Feeding and Eating Disorders

Diagnostic standard

A diagnosis from a qualified medical practitioner (family physician or psychiatrist), nurse practitioner, or a registered/licensed psychologist is required.

The diagnosis is made clinically. Supporting documentation should be as comprehensive as possible.

Clinical features

Feeding and eating disorders are complex psychiatric conditions and their development is dependent on multiple biological, psychological, and environmental variables. None of the considerations for a feeding and eating disorder alone is sufficient for the development of a feeding and eating disorder. These variables operate at various levels to contribute to the onset and progression of a feeding and eating disorder.

Biological considerations: Genetic factors strongly contribute to the development of both anorexia nervosa and bulimia. Genetic risk has also been shown in the co-occurrence of eating disorders with other psychiatric diagnoses.

Genes associated with other metabolic functions, including appetite and weight control, have also proven to be involved in eating disorder development and severity. The role of gut microbiota and immune system reactions in the development and continuation of eating disorders is an emerging field.

Hereditary patterns of eating disorders have been shown to disproportionately affect females. Females are associated with greater genetic risk for disordered eating than males.

Psychological considerations: Certain psychological factors (such as anxiety, perfectionism, and obsessive-compulsivity) are frequently associated with increased risk of eating disorders and may play a role in severity of symptoms, response to treatment, and risk of relapse. Individuals with eating disorders can have elevated levels of perfectionism accompanied by self-critical evaluation, impulsivity, and introversion.

Environmental considerations: There are childhood exposures, including, but not limited to, childhood abuse and trauma linked to the development of eating disorders.

Food insecurity may also be a predictor for disordered eating behaviours. Concerns about weight and shape, a drive for thinness, and internalization of a perceived ideal of thinness are key considerations and predictors in eating disorder development.

Bulimia is more common in females than males. Males are less likely than females to engage in purging behaviours and have a greater tendency to use excessive exercise or steroids as compensatory behaviours in response to binges. Males are less likely to seek treatment.

Binge-eating disorder is more common in females. There are no significant sex-related differences in the symptoms or course of binge-eating disorder.

Avoidant/restrictive food intake disorder is similar in males and females. Avoidant/restrictive food intake disorder co-occurs with autism spectrum disorder higher in males.

Criteria sets

The feeding and eating disorder criteria sets are derived from the DSM-5-TR.

This EEG provides the DSM-5-TR diagnostic criteria; however, the International Classification of Diseases 11^th Revision (ICD-11) is also considered an acceptable diagnostic standard.

Anorexia nervosa

There are three essential features of anorexia nervosa:

• persistent energy intake restriction
• intense fear of gaining weight or persistent behaviour that interferes with weight gain
• and a disturbance in self-perceived weight or shape.

The individual maintains a body weight that is below a minimally normal level for age, sex, developmental trajectory, and physical health. Individuals with anorexia nervosa typically display an intense fear of gaining weight or of becoming fat which is usually not alleviated by weight loss. Anorexia nervosa can result in significant and potentially life-threatening medical conditions.

Criteria set for anorexia nervosa

Criterion 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.

Criterion B

Intense fear of gaining weight or becoming fat, or persistent behaviour that interferes with weight gain, even though at a significantly low weight.

Criterion 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 whether:

• Restricting type: During the last three months, the individual has not engaged in recurrent episodes of binge-eating or purging behaviour, (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise.
• Binge-eating/purging type: During the last three months, the individual has engaged in recurrent episodes of binge-eating or purging behaviour, (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas).

Specify current severity:

• The minimum level of severity is based, for adults, on current body mass index (BMI) (see below) on BMI percentile. The ranges below are derived from World Health Organization (WHO) categories for thinness in adults. The level of severity may be increased to reflect clinical symptoms, the degree of functional disability, and the need for supervision.
  • Mild: BMI>/= 17kg/m²
  • Moderate: BMI 16 to 16.99 kg/m²
  • Severe: BMI 15 to 15.99 kg/m²
  • Extreme: BMI <15kg/m²

Bulimia nervosa

There are three essential features of bulimia nervosa:

• recurrent episodes of binge eating
• recurrent inappropriate compensatory behaviours to prevent weight gain
• and self-evaluation that is unduly influenced by body shape or weight.

Binge eating is defined as eating an amount of food that is definitely larger than most individuals would consume in similar time period under similar circumstances.  The binge eating tends to continue until the individual is uncomfortably, or even painfully, full.  Individuals with bulimia nervosa are typically within normal weight or overweight range.

Criteria set for bulimia nervosa

Criterion 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 two 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).

Criterion B

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

Criterion C

The binge eating and inappropriate compensatory behaviours both occur, on average, at least once a week for three months.

Criterion D

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

Criterion E

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

Binge-eating disorder

The essential feature of binge-eating disorder is recurrent episodes of binge eating that must occur on average, at least once per week for three months.

Binge eating is defined as eating in a discrete amount of time, an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances. The binge eating must be characterized by marked distress and a sense of lack of control. Unlike bulimia nervosa, binge eating episodes are not regularly followed by inappropriate compensatory behaviours aimed at preventing weight gain.

Criteria set for binge-eating disorder

Criterion 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 two hour period), an amount of food that is definitely larger than 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).

Criterion 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.

Criterion C

Marked distress regarding binge eating is present.

Criterion D

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

Criterion E

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

Avoidant/restrictive food intake disorder

Characteristics of avoidant/restrictive food intake disorder include:

• avoidance or restriction of food intake. This results in an insufficient intake of food to meet adequate energy or nutritional requirements, and therefore results in significant weight loss
• clinically significant nutritional deficiencies
• dependence on oral nutritional supplements or tube feeding
• marked interference with psychosocial (personal, family, social, educational, occupational) functioning.

This pattern of eating behaviour is not motivated by a preoccupation about body weight or shape. Restricted food intake and its effect on weight, other aspects of health, or functioning is not due to unavailability of food, not a manifestation of another medical condition or medical disorder, and is not due to the effect of a substance or medication on the central nervous system including withdrawal effects.

Criteria set for avoidant/restrictive food intake disorder

Criterion 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)
2. significant nutritional deficiency
3. dependance on enteral feeding or oral nutritional supplements
4. marked interference with psychosocial functioning.

Criterion B

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

Criterion 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.

Criterion 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.

Entitlement considerations

Section A: Causes and/or aggravation

Causal or aggravating factors versus predisposing factors

Causal or aggravating factors directly result in the onset or aggravation of the claimed psychiatric condition.

Predisposing factors make an individual more susceptible to developing the claimed condition. They are experiences or exposures which affect the individual's ability to cope with stress. For example, severe childhood abuse may be a predisposing factor in the onset of a significant psychiatric condition later in life. These factors do not cause a claimed condition. Partial entitlement should not be considered for predisposing factors.

Physical/constitutional symptoms are prevalent in people living with psychiatric diagnoses and are often associated with psychological distress. Physical and mental health symptoms frequently co-occur. Physical symptoms associated with psychiatric conditions are included in entitlement/assessment. However, once a symptom has developed into a separate and distinct diagnosis, the new diagnosis becomes a separate entitlement consideration.

For Veterans Affairs Canada (VAC) entitlement purposes, the following factors are accepted to cause or aggravate the conditions included in the Definition section of this EEG, and may be considered along with the evidence to assist in establishing a relationship to service. The factors have been determined based on a review of up-to-date scientific and medical literature, as well as evidence-based medical best practices. Factors other than those listed may be considered, however consultation with a disability consultant or medical advisor is recommended. 

The timelines cited below are for guidance purposes. Each case should be adjudicated on the evidence provided and its own merits.

Factors

1. Directly experiencing a traumatic event(s) within two years before the clinical onset or aggravation of a feeding and eating disorder.

   Traumatic events include, but are not limited to:

   • exposure to military combat
   • threatened or actual physical assault
   • threatened or actual sexual trauma
   • being kidnapped
   • being taken hostage
   • being in a terrorist attack
   • being tortured
   • incarceration as a prisoner of war
   • being in a natural or human-made disaster
   • being in a severe motor vehicle accident
   • killing or injuring a person
   • experiencing a sudden, catastrophic medical incident.
2. In-person witnessing of a traumatic event(s) as it occurred to another person(s) within the two years before the clinical onset or aggravation of a feeding and eating disorder.

   Witnessed traumatic events include, but are not limited to:

   • threatened or serious injury to another person
   • an unnatural death
   • physical or sexual abuse of another person
   • a medical catastrophe in a close family member or close friend.
3. Experiencing repeated or extreme exposure to aspects of traumatic event(s) within the two years before the clinical onset or aggravation of a feeding and eating disorder.

   Exposures include, but are not limited to:

   • viewing and/or collecting human remains
   • viewing and/or participating in the clearance of critically injured casualties
   • repeated exposure to the details of abuse and/or atrocities inflicted on another person(s)
   • dispatch operators exposed to violent or accidental traumatic event(s).

   Note: If the exposure under factor three is to electronic media, television, movies and pictures, the exposure must be work related.

4. Living or working in a hostile or life-threatening environment for a period of at least four weeks before the clinical onset or aggravation of a feeding and eating disorder.

   Situations or settings which threaten life or body include, but are not limited to:

   • being under threat of artillery, missile, rocket, mine or bomb attack
   • being under threat of nuclear, biologic or chemical agent attack
   • being involved in combat or going on combat patrols.
5. Experiencing a stressful life event within one year before the clinical onset or aggravation of a feeding and eating disorder.

   Events which qualify as stressful life events include, but are not limited to:

   • being socially isolated and unable to maintain friendships or family relationships, due to physical location, language barriers, disability, or medical or psychiatric illness
   • experiencing a problem with a long-term relationship including the break-up of a close personal relationship, the need for marital or relationship counselling, marital separation, or divorce
   • having severe financial hardship including, but not limited to, loss of employment, long periods of unemployment, foreclosure on a property, or bankruptcy
   • ongoing conflict with fellow work or school colleagues, perceived lack of social support within the work or school environment, perceived lack of control over tasks performed and stressful workloads, or experiencing bullying in the workplace or school environment
   • experiencing serious legal issues including being detained or held in custody, on-going involvement with the police concerning violations of the law, or court appearances associated with personal legal problems
   • having severe financial hardship including, but not limited to, loss of employment, long periods of unemployment, foreclosure on a property, or bankruptcy
   • having a close family member or close friend experience a major deterioration in their health
   • being a full-time caregiver to a family member or close friend with a severe physical, mental or developmental disability.
6. Experiencing the death of a close family member or close friend within one year before the clinical onset or aggravation of a feeding and eating disorder.

   Note: The relationship between individuals in a leadership role with subordinates should be considered akin to close family or friend.

7. Having a clinically significant psychiatric condition within two years before the clinical onset or aggravation of a feeding and eating disorder. A clinically significant psychiatric condition as defined by the DSM-5-TR is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion, regulation, or behaviour that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning.
8. Having a serious medical illness or injury which is life-threatening or which results in serious physical or cognitive disability within the two years before the clinical onset or aggravation of a feeding or eating disorder.
9. Inability to obtain appropriate clinical management of a feeding and eating disorder.

Section B: Medical conditions which are to be included in entitlement/assessment

Section B provides a list of diagnosed medical conditions which are considered to be included in the entitlement and assessment of feeding and eating disorders.

• All other feeding and eating disorders
• All other trauma-and stressor-related disorders
• Anxiety disorders
• Adjustment disorder
• Bipolar and related disorders
• Depressive disorders
• Dissociative disorders
• Neurodevelopmental disorders
  • Attention-deficit/hyperactivity disorder
• Obsessive-compulsive and related disorders
• Pain disorder (Diagnostic and Statistical Manual of Mental Disorders Fourth Edition-Text Revision [DSM-4-TR] Axis I Diagnosis)
• Posttraumatic stress disorder
• Personality disorders
• Schizophrenia spectrum and other psychotic disorders
• Sleep-wake disorders
  • Insomnia disorder
  • Hypersomnolence disorder
• Somatic symptom disorder with predominant pain (previously pain disorder in the DSM-4-TR)
• Substance use disorders

Note:

• If specific conditions are listed for a category, only these conditions are included in the entitlement and assessment of a feeding and eating disorder. Otherwise, all conditions within the category are included in the entitlement and assessment of a feeding and eating disorder.
• Separate entitlement is required for a DSM-5-TR condition not included in Section B of this EEG.
• Somatic symptom and related disorders, such as functional neurological symptom disorder (conversion disorder), somatic symptom disorder, illness anxiety disorder, and bodily distress disorder (ICD-11 diagnosis) are entitled separately and assessed on individual merits.

Section C: Common medical conditions which may result, in whole or in part, from a feeding and eating disorder and/or its treatment

Section C is a list of conditions which can be caused or aggravated by a feeding and eating disorder and/or its treatment. Conditions listed in Section C are not included in the entitlement and assessment of feeding and eating disorder. A consequential entitlement decision may be considered where the individual merits and the medical evidence of the case support a consequential relationship.

Conditions other than those listed in Section C may be considered; consultation with a disability consultant or medical advisor is recommended.

• Osteoporosis
• Perimolysis type of dental erosion

If it is claimed a medication required to treat a feeding and eating disorder resulted in whole, or in part, in the clinical onset or aggravation of a medical condition the following must be established:

• The medication was prescribed to treat the feeding and eating disorder.
• The individual was receiving the medication at the time of the clinical onset or aggravation of the condition being claimed to the medication.
• The current medical literature supports the medication can result in the clinical onset or aggravation of the condition being claimed to the medication.
• The medication use is long-term, ongoing, and cannot reasonably be replaced with another medication or the medication is known to have enduring effects after discontinuation.

Note: Individual medications may belong to a class of medications. The effects of a specific medication may vary from the grouping. The effects of the specific medication should be considered.

Links

Related VAC guidance and policy:

• Adjustment Disorder - Entitlement Eligibility Guidelines
• Anxiety Disorders – Entitlement Eligibility Guidelines
• Bipolar and Related Disorders - Entitlement Eligibility Guidelines
• Depressive Disorders - Entitlement Eligibility Guidelines
• Osteoporosis – Entitlement Eligibility Guidelines
• Posttraumatic Stress Disorder – Entitlement Eligibility Guidelines
• Schizophrenia - Entitlement Eligibility Guidelines
• Substance Use Disorders - Entitlement Eligibility Guidelines
• Pain and Suffering Compensation – Policies
• Royal Canadian Mounted Police Disability Pension Claims – Policies
• Dual Entitlement – Disability Benefits – Policies
• Establishing the Existence of a Disability – Policies
• Disability Benefits in Respect of Peacetime Military Service – The Compensation Principle – Policies
• Disability Benefits in Respect of Wartime and Special Duty Service – The Insurance Principle – Policies
• Disability Resulting from a Non-Service Related Injury or Disease – Policies
• Consequential Disability – Policies
• Benefit of Doubt – Policies

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