The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), has been under development since 2006 and is scheduled for publication in 2013. In anticipation of this important event, this issue of Psychiatric Annals lays out the rationale for the changes recommended to the feeding and eating disorders described in DSM-IV.
The need to deal with two major issues drove many of the recommendations for change. First, a large number of individuals presenting for care with a clinically significant problem with eating behavior do not meet criteria for any of the diagnostic categories recognized by DSM-IV. In a number of studies, an eating disorder not otherwise specified (EDNOS) was the most frequent diagnostic category. This was the source of great frustration for individuals seeking care, who believed their problems had not been properly recognized, and for clinicians, who did not have an established diagnostic label to describe their patients’ difficulties.
In order to reduce the frequency of EDNOS, several modest changes were recommended to the DSM-IV criteria for anorexia nervosa and bulimia nervosa. Furthermore, the Eating Disorders Work Group recommended that binge eating disorder, which was described in an appendix in DSM-IV, be formally recognized in DSM-5.
Second, early in the course of the development of DSM-5, the importance of taking a life-span approach to all disorders was recognized. Most psychiatric disorders develop relatively early in life, often during childhood, adolescence, or young adulthood. Manifestations often change over time, and the disorder may not be recognized or come to clinical attention until later in life. In order to underscore these important phenomena, it was decided to eliminate the DSM-IV section titled ‘Disorders Usually First Diagnosed in Infancy, Childhood or Adolescence.’
As a result, three disorders in that section in DSM-IV, namely, pica, rumination disorder, and feeding disorder of infancy or early childhood, were reviewed by the Eating Disorders Work Group. Several changes were recommended to the criteria for pica and rumination disorder to reflect the fact that these disorders may be first recognized in adults.
In addition, after substantial thought, study, and consultation with a number of experienced clinicians, the Eating Disorders Work Group recommended that feeding disorder of infancy or early childhood be expanded and that it be retitled avoidant/restrictive food intake disorder (ARFID).
Information collected since these recommendations were first made suggests that their adoption will lead to a significant reduction in the use of EDNOS. Nonetheless, a considerable number of individuals who do not meet criteria for any of the feeding or eating disorders recognized in DSM-5 will likely present for care. In order to facilitate their treatment and to aid further research, the EDNOS section has been retitled “Feeding and Eating Conditions Not Elsewhere Classified,” and descriptions of several sub-threshold and inadequately studied but clinically important problems will be briefly presented.
An additional question posed to the Eating Disorders Work Group was whether obesity, one of the most serious public health problems facing the United States and of increasing importance throughout the world, should be included in DSM-5 as a mental disorder.
Mental health professionals are increasingly aware of important associations between weight gain and emotional problems, and of the possible impact of commonly used medications on weight gain. In the end, however, the Eating Disorders Work Group recommended against the formal recognition of obesity in DSM-5.
The articles featured this month describe the thinking of the Eating Disorders Work Group concerning each of these issues and briefly outline how the likely changes to DSM-5 feeding and eating disorders may affect clinical practice.
All of the recommendations for DSM-5 are currently undergoing rigorous final review. As of this writing, it appears likely that the recommendations of the Eating Disorders Work Group will be accepted and implemented. However, the precise wording of diagnostic criteria and of the text describing their interpretation and use are not absolutely fixed. Therefore, the current issue does not provide the criteria. Interested readers should refer to www.DSM5.org for information on the most recent drafts.