DSM criteria for AN, BN, and BED to be changed

There used to be only two eating disorders: anorexia nervosa and bulimia nervosa. Anorexia is defined as disordered body image along with refusal to maintain weight above 85% of ideal body weight, and, in women, amenorrhea. Bulimia is defined as frequent episodes of binge eating, along with extreme efforts to lose weight, such as purging or excessive exercise.

While these are real diagnostic entities, it turns out the majority of people who are referred to eating disorders specialists end up being diagnosed with neither AN nor BN, but rather with something called EDNOS – “eating disorder, not otherwise specified.” In fact, up to 60% of people with eating disorders are diagnosed with EDNOS, a heterogeneous entity that includes people with subthreshold eating disorders, binge eating disorder (not yet an official DSM diagnosis), and a smattering of other diagnostic entities. The problem is that the EDNOS diagnosis is too broad to guide our treatment decisions.

Well, a recent article in the International Journal of Eating Disorders lays out a blueprint for DSM-V in order to remedy this problem (Wilfley DE et al., 2007, early view, published online Aug 8 2007). According to the authors, all of whom are prominent researchers in the field, the following changes are likely to be incorporated in DSM-V.

1. The amenorrhea criteria will be removed from AN, since there are no prognostic differences between anorexics with and without amenorrhea.

2. The minimum required frequency of binging will be lowered to once weekly (from the current twice weekly), because there is no evidence that patients who binge weekly are less sick than those who binge more frequently.

3. Binge eating disorder (BED) will become an officially recognized diagnosis. BED, currently listed as a “disorder worthy of study,” is now defined as recurrent binge eating (at least twice weekly for 6 months) without efforts to lose weight (i.e., bulimia without the purging). As with bulimia, the criteria for BED will be loosened a bit, to once weekly binges for 3 months.

Of course, anytime the DSM adds or broadens diagnoses, there is a concern among some that a hidden agenda is to bring more potential customers into the psychiatric fold. In this case, however, it’s likely that the total number of patients diagnosed with eating disorders won’t change drastically. Instead, the “EDNOS” category will shrink at the expense of AN, BN, and BED, all of which will expand. Hopefully, this will allow us to make our eating disorder diagnoses significantly more precise.

How is all this helpful for front-line clinicians right now? Be less insistent about applying rigid binge frequency criteria in your bulimia diagnoses, and throw out the amenorrhea criterion for AN. Focus less on checklists of symptoms and more on the core psychopathology of most eating disorders, which is, in its essence, the excess concern about body shape and weight.

As I have adopted this different mind-set in my own practice, I’ve been picking up on important body image and weight concerns in many more patients, even in those who would not qualify for a formal eating disorder. This leads to productive discussions and in some cases, informs treatment.