Understanding other types of eating disorders

The disorders explained below are not an indication of a less severe eating disorder; simply a different group of symptoms. Please still seek help if you are concerned about yourself or a loved one.   

About the DSM-5 

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a publication of the American Psychiatric Association. It is currently in its 5th edition. The DSM contains sets of diagnostic criteria (symptoms being experienced) grouped into categories (disorders) to assist clinicians with the effective diagnoses and care of people with mental health disorders. It includes the following criteria.

The most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) includes the following eating disordes:

  • Other specified feeding or eating disorder (OSFED)
  • Unspecified feeding or eating disorder (UFED)
  • Pica
  • Rumination disorder
  • Chewing and spitting (CHSP)

Other specified feeding or eating disorder (OSFED)

According to the DSM-5 criteria, to be diagnosed as having OSFED, a person must present with symptoms similar to other eating disorders but not meet the full criteria of, for example, anorexia nervosa or bulimia nervosa.

This does not mean that their illness should be taken any less seriously. People with OSFED still present with disturbed eating patterns and need to seek help from a health professional, such as a GP or psychologist, as soon as possible. 

A diagnosis might then be allocated that specifies a specific reason why the presentation does not meet the specifics of another disorder. These could be any of the following: 

  • Atypical anorexia nervosa — This is where all criteria are met for anorexia, except significant weight loss. The individual’s weight might be within or above the normal range. 
  • Binge eating disorder (of low frequency and/or limited duration) — When all of the criteria for BED are met, but binges happen less frequently than expected or have been occurring for less than three months. 
  • Bulimia nervosa (of low frequency and/or limited duration) — When a person has all the symptoms of bulimia but the binge eating and subsequent purging occurs at a lower frequency and/or for less than three months. 
  • Purging disorder — This is when a person eats what is considered a ‘normal’ amount of food (i.e. does not engage in binges or food restrictions) but still uses laxatives or self-induced vomiting to influence their weight or shape. 
  • Night eating syndrome — When someone either wakes up during the night to eat or consumes a lot of food just before going to bed, after their evening meal. Night eating syndrome is diagnosed when the behaviour cannot be better explained by environmental influences or social norms or by another mental health disorder (such as BED). 

Unspecified feeding or eating disorder (UFED)

According to the DSM-5, this category applies to where behaviours cause clinically significant distress or impairment of functioning, but do not meet the full criteria of any of the feeding or eating disorder criteria, nor resemble the disorders under OSFED.

This eating disorder diagnosis is broad and non-specific. It may be used by clinicians when they are unable to, or choose not to, specify why criteria are not met, including presentations where there may be insufficient information to make a more specific diagnosis (e.g. in emergency room settings).

Despite being a broad diagnosis, UFED is still a serious eating disorder that warrants attention and treatment.

Pica

According to the DSM-5, pica is the diagnosis given to someone who regularly and persistently eats non-food substances such as chalk, soap or paper for more than one month. It also extends to any edible items that hold no nutritional value, such as ice.

In order to be diagnosed with pica, GPs or psychologists will consider whether the eating behaviour is part of a culturally supported or socially normative practice, and if occurring in the presence of neurodevelopmental condition (e.g. autism), or during a medical condition (e.g. pregnancy), whether it is severe enough to warrant independent clinical attention.

The developmental level of the individual is also considered. For example, it is common for babies and toddlers to put non-food items into their mouths out of curiosity. Therefore, normally only children older than two will be diagnosed with pica. It is most common in children and some scientists have linked it to the nervous system, and have understood it as a learned behaviour or coping mechanism.

It can be difficult to identify people with pica, as they usually don’t avoid regular food and don’t typically have a desire for weight loss or to affect their shape. Often pica is only diagnosed when the items they have been eating cause other medical issues, such as cracked teeth, toxicity or infection.

Rumination disorder

According to the DSM-5, a person with rumination disorder will repeatedly regurgitate their food effortlessly and painlessly for more than a month. The regurgitated food may be re-chewed, re-swallowed, or spat out and it is not caused by a medical condition such as a gastrointestinal condition.

The key difference between rumination disorder and conditions like bulimia nervosa is that typically a person with rumination disorder won’t appear to make an effort to bring up their food and it can happen spontaneously or without intent. However, people with anorexia nervosa, bulimia nervosa, binge eating disorder or avoidant/restrictive food intake disorder may also have rumination disease.

Rumination disorder can lead to malnutrition, weight loss, damage to teeth and gums, and electrolyte disturbances if left untreated.

Chewing and spitting

Chewing and spitting (CHSP) is a form of disordered eating where someone chews food, but spits it out, rather than consuming it.

Often the food is high in salt, sugar or fat, or regarded by the person as ‘bad’ or ‘junk’ food. Chewing the food for some time and then spitting it out is seen as a way of enjoying the taste without gaining weight or consuming calories. CHSP can exist as a symptom of a diagnosed eating disorder, or as a separate form of disordered eating. CHSP is not widely recognised or researched, and people who engage in this behaviour can be reluctant to seek help due to guilt or shame.

Effects of chewing and spitting

Damage to digestive system – The sight, smell, thought and taste of food triggers the cephalic phase of gastric secretion, which prepares the body for digesting food. Even though the food is not swallowed, CHSP triggers this response increasing stomach acids, digestive enzymes and insulin. When the food is not digested, the stomach acid can damage the stomach lining, causing ulcers. Insulin levels are also affected, which may potentially lead to weight gain and an altered metabolism.

Damage to teeth and mouth – Like bulimia, CHSP can also lead to dental problems, such as tooth decay and cavities. Excessive chewing can also cause swollen salivary glands.

Malnourishment – CHSP can lead to malnutrition if insufficient calories or nutrients are consumed. Many people who engage in chewing and spitting actually gain weight. This can be as a result of increased likelihood of binging on the “forbidden” foods, or unintentionally consuming extra calories. It may also be caused by the increase in insulin released into the body.

Social isolation – CHSP can be an addictive and uncontrollable behaviour that is very difficult to stop. It can lead to social isolation and feelings of guilt and shame.

Financial – CHSP can lead to financial difficulties due to the large quantities of food that are purchased but not consumed.