Definitions

Definitions & Diagnosis

People like to categorise and define things and eating disorders are no exception. On this page you'll find some information about some of the ways eating disorders are 'defined' and diagnosed. At times it can get rather complex and, if you're struggling with an eating disorder or supporting someone who is, it may even seem a bit pointless, if you don't quite 'fit in the boxes' it might even feel positively unhelpful, however such tools are designed for the aiding of clinicians in identifying an eating disorder and are in common use, as such it can be useful to be familiar with them.

It is interesting to note that there are more than one set of such diagnostic tools and that they do not necessarily concur in all instances. Equally the two main systems of diagnostic criteria do not necessarily recognise all of the same disorders as each other. In addition to this, both diagnostic systems provide a category in which to place eating disorders that do not conform to criteria laid down in their respective systems. In the absence of formal criteria for these unspecified eating disorders there exist a number of 'unofficial' eating disorders which technically can not be diagnosed but are recognise in some quarters. As you can see, defining and diagnosing an eating disorder is not as simple as might at first be assumed and a diagnosis may well differ depending on the criteria used and, possibly, the acceptance or rejection of certain types of 'unofficial' disorders usually referred to as unspecified.A this point it may also be useful to note that Somerset & Wessex Eating Disorders Association considers any pattern of disordered eating used by an individual to cope but which causes distress to that person, to be an 'eating disorder' and that the person experiencing this to be as in need, and worthy, of help and support as someone meeting absolutely the diagnostic criteria described here.

For the medical profession Eating Disorders are usually defined and diagnosed clinically according to diagnostic criteria laid out in one two systems:~

The 'Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition' (more commonly referred to as DSM-IV) published by the American Psychiatric Association. DSM-IV groups 'mental disorders' into 'Major Classifications' such as Schizophrenia and other Psychotic disorders, Anxiety Disorders and so on with each Major Classification having a numeric code. Eating Disorders constitutes a Major Classification and is coded 307. Major Classifications are further subdivided giving a code for individual disorders in the form of xxx.xx.

The International Statistical Classification of Diseases and Related Health Problems, tenth revision - ICD-10. Published by the World Health Organisation and often used in Europe. The list of ICD-10 codes for eating disorders reads :~ F50.0 Anorexia nervosa, F50.1 Atypical anorexia nervosa, F50.2 Bulimia nervosa, F50.3 Atypical bulimia nervosa, F50.4 Overeating associated with other psychological disturbances, F50.5 Vomiting associated with other psychological disturbances, F50.8 Other eating disorders, F50.9 Eating disorder, unspecified.

Some of the codes from these two systems for specific eating disorders can be seen in the table below.

	DSM-IV	ICD-10
Eating Disorders		F50
Anorexia Nervosa	307.1	F50.0
Atypical Anorexia Nervosa	*	F50.1
Bulimia Nervosa	307.51	F50.2
Atypical Bulimia Nervosa	*	F50.3
Overeating associated with other psychological disturbances	*	F50.4¹
Vomiting associated with other psychological disturbances	*	F50.5
Other eating disorders	²	F50.8
Eating Disorders Not Otherwise Specified	307.50
Eating Disorders Unspecified		F50.9
(Binge Eating Disorder)*	Research Criteria
* EDNOS under DSM-IV. ¹ Possibly comparable to DSM-IV's research criteria for Binge Eating Disorder. ² May be considered an ENDOS under DSM-IV ³ Psychogenic - Having a psychological rather than physiological origin.

Notice how a diagnosis may vary depending on the system used and also how the range of eating disorders varies between systems. For example someone with bulimic like symptoms may, depending on the the system used and the variety and/or frequency of other symptoms, be diagnosed as having:-

Bulimia Nervosa
Bulimia Nervosa Purging Type
Bulimia Nervosa Non-Purging Type
Atypical Bulimia Nervosa
Eating Disorder Not Otherwise Specified
Eating Disorder Unspecified
Anorexia Nervosa -Binge Eating and Purging Type

ICD-10
DSM-IV
DSM_IV
ICD-10
DSM-IV (depending on the frequency and volume of binges)
ICD-10
DSM-IV (if criteria for anorexia nervosa are also meet)

Binge Eating Disorder / Compulsive Eating

It is worth taking time to consider Binge Eating Disorder or 'Compulsive Eating'. It is often listed alongside Anorexia Nervosa and Bulimia Nervosa as another eating disorder but things are not quite as simple as that.

Currently Binge Eating Disorder (BED) is not fully recognised by DSM-IV and is listed as being a disorder meriting further study, it is considered to meet the diagnostic criteria for an Eating Disorder Not Otherwise Specified (307.50). Details of the Research Criteria for Binge Eating Disorder can be found in the appendix to DSM-IV, page 731.

ICD-10 provides criteria for 'Overeating associated with other psychological disturbances' which can include overeating as a result of emotion/psychological stress.

Binge Eating and Compulsive Eating are frequently used interchangeably, often to describe a pattern of overeating as a coping mechanism for underlying emotional pain. However it is worth pointing out that in some quarters they are considered separate and distinct from each other with compulsive eating relating to a condition whereby overeating occurs consistently and in the absence of 'binges' and Binge Eating Disorder relating to a pattern of relatively normal eating interspersed with episodes of bingeing.

DSM-IV defines a 'binge' as "eating, in a discrete period of time (e.g., within any two hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances".

Eating Disorders Not Otherwise Specified (EDNOS)

It is also worth taking some time to look at Eating Disorders Not Otherwise Specified (ednos) DSM-IV or Eating Disorders Unspecified ICD-10, whilst also noting the differences in certain diagnostic criteria between DSM-IV and ICD-10. A diagnosis may differ depending on the system being used.

The symptoms of eating disorders can vary greatly between individuals and many sufferers recollect periods of shifting symptoms that would at times move them between disorders as defined by DSM-IV/ICD-10.

Eating Disorders Not Otherwise Specified is used to define 'atypical' eating disorders - in other words eating disorders whose symptoms do not fully meet the 'typical' symptoms laid down in the diagnostic criteria. ICD-10 has separate sets of diagnostic criteria for 'atypical' anorexia and bulimia nervosa as well as a number of other eating disorders which, lacking formal DSM-IV criteria, would fall within DSM-IV's ENDOS category if diagnosed using that system. Binge Eating Disorder , until fully recognised as a separate disorder, is also considered to be an Eating Disorder Not Otherwise Specified.

This can be rather confusing but satisfies the medical professions penchant for neatly delineated and separated diagnoses. The criteria for ENDOS, as with the other disorders, do not seem to consider the motivations driving eating disorders (such as a coping mechanism for underlying trauma although this is hinted by ICD-10 F50.4 and F50.5) and differences in diagnoses may be based on the presence or absence of a physical symptom or perhaps the frequency of particular behavioural occurrences!

For example, the diagnostic criteria for Eating Disorders Not Otherwise Specified (DSM-IV) include:-

All criteria for Anorexia Nervosa are met except that, in females, regular periods are present.

All criteria for Bulimia Nervosa are met except that bingeing and consequent inappropriate compensatory behaviours occur less than twice a week or for a duration of less than 3 months.

Regular use of inappropriate compensatory behaviour (such as vomiting) by individuals of a normal body weight after eating small amount of food. (An individual of low body weight (or reaching a low body weight after being diagnosed with an EDNOS) might well be considered anorexic or if 'bingeing' occurred as defined by the diagnostic criteria - then bulimic).

Repeatedly chewing and spitting out (but not consuming) large amounts of food.

Recurrent episodes of binge eating in the absence of the regular use of inappropriate compensatory behaviours characteristic of bulimia nervosa. (Binge Eating Disorders/Compulsive Eating).

This can all be rather confusing and individuals rarely fit neatly (or constantly over time) within the bounds of any given set of diagnostic criteria, consequently many people now consider an Eating Disorder to be an inappropriate use of food to deal with underlying distress with the exact nature of the inappropriate use/behaviour being less important than the motivation driving it.

Somerset & Wessex Eating Disorders Association considers anyone struggling with an inappropriate use of food to be 'eating disordered' and equally in need of help and support whether officially anorexic, bulimic or within the scope of Eating Disorders Not Otherwise Specified.

These systems, however, are rather complex, not particularly accessible and sometimes confusing in comparison. Below is a table showing some commonly recognised symptoms of eating disorders along with some additional information if DSM-IV, ICD-10 or another reference source have anything specific to add (hold the mouse pointer over the

the view this - note this requires a DHTML compatible browser).

Some Common Diagnostic Symptoms of Eating Disorders Please note that this symptoms list is a summary of common symptoms. It is neither complete or exhaustive nor does it constitute a set of diagnostic criteria. It is provided for information purposes and to show and compare some common symptoms only and should not be used for diagnostic purposes.
Anorexia Nervosa	Bulimia Nervosa	Compulsive (Binge) Eating
DSM-IV defines two subtypes of anorexia nervosa (1) a restricting type which is characterised by strict dieting and exercise but without binge eating (2) a binge-eating & purging type, marked by episodes of compulsive eating with or without self-induced vomiting and the use of laxatives or enemas. Extreme fear of 'fatness' low body weight/refusal to maintain normal body weight at least 15% below that expected according to DSM-IV & ICD-10. Encyclop�dia Britannica Online states >25% of expected₍₁₎ The weight loss is self-induced by avoidance of "fattening foods" and one or more of the following: self-induced vomiting; self-induced purging; excessive exercise; use of appetite suppressants and/or diureticsICD-10 criteria loss of menstrual periods in females distorted body image	extreme fear of 'fatness' preoccupation with eating, and an irresistible craving for food leading to episodes of bingeing A purging reaction in order to counteract the effects of bingeing, which may include self-induced vomiting, laxative/diuretic abuse, periods of starvation, exercise etc. a feeling of loss of control around the bingeing/purging cycle Self-evaluation is unduly influenced by body shape and weight The disturbance does not occur exclusively during episodes of anorexia nervosaDSM-IV criteria	Preoccupation with food, and binge eating episodes Lack of purging or other compensatory behaviour Thus EDNOS. It is worth noting a potential ambiguity here as some sufferers of Compulsive Eating when describing 'good days' relate to days on which eating is restricted. Whether this constitutes compensatory behaviour and thus may imply bulimia is unclear. Marked distress/guilt at the binge eating episodes
(1) "mental disorder" Encyclop�dia Britannica Online. <http://members.eb.com/bol/topic?eu=118186&sctn=33> [Accessed 15 April 2001].	(2) "bulimia" Encyclop�dia Britannica Online. <http://members.eb.com/bol/topic?idx_id=77826> [Accessed 15 April 2001].

It is interesting to note that the Nation Health Service has a number of Primary Care Protocols which can be used for identification of, and referral for, a disorder. Protocol III: is for Eating Disorders (in which only Anorexia Nervosa and Bulimia Nervosa are included) for the 18+ (non-adolsescent) age group.This Protocol has its own set of Diagnostic Criteria Which are show below.

NHS Primary Care Protocols for Common Mental Illness Protocol III: Eating Disorders (18+ Years)
Diagnostic Criteria Anorexia Nervosa	Diagnostic Criteria Bulimia Nervosa
Body weight maintained 15% below that expected for age and height /BMI<17.5kg/m2 Weigh loss self-induced by restriction of intake self-induced vomiting self-induced purging excessive exercise use of appetite suppressant or diuretics Morbid dread of fatness (over-valued idea) Self-set low weight threshold Disturbance of endocrine function to produce amenorrhoea in women and loss of sexual interest and potency in men (in prepubertal onset there is a delay of puberty and growth restriction	Bingeing, with preoccupation with food and craving of the same Attempts to counteract excess calorie intake by self-induced vomiting self-induced purging alternating periods of starvation and bingeing use of appetite suppressants, diuretics, thyroid preparations or, in diabetes, neglect of insulin treatment Morbid dread of fatness Self-set low weight threshold Possible history of anorexia nervosa or atypical anorexia nervosa
For more details of this the Royal College of Psychiatrists have a PDF document as part of their Eating Disorders Special Interest Group site which shows this Identification/Referral process. It can be found at http://www.rcpsych.ac.uk/college/sig/pcProtocol.pdf and requires Adobe Acrobat Reader to view.

Whilst such systems provide strong diagnostic criteria aiding clinicians in diagnosing an Eating Disorder they are not in themselves particularly effective or useful in explaining to a sufferer or carer what an eating disorder is or, perhaps more importantly, why she or he is suffering from one.

There is a great deal that has been written about eating disorders but rather less that is conclusive and the causes of eating disorders are still not fully understood.

What does seem apparent, however, is that eating disorders are an expression of psychological and emotional problems in which sufferers use food in different ways to cope with and manage their distress - a coping mechanism, if you will, for underlying anguish that the sufferer feels unable to manage in any other way. It is, therefore, essential to address not only the very real and distressing problems around food and eating that sufferers struggle so much with but also the underlying pain for which the eating disorder provides a way to cope.

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