DSM-III

Diagnostic Criteria

A. Intense fear of becoming obese, which does not diminish as weight loss progresses.

B. Disturbance of body image, e.g., claiming to "feel fat" even when emaciated.

C. Weight loss of at least 25% of original body weight or, if under 18 years of age, weight loss from original body weight plus projected weight gain expected from growth charts may be combined to make the 25%.

D. Refusal to maintain body weight over a minimal normal weight for age and height.

E. No known physical illness that would account for the weight loss.

Differential Diagnosis

Depressive Disorders and physical disorders

In Depressive Disorders, and certain physical disorders, weight loss can occur, but there is no intense fear of obesity or disturbance of body image.

Schizophrenia

In Schizophrenia there may be bizarre eating patterns; however, the full syndrome of Anorexia Nervosa is rarely present; when it is, both diagnoses should be given.

Bulimia

In Bulimia, weight loss, if it does occur, is never as great as 25% of original body weight. In rare instances an episode of Anorexia Nervosa occurs in an individual with Bulimia, in which case both diagnoses are given.

DSM-IV

Diagnostic Criteria

A. Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected).

B. Intense fear of gaining weight or becoming fat, even though underweight.

C. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.

D. In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen, administration.)

Specify type:

  • Restricting Type: during the current episode of Anorexia Nervosa, the person has not regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas)
  • Binge-Eating/Purging Type: during the current episode of Anorexia Nervosa, the person has regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas)

Subtypes

The following subtypes can be used to specify the presence or absence of regular binge eating or purging during the current episode of Anorexia Nervosa:

Restricting Type

This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, or excessive exercise. During the current episode, these individuals have not regularly engaged in binge eating or purging.

Binge-Eating/Purging Type

This subtype is used when the individual has regularly engaged in binge eating or purging (or both) during the current episode. Most individuals with Anorexia Nervosa who binge eat also purge through self-induced vomiting or the misuse of laxatives, diuretics, or enemas. Some individuals included in this subtype do not binge eat, but do regularly purge after the consumption of small amounts of food. It appears that most individuals with Binge-Eating/Purging Type engage in these behaviors at least weekly, but sufficient information is not available to justify the specification of a minimum frequency.

Differential Diagnosis

General Medical Conditions

Other possible causes of significant weight loss should be considered in the differential diagnosis of Anorexia Nervosa, especially when the presenting features are atypical (such as an onset of illness after age 40 years). In general medical conditions (e.g., gastrointestinal disease, brain tumors, occult malignancies, and acquired immunodeficiency syndrome [AIDS]), serious weight loss may occur, but individuals with such disorders usually do not have a distorted body image and a desire for further weight loss. The superior mesenteric artery syndrome (characterized by postprandial vomiting secondary to intermittent gastric outlet obstruction) should be distinguished from Anorexia Nervosa, although this syndrome may sometimes develop in individuals with Anorexia Nervosa because of their emaciation.

Major Depressive Disorder

In Major Depressive Disorder, severe weight loss may occur, but most individuals with Major Depressive Disorder do not have a desire for excessive weight loss or excessive fear of gaining weight.

Schizophrenia

In Schizophrenia, individuals may exhibit odd eating behavior and occasionally experience significant weight loss, but they rarely show the fear of gaining weight and the body image disturbance required for a diagnosis of Anorexia Nervosa.

Social Phobia, Obsessive-Compulsive Disorder, and Body Dysmorphic Disorder

Some of the features of Anorexia Nervosa are part of the criteria sets for Social Phobia, Obsessive-Compulsive Disorder, and Body Dysmorphic Disorder. Specifically, individuals may be humiliated or embarrassed to be seen eating in public, as in Social Phobia; may exhibit obsessions and compulsions related to food, as in Obsessive-Compulsive Disorder; or may be preoccupied with an imagined defect in bodily appearance, as in Body Dysmorphic Disorder. If the individual with Anorexia nervosa has social fears that are limited to eating behavior alone, the diagnosis of Social Phobia should not be made, but social fears unrelated to eating behaviors (e.g., excessive fear of speaking in public) may warrant an additional diagnosis of Social Phobia. Similarly, an additional diagnosis of Obsessive-Compulsive Disorder should be considered only if the individual exhibits obsessions and compulsions unrelated to food (e.g., an excessive fear of contamination), and an additional diagnosis of Body Dysmorphic Disorder should be considered only if the distortion is unrelated to body shape and size (e.g., preoccupation that one's nose is too big).

Bulimia Nervosa

In Bulimia Nervosa, individuals exhibit recurrent episodes of binge eating, engage in inappropriate behavior to avoid weight gain (e.g., self-induced vomiting), and are overly concerned with body shape and weight. However, unlike individuals with Anorexia Nervosa, Binge-Eating/Purging Type, individuals with Bulimia Nervosa are able to maintain body weight at or above a minimally normal level.

DSM-5

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. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than 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.

C. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.

Specify whether:

  • Restricting type: During the last 3 months, the individual has not engaged in recurrent episode of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise.
  • Binge-eating/purging type: During the last 3 months, the individual has engages in recurrent episodes of binge eating 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 nervosa were previously met, Criterion 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 nervosa 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, 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 adolescents, corresponding BMI percentiles should be used. The level of severity may be increased 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 the misuse of laxatives, diuretics, or enemas. Some individuals with this subtype of anorexia nervosa do not binge eat but to regularly purge after the consumption of small amounts of food.

Crossover between the subtypes over the course of the disorder is not uncommon; therefore, subtype description should be used to describe current symptoms rather than longitudinal course.

Differential Diagnosis

Other possible causes of either significantly low body weight or significant weight loss should be considered in the differential diagnosis 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 malignancies, and acquired immunodeficiency syndrome [AIDS])

Serious weight loss may occur in medical conditions, but individuals with these disorders usually do not also manifest a disturbance in the way their body weight 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 develops after bariatric surgery for obesity.

Major depressive disorder

In major depressive disorder, severe weight loss may occur, but most individuals with major depressive disorder do not have either a desire for excessive weight loss or an intense fear of gaining weight.

Schizophrenia

Individuals with schizophrenia may exhibit odd eating behavior and occasionally experience significant weight loss, but they rarely show the fear of gaining weight and the body image disturbance required for a diagnosis of anorexia nervosa.

Substance use disorders

Individuals with substance use disorders may experience low weight due to poor nutritional intake but generally do not fear gaining weight and do not manifest body image disturbance. Individuals who abuse substances that reduce appetite (e.g., cocaine, stimulants) 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 interferes with weight gain (Criterion B).

Social anxiety disorder (social phobia), obsessive-compulsive disorder, and body dysmorphic disorder

Some of the features of anorexia nervosa overlap with the criteria for social phobia, OCD, and body dysmorphic disorder. Specifically, individuals may feel humiliated or embarrassed to be seen eating in public, as in social phobia; may exhibit obsessions and compulsions related to food, as in OCD; or may be preoccupied with an imaged defect in bodily appearance, as in body dysmorphic disorder. If the individual with anorexia nervosa has social fears that are limited to eating behavior alone, the diagnosis of social phobia should not be made, but social fears unrelated to eating behavior (e.g., excessive fear of speaking in public) may warrant an additional diagnosis of social phobia. Similarly, an additional diagnosis of OCD should be considered only if the individual exhibits obsessions and compulsions unrelated to food (e.g., an excessive fear of contamination), and an additional diagnosis of body dysmorphic disorder should be considered only if the distortion is unrelated to body shape and size (e.g., preoccupation that one's nose is too big).

Bulimia nervosa

Individuals with bulimia nervosa exhibit recurrent episodes of binge eating, engage in inappropriate behavior to avoid weight gain (e.g., self-induced vomiting), and are overly concerned with body shape and weight. However, unlike individuals with anorexia nervosa, binge-eating/purging type, individuals with bulimia nervosa maintain body weight at or above a minimally normal level.

Avoidant/restrictive food intake disorder

Individuals with this disorder may exhibit significant weight loss or significant nutritional deficiency, but they do not have a fear of gaining weight or of becoming fat, nor do they have a disturbance in the way they experience their body shape or weight.

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