Diagnostic Criteria for Anorexia Nervosa

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The Diagnostic & Statistical Manual of Mental Disorders, fifth edition, (DSM-5) was published in 2013 by the American Psychiatric Association. It provides physicians and mental-health professionals with the criteria for diagnosing specific mental disorders, including anorexia nervosa. 

Previous Diagnostic Manual

The previous diagnostic manual, the DSM-IV (published in 1994), was problematic because as many as three-quarters of patients diagnosed with an eating disorder fell into the catchall and varied category of Eating Disorder Not Otherwise Specified (EDNOS).

This made it hard for researchers and clinicians to adequately define and treat the range of patients in this group.

Changes to Anorexia in the DSM-5

The DSM-5 also merged the former categories of Eating Disorders and Feeding Disorder in Infancy or Early Childhood and formed the new category, Feeding and Eating Disorders. The DSM-5 attempted to relax some of the criteria and broaden the categories for the specific disorders in order to reduce the number of patients in the EDNOS (now called OSFED) group. In terms of the criteria for anorexia nervosa, there were two primary changes in DSM-5:

  1. amenorrhea (loss of a menstrual period) was eliminated as a criterion. This is important because it allows males to meet criteria for anorexia nervosa. It also allows official inclusion of the small minority of females who continue menstruating despite extreme weight loss and malnutrition
  2. the low weight criterion was revised to allow more subjectivity and clinical judgement. This is also an important revision because we know that anorexia nervosa can occur in individuals who are not what would be considered objectively low weight on a BMI chart. It allows professionals to take into account an individual's unique growth trajectory and weight history

    DSM-5 Criteria for Anorexia Nervosa

    A person must meet all of the current DSM criteria to be diagnosed with anorexia nervosa:

    • Restriction of food intake leading to weight loss or a failure to gain weight resulting in a "significantly low body weight" of what would be expected for someone's age, sex and height.​
    • Fear of becoming fat or of gaining weight.​
    • Have a distorted view of themselves and of their condition. Examples of this might include the person thinking that he or she is overweight when they are actually underweight, or believing that they will gain weight from eating one meal. A person with anorexia might also make excuses or deny that there is a problem with being at a low body weight. These thoughts are known to professionals as "distortions."

    The DSM-5 also allows professionals to specify subcategories of anorexia nervosa:

    • Restricting Type: This is a subtype that is typically associated with the stereotypical view of anorexia nervosa. The person does not regularly engage in binge eating.​
    • Binge-Eating/Purging Type: The person regularly engages in binge eating and purging behaviors, such as self-induced vomiting and/or the misuse of laxatives or diuretics. The binge eating/purging subtype is similar to bulimia nervosa; however, there is no weight-loss criterion for bulimia nervosa. As in previous editions of the DSM, anorexia nervosa "trumps" bulimia nervosa, meaning that if a person meets criteria for both anorexia nervosa and bulimia nervosa that anorexia nervosa (binge-eating/purging type) is diagnosed.

      It also allows professionals to specify if the person is in partial remission or full remission (recovery), as well as to specify the current severity of the disorder, based on BMI.

      For Patients Who Do Not Meet Criteria for Anorexia Nervosa

      For patients who do not meet full criteria for anorexia nervosa, Other Specified Feeding and Eating Disorder may be an appropriate diagnosis. Being diagnosed with OSFED as opposed to anorexia nervosa does not mean that one is not still ill and does not need help. It is also important to note that individuals may meet criteria for different eating disorders at different times as symptoms can change.

      There is also not a distinct line between healthy and disordered, but many shades of grey in the middle.

      Getting Help

      Anorexia nervosa can cause a number of serious health consequences. Recovery from anorexia nervosa is definitely possible. Getting help early improves the chance of a complete and lasting recovery. If you or someone you know is suffering from some or all of the above criteria, it is important they see a physician, dietician or a mental-health professional for an assessment. Treatment for anorexia nervosa can occur in a variety of settings based on individual need. 

      Sources:

      American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

      Vo, Megen, Erin C. Accurso, Andrea B. Goldschmidt, and Daniel Le Grange. 2017. “The Impact of DSM-5 on Eating Disorder Diagnoses.” International Journal of Eating Disorders 50 (5): 578–81. doi:10.1002/eat.22628.

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