Rumination Disorder 333
hand over the mouth or coughing. Some will a void eating with others because of the ac-
knowledged social undesirability of the behavi or. This may extend to an avoidance of eat-
ing prior to social situations, such as work or school (e.g., avoidi ng breakfast because it
may be followed by regurgitation).
Prevalence
Prevalence data for rumination disorder ar e inconclusive, but the disorder is commonly
reported to be higher in certain groups, such as individuals with intellectual disability.
Development and Course
Onset of rumination disorder can occur in in fancy, childhood, adolescence, or adulthood.
The age at onset in infants is usually between ag es 3 and 12 months. In infants, the disorder
frequently remits spontaneously, but its course can be protract ed and can result in medical
emergencies (e.g., severe malnutrition). It can potentially be fatal, particularly in infancy.
Rumination disorder can have an episodic course or occur continuously until treated. In
infants, as well as in older individuals with intellectual disability (intellectual developmen-
tal disorder) or other neurodevelopmental diso rders, the regurgitation and rumination be-
havior appears to have a self-soothing or self-stimulating func tion, similar to that of other
repetitive motor behaviors such as head banging.
Risk and Prognostic Factors
Environmental. Psychosocial problems such as lack of stimulation, neglect, stressful life
situations, and problems in the parent-child relationship may be predisposing factors in
infants and young children.
Functional Consequences of Rumination Disorder
Malnutrition secondary to repeated regurgit ation may be associated with growth delay
and have a negative effect on development an d learning potential. Some older individuals


and have a negative effect on development an d learning potential. Some older individuals
with rumination disorder deliberately restrict their food intake because of the social un-
desirability of regurgitation. They may therefore present with  weight loss or low weight.
In older children, adolescents, and adults, soci al functioning is more likely to be adversely
affected.
Differential Diagnosis
Gastrointestinal conditions. It is important to differentiate regurgitation in rumination
disorder from other conditions characterized by gastroesophageal re flux or vomiting. Con-
ditions such as gastroparesis, pyloric stenosis, hiatal hernia, and Sandifer syndrome in in-
fants should be ruled out by appropriate physical examinations and laboratory tests.
Anorexia nervosa and bulimia nervosa. Individuals with anorexia nervosa and bulimia
nervosa may also engage in regurgitation with subsequent spitting ou t of food as a means
of disposing of ingested calories be cause of concerns about weight gain.
Comorbidity
Regurgitation with associated rumination can occur in the context of a concurrent medical
condition or another mental disorder (e.g., ge neralized anxiety disorder). When the regur-
gitation occurs in  this context, a diagnosis of ruminati on disorder is appropriate only when
the severity of the disturbance exceeds that routinely associated with such conditions or
disorders and warrants additional clinical attention.


334 Feeding and Eating Disorders
Avoidant/Restrictive Food Intake Disorder
Diagnostic Criteria 307.59 (F50.8)
A. An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoid-
ance based on the sensory characteristics of food; concern about aversive conse-
quences of eating) as manifested by persistent failure to meet appropriate nutritional
and/or energy needs associated with one (or more) of the following:
1. Significant weight loss (or failure to achieve expected weight gain or faltering
growth in children).
2. Significant nutritional deficiency.
3. Dependence on enteral feeding or oral nutritional supplements.
4. Marked interference with psychosocial functioning.
B. The disturbance is not better explained by lack of available food or by an associated
culturally sanctioned practice.
C. The eating disturbance does not occur exclusively during the course of anorexia ner-
vosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which
one’s body weight or shape is experienced.
D. The eating disturbance is not attributable to a concurrent medical condition or not bet-
ter explained by another mental disorder. When the eating disturbance occurs in the
context of another condition or disorder, t he severity of the eating disturbance exceeds
that routinely associated with the condition or disorder and warrants additional clinical
attention.
Specify if:
In remission:  After full criteria for avoidant/restrictive food intake disorder were previ-
ously met, the criteria have not been met for a sustained period of time.
Diagnostic Features
Avoidant/restrictive food intake disorder replaces and extends the DSM-IV diagnosis of
feeding disorder of infancy or  early childhood. The main diagnostic feature of avoidant/
restrictive food intake disorder is avoidance or restriction of food intake (Criterion A)


restrictive food intake disorder is avoidance or restriction of food intake (Criterion A)
manifested by clinically significant failure to  meet requirements for nutrition or insuffi-
cient energy intake through oral intake of food. One or more of the following key features
must be present: significant weight loss, si gnificant nutritional deficiency (or related
health impact), dependence on enteral feedin g or oral nutritional supplements, or marked
interference with psychosocial functioning.  The determination of whether weight loss is
significant (Criterion A1) is a clinical judgme nt; instead of losing weight, children and ad-
olescents who have not completed growth may not maintain weight or height increases
along their developmental trajectory.
Determination of significant nu tritional deficiency (Criterion A2) is also based on clin-
ical assessment (e.g., assessment of dietary intake, physical examination, and laboratory
testing), and related impact on physical health can be of a similar seve rity to that seen in
anorexia nervosa (e.g., hypother mia, bradycardia, anemia). In severe cases, particularly in
infants, malnutrition can be life threatening.  “Dependence” on enteral feeding or oral nu-
tritional supplements (Criterion A3) means that  supplementary feeding is required to sus-
tain adequate intake. Examples of individu als requiring supplementary feeding include
infants with failure to thrive who require na sogastric tube feeding, children with neuro-
developmental disorders who are dependent on  nutritionally complete supplements, and
individuals who rely on gastrostomy tube feeding or complete oral nutrition supplements
in the absence of an underlying medical condit ion. Inability to participate in normal social


Avoidant/Restrictive Food Intake Disorder 335
activities, such as eating with others, or to sustain relationsh ips as a result of the distur-
bance would indicate marked interference wi th psychosocial functioning (Criterion A4).
Avoidant/restrictive food intake disorder does not include avoidance or restriction of
food intake related to lack of availability of food or to cultural practices (e.g., religious fast-
ing or normal dieting) (Criterion B), nor does it include developmentally normal behaviors
(e.g., picky eating in toddlers, reduced intake in older adults). The disturbance is not better
explained by excessive concern about body weight  or shape (Criterion C) or by concurrent
medical factors or mental disorders (Criterion D).
In some individuals, food av oidance or restriction may be based on the sensory char-
acteristics of qualities of fo od, such as extreme sensitivity to appearance, color, smell,
texture, temperature, or taste. Such behavior  has been described as  “restrictive eating,”
“selective eating,” “choosy eating,” “perseverant eating,” “chronic food refusal,” and
“food neophobia” and may manifest as refusal to  eat particular brands of foods or to tol-
erate the smell of food being eaten by others . Individuals with heightened sensory sensi-
tivities associated with autism  may show similar behaviors.
Food avoidance or restriction may also repr esent a conditioned negative response as-
sociated with food intake following, or in an ticipation of, an aversive experience, such as
choking; a traumatic investigation, usually invo lving the gastrointestinal tract (e.g., esoph-
agoscopy); or repeated vomiting. The terms functional dysphagia and globus hystericus  have
also been used for such conditions.
Associated Features Supporting Diagnosis


also been used for such conditions.
Associated Features Supporting Diagnosis
Several features may be associated with food avoidance or reduced food intake, including
a lack of interest in eating or food, leading to weight loss or faltering growth. Very young
infants may present as being too sleepy, distre ssed, or agitated to feed. Infants and young
children may not engage with the primary ca regiver during feeding or communicate hun-
ger in favor of other activities. In older child ren and adolescents, food  avoidance or restric-
tion may be associated with more generali zed emotional difficulties that do not meet
diagnostic criteria for an an xiety, depressive, or bipolar disorder, sometimes called “food
avoidance emotional disorder.”
Development and Course
Food avoidance or restriction associated with in sufficient intake or lack of interest in eat-
ing most commonly develops in infancy or early childhood and may persist in adulthood.
Likewise, avoidance based on sensory characterist ics of food tends to arise in the first de-
cade of life but may persist into adulthood. Avoidance related to aversive consequences
can arise at any age. The scant literature re garding long-term outcomes suggests that food
avoidance or restriction based on sensory aspects is relatively stable and long-standing,
but when persisting into adulthood, such avoidance/restriction can be associated with rel-
atively normal functioning. There is currently insufficient evidence directly linking avoid-
ant/restrictive food intake disorder and subsequent onset of an eating disorder.
Infants with avoidant/restrictive food intake  disorder may be irritable and difficult to
console during feeding, or ma y appear apathetic and withdrawn. In some instances, par-
ent-child interaction may contri bute to the infant’s feeding problem (e.g., presenting food


inappropriately, or interpreting the infant’s be havior as an act of aggression or rejection).
Inadequate nutritional intake may exacerbate the associated fe atures (e.g., irritability, de-
velopmental lags) and further contribute to f eeding difficulties. Associated factors include
infant temperament or developm ental impairments that reduce  an infant’s responsiveness


velopmental lags) and further contribute to f eeding difficulties. Associated factors include
infant temperament or developm ental impairments that reduce  an infant’s responsiveness
to feeding. Coexisting parental psychopathology, or child abus e or neglect, is suggested if
feeding and weight improve in response to ch anging caregivers. In infants, children, and
prepubertal adolescents, avoidant/restrictive food intake di sorder may be associated with
growth delay, and the resulting malnutrition  negatively affects development and learning


336 Feeding and Eating Disorders
potential. In older children, adolescents, an d adults, social functioning tends to be ad-
versely affected. Regardless of the age, fami ly function may be affected, with heightened
stress at mealtimes and in other feeding or ea ting contexts involving friends and relatives.
Avoidant/restrictive food intake disorder  manifests more commonly in children than
in adults, and there may be a long delay betw een onset and clinical presentation. Triggers
for presentation vary considerably and includ e physical, social, and emotional difficulties.
Risk and Prognostic Factors
Temperamental. Anxiety disorders, autism spectrum disorder, obsessive-compulsive
disorder, and attention-deficit/ hyperactivity disorder may in crease risk for avoidant or
restrictive feeding or eating behavi or characteristic of the disorder.
Environmental. Environmental risk factors for avoida nt/restrictive f ood intake disor-
der include familial anxiety. Higher rates of  feeding disturbances may occur in children of
mothers with eating disorders.
Genetic and physiological. History of gastrointestinal co nditions, gastroesophageal re-
flux disease, vomiting, and a range of othe r medical problems has been associated with
feeding and eating behaviors characteristic of  avoidant/restrictive food intake disorder.
Culture-Related Diagnostic Issues
Presentations similar to avoidant/restrictive fo od intake disorder occur in various popu-
lations, including in the United States, Cana da, Australia, and Euro pe. Avoidant/restrictive
food intake disorder should not be diagnosed when avoidance of food intake is solely re-
lated to specific religious or cultural practices.
Gender-Related Diagnostic Issues
Avoidant/restrictive food intake disorder is equally common in males and females in in-


Avoidant/restrictive food intake disorder is equally common in males and females in in-
fancy and early childhood, but avoidant/restric tive food intake di sorder comorbid with
autism spectrum disorder has a male predominance. Food avoidance or restriction related
to altered sensory sensitivities can occur in some physiological conditions, most notably
pregnancy, but is not usually extreme and does  not meet full criter ia for the disorder.
Diagnostic Markers
Diagnostic markers include malnutrition, low weight, growth delay, and the need for ar-
tificial nutrition in the absence of any clear medical condition other than poor intake.
Functional Consequences of Avoidant/Restrictive
Food Intake Disorder
Associated developmental and fu nctional limitations include impairment of physical de-
velopment and social difficulties that can have a significant negative impact on family
function.
Differential Diagnosis
Appetite loss preceding restricted intake is a nonspecific symptom that can accompany a
number of mental diagnoses. Avoidant/restrictive food intake disorder can be diagnosed
concurrently with the disorders below if all criteria are met, and the eating disturbance re-
quires specific clinical attention.
Other medical conditions (e.g., gastrointest inal disease, food allergies and intoler-
ances, occult malignancies). Restriction of food intake ma y occur in other medical condi-


Avoidant/Restrictive Food Intake Disorder 337
tions, especially those with on going symptoms such as vomiting, loss of appetite, nausea, ab-
dominal pain, or diarrhea. A diag nosis of avoidant/restrictive food intake disorder requires
that the disturbance of intake is beyond that directly accounted for by physical symptoms con-
sistent with a medical condition; the eating d isturbance may also persis t after being triggered
by a medical condition and following resolution of the medical condition.
Underlying medical or comorbid mental cond itions may complicate  feeding and eating.
Because older individuals, postsurgical pati ents, and individuals receiving chemotherapy
often lose their appetite, an additional diagno sis of avoidant/restric tive food intake dis-
order requires that the eating disturbance is a primary focus for intervention.
Specific neurological/neuromuscular, structural, or congenital disorders and condi-
tions associated with feeding difficulties. Feeding difficulties are common in a number
of congenital and neurological conditions often related to problems with oral/esophageal/
pharyngeal structure and function, such as hy potonia of musculature, tongue protrusion,
and unsafe swallowing. Avoidant/restrictive food  intake disorder can be diagnosed in in-
dividuals with such presentations as long as all diagnostic criteria are met.
Reactive attachment disorder. Some degree of withdrawal is characteristic of reactive
attachment disorder and can lead to a distur bance in the caregiver-child relationship that
can affect feeding and the child’s intake. Avoi dant/restrictive food intake disorder should
be diagnosed concurrently only if all criter ia are met for both di sorders and the feeding
disturbance is a primary focus for intervention.
Autism spectrum disorder. Individuals with autism spectr um disorder often present with


Autism spectrum disorder. Individuals with autism spectr um disorder often present with
rigid eating behaviors and heightened sensor y sensitivities. However, these features do
not always result in the level of impairment  that would be required for a diagnosis of
avoidant/restrictive food intake  disorder. Avoidant/restrictive  food intake disorder should
be diagnosed concurrently only if all criteria  are met for both disorders and when the eat-
ing disturbance requires  specific treatment.
Specific phobia, social anxiety disorder (social phobia), and other anxiety disorders.
Specific phobia, other type, specifies “situation s that may lead to choking or vomiting” and
can represent the primary trigge r for the fear, anxiety, or avoidance required for diagnosis.
Distinguishing specific phobia from avoidant/res trictive food intake disorder can be dif-
ficult when a fear of choking or vomiting h as resulted in food avoidance. Although avoid-
ance or restriction of food intake secondar y to a pronounced fear of choking or vomiting
can be conceptualized as specific phobia, in  situations when the eating problem becomes
the primary focus of clinical attention, avoidant/restrictive food intake disorder becomes
the appropriate diagnosis. In social anxiety disorder, the individual  may present with a
fear of being observed by others while eating , which can also occur in avoidant/restrictive
food intake disorder.
Anorexia nervosa. Restriction of energy intake relati ve to requirements  leading to sig-
nificantly low body weight is a core featur e of anorexia nervosa.  However, individuals
with anorexia nervosa also display a fear of ga ining weight or of becoming fat, or persis-
tent behavior that interferes with weight gain , as well as specific disturbances in relation to


tent behavior that interferes with weight gain , as well as specific disturbances in relation to
perception and experience of their own body weight and shape. These features are not
present in avoidant/restrictive food intake disorder, and the two disorders should not be
diagnosed concurrently. Differential diagnosis between avoidant/restrictive food intake
disorder and anorexia nervosa may be difficult,  especially in late childhood and early ad-


diagnosed concurrently. Differential diagnosis between avoidant/restrictive food intake
disorder and anorexia nervosa may be difficult,  especially in late childhood and early ad-
olescence, because these disorders may share a number of common symptoms (e.g., food
avoidance, low weight). Differential diagnosis is also potentially difficult in individuals
with anorex ia nervosa who deny any fear of fatness but nonetheless engage in persistent
behaviors that prevent weight gain and who do not recognize the medical seriousness of
their low weight—a presentation sometimes termed “non-fat phobic anorexia nervosa.”
Full consideration of symptoms, course, and fa mily history is advised, and diagnosis may


338 Feeding and Eating Disorders
be best made in the context of a clinical rela tionship over time. In some individuals, avoid-
ant/restrictive food intake disorder might precede the onset of anorexia nervosa.
Obsessive-compulsive disorder. Individuals with obsessive-compulsive disorder may
present with avoidance or restri ction of intake in relation to preoccupations with food or
ritualized eating behavior. Avoidant/restrictive  food intake disorder  should be diagnosed
concurrently only if all criteria are met for both disorders and when the aberrant eating is
a major aspect of the clinical presenta tion requiring specific intervention.
Major depressive disorder. In major depressive disorder, a ppetite might be affected to
such an extent that individuals present with significantly restricted food intake, usually in
relation to overall energy intake and often a ssociated with weight loss. Usually appetite
loss and related reduction of intake abate wi th resolution of mood problems. Avoidant/
restrictive food intake disorder should only be used concurrently if fu ll criteria are met for
both disorders and when the eating d isturbance requires specific treatment.
Schizophrenia spectrum disorders. Individuals with schizophrenia, delusional disor-
der, or other psychotic disorders may exhibit odd eating behaviors, avoidance of specific
foods because of delusional beliefs, or other ma nifestations of avoidant or restrictive in-
take. In some cases, delusional beliefs may contribute to a concern about negative conse-
quences of ingesting certain foods. Avoidant/r estrictive food intake disorder should be
used concurrently only if all criteria are me t for both disorders and when the eating dis-
turbance requires specific treatment.
Factitious disorder or factitious disorder imposed on another. Avoidant/restrictive
food intake disorder should be differentiated fr om factitious disorder or factitious disor-


food intake disorder should be differentiated fr om factitious disorder or factitious disor-
der imposed on another. In orde r to assume the sick role, so me individuals with factitious
disorder may intentionally describe diets that  are much more restrictive than those they
are actually able to consume, as well as comp lications of such behavior, such as a need for
enteral feedings or nutritional supplements,  an inability to tolera te a normal range of
foods, and/or an inability to participate normally in age-a ppropriate situations involving
food. The presentation may be impressively dramatic and engaging, and the symptoms re-
ported inconsistently. In factitious disorder  imposed on another, the caregive r describes
symptoms consistent with avoidant/restric tive food intake di sorder and may induce
physical symptoms such as failure to gain weig ht. As with any diagno sis of factitious dis-
order imposed on another, the caregiver receives the diagnosis rather than the affected in-
dividual, and diagnosis should be made only on the basis of a careful, comprehensive
assessment of the affected individual, the caregiver, and their interaction.
Comorbidity
The most commonly observed disorders comorb id with avoidant/restrictive food intake
disorder are anxiety disorders, obsessive- compulsive disorder, and neurodevelopmental
disorders (specifically autism spectrum disorder, attention-deficit/hyperactivity disor-
der, and intellectual disability [int ellectual developm ental disorder]).
Anorexia Nervosa
Diagnostic Criteria
A. Restriction of energy intake relative to requirements, leading to a significantly low body
weight in the context of age, sex, developmental trajectory, and physical health.  Sig-
nificantly low weight  is defined as a weight that is less than minimally normal or, for


children and adolescents, less than that minimally expected.
B. Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes
with weight gain, even though at a significantly low weight.


Anorexia Nervosa 339
C. Disturbance in the way in which one’s body weight or shape is experienced, undue in-
fluence of body weight or shape on self-eval uation, or persistent lack of recognition of
the seriousness of the current low body weight.
Coding note:  The ICD-9-CM code for anorexia nervosa is 307.1,  which is assigned re-
gardless of the subtype. The ICD-10-CM  code depends on the subtype (see below).
Specify whether:
(F50.01) Restricting type: During the last 3 months, the individual has not engaged in re-
current episodes of binge eating or purging behavior (i.e., self-induced vomiting or the mis-
use of laxatives, diuretics, or enemas). This subtype describes presentations in which
weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise.
(F50.02) Binge-eating/purging type: During the last 3 months, the individual has en-
gaged in recurrent episodes of binge eat ing or purging behavior (i.e., self-induced
vomiting or the misuse of laxatives, diuretics, or enemas).
Specify if:
In partial remission: After full criteria for anorexia ne rvosa were previously met, Cri-
terion A (low body weight) has not been met for a sustained period, but either Criterion
B (intense fear of gaining weight or becoming fat or behavior that interferes with weight
gain) or Criterion C (disturbances in self-perception of weight and shape) is still met.
In full remission: After full criteria for anorexia ner vosa were previously met, none of
the criteria have been met for a sustained period of time.


the criteria have been met for a sustained period of time.
Specify current severity:
The minimum level of severity is based, for adults, on current body mass index (BMI) (see
below) or, for children and adolescents, on BMI percentile. The ranges below are derived
from World Health Organization categories for thinness in adults; for children and adoles-
cents, corresponding BMI percentiles should be used. The level of severity may be in-
creased to reflect clinical symptoms, the degree of functional disability, and the need for
supervision.
Mild:  BMI ≥ 17 kg/m2
Moderate: BMI 16–16.99 kg/m2
Severe:  BMI 15–15.99 kg/m2
Extreme:  BMI < 15 kg/m2
Subtypes
Most individuals with the binge-eating/purging type of anorexia nervosa who binge eat
also purge through self-induced vomiting or th e misuse of laxatives, diuretics, or enemas.
Some individuals with this subtype of anorexia nervosa do not binge eat but do regularly
purge after the consumption of small amounts of food.
Crossover between the subtypes over the c ourse of the disorder is not uncommon;
therefore, subtype description should be used to describe current symptoms rather than
longitudinal course.
Diagnostic Features
There are three essential features of anorexia  nervosa: persistent en ergy intake restriction;
intense fear of gaining weight or of becoming  fat, or persistent behavior that interferes
with weight gain; and a disturbance in self-perceived weight or shape. The individual main-
tains a body weight that is below a minimally normal level for age, sex, developmental tra-
jectory, and physical health (Criterion A). In dividuals’ body weights frequently meet this


jectory, and physical health (Criterion A). In dividuals’ body weights frequently meet this
criterion following a significant weight loss, but among children and adolescents, there
may alternatively be failure to make expected weight gain or to maintain a normal devel-
opmental trajectory (i.e., while grow ing in height) instead of weight loss.


340 Feeding and Eating Disorders
Criterion A requires that the individual’s weight be significantly low (i.e., less than
minimally normal or, for children and adoles cents, less than that minimally expected).
Weight assessment can be challenging because normal weight range differs among indi-
viduals, and different thresholds have been published defining thinness or underweight
status. Body mass index (BMI; calculated as weight in kilograms/height in meters2) is a
useful measure to assess body weight for height. For adults, a BMI of 18.5 kg/m2 has been
employed by the Centers for Disease Control and Prevention (CDC) and the World Health
Organization (WHO) as the lower limit of normal body we ight. Therefore, most adults with
a BMI greater than or  equal to 18.5 kg/m2 would not be considered to have a significantly
low body weight. On the other ha nd, a BMI of lower than 17.0 kg/m2 has been considered
by the WHO to indicate moderate or severe thinness; therefore, an individual with a BMI
less than 17.0 kg/m2 would likely be considered to have a significantly low weight. An
adult with a BMI between  17.0 and 18.5 kg/m2, or even above 18.5 kg/m2, might be consid-
ered to have a significantly low weight if clinical history or other physiological informa-
tion supports this judgment.
For children and adolescents, de termining a BMI-for-age percentile is useful (see, e.g.,
the CDC BMI percentile calculator for children and teenagers. As for adults, it is not pos-
sible to provide definitive standards for judgin g whether a child’s or an adolescent’s weight
is significantly low, and variations in deve lopmental trajectories among youth limit the


is significantly low, and variations in deve lopmental trajectories among youth limit the
utility of simple numerical guidelines. The CD C has used a BMI-for-age below the 5th per-
centile as suggesting underweight; however,  children and adolesce nts with a BMI above
this benchmark may be judged to be significantly underweight in light of failure to main-
tain their expected growth trajectory. In su mmary, in determining whether Criterion A is
met, the clinician should consider available numerical guidelines, as well as the individual’s
body build, weight history, an d any physiological disturbances.
Individuals with this disorder typically display an intense fear of gaining weight or of
becoming fat (Criterion B). This intense fear of becoming fat is usually not alleviated by
weight loss. In fact, concern about weight gain  may increase even as weight falls. Younger
individuals with anorexia nervosa, as well as  some adults, may not recognize or acknowl-
edge a fear of weight gain. In the absence of  another explanation for the significantly low
weight, clinician inference drawn from collateral history, observatio nal data, physical and
laboratory findings, or longitudinal course eith er indicating a fear of weight gain or sup-
porting persistent behaviors that prevent it  may be used to es tablish Criterion B.
The experience and significance of body weight and shape are distorted in these indi-
viduals (Criterion C). Some individuals feel globally overweight. Others realize that they
are thin but are still concerned th at certain body parts, partic ularly the abdomen, buttocks,
and thighs, are “too fat.” They may employ a variety of techniques to evaluate their body
size or weight, including frequent weighing, obsessive measuring of body parts, and per-


size or weight, including frequent weighing, obsessive measuring of body parts, and per-
sistent use of a mirror to check for perceived areas of “fat.” The self-esteem of individuals
with anorexia nervosa is highly dependent on their perceptions of body shape and weight.
Weight loss is often viewed as an impressive ac hievement and a sign of extraordinary self-
discipline, whereas weight gain is perceived as an unacceptable failure of self-control. Al-
though some individuals with this disorder  may acknowledge being thin, they often do
not recognize the serious medical implic ations of their malnourished state.
Often, the individual is brought to professional attention by family members after marked


not recognize the serious medical implic ations of their malnourished state.
Often, the individual is brought to professional attention by family members after marked
weight loss (or failure to make expected weight gains) has occurred. If individuals seek help
on their own, it is usually because of dist ress over the somatic and psychological sequelae
of starvation. It is rare for an individual with anorexia nervosa to complain of weight loss
per se. In fact, individuals with anorexia nervos a frequently either lack insight into or deny
the problem. It is therefore often important to obtain information from family members or
other sources to evaluate the history of weight loss and other features of the illness.


Anorexia Nervosa 341
Associated Features Supporting Diagnosis
The semi-starvation of anorex ia nervosa, and the purging behaviors sometimes associated
with it, can result in significant and potentially life-threatening medical conditions. The
nutritional compromise associated with this  disorder affects most  major organ systems
and can produce a variety of disturbances. Ph ysiological disturbances, including amenor-
rhea and vital sign abnormalities, are comm on. While most of the physiological distur-
bances associated with malnutrition are reversible with nutritiona l rehabilitation, some,
including loss of bone mineral density, are often not completely re versible. Behaviors such
as self-induced vomiting and misuse of laxa tives, diuretics, and enemas may cause a num-
ber of disturbances that lead to abnormal la boratory findings; howe ver, some individuals
with anorexia nervosa exhibit no laboratory abnormalities.
When seriously underweight, ma ny individuals with anorex ia nervosa have depressive
signs and symptoms such as depressed mood, so cial withdrawal, irrita bility, insomnia, and
diminished interest in sex. Because these feat ures are also observed in individuals without
anorexia nervosa who are significantly undern ourished, many of the depressive features
may be secondary to the physiological sequelae of semi-starvation, although they may also
be sufficiently severe to warr ant an additional diagnosis of major depressive disorder.
Obsessive-compulsive features, both related and unrelated to food, are often prominent.
Most individuals with anorexia nervosa are pr eoccupied with thoughts of food. Some col-
lect recipes or hoard food. Ob servations of behaviors associated with other forms of star-
vation suggest that obsessions and compulsi ons related to food may be exacerbated by


vation suggest that obsessions and compulsi ons related to food may be exacerbated by
undernutrition. When individuals with anorexia nervosa exhibit obsessions and compul-
sions that are not related to food, body shape, or weight, an additional diagnosis of obses-
sive-compulsive disorder (OCD) may be warranted.
Other features sometimes associated with anorexia nervosa incl ude concerns about
eating in public, feelings of ineffectiveness, a strong desire  to control one’s environment,
inflexible thinking, limited social spontaneity, and overly restrained emotional ex-
pression. Compared with indivi duals with anorexia nervosa, restricting type, those with
binge-eating/purging type have higher rates of impulsivity and are more likely to abuse
alcohol and other drugs.
A subgroup of individuals with anorexia ne rvosa show excessive levels of physical ac-
tivity. Increases in physical activity often precede onset of the disorder, and over the
course of the disorder increased activity ac celerates weight loss. During treatment, exces-
sive activity may be difficult to control,  thereby jeopardizing weight recovery.
Individuals with anorexia nervosa may misu se medications, such as by manipulating
dosage, in order to achieve we ight loss or avoid weight ga in. Individuals with diabetes
mellitus may omit or reduce insulin doses in order to minimi ze carbohydrate  metabolism.
Prevalence
The 12-month prevalence of anorexia nervosa among youn g females is approximately
0.4%. Less is known about prevalence among ma les, but anorexia nerv osa is far less com-
mon in males than in females, with clinical populations generally reflecting approximately
a 10:1 female-to-male ratio.
Development and Course


a 10:1 female-to-male ratio.
Development and Course
Anorexia nervosa commonly begins during adolescence or young adulthood. It rarely be-
gins before puberty or after age 40, but cases of both early and late onset have been de-
scribed. The onset of this disorder is often a ssociated with a stressful life event, such as
leaving home for college. The course and outcom e of anorexia nervosa are highly variable.
Younger individuals may manifest atypical features, including denying “fear of fat.” Older


342 Feeding and Eating Disorders
individuals more likely have a longer duration of illness, and their clinical presentation may
include more signs and symptoms of long-stand ing disorder. Clinicians should not exclude
anorexia nervosa from the differential diag nosis solely on the basis of older age.
Many individuals have a period of changed ea ting behavior prior to full criteria for the
disorder being met. Some individuals with anorexia nervosa recover fully after a single
episode, with some ex hibiting a fluctuating pattern of weight gain followed by relapse,
and others experiencing a chronic course over many years. Hospitalization may be re-
quired to restore weight and to address medical complications. Most individuals with an-
orexia nervosa experience remission within 5 years of presentation. Among individuals
admitted to hospitals, overall remission rates may be lower. The crude mortality rate (CMR)
for anorexia nervosa is approximately 5% pe r decade. Death most commonly results from
medical complications associated with the disorder itself or from suicide.
Risk and Prognostic Factors
Temperamental. Individuals who develop anxiety disorders or display obsessional
traits in childhood are at increased risk of developing anorexia nervosa.
Environmental. Historical and cross-cultural variab ility in the prevalence of anorexia
nervosa supports its association with cultures and settings in which thinness is valued. Oc-
cupations and avocations that encourage thinness, such as modeling and elite athletics, are
also associated with increased risk.
Genetic and physiological. There is an increased risk of  anorexia nervosa and bulimia
nervosa among first-degree biolog ical relatives of individuals with the disorder. An in-
creased risk of bipolar and depressive diso rders has also been found among first-degree


creased risk of bipolar and depressive diso rders has also been found among first-degree
relatives of individuals with anorexia nervos a, particularly relati ves of individuals with
the binge-eating/purging type. Concordance rates for anorexia nervosa in monozygotic
twins are significantly higher than those for dizygotic twins. A range of brain abnormali-
ties has been described in an orexia nervosa using functional imaging technologies (func-
tional magnetic resonance imaging, positro n emission tomography).  The degree to which
these findings reflect changes associated with  malnutrition versus primary abnormalities
associated with the disorder is unclear.
Culture-Related Diagnostic Issues
Anorexia nervosa occurs across culturally and so cially diverse populations, although available
evidence suggests cross-cultural variation in its occurrence and pres entation. Anorexia ner-
vosa is probably most prevalent in post-industr ialized, high-income coun tries such as in the
United States, many European c ountries, Australia, New Zealand,  and Japan, but its incidence
in most low- and middle-income countries is uncertain. Whereas the prevalence of anorexia
nervosa appears comparatively low among Latino s, African Americans, and Asians in the
United States, clinicians should be aware that mental health service utilization among individ-
uals with an eating disorder is significantly lo wer in these ethnic groups and that the low rates
may reflect an ascertainment bias. The presenta tion of weight concer ns among individuals
with eating and feeding disorders varies substa ntially across cultural contexts. The absence of
an expressed intense fear of we ight gain, sometimes referred to  as “fat phobia,” appears to be
relatively more common in popu lations in Asia, where the rati onale for dietary restriction is


commonly related to a more culturally sanction ed complaint such as gastrointestinal discom-
fort. Within the United States, presentations with out a stated intense fear of weight gain may
be comparatively more common among Latino groups.
Diagnostic Markers
The following laboratory abnorm alities may be observed in anorexia nervosa; their pres-
ence may serve to increase diagnostic confidence.


Anorexia Nervosa 343
Hematology. Leukopenia is common, with the loss of all cell types but usually with ap-
parent lymphocytosis. Mild anemia can occur,  as well as thrombocytopenia and, rarely,
bleeding problems.
Serum chemistry. Dehydration may be reflected by an elevated blood urea nitrogen
level. Hypercholesterolemia is common. Hepa tic enzyme levels may be elevated. Hypo-
magnesemia, hypozincemia, hypophosphatemia, and hyperamylasemia are occasionally
observed. Self-induced vomiting may lead to metabolic alkalosis (elevated serum bicarbon-
ate), hypochloremia, and hypokalemia; laxative  abuse may cause a mild metabolic acidosis.
Endocrine. Serum thyroxine (T4) levels are usually in the low-normal rang e; triiodothy-
ronine (T3) levels are decreased, while reverse T3 levels are elevated. Females have low se-
rum estrogen levels, whereas males have  low levels of se rum testosterone.
Electrocardiography. Sinus bradycardia is common, and,  rarely, arrhythmias are noted.
Significant prolongation of the QTc interv al is observed in some individuals.
Bone mass. Low bone mineral density, with specific areas of osteopenia or osteoporo-
sis, is often seen. The risk of fr acture is significantly elevated.
Electroencephalography. Diffuse abnormalities, reflecting a metabolic encephalopa-
thy, may result from significant fluid and electrolyte disturbances.
Resting energy expenditure. There is often a significant redu ction in resting energy ex-
penditure.


penditure.
Physical signs and symptoms. Many of the physical sign s and symptoms of anorexia
nervosa are attributable to starvation. Amen orrhea is commonly present and appears to
be an indicator of physiological dysfunction. If present, amenorrhea is usually a conse-
quence of the weight loss, but in a minority  of individuals it may actually precede the
weight loss. In prepubertal females, menarche may be delayed. In addition to amenorrhea,
there may be complaints of constipation, abdo minal pain, cold intole rance, lethargy, and
excess energy.
The most remarkable finding on physical ex amination is emaciation. Commonly, there
is also significant hypotension, hypothermia, and bradycardia. Some individuals develop
lanugo, a fine downy body hair. Some de velop peripheral edema, especially during
weight restoration or upon cessation of laxa tive and diuretic abuse. Rarely, petechiae or
ecchymoses, usually on the extremities, may indicate a bleeding diathesis. Some individ-
uals evidence a yellowing of the skin associat ed with hypercarotenemia. As may be seen in
individuals with bulimia nervosa, individu als with anorexia ne rvosa who self-induce
vomiting may have hypertrophy of the salivary glands, particularly the parotid glands, as
well as dental enamel erosion. Some individu als may have scars or calluses on the dorsal
surface of the hand from repeated contac t with the teeth while inducing vomiting.
Suicide Risk
Suicide risk is elevated in anorexia nervosa,  with rates reported as 12 per 100,000 per year.


Comprehensive evaluation of individuals wi th anorexia nervosa should include assess-
ment of suicide-related ideation and behavior s as well as other risk factors for suicide, in-
cluding a history of suicide attempt(s).
Functional Consequences  of Anorexia Nervosa
Individuals with anorexia nervosa may exhibit a range of functional limitations associated
with the disorder. While some individuals rema in active in social and professional func-
tioning, others demonstrate significant social isolation and/or failure to fulfill academic or
career potential.


344 Feeding and Eating Disorders
Differential Diagnosis
Other possible causes of either significantly low body weight or significant weight loss
should be considered in the differential diagno sis of anorexia nervosa, especially when the
presenting features are atypical (e.g., onset after age 40 years).
Medical conditions (e.g., gastrointestinal disease, hyperthyroidism, occult malignan-
cies, and acquired immunodeficiency syndrome [AIDS]). Serious weight loss may oc-
cur in medical conditions, but individuals with  these disorders usually do not also mani-
fest a disturbance in the way their body weig ht or shape is experienced or an intense fear
of weight gain or persist in behaviors that interfere with appropriate weight gain. Acute
weight loss associated with a medical condition can occasionally be followed by the onset
or recurrence of anorexia nervosa, which can initially be masked by the comorbid medical
condition. Rarely, anorexia nervosa develo ps after bariatric surgery for obesity.
Major depressive disorder. In major depressive disorder, severe weight loss may occur,
but most individuals with major depressive diso rder do not have either a desire for exces-
sive weight loss or an inte nse fear of gaining weight.
Schizophrenia. Individuals with schizophrenia may exhibit odd eating behavior and oc-
casionally experience significant weight loss, but they rarely show the fear of gaining
weight and the body image disturbance requir ed for a diagnosis of anorexia nervosa.
Substance use disorders. Individuals with subs tance use disorders may experience low
weight due to poor nutritional intake but gene rally do not fear gaining weight and do not
manifest body image di sturbance. Individuals who abuse substances that reduce appetite
(e.g., cocaine, stimulan ts) and who also endorse fear of weight gain should be carefully


evaluated for the possibility of  comorbid anorexia nervosa, given that the substance use
may represent a persistent behavior that inte rferes with weight gain (Criterion B).
Social anxiety disorder (social phobia), ob sessive-compulsive disorder, and body dys-
morphic disorder. Some of the features of anorexia ne rvosa overlap with the criteria for
social phobia, OCD, and body dysmorphic diso rder. Specifically, individuals may feel hu-
miliated or embarrassed to be seen eating in public, as in social phobia; may exhibit obses-
sions and compulsions related to  food, as in OCD; or may be preoccupied with an imagined
defect in bodily appearance, as in body dysmor phic disorder. If the in dividual with anorexia
nervosa has social fears that are limited to eating behavior alone, the diagnosis of social pho-
bia should not be made, but social fears unrelate d to eating behavior (e.g., excessive fear of
speaking in public) may warrant an additional diagnosis of social phobia. Similarly, an ad-
ditional diagnosis of OCD should be considered only if the individu al exhibits obsessions
and compulsions unrelated to food (e.g., an ex cessive fear of contamination), and an addi-
tional diagnosis of body dysmorphic disorder sh ould be considered only if the distortion is
unrelated to body shape and size (e.g., preoccupation th at one’s nose is too big).
Bulimia nervosa. Individuals with bulimia nervosa ex hibit recurrent ep isodes of binge
eating, engage in inappropriat e behavior to avoid weight ga in (e.g., self-induced vomit-
ing), and are overly concerned with body sh ape and weight. However, unlike individuals


ing), and are overly concerned with body sh ape and weight. However, unlike individuals
with anorexia nervosa, binge-eating/purging type, individuals with bulimia nervosa main-
tain body weight at or ab ove a minimally normal level.
Avoidant/restrictive food intake disorder. Individuals with this disorder may exhibit
significant weight loss or significant nutritiona l deficiency, but they do not have a fear of
gaining weight or of becoming fat, nor do th ey have a disturbance in the way they expe-
rience their body shape and weight.
Comorbidity


gaining weight or of becoming fat, nor do th ey have a disturbance in the way they expe-
rience their body shape and weight.
Comorbidity
Bipolar, depressive, and anxiety disorders commonly co-occur with anorexia nervosa.
Many individuals with anorexia nervosa report  the presence of either an anxiety disorder


Bulimia Nervosa 345
or symptoms prior to onset of their eating d isorder. OCD is described in some individuals
with anorexia nervosa, especially those with the restricting type. Alcohol use disorder and
other substance use disorders may also be co morbid with anorexia nervosa, especially
among those with the binge-eating/purging type.
Bulimia Nervosa
Diagnostic Criteria 307.51 (F50.2)
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by
both of the following:
1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of
food that is definitely larger than what most individuals would eat in a similar period
of time under similar circumstances.
2. A sense of lack of control over eating during the episode (e.g., a feeling that one
cannot stop eating or control what or how much one is eating).
B. Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such
as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting;
or excessive exercise.
C. The binge eating and inappropriate compensatory behaviors both occur, on average,
at least once a week for 3 months.
D. Self-evaluation is unduly influenced by body shape and weight.
E. The disturbance does not occur exclusively during episodes of anorexia nervosa.
Specify if:
In partial remission:  After full criteria for bulimia nervosa were previously met, some,
but not all, of the criteria have been met for a sustained period of time.
In full remission:  After full criteria for bulimia nervosa were previously met, none of
the criteria have been met for a sustained period of time.
Specify current severity:


the criteria have been met for a sustained period of time.
Specify current severity:
The minimum level of severity is based on the frequency of inappropriate compensatory
behaviors (see below). The level of severity may be increased to reflect other symptoms
and the degree of functional disability.
Mild:  An average of 1–3 episodes of inappropriate compensatory behaviors per week.
Moderate: An average of 4–7 episodes of inappropriate compensatory behaviors per
week.
Severe:  An average of 8–13 episodes of inappropriate compensatory behaviors per
week.
Extreme:  An average of 14 or more episodes of inappropriate compensatory behav-
iors per week.
Diagnostic Features
There are three essential features of bulimia nervosa: recurrent episodes of binge eating
(Criterion A), recurrent inappropriate comp ensatory behaviors to prevent weight gain
(Criterion B), and self-evaluat ion that is unduly influenced by body shape and weight
(Criterion D). To qualify for the diagnosis, the binge eating and inappropriate compensa-
tory behaviors must occur, on average, at least once per week for 3 months (Criterion C).
An “episode of binge eating” is defined as  eating, in a discrete period of time, an
amount of food that is definitely larger than  most individuals would eat in a similar period
of time under similar circumstances (Criterion  A1). The context in which the eating occurs


346 Feeding and Eating Disorders
may affect the clinician’s esti mation of whether the intake is excessive. For example, a
quantity of food that might be regarded as excessive for a typical meal might be consid-
ered normal during a celebration or holiday me al. A “discrete period of time” refers to a
limited period, usually less than  2 hours. A single episode of binge eating need not be re-
stricted to one setting. For example, an individual may begin a binge in a restaurant and
then continue to eat on re turning home. Continual snacki ng on small amounts of food
throughout the day would not be considered an eating binge.
An occurrence of excessive food consumptio n must be accompanied by a sense of lack
of control (Criterion A2) to be considered an episode of binge eating. An indicator of loss
of control is the inability to refrain from eating  or to stop eating once started. Some indi-
viduals describe a dissociative quality during , or following, the bing e-eating episodes. The
impairment in control associated with binge eating may not be abso lute; for example, an
individual may continue binge eating while the telephone is ringing but will cease if a
roommate or spouse unexpected ly enters the room. Some in dividuals report that their
binge-eating episodes are no longer characterize d by an acute feeling of  loss of control but
rather by a more generalized pattern of uncont rolled eating. If individuals report that they
have abandoned efforts to control their eati ng, loss of control should be considered as
present. Binge eating can also be planned in some instances.
The type of food co nsumed during binges varies both across individuals and for a
given individual. Binge eating appears to be characterized more by an abnormality in the


given individual. Binge eating appears to be characterized more by an abnormality in the
amount of food consumed than by a craving for a specific nutrient. However, during binges,
individuals tend to eat foods they would otherwise avoid.
Individuals with bulimia nervosa are typica lly ashamed of their eating problems and
attempt to conceal their symptoms. Binge eating  usually occurs in secrecy or as inconspic-
uously as possible. The binge eating often cont inues until the individual is uncomfortably,
or even painfully, full. The most common antecedent of binge eating is negative affect.
Other triggers include interpersonal stressors; dietary restraint; negative feelings related
to body weight, body shape, and food; and boredom. Binge eating may minimize or mit-
igate factors that precipitated  the episode in the short-term, but negative self-evaluation
and dysphoria often are the delayed consequences.
Another essential feature of bulimia nervosa is the recurrent use of inappropriate com-
pensatory behaviors to prevent weight gain, collectively referred to as purge behaviors or
purging  (Criterion B). Many individuals with bulimia nervosa employ  several methods to
compensate for binge eating. Vomiting is the most common inappropriate compensatory
behavior. The immediate effects of vomiting include relief from physical discomfort and re-
duction of fear of gaining weight. In some cases, vomiting becomes a goal in itself, and the
individual will binge eat in orde r to vomit or will vomit after eating a small amount of food.
Individuals with bulimia nervosa may use a vari ety of methods to induce vomiting, includ-
ing the use of fingers or instruments to stimulate the gag reflex. Individuals generally
become adept at inducing vomit ing and are eventually able to  vomit at will. Rarely, indi-


viduals consume syrup of ipecac to induce vomiting. Other purging behaviors include the
misuse of laxatives and diuretics. A number  of other compensatory methods may also be
used in rare cases. Individuals with bulim ia nervosa may misuse enemas following epi-
sodes of binge eating, but this is seldom th e sole compensatory method employed. Individ-
uals with this disorder may take thyroid ho rmone in an attempt to avoid weight gain.


sodes of binge eating, but this is seldom th e sole compensatory method employed. Individ-
uals with this disorder may take thyroid ho rmone in an attempt to avoid weight gain.
Individuals with diabetes mellitus and bulimia nervosa may omit or reduce insulin doses in
order to reduce the metabolism of food cons umed during eating bi nges. Individuals with
bulimia nervosa may fast for a da y or more or exercise excessive ly in an attempt to prevent
weight gain. Exercise may be considered excessi ve when it significantly interferes with im-
portant activities, when it occurs at inappr opria te times or in i nappropriate settings, or
when the individual continues to exercise despite injury or  other medical complications.
Individuals with bulimia nervosa place an ex cessive emphasis on body shape or weight
in their self-evaluation, and these factors ar e typically extremely important in determining


Bulimia Nervosa 347
self-esteem (Criterion D). Individuals with this disorder may closely resemble those with
anorexia nervosa in their fear of gaining weight, in their desire to lose weight, and in the
level of dissatisfaction with their bodies. Ho wever, a diagnosis of bulimia nervosa should
not be given when the disturbance occurs only  during episodes of anorexia nervosa (Cri-
terion E).
Associated Features Supporting Diagnosis
Individuals with bulimia nervosa typically ar e within the normal weight or overweight
range (body mass index [BMI] ≥ 18.5 and < 30 in adults). The disorder occurs but is un-
common among obese individuals. Between eati ng binges, individuals with bulimia ner-
vosa typically restrict their to tal caloric consumption and preferentially select low-calorie
(“diet”) foods while avoiding foods that they pe rceive to be fattening or likely to trigger a
binge.
Menstrual irregularity or amenorrhea ofte n occurs among females with bulimia ner-
vosa; it is uncertain whether su ch disturbances are related to weight fluctuations, to nu-
tritional deficiencies, or to emotional dist ress. The fluid and electrolyte disturbances
resulting from the purging behavior are some times sufficiently severe to constitute med-
ically serious problems. Rare but potentially fatal complications include esophageal tears,
gastric rupture, and cardiac arrhythmias. Serious cardiac and skeletal myopathies have
been reported among individual s following repeated use of syrup of ipecac to induce vom-
iting. Individuals who chronically abuse laxatives may become dependent on their use to
stimulate bowel movements. Gastrointestin al symptoms are commonly associated with
bulimia nervosa, and rectal prolapse has also  been reported among individuals with this


disorder.
Prevalence
Twelve-month prevalence of bulimia ner vosa among young female s is 1%–1.5%. Point
prevalence is highest among young adults si nce the disorder peaks in older adolescence
and young adulthood. Less is known about th e point prevalence of bulimia nervosa in
males, but bulimia nervosa is far less common in  males than it is in females, with an ap-
proximately 10:1 female-to-male ratio.
Development and Course
Bulimia nervosa commonly begins in adolesce nce or young adulthood. Onset before pu-
berty or after age 40 is uncommon. The binge eating frequently begins during or after an
episode of dieting to lose weight. Experiencing  multiple stressful lif e events also can pre-
cipitate onset of bulimia nervosa.
Disturbed eating behavior persists for at least several years in a high percentage of
clinic samples. The course may be chronic or intermittent, with periods of remission
alternating with recurrences of binge eating. However, over longer -term follow-up, the
symptoms of many individuals appear to diminish with or without treatment, although
treatment clearly impacts outcome. Periods of remission longer than 1 year are associated
with better long-term outcome.
Significantly elevated risk fo r mortality (all-cause and suic ide) has been reported for
individuals with bulimia nervosa. The CMR (c rude mortality rate) for bulimia nervosa is
nearly 2% per decade.
Diagnostic cross-over from initial bulimia ne rvosa to anorexia nervosa occurs in a mi-
nority of cases (10%–15%). Individuals who do experience cross-over to anorexia nervosa


commonly will revert back to bulimia nervosa or have multiple occurrences of cross-overs
between these disorders. A subset of individu als with bulimia nervosa continue to binge
eat but no longer engage in inappropriate compensatory behaviors, and therefore their


348 Feeding and Eating Disorders
symptoms meet criteria for binge-eating disord er or other specified eating disorder. Diag-
nosis should be based on the current (i.e.,  past 3 months) clinical presentation.
Risk and Prognostic Factors
Temperamental. Weight concerns, low self-esteem, de pressive symptoms, social anxi-
ety disorder, and overanxious d isorder of childhood are associated with increased risk for
the development of bulimia nervosa.
Environmental. Internalization of a thin body ideal has been found to increase risk for
developing weight concerns, which in turn increase risk for the development of bulimia
nervosa. Individuals who experienced childhood  sexual or physical abuse are at increased
risk for developing bulimia nervosa.
Genetic and physiological. Childhood obesity and early pubertal maturation increase
risk for bulimia nervosa. Familial transmission of bulimia ne rvosa may be present, as well
as genetic vulnerabilities for the disorder.
Course modifiers. Severity of psychiatric comorbidity predicts worse long-term outcome
of bulimia nervosa.
Culture-Related Diagnostic Issues
Bulimia nervosa has been reported to occur wi th roughly similar frequencies in most in-
dustrialized countries, including the United  States, Canada, many European countries,
Australia, Japan, New Zealand, and South Afri ca. In clinical studies of bulimia nervosa in
the United States, individuals presenting with  this disorder are pr imarily white. However,
the disorder also occurs in ot her ethnic groups and with prevalence comparable to esti-
mated prevalences observed in white samples.
Gender-Related Diagnostic Issues
Bulimia nervosa is far more common in females than in males. Males are especially under-


represented in treatment-seeking samples, for reasons that have not yet been systemati-
cally examined.
Diagnostic Markers
No specific diagnostic test for bulimia nerv osa currently exists. However, several labora-
tory abnormalities may occur as a conseque nce of purging and may increase diagnostic
certainty. These include fluid and electrolyte abnormalities, such as hypokalemia (which
can provoke cardiac arrhythmias), hypochloremia, and hyponatremia. The loss of gastric
acid through vomiting may prod uce a metabolic alkalosis (elevated serum bicarbonate),
and the frequent induction of diarrhea or de hydration through laxative and diuretic abuse
can cause metabolic acidosis. Some individual s with bulimia nervosa exhibit mildly ele-
vated levels of serum amylase, pr obably reflecting an increase in the salivary isoenzyme.
Physical examination usually yields no physical findings. However, inspection of the
mouth may reveal significant and permanent loss of dental enamel, especially from lin-
gual surfaces of the front teeth due to recurrent vomiting. These teeth may become
chipped and appear ragged and “moth-eaten.” There may also be an increased frequency
of dental caries. In some individuals, the salivary glands, particularly the parotid glands,
may become notably enlarged. Individuals who induce vomiting by manually stimulating
the gag reflex may develop calluses or scars on the dorsal surface of the hand from re-
peated contact with the teeth. Serious cardia c and skeletal myopathies have been reported
among individuals following repeated use of  syrup of ipecac to induce vomiting.


Bulimia Nervosa 349
Suicide Risk
Suicide risk is elevated in bu limia nervosa. Comprehensive ev aluation of individuals with
this disorder should include assessment of su icide-related ideation and behaviors as well
as other risk factors for suicide, including a history of suicide attempts.
Functional Consequences  of Bulimia Nervosa
Individuals with bulimia nervosa may exhibit a range of functional limitations associated
with the disorder. A minority of individuals report severe role impairment, with the so-
cial-life domain most likely to be ad versely affected by  bulimia nervosa.
Differential Diagnosis
Anorexia nervosa, binge-eating/purging type. Individuals whose bi nge-eating behav-
ior occurs only during episodes of anorexia  nervosa are given the diagnosis anorexia ner-
vosa, binge-eating/purging type, and should  not be given the additional diagnosis of
bulimia nervosa. For individuals with an init ial diagnosis of anorexia nervosa who binge
and purge but whose presentation no longer meets the full criteria for anorexia nervosa,
binge-eating/purging type (e.g., when weight  is normal), a diagnosis of bulimia ner-
vosa should be given only when all criteria for bulimia nervosa have been met for at least
3m o n t h s .
Binge-eating disorder. Some individuals binge eat but do  not engage in regular inap-
propriate compensatory behaviors. In these ca ses, the diagnosis of binge-eating disorder
should be considered.
Kleine-Levin syndrome. In certain neurological or other medical conditions, such as
Kleine-Levin syndrome, there is disturbed eating behavior, but the characteristic psycho-


Kleine-Levin syndrome, there is disturbed eating behavior, but the characteristic psycho-
logical features of bulimia nervosa, such as overconcern with body shape and weight, are
not present.
Major depressive disorder, with atypical features. Overeating is common in major de-
pressive disorder, with atypical  features, but individuals with this disorder do not engage
in inappropriate compensatory behaviors an d do not exhibit the excessive concern with
body shape and weight characteristic of bulimia  nervosa. If criteria for both disorders are
met, both diagnoses should be given.
Borderline personality disorder. Binge-eating behavior is included in the impulsive be-
havior criterion that is part of the definition  of borderline personality disorder. If the cri-
teria for both borderline personality disorder and bulimia nervosa are met, both diagnoses
should be given.
Comorbidity
Comorbidity with mental diso rders is common in individuals with bulimia nervosa, with
most experiencing at least on e other mental disorder and many experiencing multiple co-
morbidities. Comorbidity is not limited to any particular su bset but rather occurs across a
wide range of mental disorders. There is an  increased frequency of depressive symptoms
(e.g., low self-esteem) and bipo lar and depressive disorders (particularly depressive dis-
orders) in individuals with bu limia nervosa. In many indivi duals, the mood disturbance
begins at the same time as or following th e development of bulimia nervosa, and individ-
uals often ascribe their mood disturbances to  the bulimia nervosa. However, in some in-
dividuals, the mood disturbance clearly precedes the development of bulimia nervosa.
There may also be an increased frequency of anxiety symptoms (e.g., fear of social situa-


tions) or anxiety disorders. These mood and anxiety disturbances fr equently remit follow-


350 Feeding and Eating Disorders
ing effective treatment of the bulimia nervosa. The lifetime prevalence of substance use,
particularly alcohol or stimulant use, is at least 30% among individuals with bulimia ner-
vosa. Stimulant use often begins in an attempt to control appetite and weight. A substan-
tial percentage of individuals with bulimia nervosa also have personality features that
meet criteria for one or more personality diso rders, most frequently  borderline personality
disorder.
Binge-Eating Disorder
Diagnostic Criteria 307.51 (F50.8)
A. Recurrent episodes of binge eating. An episode of binge eating is characterized
by both of the following:
1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of
food that is definitely larger than what most people would eat in a similar period of
time under similar circumstances.
2. A sense of lack of control over eating during the episode (e.g., a feeling that one
cannot stop eating or control what or how much one is eating).
B. The binge-eating episodes are associated with three (or more) of the following:
1. Eating much more rapidly than normal.
2. Eating until feeling uncomfortably full.
3. Eating large amounts of food when not feeling physically hungry.
4. Eating alone because of feeling embarrassed by how much one is eating.
5. Feeling disgusted with oneself, depressed, or very guilty afterward.
C. Marked distress regarding binge eating is present.
D. The binge eating occurs, on average, at least once a week for 3 months.
E. The binge eating is not associated with the recurrent use of inappropriate compensa-
tory behavior as in bulimia nervosa and does not occur exclusively during the course


tory behavior as in bulimia nervosa and does not occur exclusively during the course
of bulimia nervosa or anorexia nervosa.
Specify if:
In partial remission:  After full criteria for binge-eating disorder were previously met,
binge eating occurs at an average frequency of less than one episode per week for a
sustained period of time.
In full remission: After full criteria for binge-eating disorder were previously met, none
of the criteria have been met for a sustained period of time.
Specify current severity:
The minimum level of severity is based on the frequency of episodes of binge eating (see
below). The level of severity may be increased to reflect other symptoms and the degree
of functional disability.
Mild:  1–3 binge-eating episodes per week.
Moderate: 4–7 binge-eating episodes per week.
Severe:  8–13 binge-eating episodes per week.
Extreme:  14 or more binge-eating episodes per week.
Diagnostic Features
The essential feature of binge-eating disorder is recurrent episodes of binge eating that
must occur, on average, at le ast once per week for 3 months (Criterion D). An “episode of
binge eating” is defined as eating, in a discrete pe riod of time, an amount of food that is defi-


Binge-Eating Disorder 351
nitely larger than most people would eat in a similar period of time under similar circum-
stances (Criterion A1). The context in which the eating occurs may affect the clinician’s
estimation of whether the intake is excessive. For example, a quantity of food that might be
regarded as excessive for a typical meal migh t be considered normal  during a celebration
or holiday meal. A “discrete period of time” refers to a limited pe riod, usually less than
2 hours. A single episode of binge eating need not be restricted to one setting. For example,
an individual may begin a binge in a restaurant and then continue to eat on returning
home. Continual snacking on small amounts of  food throughout the day would not be con-
sidered an eating binge.
An occurrence of excessive food consumptio n must be accompanie d by a sense of lack
of control (Criterion A2) to be considered an episode of binge eating. An indicator of loss
of control is the inability to refrain from eating  or to stop eating once started. Some indi-
viduals describe a dissociative quality during , or following, the bing e-eating episodes. The
impairment in control associated with binge eating may not be abso lute; for example, an
individual may continue binge eating while the telephone is ringing but will cease if a
roommate or spouse unexpected ly enters the room. Some in dividuals report that their
binge-eating episodes are no longer characterize d by an acute feeling of loss of control but
rather by a more generalized pattern of uncont rolled eating. If individuals report that they
have abandoned efforts to control their eating , loss of control may still be considered as
present. Binge eating can also be planned in some instances.


present. Binge eating can also be planned in some instances.
The type of food consumed during binges varies both across individuals and for a given
individual. Binge eating appears to be characterized more by an abnormality in the amount
of food consumed than by a cr aving for a specific nutrient.
Binge eating must be characterized by marked  distress (Criterion C) and at least three
of the following features: eating much more rapidly than normal; eating until feeling un-
comfortably full; eating large amounts of food when not feeling physically hungry; eating
alone because of feeling embarrassed by how much one is eating; and feeling disgusted
with oneself, depressed, or very  guilty afterward (Criterion B).
Individuals with binge-eating disorder are typically ashamed of their eating problems
and attempt to conceal their symptoms. Binge ea ting usually occurs in secrecy or as incon-
spicuously as possible. The most common antece dent of binge eating is negative affect.
Other triggers include interpersonal stressors; dietary restraint; negative feelings related
to body weight, body shape, and food; and boredom. Binge eating may minimize or mit-
igate factors that precipitated the episode in  the short-term, but negative self-evaluation
and dysphoria often are the delayed consequences.
Associated Features Supporting Diagnosis
Binge-eating disorder occurs in normal-weight/ overweight and obese individuals. It is re-
liably associated with overweight and obes ity in treatment-seekin g individuals. Never-
theless, binge-eating disorder is distinct from obesity. Most obese individuals do not
engage in recurrent binge eating. In addition, compared with weight-matched obese indi-
viduals without binge-eating disorder, those with the disorder consume more calories in
laboratory studies of eating behavior and ha ve greater functional impairment, lower qual-


laboratory studies of eating behavior and ha ve greater functional impairment, lower qual-
ity of life, more subjective distress,  and greater psychiatric comorbidity.
Prevalence
Twelve-month prevalence of binge-eating disorder among U.S. adult (age 18 or older) fe-
males and males is 1.6% and 0.8%, respectively. The gender ratio is far less skewed in binge-
eating disorder than in bulimia nervosa. Bing e-eating disorder is as prevalent among fe-


males and males is 1.6% and 0.8%, respectively. The gender ratio is far less skewed in binge-
eating disorder than in bulimia nervosa. Bing e-eating disorder is as prevalent among fe-
males from racial or ethnic minority groups as has been reported for white females. The
disorder is more prevalent among individual s seeking weight-loss treatment than in the
general population.


352 Feeding and Eating Disorders
Development and Course
Little is known about the deve lopment of binge-eating disorder. Both binge eating and
loss-of-control eating without objectively ex cessive consumption occur in children and are
associated with increased body fat, weight gain, and increases in psychological symptoms.
Binge eating is common in adolescent and college-age samples. Loss -of-control eating or
episodic binge eating may represent a prodroma l phase of eating disorders for some indi-
viduals.
Dieting follows the development of binge eating in many indi viduals with binge-
eating disorder. (This is in contrast to bu limia nervosa, in which dysfunctional dieting
usually precedes the onset of binge eating.) Binge-eating disorder typically begins in ad-
olescence or young adulthood but can begin in later adulthood. In dividuals with binge-
eating disorder who seek treatment usually ar e older than individuals with either bulimia
nervosa or anorexia nerv osa who seek treatment.
Remission rates in both natural course an d treatment outcome studies are higher for
binge-eating disorder than fo r bulimia nervosa or anorexia nervosa. Binge-eating disorder
appears to be relatively persistent, and the cour se is comparable to that of bulimia nervosa
in terms of severity and duration. Crossover from binge-eating diso rder to other eating
disorders is uncommon.
Risk and Prognostic Factors
Genetic and physiological. Binge-eating disorder appears to run in families, which may
reflect additive genetic influences.
Culture-Related Diagnostic Issues
Binge-eating disorder occurs with roughly similar frequencies in most industrialized
countries, including the United States, Cana da, many European countries, Australia, and


countries, including the United States, Cana da, many European countries, Australia, and
New Zealand. In the United States, the prevalence of binge-eating disorder appears com-
parable among non-Latino whites, Latinos, Asians, and African Americans.
Functional Consequences of Binge-Eating Disorder
Binge-eating disorder is associated with a ra nge of functional consequences, including so-
cial role adjustment problems, impaired health-related quality of life and life satisfaction,
increased medical morbidity and mortality, an d associated increased health care utiliza-
tion compared with body mass index (BMI)–ma tched control subjects. It may also be as-
sociated with an increased risk for weig ht gain and the development of obesity.
Differential Diagnosis
Bulimia nervosa. Binge-eating disorder has recurrent binge eating in common with bu-
limia nervosa but differs from the latter disord er in some fundamental respects. In terms of
clinical presentation, the recurrent inapprop riate compensatory behavior (e.g., purging,
driven exercise) seen in bulim ia nervosa is absent in binge-eating disorder. Unlike in-
dividuals with bulimia nervosa, individuals wi th binge-eating disorder typically do not
show marked or sustained dietary restriction designed to influence body weight and
shape between binge-eating episodes. They may, however, report frequent attempts at
dieting. Binge-eating disorder al so differs from bulimia nervosa in terms of response to treat-
ment. Rates of improvement ar e consistently higher among individuals with binge-eating
disorder than among those with bulimia nervosa.
Obesity. Binge-eating disorder is associated  with overweight and obesity but has
several key features that are distinct from ob esity. First, levels of overvaluation of body


Other Specified Feeding or Eating Disorder 353
weight and shape are higher in obese individuals with the disorder than in those without
the disorder. Second, rates of psychiatric comorbidity are significantly higher among
obese individuals with the disorder compared with those without the disorder. Third, the
long-term successful outcome of evidence-based psychological treatments for binge-
eating disorder can be contrasted with the absence of effective long-term treatments for
obesity.
Bipolar and depressive disorders. Increases in appetite and weight gain are included
in the criteria for major depressive episode an d in the atypical features specifiers for de-
pressive and bipolar disorders. Increased eati ng in the context of a major depressive epi-
sode may or may not be associated with loss of control. If the full crit eria for both disorders
are met, both diagnoses can be given. Binge eating and other symptoms of disordered eat-
ing are seen in association with bipolar disorder . If the full criteria for both disorders are
met, both diagnoses should be given.
Borderline personality disorder. Binge eating is included in  the impulsive behavior cri-
terion that is part of the definition of border line personality disorder. If the full criteria for
both disorders are met, both  diagnoses should be given.
Comorbidity
Binge-eating disorder is associated with si gnificant psychiatric comorbidity that is com-
parable to that of bulimia ne rvosa and anorexia nervosa. Th e most common comorbid dis-
orders are bipolar disorders, depressive disorders, anxiety disorders, and, to a lesser
degree, substance use disorders. The psychiat ric comorbidity is linked to the severity of
binge eating and not to the degree of obesity.
Other Specified Feeding or Eating Disorder
307.59 (F50.8)


Other Specified Feeding or Eating Disorder
307.59 (F50.8)
This category applies to presentations in wh ich symptoms characteristic of a feeding and
eating disorder that cause clinically significant distress or impairment in social, occupation-
al, or other important areas of functioning predominate but do not meet the full criteria for
any of the disorders in the feeding and eating disorders diagnostic class. The other spec-
ified feeding or eating disorder category is used in situations in which the clinician chooses
to communicate the specific reason that the presentation does not meet the criteria for any
specific feeding and eating disorder. This is done by recording “other specified feeding or
eating disorder” followed by the specific reason (e.g., “bulimia nervosa of low frequency”).
Examples of presentations that can be specified using the “other specified” designation
include the following:
1.Atypical anorexia nervosa: All of the criteria for anorexia nervosa are met, except
that despite significant weight loss, the indi vidual’s weight is within or above the normal
range.
2.Bulimia nervosa (of low freque ncy and/or limited duration):  All of the criteria for
bulimia nervosa are met, except that the binge eating and inappropriate compensatory
behaviors occur, on average, less than once a week and/or for less than 3 months.
3.Binge-eating disorder (of low frequency and/ or limited duration):  All of the criteria
for binge-eating disorder are met, except that the binge eating occurs, on average, less
than once a week and/or for less than 3 months.
4.Purging disorder:  Recurrent purging behavior to influence weight or shape (e.g., self-
induced vomiting; misuse of laxatives, diur etics, or other medications) in the absence


354 Feeding and Eating Disorders
5.Night eating syndrome:  Recurrent episodes of night eating, as manifested by eating
after awakening from sleep or by excessive food consumption after the evening meal.
There is awareness and recall of the eating. The night eating is not better explained by
external influences such as changes in the individual’s sleep-wake cycle or by local so-
cial norms. The night eating causes significant distress and/or impairment in function-
ing. The disordered pattern of eating is not better explained by binge-eating disorder
or another mental disorder, including substance use, and is not attributable to another
medical disorder or to an effect of medication.
Unspecified Feeding or Eating Disorder
307.50 (F50.9)
This category applies to presentations in which symptoms characteristic of a feeding and
eating disorder that cause clinically significant distress or impairment in social, occupation-
al, or other important areas of functioning predominate but do not meet the full criteria for
any of the disorders in the feeding and eating disorders diagnostic class. The unspecified
feeding or eating disorder category is used in situations in which the clinician chooses not
to specify the reason that the criteria are not met for a specific feeding and eating disorder,
and includes presentations in which there is insufficient information to make a more spe-
cific diagnosis (e.g., in emergency room settings).


355Elimination
 Disorders
Elimination disorders  all involve the inappropriate elimination of urine or feces
and are usually first diagnosed in childhood or adolescence. This group of disorders in-
cludes enuresis,  the repeated voiding of urine into inappropriate places, and encopresis, the
repeated passage of feces into inappropriate places. Subtypes are provided to differentiate
nocturnal from diurnal (i.e., during waking hours) voiding for enuresis and the presence or
absence of constipation and ove rflow incontinence for encopresis. Although there are min-
imum age requirements for diagnosis of both disorders, these are based on developmental
age and not solely on chronological age. Both  disorders may be volun tary or involuntary.
Although these disorder s typically occur separa tely, co-occurrence may also be observed.
Enuresis
Diagnostic Criteria 307.6 (F98.0)
A. Repeated voiding of urine into bed or clothes, whether involuntary or intentional.
B. The behavior is clinically significant as manifested by either a frequency of at least twice a
week for at least 3 consecutive months or the presence of clinically significant distress or
impairment in social, academic (occupational), or other important areas of functioning.
C. Chronological age is at least 5 years (or equivalent developmental level).
D. The behavior is not attributable to the physiological effects of a substance (e.g., a di-
uretic, an antipsychotic medication) or another medical condition (e.g., diabetes, spina
bifida, a seizure disorder).
Specify whether:
Nocturnal only: Passage of urine only during nighttime sleep.
Diurnal only: Passage of urine during waking hours.
Nocturnal and diurnal:  A combination of the two subtypes above.
Subtypes


Subtypes
The nocturnal-only subtype of enuresis, sometimes referred to as monosymptomatic enure-
sis, is the most common subtype and involves incontinence only during nighttime sleep,
typically during the fi rst one-third of the night. The di urnal-only subtype occurs in the
absence of nocturnal enuresis and may be referred to simply as urinary incontinence.  Indi-
viduals with this subtype can be divided in to two groups. Individu als with “urge incon-
tinence” have sudden urge symptoms and de trusor instability, whereas individuals with
“voiding postponement” consciously defer micturition urges until incontinence results.
The nocturnal-and-diurnal subtype is also known as nonmonosymptomatic enuresis.
Diagnostic Features
The essential feature of enuresis  is repeated voiding of urine during the day or at night into
bed or clothes (Criterion A). Most often the voiding is involuntary, bu t occasionally it may


356 Elimination Disorders
be intentional. To qualify for a diagnosis of  enuresis, the voiding of urine must occur at
least twice a week for at least 3 consecutive months or must cause clinically significant dis-
tress or impairment in social, academic (occu pational), or other im portant areas of func-
tioning (Criterion B). The indi vidual must have reached an age at which continence is
expected (i.e., a chronological age of at leas t 5 years or, for childre n with developmental
delays, a mental age of at least 5 years) (Cri terion C). The urinary incontinence is not at-
tributable to the physiological effects of a substance (e.g., a diuretic, an antipsychotic med-
ication) or another medical co ndition (e.g., diabetes, spina bifida, a seizure disorder)
(Criterion D).
Associated Features Supporting Diagnosis
During nocturnal enuresis, occasionally the voiding takes place during rapid eye movement
(REM) sleep, and the child may recall a dream that involved the act of urinating. During day-
time (diurnal) enuresis, the child defers voiding until incontinence occurs, sometimes because
of a reluctance to use the toilet as a result of social anxiety or  a preoccupation with school or
play activity. The enuretic event most commonly occurs in the early afternoon on school days
and may be associated with symptoms of disr uptive behavior. The enuresis commonly per-
sists after appropriate treatment of an associat ed infection.
Prevalence
The prevalence of enuresis is 5%–10% am ong 5-year-olds, 3%–5%  among 10-year-olds,


and around 1% among individuals 15 years or older.
Development and Course
Two types of course of enuresis have been de scribed: a “primary” type, in which the indi-
vidual has never established urinary continence, and a “secondary” type, in which the dis-
turbance develops after a period of establis hed urinary continence. There are no differences
in prevalence of comorbid me ntal disorders between the two types. By definition, primary
enuresis begins at age 5 years. The most co mmon time for the onset of secondary enuresis
is between ages 5 and 8 years, but it may occur at any time. After age 5 years, the rate of spon-
taneous remission is 5%–10% per year. Most ch ildren with the disord er become continent
by adolescence, but in approximately 1% of cases the disorder continues into adulthood.
Diurnal enuresis is uncommon after age 9 year s. While occasional diurnal incontinence is
not uncommon in middle childhood, it is substantially more common in those who also
have persistent nocturnal enures is. When enuresis persists in to late childhood or adoles-
cence, the frequency of incontinence may in crease, whereas continence in early childhood
is usually associated with a dec lining frequency of wet nights.
Risk and Prognostic Factors
Environmental. A number of predisposing factors for enuresis have been suggested, in-
cluding delayed or lax toilet training and psychosocial stress.
Genetic and physiological. Enuresis has been associated with delays in the develop-
ment of normal circadian rhyt hms of urine production, with resulting nocturnal polyuria
or abnormalities of central v asopressin receptor sensitivity, and reduced functional blad-


or abnormalities of central v asopressin receptor sensitivity, and reduced functional blad-
der capacities with bladder hyperreactivity (unstable bladder syndrome). Nocturnal en-
uresis is a genetically heterogeneous disorder. Heritability has been shown in family, twin,
and segregation analyses. Risk for childhood nocturnal enuresis is approximately 3.6 times
higher in offspring of enuretic mothers and 10.1 times higher  in the presence of paternal
urinary incontinence. The risk magnitudes fo r nocturnal enuresis and diurnal incontinence
are similar.


Encopresis 357
Culture-Related Diagnostic Issues
Enuresis has been reported in a variety of Eu ropean, African, and Asian countries as well
as in the United States. At a national level,  prevalence rates are remarkably similar, and
there is great similarity in the developmenta l trajectories found in different countries.
There are very high rates of enuresis in orphanages and other residential institutions,
likely related to the mode and environment in which toilet training occurs.
Gender-Related Diagnostic Issues
Nocturnal enuresis is more common in males. Diurnal incontinence is more common in fe-
males. The relative risk of having a child who develops enuresis is greater for previously
enuretic fathers than for pr eviously enuretic mothers.
Functional Consequences of Enuresis
The amount of impairment associated with enur esis is a function of the limitation on the
child’s social activities (e.g., ineligibility fo r sleep-away camp) or its effect on the child’s
self-esteem, the degree of social ostracism by peers, and the anger, punishment, and rejec-
tion on the part of caregivers.
Differential Diagnosis
Neurogenic bladder or another medical condition. The diagnosis of enuresis is not made
in the presence of a neurogenic bladder or an other medical condition that causes polyuria or
urgency (e.g., untreated diabetes mellitus or diabetes insipidus) or during an acute urinary
tract infection. However, a diagnosis is compat ible with such conditions if urinary inconti-
nence was regularly present prior to the development of another me dical condition or if it per-
sists after the institution of appropriate treatment of the medical condition.
Medication side effects. Enuresis may occur during treatment with antipsychotic med-


Medication side effects. Enuresis may occur during treatment with antipsychotic med-
ications, diuretics, or other medications that may induce incontinence. In this case, the di-
agnosis should not be made in isolation but may be noted as a medication side effect.
However, a diagnosis of enuresis may be made if urinary incontinence was regularly pres-
ent prior to treatment with the medication.
Comorbidity
Although most children with enuresis do not have a comorbid mental disorder, the prevalence
of comorbid behavioral symptoms is higher in children with enuresis than in children without
enuresis. Developmental delays, including speech, language, learning, and motor skills
delays, are also present in a portion of childr en with enuresis. Encopresis, sleepwalking, and
sleep terror disorder may be present. Urinar y tract infections are more common in children
with enuresis, especially the diurnal subtype, than in those who are continent.
Encopresis
Diagnostic Criteria 307.7 (F98.1)
A. Repeated passage of feces into inappropriate places (e.g., clothing, floor), whether in-
voluntary or intentional.
B. At least one such event occurs each month for at least 3 months.
C. Chronological age is at least 4 years (or equivalent developmental level).
D. The behavior is not attributable to the physiological effects of a substance (e.g., laxa-
tives) or another medical condition except through a mechanism involving constipation.


358 Elimination Disorders
Specify whether:
With constipation and overflow incontinence:  There is evidence of constipation on
physical examination or by history.
Without constipation and overflow incontinence:  There is no evidence of constipa-
tion on physical examination or by history.
Subtypes
Feces in the with constipation and overflow incontinence subtype are characteristically
(but not invariably) poorly fo rmed, and leakage can be infr equent to cont inuous, occur-
ring mostly during the day and rarely during sleep. Only part of the feces is passed during
toileting, and the incontinence resolves after treatment of the constipation.
In the without constipation and overflow inco ntinence subtype, feces are likely to be of
normal form and consistency, and soiling is intermittent. Feces may be deposited in a
prominent location. This is usually associated  with the presence of  oppositional defiant
disorder or conduct disorder or may be th e consequence of anal masturbation. Soiling
without constipation appears to be less common than soiling with constipation.
Diagnostic Features
The essential feature of encopresis is repeated passage of feces into in appropriate places (e.g.,
clothing or floor) (Criterion A). Most often the passage is involuntary but occasionally may be
intentional. The event must occur at least once a month for at least 3 months (Criterion B), and
the chronological age of the child must be at least 4 years (or for children with developmental
delays, the mental age must be at least 4 years)  (Criterion C). The fecal incontinence must not
be exclusively attributable to the physiological ef fects of a substance (e.g., laxatives) or another
medical condition except thr ough a mechanism involving constipation (Criterion D).


medical condition except thr ough a mechanism involving constipation (Criterion D).
When the passage of feces is involuntary rath er than intentional, it is often related to
constipation, impaction, and retention with subsequent overflow. The constipation may
develop for psychological reasons (e.g., anxiet y about defecating in a particular place, a
more general pattern of anxious or oppositional behavior), leading to avoidance of defeca-
tion. Physiological predispositi ons to constipation include ineffectual straining or paradox-
ical defecation dynamics, with contraction rath er than relaxation of the external sphincter
or pelvic floor during straining for defecati on. Dehydration associated with a febrile ill-
ness, hypothyroidism, or a medication side ef fect can also induce constipation. Once con-
stipation has developed, it may be complicated by an anal fissure, painful defecation, and
further fecal retention. The con sistency of the stool may vary. In some individuals the stool
may be of normal or near-normal consistency. In other individuals—such as those with
overflow incontinence secondary to  fecal retention—it may be liquid.
Associated Features Supporting Diagnosis
The child with encopresis often feels ashame d and may wish to avoid situations (e.g.,
camp, school) that might lead to embarrassment. The amount of impairment is a function
of the effect on the child's self-esteem, the degree of social ostracism by peers, and the an-
ger, punishment, and rejection on the part of  caregivers. Smearing feces may be deliberate
or accidental, resulting from the child’s attempt to clean or hide feces that were passed in-
voluntarily. When the incontinence is clearly deliberate, features of  oppositional defiant


voluntarily. When the incontinence is clearly deliberate, features of  oppositional defiant
disorder or conduct disorder may also be present. Many children with encopresis and
chronic constipation also have enuresis symp toms and may have associated urinary reflux
in the bladder or ureters that may lead to  chronic urinary infections, the symptoms of
which may remit with treatment of the constipation.


Other Specified Elimination Disorder 359
Prevalence
It is estimated that approximately 1% of 5-year-olds have encopresis, and the disorder is
more common in males than in females.
Development and Course
Encopresis is not diagnosed until a child has re ached a chronological ag e of at least 4 years
(or for children with developmental delays, a mental age of at least 4 years). Inadequate,
inconsistent toilet training and psychosocial st ress (e.g., entering school, the birth of a sib-
ling) may be predisposing factors. Two types of  course have been described: a “primary”
type, in which the individual has never established fecal continence, and a “secondary”
type, in which the disturbance develops after a period of established fecal continence. En-
copresis can persist, with interm ittent exacerbations, for years.
Risk and Prognostic Factors
Genetic and physiological. Painful defecation can lead to co nstipation and a cycle of with-
holding behaviors that make encopresis more likely. Use of some medications (e.g., anti-
convulsants, cough suppressants) may increase constipation and make encopresis more
likely.
Diagnostic Markers
In addition to physical examination, gastrointestinal imaging (e.g., abdominal radiograph)
may be informative to assess retained stool an d gas in the colon. Additional tests, such as
barium enema and anorectal ma nography, may be used to help exclude other medical
conditions, such as Hirschsprung’s disease.
Differential Diagnosis
A diagnosis of encopresis in the presence of  another medical condition is appropriate only
if the mechanism involves constipation that cannot be explained by other medical condi-


if the mechanism involves constipation that cannot be explained by other medical condi-
tions. Fecal incontinence related to other me dical conditions (e.g., chronic diarrhea, spina
bifida, anal stenosis) would not warrant a DSM-5 diagnosis of encopresis.
Comorbidity
Urinary tract infections can be comorbid with encopresis and are more common in females.
Other Specified Elimination Disorder

This category applies to presentations in which symptoms characteristic of an elimination
disorder that cause clinically significant distress or impairment in social, occupational, or
other important areas of functioning predominate but do not meet the full criteria for any of
the disorders in the elimination disorders di agnostic class. The other specified elimination
disorder category is used in situations in which the clinician chooses to communicate the
specific reason that the presentation does not meet the criteria for any specific elimination
disorder. This is done by recording “other s pecified elimination disorder” followed by the
specific reason (e.g., “low-frequency enuresis”).
Coding note:  Code 788.39 (N39.498)  for other specified elimi nation disorder with urinary
symptoms; 787.60 (R15.9)  for other specified elimination disorder with fecal symptoms.


360 Elimination Disorders
Unspecified Elimination Disorder

This category applies to presentations in which symptoms characteristic of an elimination
disorder that cause clinically significant distress or impairment in social, occupational, or
other important areas of functioning predominate but do not meet the full criteria for any of
the disorders in the elimination disorders di agnostic class. The unspecified elimination dis-
order category is used in situations in which the clinician chooses not  to specify the reason
that the criteria are not met for a specific elimination disorder, and includes presentations
in which there is insufficient information to make a more specific diagnosis (e.g., in emer-
gency room settings).
Coding note: Code 788.30 (R32) for unspecified elimination disorder with urinary symp-
toms; 787.60 (R15.9)  for unspecified elimination disorder with fecal symptoms.