The new Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) has a number of changes to feeding and eating disorders — such as anorexia, bulimia, and binge eating. This article outlines some of the major changes to these conditions.
According to the American Psychiatric Association (APA), the publisher of the DSM-5, the major changes include the addition of binge eating disorder (a condition widely diagnosed by clinicians for years) and changes to bulimia and anorexia diagnostic criteria. In addition, the DSM has moved three disorders that were contained within the DSM-IV chapter, “Disorders Usually First Diagnosed in In-fancy, Childhood, or Adolescence” to this chapter, as the DSM-5 no longer has a childhood disorders chapter.
The diagnostic criteria for anorexia remain largely the same as in the DSM-IV. Amenorrhea — the absence of a menstrual cycle in a woman — has been removed as a requirement for anorexia to be diagnosed in women (it wasn’t found to be very useful, since there were so many exceptions to it).
The other primary change was with the first criteria, Criterion A, which now focuses on behaviors, like restricting calorie intake. More importantly, this criterion no longer includes the word “refusal” in terms of weight maintenance. The word was removed because it implied intention on the part of the patient, and can be difficult to assess.
As in DSM-IV, individuals with this disorder are required by Criterion A to be at a significantly low body weight for their developmental stage. The wording of the criterion has been changed for clarity, and guidance regarding how to judge
whether an individual is at or below a significantly low weight is now provided in the text.
Criterion B has also been expanded to include not only overtly expressed fear of weight gain, but also persistent behavior that interferes with weight gain.
Bulimia symptoms change little from the DSM-IV. The only change is that the DSM-5 criteria reduce the frequency of binge eating and compensatory behaviors that people with bulimia nervosa must exhibit — to just once a week. In the DSM-IV, this threshold was set at a minimum of twice a week.
According to the APA, “The clinical characteristics and outcome of individuals meeting this slightly lower threshold are similar to those meeting the DSM-IV criterion.”
Binge Eating Disorder
Binge eating disorder graduates from the DSM-IV category of “disorders needing further research” into its own diagnostic label. Which is just as well, given that it’s been used by clinicians in the field for years.
According to the APA, “Binge eating disorder is defined as recurring episodes of eating significantly more food in a short period of time than most people would eat under similar circumstances, with episodes marked by feelings of lack of control. Someone with binge eating disorder may eat too quickly, even when he or she is not hungry.
“The person [with binge eating disorder] may have feelings of guilt, embarrassment, or disgust and may binge eat alone to hide the behavior. This disorder is associated with marked distress and occurs, on average, at least once a week over three months.”
It’s important to differentiate binge eating disorder from simple over-eating. Over-eating happens only occasionally, and isn’t accompanied by the overwhelming feelings — often experienced non-stop — of guilt, shame, and embarrassment that someone with binge eating disorder experiences.
The DSM-5 criteria for binge eating are the same as what appeared in the DSM-IV, except that the minimum average frequency of binge eating has been changed from at least twice weekly for 6 months to at least once weekly over the last 3 months. This was changed, in part, to be consistent with the DSM-5 frequency criterion for bulimia nervosa.
The next three disorders are disorders that typically occur in childhood or affect teens.
Avoidant/Restrictive Food Intake Disorder
According to the APA, the DSM-IV feeding disorder of infancy or early childhood has been renamed avoidant/restrictive food intake disorder. The criteria for this disorder also have been significantly expanded.
Additionally, 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 but do not meet criteria for any DSM-IV eating disorder. Avoidant/restrictive food intake disorder is a broad category intended to capture this range of presentations.
No significant changes have been made to the elimination disorders. The disorders in this chapter were previously classified under disorders usually first diagnosed in infancy, childhood, or adolescence in DSM-IV. They now exist as an independent classification in DSM-5.
Pica and Rumination Disorder
The DSM-IV criteria for pica and for rumination disorder have been revised for clarity and to indicate that the diagnoses can be made for individuals of any age.