold of binge eating and compensatory behaviors as an average of once per week, over the past 3 months.

Binge eating disorder

Binge eating disorder was identified as worthy of further study in DSM-IV-TR and is officially recognized in DSM-5. However, although widely accepted as a diagnosis, binge eating disorder is not recognized in ICD-10, and individuals would receive a diagnosis of F50.8 under other eating disorders. Binge eating disorder criteria include recurrent binge eating at the frequency threshold of at least an average of once per week, over the past 3 months, and the presence of at least 3 of the following 5 criteria:

• Eating much more quickly than usual

• Eating until uncomfortably full

• Eating a lot when not physically hungry

• Eating alone because of embarrassment

• Feeling very bad or guilty after eating

Additional diagnoses

In DSM-5, individuals who meet significant criteria for an eating disorder but do not meet criteria for 1 of the 3 disorders described above may receive a diagnosis of other specified feeding and eating disorder, or OSFED. This includes individuals who may not meet the weight threshold for anorexia nervosa, or the frequency and duration of bulimia nervosa or binge eating disorder. In addition, purging disorder (ie, recurrent purging in the absence of bingeing) and night eating syndrome (ie, recurrent episodes of consciously eating at night) may be specified under an OSFED diagnosis. In ICD-10, diagnoses of atypical anorexia nervosa (F50.1) and atypical bulimia nervosa (F50.3) are specified as unique disorders, but any other eating disorder may receive the code of F50.8 for other eating disorders.

Shortcomings of diagnostic criteria

The differences across eating disorder diagnoses in DSM-5 and ICD-10 complicate the work of clinicians. One obvious criticism of ICD-10 is the absence of a unique code for and recognition of binge eating disorder as a distinct eating disorder-given that it is the most common eating disorder and is associated with significant comorbidities and impairment.

Some additional guidance for determining low weight has been added to the criteria for anorexia nervosa in DSM-5. However, it still may be somewhat subjective and may be difficult to assess without obtaining a patient’s growth charts.

The frequency threshold of binges and compensatory behavior for bulimia nervosa and binge eating disorder was reduced from DSM-IV-TR, because DSM-IV criteria were criticized for being arbitrary. 2 Findings suggest that reducing the criteria to once per week over 3 months would not significantly increase the prevalence but should still identify the majority of individuals who have clinically significant eating disorder pathology. 2,3

There is some criticism regarding the definition of a binge. As written, there are no well-defined guidelines as to what constitutes “objectively large.” Similarly, criticism surrounds whether the amount of food consumed is necessary or whether the feeling of loss of control is sufficiently indicative of pathology. Perhaps the most salient critique of the diagnostic criteria in DSM-5 is the absence of any shape and weight concerns in the diagnosis of binge eating disorder.

Clinically significant shape and weight concerns are related to greater psychopathology among those with binge eating disorder. However, a considerable number of individuals with clinically significant binge eating do not exhibit shape and weight concerns, so many feel that these concerns should be a specifier because they may indicate severity of pathology. 4,5

The severity specifiers in DSM-5 for binge eating disorder are based on number of binge episodes per week and are not empirically derived. Subsequent research has demonstrated that these severity criteria are not related to pathology. A shape and weight specifier would provide more clinical utility. 6,7

Assessment for eating disorders

Knowing how to conduct a differential diagnosis is important; however, it necessitates first asking questions to assess eating behaviors. Because many of the behaviors associated with eating disorders can occur in secret, these disorders may go unnoticed for years. Thus, all physicians should routinely ask their patients about eating behaviors.

Because of the high levels of comorbidity of other psychiatric conditions with eating disorders, psychiatrists need to ask eating behavior questions even if eating is not the primary reason a client presents for treatment. Furthermore, although weight may be associated with certain eating disorders, clinically significant disordered eating behaviors may be present across the weight spectrum. For example, a person who is of normal weight may endorse bingeing and purging behaviors, or someone who is overweight may significantly restrict food intake-resulting in substantial weight loss-and thus meet the criteria for atypical anorexia nervosa.

Universal assessment is necessary because eating disorders are found across ages, races, ethnicities, sex, and the weight continuum. Depending on how much time you have for assessment, it may be best to begin by learning about a patient’s eating behaviors. Understanding eating patterns is a good start to see whether patients report that they regularly eat meals. Assessment for any appetite changes is also useful. To evaluate shape and weight concerns, ask how patients feel about their current shape and whether they are actively trying to lose weight. At first it may feel awkward to pose these questions; however, asking in a matter-of-fact way and stating that you ask this of all patients may reduce the stigma and increase the odds your patient will be truthful and less defensive.

If you have minimal time, at least assess for several key eating disorder behaviors so that you can provisionally diagnose an eating disorder and follow up with a more thorough evaluation at the next session. Assess all patients for binge eating by asking about eating large amounts of food and feeling a loss of control over eating. Inquire about purging behaviors, including self-induced vomiting, use of diet pills or laxatives, or excessive exercise. For patients with diabetes, it is important to ask whether an individual manipulates insulin intake to affect weight. Lastly, assess for significant restriction (ie, consciously restricting or limiting the amount that one consumes) and fasting, which is typically defined as refraining from eating for 8 hours or more while awake.

Many providers ask whether a quick screener is available. The one most widely used in primary care is the 5-item SCOFF questionnaire. However, it was initially created to assess for anorexia nervosa and bulimia nervosa and was created in “British English”; thus, some language modification is needed for use in the US. 8,9 More detailed eating disorder assessment tools exist, such as the Eating Disorder Examination (EDE) and the questionnaire version. 10 There is also a version of the EDE for children (Ch-EDE). 11 However, specialty training is needed to administer the EDE and Ch-EDE interviews.

The EDE was updated to version 17.019 to provide DSM-5 diagnoses by adding detailed description of an algorithm to determine diagnosis. The question about amenorrhea was removed as well. To our knowledge, the Ch-EDE has not been formerly modified; however, because of minor adjustments to the diagnostic criteria, the information needed to determine DSM-5 diagnoses is collected.

Differential diagnosis

Currently, patients cannot present with more than one eating disorder, although certain symptoms (eg, bingeing) may occur across diagnoses. DSM specifies that a diagnosis of anorexia nervosa prevails over a diagnosis of bulimia nervosa. Thus, if a patient binges and purges and meets the low weight threshold for anorexia nervosa, he or she would receive only a diagnosis of anorexia nervosa. Furthermore, the presence of regular compensatory behaviors distinguishes bulimia nervosa from binge eating disorder. Also, avoidant and restrictive food intake disorder may result in similar low weight as in anorexia nervosa but without the pervasive concern about one’s shape and weight or fear of gaining weight.

When diagnosing an eating disorder, it is important to ensure that symptoms such as low weight or vomiting are not due to a medical condition (eg, gastrointestinal condition, hyperthyroidism). Typically, patients with medical conditions responsible for low weight and/or vomiting do not present with significant concern for shape and weight. Keep in mind that decreased or increased appetite may be a symptom of MDD.

Fear of or embarrassment about eating in front of others may be present in binge eating disorder or anorexia nervosa; however, if fears around other social situations outside of eating occur, both an eating disorder diagnosis and a social anxiety disorder diagnosis would be appropriate. Obsessions and compulsions, similar to those seen in obsessive-compulsive disorder, may be characteristic of anorexia nervosa. If they are confined to eating and food alone, anorexia nervosa is the appropriate diagnosis; however, if obsessions and/or compulsions are more general, a diagnosis of obsessive-compulsive disorder may also be appropriate.

Lastly, patients with body dysmorphic disorder may exhibit similar misperception of their body. If these thoughts are confined to shape and weight, only an eating disorder diagnosis is warranted. However, if thoughts extend to a specific body part, then an additional diagnosis of body dysmorphic disorder may be justified.

If you’ve missed Part 1 of this Special Report on Eating Disorders, you can find the articles here .

Disclosures:

Dr Eichen is a Postdoctoral Fellow at the University of California, San Diego. Dr Wilfley is The Scott Rudolph University Professor of Psychiatry, Medicine, and Psychological and Brain Sciences at the Washington University School of Medicine in St Louis. Dr Eichen reports no conflicts of interest concerning the subject matter of this article; Dr Wilfley reports that she is a consultant for Shire Pharmaceuticals.

References:

1. Andersen AE, Bowers WA, Watson T. A slimming program for eating disorders not otherwise specified. Reconceptualizing a confusing, residual diagnostic category. Psychiatr Clin North Am . 2001;24:271-280.

2. Wilson GT, Sysko R. Frequency of binge eating episodes in bulimia nervosa and binge eating disorder: diagnostic considerations. Int J Eat Disord . 2009;42:603-610.

3. Trace SE, Thornton LM, Root TL, et al. Effects of reducing the frequency and duration criteria for binge eating on lifetime prevalence of bulimia nervosa and binge eating disorder: implications for DSM-5. Int J Eat Disord . 2012;45:531-536.

4. Goldschmidt AB, Hilbert A, Manwaring JL, et al. The significance of overvaluation of shape and weight in binge eating disorder. Behav Res Ther . 2010;48:187-193.

5. Grilo CM, Hrabosky JI, White MA, et al. Overvaluation of shape and weight in binge eating disorder and overweight controls: refinement of a diagnostic construct. J Abnorm Psych . 2008;117:414-419.

6. Grilo CM, Ivezaj V, White MA. Evaluation of the DSM-5 severity indicator for binge eating disorder in a clinical sample. Behav Res Ther . 2015;71:110-114.

7. Grilo CM, Ivezaj V, White MA. Evaluation of the DSM-5 severity indicator for binge eating disorder in a community sample. Behav Res Ther . 2015;66: 72-76.

8. Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire: assessment of a new screening tool for eating disorders. BMJ . 1999;319:1467-1468.

9. Mond JM, Myers TC, Crosby RD, et al. Screening for eating disorders in primary care: EDE-Q versus SCOFF. Behav Res Ther . 2008;46:612-622.

10. Fairburn CG, Cooper Z. The eating disorder examination. In: Fairburn CG, Wilson GT, eds. Binge Eating: Nature, Assessment and Treatment . 12th ed. New York: Guilford Press; 1993:317-360.

11. Bryant-Waugh RJ, Cooper PJ, Taylor CL, Lask BD. The use of the Eating Disorder Examination with children: a pilot study. Int J Eat Disord . 1996;19:391-397.

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  • v.11(2); 2012 Jun

Classification of feeding and eating disorders: review of evidence and proposals for ICD-11

Rudolf uher.

1 Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, King’s College London, UK

MICHAEL RUTTER

2 Department of Psychiatry, Dalhousie University, Halifax, NS, Canada

Current classification of eating disorders is failing to classify most clinical presentations; ignores continuities between child, adolescent and adult manifestations; and requires frequent changes of diagnosis to accommodate the natural course of these disorders. The classification is divorced from clinical practice, and investigators of clinical trials have felt compelled to introduce unsystematic modifications. Classification of feeding and eating disorders in ICD-11 requires substantial changes to remediate the shortcomings. We review evidence on the developmental and cross-cultural differences and continuities, course and distinctive features of feeding and eating disorders. We make the following recommendations: a) feeding and eating disorders should be merged into a single grouping with categories applicable across age groups; b) the category of anorexia nervosa should be broadened through dropping the requirement for amenorrhoea, extending the weight criterion to any significant underweight, and extending the cognitive criterion to include developmentally and culturally relevant presentations; c) a severity qualifier “with dangerously low body weight” should distinguish the severe cases of anorexia nervosa that carry the riskiest prognosis; d) bulimia nervosa should be extended to include subjective binge eating; e) binge eating disorder should be included as a specific category defined by subjective or objective binge eating in the absence of regular compensatory behaviour; f) combined eating disorder should classify subjects who sequentially or concurrently fulfil criteria for both anorexia and bulimia nervosa; g) avoidant/restrictive food intake disorder should classify restricted food intake in children or adults that is not accompanied by body weight and shape related psychopathology; h) a uniform minimum duration criterion of four weeks should apply.

The classification of feeding and eating disorders in the ICD-10 and DSM-IV is unsatisfactory. The deficiencies of these systems are most evident in four facts. First, the majority of patients presenting with eating-related psychopathology do not fulfil criteria for a specific disorder and are classified in the residual “other” or “not otherwise specified” categories. Second, most individuals with an eating disorder sequentially receive several diagnoses instead of a single diagnosis that would describe the individual’s problems at various developmental stages. Third, most recent clinical trials have used modified diagnostic criteria that may better reflect clinical practice, but deny the purpose of the classification as a means for communication between clinicians and researchers. Fourth, although childhood feeding disorders are typically described in the history of adolescents and adults with eating disorders, there is little research on the developmental continuity between childhood, adolescent and adult disorders that involve aberrant eating behaviours. Issues have also been raised about developmental and cultural dependencies of feeding and eating disorders as currently conceptualized.

Given these problems, it is not surprising that the World Health Organization (WHO) and the American Psychiatric Association are contemplating significant changes in classification. A number of proposals for changes have been made. The purpose of this article is to summarize the issues in the classification of feeding and eating disorders, review relevant aspects of evidence, and make proposals for modifications in the context of the development of ICD-11.

THE INTERNATIONAL CLASSIFICATION OF DISEASES

The primary purpose of the International Classification of Diseases (ICD) is to facilitate the work of health professionals in various clinical settings across the world. Therefore, the primary requisite for ICD diagnostic categories is clinical utility, and evidence from clinical and epidemiological research is given more weight than data from basic and etiological research 1 . Attention is paid to global cross-cultural validity and the needs of health professionals from medium and low income countries 1 .

Several conceptual directions have been proposed for the ICD-11 2 . First, to reflect the growing evidence on continuity between child, adolescent and adult psychopathology, it has been proposed that the grouping of disorders with onset usually occurring in childhood and adolescence should be removed. Instead, disorders should be organized in groupings by psychopathology and a life-course approach should be adopted to conceptualize child, adolescent and adult manifestations of the same disorders.

Second, it has been agreed that the ICD-10 and DSM-IV contain an excessively large number of over-specified diagnoses, leading to artificially high rates of comorbidity and frequent use of the uninformative “not otherwise specified” and “other” categories 2 . It has been proposed that evidence is required not just for changing or adding diagnostic categories but also for retaining existing ones. The overuse of the “not otherwise specified” categories should be reduced by revising the boundaries of specific disorders to include most clinically significant presentations.

Third, to best serve the clinical use, the ICD takes a prototypic approach in which presentations characteristic of each diagnostic category are described in a narrative format, which most health professionals find easier to use in practice 3 , 4 . The ICD avoids the use of exact count, frequency and duration criteria to modulate diagnostic thresholds. Since most duration criteria for various disorders are not based on evidence and are difficult to memorize and apply, it has been proposed that a uniform duration criterion of four weeks should be adopted, with qualified exceptions for disorders which require rapid clinical attention (e.g., delirium, mania and catatonia) or that manifest by relatively brief events (e.g., intermittent explosive disorder).

Fourth, it has been proposed that categories with some evidence of clinical usefulness, but insufficient evidence for validity of specific criteria, should be included in the main body of the ICD, but signposted as categories that require further testing.

Fifth, to reflect the evidence that most mental disorders are multifactorial, it is proposed to remove the distinction between organic and functional forms of disorders.

CLINICAL EVIDENCE AND DIAGNOSTIC CRITERIA

The most important reason against changing the current diagnostic criteria is that it could invalidate available evidence. It is therefore important to assess the clinically relevant evidence and its relationship to classification. We have reviewed recent clinical trials on treatments of eating disorders published in six influential child and general psychiatry journals (Journal of the American Academy of Child and Adolescent Psychiatry, Journal of Child Psychology and Psychiatry, American Journal of Psychiatry, Archives of General Psychiatry, British Journal of Psychiatry and Psychological Medicine) between January 2000 and May 2011.

We identified 18 clinical trials (Table ​ (Table1). 1 ). Seven trials tested treatments for anorexia nervosa. Of these, three (published between 2000 and 2003) used “strict” DSM-IV or ICD-10 criteria. Four more recent trials (published between 2005 and 2010) used broader criteria, relaxing the weight and/or the amenorrhoea criterion. Eleven trials tested treatments for bulimia and related conditions. Three of these (published between 2000 and 2003) applied “strict” DSM-IV or DSM-III-R criteria. Eight of these trials (published between 2001 and 2009) used broader criteria, including bulimic-type eating disorders not otherwise specified or all eating disorders without underweight in addition to bulimia nervosa.

Table 1 Diagnostic inclusion criteria in recent clinical trials in eating disorders

We conclude that the clinical trial literature reflects the deficiencies of the current diagnostic systems by broadening the diagnostic criteria in attempts to reflect clinical reality. No clinical trial published in the last seven years in the six journals used DSM-IV or ICD-10 criteria exactly. The result is that inclusion criteria differ between trials and the classification has effectively lost its purpose in defining the same group of patients across research studies and clinical settings. We conclude that changes in classification will not invalidate useful evidence, because most recent evidence is based on modified diagnostic criteria.

DEVELOPMENTAL CONTEXT

An important issue is the relationship between feeding and eating disorders. Feeding problems and selective eating in childhood have been described in the history of patients with eating disorders since the early case reports 23 , but there has been little research on the continuity between feeding and eating disorders. The available research suggests a degree of continuity of eating problems from infancy to adulthood 24 , 25 , 26 . For example, in a large prospective study, feeding problems in infancy and undereating in childhood predicted anorexia nervosa in adulthood with odds ratios of 2.6 and 2.7 respectively 26 . For bulimia nervosa, the evidence is limited to a retrospective study showing that history of overeating and rapid eating in childhood was more common in women with bulimia nervosa than in their unaffected sisters 25 . However, long-term follow-ups of individuals diagnosed with feeding disorders in childhood are lacking. At the same time, clinical trends indicate that the boundary between feeding disorders of childhood and eating disorders is problematic. On the one hand, there is a trend for younger and younger children to present with symptoms resembling “adult” eating disorders 27 . On the other hand, many adults presenting with underweight, restrictive and selective eating lack the typical body-weight and shape related psychopathology that characterizes eating disorders and may be better described by criteria of feeding disorders 28 , 29 , 30 , 31 .

It has been pointed out that similarity between child and adult manifestations of eating-related psychopathology might have been obscured by the fact that existing criteria are rigidly applied without sensitivity to developmental stage 28 , 32 , 33 , 34 . This is most apparent in the requirement for self-reported cognitions regarding weight, shape and body image. It has been argued that children and some adolescents may not be able to formulate and communicate such concerns due to incompletely developed capacity for abstract thinking 28 , 32 , 33 , 34 . It has been proposed that behavioural indicators of such concerns should be accepted as a basis for diagnosis, whether they are observed by clinicians or reported by parents, teachers or other adults 32 , 35 , 36 . For example, observation of the child frequently checking her/his weight and shape or expressing aspects of shape/weight-related self-image in drawings might be taken into account as indicators of preoccupation with weight and shape in the context of pathological eating behaviours. In the case of anorexia nervosa, it has also been suggested that restrictive and binge-purge subtypes often represent developmental stages of the same disorder – children and younger adolescents usually present with the restrictive type, and binge-purging behaviours develop in a proportion of individuals at later stages 32 , 35 , 37 .

The summary of evidence suggests that a single classification applied across age groups and sensitive to developmentally specific manifestations would more accurately describe the course of these disorders and reflect the continuity between child, adolescent and adult manifestations than the current system.

CULTURAL CONTEXT

Eating plays an important role in most cultures. Acceptable eating habits vary widely between religious and ethnic groups, and eating disorders have been conceptualized as culture-bound syndromes 38 . In this context, it is notable that most published research is based on North American and European populations. In the last decade, reports on eating disorders and related conditions from various countries, including low income countries and countries undergoing sociocultural transitions 39 , 40 , 41 , have accumulated which may inform a classification that is sensitive to local variation 42 .

Anorexia nervosa occurs in all cultures, but the incidence is higher among individuals who have been exposed to Western culture and values and those who live in relative affluence 40 , 41 , 43 . For example, in the Caribbean island of Curaçao, all identified cases of anorexia nervosa were among young women of mixed ethnicity who had spent time in the USA or the Netherlands; there were no cases of anorexia nervosa among the majority of young women in the island, who are black and had not been abroad 40 , 44 . Anorexia nervosa is relatively rare among black women in Africa, the Caribbean, and the USA 45 , 46 , 47 . In the Czech Republic, the incidence of anorexia nervosa increased sharply after the fall of the iron curtain, that was associated with exposure to Western-style media and values 41 .

In addition to influence on prevalence, culture also shapes the manifestation of anorexia nervosa. For example, in South-East Asia, a larger proportion of patients with anorexia nervosa report abdominal discomfort and other factors as a rationale for restrictive eating 28 , 48 . However, typical presentations with weight and shape-related preoccupations and fear of gaining weight have also been recorded in most non-Western cultures 28 , 48 , 49 , 50 , and the rates of full-syndrome anorexia nervosa in South East Asia are intermediate between Western countries and African populations 50 . There is evidence that patients who initially present with other rationales often develop intense fear of weight gain 51 and that the proportion of patients reporting fear of weight gain increases with exposure to Western cultural values 52 . This suggests that weight-phobic and non-weight-phobic anorexia are context-dependent manifestations of the same disorder. Therefore, it is recommended that fear of weight gain is not required for the diagnosis of anorexia nervosa, provided that behaviours maintaining underweight or other psychopathology suggestive of eating disorder are present.

Bulimia nervosa has been conceptualized as strongly bound to Western culture 38 . The disorder is more common among individuals who were exposed to Western culture and who grew up in relative affluence 38 , 41 , 43 . Although all component symptoms of bulimia nervosa occur in non-Western low income countries, the syndrome appears to be less common in those countries than in North America and Western Europe 43 , 49 , 50 , 53 . The incidence of bulimia nervosa increases in parallel with exposure to Western media and values and correlates with the degree of acculturation 41 , 43 , 52 , 54 . Therefore, the manifestation of bulimia nervosa and its separation from normality have to be considered within cultural context. For example, culturally sanctioned feasting followed by the use of indigenous purgatives in Pacific islands should not be medicalized, but the use of the same herbal purgatives in the context of typical psychopathology and outside the culturally sanctioned events is a symptom of an eating disorder 39 , 55 . The motives for pursuing a thin body shape may also depend on socioeconomic context. For example, in societies undergoing socioeconomic transition, a thin body can be perceived as a valuable commodity that may help obtain a lucrative job and guarantee career success 42 , 56 , 57 . There is little evidence on whether such cultural variations in manifestation have an impact on the long-term prognosis and treatment response. In the USA, patients with bulimia nervosa belonging to ethnic minorities appear to respond to the same psychological treatments as European Americans 58 .

Binge eating disorder is relatively equally distributed across countries and ethnic groups, but details of manifestation vary in culture-dependent manner. Black women with binge eating disorder are on average heavier, have fewer concerns related to body weight, shape and eating, a less frequent history of bulimia nervosa, but similar levels of depressive symptoms and impairment compared to white women with the same diagnosis 59 . In general, the associations between binge eating, obesity, weight and shape dissatisfaction, and general psychopathology hold across ethnic groups 60 , 61 . While no modifications of diagnostic criteria are required, the lower rates of treatment among black women with binge eating disorder suggest that increased alertness of clinicians to eating disorders in non-European ethnic groups is warranted 59 .

TEMPORAL INSTABILITY AND DIAGNOSTIC TRANSITIONS

Longitudinal follow-up studies of anorexia and bulimia nervosa have found that a significant proportion of subjects change diagnostic status to another eating disorder 62 , 63 , 64 , 65 , 66 , 67 . Diagnostic crossovers are more common in the initial years of illness and follow a predictable sequence. Typically, restrictive anorexia nervosa mutates into binge eating/purging anorexia nervosa, before crossing over to bulimia nervosa 68 , 69 , 70 , 71 , 72 . Crossover in the opposite direction is less common. While one-third of individuals with an initial diagnosis of anorexia nervosa develop bulimia nervosa during a five-to-ten year follow-up, only 10-15% of those with an initial diagnosis of bulimia nervosa develop anorexia 68 , 70 , 72 . Larger proportions of subjects with an initial diagnosis of bulimia nervosa develop binge eating disorder or eating disorder not otherwise specified (EDNOS) 65 , 68 . There are also numerous transitions between specific eating disorder categories and EDNOS, with the latter often representing an intermediate state on the way to recovery 68 , 73 , 74 .

The diagnostic transitions may also extend to a relationship between feeding disorders in childhood and eating disorders in adolescence and adulthood. Restrictive eating and hyperactivity are often present in children and adolescents who deny any motivation of these behaviours by fear of gaining weight, but who later demonstrate weight phobia and receive a diagnosis of an eating disorder 28 , 33 , 35 .

Importantly, a significant minority of cases show repeated diagnostic crossovers. For example, half of those who transit from an initial anorexia nervosa to bulimia nervosa experience a “recurrence” of anorexia nervosa within a few years 70 . In long-standing eating disorders, diagnostic transitions are the rule, with most patients who remain ill for at least several years changing diagnostic status one or more times 68 , 70 , 72 . Comorbid depression and alcohol abuse are associated with more diagnostic instability in eating disorders 68 . With these rates of transitions, it is clear that the sequential diagnoses represent stages of the same disorder rather than separate disorders.

The apparent sequential comorbidity of various eating disorders is probably an artefact of applying a system of overly specified diagnostic categories with overlapping psychopathology. In ICD-10 and DSM-IV, the various eating disorder categories are mutually exclusive, so they cannot be diagnosed at the same time. However, there is no such restriction for sequential diagnoses, and neither ICD-10 nor DSM-IV takes the longitudinal course of psychopathology into account. This state of affairs is clearly unsatisfactory. On the one hand it creates an impression of an overly complex pattern of sequential comorbidity, on the other hand it misses important prognostic information. For example, it was shown that, among patients with current bulimia nervosa, a history of anorexia nervosa is associated with reduced chance of recovery and much larger risk of transiting into anorexia nervosa 75 . It has been proposed that bulimia nervosa should be subtyped according to history of anorexia nervosa 75 . A more radical solution to the problem of spurious sequential comorbidity may require restrictions on frequent changes of diagnostic categories (e.g., the diagnosis of anorexia nervosa may be retained for a year after weight normalization) or establishing a combined eating disorder category to capture cases that sequentially fulfil criteria for both anorexia and bulimia nervosa and have a tendency to repeatedly change presentations.

FEEDING DISORDERS

Feeding disorders of infancy/childhood and eating disorders of adolescence/adulthood are classified in different sections of ICD-10 and DSM-IV. Feeding disorders of childhood/infancy include refusal of food and selective (faddy) eating, regurgitation of food with or without re-chewing, or eating of non-edible substances (pica). This classification has serious problems as it includes one heterogeneous condition with unclear boundaries from eating disorders and two less common and more specific conditions that occur in both children and adults 76 , 77 .

Alternative classifications of feeding disorders have been proposed, that attempt to reconceptualize this heterogeneous category as four to six specific categories 78 , 79 , 80 and/or emphasize the relational context of feeding and the role of primary caregiver 80 , 81 . The problems are that the specific subtypes leave a large number of clinical presentations unclassified and some require allocation of a single etiology to disorders that are multifactorial. As a result, none of these proposals has been accepted. The situation is clearer for pica and regurgitation, which are relatively distinct syndromes. However, both of these are frequent in adults and in the context of other mental disorders (e.g., autism and learning disability) and physiological conditions (iron deficiency, pregnancy). It is proposed that pica and regurgitation disorder should be diagnosed based on behaviour and irrespective of age 76 .

Avoidant/restrictive food intake disorder (ARFID)

Avoidant/restrictive food intake disorder (ARFID) has been proposed to replace the non-specific category of feeding disorder of infancy or early childhood and, in addition, explicitly include adolescent and adult cases presenting with psychologically motivated inadequate food intake for reasons related to the physical properties or feared consequences of eating specific types of food other than effects on body weight and shape 76 .

ARFID overlaps with anorexia nervosa in terms of restrictive food intake and the resulting underweight, but differs in psychopathology and motives for restrictive eating. These include avoiding types of food of specific colour or texture or limiting food intake to a small number of specific “safe” types of food because of perceived health consequences. ARFID is typically not associated with gross disturbance of body image.

Since there is vast normal variation in eating habits among children and adults, differentiation from normality is important. As a rule, ARFID should only be diagnosed when the restrictive/avoidant eating is a cause of inadequate nutrition that may be associated with delayed growth in children, weakness, anaemia or other medical consequences in any age group, or inadequate development of the foetus in pregnant women. Dietary practices that are endorsed by large groups of people, such as vegetarianism or religious fasting, do not constitute a basis for diagnosing ARFID.

The proposed ARFID category conforms with the general direction of merging feeding and eating disorders and opening diagnostic categories to all age groups. It also provides an appropriate category for some cases that previously received the diagnosis of EDNOS. Since ARFID is a new concept, we propose that it is included in ICD-11 as a category that requires further testing. In particular, the boundaries between ARFID and anorexia nervosa, including the culturally determined non-fat phobic presentations, and between ARFID and specific phobias need to be explored. It is also hoped that the inclusion of ARFID will stimulate research on continuity between child and adult presentations.

Pica describes persistent eating of non-food substances, such as earth, chalk, metal or plastic objects, hair or faeces. In ICD-10 and DSM-IV, pica is included among the disorders with onset usually occurring in childhood and adolescence, and adult presentations are coded elsewhere (e.g., as an EDNOS). Since pica frequently first comes to attention in adulthood, it is proposed that there are no age restrictions for its diagnosis 76 . Pica only requires a diagnosis if it is severe, leads to adverse consequences (e.g., heavy-metal poisoning or parasite infestation), does not exclusively occurs during socially sanctioned events (e.g., religious rituals) or culturally accepted practice (e.g., eating of clay in Nigeria) and is not fully explained by another mental disorder (e.g., psychosis or obsessive-compulsive disorder). Eating non-food substances also frequently occurs in pregnancy, and pica should not be diagnosed in pregnant women unless it is of unusual extent or causes health concerns.

Regurgitation disorder

Regurgitation disorder describes repetitively bringing previously swallowed food from stomach back to the mouth and either spitting or re-chewing it. It was included in ICD-10 and DSM-IV under the name of rumination disorder. Since rumination is commonly used to describe a psychological process involving repetitive thoughts, we propose changing the name to “regurgitation disorder” to avoid confusion. Regurgitation disorder was previously classified in the section of disorders with onset specific to childhood, but it frequently first comes to attention in adulthood. Therefore, it should be diagnosed without age restrictions 76 .

EATING DISORDERS NOT OTHERWISE SPECIFIED (EDNOS)

The field of eating disorders has evolved around the concepts of anorexia and bulimia nervosa. However, when DSM-IV criteria are applied to patients presenting to eating disorders services, the most common diagnosis is EDNOS. The proportion of patients diagnosed with EDNOS is consistent across settings and age groups, with approximately 60% of patients referred to child, adolescent or adult eating disorders services classified as EDNOS 82 , 83 , 84 .

In ICD-10, EDNOS is split between atypical anorexia nervosa, atypical bulimia nervosa, other eating disorder, and eating disorder, nonspecified. However, this does not improve the matters, since the diagnoses of atypical anorexia and atypical bulimia are highly unreliable and nearly 40% of patients still receive the “other” or “unspecified” residual diagnoses 82 . There is also confusion about the meaning of “atypical anorexia nervosa”. In ICD-10, atypical anorexia nervosa is defined as a condition that resembles anorexia nervosa, but does not fulfil all of the diagnostic criteria (e.g., there is no amenorrhoea or not a sufficient degree of weight loss). In the literature, the term “atypical anorexia nervosa” is used more narrowly to describe an eating disorder with significant underweight but no concerns about body shape or weight 85 , 86 . For these reasons, it is concluded that ICD-10 is as unsatisfactory as DSM-IV.

The cause of the current problems is that criteria for specific eating disorders, such as anorexia and bulimia nervosa, are too narrow and rigid. Indeed, the definitions of eating disorders are somewhat anomalous by requiring the presence of all criteria, rather than a minimum number of a longer list of symptoms. For example, the diagnosis of depressive episode requires five out of nine symptoms, but the diagnosis of anorexia nervosa requires four out of four (underweight, fear of weight gain, body image disturbance and amenorrhoea). This rigid requirement means that cases where any one of the four symptoms is absent are diagnosed as EDNOS, even if the presentation otherwise resembles typical anorexia nervosa. A significant proportion of EDNOS is composed of such subthreshold cases. Common types of EDNOS include anorexia nervosa without amenorrhoea, anorexia nervosa without fear of gaining weight, anorexia nervosa not fulfilling the weight loss criterion, bulimia nervosa with binges that are not objective (i.e., do not involve an amount of food that is definitely larger than what most people would eat), bulimia without bingeing (purging disorder), bulimia without purging (binge eating disorder), and bulimia nervosa with bingeing and compensatory behaviours occurring less than twice a week for three months 29 , 84 . For example, in a specialized clinic for eating disorders, subthreshold anorexia and bulimia nervosa accounted for 83% of EDNOS 84 .

Having most patients diagnosed with EDNOS is unhelpful for several reasons. First, EDNOS is a highly heterogeneous group in terms of presentation, prognosis, physical sequelae, and treatment outcomes 37 , 84 . Second, most cases of EDNOS represent a phase of an eating disorder in individuals who fulfilled criteria for anorexia or bulimia nervosa at other times 29 , 73 . Third, the residual character of this category implicitly conveys that it is a less severe disorder. This contrasts with the demonstrated severity, impairing character, and a grave prognosis including elevated mortality in EDNOS 87 , 88 . Finally, EDNOS has no specific implications for treatment selection or service provision. There has been an attempt to introduce a “transdiagnostic” treatment that would be effective for most types of eating disorders, but the published evidence on this treatment excludes eating disorders with underweight and subsequently better fits a broader category of bulimia nervosa 12 . A similar approach has been taken in recent clinical trials in bulimia nervosa, which also included bulimia-like EDNOS 13 , 14 , 15 . We conclude that continued widespread use of EDNOS would be unhelpful and potentially harmful.

A number of proposals have been made to reduce the reliance on EDNOS. Most proposals include broadening of diagnostic criteria for anorexia and bulimia nervosa so that they subsume a proportion of cases currently diagnosed with EDNOS. The proposed expansions of criteria for anorexia nervosa include: dropping the requirement for amenorrhoea, relaxing the underweight criterion, and relaxing the requirement for fear of weight gain. The proposed broadening of criteria for bulimia nervosa include reducing the frequency requirement for bingeing and compensatory behaviour, and dropping the binge “objectivity” criterion (requirement that a binge involves eating an unusually large amount of food). Preliminary studies in adolescents and adults indicate that dropping the binge objectivity criterion has the greatest impact on reducing the use of the residual category 29 , 84 . Depending on the degree of broadening, the extended categories can reduce the use of EDNOS moderately 68 , 89 or nearly eliminate its use 90 .

The other set of proposals include introducing more specific diagnostic categories. There is most support for the introduction of binge eating disorder 91 , 92 . Other proposed additional categories include purging disorder 93 and night eating syndrome 94 . A mixed category of eating disorder with features of both anorexia and bulimia nervosa has been proposed to capture the cases that do not easily fit the prototype of one specific eating disorder 95 . Finally, there is a proposal that includes relaxing the strict requirement that all defining symptoms must be present to make a diagnosis and suggests a list of symptoms of which one or more needs to be present to fulfil a diagnostic criterion 96 .

While all of the above proposals appear sensible and each would reduce the need for EDNOS, it is difficult to estimate the impact of combining aspects of the various proposals. There are also problems with adopting some of the proposals entirely. For example, the alternative classification system proposed by Hebebrand and Bulik 96 represents conceptually the strongest departure from current classification, by removing the requirement for all symptoms to be present, but it only concerns anorexia nervosa and it allows relatively nonspecific symptoms such as irritability and depressed mood to count towards the diagnosis, raising concerns about how well it would differentiate against disorders from other groupings. On balance, we favour the combination of introducing binge eating disorder as an additional specific category with substantial broadening of diagnostic criteria, similar to the proposal by Walsh and Sysko 97 , which has been shown to nearly eliminate the use of EDNOS 90 and is consistent with recent trends in clinical trial literature (Table ​ (Table1). 1 ).

It is unclear whether purging disorder or night eating syndrome will still be needed when the criteria for anorexia nervosa, bulimia nervosa and binge eating disorder are broadened. The available evidence suggests that most individuals with purging disorder have subjective binges, therefore the removal of requirement for an unusually large amount of food to be eaten during a binge may be sufficient to classify most of these subjects as bulimia nervosa, which does not differ from purging disorder in terms of impairment and response to treatment 12 , 98 . Most cases of night eating syndrome can be subsumed under the broad category of binge eating disorder. The one remaining issue concerns cases that frequently change presentation and sequentially fulfil criteria for different eating disorders. Following suggestions by Fairburn 95 , we support the use of a mixed category. However, to avoid redundancy when implemented alongside broader specific categories, we propose reserving such category for the relatively severe cases that fulfil criteria for both anorexia and bulimia nervosa either concurrently or sequentially. This category may be more appropriately called “combined” rather than “mixed” eating disorder.

ANOREXIA NERVOSA

Anorexia nervosa is the prototypical eating disorder that has been consistently described since the 19th century 99 , 100 . In ICD-10 and DSM-IV, it is defined by four criteria, all of which are required for diagnosis. Three of these are essentially the same in the two systems: low body weight (maintained at body mass index, BMI<17.5 or under 85% of weight expected for height, age and sex), body image disturbance and amenorrhoea. The fourth criterion differs between the two classifications: in ICD-10, it is a requirement that low weight is self-induced through dietary restriction and/or purging behaviour; in DSM-IV, intense fear of gaining weight or becoming fat is required. In DSM-IV, anorexia nervosa is further divided into restrictive and binge-eating/purging subtypes.

These classifications have been criticized for several reasons. First, the requirement of all four criteria excludes a significant proportion of clinical presentations that fit the prototype of anorexia nervosa. The requirements of amenorrhoea, low body weight threshold, and fat phobia have all been criticized on this ground. Second, these criteria are insensitive to cultural variations; fear of gaining weight is reported by a smaller proportion of cases in non-Western cultures. Third, it has been argued that extant criteria omit hyperactivity, which is a salient feature in the presentation of anorexia nervosa 96 . The problems with present diagnostic criteria are reflected in the fact that most recent clinical trials have used broader inclusion criteria, mostly relaxing the weight and amenorrhoea criteria (Table ​ (Table1). 1 ). We will first review the rationale for retaining or dropping each specific criterion and then move to the diagnostic concept and proposals for revision.

Amenorrhoea, defined as absence of three consecutive menstrual bleedings, is a common feature of anorexia nervosa that is strongly associated with underweight and excessive exercise and may have prognostic implications for bone mineral density and fertility outcomes. However, several facts make amenorrhoea problematic as a diagnostic criterion. First, it is not applicable to girls prior to menarche, to post-menopausal women, women taking hormonal preparations and men. The ICD-10 has proposed a male equivalent of hormonal disturbance manifest as “loss of sexual interest and potency”, which is however rarely assessed or researched and whose contribution to the diagnosis is unclear. Second, a significant minority of women (5 to 25% in clinical samples) who otherwise fulfil criteria for anorexia nervosa and require clinical attention menstruate and consequently are classified as EDNOS. Third, the requirement of missing three consecutive menstrual bleedings interferes with timely diagnosis and treatment. There is a broad agreement that amenorrhoea should not be required for the diagnosis of anorexia nervosa, but should be recorded since it may be an indicator of severity and may help distinguish between constitutional thinness and anorexia nervosa 101 .

The low weight criterion is the defining feature of anorexia nervosa, but its exact specification has been discussed. A number of women who fit the prototype of anorexia nervosa narrowly miss the weight criterion of BMI<17.5 (or body weight less than 85% of what is expected for age and height) and are classified as EDNOS. Depending on body constitution, the above threshold for underweight may be seen as too high or too low in individual cases. Therefore, it has been proposed that this threshold should be relaxed and/or left to clinical judgement (www.dsm5.org). This proposal has the advantage of reducing the use of the uninformative EDNOS, but risks loss of objectivity and important information. Severe underweight has been repeatedly shown to be a strong predictor of poor prognosis and mortality 102 , 103 , 104 , 105 and is routinely used as an indication for inpatient treatment. We propose relaxing the underweight criterion to the WHO definition of underweight (BMI<18.5) with a room for clinical judgement, and recording a history of severe underweight (e.g., BMI<14.0) as a severity qualifier (with dangerously low body weight). Low body weight is only considered a symptom of anorexia nervosa if it is due the individual’s eating behaviour rather than factors such as a medical condition or unavailability of food.

Morbid fear of gaining weight is required for diagnosing anorexia nervosa in the DSM-IV. In the ICD-10, fear of fatness is included under the body-image distortion criterion. This has been perhaps the most discussed criterion. The requirement of fear of fatness is problematic from both a developmental and a cultural perspective. Developmentally, fear of gaining weight is rarely reported by children and may require an ability of abstract reasoning that only develops during adolescence 32 . Cross-culturally, females with otherwise typical anorexia nervosa in non-Western countries less frequently report fear of fatness as the reason for self starvation 48 , 106 . Even in Western countries, a significant minority of patients report no fear of weight gain and are consequently classified as EDNOS 106 , 107 , 108 . It has also been pointed out that fat phobia often emerges during weight restoration in patients who previously denied any fear of gaining weight 51 . The dependency on development, culture and illness stage argues against the usefulness of weight phobia as a diagnostic criterion. However, it has also been argued that fear of weight gain is part of the core defining psychopathology of anorexia nervosa 109 . We propose extending this criterion to include preoccupation with body weight and shape, preoccupations with food and nutrition, and persistent behaviours that are intended to reduce energy intake or increase energy expenditure.

Body image disturbance is a striking aspect of anorexia nervosa and is required in both ICD-10 and DSM-IV. It includes both the perception of own body or its parts as larger than they are and the lack of recognition of the seriousness of underweight. Body image disturbance often precedes other symptoms and its persistence upon weight recovery has prognostic significance. Only minor rephrasing of this criterion has been recommended for DSM-5 and we agree with retaining this criterion essentially unchanged. Cases of restrictive eating with no body image related psychopathology may better be classified as ARFID.

Hyperactivity is a remarkable feature of many cases of anorexia nervosa and is a differentiator from other causes of starvation. Hyperactivity is not among the criteria in either ICD-10 or DSM-IV. Its inclusion under the behavioural indicators of anorexia nervosa has been recommended 96 . However, since hyperactivity is not universally present in all cases of otherwise typical anorexia nervosa and its manifestation may depend on stage of illness, we propose to include it as a supporting criterion, which may help differentiate between anorexia nervosa and normality in cases with borderline underweight.

In the DSM-IV, anorexia nervosa is further classified into restrictive and binge-eating/purging subtypes according to the presence of bingeing and purging behaviours. This subtyping has been criticized since the subtypes often represent developmental stages of the same illness and do not consistently predict outcome 69 . While children and younger adolescents usually present with restrictive symptomatology, binge-purging behaviours develop in the majority at later stages 69 , 110 . Purging behaviour has been found to predict poor outcome in some studies but not in others 69 , 105 , 110 . Binge-purge anorexia nervosa has a high rate of diagnostic transitions with bulimia nervosa 68 , 70 . To avoid repeated diagnosis changes, we propose that anorexia nervosa with bingeing and purging behaviour should be classified as combined eating disorder. The proposed category of “combined eating disorder” will include cases that were classified as anorexia nervosa, binge-purge subtype as well as cases that display clinically significant anorectic and bulimic symptomatology sequentially.

BULIMIA NERVOSA

Bulimia nervosa was first described in 1979 as a variant of anorexia nervosa 111 , and soon afterwards was accepted as a separate diagnosis. In ICD-10 and DSM-IV, bulimia nervosa is defined by three criteria: recurrent binge eating, recurrent compensatory behaviour, and preoccupation with own body weight or shape, all of which are required for making the diagnosis.

Overall, bulimia nervosa is a valid category 112 that is used in practice 113 , and its treatment has a broad evidence base 114 . However, various aspects of the binge eating criterion have been criticized for making the diagnosis too restrictive and resulting in a substantial proportion of patients with bulimia-like problems classified as EDNOS. The need for a broader diagnostic category is reflected in the clinical trial literature, with eight of the eleven recent trials using broader criteria (Table ​ (Table1). 1 ). The two aspects of the definition that have been relaxed in these trials and discussed in the literature are the amount of food eaten in a binge eating episode and the frequency of binge-purge behaviours.

We first consider the amount of food eaten. Both ICD-10 and DSM-IV specify that binge eating is only present when an unusually large amount of food is eaten in one go and the subject experiences loss of control over eating (i.e., feels unable to stop eating or limit the amount or type of food eaten). However, a number of reports have highlighted the fact that many patients report eating amounts of food that may objectively appear normal, but are subjectively considered too large 115 , 116 . Episodes of eating that are accompanied by subjective loss of control but do not involve eating an unusually large amount of food are described as “subjective” binges 117 . A number of studies have compared patients presenting with “subjective” and “objective” binges and found little or no clinically meaningful differences 116 , 118 , 119 , 120 , 121 . While objective binge eating episodes may be associated with higher body mass index 116 , 119 and impulsivity 118 , subjective and objective binge eating episodes show a similar pattern of psychiatric comorbidity 116 , 118 , 119 , 120 , 121 , 122 , are associated with similar levels of service utilization 116 , 119 and have a similar response to treatment 12 , 120 . The literature suggests that subjective experience of loss of control over eating is the core defining feature of binge eating that is associated with psychopathology and quality of life, irrespective of the amount of food eaten, in both adults 122 , 123 and children 124 . It has therefore been proposed that the requirement for an unusually large amount of food should be removed 116 , 119 . Dropping the requirement for an unusually large amount of food is the one modification that strongly reduces the use of EDNOS and allows most bulimia-like presentations to be classified as bulimia nervosa 29 , 84 , 90 .

The other contentious aspect of the diagnostic criteria is the frequency of bingeing and purging behaviour that is required for the diagnosis. This criterion is handled differently in ICD-10 and DSM-IV. While ICD-10 simply requires binge eating and compensatory behaviours to be repeated, DSM-IV specifies a minimum frequency of two binge-eating/purging episodes per week for at least three months. Although there is a general consensus that the diagnosis should not be applied to cases with infrequent episodes of binge eating, there is no evidence supporting a specific frequency, and most researchers and clinicians suggest either removing or lowering the frequency criterion 125 . Since there appear to be no meaningful differences between subjects who binge-eat twice or more versus those who binge eat once a week 126 , a lowering or loosening of the frequency criterion appears to be in order. Although lowering the frequency requirement to once a week on its own has a relatively modest effect, in conjunction with allowing subjective binge eating episodes it leads to a substantial reduction in the use of EDNOS 29 , 90 .

The requirement for dread of fatness (ICD-10) or an undue influence of body weight and shape on self-evaluation (DSM-IV) is adequate in most Western adult settings, but may be problematic in children and in non-Western cultures 28 , 32 . It is proposed that this criterion be applied flexibly, include developmental-stage and culture-specific manifestations, and regard behavioural equivalents as indicators of eating-disorder specific psychopathology 32 , 42 .

In the DSM-IV, bulimia nervosa is further classified into purging and non-purging subtypes. The non-purging subtype is defined by compensatory behaviours that are limited to fasting and exercising and represent a relatively small minority of patients with bulimia nervosa. In practice, subtyping of bulimia nervosa is little used 113 and there is virtually no evidence to support its validity or utility 127 . In terms of severity, non-purging bulimia nervosa appears to be intermediate between purging bulimia nervosa and binge eating disorder 127 . It has been proposed to either abandon subtyping or to remove the non-purging behaviours from the list of inappropriate compensatory behaviours that define bulimia nervosa 127 . Adopting the latter proposal would mean that cases previously classified as non-purging bulimia would be diagnosed as binge eating disorder. An alternative proposal has been made to subtype bulimia nervosa based on the history of anorexia nervosa, which has more predictive validity 75 . We think this proposal can be applied as part of the combined eating disorder. In the absence of evidence either way, we favour retaining non-purgative compensatory behaviours in the definition of bulimia nervosa.

BINGE EATING DISORDER

Binge eating disorder, characterized by recurrent binge eating without compensatory behaviours, was described in 1959, but only became a focus of clinical and research attention in the last two decades. It was not included in ICD-10, but was listed in DSM-IV as a provisional diagnosis in need of further testing. Since then, a large body of research has accumulated, and binge eating disorder is now considered a valid and useful category 91 , 92 .

Binge eating disorder is strongly associated with obesity, with approximately two-thirds of affected individuals being obese. Binge eating disorder frequently co-occurs with other mental disorders, especially anxiety and depression 128 , yet has been found to be distinct from these and not a mere indicator of general psychopathology 129 . The distinction between binge eating disorder and bulimia nervosa is less clear-cut and in many cases the two categories may represent different stages of the same disorder 65 , 68 . Patients with binge eating disorder are on average older than those of bulimia nervosa, and approximately two-thirds have a history of using inappropriate compensatory behaviours, suggesting a past diagnosis of bulimia nervosa 130 . Although weight and shape concerns are not required for the diagnosis of binge eating disorder, they are commonly part of the presentation 131 , 132 .

As in bulimia nervosa, the specific diagnostic criteria for binge eating disorder have been a subject of discussion. In DSM-IV, it was required that binge eating episodes consist in eating an amount of food that is definitely larger than what most individuals would eat in a similar situation, and that the individual experiences loss of control over eating (i.e., feels unable to stop eating or limit the amount or type of food eaten). However, similar to binges in bulimia nervosa, it was found that loss of control is the core defining feature of binging 133 . Although the amount of food eaten is often large, it is less useful as a defining factor, because binges involving eating amounts of food that are objectively not unusually large but are considered large by the individual are associated with similar psychopathology and impairment 133 . In addition, binge eating is frequently characterized by eating alone because of embarrassment, eating other types of foods, and feelings of guilt and disgust. DSM-IV requires that binge eating is associated with distress, and the validity of this additional criterion is generally supported 134 .

The duration of a binge varies. Most episodes of binge eating last less than two hours, but extended binge eating has been described as binge days. The DSM-IV further required that binge eating be present in at least two days per week for at least six months. There appears to be little evidence supporting this frequency and the unusually long requested duration. Since binge eating disorder is often associated with rapid weight gain, waiting six months before establishing the diagnosis may be contraproductive. It has been shown that relaxing the frequency criterion to once a week would lead to only small increase in the rate of binge eating disorder 135 .

In summary, there is a consensus that binge eating disorder is a valid and useful diagnosis. It is proposed that binge eating disorder be included in ICD-11. It is also proposed that the diagnostic criteria for binge eating disorder be broadened to include binges that do not involve eating an unusually large amount of food as long as there is definite loss of control over eating, binge eating is distinct from regular eating patterns and causes distress 97 , 116 . There is no specific evidence to override the proposed uniform duration criterion. Therefore, the diagnosis of binge eating disorder may be appropriate if binge eating occurs regularly for at least four weeks. In less severe cases, longer duration may be needed to establish clinical significance.

EATING AND FEEDING DISORDERS DUE TO OTHER CONDITIONS WITH A KNOWN CA

In addition to the feeding and eating disorders described above, the ICD-11 chapter should include a reference to disorders that are classified elsewhere but may primarily manifests with disordered eating. The most prominent example is Prader-Willi syndrome, which is caused by a deletion of the paternal copy of a region on chromosome 15, and is primarily classified in chapter XVII of ICD-10 (Congenital malformations, deformations and chromosomal abnormalities). This syndrome often presents with insatiable appetite, overeating, food hoarding and eating of non-food substances, but also includes intellectual disability.

CONCLUSIONS

We have reviewed published evidence relevant to the classification of feeding and eating disorders, with particular emphasis on clinical utility, response to treatment, prognosis, and developmental and cultural context. Based on this evidence, we make recommendations consistent with the general directions for the development of ICD-11. The principal recommendations are listed in Table ​ Table2 2 .

Table 2 Recommendations for the classification of feeding and eating disorders in ICD-11

We hope that the proposed changes will substantially improve the clinical utility of the classification of feeding and eating disorders, will eliminate the need for using uninformative “not otherwise specified” diagnoses, and will stimulate research on continuity between child and adult presentations and on treatment efficacy in groups of patients that represent the vast majority of those presenting with eating related psychopathology in routine clinical settings.

Acknowledgements

This article has been informed by the activity of the Working Group on Classification of Mental and Behavioural Disorders in Children and Adolescents, referring to the International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders. M. Rutter is the chair of this working group. R. Uher works for this group as a consultant. This manuscript reflects the work and opinions of the authors, who take full responsibility for its content. The authors thank U. Schmidt, I. Campbell and B.T. Walsh for their comments on earlier versions of this manuscript.

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A psychiatric illness in which the patients starve themselves or use other techniques, such as vomiting or taking laxatives, to induce weight loss. To fulfil ICD-10 criteria for anorexia nervosa a patient must have a distorted body image (thinking they are overweight when they are not), a defined weight loss or body mass index reduction, amenorrhoea, and vomiting or purging. The illness is most common in female adolescents, but about 10% of sufferers are male. There is a significant mortality associated with anorexia nervosa because of the medical consequences of weight loss. The causes of the illness are not well understood: problems within the family, rejection of adult sexuality, self-harming behaviour in the context of a borderline-type emotionally unstable personality disorder, and performance pressure are hypothesized as factors involved. Patients must be persuaded to eat enough to maintain a normal body weight and their emotional disturbance is usually treated with psychotherapy supported by a dietitian and possibly the community mental health team. See also bulimia.

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Eating disorders: When should I suspect an eating disorder?

Last revised in July 2019

When should I suspect an eating disorder?

  • Unusually low or high BMI for their age (including children with faltering growth).
  • Rapid weight loss.
  • Change in eating behaviour including dieting or restrictive eating practices that are causing concern to the person, their family/carers, or other professionals.
  • Mental health problems (such as stress, anxiety and depression) or social withdrawal.
  • Disproportionate concern about body weight or shape.
  • Poor control of chronic diseases affected by diet (such as diabetes or coeliac disease).
  • Menstrual or other endocrine disturbances.
  • Unexplained gastrointestinal symptoms, electrolyte imbalance or hypoglycaemia.
  • Physical signs of malnutrition (such as poor circulation, dizziness, palpitations, fainting or pallor) or compensatory behaviours such as laxative misuse, vomiting or excessive exercise.
  • Risk in young men and women is highest between 13 and 17 years of age.
  • Some people may talk openly about an eating disorder, others might be unaware that they have one or find it too difficult to disclose.
  • Some occupational or recreational activities are associated with a greater risk of eating disorder such as professional sport, fashion, dance, and modelling.
  • Other causes must be excluded but clinicians should have a high index of suspicion in people presenting with weight loss, faltering growth, delayed puberty or menstrual irregularities.
  • For more information, see the CKS topic on  Faltering growth .
  • Clinical features of anorexia nervosa .
  • Clinical features of bulimia nervosa .
  • Clinical features of binge eating disorder .
  • Clinical features of atypical eating disorders .

Clinical features of anorexia nervosa

  • Low weight is defined as less than minimally normal in adults (typically BMI less than 18.5) or minimally expected in children and young people (typically BMI-for-age less than the 5th percentile on an appropriate growth chart).
  • Preoccupation with food and weight is often related to a pursuit of thinness, or later in the course of illness, a fear of gaining weight.
  • Changes in behaviour may be noticed for example becoming increasingly selective about food, avoiding eating with others, saying they aren't hungry, that they have already eaten, or refusing food they used to enjoy.
  • Other behaviours may include repeated weighing, measuring and checking in the mirror.
  • Compensatory behaviours such as self-induced purging (by vomiting or misuse of laxatives), excessive exercise, and use of appetite suppressant medication or diuretics may be present.
  • Distortion of body image, with a dread of being overweight.
  • Low self-esteem and a drive for perfection.
  • Over-evaluation of self-worth in terms of body weight and shape.
  • Many people with anorexia nervosa have difficulty acknowledging there is a problem, do not consider themselves to be ill and may be ambivalent about change.
  • In others, there may be secrecy about the symptoms, for example hiding weight loss.
  • Females with anorexia nervosa may present with amenorrhoea or other menstrual irregularities.
  • Hormonal disturbance is a common feature of anorexia nervosa but amenorrhea is no longer in the criteria for diagnosis in females and is only one of a number of markers of hormonal insufficiency due to low weight.
  • Males with anorexia nervosa may present with loss of libido and potency.
  • In children, onset of puberty, growth and physical development can be affected.
  • For more information, see the section on Complications .

Clinical features of bulimia nervosa

  • A binge is defined as consuming an excessive amount of food in a discreet time period accompanied by a sense of loss of control over eating at that time.
  • In-between binges there are also typically continuing attempts to restrict eating.
  • Compensatory behaviours include vomiting, purging, fasting, excessive exercise, laxative, diuretic or diet pill use.
  • Bulimia nervosa may be kept secret for many years, as the person’s appearance is typically unremarkable and they can often eat normally in public.
  • Many people delay seeking help because of the shame associated with binge eating or because they do not know that treatment is available.
  • Fear of gaining weight, with a sharply defined weight threshold set by the person.
  • Mood disturbance and symptoms of anxiety and tension.
  • Persistent preoccupation and craving for food and feelings of guilt and shame about binge eating.
  • Self-harm, often by scratching or cutting.
  • In severe cases, physical signs may include Russell's sign (knuckle calluses from inducing vomiting), dental enamel erosion, and salivary gland enlargement.

Clinical features of binge eating disorder

  • A binge is defined as consuming an excessive amount of food in a discreet time period accompanied by a feeling of loss of control where the person cannot stop eating or control the amount of food they eat at that time.
  • During a binge the person may eat more rapidly than normal, eat until uncomfortably full or when not hungry and experience significant distress and feelings of guilt and shame.
  • Many people with binge eating disorder are overweight or obese.

Clinical features of atypical eating disorders

  • The majority of eating disorders are atypical.
  • Over-concern with body weight and shape is generally present.
  • Many people with atypical eating disorders have had anorexia or bulimia nervosa previously or may in the future develop the full diagnostic criteria for anorexia or bulimia nervosa.

Basis for recommendation

The information on the clinical features of eating disorders is based on the Diagnostic and statistical manual of mental disorders: DSM-5 [ APA, 2013 ], clinical guidance Junior MARSIPAN: Management of Really Sick Patients under 18 with Anorexia Nervosa [ Royal College of Psychiatrists, 2012 ],  Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of eating disorders [ Hay, 2014 ],  MARSIPAN: Management of really sick patients with anorexia nervosa. 2nd edition [ Royal College of Psychiatrists, 2014 ],  Practice parameter for the assessment and treatment of children and adolescents with eating disorders [ Lock, 2015 ] and Eating disorders: recognition and treatment [ NICE, 2017 ], a Position statement on early intervention for eating disorders [ Royal College of Psychiatrists, 2019 ] and expert opinion in review articles [ Campbell, 2014 ; Bould, 2015 ; Zipfel, 2015 ; Montano, 2016 ; Allison, 2017 ; Rowe, 2017 ; Wassenaar, 2018 ].

  • Most people with an eating disorder are of normal weight or above and it is important to note that many go undiagnosed and may present many years after onset.

The content on the NICE Clinical Knowledge Summaries site (CKS) is the copyright of Clarity Informatics Limited (trading as Agilio Software Primary Care) . By using CKS, you agree to the licence set out in the CKS End User Licence Agreement .

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Home / Mental Health / What is disordered eating and when does it become an eating disorder?

What is disordered eating and when does it become an eating disorder?

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anorexia nervosa icd 10 criteria

Disordered eating refers to a wide range of behaviors that involve eating in a way that prevents full participation in life activities or impairs healthy growth and development. At best, disordered eating can lead to physical and psychological symptoms in children and teens. At worst, disordered eating can develop into an eating disorder. Eating disorders refer to a number of related mental illness diagnoses that affect millions of Americans each year. If left untreated they can become life-threatening. Eating disorders have one of the highest rates of death associated with them of any mental health diagnosis. Though the phrase “ disordered eating” can be used to describe a range of problematic eating behaviors, there are specific criteria for eating disorders defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5 TR). These include anorexia nervosa, bulimia nervosa, binge eating disorder, avoidant restrictive food intake disorder (ARFID), and other specified feeding and eating disorders.

Who is most at risk for eating disorders?

“More and more, our data suggests that eating disorders are much more equal opportunity and affect a much broader range of individuals than the stereotypical white, cisgender, wealthy, emaciated adolescent girl,” states Dr. Jocelyn Lebow, Ph.D., L.P., a clinical psychologist at Mayo Clinic in Rochester, Minnesota. Eating disorders affect people of all gender identities, ethnicities, cultures, ages and body sizes.

What causes eating disorders?

A variety of factors increase the risk of eating disorders including family history, trauma, weight-related bullying and many mental health diagnoses such as obsessive-compulsive disorder. People who identify as transgender or nonbinary also are at increased risk. One of the biggest risk factors, Dr. Lebow stresses, is any sort of dieting or food restriction, even when these behaviors begin as a result of good intentions to “get healthier” or even in response to advice from professionals. Certain sports where size or weight plays a role also can put young athletes at risk. Weight bias also increases the risk of eating disorders, which is important, as more than 40% of American adults report having faced some sort of stigma, teasing or unfair treatment related to their weight, according to the American Psychological Association. Additional culprits may include individual biology and personality traits, environmental triggers such as trauma, and societal influence including social media and the too-common unspoken narrative that “thin = good,” which is often referred to as the “thin ideal.”

When does being health-conscious cross over into eating disorder risk?

“In kids, one of the signs that eating behaviors have crossed the line is when we see a large deviation from their growth curve or trend. This doesn ‘ t just happen with weight loss; we also see it when kids stop making the gains in height or weight we’d expect based on their age,” says Dr. Lebow. Additional physiological warning signs can include:

* Changes to or even the loss of a period in girls.

* Abnormal lab values or negative change to vital signs.

* A stress fracture or other injury that indicates loss of bone strength.

Those symptoms occur frequently, but an eating disorder may still be present even if things look clinically normal.

Behaviorally, disordered eating often presents as inflexibility or rigidity around diet and exercise. For example:

* Are eating or exercise habits so rigid that they interfere with normal activities or functioning?

* Does the thought of eating certain foods provoke anxiety or fear?

* Can all different kinds of foods be enjoyed without significant guilt or overthinking?

Impairment or impact on life is key to look for. Although physiological markers also can be present in adults, someone is likely to be quite ill by the time they show up.

How can I address my concern about their eating with a family member or friend?

“There’s no guarantee it’s going to go well. That doesn’t mean you shouldn’t say something if you are worried,” states Dr. Lebow. She emphasizes the ideal approach should be free of blame or judgement, as eating disorders often are characterized by a lot of shame and suffering for the people who have them. Concerned friends and family should take a compassionate, respectful and direct approach. For example: “I’m concerned. I’m noticing you’re not eating very much. Do you think it might be a good idea to talk to your doctor about this?” This type of conversation, of course, depends on your relationship. If it is a child you’re concerned about, talk to their parent or guardian privately first.

What does treatment look like?

If you or a family member believes you may need treatment for an eating disorder, start with your primary care provider. They should be able to make an assessment, ensure your medical stability and determine the best treatment type. Treatment for eating disorders may occur in an outpatient, day treatment, inpatient or residential setting. Seek out a therapist and a registered dietitian who specializes in eating disorders. Eating disorder treatment is not something all therapists and dieticians are trained to do.

In children, family-based treatment (FBT) is the first line treatment for anorexia nervosa, while bulimia nervosa may be addressed through family-based treatment (FBT), enhanced cognitive behavioral therapy (CBT-E), dialectical behavior therapy (DBT), and acceptance and commitment therapy (ACT). For adults with anorexia nervosa, there are unfortunately no evidence-based outpatient approaches. Many adults with anorexia nervosa need to be treated in higher levels of care, like day treatment or residential programs. For adults with bulimia nervosa or binge-eating disorder, options include enhanced cognitive behavioral therapy (CBT-E), dialectical behavior therapy (DBT), acceptance and commitment therapy (ACT), or integrative cognitive-affective therapy (ICAT). Intervention options and recommendations are dependent on age, diagnosis, health status and severity.

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  3. Anorexia Nervosa Diagnostic Criteria ICD-10 v DSM-5

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  4. Anorexia Nervosa

    anorexia nervosa icd 10 criteria

  5. Eating disorders

    anorexia nervosa icd 10 criteria

  6. Initial Evaluation, Diagnosis, and Treatment of Anorexia Nervosa and

    anorexia nervosa icd 10 criteria

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  6. [by Request] Anorexia Nervosa 厭食症 by Dr. Patrick Cheung (Jan 2021)

COMMENTS

  1. Anorexia Nervosa: Symptoms and ICD Diagnostic Criteria

    Diagnostic Guidelines For a definite diagnosis, all the following are required: Body weight is maintained at least 15% below that expected (either lost or never achieved), or Quetelet's body-mass index is 17.5 or less. Prepubertal patients may show failure to make the expected weight gain during the period of growth.

  2. 2024 ICD-10-CM Diagnosis Code F50.00: Anorexia nervosa, unspecified

    F50.00 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2024 edition of ICD-10-CM F50.00 became effective on October 1, 2023. This is the American ICD-10-CM version of F50.00 - other international versions of ICD-10 F50.00 may differ.

  3. Initial Evaluation, Diagnosis, and Treatment of Anorexia Nervosa and

    The DSM-5 diagnostic criteria for anorexia nervosa ( Table 1 3 ) are similar to the previous DSM-IV criteria with respect to behavioral and psychological characteristics involving...

  4. The Diagnosis and Treatment of Eating Disorders

    Anorexia and bulimia nervosa are diagnosed according to the ICD-10 criteria (International Classification of Diseases), binge-eating disorder according to those of the DSM (Diagnostic and Statistical Manual of Mental Disorders).

  5. PDF Initial Evaluation, Diagnosis, and Treatment of Anorexia Nervosa and

    The ICD-9-CM code for anorexia nervosa is . 307.1, which is assigned regardless of the subtype. The ICD-10-CM ... After full criteria for anorexia nervosa were previously met, Criterion A (low ...

  6. 2024 ICD-10-CM Diagnosis Code F50.9

    F50.9 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2024 edition of ICD-10-CM F50.9 became effective on October 1, 2023. This is the American ICD-10-CM version of F50.9 - other international versions of ICD-10 F50.9 may differ. Applicable To Atypical anorexia nervosa

  7. Anorexia Nervosa

    Anorexia nervosa occurs predominantly in girls and young women. Onset is usually during adolescence and rarely after age 40. Two types of anorexia nervosa are recognized: Restricting type: Patients restrict food intake but do not regularly engage in binge eating or purging behavior; some patients exercise excessively.

  8. PDF Anorexia nervosa: aetiology, assessment, and treatment

    overview of diagnostic criteria for anorexia nervosa according to DSM 2 and ICD11. Restricting and binge-purge subtypes and remission and severity specifi ers exist. Amenorrhoea is no longer required in the new DSM-5 diagnostic criteria and is also expected to be dropped in ICD-11.12 Main reasons for eliminating this criterion are

  9. Anorexia Nervosa: Definition, Epidemiology, and Cycle of Risk

    TABLE 1. Comparison of diagnostic criteria for anorexia nervosa: DSM-IV and ICD-10 DSM-IV ICD-10 Code 307.1 F50.0 Weight —Refusal to maintain body weight at or above minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight < 85% of expected weight) OR —Failure to make expected weight gain during

  10. Anorexia Nervosa: Diagnostic Criteria, Symptoms, Causes

    Constipation, bloating, and stomach pains. Dehydration. Distorted body image. Dizzy spells and faintness. Extreme tiredness (fatigue) Extremely restrictive eating. Intense fear of gaining weight. Loss of periods or failure to begin a menstrual cycle. Loss or fluctuation of body fat and muscle.

  11. Diagnosis and Assessment Issues in Eating Disorders

    Moreover, diagnosis is further complicated by the differences in criteria outlined in DSM-5 and ICD-10 (Table). Many applaud the recognition of binge eating disorder in DSM-5 as a major improvement in the field, but it does not have its own code in ICD-10. Anorexia nervosa. Anorexia nervosa was first included in DSM-III and ICD-9.

  12. Classification of feeding and eating disorders: review of evidence and

    In ICD-10, atypical anorexia nervosa is defined as a condition that resembles anorexia nervosa, but does not fulfil all of the diagnostic criteria (e.g., there is no amenorrhoea or not a sufficient degree of weight loss). ... The proposed expansions of criteria for anorexia nervosa include: dropping the requirement for amenorrhoea, relaxing the ...

  13. 2024 ICD-10-CM Diagnosis Code F50.0: Anorexia nervosa

    Clinical Information A disorder most often seen in adolescent females characterized by a refusal to maintain a minimally normal body weight, an intense fear of gaining weight, a disturbance in body image, and, in postmenarcheal females, the development of amenorrhea.

  14. ICD-10-CM Code F50.0

    Section F50-F59 Code F50.0 Copy ICD-10-CM Code F50.0 Anorexia nervosa NON-BILLABLE | ICD-10 from 2011 - 2016 ICD Code F50.0 is a non-billable code. To code a diagnosis of this type, you must use one of the three child codes of F50.0 that describes the diagnosis 'anorexia nervosa' in more detail. F50.0 Anorexia nervosa

  15. 2024 ICD-10-CM Diagnosis Code R63.0: Anorexia

    R63 Symptoms and signs concerning food and fluid intake Approximate Synonyms Loss of appetite Clinical Information A disorder characterized by a loss of appetite. An abnormal loss of the appetite for food. Anorexia can be caused by cancer, aids, a mental disorder (i.e., anorexia nervosa), or other diseases.

  16. Anorexia nervosa

    To fulfil ICD-10 criteria for anorexia nervosa a patient must have a distorted body image (thinking they are overweight when they are not), a defined weight loss or body mass index reduction, amenorrhoea, and vomiting or purging. The illness is most common in female adolescents, but about 10% of sufferers are male.

  17. ICD-10-CM Code for Anorexia nervosa F50.0

    ICD-10 code F50.0 for Anorexia nervosa is a medical classification as listed by WHO under the range - Mental, Behavioral and Neurodevelopmental disorders . Official Long Descriptor Anorexia nervosa Excludes1: loss of appetite ( R63.0) psychogenic loss of appetite ( F50.89) F50 Excludes1: anorexia NOS ( R63.0) feeding problems of newborn ( P92 .-)

  18. ICD-10-CM Diagnosis Code F50.01

    ( F50-F59) Eating disorders ( F50) F50.01 is a billable diagnosis code used to specify a medical diagnosis of anorexia nervosa, restricting type. The code is valid during the current fiscal year for the submission of HIPAA-covered transactions from October 01, 2023 through September 30, 2024. Approximate Synonyms

  19. Clinical features

    Clinical features of anorexia nervosa. Restriction of energy intake resulting in low body weight. Low weight is defined as less than minimally normal in adults (typically BMI less than 18.5) or minimally expected in children and young people (typically BMI-for-age less than the 5th percentile on an appropriate growth chart).

  20. Anorexia nervosa: aetiology, assessment, and treatment

    Anorexia nervosa is an important cause of physical and psychosocial morbidity. Recent years have brought advances in understanding of the underlying psychobiology that contributes to illness onset and maintenance. Genetic factors influence risk, psychosocial and interpersonal factors can trigger onset, and changes in neural networks can sustain the illness. Substantial advances in treatment ...

  21. What is disordered eating and when does it become an eating disorder

    Though the phrase "disordered eating" can be used to describe a range of problematic eating behaviors, there are specific criteria for eating disorders defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5 TR). These include anorexia nervosa, bulimia nervosa, binge eating disorder, avoidant restrictive food intake ...

  22. ICD-10-CM Diagnosis Code F50.0

    FY 2016 - New Code, effective from 10/1/2015 through 9/30/2016. This was the first year ICD-10-CM was implemented into the HIPAA code set. Previous Code: F50. Parent Code: F50. F50.0 is a non-billable diagnosis code for anorexia nervosa, use codes with a higher level of specificity: F50.00, F50.01 or F50.02.

  23. ICD-10-CM Code for Anorexia nervosa, restricting type F50.01

    ICD-10 code F50.01 for Anorexia nervosa, restricting type is a medical classification as listed by WHO under the range - Mental, Behavioral and Neurodevelopmental disorders . Official Long Descriptor Anorexia nervosa, restricting type F50.0 Excludes1: loss of appetite ( R63.0) psychogenic loss of appetite ( F50.89) F50

  24. 2024 ICD-10-CM Diagnosis Code F50.01: Anorexia nervosa, restricting type

    F01-F99 Mental, Behavioral and Neurodevelopmental disorders F50 Eating disorders F50.0 Anorexia nervosa Approximate Synonyms Anorexia nervosa Anorexia nervosa, restricting subtype Anorexia nervosa, restricting type, extreme Anorexia nervosa, restricting type, in full remission Anorexia nervosa, restricting type, in partial remission