Eating disorder diagnostic criteria for DSM-V

The draft criteria for eating disorders in the upcoming (and much discussed) revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM) have been published this morning. The two most important changes are the listing of Binge Eating Disorder as a stand-alone diagnosis and the removal of the amenorrhea criteria for anorexia nervosa. There were other, more subtle changes that I will discuss in their own blog post a little later.

You can click here for the eating disorders section of the DSM draft criteria.

Here are the diagnosis as listed in the draft version:

Anorexia Nervosa

A. Restriction of food intake relative to caloric requirements leading to the maintenance of a body weight less than a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected).

B. Intense fear of gaining weight or becoming fat, even though underweight, or persistent behavior to avoid weight gain, even though underweight.

C. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.

Specify current type:

Restricting Type: during the last three months, the person has not engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas)

Binge-Eating/Purging Type: during the last three months, the person has engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas)

Bulimia Nervosa

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

(1) Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances

(2) A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
B. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, or diuretics.

C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months.

D. Self-evaluation is unduly influenced by body shape and weight.

E. The disturbance does not occur exclusively during episodes of anorexia nervosa.

Eating Disorder Not Otherwise Specified

(These aren't actual diagnostic criteria, just a discussion of the issues around EDNOS and how it might change based on other changes in ED diagnostic criteria.)

It is recommended that Binge Eating Disorder, described in this section of DSM-IV, be recognized as an independent disorder in DSM-5. Recommended changes in the criteria for Anorexia Nervosa, Bulimia Nervosa, and for eating and feeding disorders usually beginning in childhood should also reduce the need for Eating Disorder Not Otherwise Specified.

The work group is considering whether it may be useful and appropriate to describe other eating problems (such as purging disorder--recurrent purging in the absence of binge eating, and night eating syndrome) as conditions that may be the focus of clinical attention. Measures of severity would be required, and these conditions might be listed in an Appendix of DSM-5.

If these recommendations are accepted, the examples in Eating Disorder Not Otherwise Specified will be changed accordingly.

Binge Eating Disorder

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

1. eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances

2. a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)
B. The binge-eating episodes are associated with three (or more) of the following:

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
C. Marked distress regarding binge eating is present.

D. The binge eating occurs, on average, at least once a week for three months.

E. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior (i.e., purging) and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa

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Cathy (UK) said...

Thanks for posting these new criteria Carrie. I could write reams but I won't...

The main point I would make is that the criteria for AN still focus heavily (forgive the pun..) on weight and body image - suggesting cause and effect. In other words, the patients' behaviours are focused on getting/remaining thin.

Yet, some (many?) people with AN restrict food (and perhaps also purge and over-exercise) to regulate MOOD and to control anxiety. Sometimes being thin is simply the end-result of behaviours which the patient has become dependent upon to control mood.

So now people will continue to equate anorexia nervosa with that dreadful cliche 'dying to be thin'.


Kim said...

Very interesting. Thanks for posting as I don't know if I would have been aware otherwise. I'm glad they took out the amenorrhea criteria, as I think it's possible to be very sick and get a period. Have they always separated anorexia as restricting vs. binge eating/purging? I didn't know about that...

Kim said...

Also, I agree with Cathy that much of the focus on anorexia is still on weight/body image. Personally, I never related to this. Restricting for me was not about wanting to be thin, and I was never really afraid of getting fat. I felt like my anxiety went way down when I restricted, and I think that was the driver.

A:) said...

I still think they need a classification for AN in remission, etc. . .

When someone with AN regains enough weight to no longer meet the 85% criteria, but thoughts/eating/behaviours are still messed up, they may be on the way to recovery, but they are not recovered. Classifying these people as EDNOS is a diservice because it does not say anything about their past history and risk for relapse back into AN.

From what I have read, there is no one definition of what constiutes AN in partial remission or AN in remission vs, recovery.

Ideally it would be nice if it almost like being in remission from cancer -- where the ED patient is "in remission" for the first 2-3 years and then considered recovered afterward.


marcella said...

Perhaps we should stage an uprising! I agree, the concentration on ideas of shape and weight sounds wrong to me, and although it MUST be sensible to remove the necessity of amenorrhoea for diagnosis both because many women still menstruate at low weights and because ALL men never menstruate at any weight and yet can suffer from AN, apart from that there doesn't seem to be much improvement. I heard one definition of recovery as "an end to preoccupation about weight and shape" Well, apart from the cruel observation that people who die of the illness can therefore qualify as recovered, what about those who never had a preoccupation with weight and shape or for whom that was a minor side effect of the illness rather than a major factor. Does that mean they can't be sick. No way. Does it mean they aren't offered treatment? All too often.

Fugu Sushi said...

I think all criterias body shape related need to be removed. The APA is in the business of evaluating people's mental health, not in the business of telling people how much to weigh.

The way they phrase this "85% below normal weight" criteria makes it sound like they're encouraging EDNOS folks to try harder so they qualify for treatment and medical attention.

I know that's how I took it. I wasn't good enough of an anorexic so I needed to try harder so I can finally earn the label I felt I deserved.

CG said...

I'm still very confused about the difference between anorexia-binge/purge type, and bulimia....what do you think, Carrie?

Katie said...

Oh dear, non fat-phobic anorexics miss out on recognition again! I guess my diagnosis would still be as it was under DSM-IV, a-typical anorexia nervosa. It doesn't seem so a-typical to me though, I know a lot of other people now who were at anorexic weights for reasons other than a deathly fear of being overweight. Like Cathy ;) the things that kept me ill were very similar to hers.

C-G - I hope you don't mind my thoughts on the subject, but I know a lot of people with purging anorexia, and they tend to come in several different subtypes. All meet the weight criteria for anorexia, but either purge small or normal amounts of food without bingeing; mainly restrict but binge and purge occasionally; or binge and purge often multiple times a day and barely keep anything down aside from that. I think people with purging anorexia are different to people with 'typical' bulimia in that they suffer from all the medical and cognitive problems of being at a low weight AND all the medical complications of bingeing and purging. It's one of the most immediately medically dangerous sets of behaviours. People can live for decades at anorexic weights (although quality of life is pretty crappy) but bingeing and purging combined with being at a low weight often results in organ damage/failure very quickly.

I agree with A that there should be a remission diagnosis. It doesn't seem quite right that weight restored anorexics would be categorised as EDNOS somehow.

My, I'm opinionated today :P

Merricat said...

I don't think this helps, as long as BMI is still in the criteria for diagnosis. I also wonder at the wisdom of making such differences between all the eating disorders, since so many of us have different symptoms at different times in our lives. I think what often happens is when weight is restored, or doesn't ever get "too" low, not enough treatment is available or affordable, so the root of the problem, where all the food related behaviors are coming from, never really gets addressed, which is why eating disorders tend to be a lifelong challenge.
I don't have a better answer myself. Maybe when I've learned more and have some credentials I will, but for now I guess we'll have to work with the flawed system we have.

Jane Cawley said...

I was glad to see "refusal" removed from criteria A. The Rationale section reads: "The word “refusal” in DSM-IV was viewed as possibly pejorative and difficult to assess, as it implies intention. Rewording of the criterion to focus on behaviors is recommended."

The new wording of criteria B includes "OR persistent behavior to avoid weight gain, even though underweight" so fear of weight gain is not necessary for diagnosis. It seems they are attempting to consider non-fat phobic AN.
The Rationale section reads: "In DSM-IV, 'fear of weight gain' is required. A significant minority of individuals with the syndrome explicitly deny such fear. Therefore, the addition of a clause to focus on behavior is recommended."

Autumn said...

As a recovering ED-NOSer (ED-NOSee?) I am somewhat naively (no, optimistically! optimistically!) hoping that adding BED and removing the amenorrhea criterion will help clinicians understand ED-NOS more so that its sufferers will recognize themselves. I'm not sure where I stand on the continuum vs. on/off switch of eating disorders, but ED-NOS does qualify for treatment under my insurance, and others. So being diagnosed with ED-NOS after beginning physical recovery from anorexia does not necessarily mean that the care will end.

(I wrote more at length about this at

Katie said...

To Jane: it is criteria C which discounts non fat-phobic anorexics, not B - if diagnosis depends on the presence of all three criteria, at my worst I would have met A and B but not C. I did not perceive myself as overweight, my self esteem was not based on my weight and I knew that I was dangerously underweight and could suffer health problems. I don't mind being a-typical now because I'm weight restored and doing well, but on principle and for all the other non fat-phobic anorexics out there, I still object to criteria C not having something relating to the fact that not ALL anorexics are driven by a fear of being overweight.

Jane said...

I don't have any special wish to defend the DSM but I wonder if tweaking the "or persistent lack of recognition of the seriousness of the current low body weight" part of criteria C might help. It seems to me that if recognition of seriousness of low body weight doesn't outweigh drive to restrict then that's a problem (rather than an absolute blindness to the perils of low weight status.)

Katie said...

Good point, and I guess I'm being a bit pedantic - it just doesn't really capture the thought processes very well. Not that this revised definition will make any difference to my life or my recovery, but the constant barrage of messages that all anorexics want to emulate Victoria Beckham drives me right up the wall so it would be nice to see a real understanding of the different things that can drive anorexia. It doesn't matter in the grand scheme of things, it just bugs me!

Jane said...

I know what you mean.

eating disorder said...

If one should binge on food, let it be on fruits and vegetables. Doing so will be beneficial for the body because these foods are rich in essential nutrients, so it will not really harm much if you stock up on it.

Anonymous said...

The concern about including non-fat phobic self-induced starvation under AN is that people, for example, on political hunger strike, fussy eaters, people who are always rushing around too busy to eat or are just get too bored to eat, and more, would qualify for anorexia nervosa, even though the treatment and research they would need is vastly different.

Well, the solution should come from the word 'compulsive' in my opinion. Maybe in the first criterion. Not just 'restriction', but COMPULSIVE restriction would indicate that the person for whatever reason feels irrationally and specifically driven to not take action necessary for weight gain, as opposed to failing to take such action as a rational means to an end (e.g. hunger strike) or as a result of lack of motivation and cynicism about doctors' advice (e.g. those indifferent to and impatient with food), or as a result of avoiding sensory displeasure (e.g. fussy eaters). In none of the above cases is the starvation itself the compulsion, where there is a compulsion at all.

Underweight fussy eaters and people with phobias of swallowing or vomiting might be described as compulsively avoiding most food and trying new foods, but they're not compulsively STARVING because no aspect of starvation - neither body image, the euphoric neurological effects, nor self-esteem derived from self-control - is what compels the behaviour. Starvation is just a side effect.

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I'm a science writer, a jewelry design artist, a bookworm, a complete geek, and mom to a wonderful kitty. I am also recovering from a decade-plus battle with anorexia nervosa. I believe that complete recovery is possible, and that the first step along that path is full nutrition.

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