Eating Disorders DSM5-TR

Anorexia Nervosa

A. Restriction of energy intake relative to requirements, leading to a significantly lowbody weight in the context of age, sex, developmental trajectory, and physicalhealth. Significantly low weight is defined as a weight that is less than minimallynormal or, for children and adolescents, less than that minimally expected.

B. Intense fear of gaining weight or of becoming fat, or persistent behavior thatinterferes with weight gain, even though at a significantly low weight.

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

Coding note: The ICD-10-CM code depends on the subtype (see below).

Anorexia Nervosa Specifers 

 

-Restricting type: During the last 3 months, the individual has not engaged in recurrent episodes of binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). This subtypedescribes presentations in which weight loss is accomplished primarily throughdieting, fasting, and/or excessive exercise.

-Binge-eating/purging type: During the last 3 months, the individual has engaged in recurrent episodes of binge-eating or purging behavior (i.e., self- induced vomiting or the misuse of laxatives, diuretics, or enemas).

Specify if:

In partial remission: After full criteria for anorexia nervosa were previously met, Criterion A (low body weight) has not been met for a sustained period, but either Criterion B (intense fear of gaining weight or becoming fat or behavior that interferes with weight gain) or Criterion C (disturbances in self-perception of weight and shape) is still met. In full remission: After full criteria for anorexia nervosa were previously met, none of the criteria have been met for a sustained period of time.

Specify current severity:

Mild: BMI ≥ 17 kg/m2

Moderate: BMI 16–16.99 kg/m2

Severe: BMI 15–15.99 kg/m2

Extreme: BMI < 15 kg/m2

Anorexia Nervosa Onset 

begins during adolescence or young adulthood. It rarely begins before puberty or after age 40, but cases of both early and late onset have been described.

Anorexia Nervosa Course

The course and outcome of anorexia nervosa are highly variable.

Younger individualsmay manifest atypical features, including denying “fear of fat.” Older individuals more likelyhave a longer duration of illness, and their clinical presentation may include more signs and symptoms of long-standing disorder.

Bulimia Nervosa

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

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

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 one is eating).

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

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

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

E. The disturbance does not occur exclusively during episodes of anorexia nervosa.

Bulimia Nervosa Specifiers

Specify if:

In partial remission: After full criteria for bulimia nervosa were previously met, some, but not all, of the criteria have been met for a sustained period of time.

In full remission: After full criteria for bulimia nervosa were previously met, none of the criteria have been met for a sustained period of time.

Specify current severity:

The minimum level of severity is based on the frequency of inappropriate compensatory behaviors (see below). The level of severity may be increased to reflect other symptoms and the degree of functional disability.

Mild: An average of 1–3 episodes of inappropriate compensatory behaviors per week.

Moderate: An average of 4–7 episodes of inappropriate compensatory behaviors per week.

Severe: An average of 8–13 episodes of inappropriate compensatory behaviors per week.

Extreme: An average of 14 or more episodes of inappropriate compensatory behaviors per week.

Bulimia Nervosa Onset 

begins in adolescence or young adulthood. Onset before puberty or after age 40 is uncommon.

Bulimia Nervosa Course

The binge eating frequently begins during or after an episode of dieting to lose weight

Chronic or intermittent courses. Remission sometimes after years.

Binge- Eating Disorder

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

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

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 one is eating).

B. The binge-eating episodes are associated with three (or more) of the following:

1. Eating much more rapidly than normal.

2. Eating until feeling uncomfortably full.

3. Eating large amounts of food when not feeling physically hungry.

4. Eating alone because of feeling embarrassed by how much one is eating.

5. Feeling disgusted with oneself, depressed, or very guilty afterward.

C. Marked distress regarding binge eating is present.

D. The binge eating occurs, on average, at least once a week for 3 months.

E. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa.

Binge- Eating Disorder Specifiers

Specify if:

-In partial remission: After full criteria for binge-eating disorder were previously met, binge eating occurs at an average frequency of less than one episode per week for a sustained period of time.

-In full remission: After full criteria for binge-eating disorder were previously met, none of the criteria have been met for a sustained period of time.

Specify current severity:

The minimum level of severity is based on the frequency of episodes of binge eating(see below). The level of severity may be increased to reflect other symptoms and the degree of functional disability.

Mild: 1–3 binge-eating episodes per week.

Moderate: 4–7 binge-eating episodes per week.

Severe: 8–13 binge-eating episodes per week.

Extreme: 14 or more binge-eating episodes per week.

Binge- Eating Disorder Onset

Adolescent/ Young adulthood

Binge- Eating Disorder Course

Remission rates in both natural course and treatment outcome studies are higher for binge- eating disorder than for bulimia nervosa or anorexia nervosa. The course of binge-eating disorder is variable and as yet incompletely understood, with at least some affected individuals showing a relatively persistent, at times relapsing and remitting, symptom trajectory comparable to that of bulimia nervosa in terms of severity and duration. Crossover from binge-eating disorder to other eating disorders is uncommon.

Avoidant/Restrictive Food Intake Disorder

A. An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) associated with one (or more) of the following:

1. Significant weight loss (or failure to achieve expected weight gain or falteringgrowth in children).

2. Significant nutritional deficiency.

3. Dependence on enteral feeding or oral nutritional supplements.

4. Marked interference with psychosocial functioning.

B. The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice.

C. The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced.

D. The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder. When 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 and warrants additional clinical attention.

Avoidant/Restrictive Food Intake Disorder Specifiers

In remission: After full criteria for avoidant/restrictive food intake disorder were previously met, the criteria have not been met for a sustained period of time.

Avoidant/Restrictive Food Intake Disorder Onset

commonly develops in infancy or early childhood and may persist in adulthood.

Avoidant/Restrictive Food Intake Disorder Course

that food avoidance or restriction based on sensory aspects is relatively stable and long-standing, but when persisting into adulthood, such avoidance/restriction can be associated with relatively normal functioning. There is currently insufficient evidence directly linking avoidant/restrictive food intake disorder and subsequent onset of an eating disorder.

Pica

A. Persistent eating of nonnutritive, nonfood substances over a period of at least 1 month.

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

C. The eating behavior is not part of a culturally supported or socially normative practice.

D. If the eating behavior occurs in the context of another mental disorder (e.g., intellectual developmental disorder [intellectual disability], autism spectrum disorder, schizophrenia) or medical condition (including pregnancy), it is sufficiently severe to warrant additional clinical attention.

Pica Specifiers

Specify if:

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

Pica Onset

Onset of pica can occur in childhood, adolescence, or adulthood, although childhood onset is most commonly reported.

Pica Course

The course of the disorder can be protracted and can result in medical emergencies (e.g., intestinal obstruction, acute weight loss, poisoning). The disorder can potentially be fatal depending on substances ingested.

Rumination Disorder

A. Repeated regurgitation of food over a period of at least 1 month. Regurgitated food may be re-chewed, re-swallowed, or spit out.

B. The repeated regurgitation is not attributable to an associated gastrointestinal or other medical condition (e.g., gastroesophageal reflux, pyloric stenosis).

C. The eating disturbance does not occur exclusively during the course of anorexia nervosa, bulimia nervosa, binge-eating disorder, or avoidant/restrictive food intake disorder.

D. If the symptoms occur in the context of another mental disorder (e.g., intellectual developmental disorder [intellectual disability] or another neurodevelopmental disorder), they are sufficiently severe to warrant additional clinical attention.

Rumination Disorder Specifiers

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

Rumination Disorder Onset

Onset of rumination disorder can occur in infancy, childhood, adolescence, or adulthood. The age at onset in infants is usually between ages 3 and 12 months.

Rumination Disorder Course

In infants, the disorder frequently remits spontaneously, but its course can be protracted and can result in medical emergencies (e.g., severe malnutrition). It can potentially be fatal, particularly in infancy. Rumination disorder can have an episodic course or occur continuously until treated.

Enuresis

A. Repeated voiding of urine into bed or clothes, whether involuntary or intentional.

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

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

D. The behavior is not attributable to the physiological effects of a substance (e.g., a diuretic, an antipsychotic medication) or another medical condition (e.g., diabetes, spina bifida, a seizure disorder).

Enuresis Specifiers

Specify whether:

Nocturnal only: Passage of urine only during nighttime sleep.

Diurnal only: Passage of urine during waking hours.

Nocturnal and diurnal: A combination of the two subtypes above.

Enuresis Onset

By definition, primary enuresis begins at age 5 years. The most common time for the onset of secondary enuresis is between ages 5 and 8 years, but it may occur at any time.

Enuresis Course

-Enuresis can follow two courses: a “primary” type, in which the individual has never established urinary continence, and a “secondary” type, in which the disturbance develops after a period of established urinary continence.

-After age 5 years, the rate of spontaneous remission is 5%–10% per year. Most children with the disorder become continent by adolescence, but in approximately 1% of cases the disorder continues into adulthood. Diurnal enuresis is uncommon after age 9 years.

Encopresis

A. Repeated passage of feces into inappropriate places (e.g., clothing, floor), whether involuntary or intentional.

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

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

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

Encopresis Specifiers

Specify whether:

• With constipation and overflow incontinence: There is evidence of constipation on physical examination or by history.

• Without constipation and overflow incontinence: There is no evidence of constipation on physical examination or by history.

Encopresis Onset

Encopresis is not diagnosed until a child has reached a chronological age of at least 4 years (or for children with developmental delays, a mental age of at least 4 years).

Encopresis Course

Two types of course have been described: a “primary” type, in which the individual has never established fecal continence, and a “secondary” type, in which the disturbance develops after a period of established fecal continence. Encopresis can persist, with intermittent exacerbations, for years.

Insomnia Disorder

A. A predominant complaint of dissatisfaction with sleep quantity or quality,

associated with one (or more) of the following symptoms:

1. Difficulty initiating sleep. (In children, this may manifest as difficulty initiating sleep without caregiver intervention.)

2. Difficulty maintaining sleep, characterized by frequent awakenings or problems returning to sleep after awakenings. (In children, this may manifest as difficulty returning to sleep without caregiver intervention.)

3. Early-morning awakening with inability to return to sleep.

B. The sleep disturbance causes clinically significant distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning.

C. The sleep difficulty occurs at least 3 nights per week.

D. The sleep difficulty is present for at least 3 months.

E. The sleep difficulty occurs despite adequate opportunity for sleep.

F. The insomnia is not better explained by and does not occur exclusively during the course of another sleep-wake disorder (e.g., narcolepsy, a breathing-related sleep disorder, a circadian rhythm sleep-wake disorder, a parasomnia).

G. The insomnia is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication).

H. Coexisting mental disorders and medical conditions do not adequately explain the predominant complaint of insomnia.

Insomnia Disorder Specifiers

Specify if:

With mental disorder, including substance use disorders

With medical condition

With another sleep disorder

Specify if:

Episodic: Symptoms last at least 1 month but less than 3 months.

Persistent: Symptoms last 3 months or longer.

Recurrent: Two (or more) episodes within the space of 1 year.

Insomnia Disorder Onset

The onset of insomnia symptoms can occur at any time during life, but the first episode is more common in young adulthood. Less frequently, insomnia begins in childhood or adolescence. In women, the incidence of new-onset insomnia increases with menopause and may persist even after other symptoms (e.g., hot flashes) have resolved.

Insomnia Disorder Course

Insomnia may have a late-life onset, which is often associated with the onset of other health-related conditions. Insomnia can be situational, persistent, or recurrent.

Hypersomnolence Disorder

A. Self-reported excessive sleepiness (hypersomnolence) despite a main sleep period lasting at least 7 hours, with at least one of the following symptoms:

1. Recurrent periods of sleep or lapses into sleep within the same day.

2. A prolonged main sleep episode of more than 9 hours per day that is nonrestorative (i.e., unrefreshing).

3. Difficulty being fully awake after abrupt awakening.

B. The hypersomnolence occurs at least three times per week, for at least 3 months.

C. The hypersomnolence is accompanied by significant distress or impairment in cognitive, social, occupational, or other important areas of functioning.

D. The hypersomnolence is not better explained by and does not occur exclusively during the course of another sleep disorder (e.g., narcolepsy, breathing-related sleep disorder, circadian rhythm sleep-wake disorder, or a parasomnia).

E. The hypersomnolence is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication).

F. Coexisting mental and medical disorders do not adequately explain the predominant complaint of hypersomnolence.

Hypersomnolence Disorder Specifiers

Specify if:

With mental disorder, including substance use disorders

With medical condition

With another sleep disorder

Specify if:

Acute: Duration of less than 1 month.

Subacute: Duration of 1–3 months.

Persistent: Duration of more than 3 months.

Specify current severity:

Specify severity based on degree of difficulty maintaining daytime alertness as manifested by the occurrence of multiple attacks of irresistible sleepiness within any given day occurring, for example, while sedentary, driving, visiting with friends, or working.

Mild: Difficulty maintaining daytime alertness 1–2 days/week.

Moderate: Difficulty maintaining daytime alertness 3–4 days/week.

Severe: Difficulty maintaining daytime alertness 5–7 days/week.

Hypersomnolence Disorder Onset

begins in late adolescence or early adulthood, with a mean age at onset of 17–24 years and a gradual progression over weeks to months.

Hypersomnolence Disorder Course

for most individuals, the symptoms are persistent and stable, unless treatment is initiated. Spontaneous remission occurs in about 11%–25% of individuals after 5–7 years. Individuals with hypersomnolence disorder are diagnosed, on average, 10–15 years after the appearance of the first symptoms. Pediatric cases are rare.

Narcolepsy

A. Recurrent periods of an irrepressible need to sleep, lapsing into sleep, or napping occurring within the same day. These must have been occurring at least three times per week over the past 3 months.

B. The presence of at least one of the following:

1. Episodes of cataplexy, defined as either (a) or (b), occurring at least a fewtimes per month:

a. In individuals with long-standing disease, brief (seconds to minutes) episodes of sudden bilateral loss of muscle tone with maintained consciousness that are precipitated by laughter or joking.

b. In children or in individuals within 6 months of onset, spontaneous grimaces or jaw-opening episodes with tongue thrusting or a global hypotonia, without any obvious emotional triggers.

2. Hypocretin deficiency, as measured using cerebrospinal fluid (CSF) hypocretin-1 immunoreactivity values (less than or equal to one-third of values obtained in healthy subjects tested using the same assay, or less than or equal to 110 pg/mL). Low CSF levels of hypocretin-1 must not be observed in the context of acute brain injury, inflammation, or infection.

3. Nocturnal sleep polysomnography showing rapid eye movement (REM) sleep latency less than or equal to 15 minutes, or a multiple sleep latency test showing a mean sleep latency less than or equal to 8 minutes and two or more sleep-onset REM periods.

Narcolepsy Specifiers

-Narcolepsy with cataplexy or hypocretin deficiency (type 1): Criterion B1 (episodes of cataplexy) or Criterion B2 (low CSF hypocretin-1levels) is met.

-Narcolepsy without cataplexy and either without hypocretin deficiency or hypocretin unmeasured (type 2): Criterion B3 (positive polysomnography/multiple sleep latency test) is met, but Criterion B1 is not met(i.e., no cataplexy is present) and Criterion B2 is not met (i.e., CSF hypocretin-1 levels are not low or have not been measured).

-Narcolepsy with cataplexy or hypocretin deficiency due to a medical condition

- Narcolepsy without cataplexy and without hypocretin deficiency due to a medical condition

Specify current severity:

Mild: Need for naps only once or twice per day. Sleep disturbance, if present, is mild. Cataplexy, when present, is infrequent (occurring less than once per week).

Moderate: Need for multiple naps daily. Sleep may be moderately disturbed. Cataplexy, when present, occurs daily or every few days.

Severe: Nearly constant sleepiness and, often, highly disturbed nocturnal sleep (which may include excessive body movement and vivid dreams). Cataplexy, when present, is drug-resistant, with multiple attacks daily.

Narcolepsy onset

childhood and adolescence or young adulthood but rarely in old age.

Narcolepsy Course

Onset can be abrupt or progressive, with cataplexy developing over years. It has been reported that children presenting with abrupt onset of NT1 symptoms have the highest disease severity but that disease severity in these cases tends to partially improve in the first few years after onset. Abrupt onset in young, prepubescent childrencan be associated with obesity and premature puberty. About 50% of individuals with narcolepsy diagnosed in adulthood recall symptom onset in childhood or adolescence, highlighting problems of diagnostic delays for this condition. Once the disorder has manifested, the course is persistent and lifelong.

Circadian Rhythm Sleep-Wake Disorders

A. A persistent or recurrent pattern of sleep disruption that is primarily due to an alteration of the circadian system or to a misalignment between the endogenous circadian rhythm and the sleep-wake schedule required by an individual’s physical environment or social or professional schedule.

B. The sleep disruption leads to excessive sleepiness or insomnia, or both.

C. The sleep disturbance causes clinically significant distress or impairment in social, occupational, and other important areas of functioning.

Circadian Rhythm Sleep-Wake Disorders Specifiers

Specify whether:

Delayed sleep phase type: A pattern of delayed sleep onset and awakening times, with an inability to fall asleep and awaken at a desired or conventionally acceptable earlier time.

Specify if:

Familial: A family history of delayed sleep phase is present.

Specify if:

Overlapping with non-24-hour sleep-wake type: Delayed sleep phase type may overlap with another circadian rhythm sleep-wake disorder, non-24-hour sleep-wake type.

G47.22 Advanced sleep phase type: A pattern of advanced sleep onset and

awakening times, with an inability to remain awake or asleep until the desired or

conventionally acceptable later sleep or wake times.

Specify if:

Familial: A family history of advanced sleep phase is present.

Irregular sleep-wake type: A temporally disorganized sleep-wake pattern, such that the timing of sleep and wake periods is variable throughout the 24-hour period.

Non-24-hour sleep-wake type: A pattern of sleep-wake cycles that is not synchronized to the 24-hour environment, with a consistent daily drift (usually to later and later times) of sleep onset and wake times.

Shift work type: Insomnia during the major sleep period and/or excessive sleepiness (including inadvertent sleep) during the major awake period associated with a shift work schedule (i.e., requiring unconventional work hours).

Unspecified type

Specify if:

Episodic: Symptoms last at least 1 month but less than 3 months.

Persistent: Symptoms last 3 months or longer.

Recurrent: Two or more episodes occur within the space of 1 year.

SPECIFERS/ THE TYPES OF THE DISORDERS

Circadian Rhythm Sleep-Wake Disorders Onsets UPDATE