Anorexia Nervosa (AN) |
|---|
Restricted caloric intake relative to energy requirements, leading to significantly low body weight for age, sex, projected growth, and physical health |
Intense fear of gaining weight or behaviors that consistently interfere with weight gain, despite being at a significantly low weight |
Altered perception of one’s body weight or shape, excessive influence of body weight or shape on self-value, or persistent lack of acknowledgment of the seriousness of one’s low body weight |
Subtypes: restricting type (weight loss is achieved primarily through dieting, fasting, and/or excessive exercise. In the previous 3 months, there have been no repeated episodes of binge eating or purging); binge-eating/purging type (in the previous 3 months, there have been repeated episodes of binge eating or purging; ie, self-induced vomiting or misuse of laxatives, diuretics, or enemas) |
Atypical AN |
Restricted caloric intake relative to energy requirements, with weight normal, obese, or overweight despite this limited intake |
Intense fear of gaining weight or behaviors that consistently interfere with weight gain, despite being at a significantly low weight |
All of the criteria for AN are met, yet the individual’s weight is within or above the normal range despite significant weight loss |
Subtypes: none in the DSM-5 |
Bulimia Nervosa (BN) |
Repeated episodes of binge eating. Binge eating is characterized by both of the following: within a distinct period of time (eg, 2 hours), eating an amount of food that is larger than what most individuals would eat during a similar period of time under similar circumstances and a sense that one cannot limit or control their overeating during the episode |
Repeated use of inappropriate compensatory behaviors for the prevention of weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise |
On average, the binge eating and compensatory behaviors both occur at least once a week for 3 months |
Self-value is overly influenced by body shape and weight |
The binge eating and compensatory behaviors do not occur exclusively during episodes of AN |
Subthreshold BN |
BN (of low frequency and/or limited duration): All of the criteria for BN are met, but, on average, the binge eating and compensatory behaviors occur less than once a week and/or for <3 months |
Binge-Eating Disorder (BED) |
Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: within a distinct period of time (eg, 2 hours), eating an amount of food that is clearly larger than what most individuals would eat during a similar period of time under similar circumstances and sense that one cannot limit or control their overeating during the episode |
The binge-eating episodes include 3 or more of the following: eating much more quickly than normal, eating until uncomfortably full, eating large amounts of food when not feeling hungry, eating alone because of embarrassment at how much one is eating, and feeling guilty, disgusted, or depressed afterward |
Marked anguish is experienced regarding binge eating |
On average, the binge eating occurs at least once a week for 3 months |
The binge eating is not associated with the use of inappropriate compensatory behavior as in BN and does not occur only in the context of BN or AN |
BED of Low Frequency |
BED (of low frequency and/or limited duration): All of the criteria for BED are met, but, on average, the binge eating occurs less than once a week and/or for <3 months |
Avoidant/Restrictive Food Intake Disorder (ARFID) |
A disrupted eating pattern (eg, seeming lack of interest in eating or food; avoidance based on the sensory qualities of food; concern about unpleasant consequences of eating) as evidenced by persistent failure to meet appropriate nutritional and/or energy needs associated with 1 (or more) of the following: significant weight loss or, in children, failure to achieve expected growth and/or weight gain, marked nutritional deficiency, reliance on enteral feeding or oral nutritional supplements, significant interference with psychosocial functioning |
The disturbance cannot be better explained by lack of available food or by an associated culturally sanctioned practice |
The eating disturbance cannot be attributed to a coexisting medical condition nor better explained by another mental disorder. If the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder |
Other Specified Feeding or Eating Disorders, Examples |
Purging disorder: recurrent purging behavior (eg, self-induced vomiting; misuse of laxatives, diuretics, or other medications) in the absence of binge eating with the intent to influence weight or body shape |
Differential Diagnosis of Eating Disorders
Diagnosis | Clinical Features |
|---|---|
Vomiting | |
Constant right upper quadrant pain | |
CNS lesion | Headache, seizure, visual disturbances |
Pancreatitis | Persistent, severe epigastric abdominal pain |
Pregnancy | Amenorrhea, fatigue, (+) pregnancy test result |
Superior mesenteric artery syndrome | Postprandial epigastric pain with early satiety, bilious emesis |
Weight Loss | |
Adrenal insufficiency | Postural dizziness, hypotension, hyperkalemia, hypercalcemia, hyponatremia |
Celiac disease | Chronic diarrhea with foul-smelling and/or floating stools, constipation with abdominal distention |
Anhedonia, ⭣ appetite, sleep disturbance, feelings of worthlessness or guilt, impaired concentration | |
Diabetes mellitus | Polyuria, polydipsia, hyperglycemia |
HIV | Fever, lymphadenopathy, sore throat, mucocutaneous ulcer, rash, myalgia, night sweats, diarrhea |
Hyperthyroidism | Anxiety, emotional lability, weakness, tremor, palpitations, heat intolerance, ⭡ perspiration |
Inflammatory bowel disease | Bloody diarrhea, colicky abdominal pain, urgency, tenesmus, incontinence, hypotension |
Substance use | Needle marks, skin infections, unexplained burns, atrophy of nasal mucosa |
CNS indicates central nervous system. (+) indicates a positive finding; ⭣, decreased; and ⭡, increased.
From American Academy of Pediatrics Section on Hospital Medicine. Caring for the Hospitalized Child: A Handbook of Inpatient Pediatrics. Gershel JC, Rausch DA, eds. 3rd ed. American Academy of Pediatrics; 2023:13.
One or more of the following justify hospitalization:
≤75% median body mass index for age and sex
Dehydration
Electrolyte disturbance (hypokalemia, hyponatremia, hypophosphatemia)
Electrocardiographic abnormalities (eg, prolonged QTc or severe bradycardia)
Physiological instability
a.Severe bradycardia (heart rate <50 beats/minute daytime; <45 beats/minute at night)
b.Hypotension (<90/45 mm Hg)
c.Hypothermia (body temperature <96°F [35.6°C])
d.Orthostatic increase in pulse (>20 beats per minute) or decrease in blood pressure (>20 mm Hg systolic or >10 mm Hg diastolic)
Arrested growth and development
Failure of outpatient treatment
Acute food refusal
Uncontrollable bingeing and purging
Acute medical complications of malnutrition (eg, syncope, seizures, cardiac failure, pancreatitis, etc)
Comorbid psychiatric or medical condition that prohibits or limits appropriate outpatient treatment (eg, severe depression, obsessive compulsive disorder, type 1 diabetes mellitus)
From American Academy of Pediatrics Committee on Nutrition. Pediatric Nutrition. Kleinman RE, Greer FR, eds. 8th ed. American Academy of Pediatrics; 2020:1091.
Screening for Disordered Eating: Example Questions to Ask Adolescents
History/Information | Example Questions |
|---|---|
Weight history | What was your highest weight? How tall were you? How old were you? |
What was your lowest weight? How tall were you? How old were you? | |
Body image | What do you think your weight should be? What feels too high? What feels too low? |
Are there body areas that cause you stress? Which areas? | |
Do you do any body checking (ie, weighing, body pinching or checking, mirror checking)? | |
How much of your day is spent thinking about food or your body? | |
24-hour diet history. | |
Do you count calories, fat, carbohydrates? How much do you allow? What foods do you avoid? | |
Do you ever feel guilty about eating? How do you deal with that guilt (ie, exercising, purging, eating less)? | |
Do you feel out of control when eating? | |
Exercise history | Do you exercise? What activities? How often? How intense is your workout? |
How stressed do you feel when you are unable to exercise? | |
Binge eating and purging | Do you ever binge? On what foods? How much? How often? Any triggers? |
Do you vomit? How often? How soon after eating? | |
Do you use laxatives, diuretics, diet pills, caffeine? What types? How many? How often? | |
Family history | Does anyone in your family have a history of dieting or an eating disorder? Anyone on special diets (eg, vegetarian, gluten-free)? Anyone with obesity? |
Does anyone in your family have a history of depression, anxiety, bipolar disorder, obsessive-compulsive disorder, substance abuse, or other psychiatric illness? | |
Does anyone in your family take psychiatric medication? | |
Review of systems | Dizziness, syncope, weakness or fatigue? |
Pallor, easy bruising or bleeding, cold intolerance? | |
Hair loss, lanugo (extra hair growth on trunk, face, or extremities; the body’s attempt to provide an extra layer of warmth in the face of starvation), dry skin? | |
Constipation, diarrhea, early fullness, bloating, abdominal pain, heartburn? | |
Palpitations, chest pain? | |
Muscle cramps, joint pains? | |
Excessive thirst and voiding? | |
For girls: Age at menarche? Frequency of menses? LMP? Weight at time of LMP? | |
Psychosocial History (HEADSS) | |
Home | Who lives in the home? |
How well do the family members get along with each other? | |
Is the family experiencing any stressors? | |
Education | Where do you attend school? What grade? Regular classroom? |
Is school challenging for you? What grades do you receive? Has there been a change in your grades? | |
Activities | What activities are you involved in outside of the classroom? |
Do you have friends you can trust? Have you experienced any bullying? | |
What social media sites/websites do you most often visit when you go online? How much time is spent online each day? | |
Drug use | Have you ever used tobacco, e-cigarettes, alcohol, or drugs? Which ones? How much? How often? With alcohol, any blackouts or passouts? |
Have you ever used anabolic steroids or stimulants? Caffeine consumption? Other substances? | |
Depression/suicide | How is your mood? Increased irritability? Feelings of depression or hopelessness? Any anxiety or obsessive-compulsive thoughts or behaviors? |
Any history of cutting or self-injury? | |
Have you ever wished you were dead? How often do you have these thoughts? When was the last time? Any thoughts of suicide? What methods have you imagined? Any attempts? | |
History of physical, sexual, or emotional abuse? | |
Any previous mental health care? | |
Sexual history | Do you feel that the gender you feel inside matches your body on the outside? |
Are you romantically or sexually attracted to guys, girls, or both? Not sure? | |
Have you had any sexual contact with another person? If yes, was it with guys, girls, or both? Use of condoms? Use of contraceptives? History of pregnancy or sexually transmitted infection? | |
Has anyone done anything to you sexually that made you uncomfortable? | |
LMP indicates last menstrual period.
Adapted from Hornberger LL, Lane MA; American Academy of Pediatrics Committee on Adolescence. Identification and management of eating disorders in children and adolescents. Pediatrics. 2021;147(1):e2020040279. Originally adapted from Rome ES, Strandjord SE. Eating disorders. Pediatr Rev. 2016;37(8):323-336.