Anorexia nervosa diagnostic criteria

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2] , Joseph Nasr, M.D.[3]

Diagnostic Criteria

DSM-V Diagnostic Criteria for Anorexia Nervosa

“

A. Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected. AND B. Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight. AND 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. 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: The minimum level of severity is based, for adults, on current body mass index (BMI) (see below) or, for children and adolescents, on BMI percentile. The ranges below are derived from World Health Organization categories for thinness in adults; for children and adolescents, corresponding BMI percentiles should be used. The level of severity may be increased to reflect clinical symptoms, the degree of functional disability, and the need for supervision. 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

Step 1. Confirm the clinical problem Ask directly, nonjudgmental: 1.Are you intentionally restricting what you eat? 2.Are you afraid of gaining weight even when others say you are too thin? 3.How much does your weight or body shape affect how you feel about yourself? 4.Do you exercise to control weight, even when ill, injured, or exhausted? 5.Do you vomit or use laxatives, diuretics, diet pills, or appetite suppressants?

Step 2. Establish DSM pattern Checklist to document core criteria: 1.Restriction of energy intake relative to requirements 2.Significantly low body weight for age, sex, developmental trajectory, and physical health 3.Fear of weight gain or persistent behavior preventing weight gain 4.Body image disturbance or undue influence of weight or shape on self evaluation or lack of recognition of seriousness

Step 3. Characterize behaviors and subtype Clarify weight control methods and subtype: 1.Restricting pattern: dieting, fasting, rigid food rules, excessive exercise 2.Binge eating or purging pattern: self induced vomiting, laxatives, diuretics, enemas 3.Frequency and triggers of binge or purge if present 4.Daytime hyperactivity, restlessness, insomnia, compulsive weighing or body checking

Step 4. Screen for medical instability first Immediate safety check before extensive history: 1.Syncope, presyncope, chest pain, palpitations, seizures, severe weakness 2.Inability to maintain oral intake, persistent vomiting, severe dehydration 3.Suicidality or severe psychiatric crisis If any present, escalate level of care urgently

Step 5. Focused symptom review that changes management 1.GI: abdominal discomfort, bloating, constipation, early satiety 2.Thermoregulation: cold intolerance 3.Endocrine: menstrual history, libido, pubertal delay or growth arrest if early onset 4.Exercise: intensity, compulsion, exercising despite illness or injury 5.Sleep: insomnia, daytime hyperactivity

Step 6. Physical examination in the right order 1.Vitals including orthostatic blood pressure and heart rate 2.Cardiac exam for bradycardia, irregular rhythm, murmurs, peripheral edema 3.Skin and hair: lanugo, dry skin, hair thinning, yellowish discoloration 4.General: muscle wasting, weakness, delayed growth or puberty in youth 5.Oral and hands: signs of vomiting or purging behaviors if suspected

Step 7. Core investigations to confirm severity and complications 1.Complete blood count 2.Serum electrolytes including sodium, potassium, magnesium, phosphate 3.Urea and creatinine 4.Blood glucose 5.Liver function tests and albumin 6.Thyroid function tests 7.Electrocardiogram for QTc and rhythm 8.Bone densitometry if prolonged undernutrition or amenorrhea or high fracture risk

Step 8. Rule out common mimics before finalizing diagnosis 1.Endocrine: hyperthyroidism, hypothyroidism 2.GI or systemic disease causing weight loss: inflammatory bowel disease, malignancy 3.Depression or anxiety with reduced intake 4.Substance use disorder Proceed with eating disorder diagnosis when pattern fits and alternates do not explain presentation