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
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
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,
Some of the codes from these two systems for specific
eating disorders can be seen in the table below.
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
DSM-IV (depending on the frequency and volume
DSM-IV (if criteria for anorexia nervosa are
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
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
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
Somerset & Wessex
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
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.
||Compulsive (Binge) Eating
Extreme fear of 'fatness'
low body weight/refusal to maintain normal body weight
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
loss of menstrual periods in females
distorted body image
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 nervosa
|Preoccupation with food,
and binge eating episodes
Lack of purging or other compensatory behaviour
Marked distress/guilt at the binge eating episodes
disorder" Encyclopędia Britannica Online.
[Accessed 15 April 2001].
Encyclopędia Britannica Online.
[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.
Primary Care Protocols for Common Mental Illness
Protocol III: Eating Disorders (18+ Years)
- Body weight maintained 15% below that expected for age and
- 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
- 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
|For more details of this the Royal
College of Psychiatrists have a PDF document as part of their
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.
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.
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.