Diagnostic and Statistical Manual of Mental Disorders

About the DSM-5
Anorexia Nervosa
Bulimia Nervosa
Binge Eating Disorder
Pica
Rumination Disorder
Avoidant/Restrictive Food Intake Disorder (ARFID)
Other Specified Feeding or Eating Disorder (OSFED)
Unspecified Feeding or Eating Disorder (UFED)

About the DSM-5

What is it?

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a publication of the American Psychiatric Association (APA). The DSM which contains sets of diagnostic criteria (symptoms being experienced) grouped into categories (disorders) to assist clinicians with effective diagnoses and care of people with mental health disorders. There are several diagnostic criteria manuals used worldwide, but the DSM is the one used most commonly in Australia.

Who uses it?

Following an assessment doctors (GPs and psychiatrists) are usually the people who will use the criteria from the DSM to match against an individual’s symptoms. This matching process will help them to decide whether the individual meets the diagnosis for a mental health disorder.

This diagnostic information can then be passed on to clinicians who will be treating the individual, such as a psychologist or dietitian. In some ways the DSM criteria are a form of shorthand between people like clinicians, and between clinicians funding providers, to briefly summarise what problems a person is experiencing. This information is then used to assist the treating clinicians in selecting the treatments with the best evidence for good outcomes that are associated with the disorder symptoms.

Why is there a revised edition?

Periodically the APA update the information in the DSM based on feedback from working people within mental health treatment, and following extensive working committee discussions with specialists who diagnose/treat the various disorders. The latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was released in May 2013.

How does this affect people diagnosed with eating disorders?

The DSM-5 includes changes from the previous DSM, which aim to better represent the behaviours and symptoms of people dealing with eating disorders. In order to do this there are updated clinical classification categories for eating disorders, and changes to diagnostic criteria (symptom lists).

One of the most notable changes is that Binge Eating Disorder (BED) has been acknowledged as a separate diagnosis for the first time. This will help increase awareness of the differences between Binge Eating Disorder and the more common issue of overeating.

Additionally, the category that was known as Eating Disorder Not Otherwise Specified (EDNOS), has been removed. There are two new categories; Other Specified Feeding or Eating Disorder (OSFED) and Unspecified Feeding or Eating Disorder (UFED). These new categories are intended to more appropriately recognise and categorise conditions that do not more accurately fit into Anorexia Nervosa, Bulimia Nervosa, BED, or the other eating and feeding disorders. It is important to note that these new categories are not an indication of a less severe eating disorder, simply a different constellation of symptoms.

Another significant change is the inclusion of some types of ‘Feeding Disorders’ that were previously listed in other chapters of the DSM, and now listed together with eating disorders.

Anorexia Nervosa

According to the DSM-5 criteria, to be diagnosed as having Anorexia Nervosa a person must display:

• Persistent restriction of energy intake leading to significantly low body weight (in context of what is minimally expected for age, sex, developmental trajectory, and physical health) .
• Either an intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain (even though significantly low weight).
• Disturbance in the way one's body weight or shape is experienced, undue influence of body shape and weight on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.

Subtypes:
Restricting type
Binge-eating/purging type

Learn more about Anorexia Nervosa

Bulimia Nervosa

According to the DSM-5 criteria, to be diagnosed as having Bulimia Nervosa a person must display:

• Recurrent episodes of binge eating. An episode of binge eating is characterised by both of the following:
  • 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.
  • 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).
• Recurrent inappropriate compensatory behaviour in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, or excessive exercise.
• The binge eating and inappropriate compensatory behaviours both occur, on average, at least once a week for three months.
• Self-evaluation is unduly influenced by body shape and weight.
• The disturbance does not occur exclusively during episodes of Anorexia Nervosa.

Learn more about Bulimia Nervosa

Binge Eating Disorder

According to the DSM-5 criteria, to be diagnosed as having Binge Eating Disorder a person must display:

• Recurrent episodes of binge eating. An episode of binge eating is characterised by both of the following:
  • 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.
  • 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).
• The binge eating episodes are associated with three or more of the following:
  • eating much more rapidly than normal
  • eating until feeling uncomfortably full
  • eating large amounts of food when not feeling physically hungry
  • eating alone because of feeling embarrassed by how much one is eating
  • feeling disgusted with oneself, depressed or very guilty afterward

• Marked distress regarding binge eating is present
• Binge eating occurs, on average, at least once a week for three months
• Binge eating not associated with the recurrent use of inappropriate compensatory behaviours as in Bulimia Nervosa and does not occur exclusively during the course of Bulimia Nervosa, or Anorexia Nervosa methods to compensate for overeating, such as self-induced vomiting.

Note: Binge Eating Disorder is less common but much more severe than overeating. Binge Eating Disorder is associated with more subjective distress regarding the eating behaviour, and commonly other co-occurring psychological problems.

Learn more about Binge Eating Disorder

Pica

According to the DSM-5 criteria, to be diagnosed with Pica a person must display:

• Persistent eating of non-nutritive substances for a period of at least one month.
• The eating of non-nutritive substances is inappropriate to the developmental level of the individual.
• The eating behaviour is not part of a culturally supported or socially normative practice.
• If occurring in the presence of another mental disorder (e.g. autistic spectrum disorder), or during a medical condition (e.g. pregnancy), it is severe enough to warrant independent clinical attention.

Note: Pica often occurs with other mental health disorders associated with impaired functioning.

Rumination Disorder

 According to the DSM-5 criteria, to be diagnosed as having Rumination Disorder a person must display:

• Repeated regurgitation of food for a period of at least one month Regurgitated food may be re-chewed, re-swallowed, or spit out.
• The repeated regurgitation is not due to a medication condition (e.g. gastrointestinal condition).
• The behaviour does not occur exclusively in the course of Anorexia Nervosa, Bulimia Nervosa, BED, or Avoidant/Restrictive Food Intake disorder.
• If occurring in the presence of another mental disorder (e.g. intellectual developmental disorder), it is severe enough to warrant independent clinical attention.

 

Avoidant/Restrictive Food Intake Disorder (ARFID)

 According to the DSM-5 criteria, to be diagnosed as having ARFID a person must display:

• An Eating or Feeding disturbance as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following:

1. Significant loss of weight (or failure to achieve expected weight gain or faltering growth in children).
2. Significant nutritional deficiency
3. Dependence on enteral feeding or oral nutritional supplements
4. Marked interference with psychosocial functioning

• The behavior is not better explained by lack of available food or by an associated culturally sanctioned practice.
• The behavior does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way one’s body weight or shape is experienced.
• The eating disturbance is not attributed to a medical condition, or better explained by another mental health disorder. When is does occur in the presence of another condition/disorder, the behavior exceeds what is usually associated, and warrants additional clinical attention.

 

Other Specified Feeding or Eating Disorder (OSFED)

According to the DSM-5 criteria, to be diagnosed as having OSFED a person must present with a feeding or eating behaviours that cause clinically significant distress and impairment in areas of functioning, but do not meet the full criteria for any of the other feeding and eating disorders.

A diagnosis might then be allocated that specifies a specific reason why the presentation does not meet the specifics of another disorder (e.g. Bulimia Nervosa- low frequency). The following are further examples for OSFED:

• Atypical Anorexia Nervosa: All criteria are met, except despite significant weight loss, the individual’s weight is within or above the normal range.
• Binge Eating Disorder (of low frequency and/or limited duration): All of the criteria for BED are met, except at a lower frequency and/or for less than three months.
• Bulimia Nervosa (of low frequency and/or limited duration): All of the criteria for Bulimia Nervosa are met, except that the binge eating and inappropriate compensatory behaviour occurs at a lower frequency and/or for less than three months.
• Purging Disorder: Recurrent purging behaviour to influence weight or shape in the absence of binge eating
• Night Eating Syndrome: Recurrent episodes of night eating. Eating after awakening from sleep, or by excessive food consumption after the evening meal. The behavior is not better explained by environmental influences or social norms. The behavior causes significant distress/impairment. The behavior is not better explained by another mental health disorder (e.g. BED).

 

Unspecified Feeding or Eating Disorder (UFED)

According to the DSM-5 criteria this category applies to where behaviours cause clinically significant distress/impairment of functioning, but do not meet the full criteria of any of the Feeding or Eating Disorder criteria. This category may be used by clinicians where a clinician chooses not to specify why criteria are not met, including presentations where there may be insufficient information to make a more specific diagnosis (e.g. in emergency room settings).