Feeding Disorders: Essential Features

Feeding disorders in infants and young children are complex and include pica, rumination disorder, and avoidant/restrictive food intake disorder. For there to be successful feeding, there needs to be an interaction between the child and the caregiver, and maternal psychopathology is a factor in a child developing feeding difficulties (Micali, Simonoff, Stahl, & Treasure, 2011). Additionally, a child’s temperament has been related to feeding difficulties (Lindberg, Bohlin, Hagekull, & Thunström, 1994). Like eating disorders, feeding disorders are often characterized by some type of avoiding or restricting food intake; however, feeding disorders typically manifest in early childhood rather than adolescence (Bryant-Waugh, Markham, Kreipe, & Walsh, 2010). Feeding disorders and short-term feeding issues may present similarly at first. Thus, counselors should pay close attention to diagnostic criteria so they may more accurately differentiate between developmentally appropriate behavior (e.g., a child being a “picky eater”) and disordered eating (e.g., a child steering clear of events that entail eating). Prevalence rates for feeding disorders are not clearly identified (Bryant-Waugh et al., 2010).

Eating Disorders: Essential Features

Similar to feeding disorders in infants and young children, eating disorders in adolescents and adults are complex in nature and have a significant, daily impact for those who experience them. An eating disorder is an illness that negatively affects an individual’s diet. This can range from eating small amounts of food or nothing at all to eating extremely large amounts of food (NIMH, 2013). Eating disorders can be detrimental to one’s physical health, emotional well-being, and interpersonal relationships. Some counselors may struggle to comprehend how eating disorders develop. Given that they can present in a number of ways across age, race, and ethnicity, eating disorders can pose challenges for any mental health professional (Roman & Reay, 2009). Eating disorders covered in this chapter include anorexia nervosa, bulimia nervosa, and binge-eating disorder.

Almost 20 million women and 10 million men have suffered from some kind of eating disorder in their lives (Wade, Keski-Rahkonen, & Hudson, 2011). As high as these figures are, there are many individuals who have eating disorders or are at risk for them but do not seek treatment. The rates of eating disorder cases have increased since the 1950s (Striegel-Moore & Franko, 2003; Wade et al., 2011).

Prevalence rates for eating disorders vary considerably. Over a 12-month period, the prevalence rate of anorexia nervosa is approximately 0.4% among the general population, whereas the prevalence of bulimia nervosa is 1.0% to 1.5% (APA, 2013a). According to the DSM-5, the 12-month prevalence of binge-eating disorder is 1.6% among U.S. adult females and 0.8% among U.S. adult males. A study using proposed DSM-5 criteria for eating disorders revealed the following prevalence rates: 0.8% for anorexia nervosa, 2.6% for bulimia nervosa, and 3.0% for binge-eating disorder (Stice, Marti, & Rohde, 2013). As detailed in the section regarding Major Changes From DSM-IV-TR to DSM-5 (see below), increased prevalence rates are the result of a general lowering of diagnostic thresholds for eating disorders.

Adolescence is the period of greatest risk for developing an eating disorder (Striegel-Moore & Bulik, 2007). However, concerns about body shape, image, and weight that underlie eating disorder processes may begin much younger; 40% to 60% of elementary school girls (ages 6–12) expressed concern about weight or becoming fat (Smolak, 2011). Girls in this age range are forming their self-concepts and may be readily influenced by direct and indirect messages from parents and peers (Linville, Stice, Gau, & O’Neil, 2011). Eating disorders can develop in individuals during the college years and into adulthood as well (Schwitzer, 2012). Estimates of prevalence rates for college students with eating disorders range from 8% to 17% (Eisenberg, Nicklett, Roeder, & Kirz, 2011; Prouty, Protinsky, & Canady, 2002). Although eating disorders are typically prevalent in females, males can also be at risk. Typically, men with eating disorders are more interested in making their bodies more muscular and larger as opposed to women, who are more focused on maintaining a smaller-sized body (Ousley, Cordero, & White, 2008).

Although many feeding and eating disorders have similar psychological and behavioral features, with the exception of pica, only one diagnosis can be given. Diagnostic criteria for the disorders are mutually exclusive, meaning it is not possible to have both binge-eating disorder and bulimia. This ensures differentiation of each disorder and helps counselors target treatment planning and outcome management to unique characteristics of the disorders (APA, 2013a).

Note

Disorders in this section will sometimes resemble substance use disorders (APA, 2013a). For example, symptoms such as craving and compulsive usage are typical to both diagnostic categories. This is because eating and substance use disorders involve the same neural systems that control self-regulation and reward. More research is needed regarding commonalities between development and treatment of eating disorders and substance abuse; however, cognitive-behavioral interventions appear to be effective in the treatment of both eating and substance use disorders.

Major Changes From DSM-IV-TR to DSM-5

The DSM-5 contains changes in diagnostic criteria and the inclusion of additional disorders from the DSM-IV-TR. These changes provide a more representative look at clients’ behaviors and symptoms as they deal with these conditions throughout the life span. Some of the more significant changes made by the DSM-5 Eating Disorders Work Group include the revision of diagnostic criteria in anorexia nervosa and bulimia nervosa as well as the recognition of binge-eating disorder (APA, 2013b).

In addition, the following disorders have been added to the Feeding and Eating Disorders chapter: pica, rumination, and avoidant/restrictive food intake disorder. These three disorders were listed in the DSM-IV-TR under Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence; that section has been eliminated in the DSM-5 (APA, 2013b). Although these three disorders have been moved to the Feeding and Eating Disorders chapter, individuals who seek treatment for pica, rumination disorder, or avoidant/restrictive food intake disorder are more likely to present to a medical clinic as opposed to a mental health clinic (Berg & Peterson, 2013).

Eating disorder NOS was renamed to other specified feeding and eating disorder and unspecified feeding and eating disorder (APA, 2013a). Studies have shown that many individuals being treated for an eating disorder have previously been categorized as eating disorder NOS because, although they display some symptoms of an eating disorder, these individuals did not meet stringent requirements for either anorexia nervosa or bulimia nervosa (Hebebrand & Bulik, 2011; Sysko & Walsh, 2011). By broadening diagnostic criteria for both anorexia nervosa and bulimia nervosa, it is hoped instances of other specified and unspecified feeding and eating disorders will be reduced (Berg & Peterson, 2013; Fairburn & Cooper, 2011). For example, the DSM-5 criteria reduced the frequency of binge eating from a minimum of twice a week in the DSM-IV-TR to once a week. Although critics report instances of diagnostic inflation in the DSM-5 (Frances, 2013), under the DSM-IV-TR criteria at least 50% of clients seen for eating disorders were diagnosed with eating disorder NOS (Fairburn & Cooper, 2011).

Differential Diagnosis

Feeding and eating disorders can present in many different ways. It is important first to understand whether the behavior and accompanying symptoms can be better explained by another medical or psychiatric condition. For all eating disorders, it is important to look at the following variables: weight status, fear of weight gain, dietary restriction, overevaluation of shape and weight, body image disturbance, presence and frequency of binge eating, and presence and frequency of compensatory behaviors (Berg & Peterson, 2013). Although popular culture links anorexia nervosa to restricted eating and bulimia nervosa to binge-purge behavior, both disorders include mention of restriction and compensatory behaviors. Careful assessment regarding disorder processes, underlying thought patterns, and impairments will help counselors identify the eating disorder that best fits the client’s experience.

Many individuals who have an eating disorder also have additional pathological behaviors and psychological symptoms. These symptoms include depression, anxiety, substance use, and personality disorders (Choate, 2010; Eisenberg et al., 2011; Kaye, Klump, Frank, & Strober, 2000). In addition, changes in appetite and eating are characteristic of depressive and anxiety disorders, and screening for mood disorders should also be a part of any screening process for eating disorders. In some instances, it might be beneficial for individuals to seek treatment for co-occurring mental health or substance abuse concerns before treatment for the eating disorder (Berg, Peterson, & Frazier, 2012). This way, the client will be able to better manage the symptoms for other co-occurring disorders before working on symptoms and behaviors that are a part of the eating disorder.

Etiology for Feeding Disorders

Feeding difficulties are fairly common among infants and children, and not all difficulties will manifest into feeding disorders (Kerwin, Eicher, & Gelsinger, 2005). However, it is important to make note of such difficulties and use treatment to prevent them from turning into a disorder. Feeding disorders often have different medical and developmental etiologies that call for various interventions (Bryant-Waugh et al., 2010).

It may be difficult to notice if a child has a feeding disorder because the child may still gain weight and not have any medical conditions while symptoms and behaviors of the disorder occur. These children are often seen in different settings and by both medical and mental health professionals. Because there is an overlap of physical and psychological problems, professionals may struggle to determine the cause and effect of feeding disorders (Bryant-Waugh et al., 2010).

As with treatment of other childhood concerns, feeding disorders need to be addressed from a variety of contexts. Counselors should consider characteristics of both the child and caregivers interdependently as opposed to separately (Bryant-Waugh et al., 2010). More detailed assessments may give better insight to the origin of these problems alongside other emotional and behavioral symptoms. It is also important to look at maternal factors and characteristics when examining the etiology of feeding disorders (Maldonado-Duran et al., 2008), especially given the finding that maternal anxiety, depression, and active eating disorder symptomatology in pregnancy predicted feeding difficulties (Micali et al., 2011).

Temperament may also play a role in whether a child has feeding difficulties or disorders. Lucarelli, Cimino, D’Olimpio, and Ammaniti (2012) found that many of the children in their sample were identified as having a difficult temperament. The children displayed some aggressive behavior, including angry moods and temper tantrums, and mothers in the study had higher levels of anxiety and obsessive-compulsive symptoms.

Etiology for Eating Disorders

Disordered eating can be caused by a number of genetic, biological, behavioral, psychological, and social factors (NIMH, 2013). Many times, etiology of eating disorders is seen as black-and-white in that there are either biological or cultural influences that cause these disorders without taking into account possible linkage between other factors (Striegel-Moore & Bulik, 2007). Although some researchers emphasize cultural considerations within eating disorders, it is difficult to determine how much of a role one’s culture plays in the development. There is not one specific factor that causes eating disorders, and multiple causal factors may influence each other to differing degrees. These interactions between the different factors, for example, genetic factors interacting with social–cultural influences such as media images, may work in shaping the onset and maintenance of eating disorders (Smolak & Chun-Kennedy, 2013). It is important to look at eating disorders holistically.

Sociocultural models of eating disorders have placed more focus on the extreme thinness and objectification of women. This emphasis on “Western” culture’s beauty ideals is considered a risk factor for developing an eating disorder (Striegel-Moore & Bulik, 2007). The mainstream media tends to view anorexia nervosa as a disorder that is caused more in part from viewing thin-ideal media images (Crisafulli, Von Holle, & Bulik, 2008); however, many individuals are exposed to these sociocultural images, and not all of them develop eating disorders. Therefore, the causes and development of eating disorders need to be addressed from a holistic standpoint.

Core features of eating disorders include body image disturbance, control in eating, and exhibiting behaviors to control weight (Striegel-Moore & Bulik, 2007). The body image disturbance can lead to internalizing the thin ideal and can lead one to put greater value on being thin. An individual may then control food consumption by restricting calories. However, if the thin ideal is internalized by someone who is at risk for bulimia nervosa or binge-eating disorder, the individual may lose control over the amount of food consumed.

Treatment of Feeding and Eating Disorders

Complex etiologies of the feeding and eating disorders can make their treatment difficult and multifaceted. Treatment varies based on the disorder as well as the individual presentation of the client but should include attention to physical, behavioral, and emotional health (Roman & Reay, 2009). The disorders are also treated at different levels of care ranging from outpatient to inpatient and residential (Berg et al., 2012). This depends on the level of severity at time of presentation.

Different approaches look at the importance of the therapeutic relationship in treating eating disorders. Oftentimes, clients need to feel a sense of security before beginning the therapeutic process (Ross & Green, 2011). Eating disorders generally isolate a client because many of the behaviors are usually secretive, not discussed, and done in private; therefore, an individual may be reluctant to see a therapist. It is also common for individuals with eating disorders to refuse treatment (Allen, Fursland, Watson, & Byrne, 2011). Typically, this is due to denial or difficulty understanding the need for treatment. Counselors treating clients with eating disorders need to work with the client to develop a therapeutic alliance and help the client understand why treatment may be appropriate.

DBT has been used to treat various eating disorders. DBT is often an effective treatment for individuals who have tried other methods but have been unsuccessful. Using DBT may work with individuals who are ambivalent to change as well as those who present as rigid and perfectionistic. This type of therapy helps individuals see that they can act on their own behalf (Federici, Wisniewski, & Ben-Porath, 2012). In addition to DBT, CBT and interpersonal psychotherapy (IPT) may be effective for the treatment of eating disorders (Murphy, Straebler, Cooper, & Fairburn, 2010). Mental health professionals posit that CBT may be a good match for individuals who experience bulimia and anorexia, whereas IPT may be particularly effective for those battling binge eating (Wilson, Wilfley, Agras, & Bryson, 2010).

Implications for Counselors

Given the high prevalence rates of eating and feeding disorders, it is likely that counselors will encounter clients with eating disorders and disordered eating (APA, 2013a; Hudson, Hiripi, Pope, & Kessler, 2007). Counselors should be particularly concerned with mortality rates of eating disorders: 4% for anorexia nervosa, 3.9% for bulimia nervosa, and 5.2% for eating disorder NOS (Crow et al., 2009). Given the medical consequences of these behaviors, it is essential that counselors collaborate with medical professionals. Furthermore, because eating disorders are complex in both etiology and treatment, counselors will likely collaborate with physicians, dietitians, psychiatrists, and other medical professionals as needed to provide the best possible treatment (Berg & Peterson, 2013). Although there is no one cause of eating disorders, it is necessary that they be looked at from a variety of perspectives, including attention to social and cultural influences that may have facilitated the rise of body image disturbance and eating disorders over the years (Striegel-Moore & Franko, 2003; Wade et al., 2011).

Proper assessment is necessary for accurate identification of individuals with eating disorders (Berg & Peterson, 2013) and selection of effective treatment plans (APA, 2013b). Individuals who are at a normal weight or have not experienced major weight changes may still experience eating disorders or be at risk for developing an eating disorder. Therefore, it is important for counselors to screen for eating disorders even among individuals who appear to be at a normal weight. Asking general questions about various behaviors in terms of self-care can help counselors get a better idea whether an individual might be at risk for an eating disorder (Berg et al., 2012).

Counselors should be aware that individuals with eating disorders are more likely to have other co-occurring psychiatric symptoms. These individuals are at increased risk for suicide and self-injury. Counselors need to be aware of these risks and should take extra time to conduct a thorough suicide risk assessment (Berg et al., 2012). Individuals with anorexia nervosa and bulimia nervosa often deal with low self-esteem, low self-concept, depression, and anxiety (Blank & Latzer, 2004; Cooley & Toray, 2001; Kaye et al., 2000). The assessments used should also incorporate screening questions pertaining to self-esteem (Berg et al., 2012).

Adolescents and adults may experience eating disorders in different ways, including the internalization of maternal messages and communication to be thin, social and peer group comparisons, and birth order issues. It is important for counselors to take these into consideration when evaluating their clients and developing treatment plans (Fisher, Schneider, Burns, Symons, & Mandel, 2001). Because eating disorders are complex and may often involve medical issues, it is also important that counselors develop working relationships with medical providers (Berg et al., 2012).

Individuals who have eating disorders may experience stigma and blame by people who do not understand why they cannot manage their eating behaviors. A study found that those in the general public who were given information on the biological and genetic factors of anorexia nervosa did not blame individuals with the disorder as much as those who were provided information regarding how sociocultural factors can lead to the disorder (Crisafulli et al., 2008).

To help readers better understand changes from the DSM-IV-TR to the DSM-5, the following sections outline each disorder within the Feeding and Eating Disorders chapter of the DSM-5. Readers should note that we have focused on major changes from the DSM-IV-TR to the DSM-5; however, this is not a stand-alone resource for diagnosis. Although a summary and special considerations for counselors are provided for each disorder, counselors need to reference the DSM-5 directly when considering a diagnosis. It is essential that counselors understand diagnostic criteria and features, subtypes and specifiers (if applicable), prevalence, course, and risk and prognostic factors for each disorder prior to diagnosis.

Essential Features

Pica is a feeding disorder that is characterized by the repetitive eating of nonnutritive, nonfood substances including, dirt, paper, and paint (Shisslak, Swain, & Crago, 1987; Stiegler, 2005). Pica is a common diagnosis in individuals with intellectual disabilities (Danford & Huber, 1982). Individuals with pica may develop serious health problems, including lead poisoning and intestinal blockages (Wiley, Henretig, & Selbst, 1992). Understanding pica can be complex because there is not a single etiology for the disorder (Stiegler, 2005). There were no significant changes to the diagnostic criteria for pica in the DSM-5, but the disorder was moved from the Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence chapter in the DSM-IV-TR to the Feeding and Eating Disorders chapter in the DSM-5.

An essential feature of pica is eating nonnutritive, nonfood substances for a period of at least 1 month (APA, 2013a). These consumed substances do not aid in the development of the individual. The minimum age for diagnosis is recommended to be 2 years so the developmentally normal practice of mouthing objects is excluded (Stiegler, 2005). It is important to recognize that the consumption is also not part of a cultural or social practice. If pica is present in conjunction with another mental disorder or medical condition, counselors should diagnose pica only if it requires additional clinical attention (APA, 2013a).

Special Considerations

The prevalence of pica is not clear, although it does seem to occur at a higher rate in individuals with intellectual disability and increases with the severity of the condition (APA, 2013a). Because of its self-injurious nature, pica has been known to lead to death in individuals with developmental disabilities (D. E. Williams & McAdam, 2012). Although pica can be diagnosed in otherwise normally developing children, adults who are diagnosed with it typically have an intellectual disability or other mental disorder (APA, 2013a). Pica is also common among children diagnosed with pervasive developmental disorders (Kerwin et al., 2005).

Although feeding disorders are typically seen in medical settings, therapeutic approaches such as CBT have been found effective for treating pica. Typically used in conjunction with parental involvement, strategies such as self-monitoring, behavioral experiments, and cognitive restructuring have yielded successful treatment outcomes (Bryant-Waugh, 2013). In milder cases of pica, behavioral interventions such as positive reinforcement and overcorrection have reduced symptoms (D. E. Williams & McAdam, 2012). Whatever the course of treatment, less restrictive interventions should be applied first (Kerwin & Berkowitz, 1996). In treating pica, however, counselors need to understand how complex the disorder is, because these complexities may lead to different treatment approaches. For example, food aversion has been effective in reducing ingestion of nonnutritive, nonfood substances, but counselors must be competent in using aversion techniques as well as knowing which clients are suited to this type of treatment approach (Ferreri, Tamm, & Wier, 2006).

In terms of cultural considerations, there are some populations for which eating dirt or other nonnutritive substances has spiritual, cultural, or other social value. If the behavior of eating such substances is due to one of these practices, a diagnosis of pica would not be applicable (APA, 2013a). Pathological pica behavior can be seen across cultural, regional, and socioeconomic boundaries (Stiegler, 2005), and the prevalence of pica eating varies widely across diverse social and clinical contexts (Hartmann, Becker, Hampton, & Bryant-Waugh, 2012). In some school-age populations, eating nonfood substances has been reported as a result of medical conditions, such as iron deficiencies (Moore & Sears, 1994). More research is needed to examine the influence of culture on pica in children and adults (Kerwin & Berkowitz, 1996).

Differential Diagnosis

Common differential diagnoses for pica include anorexia nervosa, factitious disorder, and nonsuicidal self-injurious behaviors in personality disorders (APA, 2013a). Pica may also be a symptom in individuals who have a developmental disability or other pervasive developmental disorders (Bryant-Waugh et al., 2010). Pica can also be related to medical conditions. One study found that 33% of children being treated for sickle cell anemia had pica symptoms (Ivascu et al., 2001).

Coding, Recording, and Specifiers

The diagnostic code for pica is 307.52 (F98.3) for children and 307.52 (F50.8) for adults. The ICD-9-CM code for pica is 307.52 and is used for children or adults. If, after the full criteria have been met for the disorder, the diagnostic criteria have not been met for a sustained period of time, a person can be considered in remission (APA, 2013a). Although the DSM-5 does not indicate a specific duration for this specifier, counselors can assume that an individual must consistently not ingest any nonnutritive, nonfood substance for at least 1 month.

Essential Features

Rumination disorder is a feeding disorder that involves repetitive regurgitation of swallowed or partially digested food. The individual may then rechew, reswallow, or spit out the food. Although the disorder is typically found in children, it occurs across age ranges and can develop in healthy adolescents (Schroedl, Alioto, & DiLorenzo, 2013). Rumination disorder occurs most often in infants within the 1st or 2nd year of life. However, it has been known to develop at a later age in individuals with intellectual disabilities. Adults with rumination disorder are more likely to swallow and regurgitate or spit out the food (Bryant-Waugh et al., 2010). When assessing for rumination disorder in infants, it is necessary to look at the length of time between feedings and rumination once the infant begins regurgitating (Franco, Campbell, Tamburrino, & Evans, 1993). More research needs to be conducted to determine if individuals with rumination disorder are more likely to develop an eating disorder later in life (Franco et al., 1993). The only major change to this disorder was moving it from the Disorders Usually First Diagnosed in Infancy, Childhood, and Adolescence chapter in the DSM-IV-TR to the Feeding and Eating Disorders chapters in the DSM-5.

One of the essential features of rumination disorder is the repeated regurgitation of food. This regurgitation must occur over a period of at least 1 month. The regurgitation occurs frequently, often daily, and at least several times per week. The symptoms should not occur during any other episodes of a different feeding or eating disorder. Symptoms may occur during another mental disorder; however, for a rumination disorder diagnosis, these symptoms should be a main aspect of the presenting issue (APA, 2013a).

Special Considerations

The prevalence for rumination disorder is unclear; however, this disorder is more common among individuals with intellectual disabilities (APA, 2013a). Adults with rumination disorder are less likely to talk about their behaviors with others because they see it as very secretive (Eckern, Stevens, & Mitchell, 1999). It has been pointed out that this is a rare and infrequently identified disorder (Franco et al., 1993; Hartmann et al., 2012). This is likely due to the wide range of clinical terms used to describe rumination, confusion about whether the individual’s behavior is voluntary or involuntary, and the fact this behavior typically occurs in private (Hartmann et al., 2012). Because many counselors fail to ask about rumination behaviors, rumination disorder may go undetected. Many professionals may also struggle to determine the clinical boundary between regurgitation and self-induced vomiting among adolescents and adults.

Research does not indicate one specific medical or mental health-based treatment approach to treating rumination disorder. Different behavioral techniques may help lessen symptoms. One treatment method that seems to be effective in infants with rumination disorder is intense nurturing. In older individuals, counselors have found cognitive techniques beneficial in improving self-control. Although interventions do not totally disrupt the behavior, they do offer individuals an improved quality of life and enhanced functioning (Schroedl et al., 2013).

Because rumination disorder is rare, it is difficult to assess cultural considerations. However, research shows that the disorder dates back as early as the 17th century and cuts across social classes (Parry-Jones, 1994). As the world became more industrialized in later centuries, the disorder occurred less and tended to be typically present in settings where there was not enough social and environmental stimulation (Parry-Jones, 1994).

Differential Diagnosis

Common differential diagnoses for rumination disorder include gastrointestinal conditions, anorexia nervosa, and bulimia nervosa (APA, 2013a). Observable behaviors such as tongue thrusting and putting hands in the individual’s mouth are still used in determining if one has rumination disorder or if the behaviors are because of other physiological issues (Kerwin & Berkowitz, 1996).

Coding, Recording, and Specifiers

There is only one diagnostic code for rumination disorder: 307.53 (F98.21). It should be specified if the disorder is in remission. It is in remission if, after the full criteria were met, the diagnostic criteria have not been met for a sustained period of time (APA, 2013a). As with pica, the DSM-5 does not clarify duration for this specifier. Counselors should ensure that an individual must consistently not regurgitate or rechew food for at least 1 month.

Essential Features

Avoidant/restrictive food intake disorder is a feeding condition that typically occurs in middle childhood. As the name implies, this disorder occurs when a child evades or severely limits his or her intake of food. Parents may struggle to notice avoidant or restrictive food processes if children do not have visible weight loss or growth impairment (Bryant-Waugh et al., 2010). Moreover, atypical eating behaviors and disturbances are common in young children (Equit, Palmke, Becker, Moritz, & Becker, 2012), and differentiating between developmentally appropriate behavior and disordered eating behavior is challenging for parents, guardians, or caretakers. One difference between atypical eating behaviors and avoidant/restrictive food intake disorder is that individuals with the disorder are likely to have little interest in eating (Equit et al., 2012).

Core symptoms of restrictive eating and food refusal are avoidance of certain foods, unwillingness to try new foods and only eating certain foods, and consumption of smaller than normal amounts of food as well as the complete refusal of food (Equit et al., 2012). The only major change to this disorder was moving it from the Disorders Usually First Diagnosed in Infancy, Childhood, and Adolescence chapter in the DSM-IV-TR to the Feeding and Eating Disorders chapters in the DSM-5.

An essential feature of this disorder is avoiding or restricting food intake that leads to persistent failure to meet necessary nutritional needs. The eating disturbance does not occur during the course of anorexia nervosa or bulimia nervosa. There is no disturbance of an individual’s body weight or shape (APA, 2013a). The food restriction can be related to a lack of interest in food or eating, avoidance of food for sensory reasons, and avoidance because of feared consequences of eating (Bryant-Waugh, 2013).

Special Considerations

Although this disorder is typically more common in children than adults, there could be a delay between the onset and when it actually presents (APA, 2013a). This disorder can sometimes be confused with other feeding or eating disorders; however, individuals with this disorder do not express concern with weight or body shape (Bryant-Waugh et al., 2010).

Although feeding disorders are typically seen in medical settings, therapeutic approaches such as CBT have been found effective for treating avoidant/restrictive food intake disorder. Typically used in conjunction with parental involvement, strategies such as self-monitoring, behavioral experiments, and cognitive restructuring have yielded successful treatment outcomes (Bryant-Waugh, 2013).

In terms of cultural considerations, it is necessary to make sure that the food disturbance is not part of a culturally approved ritual (APA, 2013a). If it is part of a culturally approved ritual, it would not be considered avoidant/restrictive food intake disorder.

Differential Diagnosis

Common differential diagnoses for avoidant/restrictive food intake disorder are medical conditions including but not limited to gastrointestinal disease and food allergies, specific neurological or congenital disorders, RAD, ASD, specific phobias or anxiety disorders, anorexia nervosa, OCD, MDD, schizophrenia spectrum disorder, and factitious disorder (APA, 2013a). Moving this disorder to the Feeding and Eating Disorders chapter allows it to be looked at across age ranges. Additionally, this disorder has a range of symptoms and presentations, which can make it difficult to diagnosis (Bryant-Waugh, 2013). Selective and restrictive eating behaviors may be associated with anxiety and oppositional symptoms. Equit et al. (2012) found that children who exhibited these restrictive and selective eating behaviors were likely to externalize oppositional symptoms and internalize anxiety symptoms.

Coding, Recording, and Specifiers

There is only one diagnostic code for avoidant/restrictive food intake disorder: 307.59 (F50.8). It should be specified if the disorder is in remission. It is in remission if after the full criteria were met, the diagnostic criteria have not been met for a sustained period of time (APA, 2013a). Similar to other disorders in this section, the DSM-5 does not clarify a specific duration for the in remission specifier. Because of the diagnostic criteria for this disorder, counselors can assume that individuals in remission are free of symptoms and have restored all related adverse health effects, such as weight loss and nutritional deficiencies; no longer require enteral feeding or oral nutritional supplements; and have marked improvements in psychosocial functioning.

Essential Features

People with anorexia nervosa often view themselves as being overweight, even if they are visibly underweight. They weigh themselves repetitively, and what they eat and how much they weigh often become obsessions (Kaye et al., 2000; NIMH, 2013). The average age of onset is 19 years (Hudson et al., 2007). Common symptoms of anorexia nervosa include extreme thinness, an unwillingness to maintain a healthy body weight, restricted eating, and disordered body image (NIMH, 2013). Common risk factors for anorexia include gender, ethnicity, socioeconomic status, and psychosocial factors (Lindberg & Hjem, 2003).

Essential features of anorexia nervosa include energy intake restriction, significantly low weight, and an intense fear of becoming fat. In addition, an individual experiences a disturbance based on his or her body weight or shape (APA, 2013a). Predictors of anorexia nervosa include history of eating disorder, sexual problems, and co-occurring disorders (Fichter, Quadflieg, & Hedlund, 2006). Counselors should note that an increased risk is present for clients who have biological relatives who have been diagnosed with anorexia, particularly the binge-eating/purging type (APA, 2013a). Other genetic risk factors include having biological relatives with a history of bipolar or depressive disorders. Children who displayed anxiety or obsessive-compulsive behavior also have a higher risk of developing anorexia nervosa. Finally, environments in which thinness is valued, including occupations or vocational activities such as modeling or sports, are associated with higher rates of anorexia nervosa.

Counselors should not underestimate the seriousness of anorexia nervosa. This disorder has one of the highest mortality rates among all psychiatric disorders (Harris & Barraclough, 1998). Although rates may vary on the basis of how the death is reported (e.g., heart failure, malnutrition), there is an estimated 4% mortality rate for anorexia nervosa (Crow et al., 2009).

Major Changes From DSM-IV-TR to DSM-5

In the DSM-IV-TR, 85% of one’s ideal body weight was considered a minimally normal body weight (APA, 2000). However, the DSM-5 Eating Disorders Work Group eliminated this criterion and replaced it with a calculation of body mass index (BMI) and the requirement that an individual be at “significantly low weight . . . defined as a weight that is less than minimally normal or, for children and adolescents, less than minimally expected” (APA, 2013a, p. 338). Individuals who deny having an intense fear of gaining weight will still meet the criterion if they engage in behaviors such as fasting or excessive exercising to prevent or avoid weight gain. The DSM-IV-TR criterion of amenorrhea, or the loss of menstrual cycle, is not included in the DSM-5 (APA, 2013a). However, it is still important to recognize if a girl or woman no longer has a menstrual cycle, as this could be a factor in determining if she is of significantly low weight (Berg & Peterson, 2013).

Special Considerations

The prevalence rate for women with anorexia nervosa ranges from 0.4% to 0.9% (APA, 2013; Hudson et al., 2007). Less is known about prevalence for men with anorexia nervosa, although the rate for lifetime prevalence has been reported at 0.3% (Hudson et al., 2007). The behaviors can keep the individual in a starved state and prevent the transition to more normal functioning in terms of eating and psychological functioning (Hebebrand & Bulik, 2011). Furthermore, some researchers speculate that the lifetime prevalence of eating disorders could increase dramatically under the DSM-5 because of the relaxed criteria, with estimates around 2.9% for women and 3% for men (Hudson, Coit, Lalonde, & Pope, 2012).

Approximately 33.8% of those with anorexia nervosa are receiving treatment (Hudson et al., 2007). However, the results in treatment can fluctuate over time (Fichter et al., 2006). Over the course of a 12-year study, Fichter et al. (2006) found that there was improvement during therapy, then a decline during the first 2 years after therapy, but more improvement and stabilization during Years 3 to 12. This is important because it shows that the treatment process for anorexia can be a lengthy one. Counselors may wish to incorporate client education regarding the peaks and valleys of the recovery process into treatment.

As stated previously, the 85% ideal body weight criterion was eliminated in the DSM-5. This means that counselors will now have to use more clinical judgment to determine whether an individual is considered underweight based on the significantly low weight criterion (Berg & Peterson, 2013). However, the cutoff between a healthy and harmful weight is not drastic and, despite the change from weight to BMI, cannot be defined by a specific number (Hebebrand & Bulik, 2011). Counselors who work with clients who have eating disorders need to be fully aware of risk factors, including previous treatment for an eating disorder, and consult with others when necessary. Individuals who have been treated for, and have recovered from, anorexia nervosa may still display some eating disorder symptoms such as drive for thinness; however, the symptoms are not as strong following recovery (Kaye et al., 2000). Additionally, these individuals are often fixated on their weight. An important therapeutic goal might be to focus more on a healthy weight range because weight often fluctuates (Hebebrand & Bulik, 2011).

According to the NIMH (2013), there are three components in treating anorexia nervosa: (a) restoring the individual to a healthy weight, (b) treating the psychological issues related to the eating disorder, and (c) reducing or eliminating behaviors or thoughts that lead to the eating issue and preventing relapse. CBT is often used in treating clients with anorexia nervosa. Brown, Mountford, and Waller (2013) examined therapeutic alliance and weight gain in clients with anorexia nervosa and found that clients can still experience weight gain despite a therapeutic alliance between the therapist and client. However, the CBT approach could be more effective if the counselor focused more on eating and weight gain issues instead of depending on the therapeutic alliance to bring about the change.

Individuals with anorexia nervosa may experience cognitive inflexibility whereby they are fixated on certain rules about eating. This can also lead to rigid thinking about the disorder. Cognitive remediation therapy helps the client think about the disorder in a broad manner and more holistically as opposed to focusing only on weight or shape (Tchanturia, Lloyd, & Lang, 2013). This type of therapy is newer, and more research needs to be done to determine its effectiveness.

Family-based treatments may also help individuals with anorexia (Chavez & Insel, 2007). These types of treatments may be more beneficial when treating adolescents, although there still needs to be more research done to determine the full effect. Counselors may face some barriers when working with families. These include the time commitment needed from families, parental consistency, and lack of attention to co-occurring symptoms. Additionally, barriers such as not having family meals together can negatively affect treatment. This can stall treatment because the individual with anorexia nervosa needs to be able to work on changing behaviors in real-life situations outside of the counselor’s office (Couturier et al., 2013).

Anorexia nervosa occurs across diverse populations but is typically seen more in postindustrialized, high-income countries. It is important to take into consideration weight concerns across different cultures and regions (APA, 2013a). There is evidence that subcultural norms among peer groups can influence attitudes and behaviors about eating (Linville et al., 2011). Although the prevalence of eating disorders in the United States is similar among non-Hispanic Whites, Hispanics, African Americans, and Asians, anorexia nervosa is more common among non-Hispanic Whites (Hudson et al., 2007; Wade et al., 2011).

Differential Diagnosis

Common differential diagnoses for anorexia nervosa are medical conditions, MDD, schizophrenia, substance use disorders, social anxiety disorder, OCD, BDD, bulimia nervosa, and avoidant/restrictive food intake disorder (APA, 2013a). Individuals with anorexia nervosa have reported higher functional impairment and lower BMI scores than individuals without eating disorders (Stice et al., 2013).

Coding, Recording, and Specifiers

There is only one ICD-9-CM diagnostic code for anorexia nervosa: 307.1. This coding is assigned regardless of the subtype. However, the ICD-10-CM code depends on the subtype, whether the restricting type (F50.01) or binge-eating/purging type (F50.02). In the restricting type, the individual has not engaged in recurrent episodes of binge eating or purging over the last 3 months. Additionally, the presentation in this subtype typically involves weight loss through dieting, fasting, or excessive exercise. In the binge-eating/purging type, the individual has engaged in repetitive episodes of binge eating or purging over the last 3 months (APA, 2013a).

Counselors should specify if the disorder is in full remission or in partial remission. It is in partial remission if after full criteria were previously met, the criteria for low body weight has not been met for a sustained period of time but there is still an intense fear of gaining weight or disturbance in self-perception of weight or shape. The disorder is in full remission if no criteria have been met for a sustained period of time (APA, 2013a). The DSM-5 is unclear about duration needed for remission, but counselors can assume that all physical and medical health concerns, such as low body weight, fear of becoming fat, restriction of food intake, and disturbances in self-perception related to weight, must be reconciled.

Essential Features

Individuals with bulimia nervosa often engage in frequent and recurrent episodes of binge eating and then feel a lack of control following those episodes (NIMH, 2013). This lack of control often causes one to engage in behaviors to compensate for the binge eating. These behaviors can include vomiting, excessive exercise, and use of laxatives (NIMH, 2013). Although some studies have shown a lack of relationship between meal frequency and binge eating, restraint theory models propose that the dietary restrictions will often lead to purging behaviors (Masheb, Grilo, & White, 2011). These behaviors, coupled with feelings of lack of control, can make this a cyclical process. Physical symptoms of bulimia nervosa include but are not limited to inflamed and sore throat, swollen salivary glands, worn tooth enamel, and severe dehydration (NIMH, 2013). Individuals who develop bulimia nervosa may do so after periods of dieting (Kaye et al., 2000). Finally, the mortality rate for bulimia nervosa is high and has been reported at 3.9% (Crow et al., 2009).

There are three essential features of bulimia nervosa: recurrent episodes of binge eating, repetitive compensatory behaviors, and self-evaluation that is influenced by body shape and weight. For a diagnosis to be made, binge eating and engaging in compensatory behaviors must occur at least once a week for 3 months (APA, 2013a). Binge eating is often triggered by negative affect. Episodes may also be set off when there are interpersonal stressors involved along with dietary restraint. After experiencing an episode of binge eating, the individual will engage in an inappropriate compensatory behavior such as purging or excessive exercising (APA, 2013a).

Major Changes From DSM-IV-TR to DSM-5

The criteria for bulimia nervosa remain mostly unchanged from the DSM-IV-TR; however, there is one major change. The DSM-5 Eating Disorders Work Group changed the frequency criterion for binge eating and compensatory behaviors from twice per week for 3 months in the DSM-IV-TR to only once per week for 3 months in the DSM-5 (APA, 2013a).

Special Considerations

The prevalence of bulimia nervosa is 1.0% to 1.5% over a 12-month period (APA, 2013a). Individuals with bulimia nervosa are usually at a healthy or normal weight, so it can be difficult to look at someone and determine whether the individual has the disorder (NIMH, 2013). Between 25% to 30% of individuals presenting to treatment centers with bulimia nervosa have had a prior history of anorexia nervosa (Kaye et al., 2000). Because of morbidity rates, bulimia nervosa has been described as an eating disorder with greater severity compared with binge-eating disorder (Roberto, Grilo, Masheb, & White, 2010). Rates of bulimic symptoms may increase as adolescents moved through young adulthood (Linville et al., 2011).

CBT is often used when treating clients with bulimia nervosa (NIMH, 2013). CBT was found to be effective for at least 60% to 70% of individuals with bulimia nervosa and led to remission of binge eating and purging in 30% to 50% of cases (Kaye et al., 2000). In addition, Kaye et al. (2000) pointed out that CBT helps improve some symptoms including body dissatisfaction and perfectionism. CBT for bulimia nervosa can help individuals establish regular meal and snack patterns, breaking chronic restrained eating that has been shown to lead to cycles of binge eating and purging (Masheb et al., 2011). IPT and DBT have also been shown to be effective interventions for clients with bulimia nervosa (Chavez & Insel, 2007).

Bulimia nervosa is seen in similar frequencies across many industrialized countries. Although it was noted that individuals in the United States who typically present with this disorder are White, it should be pointed out that other ethnic groups have prevalence rates similar to those observed in the White samples (APA, 2013a).

Differential Diagnosis

Common differential diagnoses for bulimia nervosa are anorexia nervosa, binge-eating/purging type, binge-eating disorder, Kleine-Levin syndrome, MDD with atypical features, and borderline personality (APA, 2013a). Individuals with bulimia nervosa noted significantly higher levels of functional impairment, suicidality, and emotional distress than those without bulimia nervosa (Stice et al., 2013). Results from one study show that depressive/negative affect may trigger binge eating among these individuals (Roberto et al., 2010).

Note

Kleine-Levin syndrome, although rare, is a neurological disorder that causes significant problems with cognitive and behavioral functioning (Arnulf, Zeitzer, File, Farber, & Mignot, 2005). One of these disturbances includes bulimic-like cravings for food, or compulsive hyperphagia, which may result in self-induced vomiting. Counselors can differentiate between Kleine-Levin syndrome and bulimia nervosa because individuals diagnosed with Kleine-Levin syndrome do not alternate between periods of self-induced vomiting and voluntary fasting.

Coding, Recording, and Specifiers

There is only one diagnostic code for bulimia nervosa: 307.51 (F50.2). It should be specified if the disorder is in partial remission or in full remission. Partial remission is indicated if some criteria have been met for a sustained period of time after the full criteria had been previously met. Likewise, full remission is indicated if no criteria have been met for a sustained period of time (APA, 2013a). Finally, counselors should indicate the current level of severity. Severity is based on the frequency of compensatory behaviors engaged in per week. The levels of severity are mild (an average of one to three episodes of inappropriate compensatory behavior per week), moderate (an average of four to seven episodes of inappropriate compensatory behavior per week), severe (an average of eight to 13 episodes of inappropriate compensatory behavior per week), and extreme (an average of 14 or more episodes of inappropriate compensatory behavior per week; APA, 2013a).

Case Example

Nisha is a 21-year-old, Indian American female who is in her junior year of college. She is currently seeing a counselor at the college counseling center. She told her counselor that she has had concerns about her weight during adolescence and into her young adult life. Nisha has her sights set on being a professionally trained dancer. She was taught early on to restrict her weight. Looking back, she thinks that her training led to a preoccupation with her weight and body image. She recalls her instructors constantly telling her she was not thin enough even though she dieted continuously. Her friends even began to notice her thinness. Nisha has not really been able to get rid of the feeling that she is too fat even though she weighs 110 pounds and is 5 feet 10 inches tall. Nisha has said that she sometimes gets so hungry after dieting for several days at a time that she would lose control of her eating and eat large amounts of cookies, ice cream, and doughnuts. After she finished eating, she would feel awful about what she just ate and how she broke her diet. She would then force herself to throw up what she had eaten. She disclosed to her counselor that she repeated this cycle once a week for quite a few years.

Diagnostic Questions

1. Do Nisha’s presenting symptoms meet the criteria for bulimia nervosa?
   
2. Based on the disorder identified in Question 1, which symptom(s) led you to select the diagnosis?
   
3. What would be the reason(s) a counselor may not diagnose Nisha with bulimia nervosa?
   
4. Would Nisha be more accurately diagnosed with binge-eating disorder? Why or why not?
   
5. What rule-outs would you consider for Nisha’s case?
   
6. What other information may be needed to make an accurate clinical diagnosis?

Essential Features