Changes to the Diagnostic Criteria for Eating Disorders: From DSM-IV-TR TO DSM-V

The chapter on Feeding and Eating Disorders in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) includes quite a few changes from the previous fourth edition (DSM-IV-TR) to better represent the symptoms and behaviours of patients dealing with these conditions. The DSM V criteria can be reviewed here.  The most substantial changes include the recognition of Binge-Eating Disorder as its own disorder, revisions to the diagnostic criteria for Anorexia Nervosa and Bulimia Nervosa and inclusion of Pica, Rumination and Avoidant/Restrictive Food Intake Disorder.

The Addition of Binge-Eating Disorder

Probably the most significant change made in relation to eating disorders in the new DSM-V is the addition of Binge-Eating Disorder as its own category of eating disorder. In the previous DSM-IV Binge-Eating Disorder was not recognised as its own disorder but instead was described in an Appendix and was only diagnosable through the use of the category “Eating Disorder Not Otherwise Specified”. Therapists and researchers were commonly finding that a huge number of people with eating disorders didn’t fit into either of the DSM-IV categories of Anorexia Nervosa or Bulimia Nervosa. Because of this, by default many would receive a diagnosis of “Eating Disorder Not Otherwise Specified”, although studies have suggested that a significant number of individuals in that “not otherwise specified” category may actually have Binge-Eating Disorder. Binge-Eating Disorder being listed now as a disorder of its own, has huge clinical implications in terms of accessing treatment for people who may have previously suffered from a condition that might have been considered to be “gluttony” and associated with “moral weakness”. This welcome addition plays an important part in helping people to realise that the unusual symptoms they are experiencing are actually symptoms of a psychological illness. Although this can be confronting, it can also help sufferers to realise that what they are experiencing is normal in the scope of the disorder and inspires hope knowing there is evidence based treatment for this condition.

The inclusion of Binge-Eating Disorder in DSM-V raises awareness of the differences between Binge-Eating Disorder and simply overeating. While overeating is a concern for many people recurrent binge eating is much less common, far more severe and is associated with significant physical and psychological problems. This recognition and awareness will no doubt extend to the domain of research, and with the new separate diagnosis of Binge-Eating Disorder, will hopefully come much needed research attention to the disorder.

Changes to Anorexia Nervosa

The anorexia nervosa criteria have had a few minor but important changes:

  • Criterion A focuses on behaviours such as restricting calorie intake, and no longer includes the word “refusal” in terms of weight maintenance since that implies intention on the patient’s behalf, which can be difficult to assess. The wording of the criterion has also been changed for clarity, and guidance for how to judge whether an individual is at or below a significantly low weight is now provided in the text.
  • Criterion B is expanded to include not only overtly expressed fear of weight gain but also persistent behaviour that interferes with weight gain.
  • The DSM-IV Criterion D requiring amenorrhea or the absence of at least three menstrual cycles has been removed. This criterion has been removed for a few reasons. These include the fact that it cannot be applied to males, pre-menarchal females, females taking oral contraceptives or post-menopausal females. Another reason for the removal of the criterion is that some individuals exhibit all other symptoms and signs of Anorexia Nervosa, yet still report some menstrual activity. These individuals can now meet a diagnosis of Anorexia Nervosa, even though they are still experiencing menstrual activity.

Changes to Bulimia Nervosa

The revised DSM-V criteria reduce the frequency of binge eating and compensatory behaviours (i.e. purging) that people with a diagnosis of Bulimia Nervosa must exhibit. The frequency of these behaviours has been reduced to once per week from twice weekly as specified in the DSM-IV. This is a small, but important change for sufferers of Bulimia Nervosa, as the criteria now allow for those with less frequent (once per week) bingeing and compensatory behaviours to still meet a diagnosis of Bulimia Nervosa.

Addition of Pica and Rumination Disorder

In addition to the inclusion of Pica and Rumination Disorder to the Feeding and Eating Disorders chapter of the DSM-V, the diagnostic criteria for both have been revised for clarity, and to allow for diagnoses of individuals of any age.

Avoidant/Restrictive Food Intake Disorder

Previously known as Feeding Disorder of Infancy or Early Childhood in the DSM-IV, Avoidant/Restrictive Food Intake Disorder has been renamed and the diagnostic criteria have been significantly expanded. The DSM-IV disorder was rarely used, and a limited amount of information is available on the characteristics, course and outcomes of children with this disorder. In addition, a large number of individuals (primarily, but not exclusively children and adolescents) substantially restrict their food intake and experience significant associated physiological or psychosocial problems; however do not meet criteria for any DSM-IV eating disorder. The revisions to Avoidant/Restrictive Food Intake Disorder are intended to create a broad category that captures this range of presentations.

Other Specified Feeding and Eating Disorder

Brief descriptions and preliminary diagnostic criteria are now provided for several conditions under this category. However, insufficient information about these conditions is currently available to document their clinical characteristics and validity or to provide definitive diagnostic criteria.

Overall Changes

The changes made in the DSM-V were intended to minimise the use of the “catch-all” diagnoses of Other Specified Feeding and Eating Disorder, and Unspecified Feeding and Eating Disorder. Primarily, the goal is for more people experiencing eating disorders to have a diagnosis that describes their symptoms and behaviours as accurately as possible. Being able to determine an accurate diagnosis is an important first step for clinicians and patients in defining and implementing a treatment plan.

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