Reflections on Obesity and DSM-5


Childhood Obesity News has been examining the premise that food addiction, in some form, under some nomenclature, should have been recognized in the latest edition of the Diagnostic and Statistical Manual (DSM-5). Okay, maybe calling food an addictive substance is not appropriate for whatever reason – perhaps because it is too vague or because the foods to which people become addicted are as mystifyingly diverse as chocolate and cheese. Dr. Pretlow has suggested that perhaps,

…overeating/obesity constitutes a behavioral addiction, where food’s pleasurable taste is the high, in conjunction with the displacement behavior of eating action. This is similar to gaming and gambling, where winning is the high, in conjunction with the displacement behavior of gaming and gambling action.

That idea is especially suggestive in conjunction with where gambling actually ended up in DSM-5: under the category heading of “Substance-Related and Addictive Disorders,” where it is the only member of the class “Non-Substance-Related Disorders.” In other words, even though gambling is not a substance, the disorder earned its place as a special case in the box where other substance-related disorders are cached. That is a stretch, but one that the creators of the book were comfortable with, while food addiction was left out in the cold.

It did not even get a spot under “Feeding and Eating Disorders,” along with anorexia and bulimia, where it might have appeared as an “Other Specified Feeding or Eating Disorder,” or even an “Unspecified Feeding or Eating Disorder.” But no. As Dr. Pretlow also remarked, “It’s a matter of semantics as to what constitutes addiction, and the addiction field is very much in flux.” In a spirit of academic cooperation, he began to consider whether we might be dealing with a Body-Focused Repetitive Behavior (BFRB).

BFRBs in DSM-5

In the book that is considered the Bible of the diagnostic art, the BFRB barely even exists. There is only a paragraph in a subsection of the “Obsessive Compulsive and Related Disorders.” The examples given are nail, cheek, and lip biting, mentioned here as “Other Specified Related Disorders.” In this section of DSM-5 where food addiction might conceivably have fit in, nail, cheek, and lip biting are described:

These symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Well, compulsive overeating certainly fits that description. When a person is prevented by obesity from occupying a school desk or an airplane seat, or from being a cousin’s bridesmaid or groomsman, or from getting a job, function is certainly impaired and distress is most definitely a result. Maybe this is where food addiction belongs.

But wait – here is an interesting detail. The book includes a couple of other conditions that could potentially apply. Under Movement Disorders, there is a “Stereotypic Movement Disorder.” Could the constant and repetitive motion of bringing food to the mouth be one of those?

Two other possibilities are even more promising, though neither has even made the book yet. Instead, they hang out at the end, among the 8 “Conditions for Further Study,” meaning they might make the grade someday. The two disorders are “Nonsuicidal Self-Injury” and, better yet, “Suicidal Behavior Disorder.” Why not?

Your responses and feedback are welcome!

Source: “DSM-5 Table of Contents,”, 2013
Source: “What the DSM-5 Says About: Body-Focused Repetitive Behaviours,” CanadianBFRB,org, 06/27/14
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About Dr. Robert A. Pretlow

Dr. Robert A. Pretlow is a pediatrician and childhood obesity specialist. He has been researching and spreading awareness on the childhood obesity epidemic in the US for more than a decade.
You can contact Dr. Pretlow at:


Dr. Pretlow’s invited presentation at the American Society of Animal Science 2020 Conference
What’s Causing Obesity in Companion Animals and What Can We Do About It

Dr. Pretlow’s invited presentation at the World Obesity Federation 2019 Conference:
Food/Eating Addiction and the Displacement Mechanism

Dr. Pretlow’s Multi-Center Clinical Trial Kick-off Speech 2018:
Obesity: Tackling the Root Cause

Dr. Pretlow’s 2017 Workshop on
Treatment of Obesity Using the Addiction Model

Dr. Pretlow’s invited presentation for
TEC and UNC 2016

Dr. Pretlow’s invited presentation at the 2015 Obesity Summit in London, UK.

Dr. Pretlow’s invited keynote at the 2014 European Childhood Obesity Group Congress in Salzburg, Austria.

Dr. Pretlow’s presentation at the 2013 European Congress on Obesity in Liverpool, UK.

Dr. Pretlow’s presentation at the 2011 International Conference on Childhood Obesity in Lisbon, Portugal.

Dr. Pretlow’s presentation at the 2010 Uniting Against Childhood Obesity Conference in Houston, TX.

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