Revisiting Classification of Eating Disorders-Toward Diagnostic and Statistical Manual of Mental Disorders-5 and International Statistical Classification of Diseases and Related Health Problems-11

Article excerpt

Byline: Shrigopal. Goyal, Yatan Pal. Balhara, S. Khandelwal

Two of the most commonly used nosological systems- International Statistical Classification of Diseases and Related Health Problems (ICD)-10 and Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV are under revision. This process has generated a lot of interesting debates with regards to future of the current diagnostic categories. In fact, the status of categorical approach in the upcoming versions of ICD and DSM is also being debated. The current article focuses on the debate with regards to the eating disorders. The existing classification of eating disorders has been criticized for its limitations. A host of new diagnostic categories have been recommended for inclusion in the upcoming revisions. Also the structure of the existing categories has also been put under scrutiny.


Eating disorders have been defined as "disorders of eating behaviors, associated thoughts, attitudes and emotions, and their resulting physiological impairments". Anorexia nervosa (AN) is a syndrome characterized by three essential criteria. The first is a self-induced starvation to a significant degree-a behavior. The second is a relentless drive for thinness and/or a morbid fear of fatness-a psychopathology. The third criterion is the presence of medical signs and symptoms resulting from starvation-a physiological symptomatology. [sup][1] National Comorbidity Survey Replication estimates the life time prevalence of AN, bulimia nervosa (BN) and binge eating at 0.9%, 1.5% and 3.5%, respectively, in women and 0.3%, 0.5%, and 2.0% in men.

Studies from western countries have reported that 1% college-aged women have anorexia and 4 % college-age women have bulimia in the U.S. Similarly, 2.6% of female Norwegian students and 1.3% of Italian students have been found to have anorexia. However, studies from Asian countries have reported lower prevalence as compared to western countries. The prevalence rates of AN in Japan has been reported to be 0.025-0.030% and 0.01% in China. [sup][2] In fact, eating disorders have for long being conceptualized as culture-bound syndromes seen in western settings. Understanding accurate epidemiology of eating disorder is not possible due to changing definition of what constitutes an eating disorder, presentation of eating disorders by their physical consequences in form as medical disorders and lack of clear diagnostic criteria and reliable assessment methods, especially for the nonstereotypical cases in males, minorities, and matrons. Hence there is a need to deal with all these issues appropriately in the upcoming modifications of the nosological systems.

Materials and Methods

We conducted a literature review to investigate the lacunae in current classification of eating disorder and possible modification suggested by various authors. First, we identified articles on eating disorder, AN, BN, eating disorder NOS and binge-eating disorder (BED) by searching pubmed and MEDLINE. We also searched the articles cited in the reference sections of the papers that were retrieved from our initial search. Search term included eating disorder, AN, BN, eating disorder NOS, BED, new eating disorder, recent advances and DSM-V, ICD-11 in various combinations.


Evolution of eating disorder classification

In third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) and the revised third edition of the DSM (DSM-III-R), eating disorders were classified under disorders of childhood or adolescence, perhaps in part, contributing to previous under diagnosis of later-onset cases. DSM of the American Psychiatric Association has formally recognized two specific categories for the diagnosis of eating disorders- AN and BN (termed Bulimia in DSM-III and BN in DSM-IIIR and DSM-IV). In DSM-IV, all other clinically significant eating disorder problems are captured by the residual category of eating disorder not otherwise specified (EDNOS). …


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