Eating disorders in adolescence
31
Eating Disorders in Adolescence
Dasha Nicholls
Department of Child & Adolescent Mental Health, Great Ormond Street Hospital for Children NHS
Trust, London, UK
DIAGNOSIS AND CLASSIFICATION
The term ‘eating disorder’ is restricted to disor-
ders of eating behaviour driven by overvalued
ideas about weight and shape. Within this narrow
definition, there are two well-described disorders,
anorexia nervosa (AN) and bulimia nervosa (BN).
AN is characterized by determined food avoid-
ance in pursuit of thinness, resulting in clinically
significant weight loss, which may or may not be
enhanced by so-called ‘compensatory behaviours’
designed to counteract the fattening effect of food.
The DSM-IV-TR (
Diagnostic and Statistical Man-
ual of Mental Disorders, Fourth Edition – Text
Revision
) [1] recognizes a restrictive (AN-R; food
restriction and exercise only) and a binge-purging
(AN-BP) subtype of AN. Two main features dis-
tinguish AN from BN. The first is the centrality of
binge eating to BN, characterized by loss of con-
trol over eating. The second is that, although in BN
thinness is pursued and desired, sufferers are by
definition within the normal weight range. DSM-
IV recognizes purging (BN-P) and non-purging
(BN-NP) subtypes of BN.
Despite features in common, each disorder has
a distinct course, outcome and treatment response,
with accumulating evidence for differential familial
(including genetic), personality, and neurodevel-
opmental risk. The current challenge, given the
overlap in clinical features, is accurately to predict
the course and prognosis for a given individual at
the time of presentation.
The other important diagnostic issue is that
the majority (around 60%) of patients at all ages
Child Psychology and Psychiatry: Frameworks for practice
, Second Edition. Edited by David Skuse, Helen Bruce,
Linda Dowdney and David Mrazek.
2011 John Wiley & Sons, Ltd. Published 2011 by John Wiley & Sons, Ltd.
presenting with a clinically significant eating disor-
der do not meet full diagnostic criteria for either
AN or BN, and would be diagnosed with Eating
Disorders Not Otherwise Specified (EDNOS) in
the DSM-IV [1], or Atypical AN or BN in ICD-10
(ICD-10 International Classification of Mental and
Behavioural Disorders in Children and Adoles-
cents) [2], or be unclassifiable. Common examples
of EDNOS include patients with AN-like illness
who have lost considerable weight but are still in
the healthy weight range or have not lost menses;
patients who binge and purge but at a lower fre-
quency than the BN criteria specify; patients who
purge but do not binge (purging disorder), or binge
but do not purge [Binge Eating Disorder (BED)];
or patients for whom disordered eating is one of
a number of risk behaviours or comorbidities [3].
Of more uncertain nosological status are patients
who have determined food avoidance that does
not appear to be driven by a drive for thinness
or fear of weight gain (non-fat phobic AN) [3].
Such presentations are common in young patients,
when it is sometimes known as Food Avoidance
Emotional Disorder [4], and in non-Western cul-
tures and minority ethnic groups. It is likely that
BED will be included in the DSM revision, while
other presentations such as ‘purging disorder’ [5]
and ‘non-fat phobic AN’ require further research.
Developmental issues with respect to diagnosis
include the degree of reliance on self-reported cog-
nitions, developmental differences in the impact on
physical health, and the way that parental reporting
of behaviours and eating concerns is assimilated
into the diagnostic process [6]. The diagnostic
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