ppt

Feeding, Eating, Feeding, Eating, and Elimination and Elimination

DisordersDisordersPsy 610APsy 610A

Gary S. Katz, Ph.D.Gary S. Katz, Ph.D.

Feeding, Eating, and Feeding, Eating, and Elimination DisordersElimination Disorders

Feeding Disorder of Infancy or Early Feeding Disorder of Infancy or Early Childhood (307.59)Childhood (307.59)

Pica (307.52)Pica (307.52) Rumination Disorder (307.53)Rumination Disorder (307.53) Anorexia Nervosa (307.1)Anorexia Nervosa (307.1) Bulimia Nervosa (307.51)Bulimia Nervosa (307.51) Eating Disorder NOS (307.50)Eating Disorder NOS (307.50) Encopresis (787.6, 307.7)Encopresis (787.6, 307.7) Enuresis (307.6)Enuresis (307.6)

Feeding Disorder of Infancy Feeding Disorder of Infancy or Early Childhood (307.59)or Early Childhood (307.59) Essential diagnostic feature – persistent Essential diagnostic feature – persistent

failure to eat adequately.failure to eat adequately. Lack of weight gain Lack of weight gain

or or significant weight loss.significant weight loss.

Onset before age 6.Onset before age 6.

Recommend consultation with SP/L to Recommend consultation with SP/L to look at swallowing and neuromuscular look at swallowing and neuromuscular issues with the mouth and throat.issues with the mouth and throat.

Feeding Disorder of Infancy Feeding Disorder of Infancy or Early Childhood (307.59)or Early Childhood (307.59)A. Feeding disturbance as manifested by persistent A. Feeding disturbance as manifested by persistent

failure to eat adequately with significant failure to failure to eat adequately with significant failure to gain weight or significant loss of weight over at least gain weight or significant loss of weight over at least 1 month. 1 month.

B. The disturbance is not due to an associated B. The disturbance is not due to an associated gastrointestinal or other general medical condition gastrointestinal or other general medical condition (e.g., esophageal reflux). (e.g., esophageal reflux).

C. The disturbance is not better accounted for by C. The disturbance is not better accounted for by another mental disorder (e.g., Rumination Disorder) another mental disorder (e.g., Rumination Disorder) or by lack of available food. or by lack of available food.

D. The onset is before age 6 years.D. The onset is before age 6 years.

Associated Features Associated Features

Infants with feeding disorders may be more Infants with feeding disorders may be more irritable and difficult to soothe during irritable and difficult to soothe during feeding than infants without feeding feeding than infants without feeding disorders.disorders.

May appear apathetic and withdrawn; may May appear apathetic and withdrawn; may see developmental delays.see developmental delays.

Parent-child interactions may contribute to Parent-child interactions may contribute to or exacerbate feeding disorders.or exacerbate feeding disorders. Inappropriate food presentationInappropriate food presentation Inappropriate reaction to food refusal by parent Inappropriate reaction to food refusal by parent

(seeing as act of aggression or rejection)(seeing as act of aggression or rejection)

Associated Features Associated Features Inadequate caloric intake may exacerbate other Inadequate caloric intake may exacerbate other

features including developmental lags & features including developmental lags & irritability, leading to exacerbation of feeding irritability, leading to exacerbation of feeding problems.problems.

Infant factors:Infant factors: Difficult temperamentDifficult temperament Intrautering Grown Retardation (IUGR)Intrautering Grown Retardation (IUGR) Preexisting developmental impairments leading to Preexisting developmental impairments leading to

diminished responsiveness on the part of the infant.diminished responsiveness on the part of the infant. Parental factors:Parental factors:

Parent psychopathologyParent psychopathology Undereducation or lack of knowledge of parentingUndereducation or lack of knowledge of parenting

Dyadic factorsDyadic factors Abuse, neglectAbuse, neglect

Associated Physical Associated Physical FindingsFindings

Nonspecific findings associated with Nonspecific findings associated with malnutritionmalnutrition AnemiaAnemia Low serum albumin & total proteinLow serum albumin & total protein

Malnutrition may be life threatening.Malnutrition may be life threatening.

Age & Gender FeaturesAge & Gender Features

Later onset implies diminished Later onset implies diminished impact of developmental delay and impact of developmental delay and malnutrition.malnutrition.

Growth delay, however, present with Growth delay, however, present with later onset feeding disorders.later onset feeding disorders.

Equally common in males and Equally common in males and females.females.

PrevalencePrevalence

1% to 5% of pediatric hospital 1% to 5% of pediatric hospital admissions are for failure to thrive admissions are for failure to thrive (FTT); up to ½ of these may reflect (FTT); up to ½ of these may reflect feeding disturbances without feeding disturbances without predisposing general medical predisposing general medical conditions.conditions.

Community samples suggest point Community samples suggest point prevalence for FTT to be around 3%prevalence for FTT to be around 3%

Failure to ThriveFailure to Thrive Medical diagnosisMedical diagnosis Encompasses Feeding Disorders as well as a Encompasses Feeding Disorders as well as a

range of medical and psychological range of medical and psychological conditions.conditions.

Feeding Disorder of Infancy or Early Feeding Disorder of Infancy or Early Childhood is a type of FTT, all FTT are NOT Childhood is a type of FTT, all FTT are NOT Feeding Disorders.Feeding Disorders. Organic FTT (not Feeding Disorder)Organic FTT (not Feeding Disorder) Non-organic FTT (may be Feeding Disorder)Non-organic FTT (may be Feeding Disorder)

Excessive juice consumption may be part of non-organic, Excessive juice consumption may be part of non-organic, but but

clearly not a Feeding Disorder.clearly not a Feeding Disorder. Abuse/neglect, poor parenting.Abuse/neglect, poor parenting.

CourseCourse

Onset is typically in the first year of Onset is typically in the first year of life, may have an onset in children life, may have an onset in children ages 2-3.ages 2-3.

Majority have improved growth after Majority have improved growth after variable lengths of time but typically variable lengths of time but typically remain shorter and lighter up remain shorter and lighter up through adolescence than children through adolescence than children who did not have feeding disorders.who did not have feeding disorders.

Differential DiagnosisDifferential Diagnosis Transient minor feeding problems in infancy.Transient minor feeding problems in infancy.

No significant failure to gain or loss of weight.No significant failure to gain or loss of weight. G/I, endocrinological, neurological, cardiac, & G/I, endocrinological, neurological, cardiac, &

other general medical conditionsother general medical conditions Can diagnose Feeding Disorder only if the feeding Can diagnose Feeding Disorder only if the feeding

problems are beyond what would be expected problems are beyond what would be expected given the underlying medical condition.given the underlying medical condition.

Evidence in favor of a Feeding Disorder diagnosis Evidence in favor of a Feeding Disorder diagnosis would be if there is an improvement in feeding and would be if there is an improvement in feeding and weight gain in response to changing caregivers.weight gain in response to changing caregivers.

Pica (307.52)Pica (307.52)

Essential feature – eating of one or Essential feature – eating of one or more nonnutritive substances on a more nonnutritive substances on a persistent basis.persistent basis.

Typical substances vary by age:Typical substances vary by age: Younger children eat paint, plaster, Younger children eat paint, plaster,

string, hair, cloth.string, hair, cloth. Older children eat animal droppings, Older children eat animal droppings,

sand, insects, leaves, or pebbles.sand, insects, leaves, or pebbles. Adolescents & adults eat clay or soil.Adolescents & adults eat clay or soil.

No food aversions.No food aversions.

Pica (307.52)Pica (307.52)

A. Persistent eating of nonnutritive substances for A. Persistent eating of nonnutritive substances for a period of at least 1 month. a period of at least 1 month.

B. The eating of nonnutritive substances is B. The eating of nonnutritive substances is inappropriate to the developmental level. inappropriate to the developmental level.

C. The eating behavior is not part of a culturally C. The eating behavior is not part of a culturally sanctioned practice. sanctioned practice.

D. If the eating behavior occurs exclusively during D. If the eating behavior occurs exclusively during the course of another mental disorder (e.g., the course of another mental disorder (e.g., Mental Retardation, Pervasive Developmental Mental Retardation, Pervasive Developmental Disorder, Schizophrenia), it is sufficiently severe Disorder, Schizophrenia), it is sufficiently severe to warrant independent clinical attention.to warrant independent clinical attention.

Associated FeaturesAssociated Features Frequently associated with Mental Retardation and Frequently associated with Mental Retardation and

PDD.PDD. Some cases have been reported with nutritional Some cases have been reported with nutritional

deficiencies; however, usually no specific biological deficiencies; however, usually no specific biological abnormalities.abnormalities.

Pica may only come to clinical attention as a Pica may only come to clinical attention as a medical consequence of ingesting harmful medical consequence of ingesting harmful substances:substances: Lead poisoning from paint, mechanical bowel problems or Lead poisoning from paint, mechanical bowel problems or

obstructions, intestinal perforation, infections from eating obstructions, intestinal perforation, infections from eating fecal matter.fecal matter.

Poverty, neglect, lack of appropriate parental Poverty, neglect, lack of appropriate parental supervision, developmental delay increase risk for supervision, developmental delay increase risk for diagnosis.diagnosis.

Culture, Age, & Gender Culture, Age, & Gender FeaturesFeatures

In some cultures, eating of dirt or In some cultures, eating of dirt or other seemingly nonnutritive other seemingly nonnutritive substances is culturally sanctioned – substances is culturally sanctioned – not Pica.not Pica. Odawa – soft stones eaten by pregnant Odawa – soft stones eaten by pregnant

Kenyan womenKenyan women Pica more commonly seen in young Pica more commonly seen in young

children and occasionally in children and occasionally in pregnant females.pregnant females.

Prevalence & CoursePrevalence & Course

Limited epidemiological data.Limited epidemiological data. Prevalence increases with severity of mental Prevalence increases with severity of mental

retardation (as high as 15% in adults with retardation (as high as 15% in adults with Severe Mental Retardation).Severe Mental Retardation).

Onset typically in infancy.Onset typically in infancy. Typically lasts for several months and then Typically lasts for several months and then

remits.remits. May continue into adolescence or adulthood – May continue into adolescence or adulthood –

usually diminishes in the MR population in usually diminishes in the MR population in adulthood.adulthood.

Differential DiagnosisDifferential Diagnosis Normal mouthing / haptic exploration of Normal mouthing / haptic exploration of

infancy.infancy. PDDPDD

Can occur, but Pica not the focus of the disorderCan occur, but Pica not the focus of the disorder SchizophreniaSchizophrenia

Eating is part of a delusional beliefEating is part of a delusional belief Other eating disordersOther eating disorders

Rumination Disorder, Feeding Disorder of Rumination Disorder, Feeding Disorder of Infancy or Early Childhood, Anorexia Nervosa, Infancy or Early Childhood, Anorexia Nervosa, Bulimia Nervosa.Bulimia Nervosa.

Rumination Disorder Rumination Disorder (307.53)(307.53)

Essential feature – repeated Essential feature – repeated regurgitation and re-chewing of food regurgitation and re-chewing of food occurring after feeding that develops in occurring after feeding that develops in an infant/child after a period of normal an infant/child after a period of normal functioning.functioning.

Partially digested food is brought up into Partially digested food is brought up into the mouth without nausea, retching, the mouth without nausea, retching, disgust, or associated G/I disorder.disgust, or associated G/I disorder.

Food is either ejected from the mouth or Food is either ejected from the mouth or chewed and re-swallowed.chewed and re-swallowed.

Rumination Disorder Rumination Disorder (307.53)(307.53)

A. Repeated regurgitation and rechewing of food for a A. Repeated regurgitation and rechewing of food for a period of at least 1 month following a period of period of at least 1 month following a period of normal functioning. normal functioning.

B. The behavior is not due to an associated B. The behavior is not due to an associated gastrointestinal or other general medical condition gastrointestinal or other general medical condition (e.g., esophageal reflux). (e.g., esophageal reflux).

C. The behavior does not occur exclusively during the C. The behavior does not occur exclusively during the course of Anorexia Nervosa or Bulimia Nervosa. If the course of Anorexia Nervosa or Bulimia Nervosa. If the symptoms occur exclusively during the course of symptoms occur exclusively during the course of Mental Retardation or a Pervasive Developmental Mental Retardation or a Pervasive Developmental Disorders, they are sufficiently severe to warrant Disorders, they are sufficiently severe to warrant independent clinical attention.independent clinical attention.

Associated FeaturesAssociated Features Infants are generally irritable and hungry Infants are generally irritable and hungry

between episodes of regurgitation.between episodes of regurgitation. Large amounts of food may be taken in, Large amounts of food may be taken in,

but not nutritionally broken down due to but not nutritionally broken down due to regurgitation.regurgitation. Leads to malnutrition, weight loss, in infancy – Leads to malnutrition, weight loss, in infancy –

mortality can be up to 25%mortality can be up to 25% Less common to see malnutrition in older Less common to see malnutrition in older

children and adults.children and adults.

Associated Features / Associated Features / PrevalencePrevalence

Predisposing psychosocial problemsPredisposing psychosocial problems Lack of stimulation, neglect, stressful life situations, Lack of stimulation, neglect, stressful life situations,

problems in parent-child relationshipsproblems in parent-child relationships Disruption in parent-child relationships due to Disruption in parent-child relationships due to

perceived failure to feed / noxious odor of the perceived failure to feed / noxious odor of the regurgitated food.regurgitated food.

Feeding Disorder of Infancy or Early Childhood Feeding Disorder of Infancy or Early Childhood may develop.may develop.

In older children and adults, MR is a In older children and adults, MR is a predisposing factor.predisposing factor.

Appears uncommon. May occur more in males Appears uncommon. May occur more in males than females.than females.

CourseCourse

Onset may occur in the context of other Onset may occur in the context of other developmental delays.developmental delays.

Age of onset between 3 and 12mos, Age of onset between 3 and 12mos, except when MR is present. except when MR is present.

With MR present, onset may be With MR present, onset may be somewhat later.somewhat later.

In infants, often remits spontaneously.In infants, often remits spontaneously. In some severe cases, course is In some severe cases, course is

continuous.continuous.

Differential DiagnosisDifferential Diagnosis

Congenital abnormalities of the Congenital abnormalities of the esophagus or pylorus (pyloric esophagus or pylorus (pyloric stenosis)stenosis)


Normal vomiting of early infancyNormal vomiting of early infancy Cannot diagnose rumination if the Cannot diagnose rumination if the

symptoms occur exclusively during symptoms occur exclusively during the course of Anorexia Nervosa or the course of Anorexia Nervosa or Bulimia Nervosa.Bulimia Nervosa.

Anorexia Nervosa (307.1)Anorexia Nervosa (307.1)

Essential features:Essential features: individual refuses to maintain a minimally individual refuses to maintain a minimally

normal body weight, normal body weight, is intensely afraid of gaining weight, is intensely afraid of gaining weight,

and and exhibits a significant disturbance in the exhibits a significant disturbance in the

perception of the shape or size of his/her perception of the shape or size of his/her body.body.

Postmenarcheal females become Postmenarcheal females become amenorrheic.amenorrheic.

Anorexia Nervosa (307.1)Anorexia Nervosa (307.1)A. Refusal to maintain body weight at or above a A. Refusal to maintain body weight at or above a

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

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

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

Anorexia Nervosa (307.1)Anorexia Nervosa (307.1)

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

Specify type: Specify type:

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

Binge-Eating/Purging Type:Binge-Eating/Purging Type: during the current episode of during the current episode of Anorexia Nervosa, the person has regularly engaged in binge-Anorexia Nervosa, the person has regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas)misuse of laxatives, diuretics, or enemas)

Associated FeaturesAssociated Features When seriously underweight, may see When seriously underweight, may see

depressive symptoms:depressive symptoms: depressed mood, social withdrawal, irritability, depressed mood, social withdrawal, irritability,

insomnia, diminished interest in sexinsomnia, diminished interest in sex May meet criteria for Major Depressive May meet criteria for Major Depressive

Disorder; however need to re-assess when the Disorder; however need to re-assess when the individual has restored or partially restored individual has restored or partially restored weight.weight.

OCD features, related and unrelated to food OCD features, related and unrelated to food may occur:may occur: Preoccupied with thoughts of food, collect recipes, Preoccupied with thoughts of food, collect recipes,

hoard foodhoard food If obsessions and compulsions unrelated to food If obsessions and compulsions unrelated to food

exist, consider separate DX of OCDexist, consider separate DX of OCD

Associated FeaturesAssociated Features

Also see:Also see: Concerns about eating in publicConcerns about eating in public Feelings of ineffectivenessFeelings of ineffectiveness Strong need to control one’s environmentStrong need to control one’s environment Inflexible thinkingInflexible thinking Limited social spontaneityLimited social spontaneity PerfectionismPerfectionism Overly-restrained initiative and Overly-restrained initiative and

emotional expressionemotional expression


Commonly see Axis II diagnoses as well in Commonly see Axis II diagnoses as well in adult populations with Anorexia Nervosaadult populations with Anorexia Nervosa

Binge-Eating/Purging subtypes tend to be Binge-Eating/Purging subtypes tend to be more impulsive, higher risk for substance more impulsive, higher risk for substance abuse, increased emotional lability, abuse, increased emotional lability, increased sexual activity, a greater increased sexual activity, a greater frequency of suicide in their history and frequency of suicide in their history and more likely to meet criteria for Borderline more likely to meet criteria for Borderline Personality Disorder (adults).Personality Disorder (adults).

Associated Lab FindingsAssociated Lab Findings

Starvation causes a range of physical Starvation causes a range of physical anomalies:anomalies: Anemia and other blood chemistry disordersAnemia and other blood chemistry disorders Females: low serum estrogenFemales: low serum estrogen Males: low serum testosteroneMales: low serum testosterone Heart rate changes (bradycardia, arrhythmias)Heart rate changes (bradycardia, arrhythmias) EEG changes due to significant fluid and EEG changes due to significant fluid and

electrolyte imbalanceselectrolyte imbalances Resting energy expenditure and metabolic state Resting energy expenditure and metabolic state

loweredlowered

Associated Physical Exam Associated Physical Exam FindingsFindings

Many physical symptoms attributable to starvationMany physical symptoms attributable to starvation Ammenorrhea in femalesAmmenorrhea in females Constipation, abdominal painConstipation, abdominal pain Cold intolerance, lethargy, excess energyCold intolerance, lethargy, excess energy Emaciation – most obvious findingEmaciation – most obvious finding Low blood pressure, hypothermia, dryness of skinLow blood pressure, hypothermia, dryness of skin LanugoLanugo

Fine, downy, body hair on trunkFine, downy, body hair on trunk

Edema (swelling) once laxative or diuretic abuse is Edema (swelling) once laxative or diuretic abuse is stoppedstopped

Dental enamel erosion (on the back side of the Dental enamel erosion (on the back side of the teeth)teeth)

Scars/callous on the hand from inducing vomiting.Scars/callous on the hand from inducing vomiting.

Culture, Age, Gender Culture, Age, Gender FeaturesFeatures

Prevalence of AN greatly increased in Prevalence of AN greatly increased in industrialized societiesindustrialized societies Abundance of foodAbundance of food Attractiveness is linked to being thinAttractiveness is linked to being thin

Rarely begins before pubertyRarely begins before puberty If AN begins before puberty, severity may be If AN begins before puberty, severity may be

greater in other associated mental disordersgreater in other associated mental disorders ALSO: better prognosis with onset in early ALSO: better prognosis with onset in early

adolescence (13-18yrs)adolescence (13-18yrs) More than 90% of the cases of AN are More than 90% of the cases of AN are

females.females.

PrevalencePrevalence

Among females – prevalence rates are Among females – prevalence rates are about 0.5%about 0.5%

Among males – prevalence rates are Among males – prevalence rates are about 0.05%about 0.05%

Often see individuals with Often see individuals with subthreshold eating disorders (e.g., subthreshold eating disorders (e.g., Eating Disorder Not Otherwise Eating Disorder Not Otherwise Specified).Specified).

Incidence appears to have increased Incidence appears to have increased in recent decades.in recent decades.

CourseCourse

Typical age of onset: 14-18yrsTypical age of onset: 14-18yrs Rarely occurs in females older than 40yrsRarely occurs in females older than 40yrs Onset may be associated with a stressful Onset may be associated with a stressful

life eventlife event Couse and outcome highly variableCouse and outcome highly variable

Some recover after a single episodeSome recover after a single episode Some have a fluctuating pattern of weight Some have a fluctuating pattern of weight

gain/lossgain/loss Some have a chronic, deteriorating patternSome have a chronic, deteriorating pattern

CourseCourse

Hospitalization may be required to Hospitalization may be required to restore weight, fluid, and electrolyte restore weight, fluid, and electrolyte imbalance.imbalance.

Of those admitted to University Of those admitted to University hospitals, mortality is about 10%hospitals, mortality is about 10% Death most commonly results from Death most commonly results from

starvation, suicide, or electrolyte starvation, suicide, or electrolyte imbalance.imbalance.

Familial PatternFamilial Pattern

Increased risk of AN among first-Increased risk of AN among first-degree biological relatives of AN degree biological relatives of AN probands.probands.

Increased risk of Mood Disorders Increased risk of Mood Disorders also been noted among first-degree also been noted among first-degree biological relatives of AN probands.biological relatives of AN probands.

Concordance rates for MZ twins Concordance rates for MZ twins higher than DZ twins.higher than DZ twins.

Differential DiagnosisDifferential Diagnosis General medical conditionsGeneral medical conditions Major Depressive DisorderMajor Depressive Disorder

Weight loss may occur, but no preoccupation with weight loss or Weight loss may occur, but no preoccupation with weight loss or fear of gaining weightfear of gaining weight

SchizophreniaSchizophrenia May have odd eating, may have significant weight lossMay have odd eating, may have significant weight loss Will not have fear of gaining weight or body image disturbance.Will not have fear of gaining weight or body image disturbance.

Social phobia Social phobia fear of eating in public only symptomfear of eating in public only symptom

OCD OCD Obsessions and compulsions more than just food relatedObsessions and compulsions more than just food related

Body Dysmorphic DisorderBody Dysmorphic Disorder Distortion unrelated to body shape and size (e.g., nose too big)Distortion unrelated to body shape and size (e.g., nose too big)

Bulimia NervosaBulimia Nervosa BN are able to maintain normal body weightBN are able to maintain normal body weight

Bulimia Bulimia Nervosa (307.51)Nervosa (307.51)

Essential Features:Essential Features: Binge eatingBinge eating

andand inappropriate compensatory methods to prevent weight inappropriate compensatory methods to prevent weight

gain.gain. Binge: eating in a discrete period of time an Binge: eating in a discrete period of time an

amount of food that is definitely larger that most amount of food that is definitely larger that most individuals would eat under similar circumstances.individuals would eat under similar circumstances.

Inappropriate compensatory methods: vomiting Inappropriate compensatory methods: vomiting (80-90% of individuals with BN), misuse of (80-90% of individuals with BN), misuse of laxatives (33% of individuals with BN), misuse laxatives (33% of individuals with BN), misuse enemas (rarely used), fast for a day, or excessively enemas (rarely used), fast for a day, or excessively exercise.exercise.


A. Recurrent episodes of binge eating. An episode of binge eating A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: is characterized by both of the following:

(1) eating, in a discrete period of time (e.g., within any 2-hour (1) eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar people would eat during a similar period of time and under similar circumstances circumstances

(2) a sense of lack of control over eating during the episode (e.g., a (2) a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much feeling that one cannot stop eating or control what or how much one is eating) one is eating)

B. Recurrent inappropriate compensatory behavior in order to B. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise. excessive exercise.

C. The binge eating and inappropriate compensatory behaviors C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months. both occur, on average, at least twice a week for 3 months.


D. Self-evaluation is unduly influenced by body shape and D. Self-evaluation is unduly influenced by body shape and weight. weight.

E. The disturbance does not occur exclusively during episodes E. The disturbance does not occur exclusively during episodes of Anorexia Nervosa. of Anorexia Nervosa.

Specify type: Specify type:

Purging Type: Purging Type: during the current episode of Bulimia Nervosa, during the current episode of Bulimia Nervosa, the person has regularly engaged in self-induced vomiting or the the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas misuse of laxatives, diuretics, or enemas

Nonpurging Type: Nonpurging Type: during the current episode of Bulimia during the current episode of Bulimia Nervosa, the person has used other inappropriate compensatory Nervosa, the person has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemaslaxatives, diuretics, or enemas

Associated FeaturesAssociated Features Individuals with BN are typically within the normal weight Individuals with BN are typically within the normal weight

range (some may be over or underweight).range (some may be over or underweight). Increased frequency of depressive symptoms or Mood Increased frequency of depressive symptoms or Mood

DisordersDisorders Increased frequency of anxious symptoms or Anxiety Increased frequency of anxious symptoms or Anxiety

DisordersDisorders Mood and anxiety symptoms generally remit following Mood and anxiety symptoms generally remit following

effective treatment for BNeffective treatment for BN Lifetime prevalence for Substance Abuse/Dependence is at Lifetime prevalence for Substance Abuse/Dependence is at

least 30% in individuals with BN.least 30% in individuals with BN. Often starts with stimulant use to inhibit appetite.Often starts with stimulant use to inhibit appetite.

Adults often meet criteria for Personality Disorders (most Adults often meet criteria for Personality Disorders (most frequently, Borderline Personality Disorder)frequently, Borderline Personality Disorder)

Purging subtypes are at greater risk for depressive Purging subtypes are at greater risk for depressive symptoms.symptoms.

Associated Lab/Physical Associated Lab/Physical FindingsFindings

Fluid and electrolyte imbalancesFluid and electrolyte imbalances Calcium, Sodium, and Chlorine most commonCalcium, Sodium, and Chlorine most common

Medical findings also seen with frequent vomiting Medical findings also seen with frequent vomiting (increased alkalosis) and diarrhea (increased (increased alkalosis) and diarrhea (increased acidosis).acidosis).

Loss of dental enamel on back of teethLoss of dental enamel on back of teeth Teeth can become ragged and “moth-eaten” from Teeth can become ragged and “moth-eaten” from

stomach acid exposurestomach acid exposure Scars/calluses on handScars/calluses on hand Menstrual irregularitiesMenstrual irregularities Laxative dependenceLaxative dependence

Purging subtype more likely to have physical problemsPurging subtype more likely to have physical problems

Culture & Gender Culture & Gender FeaturesFeatures

BN occurs with similar frequencies in most BN occurs with similar frequencies in most industrialized countries.industrialized countries.

Few studies in other cultures.Few studies in other cultures. In the US, individuals with BN are primarily In the US, individuals with BN are primarily

white, but has been reported in other ethnic white, but has been reported in other ethnic groups as well.groups as well.

90% of individuals with BN are female in 90% of individuals with BN are female in clinic and population samples.clinic and population samples.

Males with BN have a higher prevalence of Males with BN have a higher prevalence of premorbid obesity than do females with BN.premorbid obesity than do females with BN.

Prevalence / CoursePrevalence / Course Lifetime prevalence rates:Lifetime prevalence rates:

Females: 1% to 3%Females: 1% to 3% Males .1% to .3%Males .1% to .3%

Usually begins in late adolescence or early adulthood.Usually begins in late adolescence or early adulthood. Binge eating usually begins after an episode of dieting.Binge eating usually begins after an episode of dieting. Disturbed eating persists for several years in most Disturbed eating persists for several years in most

clinic samples.clinic samples. Course can be chronic or intermittentCourse can be chronic or intermittent Many individuals will remit over time.Many individuals will remit over time. Remission of 1yr or longer is associated with better Remission of 1yr or longer is associated with better

long-term outcome.long-term outcome.


Increased frequency of BN, Mood Increased frequency of BN, Mood Disorders, Substance Disorders, Substance Abuse/Dependence in first-degree Abuse/Dependence in first-degree biological relatives of BN probands.biological relatives of BN probands.

Familial tendency toward obesity Familial tendency toward obesity may exist; not definitively may exist; not definitively established.established.


Anorexia Nervosa, Binge-Eating/Purging Anorexia Nervosa, Binge-Eating/Purging TypeType Binge eating only occurs during Anorexia Binge eating only occurs during Anorexia

Nervosa episodes.Nervosa episodes. Key feature – fear of food, gaining weight in Key feature – fear of food, gaining weight in

AN, lack of appropriate body weight in ANAN, lack of appropriate body weight in AN Difficult to make the distinction between AN, Difficult to make the distinction between AN,

Binge-Eating/Purging, in Partial RemissionBinge-Eating/Purging, in Partial Remissionandand

Bulimia Nervosa.Bulimia Nervosa.


Major Depressive Disorder, with Major Depressive Disorder, with Atypical FeaturesAtypical Features Can see disordered eating, but not the Can see disordered eating, but not the

inappopriate compensatory behaviorinappopriate compensatory behavior Borderline Personality Disorder (in Borderline Personality Disorder (in

adults)adults) Can see binge eating as part of the Can see binge eating as part of the

impulsive symptoms of BPD.impulsive symptoms of BPD. Can give BPD and BN diagnoses (in adults)Can give BPD and BN diagnoses (in adults)

Eating Disorder NOS Eating Disorder NOS (307.50)(307.50)

The Eating Disorder Not Otherwise Specified category is for The Eating Disorder Not Otherwise Specified category is for disorders of eating that do not meet criteria for any specific disorders of eating that do not meet criteria for any specific Eating Disorder. Examples include:Eating Disorder. Examples include:1.1. For females, all of the criteria for Anorexia Nervosa are met except For females, all of the criteria for Anorexia Nervosa are met except

that the individual has regular menses.that the individual has regular menses.2.2. All of the criteria for Anorexia Nervosa are met except that, despite All of the criteria for Anorexia Nervosa are met except that, despite

significant weight loss, the individual’s current weight is in the significant weight loss, the individual’s current weight is in the normal range.normal range.

3.3. All of the criteria for Bulimia Nervosa are met except that the binge All of the criteria for Bulimia Nervosa are met except that the binge eating and inappropriate compensatory mechanisms occur at a eating and inappropriate compensatory mechanisms occur at a frequency less than twice a week or for a duration of less than 3 frequency less than twice a week or for a duration of less than 3 months.months.

4.4. The regular use of inappropriate compensatory behavior by an The regular use of inappropriate compensatory behavior by an individual of normal body weight after eating small amounts of food individual of normal body weight after eating small amounts of food (e.g., self-induced vomiting after the consumption of two cookies).(e.g., self-induced vomiting after the consumption of two cookies).

5.5. Repeatedly chewing and spitting out, but not swallowing, large Repeatedly chewing and spitting out, but not swallowing, large amounts of food.amounts of food.

6.6. Binge-eating disorder: recurrent episodes of binge eating in the Binge-eating disorder: recurrent episodes of binge eating in the absence of the regular use of inappropriate compensatory behaviors absence of the regular use of inappropriate compensatory behaviors characteristic of Bulimia Nervosa.characteristic of Bulimia Nervosa.

EncopresisEncopresis

Essential feature: passage of feces Essential feature: passage of feces into inappropriate places (e.g., into inappropriate places (e.g., clothing or floor).clothing or floor). Floor is more atypical than clothingFloor is more atypical than clothing

May be related to constipation, May be related to constipation, impaction, and retention (787.6) or impaction, and retention (787.6) or not (307.7)not (307.7)

Constipation may be due to Constipation may be due to psychological reasons or psychological reasons or physiological predispositions.physiological predispositions.

EncopresisEncopresisA. Repeated passage of feces into inappropriate places (e.g., A. Repeated passage of feces into inappropriate places (e.g.,

clothing or floor) whether involuntary or intentional. clothing or floor) whether involuntary or intentional.

B. At least one such event a month for at least 3 months. B. At least one such event a month for at least 3 months.

C. Chronological age is at least 4 years (or equivalent C. Chronological age is at least 4 years (or equivalent developmental level). developmental level).

D. The behavior is not due exclusively to the direct D. The behavior is not due exclusively to the direct physiological effects of a substance (e.g., laxatives) or a physiological effects of a substance (e.g., laxatives) or a general medical condition except through a mechanism general medical condition except through a mechanism involving constipation. involving constipation.

Code Code as follows: as follows: 787.6 With Constipation and Overflow Incontinence 787.6 With Constipation and Overflow Incontinence 307.7 Without Constipation and Overflow Incontinence307.7 Without Constipation and Overflow Incontinence


Shame, avoidance of situations (e.g., camp or Shame, avoidance of situations (e.g., camp or school) that might lead to embarrassment.school) that might lead to embarrassment.

Avoidance linked to impact on self-esteem, Avoidance linked to impact on self-esteem, social ostracism by peerssocial ostracism by peersandand

anger, punishment, and rejection by anger, punishment, and rejection by caregivers.caregivers.

Smearing feces may be deliberate (more ODD) Smearing feces may be deliberate (more ODD) or accidental (ineffective attempts to clean or or accidental (ineffective attempts to clean or hide feces).hide feces).

Euresis often co-occurs with encopresis.Euresis often co-occurs with encopresis.

Prevalence / CoursePrevalence / Course Approximately 1% of 5-year-olds have encopresis.Approximately 1% of 5-year-olds have encopresis. More common in males than females.More common in males than females.

Not diagnosed under 4yrs of age or for children Not diagnosed under 4yrs of age or for children with a developmental delay, a mental age of 4yrs.with a developmental delay, a mental age of 4yrs.

Inadequate, inconsistent toilet training and Inadequate, inconsistent toilet training and psychosocial stress may be predisposing factors.psychosocial stress may be predisposing factors.

Two types of course:Two types of course: Primary – child never was continentPrimary – child never was continent Secondary – child had a period of continence, followed by Secondary – child had a period of continence, followed by

fecal incontinence.fecal incontinence. Can persist with intermittent exacerbation for Can persist with intermittent exacerbation for

years.years.


General medical conditionsGeneral medical conditions Can diagnoses Encopresis with Can diagnoses Encopresis with

another co-occurring medical another co-occurring medical condition if that condition involves condition if that condition involves constipation.constipation.

If the co-occurring medical condition If the co-occurring medical condition produces fecal incontinence (e.g., produces fecal incontinence (e.g., chronic diarrhea, anal stenosis), chronic diarrhea, anal stenosis), Encopresis is not diagnosed.Encopresis is not diagnosed.

Enuresis (307.6)Enuresis (307.6)

Essential feature: repeated voiding Essential feature: repeated voiding of urine during the day or at night of urine during the day or at night into bed or clothes.into bed or clothes.

May be involuntary or intentional.May be involuntary or intentional.

Enuresis (307.6)Enuresis (307.6)A. Repeated voiding of urine into bed or clothes (whether involuntary or A. Repeated voiding of urine into bed or clothes (whether involuntary or

intentional). intentional).

B. The behavior is clinically significant as manifested by either a frequency B. The behavior is clinically significant as manifested by either a frequency of twice a week for at least 3 consecutive months or the presence of of twice a week for at least 3 consecutive months or the presence of clinically significant distress or impairment in social, academic clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning. (occupational), or other important areas of functioning.

C. Chronological age is at least 5 years (or equivalent developmental C. Chronological age is at least 5 years (or equivalent developmental level). level).

D. The behavior is not due exclusively to the direct physiological effect of a D. The behavior is not due exclusively to the direct physiological effect of a substance (e.g., a diuretic) or a general medical condition (e.g., substance (e.g., a diuretic) or a general medical condition (e.g., diabetes, spina bifida, a seizure disorder). diabetes, spina bifida, a seizure disorder).

Specify Specify type: type:

Nocturnal Only Nocturnal Only Diurnal Only Diurnal Only Nocturnal and DiurnalNocturnal and Diurnal

Associated FeaturesAssociated Features Amount of impairment a function of limitations on child’s Amount of impairment a function of limitations on child’s

social activities (e.g., ineligibility for sleep-away camp) social activities (e.g., ineligibility for sleep-away camp) or effect on self-esteem, social ostracism by peers, and or effect on self-esteem, social ostracism by peers, and anger, rejection, or punishment by caregivers.anger, rejection, or punishment by caregivers.

Most children with Enuresis do not have co-occurring Most children with Enuresis do not have co-occurring mental disorders.mental disorders.

Prevalence of other behavioral disorders is higher in Prevalence of other behavioral disorders is higher in children with Enuresis.children with Enuresis.

Encopresis, Sleepwalking Disorder, and Sleep Terror Encopresis, Sleepwalking Disorder, and Sleep Terror Disorder may be present.Disorder may be present.

Also see urinary tract infections predisposing to Also see urinary tract infections predisposing to Enuresis.Enuresis.

Other predisposing factors:Other predisposing factors: Delayed or lax toilet training, psychosocial stress, delays in the Delayed or lax toilet training, psychosocial stress, delays in the

development of normal circadian rhythms of urine production, development of normal circadian rhythms of urine production, reduced functional bladder capacities.reduced functional bladder capacities.

Prevalence / CoursePrevalence / Course Prevalence:Prevalence:

5% to 10% among 5-year-olds5% to 10% among 5-year-olds 3% to 5% among 10-year-olds3% to 5% among 10-year-olds ~1% among individuals 15yrs or older~1% among individuals 15yrs or older

Two types of course:Two types of course: Primary – never been continentPrimary – never been continent Secondary – incontinent after a period of continenceSecondary – incontinent after a period of continence

By definition, primary Enuresis begins at 5yrs of ageBy definition, primary Enuresis begins at 5yrs of age Secondary Enuresis begins commonly between 5 and Secondary Enuresis begins commonly between 5 and

8yrs.8yrs. Rates of spontaneous remission between 5% and Rates of spontaneous remission between 5% and

10% after age 510% after age 5 Most children with Enuresis are continent by Most children with Enuresis are continent by

adolescence, some continue into adulthood.adolescence, some continue into adulthood.


Approximately 75% of all children with Approximately 75% of all children with Enuresis have a first-degree biological Enuresis have a first-degree biological relative who has had the disorder.relative who has had the disorder.

Risk of Enuresis is 5x to 7x greater in Risk of Enuresis is 5x to 7x greater in the offspring of a parent with Enuresis.the offspring of a parent with Enuresis.

Concordance rates higher in MZ twins Concordance rates higher in MZ twins than DZ twins.than DZ twins.

No specific genetic links… yet.No specific genetic links… yet.


No DX made in the case of a general No DX made in the case of a general medical condition that causes medical condition that causes polyuria or urgency.polyuria or urgency.

Diagnosis is made when the Diagnosis is made when the Enuresis either predates the general Enuresis either predates the general medical condition medical condition oror it occurs after it occurs after the general medical condition has the general medical condition has remitted.remitted.

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