DSM-5 Proposed Diagnostic Criteria for Bulimia Nervosa
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
(1) Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances
(2) A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
B. 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.
C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months.
D. Self-evaluation is unduly influenced by body shape and weight.
E. The disturbance does not occur exclusively during episodes of anorexia nervosa.
Rationale
Criterion C:
DSM-IV requires that episodes of binge eating and inappropriate compensatory behaviors both occur on average twice/week over the last three months. A literature review found that the clinical characteristics of individuals reporting a lower frequency of once/week were similar to those meeting the current criterion. Therefore, it is recommended that the required minimum frequency be reduced to once/week over the last three months.
Level of change: Modest.
References: Literature review (Wilson & Sysko, 2009).
Subtyping
DSM-IV requires that sub-type (purging or non-purging) be specified. A literature review indicated that the non-purging subtype had received relatively little attention, and the available data suggested that individuals with this subtype more closely resemble individuals with Binge Eating Disorder. In addition, precisely how to define non-purging inappropriate behaviors (e.g., fasting or excessive exercise) is unclear.
Deletion of this subtype is recommended. This also requires rewording of Criterion B.
Level of change: Modest.
References: Literature review (van Hoeken, Veling, Sinke, Mitchell, & Hoek, 2009).
Literature Cited:
van Hoeken D, Veling W, Sinke S, et al.: The validity and utility of subtyping bulimia nervosa. Int J Eat Disord 42:595-602, 2009.
Wilson GT, Sysko R: Frequency of binge eating episodes in bulimia nervosa and binge eating disorder: Diagnostic considerations. Int J Eat Disord 42:603-610, 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 Bulimia Nervosa.
The most frequent concern voiced about the proposed criteria for Bulimia Nervosa related to the elimination of the terms "fasting or excessive exercise" from Criterion B. Commentators felt that these forms of inappropriate compensatory behavior, while difficulat to define precisely, were observed with sufficient frequency to merit their continued inclusion in the criteria. The Work Group found this persuasive, and those terms are now proposed to be maintained in Criterion B.
The text will note the lack of agreement regarding how these terms should be defined and the fact that virtually all research on Bulimia Nervosa, including its treatment, has focused on individuals who actively purge via self-induced vomiting.
Severity Criteria
Frequency of inappropriate compensatory behavior (episodes per week).
Bulimia Nervosa
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
(1) eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances
(2) a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)
B. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise.
C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months.
D. Self-evaluation is unduly influenced by body shape and weight.
E. The disturbance does not occur exclusively during episodes of Anorexia Nervosa.
Specify type:
Purging Type: during the current episode of Bulimia Nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas
Nonpurging Type: during the current episode of Bulimia Nervosa, the person has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas