Commentary

Feeding and Eating Disorders in DSM-5

T he Eating Disorders Work Group for DSM-5 was faced with two major issues.
DSM-IV recognized only two specific eating disorders, anorexia nervosa and
bulimia nervosa. However, a large minority, or in some studies a majority, of indi-
viduals with clinically significant eating problems who were presenting for care did
not meet criteria for either of these disorders and were therefore assigned to the
residual category “eating disorder not otherwise specified.” Second, the decision to
eliminate the DSM-IV chapter describing disorders usually first diagnosed in
infancy, childhood, or adolescence led to our Work Group’s being responsible for
pica, rumination disorder, and feeding disorder of infancy or early childhood.
Grappling with these issues led to virtually all of our recommended changes, which
have been incorporated into DSM-5 in the chapter “Feeding and Eating Disorders.”
Undoubtedly, the major change is the official recognition of binge-eating
disorder. Although its inclusion was considered for DSM-IV, in the end it was
decided that insufficient data were available about the characteristics, course, and
treatment of individuals with this syndrome, and criteria were provided for further
study in an appendix. Extensive re-
search followed the promulgation of
Grappling with these issues
these preliminary criteria for binge-
eating disorder, leading to the publi- led to virtually all of our
cation of more than 1,000 articles over recommended changes.
the ensuing years. These data docu-
mented the clinical utility and validity of the proposed syndrome (1). For example,
individuals with this disorder experience substantially more anxiety and mood
disturbance than do comparison subjects, and they respond well to treatments that
incorporate methods to address these symptoms. In addition, data are emerging
that the presence of binge-eating disorder in adolescents portends a greater risk of
weight gain. The only significant difference in the DSM-5 criteria from those
provided in the DSM-IV appendix is that the minimum average frequency of binge
eating required is once weekly over the last 3 months, identical to the frequency
criterion for bulimia nervosa in DSM-5.
The second major change involves the DSM-IV category “feeding disorder of
infancy or early childhood.” This disorder has been renamed “avoidant/restrictive
food intake disorder” and the criteria have been expanded. There are two major
reasons for these changes. First, the DSM-IV category was rarely used, and limited
information is available on the characteristics, course, and outcome of children
with the DSM-IV disorder. Second, a number of individuals, primarily but not
exclusively children and adolescents, substantially restrict their food intake and
experience significant associated physiological or psychosocial problems, but they
do not meet criteria for any DSM-IV feeding or eating disorder (2). For example,
after an unpleasant episode of gastrointestinal illness accompanied by vomiting,
some youngsters may avoid eating solid food and develop significant nutritional
problems. Similarly, although idiosyncratic preferences for foods of a certain taste
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or consistency are very common during childhood development and are typically
self-limited and require no intervention, in rare cases the preferences are so
extreme and persistent as to lead to clinically significant problems. Avoidant/
restrictive food intake disorder is a broad category intended to capture this latter
range of presentations.
The core diagnostic criteria for anorexia nervosa are conceptually unchanged from
DSM-IV with one exception: the requirement for amenorrhea has been eliminated in
DSM-5. In DSM-IV, this requirement was waived in a number of situations (for
example, for females taking contraceptives and for males). In addition, the clinical
characteristics and course of females meeting all DSM-IV criteria for anorexia nervosa
except the requirement for amenorrhea closely resemble those of females meeting all
DSM-IV criteria (3). As in DSM-IV, individuals with this disorder are required by
criterion A to have a significantly low body weight for their developmental stage.
The wording of this criterion has been changed from DSM-IV for clarification, and
guidance regarding how to judge whether an individual’s weight is significantly low
is provided in the text. In DSM-5, criterion B has been expanded to include not only
expressed fear of weight gain but also persistent behavior that interferes with
weight gain, as a number of individuals do not report this fear (4, 5).
The only change in the criteria for bulimia nervosa is a reduction in the required
minimum average frequency of both binge eating and inappropriate compensatory
behavior from twice to once weekly. The clinical characteristics and outcome of
individuals meeting this slightly lower threshold are similar to those meeting the
DSM-IV criteria (6). In addition, the scheme distinguishing purging and non-
purging subtypes was eliminated, since data did not support the clinical utility of
this distinction (7). Other small changes were made to the criteria for pica and
rumination disorder for clarification and to permit these diagnoses to be assigned
to individuals of any age. The section “other specified feeding or eating disorder”
lists several presentations, such as purging disorder and night eating syndrome,
that have been described in the literature; insufficient information is currently
available about these conditions to merit full recognition as a disorder (8, 9).
Studies carried out by a number of investigators during the development of DSM-5
indicate that the changes recommended will significantly reduce the need for the
use of this residual category relative to the use of the comparable “not otherwise
specified” category in DSM-IV.
Finally, as was the case in DSM-IV, obesity is not included in DSM-5 as a mental
disorder. Obesity results from the long-term excess of energy (calorie) intake
relative to energy expenditure. Genetic, physiological, behavioral, and environ-
mental factors that vary across individuals contribute to the development of
obesity; thus, obesity per se is not considered a mental disorder. However, there
are robust associations between obesity and a number of psychiatric disorders (for
example, binge-eating disorder, mood disorders, and schizophrenia) as an asso-
ciated feature of the disorder or its treatment. Therefore, while obesity is not a
psychiatric disorder, it is a highly prevalent condition important for psychiatrists
and other mental health professionals to consider in managing their patients (10).

References
1. Wonderlich SA, Gordon KH, Mitchell JE, Crosby RD, Engel SG: The validity and clinical utility of binge-eating
disorder. Int J Eat Disord 2009; 42:687–705
2. Bryant-Waugh R, Markham L, Kreipe RE, Walsh BT: Feeding and eating disorders in childhood. Int J Eat Disord
2010; 43:98–111

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3. Attia E, Roberto CA: Should amenorrhea be a diagnostic criterion for anorexia nervosa? Int J Eat Disord 2009;
42:581–589
4. Becker AE, Eddy KT, Perloe A: Clarifying criteria for cognitive signs and symptoms for eating disorders in DSM-V.
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5. Becker AE, Thomas JJ, Pike KM: Should non-fat-phobic anorexia nervosa be included in DSM-V ? Int J Eat
Disord 2009; 42:620–635
6. Wilson GT, Sysko R: Frequency of binge eating episodes in bulimia nervosa and binge-eating disorder:
diagnostic considerations. Int J Eat Disord 2009; 42:603–610
7. van Hoeken D, Veling W, Sinke S, Mitchell JE, Hoek HW: The validity and utility of subtyping bulimia nervosa.
Int J Eat Disord 2009; 42:595–602
8. Keel PK, Striegel-Moore RH: The validity and clinical utility of purging disorder. Int J Eat Disord 2009; 42:
706–719
9. Striegel-Moore RH, Franko DL, Garcia J: The validity and clinical utility of night eating syndrome. Int J Eat
Disord 2009; 42:720–738
10. Marcus MD, Wildes JE: Obesity: is it a mental disorder? Int J Eat Disord 2009; 42:739–753
EVELYN ATTIA, M.D.
ANNE E. BECKER, M.D., PH.D.
RACHEL BRYANT-WAUGH, D.PHIL.
HANS W. HOEK, M.D., PH.D.
RICHARD E. KREIPE, M.D.
MARSHA D. MARCUS, PH.D.
JAMES E. MITCHELL, M.D.
RUTH H. STRIEGEL, PH.D.
B. TIMOTHY WALSH, M.D.
G. TERENCE WILSON, PH.D.
BARBARA E. WOLFE, PH.D., R.N.
STEPHEN WONDERLICH, PH.D.

From the Departments of Psychiatry and Epidemiology, Columbia University, New York; the New York State
Psychiatric Institute, New York; Weill Cornell Medical College, New York; the Department of Psychiatry,
Massachusetts General Hospital, Boston; the Department of Global Health and Social Medicine, Harvard
Medical School, Boston; the Department of Child and Adolescent Mental Health, Great Ormond Street
Hospital, London; Parnassia Psychiatric Institute, The Hague; the Department of Psychiatry, University of
Groningen, the Netherlands; the Department of Pediatrics, University of Rochester, N.Y.; the Departments
of Psychiatry and Psychology, University of Pittsburgh, Pa.; the Department of Clinical Neuroscience,
Neuropsychiatric Research Institute, University of North Dakota School of Medicine and Health Sciences,
Fargo, N.D.; the Department of Psychology, Wesleyan University, Middletown, Conn.; the Graduate School of
Applied and Professional Psychology, Rutgers, the State University of New Jersey, New Brunswick; and the
School of Nursing, Boston College, Chestnut Hill, Mass. Address correspondence to Dr. Walsh (btw1@columbia.
edu). Commentary accepted for publication March 2013 (doi: 10.1176/appi.ajp.2013.13030326).

Dr. Attia receives research support from Eli Lilly. Dr. Becker receives an honorarium paid to the Academy for
Eating Disorders from John Wiley & Sons for her role as associate editor of the International Journal of Eating
Disorders. Dr. Marcus serves on the Scientific Advisory Board for United Health Care. Dr. Striegel is a paid
consultant of Wellness and Prevention, a Johnson & Johnson company. Dr. Walsh receives research support
from AstraZeneca. Dr. Freedman has reviewed this commentary and found no evidence of influence from
these relationships. The other authors report no financial relationships with commercial interests.

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