Source of information about DSM diagnoses: American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). American Psychiatric Publishing.

Overview

Feeding and eating disorders involve persistent disturbances in eating behaviors or eating-related behaviors that significantly impair physical health or psychosocial functioning. Some individuals exhibit eating-related symptoms (e.g., cravings, compulsive patterns) similar to those in substance use disorders, suggesting overlapping neurological systems related to reward and self-regulation may be involved. However, the exact relationship remains unclear.

Anorexia, bulimia, and binge-eating disorder are mutually exclusive; only one can be diagnosed at a time.

Key Disorders:

1. Pica – Eating non-food, non-nutritive items (e.g., dirt, paper).

2. Rumination Disorder – Repeated regurgitation of food.

3. Avoidant/Restrictive Food Intake Disorder– Inadequate eating due to lack of interest or sensory avoidance, leading to weight/nutritional issues.

4. Anorexia Nervosa – Restriction of intake, significantly low weight, fear of weight gain, body image distortion.

5. Bulimia Nervosa – Binge eating + compensatory behaviors (e.g., vomiting, fasting).

6. Binge-Eating Disorder – Binge eating without purging or compensatory behaviors.

pica

Pica is characterized by the persistent eating of nonnutritive, nonfood substances over a period of at least one month, at a level that warrants clinical attention. The specific substances consumed often vary depending on age and availability but may include items such as paper, soap, cloth, hair, string, wool, soil, chalk, talcum powder, paint, gum, metal, pebbles, charcoal, ash, clay, starch, or ice.

The term “nonfood” is important, as pica does not include the ingestion of diet products or other items with minimal nutritional value. Individuals with pica typically do not show an aversion to food, and their ingestion of nonnutritive substances is developmentally inappropriate. For this reason, a minimum age of two years is recommended for diagnosis, to avoid pathologizing normal mouthing behavior in infants. Additionally, the behavior must not be part of culturally supported or socially normative practices.

Associated Features:

• May or may not be linked to mineral or vitamin deficiencies (e.g., iron, zinc).

• Often comes to attention due to medical complications, such as:

  • Mechanical bowel problems

  • Intestinal obstruction or perforation

  • Infections (e.g., toxoplasmosis from ingesting feces or dirt)

  • Poisoning (e.g., lead poisoning from eating paint)

Criteria:

A. Persistent eating of nonnutritive, nonfood substances over a period of at least 1 month.
B. The eating behavior is inappropriate for the individual’s developmental level.
C. The eating is not part of a culturally supported or socially normative practice.
D. If the behavior occurs in the context of another mental disorder (e.g., intellectual disability, autism spectrum disorder, schizophrenia) or a medical condition (including pregnancy), the behavior must be severe enough to warrant additional clinical attention.

Specify if: In remission: After full criteria for pica were previously met, the criteria have not been met for a sustained period of time.

rumination disorder

Rumination disorder is characterized by the repeated regurgitation of food following eating or feeding, lasting for at least one month. The regurgitated food, which may be partially digested, is brought up without signs of nausea, involuntary retching, or disgust. The individual may re-chew, re-swallow, or spit out the food. This behavior typically occurs daily or several times a week.

Associated Features:

• Infants often display a distinctive posture: straining, arching the back, head tilted, and tongue movements, often appearing to gain satisfaction from the act.

• Weight loss, failure to thrive, and malnutrition are common in infants, especially when regurgitation happens after nearly every feeding.

• In older children and adults, malnutrition can also occur, especially if food intake is restricted to prevent regurgitation.

• Individuals may feel embarrassed and attempt to hide the behavior, using strategies such as covering the mouth, coughing, or avoiding eating in social settings.

• Some avoid eating prior to school, work, or social events due to anticipated regurgitation.

Criteria:

A. Repeated regurgitation of food over a period of at least 1 month. The regurgitated food may be re-chewed, re-swallowed, or spit out.
B. The behavior is not attributable to a gastrointestinal or medical condition, such as gastroesophageal reflux or pyloric stenosis.
C. The eating disturbance does not occur exclusively during the course of anorexia nervosa, bulimia nervosa, binge-eating disorder, or avoidant/restrictive food intake disorder (ARFID).
D. If the behavior occurs in the context of another mental disorder (e.g., intellectual developmental disorder or another neurodevelopmental disorder), the regurgitation must be sufficiently severe to warrant additional clinical attention.

Specify if: In Remission – Full criteria were previously met, but have not been met for a sustained period of time.

Avoidant/restrictive food intake disorder (ARFID)

Avoidant/Restrictive Food Intake Disorder (ARFID) is an eating or feeding disturbance that involves the persistent avoidance or restriction of food intake, leading to significant clinical consequences. These consequences may include substantial weight loss or failure to gain weight in children, nutritional deficiencies, dependence on enteral feeding or oral nutritional supplements, and marked interference with psychosocial functioning. Unlike other eating disorders, such as anorexia nervosa or bulimia nervosa, ARFID is not driven by concerns about body image or weight. Instead, food avoidance may result from heightened sensitivity to sensory aspects of food (e.g., texture, color, smell, or temperature), a conditioned negative response following aversive events like choking or vomiting, or an overall lack of interest in eating. The disorder can occur across the lifespan and may significantly disrupt daily life, social engagement, and family routines. It extends the former DSM-IV diagnosis of feeding disorder of infancy or early childhood to include older children, adolescents, and adults.

Associated Features:

• Infants may display food refusal, gagging, or vomiting, and show limited engagement with caregivers during feeding.
• Older children and adolescents may have emotional difficulties linked to eating but not meeting criteria for another mood or anxiety disorder.
• Failure to thrive and malnutrition may occur, particularly in severe cases.
• Individuals may avoid social situations involving food (e.g., school lunches, family meals).
• Families may experience substantial disruption, including restrictive meal planning, sourcing specific foods, or making accommodations around feeding behaviors.

Criteria:

A. An eating or feeding disturbance, such as apparent lack of interest in eating or food; avoidance based on sensory characteristics of food; concern about aversive consequences of eating. Associated with one or more of the following:

1. Significant weight loss (or failure to achieve expected weight gain or 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 availability of food or cultural practice.
C. The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of body image disturbance.
D. The eating disturbance is not attributable to a concurrent medical condition or another mental disorder, unless the severity exceeds what is typically associated with that condition and warrants additional clinical attention.

Specify: In remission. Full criteria were previously met, but have not been met for a sustained period of time.

anorexia nervosa

Anorexia nervosa is an eating disorder defined by three core features: persistent restriction of energy intake, an intense fear of gaining weight or becoming fat, and a distorted perception of body weight or shape. Individuals with this disorder maintain a significantly low body weight relative to age, sex, developmental trajectory, and physical health. In adults, this is often identified by a BMI below 18.5 kg/m², with more severe cases falling below 17.0 kg/m². In children and adolescents, diagnosis involves evaluating failure to achieve expected growth or a BMI-for-age below the 5th percentile, though clinical judgment is essential.

Despite significant weight loss, individuals often deny the seriousness of their condition and continue to engage in behaviors aimed at avoiding weight gain. They may fear gaining weight even as they become increasingly underweight. This fear may be explicitly stated or inferred through persistent behavior. Affected individuals frequently exhibit distorted body image, obsessively monitor their weight, and may focus on specific body areas they believe are “too fat,” despite being underweight. Self-esteem is often tightly linked to body image, with weight loss viewed as a personal achievement and weight gain as a failure.

Criteria:

A. Restriction of energy intake leading to a significantly low body weight for age, sex, developmental stage, and physical health.
B. Intense fear of gaining weight or becoming fat, or persistent behavior that prevents weight gain, even when already underweight.
C. Distorted self-perception of body weight or shape, excessive influence of weight/shape on self-evaluation, or lack of recognition of the medical seriousness of low body weight.

Subtypes:

• Restricting Type: Weight loss is achieved without bingeing or purging; instead through dieting, fasting, or excessive exercise.
• Binge-eating/Purging Type: Involves recurrent episodes of binge eating or purging (e.g., vomiting, laxative misuse).

Remission Specifiers:

• Partial Remission: Criterion A no longer met, but Criterion B or C is still present.

• Full Remission: None of the criteria are met for a sustained period.

bulimia nervosa

Bulimia nervosa is an eating disorder marked by a cycle of recurrent binge eating and compensatory behaviors aimed at preventing weight gain. Binge eating episodes involve consuming an abnormally large amount of food within a short, discrete period of time (typically less than two hours), accompanied by a loss of control over eating. These episodes are not simply overeating; they are experienced as compulsive and are often secretive, leading to feelings of shame, guilt, or emotional distress. The binge eating is followed by inappropriate compensatory behaviors, such as self-induced vomiting, misuse of laxatives, diuretics, or enemas, fasting, or excessive exercise. These behaviors occur, on average, at least once per week for three months.

Individuals with bulimia nervosa typically have a normal or slightly elevated body weight, which can make the disorder less visible. Despite this, they often experience a distorted self-image, with body shape and weight playing a dominant role in self-evaluation. Like those with anorexia nervosa, individuals with bulimia nervosa may express a strong desire to lose weight and fear of gaining weight, but they do not meet the criteria for anorexia nervosa if their body weight is not significantly low.

Medical complications are common and can be severe, including electrolyte imbalances, esophageal damage, cardiac arrhythmias, and gastrointestinal issues. Emotional triggers such as negative mood states, interpersonal stress, or body dissatisfaction often precede binge episodes, and while the act of bingeing may briefly relieve distress, it is usually followed by intense guilt and negative self-perception.

Criteria:

A. Recurrent episodes of binge eating, characterized by both:

1. Consuming an unusually large amount of food within a limited timeframe (typically within 2 hours), more than what most people would eat in similar situations.
2. Experiencing a loss of control during the episode, such as feeling unable to stop eating or regulate the amount or type of food consumed.

B. Recurrent inappropriate compensatory behaviors to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, or excessive exercise.
C. Binge eating and compensatory behaviors 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.

Specifiers:

• In Partial Remission: Some, but not all, criteria are still met after full criteria were previously met.
• In Full Remission: None of the criteria have been met for a sustained period.

Specify severity: mild (average of 1-3 episodes in a week), moderate (4-7 episodes in a week), severe (8-13 episodes in a week), extreme (14 or more episodes in a week), and unspecified.

binge-eating disorder

Binge-eating disorder (BED) is characterized by recurrent episodes of binge eating that occur, on average, at least once per week for three months. A binge eating episode involves consuming an unusually large amount of food within a discrete time period, typically less than two hours, accompanied by a loss of control over eating (a sense that one cannot stop or regulate what or how much is being eaten). These episodes often happen in secrecy and are followed by intense distress, guilt, or shame.

Binge episodes may be triggered by negative mood states, interpersonal stress, or body dissatisfaction, and although eating may provide temporary relief, it often results in persistent psychological distress. Individuals with BED often attempt to hide their eating behaviors, contributing to emotional isolation and diminished self-esteem.

Criteria:

A. The individual experiences repeated binge-eating episodes, which include:

1. Consuming a large quantity of food in a limited timeframe (typically within 2 hours) that exceeds what most people would eat under similar circumstances.
2. Feeling a lack of control over eating, such as being unable to stop or regulate how much is consumed.

B. These episodes are connected with at least three of the following behaviors:

• Eating more quickly than usual.
• Continuing to eat until feeling uncomfortably full.
• Eating large amounts of food even when not physically hungry.
• Eating alone due to embarrassment over eating habits.
• Feeling ashamed, guilty, or emotionally distressed afterward.

C. The individual experiences significant emotional distress related to binge eating.
D. Binge episodes happen on average once a week for at least three months.
E. The behavior is not followed by compensatory actions like purging or fasting and does not occur exclusively during anorexia nervosa or bulimia nervosa.

Specifiers:

• In Partial Remission: Some, but not all, criteria are still met after full criteria were previously met.
• In Full Remission: None of the criteria have been met for a sustained period.

Specify severity: mild (average of 1-3 episodes in a week), moderate (4-7 episodes in a week), severe (8-13 episodes in a week), extreme (14 or more episodes in a week), and unspecified.

other specified feeding or eating disorder

Other specified feeding or eating disorder is diagnosed when an individual shows clear symptoms of a feeding or eating disorder that cause distress or impair important areas of functioning, yet do not meet the full criteria for any specific disorder in this category. This diagnosis is appropriate when the clinician wants to specify the exact reason the case does not fit into a more defined diagnosis.

Examples of OSFED Presentations:

• Atypical Anorexia Nervosa: All the features of anorexia nervosa are present, such as restrictive eating and fear of weight gain, except the person’s weight remains within or above the normal range despite significant weight loss.
• Low-Frequency/Limited-Duration Bulimia Nervosa: The person meets all criteria for bulimia nervosa, except the binge-purge behaviors occur less than once a week or have lasted for less than three months.
• Low-Frequency/Limited-Duration Binge-Eating Disorder: All core symptoms of binge-eating disorder are present, but episodes happen less than once per week or for under three months.
• Purging Disorder: Repeated use of purging methods (e.g., vomiting, laxatives) to control weight or shape occurs without binge eating.
• Night Eating Syndrome: Involves repeated eating episodes at night, either after waking up or after the evening meal, with full awareness and significant distress or impairment. It is not better explained by cultural norms, other disorders, medical conditions, or medication side effects.

unspecified feeding or eating disorder

This diagnosis is used when an individual exhibits significant symptoms of a feeding or eating disorder that result in clinically meaningful distress or functional impairment, but the presentation does not fully meet the criteria for any specific disorder within the category. It is applied in cases where the clinician either chooses not to identify the reason why the criteria are unmet or when there is not enough information available to make a more precise diagnosis, for example, during emergency assessments or brief clinical encounters.

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