9.5 Eating, Neurodevelopmental, and Neurocognitive Disorder Indicators (DSM-5-TR)

9.5 Eating, Neurodevelopmental, and Neurocognitive Disorder Indicators (DSM-5-TR)

Quick Answer: Three lifespan-spanning families appear here: eating disorders (frequency and BMI thresholds), neurodevelopmental disorders (ADHD's 6-symptom, 6-month, 2-setting rule; autism's social-communication plus restricted-behavior structure; severity levels), and neurocognitive disorders (the delirium-vs-dementia differential the exam tests relentlessly with older adults).

Why This Matters for the ASWB Clinical Exam

Assessment and Planning covers the "mental and emotional illness indicators throughout the lifespan." Eating disorders are most often first diagnosed in adolescence and young adulthood; neurodevelopmental disorders in childhood; neurocognitive disorders in older adults. The exam tests whether you can apply the precise DSM-5-TR thresholds across these age groups and distinguish a reversible delirium from a progressive dementia in an older client.

Eating Disorders

Anorexia Nervosa

Anorexia nervosa (AN) requires:

1. Restriction of energy intake relative to requirements, leading to significantly low body weight in the context of age, sex, developmental trajectory, and physical health.
2. Intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain, even at significantly low weight.
3. Disturbance in the way one's body weight or shape is experienced, undue influence of body weight/shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.

Subtypes are restricting type (no recurrent binge-eating or purging in the past 3 months) and binge-eating/purging type. Severity for adults is based on BMI:

For children and adolescents, corresponding BMI percentiles are used. Severity may be increased to reflect clinical symptoms, functional disability, or need for supervision. DSM-5-TR removed the amenorrhea criterion (already removed in DSM-5) and refined the specifiers.

Bulimia Nervosa

Bulimia nervosa (BN) requires:

1. Recurrent episodes of binge eating (eating, in a discrete period, an amount larger than most would eat and with a sense of lack of control).
2. Recurrent inappropriate compensatory behavior (vomiting, laxatives, diuretics, fasting, excessive exercise) to prevent weight gain.
3. Both occur, on average, at least once a week for 3 months.
4. Self-evaluation is unduly influenced by body shape/weight.

Severity (DSM-5-TR) is based on average weekly compensatory episodes: mild 1–3, moderate 4–7, severe 8–13, extreme 14+.

Binge-Eating Disorder

Binge-eating disorder (BED) requires recurrent binge episodes (lack of control, larger than typical) at least once a week for 3 months, marked distress, and the absence of regular compensatory behavior. Severity is based on weekly binge episodes: mild 1–3, moderate 4–7, severe 8–13, extreme 14+.

Other Feeding and Eating Disorders

• Avoidant/restrictive food intake disorder (ARFID)—avoidance of certain foods based on sensory sensitivity, fear of aversive consequences, or lack of interest, leading to nutritional deficiency, weight loss, dependence on supplements, or impaired psychosocial function. No body-image disturbance.
• Rumination disorder—repeated, effortless regurgitation (not vomiting) for at least 1 month, not solely during AN, BN, BED, or another medical condition.
• Pica—persistent eating of nonnutritive, nonfood substances for at least 1 month, developmentally inappropriate and not culturally sanctioned.

Neurodevelopmental Disorders

Attention-Deficit/Hyperactivity Disorder (ADHD)

ADHD requires 6 or more symptoms of inattention and/or 6 or more of hyperactivity-impulsivity (5+ for ages 17 and older) for at least 6 months, inconsistent with developmental level; onset of several symptoms before age 12 (a DSM-5 change from the prior age-7 threshold); symptoms present in two or more settings; and clear interference with or reduction of functioning. Specifiers are combined presentation, predominantly inattentive presentation, and predominantly hyperactive-impulsive presentation.

Autism Spectrum Disorder (ASD)

ASD requires persistent deficits in social communication and social interaction across multiple contexts (social-emotional reciprocity, nonverbal communication, relationships) plus restricted, repetitive patterns of behavior (at least two of: stereotyped movements/speech/objects, insistence on sameness/rituals, restricted interests, hyper- or hyporeactivity to sensory input). Symptoms must be present in early childhood (DSM-5-TR clarifies that they may not manifest fully until demands exceed capacity) and collectively limit everyday functioning. Severity levels specify support needs:

Intellectual Disability and Specific Learning Disorder

Intellectual disability requires deficits in intellectual functions (reasoning, problem-solving, planning, abstract judgment, academic learning, learning from experience) confirmed by clinical assessment and IQ testing; deficits in adaptive functioning across conceptual, social, and practical domains; and onset during the developmental period. Severity is mild, moderate, severe, or profound, based on adaptive functioning, not IQ alone. DSM-5-TR retains the term intellectual disability (replacing the older "mental retardation").

Specific learning disorder requires difficulties in at least one academic domain (reading, written expression, mathematics) for at least 6 months despite targeted intervention, with skills substantially below age expectations.

Tic Disorders and Tourette's

Tourette's disorder requires multiple motor tics and at least one vocal tic, present for at least 1 year, with onset before age 18, not exclusively during substance use or medical condition. Persistent (chronic) motor or vocal tic disorder requires a single tic type for at least 1 year. Provisional tic disorder lasts less than 1 year.

Neurocognitive Disorders

Delirium vs. Major and Mild Neurocognitive Disorder

The central exam differential: delirium is an acute, fluctuating disturbance in attention and awareness, developing over hours to days, often reversible, and caused by a medical condition, substance intoxication/withdrawal, or medication. Major neurocognitive disorder (major NCD) is an acquired, significant cognitive decline from a previous level in one or more domains (complex attention, executive function, learning/memory, language, perceptual-motor, social cognition) that interferes with independence in everyday activities. Mild neurocognitive disorder (mild NCD) is a modest cognitive decline that does not interfere with independence.

Etiological Subtypes of Major NCD

• Alzheimer's disease—insidious onset and progressive course, most common cause of dementia.
• Vascular neurocognitive disorder—cognitive decline following cerebrovascular disease, often stepwise.
• Major frontotemporal NCD—progressive decline in executive function or language with personality/behavior changes earlier than memory deficits.
• Lewy body neurocognitive disorder—fluctuating cognition, recurrent detailed visual hallucinations, and spontaneous parkinsonism.
• Subtypes also include traumatic brain injury, substance/medication-induced, HIV, Huntington's, prion, Parkinson's, and other etiologies.

Neurocognitive Indicators in Older Adults

For older adults, the assessment must rule out reversible causes (medication effects, infection, dehydration, hypothyroidism, B12 deficiency, depression sometimes called "pseudodementia") before concluding a progressive NCD. The Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) are common cognitive screens, but the diagnostic decision is clinical and requires considering baseline function, course, and medical comorbidities.

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A 16-year-old girl presents with a 6-month history of restricting food, a 12-pound weight loss, intense fear of gaining weight, and a distorted belief that she is "fat" despite a BMI of 16.5. She has no binge or purging behavior. The correct DSM-5-TR assessment is anorexia nervosa, restricting type, moderate severity (BMI 16–16.99), with appropriate medical monitoring and referral to specialized eating-disorder care.