Feeding and Eating Disorders

Definition

Feeding and Eating Disorders is a category of conditions in the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5).

Feeding and Eating Disorders included in this Entitlement Eligibility Guideline (EEG) are:

• Anorexia Nervosa
• Bulimia Nervosa
• Binge Eating Disorder

Feeding and Eating Disorders are characterized by a persistent disturbance of eating or eating related behavior that significantly impairs physical health or psychosocial functioning.

Criteria Sets for Feeding and Eating Disorders

The Feeding and Eating Disorder criteria sets are derived from the DSM-5.

Anorexia Nervosa:

Criteria 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 the minimally normal.

Criteria B

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

Criteria 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:

Restricting type: During the last 3 months, the individual has not engaged in recurrent episodes of binge-eating or purging behavior (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 3 months, the individual has engaged in recurrent episodes of binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas).

Bulimia Nervosa:

Criteria 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 2-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).

Criteria B

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

Criteria C

The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months.

Criteria D

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

Criteria E

The disturbance does not occur exclusively during episodes of Anorexia Nervosa.

Binge-Eating Disorder:

Criteria 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 2 hour-period), an amount of food that is definitely larger than what most people 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., 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 but not feeling physically hungry.
4. Eating alone because 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 3 months.

Criterion E

The binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in Bulimia Nervosa and does not occur exclusively during the course of Bulimia Nervosa or Anorexia Nervosa.

Diagnostic Standard

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

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

Note: Entitlement should be granted for a chronic condition only. For VAC purposes, "chronic" means the signs and symptoms of the condition have existed for at least six months. Signs and symptoms are generally expected to persist despite medical attention, although they may wax and wane over the six month period and thereafter.

Entitlement Considerations

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 do not cause a claimed condition. Predisposing factors are experiences or exposures which affect the individual's ability to cope with stress. Predisposing factors makes an individual more susceptible to developing the claimed condition. For example, the presence of a remote history of severe childhood abuse may be a predisposing factor in the onset of a significant psychiatric condition later in life.

Partial entitlement should only be considered for non-service related causal or aggravating factors.

Partial entitlement should not be considered for predisposing factors.

If it is unclear if a factor is a causal or aggravating factor versus a predisposing factor consultation with Medical Advisory is strongly recommended.

Note: The factors listed in Section A of the Entitlement Considerations include specific timelines for the clinical onset or aggravation of Feeding and Eating Disorders. The timelines are not binding. Each case should be adjudicated on the evidence provided and its own merits. If the medical evidence indicates an alternate timeline, consultation with Medical Advisory is strongly recommended.

Note: The following list of factors is not all inclusive. Factors, other than those listed in Section A, may be claimed to cause or aggravate a Feeding and Eating Disorder. Other factors may be considered based on the individual merits and medical evidence provided for each case. Consultation with Medical Advisory is strongly recommended.

1. Directly experiencing a traumatic event(s) within the two years before the clinical onset or aggravation of a Feeding and Eating Disorder

   Traumatic events include, but are not limited to:

   1. exposure to military combat
   2. threatened physical assault or being physically assaulted
   3. threatened sexual assault or being sexually assaulted
   4. being kidnapped
   5. being taken hostage
   6. being in a terrorist attack
   7. being tortured
   8. incarceration as a prisoner of war
   9. being in a natural or human-made disaster
   10. being in a severe motor vehicle accident
   11. killing or injuring a person in a non-criminal act
   12. experiencing a sudden, catastrophic medical incident
2. Witnessing, in person, 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:

   1. threatened or serious injury to another person
   2. an unnatural death
   3. physical or sexual abuse of another person
   4. a medical catastrophe in a close family member or close friend.
3. Experiencing repeated or extreme exposure to aversive details of a 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:

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

   Note: Factor 3 applies to exposure through electronic media, television, movies and pictures only if the exposure is 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 have a pervasive threat to life or bodily integrity including but not limited to:

   1. being under threat of artillery, missile, rocket, mine or bomb attack
   2. being under threat of nuclear, biologic or chemical agent attack
   3. 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:

   1. being socially isolated and unable to maintain friendships or family relationships, due to physical location, language barriers, disability, or medical or psychiatric illness
   2. 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
   3. having concerns in the work or school environment including: on-going disharmony 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
   4. 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
   5. having severe financial hardship including, but not limited to: loss of employment, long periods of unemployment, foreclosure on a property, or bankruptcy
   6. having a close family member or close friend experience a major deterioration in their health
   7. 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
7. Having a clinically significant psychiatric condition within the two years before the clinical onset or aggravation of a Feeding and Eating Disorder

   A clinically significant psychiatric condition is a mental disorder as defined in the DSM-5.

8. Having a 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 and Eating Disorder
9. Having experienced severe childhood abuse before the clinical onset of a Feeding and Eating Disorder

   Severe childhood abuse is:

   1. serious physical, emotional, psychological or sexual harm to a child under the age of 16 years; or
   2. neglect involving a serious failure to provide the necessities for health, physical and emotional development, or wellbeing of a child under the age of 16 years;

   where such serious harm or neglect has been perpetrated by a parent, a care provider, an adult who works with or around the child, or any other adult in contact with the child.

10. Inability to obtain appropriate clinical management of a Feeding and Eating Disorder

B. Medical Conditions Which Are to be Included in Entitlement/Assessment

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. If no conditions are listed for a category, all conditions within the category are included in the entitlement and assessment of a Feeding and Eating Disorder.

• Other Feeding and Eating Disorders
• Trauma - and Stressor-Related Disorders
• Anxiety Disorders
• Obsessive-Compulsive and Related Disorders
• Depressive Disorders
• Bipolar and Related Disorders
• Schizophrenia Spectrum and other Psychotic Disorders
• Personality Disorders
• Substance-Related and Addictive Disorders
• Dissociative Disorders
• Somatic Symptom and Related Disorders
  • Somatic Symptom Disorder
  • Illness Anxiety Disorder
  • Conversion Disorder
• Pain Disorders/Chronic Pain Syndrome (DSM-IV-TR Axis I Diagnosis)
• Sleep-Wake Disorders
  • Insomnia Disorder
  • Hypersomnolence Disorder
• Neurodevelopmental Disorders
  • Attention-Deficit/Hyperactivity Disorder
• Decreased Libido - if the medical information indicates decreased libido is a symptom of a psychiatric condition.

Separate entitlement is required for a DSM-5 condition not included in Section B of the Feeding and Eating Disorders Entitlement Eligibility Guideline.

C. Common Medial Conditions Which May Result in Whole OR in Part From a Feeding and Eating Disorder And/Or Its Treatment

Section C medical conditions may result in whole or in part as a direct result of a Feeding and Eating Disorder, from the treatment of a Feeding and Eating Disorder or the combined effects of a Feeding and Eating Disorder and its treatment.

Conditions listed in Section C of the Entitlement Considerations are only granted entitlement if the individual merits and medical evidence of the case determines a consequential relationship exists. Consultation with Medical Advisory is strongly recommended.

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:

1. The individual was receiving the medication at the time of the clinical onset or aggravation of the medical condition.
2. The medication was used for the treatment of a Feeding and Eating Disorder.
3. The medication is unlikely to be discontinued or the medication is known to have enduring effects after discontinuation.
4. The individual's medical information and the current medical literature support the medication can result in the clinical onset or aggravation of the medical condition.
5. Note: Individual medications may belong to a class, or grouping, of medications. The effects of a specific medication may vary from the grouping. The effects of the specific medication should be considered and not the effects of the group.

The list of Section C conditions is not all inclusive. Conditions, other than those listed in Section C, may be claimed to have a consequential relationship to a Feeding and Eating Disorder and/or its treatment. Other conditions may be considered for entitlement based on the individual merits and medical evidence provided for each case. Consultation with Medical Advisory is strongly recommended.

• Osteoporosis
• Dental Erosions

References For Feeding and Eating Disorders

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4^th ed. Text Revision ( DSM-IV-TR ) Washington: American Psychiatric Association, 2000.
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5^th ed. Text Revision ( DSM-5 ) Washington: American Psychiatric Association, 2013.
3. Australia. (2008). Statement of principles concerning eating disorder. No. 47 of 2008.
4. Australia. (2009). Amendment statement of principles concerning eating disorder. No. 47 of 2009.
5. Australia. (2008). Statement of principles concerning eating disorder. No. 48 of 2008.
6. Australia. (2009). Amendment statement of principles concerning eating disorder. No. 48 of 2009.
7. Stern. Massachusetts General Hospital Comprehensive Clinical Psychiatry. 1^st ed. Mosby, 2008.
8. Harrison, T. R. (2012). Harrison's principles of internal medicine 18^th ed. New York: McGraw-Hill Medical.
9. Canada. (2002). Entitlement Eligibility Guidelines for Osteoporosis. Veterans Affairs Canada.