Updated DSM-V Draft Criteria

I blogged about the changes to the DSM-V criteria for eating disorders here and here when they were announced in February. I posted the original draft criteria in my blog the day they were announced, so you can refer to them for the changes. And there were two- two MAJOR changes that has me rather excited. I submitted my blog posts to the APA website per their request for comments, and let's just say that our voices have made a difference.

First major change

The "85%" weight criteria for anorexia has been dropped. It has been replaced with the word "markedly" and the new criteria reads as follows:

Restriction of energy intake relative to requirements leading to a markedly low body weight. Markedly low weight is defined as a weight that is less than minimally normal, or, for children and adolescents, less than that minimally expected for age and height.

Which is good, because a low body weight for one person may be normal for another, and the 85% criteria assumes that there is one "ideal" body weight for all 6.5 billion of us.

Second major change

The Eating Disorder Workgroup has changed the definition of "purging" in bulimia nervosa to include fasting, excessive exercise, and abuse of medications. They eliminated the difference in DSM-IV between purging/non-purging bulimia nervosa and just lumped them all in together. The new explanation of purging for BN reads as follows:

Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications, fasting; or excessive exercise.

You can still comment on the altered criteria until April 20.

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Cassidy said...

I'm doing an insane happy dance here! I'm so happy that they see the logic in these changes and just wish the new dsm was coming out sooner.

Carrie Arnold said...

I'm glad to hear that they listened to the comments and feedback from the community and actually took that into account.

Science can be so slow- I feel your frustration!

esqueci a ana (ex-ana) said...

Really really good news. Congratulations to you and thanks for let us know.
I will post the information (update) in my Portuguese blogue.

Mamie said...

That's amazing news. Defining anorexia as dropping to a certain percentage of body weight is just insane, and I'm glad that's finally acknowledged. There's so much more to eating disorders than numbers. I hope the focus on anorexia moves even more away from the actual weight to the horrible disordered thinking that underlies it all- that's the real disease. Thanks for this great update!

Melissa said...

I'm happy in the sense that I know this is a good development for thousands of people and for the treatment of eating disorders in general.
But it's hard to separate that from my personal disappointment. By "moving the target" of diagnosis, I can't really consider myself a "recovered" anorexic anymore. It means that if this gets published in the DSM-V, I'll just have moved from the anorexia category to the bulimia category. And that's damn depressing.

Melissa said...

Or maybe I'm just an asshole to've held so tightly to the idea that "you can't be bulimic if you've never thrown up on purpose." ;)

Anonymous said...

I don't like it. Isn't there some concern over pathologizing normal? I have worked hard to recover from anorexia but my weight is still lower than "minimum normal" (though not 15% lower). I don't like the fact that, when this takes effect, I will go from recovering back to anorexic. And it's not just a mental thing- I am a professional and having a mental health diagnosis has to be disclosed to my licensing agency (it could prevent me from working). IMO, we already had EDNOS for people who were not extremely low weight but who had distress. Anorexia should remain a diagnosis for the emaciated. The only real benefit to this is appeasing people who crave the anorexia diagnosis and that, in and of itself, is pathological behavior. The DSM should not pander to it.

Cassidy said...

In response to the last anon. quote,

The tough thing with that is that insurance companies and doctors aren't necessarily required to provide the same benefits and treatment to those who miss one of the AN criteria.

And in response to your personal thing, unless you meet all of the other requirements you wouldn't automatically 'jump' back into the AN category.

These changes are still shifting and won't be official for a long time anyway.

Angela Elain Gambrel said...

I noticed the draft criteria also dropped amenorrhea as a requirement for AN diagnosis (unless I am reading it wrong.) I have known many people with anorexia who still got their period at a very low weight, and had one friend who became pregnant at 90 pounds.

I also am happy the DSM-V is dropping the 85 percent. For one thing, who decides the 85 percent? There are so many charts out there which say you should weigh this for this height, and some of these charts throw in age. I can imagine it can get very confusing for the clinician, and I have heard of some people who have had to lose weight, i.e. get sicker, before being able to receive treatment because their insurance would not pay for EDNOS but would for treatment for anorexia or bulimia.

@Anonymous - I have to respectfully disagree that "anorexia should remain a diagnosis for the emaciated." Who defines emaciation? I can understand your feelings; my diagnosis was changed to EDNOS when I became weight-restored and it pained me to be re-diagnosed with anorexia after my recent relapse. It almost felt like a downgrade, like recovery never happened and I was back at square one (although I was assured I wasn't.)

I really hope this means treatment providers can focus on the real issues surrounding eating disorders, and stop the focus on numbers numbers numbers!

Red said...

Thank you for posting this! It is exciting to see so many steps towards increasing the awareness of how broad these categories actually are.

The one thing I am surprised about is "excessive exercise" being listed as BN. I still think that is hazy (would it belong under AN if the person still severely restricted their intake and didn't binge?).

This is a huge step towards increasing insurance coverage for so many caught in the many medical loopholes!

Anonymous said...

I am Anon at 5:31. I don't mean to discount the importance of insurance coverage but, TBH, I don't think this will have any affect on insurance treatment for a few reasons:

1. Even under the DSMIV, the 85% IBW measure is only a suggestion. It is preceded by the term "e.g.," which means "for example." Even so, insurance companies typically require 85% or less of IBW for intensive treatment. To me, this means that the insurance companies are going to interpret the new guidelines just as they did the old ones - requiring very low body weight, beginning at 85% of IBW or less.

2. 75- 85% of IBW - i.e., the point at which most professionals agree emaciation starts - is when weight, alone, begins to make people medically unstable. This is verified by the APA practice guidelines, which indicate hospitalization/IP for people whose body weight drops below 75% of IBW. It is this APA guideline, and not the DSM anorexia criteria, that most commonly determines whether insurance companies will pay for IP. In other words, a diagnosis of anorexia isn't enough to get someone IP now, and it's not going to be enough when the DSMV comes out. Weight will still matter because weight still is an indicator (not the only one, but it is highly relevant) of medical instability.

3. I guess it is possible the new criteria will help a small number of people who are now EDNOS, who have a BMI of 17.5-19.9, and who have coverage for anorexia but not EDNOS get ordinary, out-patient treatment. I think it is more likely, though, that an insurance company that wants these folks excluded from OP care will alter their criteria (eg, anorexia diagnosis and less than 85% IBW) to make this happen. And they will be able to because the big driver, under mental health parity, remains medical instability. Regardless of the DSM criteria, medical literature and research on the weight at which medical instability begins is going to remain the same, and this is what the insurance companies care about.

So, insurance notwithstanding, I still think the only real "reason" for this change is to appease people who see the 17.5/15% IBW threshhold as some sort of sick goal for which to strive. Maybe I'm wrong- but I wouldn't count on insurance companies suddenly deciding to cover more people just because the DSM has decided to increase the low weight threshold. I further note that, because underweight remains a diagnostic criteria (and the DSM doesn't say anything about "underweight for you," it still is couched in terms of medically underweight) those who strive for the magic AN label are still going to have a weight goal, it will just ostensibly be higher.

Carrie Arnold said...


Part of the reason for dropping the "85%" criteria was that insurance companies don't use it as a guideline- I've been kicked out of IP treatment (and PHP) the moment my weight hit 85%, and I've been denied residential coverage because I was slightly above the 85% threshold, nevermind that I was rapidly losing weight, purging multiple times daily, in and out of the ER several times a week, and my heart was f*cked to high hell. Insurance didn't think treatment was "medically necessary." Would an actual AN diagnosis have helped? Possibly. Would I have lived to receive that diagnosis? I don't know.

* said...

Awesome! Congrats!

A:) said...

I seriously doubt AN will suddenly become a disease of "normal weight individuals." Markedly underweight does not mean 19 or 20 in most cases. Get a grip.

This just simply means there is a little more leninecy as to diagnosing people with AN -- there is no longer the magic 85% threshold and instead, it is more focused on personal IBW, etc.

This already happens in Canada anyway. My psychiatrist will diagnose an individual with AN if she has a BMI of 18, IF she is displaying other symptoms of AN. It seems ridiculous to treat someone as ED-NOS at 87%

Similarly, I think this has more effect for people who have ALREADY been diagnosed. Moving away from the numbers is important because this is a PSYCHIATRIC illness. If weight exists on a distribution, it is stupid to base diagnosis on an 85%/17.5 threshold ESPECIALLY now that there are the complications of older women (with higher average body weights), men and very young childrne suffering from AN.

I don't know much about insurance but policy probably won't change. But Anon -- when has diagnosis ever been dependant on INSURANCE companies? DSM is international -- whether the insurance companies in the US recognize it or not, it does not bear on the validity of diagnosis.

Medical instability may occur at 75-85% IBW, but since when was medical instability a criteria for AN? We are talking about marked reduction of BODY WEIGHT, independant of medical stability. AN individuals do not strive to lose their "medical stability."

A diagnosis of diabetes does not require someone to be in a diabetic coma to be sufficiently "sick."

Does this pander to individuals with the goal of attaining "anorexic" status. Maybe -- but I would think that these individuals would NOT be diagnosed with AN by a good psychiatrist but SOME other psychiatric disorder or ED-NOS just on the basis that they do not present other symptoms.

This will also allow people in remission from AN to be re-diagnosed SOONER before the BMI dips below 17.5


Anonymous said...

This is anon, again. The fact that : (1) insurance companies don't use 18.5 as a suggestion but instead as a necessary criteria; (2) that medical instability doesn't start at BMI of 19; and (3) that the criteria should be focused on PERSONAL IBW are exactly why I don't think there is Amy reason to believe this change will helpw ith insurance coverage at all.


Insurance companies have already fudged the plain language of the current DSM by ignoring the fact that it says 85% is just a guide. Why, then, whould we believe that insurance companies won't read "markedly underweight" as also meaning 18.5? I think they probably will.

Insurance coverage (for IP/ hospital type care) generally turns on medical instability. Therefore, if a BMI of 18 or 19 is not medically unstable, there is no reason the beloved that - diagnosis of AN or not- insurance will cover IP for
higher weight anorexia.

Most importantly, THE PLAIN LANGUAGE OF THE DSMV CRITERIA DOES NOT MENTION PERSONAL IBW. I do not see that phrase anywhere in the criteria. The suggested criteria is "markedly underweight." Underweight will still be defined objectively, by reference to weight charts and average BMI.

So, no, I do not think this will facilitate insurance coverage. It will only mean more people will be diagnosed with AN, and the sole debate should be whether it is medically helpful for folks with a BMI of 18 or 19 to have that diagnosis (when the other criteria are met). Apart from insurance coverage (which, again, there are valid reasons to remain unchanged) I cannot think of a single strong justification for lowering the threshhold. On the other hand, raising the weight threshhold will mean that thousands of people who are in recovery or still at a point where medical crisis can be averted will now have the stigma of a anorexia diagnosis. And, believe it or not, for many of us there are very good reasons why it is far better to be diagnosed with a sub-threshhold eating disorder than a full blown one. With a BMI of 19, I am fully functional, my brain works well, I am a productive member of society- my thoughts may warrant a sub-threshhold diagnosis (ie, EDNOS) but I am not in the sort of medical danger that should underly a full diagnosis.

Finally, telling me to "get a grip" because I read this as lowering the diagnostic threshhold to BMI of 18 or 19 is not only rude but also incorrect. The current standard, in practice, means anorexia is diagnosed at a BMI of 17.5. If the new threshhold is not a BMI of 18 or 19 then the DSMV does not change anything at all and there is no point to this conversation.

Carrie Arnold said...


You raise a really good point that I don't think has (until this point) been mentioned: the level of impairment caused by the eating disorder. This impairment isn't going to be directly correlated with BMI, either on an individual level or at a population level. When I drop to a BMI 19, I'm usually quasi-suicidal, an anxious basketcase and many times unable to even drink minimal amounts, let alone eat.

You're right- perhaps we should be focusing less on weight as the differential between anorexia and EDNOS and perhaps the level of impairment. Of course, this level still needs to be defined, and I certainly wouldn't want the task, but lots of other diagnoses include impairment in daily functioning as a criteria.

Cathy (UK) said...

I am glad to see that less focus is placed upon the precise value of body weight in the newly suggested diagnostic criteria for AN.

The level of physiological and metabolic impairment (and in some cases psychological impairment) in AN depends not just on weight per se, but rate of weight loss. Thus, an underweight individual who has had a stable BMI of 17 for (e.g.) one year may be far less impaired than another individual who has rapidly lost weight from a BMI of 25 to one of 18. There are often more immediate physical and psychological risks in the latter, heavier individual, especially if they are using dangerous methods to try to lose weight.

The biggest treatment error (IMO) is to withdraw treatment after rapidly re-feeding an individual with AN. This is because it takes a number of months for the brain to adapt to the improved nutritional status - and often the person feels much worse psychologically after rapid weight gain, UNTIL their brain and body has adapted to the change.

I was so relieved when my current psychiatrist assured me that the important therapy starts AFTER weight gain - and so I would not just be re-fed and 'kicked out' as soon as I reached some target weight, expecting to cope alone with my self-destructive thoughts...

Edna said...

I'm a but confused about the difference between anorexia an bulimia on these new definitions.

Someone who is underweight but not markedly underweight, who 'achieves' this through restriction and overexercising us more akin to anorexia than bulimia. I think I'm with Melissa in finding it hard to work out how you can be bulimic without binging and/or purging.

I guess in some ways it doesn't really matter, but one if the problems I've had with the ednos diagnosis that it is so wide that I'm not sure how helpful it is.

And as one who's struggled with disordered thoughts, blackouts, excessive exercise etc but been able to maintain a bmi of 20, yet not bingeing or throwing up, it feels a bit strange that I probably meet the new criteria for bulimia yet my treatment actually needs to be more like that for anorexia, helping me to overcome my fear of food and learn to eat again without compensating by overexercising

Cassidy said...

Wow, this really has been a big debate I wasn't expecting.

I guess I'll throw my last 2 cents in here too.

The fact of the matter is that level of impairment and medical instability can and will happen before a person reaches certain BMIs. It's been said before and will be said again, BMI is pretty much a waste of time in determining health in some if not most cases.

ANON, I really hope that by the time these measures go into effect, if they don't change before the publication date, you are in a better place, and don't feel like you will meet the criterea for the 'new' AN diagnosis. Some of your points were totally valid, and your opinion balanced things out a lot.
I'm really happy that you stimulated a lot of intelectual conversation even if I do disagree with what you're saying.

Hopefully there will come a day where a person's diagnosis will be less of a problem, and more of a tool to outline the best course of action with treatment. Until then we're pretty much at the whim of the APA. This doesn't mean they're always right, but outside of the clinical world, diagnosis doesn't, or rather shouldn't matter.

Carrie Arnold said...

Oh dear, I'm afraid I wasn't clear with the new definitions for BN. Binge eating and purging are both still criteria for bulimia, it's just that they eliminated the purging/non-purging subtypes. The original changes had shifted the non-purging subtype into binge eating disorder. However, the changes now define fasting and excessive exercise as a form of purging, so the subtypes were unnecessary.

Hope this helps!

Angela Elain Gambrel said...

I think the thing that's starting to bother me is the thought that some people want the diagnosis of AN for pathological reasons. I doubt if the DSM committee is really trying to appease people for some kind of "sick goal." (Not ED-related, but the committee is actually considering narrowing the threshold for the diagnosis of autism; many clinicians feel it is too broad and over-diagnosed. Many parents are angered by this, as it could mean a loss in services. Does this mean they want their child to have the diagnosis of autism?)

I'm not saying that people with AN don't strive to lose weight and get to lower numbers; but then, isn't that part of the illness? I'm also concerned about the idea of stigma. I am trying very hard not feel ashamed that I developed anorexia when I was 41, but since my relapse, I am often embarrassed when people ask why I am so thin or was in the hospital (they often assume cancer; you can't possibly have this disease at this age, could you and yes, people do ask these questions!) I lost a position because I have AN (I was directly told I was not chosen because of my illness), so believe me, I would love to ditch any ED diagnosis.

And as Carrie mentioned, many people are kicked out of treatment the moment they hit the magical 85 percent number. And it happens just as they are starting to recover and gain some insight into their illness. Then they go home, drop below 85 percent and get sick, have to be re-admitted and the damn cycle - in and out, in and out of IP - starts again. Maybe if someone could stay in the hospital and really get well, she/he could avoid this stupid cycle that disrupts your life and achieve true recovery. And it would be cheaper for the insurance companies in the long run; my last stay at the Beaumont Hilton costs them about $14,000.

I've been luckier than most; my insurance kept me in IP even after I reached a BMI of 17.7 in February (for a total of a week; but that might have been because I had pretty lousy blood tests when I was admitted and was at risk of cardiac arrest.)

I think the real problem when the criteria is this number or that number is that it does not take the individual person into account. I was much sicker in February with a higher weight and BMI than when I was in August 2008, when I was first admitted for refeeding and weighed 92 pounds. As my doctor explained it, it is because I am getting older (I'm 44) and my body is becoming less able to deal with AN. (I don't like to be reminded I'm getting "older" but reality is what it is.) I was a little surprised by all this, because I have had AN only four years.

My point being is numbers do not take the individual into account; some people become ill quicker and at a higher BMI, and other people have to wait until they are practically on their deathbed because their insurance won't admit until they reach the magical number.

H. said...

AMAZING! I'm so happy, this will 1) help keep ED-NOS from being the largest category and changing the weight criteria to being something that can be applied to individuals is much smarter.
When I had AN I actually did make it below that hallowed 85% but I was as sick as some people who get to the 75% mark or maybe even less. And even after my weight mostly recovered the thinking was the same and most of the behaviors where the same.

Thanks for keeping us all updated!

Renae said...

I'm excited! I deal with bulimia (have every "symptom but the original definition of purging) and because of that I mentally convinced myself that was I was doing was "normal" and "fine." It wasn't til years later I started to really understand it all.

Angela Elain Gambrel said...

H and Renae, you both bring up excellent points. Weight alone doesn't mean you're recovered. It seems so simple, and yet many people don't get it. I also used that as an excuse (I'm near a normal weight, so I'm all better now, right.) I hope I'm getting smarter, and the next time I won't be so insistent that just because I'm weight-restored I'm magically free.

Just one more thing. There are so many diagnoses in the DSM; many with co-morbid conditions might want to check out some of the proposed changes to diagnostic criteria for other illnesses. Does anyone know the link where you can go and review the proposed changes?

CG said...

the "inappropriate" in the bulimia definition irks me for some reason. what makes something appropriate? perhaps they mean harmful?

Katie said...

Oh dear. I would have been overjoyed by this when I was a teenager, but now all I can think is that the NHS will probably use this as an excuse to define 'markedly low' as far lower than the previous 17.5! I will be expecting to hear stories of how people with BMIs higher than 15 are turned away from even outpatient treatment. I think I approve of the changes to the definition of bulimia though, it makes far more sense in my mind to put people who compensate for binges in with bulimia rather than BED, although I agree with C.G. that 'inappropriate' is a funny word to use.

Anonymous said...

Does anyone know if they are keeping the anorexia subtypes (restricting vs. binge/purging)?

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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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