DSM-5 Proposed Diagnostic Criteria for Anorexia Nervosa
A. 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.
B. Intense fear of gaining weight or becoming fat, or persistent behavior to avoid weight gain, even though at a markedly low weight.
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)
Rationale
Criterion A:
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.
Level of change: Clarification.
References: Literature review (Becker, Eddy, & Perloe, 2009). Also, Workgroup for Classification of Eating Disorders in Children and Adolescents (WCEDCA) (Bravender et al., 2007).
Criterion B:
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.
Level of change: Clarification.
References: Literature review (Becker, Eddy et al., 2009). Also, Workgroup for Classification of Eating Disorders in Children and Adolescents (WCEDCA) (Bravender et al., 2007).
Criterion D:
In DSM-IV, amenorrhea is required. However, individuals have been clearly described who exhibit all other symptoms and signs of Anorexia Nervosa but who report at least some menstrual activity. In addition, this criterion cannot be applied to pre-menarchal females, to females taking oral contraceptives, to post-menopausal females, or to males. However, there are some data that women who endorse amenorrhea have poorer bone health than do women who fail to meet this criterion.
Deletion of this criterion is recommended.
Level of change: Modest/substantial.
References: Literature review (Attia & Roberto, 2009).
Subtyping
DSM-IV requires that sub-type (binge eating/purging or restricting) be specified for the current episode. While there are data that such sub-typing is useful clinically and for research purposes, there is significant cross-over between sub-types, and resultant difficulty in specifying the subtype for the “current episode” of illness. Therefore, it is recommended that the sub-typing be specified for the last 3 months; 3 months is the timeframe used for Bulimia Nervosa and proposed for Binge Eating Disorder.
Level of change: Clarification.
References: Literature review (Peat, Mitchell, Hoek, & Wonderlich, 2009).
Literature Cited:
Attia E, Roberto CA: Should amenorrhea be a diagnostic criterion for anorexia nervosa? Int J Eat Disord 42:581-589, 2009.
Becker AE, Eddy KT, Perloe A: Clarifying criteria for cognitive signs and symptoms for eating disorders in DSM-V. Int J Eat Disord 42:611-619, 2009.
Bravender T, Bryant-Waught R, Herzog D, et al.: Classification of child and adolescent eating disturbances. Workgroup for Classification of Eating Disorders in Children and Adolescents (WCEDCA). Int J Eat Disord 40 Suppl:S117-122, 2007.
Peat C, Mitchell JE, Hoek HW, et al.: Validity and utility of subtyping anorexia nervosa. Int J Eat Disord 42:590-594, 2009.
Rationale for Chagnes to Initial Recommendations
Based on comments received, the Eating Disorders Work Group has made changes to its recommendations for the criteria for Anorexia Nervosa.
Many comments regarding Anorexia Nervosa expressed concern and confusion over the inclusion of the phrase in Criterion A, “(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)”. Although this phrase was unchanged from DSM-IV and is only an example provided as a guideline, a number of commentators expressed concern that it is too often interpreted as a standard, not a guideline, and that “expected” body weight is overly vague.
Consistent with the DSM-IV criteria, the Work Group believes that it is not desirable to set a specific numerical standard for weight for Anorexia Nervosa, such as a BMI less than 18.5 kg/m2 for adults. Such standards are at least somewhat arbitrary, and may not adequately reflect an individual’s build or history. The Work Group believes that the judgment of whether weight is inappropriately low is best made by the clinician in light of all relevant information.
Therefore, the Work Group now recommends that the example be removed from Criterion A, and that the term “markedly low body weight” be employed, with a definition provided in the Criterion. As in DSM-IV, the definition emphasizes that weight must be less than “minimally normal”. The text of DSM-5 will describe several guidelines commonly employed, such as a BMI less than 18.5 kg/m2 for adults and a BMI below the 10th percentile for children and adolescents.
To insure consistency, the Work Group recommends that the phrase “markedly low weight” be used in place of “underweight” in Criterion B.
The text will also clarify that the term “restriction” in Criterion A implies behavior on the part of the individual to limit energy intake, as assessed by the history, observation, and information from others, such as family members. The text will clarify that the term energy “requirements” should take into account energy needed to support physical activity which may be excessive.
Severity Criteria:
BMI (assessed appropriately for developmental stage).
Anorexia Nervosa
A. Refusal to maintain body weight at or above 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.
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 denial of the seriousness of the current low body weight.
D. In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen, administration.)
Specify type:
Restricting Type: during the current episode of Anorexia Nervosa, the person has not regularly engaged in binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas)
Binge-Eating/Purging Type: during the current episode of Anorexia Nervosa, the person has regularly engaged in binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas)