Eating disorders are serious psychiatric conditions that affect how someone relates to food, body image, and physical health. While cultural conversations often focus on anorexia nervosa and bulimia nervosa—a topic we covered in a recent blog—the diagnostic landscape includes a broader range of presentations that reflect the complexity of disordered eating. Understanding these categories matters not just for recognition and intervention, but plays a large role in creating access to appropriate treatment.
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) organizes eating disorders into distinct diagnostic categories based on symptom patterns, behaviors, and clinical presentation. These diagnoses help clinicians identify the specific nature of someone’s struggles and tailor treatment accordingly.
How Did We Get Here? The Evolution of Eating Disorder Diagnoses
Eating disorders were first included in the DSM-III in 1980, which recognized anorexia nervosa and bulimia. The term “bulimia nervosa” was added in the DSM-III-R in 1987. For many years, these were the only two formal eating disorder diagnoses, with everything else falling under “Eating Disorder Not Otherwise Specified” (EDNOS). EDNOS became the most commonly diagnosed eating disorder at the time, revealing the limitations of narrow diagnostic standards. Individuals who were medically compromised and psychologically distressed often did not meet the specific thresholds required for anorexia nervosa or bulimia nervosa.
The DSM-5, published in 2013, brought substantial changes. Binge eating disorder was recognized as a standalone disorder, acknowledging that binge eating without compensatory behaviors represented a distinct clinical presentation. ARFID was added to capture feeding and eating problems not driven by body image concerns. EDNOS was replaced with OSFED and UFED, clarifying that “other specified” did not mean less severe. The DSM-5-TR, published in 2022, made additional refinements to diagnostic criteria. The organizational structure also shifted. Pica and rumination disorder had previously been categorized separately under disorders typically diagnosed in childhood rather than within the eating disorders chapter. The DSM-5 integrated them into the feeding and eating disorders section, recognizing that these conditions occur across the lifespan and share clinical features with other eating disorders.
Understanding this evolution matters because diagnostic frameworks shape access to care. When binge eating disorder lacked formal recognition, individuals struggled to receive insurance coverage for treatment. The removal of amenorrhea (loss of menstruation) from anorexia nervosa criteria corrected a substantial barrier that had prevented individuals assigned male at birth from receiving an accurate diagnosis. Diagnostic categories determine who gets identified and who receives treatment. Like it or not, they dictate whose suffering is taken seriously.
Anorexia Nervosa
Anorexia nervosa involves persistent restriction of energy intake relative to requirements, leading to significantly low body weight in the context of age, sex, developmental trajectory, and physical health. The diagnosis requires intense fear of weight gain or persistent behavior that interferes with weight gain, even at a considerably low weight. Individuals with anorexia nervosa experience disturbance in the way their body weight or shape is experienced, with self-evaluation unduly influenced by body weight or shape, or a persistent lack of recognition of the seriousness of the current low body weight.
The DSM-5-TR specifies two subtypes: restricting type, where weight loss is accomplished primarily through dieting, fasting, or excessive exercise, and binge-eating/purging type, where the individual regularly engages in binge eating or purging behaviors. Anorexia nervosa carries one of the highest mortality rates of all psychiatric disorders, with deaths resulting from medical complications of starvation and suicide. Medical consequences include cardiac abnormalities, bone density loss, electrolyte imbalances, and organ damage.
Bulimia Nervosa
Bulimia nervosa is characterized by recurrent episodes of binge eating paired with recurrent inappropriate compensatory behaviors to prevent weight gain. Binge eating involves consuming an amount of food that is definitively larger than what most individuals would eat in a similar period under similar circumstances, accompanied by a sense of lack of control. Compensatory behaviors may include self-induced vomiting, misuse of laxatives or diuretics, fasting, or excessive exercise. For diagnosis, both binge eating and inappropriate compensatory behaviors must occur, on average, at least once a week for three months.
Bulimia nervosa often involves a great deal of shame and secrecy, with behaviors frequently hidden from family members and friends. Medical complications can include electrolyte imbalances, gastrointestinal problems, dental erosion from repeated vomiting, and cardiac abnormalities. The cycle of restriction, binge eating, and compensatory behaviors creates both physical and psychological distress that reinforces symptom maintenance.
Binge Eating Disorder
Binge eating disorder involves recurrent episodes of binge eating without the regular use of inappropriate compensatory behaviors characteristic of bulimia nervosa. Binge episodes must occur, on average, at least once per week for three months. The diagnosis requires that binge eating is associated with at least three characteristics: eating much more rapidly than normal, eating until feeling uncomfortably full, eating large amounts when not physically hungry, eating alone due to embarrassment, or feeling disgusted, depressed, or guilty afterward.
Binge eating disorder is the most common eating disorder diagnosis and affects people of all genders across the weight spectrum. Unlike bulimia nervosa, it does not involve regular compensatory behaviors, though individuals may engage in repeated attempts at dietary restriction between episodes. Treatment addresses both the behavioral patterns of binge eating and the psychological factors that maintain the disorder, including emotional regulation difficulties and body image concerns.
Avoidant/Restrictive Food Intake Disorder (ARFID)
ARFID involves an eating or feeding disturbance manifested by persistent failure to meet appropriate nutritional and energy needs, resulting in marked weight loss or failure to achieve expected weight gain in children, significant nutritional deficiency, dependence on enteral feeding or oral nutritional supplements, or marked interference with psychosocial functioning. Unlike anorexia nervosa, ARFID does not involve disturbance in body image or fear of weight gain. The restriction may be based on sensory characteristics of food, concern about aversive consequences of eating such as choking or vomiting, or lack of interest in eating.
ARFID can begin in childhood and persist into adulthood, or develop later in life following a traumatic event related to eating. The disorder notably impacts nutritional status and daily functioning, with medical complications that can be severe depending on the nature and extent of restriction. ARFID often co-occurs with anxiety disorders, autism spectrum disorder, or attention-deficit/hyperactivity disorder.
Other Specified Feeding or Eating Disorder (OSFED)
OSFED applies when symptoms characteristic of a feeding and eating disorder cause clinically significant distress or impairment but do not meet full criteria for any of the specific feeding and eating disorders. Examples include atypical anorexia nervosa (all criteria for anorexia nervosa except weight remains within or above normal range despite considerable weight loss), bulimia nervosa of low frequency or limited duration, binge eating disorder of low frequency or limited duration, purging disorder (recurrent purging behavior without binge eating), and night eating syndrome (recurrent episodes of night eating after awakening from sleep or excessive food consumption after the evening meal).
OSFED is not a less severe category. Individuals with OSFED experience serious medical and psychological distress and require the same level of clinical attention as those meeting full criteria for other eating disorder diagnoses. The category captures clinically significant presentations that fall outside the specific parameters of named diagnoses, not to minimize their severity.
Unspecified Feeding or Eating Disorder (UFED)
UFED is used when symptoms cause clinically significant distress or impairment but do not meet full criteria for any specific feeding and eating disorder, and the clinician chooses not to specify the reason the criteria are not met. This diagnosis is typically used in emergency settings when there is insufficient information to make a more specific diagnosis. The distinction between OSFED and UFED matters primarily for clinical documentation. Both categories capture eating disorder presentations that cause real harm and require treatment, and neither should be interpreted as less serious or less deserving of intervention.
Additional Diagnoses: Pica and Rumination Disorder
Pica involves persistent eating of nonnutritive, nonfood substances over a period of at least one month. The behavior is inappropriate to the developmental level and not part of a culturally supported practice. Pica can occur across the lifespan and may be associated with intellectual disability, autism spectrum disorder, schizophrenia, or pregnancy, though it can also occur in individuals without these conditions. Rumination disorder consists of repeated regurgitation of food over a period of at least one month, where regurgitated food may be rechewed, reswallowed, or spit out. The behavior is not attributable to a gastrointestinal or other medical condition and does not occur exclusively during the course of anorexia nervosa, bulimia nervosa, binge eating disorder, or ARFID. Both disorders require medical evaluation and may involve serious medical complications.
Why Does Diagnosis Matter?
Diagnostic clarity guides clinical decision-making, helps predict medical complications, informs treatment planning, and facilitates communication among providers. Insurance authorization for treatment often depends on meeting specific diagnostic criteria, making accurate diagnosis essential for accessing care. However, many individuals experience symptoms that shift between diagnoses over time, and diagnosis should never determine whether someone receives treatment. Distress, impairment, and medical risk matter more than whether symptoms fit neatly into a named category. Recognition that all eating disorders are serious, regardless of diagnostic category or weight status, remains essential for reducing barriers to care and improving outcomes.
As the field continues to evolve, the American Psychiatric Association has shifted toward continuous updates to the DSM-5-TR rather than releasing full new editions, allowing diagnostic criteria to stay current with emerging research. Among the diagnoses being actively debated for potential inclusion in the eating disorder category is orthorexia nervosa, characterized by an obsession with “healthy” eating that causes significant impairment. These ongoing developments remind us that our understanding of eating disorders continues to deepen as we recognize new patterns of suffering and work toward better ways to help.If you or someone you care about is struggling with an eating disorder, know that help is available, and recovery is possible. Reach out to get started today.
