How can we best classify eating disorders in the medical community?

Eating disorders are serious, complex and potentially life-threatening mental illnesses. They are characterised by disturbances in behaviours, thoughts and attitudes to food, eating, and body weight or shape. Eating disorders have detrimental impacts upon a person’s life and result in serious medical, psychiatric and psychosocial consequences.

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Long-term impacts
Classification of eating disorders

Eating disorders are common and increasing in prevalence. There is a lifetime estimated prevalence of 8.4% for women and 2.2% for men.1

Eating disorders do not discriminate and can occur in people of any age, weight, size, shape, gender identity, sexuality, cultural background or socioeconomic group.

Long-term impacts

Eating disorders are associated with serious medical and psychological complications.

A person with an eating disorder may experience long-term impairment to social and functional roles, and the impact may include psychiatric and behavioural problems, medical complications, social isolation, disability and an increased risk of death as a result of medical complications or suicide. Suicide is a major cause of mortality for people with eating disorders. Suicide is up to 31 times more likely to occur for someone with anorexia nervosa and 7.5 times higher for someone with bulimia nervosa than the general population.2

The impact of an eating disorder is not only felt by the individual, but often by that person’s entire family or circle of support. The impact may lead to caregiver stress, loss of family income, disruption to family relationships and a high suicide risk.

Mortality

The mortality rate for people with eating disorders is up to six times higher than that for people without eating disorders. The increased risk of premature death exists for all types of eating disorders, however people living with anorexia nervosa have the highest mortality rate of all psychiatric conditions due to both psychological and physiological complications.3

Classification of eating disorders

Eating disorders are classified into different types, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), Fifth Edition. Classifications are made based on the presenting symptoms and how often these occur, and include:

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Anorexia nervosa
Essential (required) features: • Significantly low body weight for the individual’s height, age, developmental stage and weight history that is not due to the unavailability of food and is not better accounted for by another medical condition. A commonly used guideline is body mass index (BMI) less than 18.5 kg/m2 in adults and BMI-for-age under 5th percentile in children and adolescents. Rapid weight loss (e.g., more than 20% of total body weight within 6 months) may replace the low body weight guideline as long as other diagnostic requirements are met. Children and adolescents may exhibit failure to gain weight as expected based on the individual developmental trajectory rather than weight loss. • A persistent pattern of restrictive eating or other behaviors that are aimed at establishing or maintaining abnormally low body weight, typically associated with extreme fear of weight gain. Behaviors may be aimed at reducing energy intake, by fasting, choosing low calorie food, excessively slow eating of small amounts of food, and hiding or spitting out food, as well as purging behaviors, such as self-induced vomiting and use of laxatives, diuretics, enemas, or omission of insulin doses in individuals with diabetes. Behaviors may also be aimed at increasing energy expenditure through excessive exercise, motor hyperactivity, deliberate exposure to cold, and use of medication that increases energy expenditure (e.g., stimulants, weight loss medication, herbal products for reducing weight, thyroid hormones). • Low body weight is overvalued and central to the person’s self-evaluation, or the person’s body weight or shape is inaccurately perceived to be normal or even excessive. Preoccupation with weight and shape, when not explicitly stated, may be manifested by behaviors such as repeatedly checking body weight using scales, checking one’s body shape using tape measures or reflection in mirrors, constant monitoring of the calorie content of food and searching for information on how to lose weight or by extreme avoidant behaviors, such as refusal to have mirrors at home, avoidance of tight-fitting clothes, or refusal to know one’s weight or purchase clothing with specified sizing.
Bulimia nervosa
Essential (required) features: • Frequent, recurrent episodes of binge eating (e.g., once a week or more over a period of at least 1 month). Binge eating is defined as a distinct period of time during which the individual experiences a loss of control over his or her eating behavior. A binge eating episode is present when an individual eats notably more and/or differently than usual and feels unable to stop eating or limit the type or amount of food eaten. Other characteristics of binge eating episodes may include eating alone because of embarrassment, eating foods that are not part of the individual’s regular diet, eating large amounts of food in spite of not feeling hungry, and eating faster than usual. • Repeated inappropriate compensatory behaviors to prevent weight gain (e.g., once a week or more over a period of at least 1 month). The most common compensatory behavior is self-induced vomiting, which typically occurs within an hour of binge eating. Other inappropriate compensatory behaviors include fasting or using diuretics to induce weight loss, using laxatives or enemas to reduce the absorption of food, omission of insulin doses in individuals with diabetes, and strenuous exercise to greatly increase energy expenditure. • Excessive preoccupation with body weight and shape. When not explicitly stated, preoccupation with weight and shape may be manifested by behaviors such as repeatedly checking body weight using scales, checking one’s body shape using tape measures or reflection in mirrors, constant monitoring of the calorie content of food and searching for information on how to lose weight or by extreme avoidant behaviors, such as refusal to have mirrors at home, avoidance of tight-fitting clothes, or refusal to know one’s weight or purchase clothing with specified sizing. • There is marked distress about the pattern of binge eating and inappropriate compensatory behavior or significant impairment in personal, family, social, educational, occupational or other important areas of functioning. • The symptoms do not meet the definitional requirements for Anorexia Nervosa.
Binge eating disorder
Essential (required) features: • Frequent, recurrent episodes of binge eating (e.g., once a week or more over a period of 3 months). Binge eating is defined as a distinct period of time during which the individual experiences a loss of control over his or her eating behavior. A binge eating episode is present when an individual eats notably more or differently than usual and feels unable to stop eating or limit the type or amount of food eaten. Other characteristics of binge eating episodes may include eating alone because of embarrassment, or eating foods that are not part of the individual’s regular diet. • The binge eating episodes are not regularly accompanied by inappropriate compensatory behaviors aimed at preventing weight gain. • The symptoms and behaviors are not better explained by another medical condition (e.g., Prader-Willi Syndrome) or another mental disorder (e.g., a depressive disorder) and are not due to the effect of a substance or medication on the central nervous system, including withdrawal effects. • There is marked distress about the pattern of binge eating or significant impairment in personal, family, social, educational, occupational or other important areas of functioning.
Avoidant-restrictive food intake disorder
Essential (required) features: • Avoidance or restriction of food intake that results in either or both of the following: o The intake of an insufficient quantity or variety of food to meet adequate energy or nutritional requirements that has resulted in significant weight loss, clinically significant nutritional deficiencies, dependence on oral nutritional supplements or tube feeding, or has otherwise negatively affected the physical health of the individual. o Significant impairment in personal, family, social, educational, occupational or other important areas of functioning (e.g., due to avoidance or distress related to participating in social experiences involving eating). • The pattern of eating behavior is not motivated by preoccupation with body weight or shape or by significant body image distortion. • Restricted food intake and consequent weight loss (or failure to gain weight) or other impact on physical health is not due to unavailability of food, not a manifestation of another medical condition (e.g., food allergies, hyperthyroidism), and not due to the effect of a substance or medication (e.g., amphetamine), including withdrawal, and not due to another mental disorder.
Pica
Essential (required) features: • Regular consumption of non-nutritive substances, such as non-food objects and materials (e.g., clay, soil, chalk, plaster, plastic, metal and paper), or raw food ingredients (e.g., large quantities of salt or corn flour). • The ingestion of non-nutritive substances is persistent or severe enough to require clinical attention. That is, the behavior causes damage to health, impairment in functioning, or significant risk due to the frequency, amount or nature of the substances or objects ingested. • Based on age and level of intellectual functioning, the individual would be expected to distinguish between edible and non-edible substances. In typical development, this occurs at approximately 2 years of age. • The symptoms or behaviors are not a manifestation of another medical condition (e.g., nutritional deficiency).
Rumination-regurgitation disorder
Essential (required) features: • The intentional and repeated bringing up of previously swallowed food back to the mouth (i.e., regurgitation), which may be re-chewed and re-swallowed (i.e., rumination), or may be deliberately spat out (but not as in vomiting). • The regurgitation behavior is frequent (at least several times per week) and sustained over a period of at least several weeks. • The diagnosis should only be assigned to individuals who have reached a developmental age of at least 2 years. • The regurgitation behavior is not a manifestation of another medical condition that directly causes regurgitation (e.g., esophageal strictures or neuromuscular disorders affecting esophageal functioning) or causes nausea or vomiting (e.g., pyloric stenosis).