Eating Disorders in DSM-5: Trading Catch-All Diagnostic Categories for Precise Descriptions

Given that eating disorders cause pronounced psychological distress and physical, even life-threatening harm, we expect the changes to the Diagnostic and Statistical Manual of Mental Disorders to prove critical for many people.
08/23/2013 01:35pm ET | Updated October 23, 2013
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The most prevalent eating disorder in DSM-IV was "Eating Disorders -- Not Otherwise Specified." Never heard of it? Not familiar with the symptoms? You're not alone. This one-size-fits-most diagnosis became a default diagnosis, reflecting the inadequate criteria of DSM-IV's eating disorders chapter.

This wasn't an issue when DSM-IV was published in 1994, but our knowledge base of eating disorders advanced in the 20 years that have passed since then. And as the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was being developed, the goal was to make sure it reflected all the progress made in this field so that definitions and criteria would be as precise as possible.

Eating disorders affect millions of Americans, with a recent estimate suggesting that 4.4 percent will experience the disorder at some point in their lives. These disorders frequently occur along with other conditions, such as major depression, and are linked with suicidal behaviors. In fact, anorexia nervosa has the highest mortality rate of any mental disorder. More precisely representing and describing these symptoms and behaviors is instrumental to better care and treatment.

So that's where we focused our work.

The most impactful change was to add binge eating as a distinct, formal disorder. This condition was noted in the appendix of the previous manual, but extensive research now supports including it as a formal diagnosis. DSM-5 defines binge eating disorder as recurring episodes of eating substantially more food in a short period of time than most people would consume under similar circumstances, a pattern that provokes feelings of a lack of control and occurs regardless of whether the person is hungry. Individuals also may feel guilty, embarrassed or disgusted by their behavior, and they typically binge eat alone to hide what they are doing. The diagnostic criteria note that episodes must occur, on average, at least once a week over three months.

DSM-5's criteria distinguish binge eating disorder from the general phenomenon of overeating. True binge eating is much less common, far more severe and is associated with significant physical and psychological problems. For individuals with this disorder, it is crucial to give it the clinical attention it deserves.

We also adjusted the diagnoses of anorexia nervosa and bulimia nervosa to ensure that the criteria more precisely describe people with these disorders.

In DSM-5, the criteria for anorexia no longer specify amenorrhea, or the absence of at least three menstrual cycles. The past requirement was problematic because it excluded men or girls who hadn't started menstruating and women whose periods continued. (In some cases of anorexia, individuals exhibit all other relevant symptoms and signs but still report some menstrual activity.) In addition, in terms of weight maintenance, the word "refusal" was removed since it implied intention on the part of a patient and was difficult for clinicians to evaluate.

The new criteria for bulimia reduce the frequency of binge eating and compensatory actions such as self-induced vomiting from twice weekly to once a week. This revision better describes the symptoms and behaviors of the patients seeking help. In addition to these substantive changes, DSM-5 includes pica (a craving to eat non-food substances like paint or dirt), rumination and avoidant/restrictive food-intake disorder in this chapter. Avoidant/restrictive food-intake disorder replaces and extends the DSM-IV diagnosis of feeding disorder of infancy or early childhood to more accurately describe people with these symptoms. Research shows that the symptoms of this disorder can continue past childhood and can even occur in adulthood.

Given that eating disorders cause pronounced psychological distress and physical, even life-threatening harm, we expect the changes to prove critical for many people. They will benefit clinical care by minimizing catch-all diagnoses that often fall short when used in real-life circumstances to describe symptoms and behaviors. Doing so will facilitate more precise diagnosis -- always the first step toward more effective treatment -- and reduce the reliance on catch-all diagnoses.

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