Welcome Changes to Eating Disorders Diagnoses in the DSM-V

The Diagnostic and Statistical Manual of Mental Disorders, better known as the DSM, contains the definitions of and criteria for what its authors have determined to be every known psychiatric disorder. The DSM is periodically revised, and the current version, the DSM-IV-TR, is soon to be replaced by the DSM-V, scheduled for release in May.

The eating disorders category will be undergoing some big changes. In the current edition, eating disorders include anorexia nervosa (AN), bulimia nervosa (BN), and eating disorder not otherwise specified, aka EDNOS. Binge eating disorder (BED) is listed in the DSM-IV-TR appendix as a diagnosis designated for further study, and as a subset of EDNOS. In the DSM-V, the criteria for AN, BN, and EDNOS will be different, and binge eating disorder (BED) will be classified as a full-fledged disorder.

The good news about these changes is that the range of eating disorder categories has been expanded to include attitudes and behaviors that previously didn’t meet the criteria for an “official” eating disorder, and modified so that the diagnoses more accurately describe and reflect the experiences of individuals who have eating issues.

Here are some of the changes I believe to be important: First, in the first criterion for anorexia nervosa, the phrase beginning with “refusal to maintain body weight at or above a minimally normal weight for age and height” has been removed. This speaks to the misperception that people who have anorexia nervosa are choosing, of their own volition, to keep their weight in a certain range. Many of my clients say to me, “My [parents, siblings, friends, etc.] think I’m doing this on purpose. They don’t understand.” And certainly, to anyone who is close to someone with anorexia nervosa, the seeming insistence of the afflicted on remaining underweight is baffling and frustrating. But the change in this criterion more accurately reflects that this is not a matter of choice. The new criterion simply states that caloric restriction resulting in significantly low body weight occurs.

This leads to the next change: The criterion, “Intense fear of gaining weight or becoming fat,” references what is, for many who have anorexia nervosa, the driving force behind the behaviors that cause the resultant, dangerously low body weight. But there are some who have anorexia nervosa who don’t experience this fear, and so the phrase, “… or persistent behaviors that prevent weight gain, even though at a significantly low weight,” will be added. In my experience, although most of my clients who have anorexia nervosa are in the grips of extreme fear of weight gain and of becoming fat, there have been some who developed an aversion to or fear of taking in an adequate number of calories, but who don’t identify with the fear of gaining weight or getting fat. These clients have been over-focused on following rules about food that they believe to be “right,” even though they’re not getting enough, or exercising to relieve anxiety, even though they’re expending too much. So this new phrase recognizes their experience.

The third criterion, which pertains to body image, is slightly changed, again, to more accurately reflect the nonvolitional nature of the illness: The DSM-IV and DSM-V versions both begin: “Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation,” but the last part in the DSM-IV reads: “or denial of recognition of the seriousness of the current low body weight.” This will change to, “or persistent lack of recognition of the seriousness of the current low body weight.” I believe this is important because “denial” implies that the person in question is aware of the seriousness but intentionally does not acknowledge it, and the new language simply states the fact of the matter.

Also, the fourth criterion for anorexia nervosa, which pertains to cessation of menstruation, has been removed and will not appear in the DSM-V. This means women whose menses have been affected by the weight loss and inadequate nutrition but who still menstruate sometimes, women who are postmenopausal, and women whose periods are artificially generated by contraception or other hormonal interventions but who otherwise meet the criteria will no longer be excluded from a diagnosis of anorexia nervosa and instead given a diagnosis of EDNOS, as is currently the case, given the EDNOS criterion in the DSM-IV for meeting all criteria for AN except the cessation of menses criterion.

The dividing of anorexia nervosa into two subtypes, restricting and binge eating/purging, remains. This makes a distinction between anorexia nervosa and bulimia nervosa. This is important because of the common misconception that binging followed by purging (defined as self-induced vomiting, or laxatives, diuretics, or enemas) is always BN. Someone who meets the criteria for AN and who binges and purges does not have BN; he or she has AN, binge/purge subtype. This distinction informs the course of treatment, as someone with AN is functioning with an undernourished brain, and that brain usually is not capable of doing much of the work of therapy. The first line of treatment for someone with AN is to get him or her appropriately re-fed.

For BN, there are a few changes, all related to one another. One is the elimination of a distinction between “purging,” as referenced above, to rid the body of food, and “inappropriate compensatory behaviors,” e.g., exercising or fasting, to make up for the calories taken in. In the BN criteria in the DSM-V, the word “purge” has been purged, and only “inappropriate compensatory behaviors” are mentioned. There’s a reduction of frequency of binge/compensate episodes from an average of twice a week to once a week for at least three months. This means that people who haven’t “qualified” for the diagnosis because they didn’t binge and compensate often enough, and would thus have met the criteria for EDNOS rather than BN, will now be able to be diagnosed with BN. (One of the reasons this is important is that BN, as well as AN, is one of the nine “parity diagnoses” that, according to U.S. law, must be covered by insurance benefits equivalent to the benefits for physical ailments by insurance companies that offer mental health coverage.) And there will no longer be a criterion for “purging and nonpurging (that was the fasting, exercise, etc., piece) subtypes.”

The best news, from my point of view, is the inclusion of binge eating disorder. In the DSM-IV, since BED was classified as a diagnosis being studied for inclusion, the only “official” mention is the one criterion of EDNOS of binge eating without inappropriate compensatory behaviors. For years, I’ve worked with people who binge eat, but who don’t believe they have an eating disorder because they’re not underweight and they don’t make themselves throw up. Binge eaters often believe they are weak and just need more willpower, and it’s my hope that the addition of BED as an official diagnosis will reduce the shame of those who have it and increase the understanding of those who don’t.

The same criteria used in the DSM-IV for the provisional BED diagnosis will be used in the DSM-V. It describes binge eating as eating an unusually large amount of food in a given period, accompanied by a sense of lack of control over eating during the episode—like the eater couldn’t control the amount of food or stop eating. The eater must experience three out of five associated states:

  1. Eating much more rapidly than normal
  2. Eating until feeling uncomfortably full
  3. Eating large amounts of food when not feeling physically hungry
  4. Eating alone because of being embarrassed by how much one is eating
  5. Feeling disgusted with oneself, depressed, or very guilty after overeating

The binge eater must be very distressed about his or her binge eating, binges must take place at least twice a week for at least six months, and there must be no “inappropriate compensatory behaviors” following a binge.

I’ve read that the EDNOS category might be renamed as “feeding and eating conditions not otherwise classified.” It will comprise “atypical AN” (all the criteria for AN except the weight criteria having been met), “subthreshold BN” and “subthreshold BED” (BN or BED behaviors and attitudes that don’t occur long enough or often enough to meet the criteria of the full-blown disorder), “purging disorder,” i.e., inducing vomiting or using other inappropriate compensatory behaviors after eating a small amount of food or a regular meal, “night eating syndrome,” and “other feeding or eating condition not elsewhere classified.” Repeatedly chewing and spitting out food, which was listed in the DSM-IV EDNOS category, doesn’t seem to be appearing in the DSM-V. I’m a little puzzled as to why this is, as I’ve worked from time to time with clients who do this.

Research tells us what the impact of these changes will be, in terms of the number of people diagnosed with eating disorders. In a University of Florida study of 396 disordered eaters, researchers found that, using DSM-IV criteria, 14% had AN; while using DSM-V criteria, 20% had AN. Eighteen percent of subjects had BN using both DSM-IV and DSM-V criteria, but 68% had EDNOS using DSM-IV criteria; while using the DSM-V criteria, 8% had BED, and 53% had EDNOS. This tells us that the upcoming DSM-V changes will decrease the number of people diagnosed with EDNOS. (Int J Eat Disord. 2011 Sep;44(6):553-60. doi: 10.1002/eat.20892. Epub 2011 Feb 14.)

These changes reflect the progress that’s been made in understanding the complex nature of eating disorders. I hope this gives more access to sound information and effective treatment for those who need it.

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  • Leave a Comment
  • GRegina

    February 26th, 2013 at 4:10 PM

    This is such good news given that there are more and more women who are falling into these categories for diordered eating and yet have fallen into the trap of not being able to receive a correct diagnosis because they may not fit that traditional mold that others might view as having a problem. As society continues to glorify the notion that you can never be too thin I think that the numbers are only going to increase therefore it is supremely important that those who do struggle with this be able to put a name to it and get the help that they need.

  • eliza

    February 26th, 2013 at 10:55 PM

    excellent news.just the wording if the definition of a disorder can make so much difference.it would be sad if I had a disorder and the definition shifted the blame onto me although I was the sufferer.

    also what made me feel good was the inclusion of sub threshold bunge eating.because at times I have felt that I have binged but it doesn’t occur too often.so for someone like me I’m not going to be included in the general binge eating category and still can have access to treatment due to this new category.kudos to the new manual.

  • annika

    February 27th, 2013 at 3:48 AM

    Well, looks like all of us will be eligible for being pigeon holed now, because there is something in the new diagnosis spectrum for every woman alive!

  • randy

    February 27th, 2013 at 8:54 AM

    always goin’ to be room for improvement in the manual. and incorporating changes with new finds in research and in a changing society is what makes a dynamic and easy to follow guide. looks like the DSM is doin’ this pretty well right now.

  • Bex

    February 27th, 2013 at 11:20 AM

    I hope that those who treat within this area are aware of the changes that are being made. . .

    But more than that i hope that the insurance companies who find it within themselves to provide care and treatment for these illnesses will listen to the recommendations for treatment that will generally now have to be expanded and that they will expand their coverage as the need for such increases too

    Too bad though that a lot of this discussion must ultimately boil down to what will and will ot be covered so that families can afford to seek help

  • Nellie

    February 27th, 2013 at 12:59 PM

    Is this really going to make any difference? The problem is the same and the treatment will be the same. Mere wording is not going to help until and unless the actual treatment of the problem changes!

    For example, I did not know what the specific definition of anorexia nervosa is.They are changing it now and had I not read it here, I wouldn’t know the new definition either. The same would hold true even if I had anorexia nervosa myself. The wording just does not matter. It is visible only to the medical fraternity and not to the patient or the general public. That is why I think treatment is the most important aspect.

  • betty

    February 27th, 2013 at 11:36 PM

    just how quickly will these change run down into the clinicians offices? because no matter what changes formally make as long as the ground situation does not change the benefits cannot be reaped.

  • valerie h

    February 28th, 2013 at 8:56 AM

    I kind of agree with Nellie in that it is great that all of these new inclusions are there but just because they are in some manual, is this really going to increase the likelihood that someone who needs help will feel comfortable enough to ask fo it? It might give doctors a better giuideline for things that they should be looking for or questions that they should be asking, but I don’t think that it will increase the chances that someone will self report, not to a clinician anyway. The DSM is not something that most of the general public is going to familiar enough with for it to make any difference to them whether something has been added to it or not. With that said, I think that it is fabulous for the medical community but for the rest of us it really doesn’t touch us too much.

  • Dawson

    February 28th, 2013 at 10:53 PM

    Be happy about the new definitions? I am surprised & angry at the old definitions! Its ignorance if regular people blame a disorder on the sufferer but for experts to have written this manual and still done that – its criminal.

    I can only imagine what else this holy grail of mental health holds!

  • Seth

    March 1st, 2013 at 3:59 AM

    Do these new items address the presence of eating disorders in males and the ways that they can differ from that of women?

  • Emma

    March 1st, 2013 at 11:40 PM

    Didnt even know purging after a binge eating session was such a significant thing. Have done that quite a lot in my younger days but it was completely a voluntary thing with the stay slim fad. Not anymore but surprised it can be a disorder for people out there!

  • Lisa

    March 3rd, 2013 at 8:36 AM

    There are so many young women these day who have serious eating disorders that are either being ignored or going undiagnosed due to a lack of education, I am glad to read that this is being given more attention than it has been in the past. I hope that for some women this is going to make a difference in their lives that they may not have otherwise thought was possible.

    I find it to be very sad that there are so many lives that are ruined all for “beauty” and trying to measure up to what we believe society wants us to be. That and eating to stop some pain in our lives, we use food as a crutch and a salve. All of this is scary as the mom of young daughters who are so impressionable and who very much are aware of what others think about them and already are quite size and weight conscious.

  • Deborah Klinger, M.A., LMFT, CEDS

    March 3rd, 2013 at 9:36 AM

    Wow, thanks everyone for the comments! I had no idea that an article such as this would generate so much thought.

    Regina, Eliza, and Randy,I agree. I think the new criteria can help clinicians who don’t have specialized training in the diagnosis and treatment of disordered eating to better understand what constitutes an eating disorder and therefore what to be aware of when working with patients, and when to enlist treatment resources. And I believe that although most people aren’t familiar with the DSM definitions of eating disorders, the information will ripple out into the general population and serve to increase the understanding of eating disorders.

    Annika, I think that, rather than pigeonholing, the new criteria reflect a greater awareness of eating and body image problems that are indicative of serious emotional and mental concerns, and can, therefore, increase access to help for those concerns. The criteria aren’t about labeling people, they’re about defining the meaning of symptoms.

    Nellie, Betty and Valerie, the accessibility of help for people who suffered starts with treatment providers. Not all medical and mental health professionals understand eating disorders, and the new criteria will, I hope, increase their understanding so that help will be more available. And information is available to the public on lots of web sites that offer resources for finding help for disordered eating. But the increase in accuracy of the diagnostic criteria should increase treatment providers’ awareness, for example, pediatricians who treat adolescents, who will know what to look for. And treatment for some people who now meet the criteria for anorexia or bulimia but who didn’t before may now have insurance coverage that they didn’t with the criteria in the DSM-IV.

    Dawson, I understand your anger. I can only say that the old definitions expressed the general understanding of the symptoms of the illnesses at the time they were written. Eating disorders are baffling to the people in the sufferers’ lives, and the criteria were based, at least to some extent, I think, on the impressions that the sufferers’ behaviors made on others rather than the internal experience of the sufferer. The new criteria reflect increased understanding of the disorders.

    Seth, the definitions are gender-neutral. They apply to anyone, regardless of gender. I’ve worked with men (and at least one transgender person, in my recollection) who experience the same symptoms. For more information about men and eating disorders, I recommend the book, “Making Weight,” by Anderson, Cohn and Holbrook.

    Emma, I think your comment speaks exactly to the relevance of the updated diagnostic criteria: there are a lot of ideas and practices in our society that aren’t healthy, but are sometimes thought of as normal. The new DSM definitions, along with ongoing advocacy, can help to raise the consciousness of society as a whole. Case in point, last week was Eating Disorders Awareness Week, and there were EDAW-related activities on college campuses and in communities across the country.

    Much appreciation to all of you for a lively discussion!

  • lisa

    May 28th, 2013 at 3:56 PM

    Would just like to reply to whomever said that this only affected professionals and not the patients- this is rarely true with EDs. I’ve noticed a lot of us know the textbook definitions by heart!

    I have AN. When I was maybe 6 months into this hell, there was a point when I knew something was wrong- but I decided to wait until I got to 85% of my ideal weight to get help, I was afraid I wouldn’t be taken seriously. By the time I reached that, I also qualified for BN. Because I still had my period, I realized they would tell me I only had BN, which to me implied lack of control, so I decided to wait till I lost my period. 5kg later, I still had it. So I decided nothing was wrong, my body was working just fine, thank you very much.

    I know that part of this might be just called typical AN denial- but it’s nice when the diagnostic criteria don’t encourage it! The earlier you get help, the better- and I know of quite a few people with EDNOS who don’t get help because they “fail at even getting into a proper ED category”. It just pushed them to lose more weight. That’s just wrong.

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