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Exploration Of Eating Disorder Diagnoses For DSM-V


The International Journal of Eating Disorders presented a special issue in 2009, exploring some controversies in the diagnosis of eating disorders, which have implications for how they may appear with the publication of the American Psychiatric and Statistical Manual of Diagnoses of Mental Disorders, fifth edition (DSM V).  The DSM V is due out in 2012.

Currently, Eating Disorder Not Otherwise Specified represents the diagnosis held by the majority of individuals seeking treatment for eating disorders.  Since the “Not Otherwise Specified” category in DSM is meant to only comprise residual cases, the fact that most people carry this diagnosis is of concern.  Therefore, an attempt has been made to identify eating disorders that exist within the “Not Otherwise Specified” category.  These include Binge Eating Disorder and Purging Disorder.

Binge Eating Disorder

Binge Eating Disorder is currently classified as an Eating Disorder Not Otherwise Specified but there is consideration for its inclusion in DSM V as its own diagnosis.

From a comprehensive review, Dr. Stephen Wonderlich and colleagues from the University of North Dakota, found the following:

  • Binge Eating Disorder is distinct from Anorexia Nervosa and Bulimia Nervosa.
  • It cannot yet be determined whether Binge Eating Disorder is distinct from obesity since insufficient study on this issue has been conducted.
  • People with Binge Eating Disorder often suffer from other eating disorder symptoms, such as over-evaluation of weight and shape; feelings of distress; impairment in functioning; and other presenting diagnoses (such as anxiety and depression), which means that Binge Eating Disorder is clinically relevant.

Purging Disorder

Purging Disorder is defined as the regular use (i.e., at least once a week for three months) of inappropriate compensatory behavior (i.e., vomiting, laxative abuse) in order to affect weight or shape by a person of normal weight after only eating small amounts of food.  The person’s self-evaluation is also overly consumed with weight and shape and/or an intense fear of gaining weight (APA, 2000).

A comprehensive review of studies on Purging Disorder by Pamela Keel at the Department of Psychology, Florida State University, and co-author Ruth Striegel-Moore showed that the amount of research on this syndrome is significant and growing.  While the disorder is distinct from normal functioning, it may not be different in terms of course, outcome or treatment response from other eating disorders.  More study is needed to determine the latter.   Therefore, it is probably premature to include Purging Disorder in DSM V as a separate disorder.

One option is to broaden the criteria for Anorexia Nervosa and/or Bulimia Nervosa to include purging only.  Another option is to retain Purging Disorder within the Eating Disorder Not Otherwise Specified category, which will probably present the most likely alternative for the DSM V.

Bulimia Nervosa

Bulimia Nervosa is characterized by binge episodes (at least twice a week for three months) and the use of methods to compensate for the calories consumed in a binge.  The methods are categorized either as “purging” (e.g., vomiting, diet pills, and laxative abuse) or non-purging (e.g., fasting or exercise).  One question has been about the validity and utility of the non-purging subtype.  Many people are unaware of this subtype and there is very little study on it, according to a review by Daphne van Hoeken, who is at the Parnassia Bavo Psychiatric Institute in the Hague, Netherlands, and her colleagues.  The authors therefore concluded that the non-purging subtype lacked evidence for validity and utility.

Another question to which they sought resolution was whether bulimia non-purging type was closer to Bulimia Nervosa or to Binge Eating Disorder in terms of its clinical utility (risk influences, course, and treatment).  However van Hoeken and colleagues were unable to make firm conclusions as studies they reviewed provided mixed results.  Their recommendation was to replace purging and non-purging subtypes with a severity hierarchy.  In such a hierarchy, purging would be viewed as more severe than non-purging as would the use of a greater number of compensatory methods.

Another issue for exploration is the frequency criteria for binge eating episodes, which has relevance for both Bulimia Nervosa and Binge Eating Disorder.  The current DSM criteria defines a binge as twice a week on average for three months for Bulimia Nervosa and for six months for Binge Eating Disorder.  Terence Wilson and Robyn Sysko at Rutgers University concluded after reviewing the available studies, that no empirical basis exists for the current criteria.  Additionally, they posed that lowering the threshold to once a week might emerge as the most favorable alternative.

Anorexia Nervosa

One major issue for the criteria for Anorexia Nervosa (refusal to maintain body weight due to fear of overweight) is the presence of amenorrhea, which is the lack of menstruation for three consecutive months.  Some of the problems with this criterion: it is not applicable to males, to young girls who have yet to start menstruating, to women that take hormones, and the fact that some women are able to keep menstruating even when they have low body weight.  Although amenorrhea may be associated with a greater risk of medical complications, such as bone mineral loss, a review of studies by Evelyn Attia (at the Department of Psychiatry at Columbia University) and Christina Roberto (the Department of Psychology at Yale University) indicates that psychologically speaking, people with anorexia with and without amenorrhea are relatively indistinct.

The authors’ conclusion, therefore, is that the amenorrhea criterion should be dropped and perhaps only retained as a medical sign associated with anorexia nervosa.  As a result of this proposed change, diagnostic criteria for Anorexia Nervosa would be relaxed slightly, allowing more cases from the Eating Disorders Not Otherwise Specified category to be introduced as Anorexia Nervosa.  This is preferable so that the Eating Disorders Not Otherwise Specified category can become smaller and less heterogeneous.

Another area of exploration for Anorexia Nervosa involves the validity and utility of its subtyping into binge-purge and restrictor (primarily fasting).   One issue is that the current language stipulating “regular engagement in binges or purges” as the stipulation for subtypes lacks any further specificity.  Therefore, the individual clinician has to interpret whether any bingeing/purging behavior constitutes “regular engagement.”

Additionally, with the eating disorders, “crossover,” meaning eating disorder behavior often changes over time, is common.  A typical pattern for Anorexia Nervosa is for people to start out with the restrictor-type.  Because that level of restriction from food is difficult to maintain, they may then engage in loss of control and binge.  At this point, they may then present as having the binge-purge subtype.  From there, many people go on to gain weight and meet diagnostic criteria for Bulimia Nervosa.  The authors posed options for handling the subtyping of Anorexia Nervosa, though none emerged as particularly favorable, including retaining the criteria as it now stands.

Attia, E., & Roberto, C. (2009). Should amernorrhea be a diagnostic criterion for anorexia nervosa? International Journal of Eating Disorders, 42, 581-589.

Keel, P., & Striegel-Moore, R. (2009). The validity and clinical utility of purging disorder. International Journal of Eating Disorders, 42, 706-719.

Peat, M., Mitchell, J., Hoek, H., & Wonderlich, S. (2009). Validity and utility of subtyping anorexia nervosa. International Journal of Eating Disorders, 42, 590-594.

van Hoeken, D., Veling, W., Sinke, S., Mitchell, J., & Hoek, H. (2009). The validity and utility of subtyping bulima nervosa.  International Journal of Eating Disorders, 42, 595-602.

Wilson, G.T., & Sysko, R. (2009). Frequency of binge eating episodes in bulimia nervosa and binge eating disorder: Diagnostic considerations. International Journal of Eating Disorders, 42, 603-610.

Wonderlich, S., Gordon, K., Mitchell, J., Crosby, R., & Engel, S. (2009). The validity and clinical utility of binge eating disorder. International Journal of Eating Disorders, 42, 687-705.

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