This month’s edition of Psychiatric Annals, guest edited by B. Timothy Walsh, MD, provides valuable insight into the content, the thinking, and the evidence behind the diagnostic process involving eating disorders.
I’d like to express my personal thanks to Tim and his team of authors for giving Psychiatric Annals the opportunity to bring our readers this useful discussion of the rationale used and data evaluated by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) Eating Disorders Work Group. This series serves as a great example of the DSM-5 process, both its intent and its execution, at its best.
Eating disorders are unlike many of the diagnostic categories in DSM-5, in that they involve an activity that is common to life, necessary for survival. Distortions and differences in eating behavior may be highly determined by cultural forces that vary from place to place. Most pathological behaviors in eating disorders are driven by various mechanisms, and involve restriction of food intake, excessive food intake, or alternating patterns of both extremes.
One of the driving forces behind the Work Group’s efforts was an effort to reduce the use of the “Eating Disorder, Not Otherwise Specified” (EDNOS) diagnostic category, which tells us little about the pathological pattern observed by the clinician. The goal is to further not only a more specific description of many disorders diagnosed as “eating disorder, not elsewhere classified” (ED NEC), but also to make more specific diagnoses that lead to helpful treatment.
The addition of the diagnosis of “avoidant/restrictive food intake disorder” (ARFID) discussed by Rachel Bryant-Waugh, BSc (Hons), MSc, DPhil, and Richard E. Kreipe, MD to cover a spectrum of early life eating disorders; and the decrease in the symptom frequency requirement for bulimia nervosa (BN), discussed by Barbara E. Wolfe, PhD, RN, and colleagues, allow for an increase in more specific diagnoses as well as an increase in patients receiving specific treatment for eating disorders.
Wolfe et al’s discussion of the evidence supporting a time/frequency threshold for BN makes a good case for the change and the likelihood of more people getting specific, helpful treatment for eating disorders. The difference between ARFID patients not wishing to alter weight or body shape, and BN sufferers being motivated by this concern, draws a clear line between the two disorders.
The ED NEC introduced with the purpose of classifying more specific subtypes are explained well by Tiffany A. Brown, MS, and colleagues. Possible NEC subcategories such as subthreshold BN, night eating syndrome (NES), subthreshold binge eating disorder, and purging disorder (PD), allow for more specific delineation of subthreshold eating disorders falling within the NEC categories.
The discussion of pica and rumination disorder by Andrea S. Hartmann, PhD, and colleagues casts light on important eating disorders that are often missed or misunderstood.
The discussion by Marsha D. Marcus, PhD and Jennifer E. Wildes, PhD, explains why obesity is not appropriate at this time to categorize it as a psychiatric diagnosis. They convincingly explain why obesity does not meet criteria for a mental disorder, despite its frequent overlap with psychiatric disorders.
One reason for updating the DSM every 12 to 18 years is to improve its utility for clinicians and to reflect the emergence of new information over the interval. Walsh et al’s series of papers illustrates this process and brings us up to date on the diagnosis and, to some extent, treatment outcomes for eating disorders.
The changes recommended for DSM-5 discussed in this issue, do not fully convey the exhaustive amount of discussion and literature review that went into the vetting and creation of the DSM-5, a process that began in 2006; however, the articles here do convey some of the reasons for the suggestions for change, as well as provide us with a peek at the extraordinary effort that went into this process. Thank you to all of you who have worked so hard.