It is essential to detect the presence of an eating disorder because of high associated mortality. Clinicians are faced with the difficulty of determining the presenting problem and identifying the appropriate diagnostic code needed for insurance billing. Although efforts have been made to improve the diagnostic criteria, not all presentations fit perfectly into the established criteria. Moreover, diagnosis is further complicated by the differences in criteria outlined in DSM-5 and ICD-10 (Table). Many applaud the recognition of binge eating disorder in DSM-5 as a major improvement in the field, but it does not have its own code in ICD-10.
Anorexia nervosa was first included in DSM-III and ICD-9. The key clinical criterion in anorexia nervosa is a significantly low body weight. However, the level at which body weight is considered “significantly low” has evolved. DSM-5 criteria for low weight consider what is “normal” for one’s age, sex, physical health, and developmental trajectory. Severity level may be assigned based on specified BMI. Previously, the weight criteria were criticized for being arbitrary because the criterion of 15% below ideal body weight was not empirically derived. ICD-10 (F50.0) quantifies low weight as at least 15% below what is expected or a BMI of 17.5 or lower.
Criteria from DSM-5 and ICD-10 recognize a fear of gaining weight and significant body image disturbance as essential features. One major change in DSM-5 is the removal of the amenorrhea criterion, which was criticized for not being applicable to males or prepubescent females. Moreover, the presence of amenorrhea does not differentiate severity of psychopathology.1 ICD-10, however, still acknowledges that amenorrhea may be present in females with anorexia nervosa. Anorexia nervosa is divided into 2 subtypes:
• Restricting type (F50.01): the patient has refrained from binge eating and/or purging in the past 3 months
• Binge-eating/purging type (F50.02): characterized by recurrent episodes of bingeing and/or purging over the past 3 months
Bulimia nervosa first appeared in DSM-III-R and ICD-9 and is characterized by recurrent episodes of binge eating followed by compensatory behaviors. Binge eating is defined as eating what would be considered an objectively large amount of food in a relatively short period. DSM specifies the presence of a feeling of “loss of control” of one’s eating in addition to the large amount consumed. Both criteria include the presence of compensatory behaviors (eg, self-induced vomiting, laxatives, diuretics, excessive exercise, or fasting) and recognize similar concern about shape and weight as found in anorexia nervosa. DSM-5 specifies a frequency threshold of binge eating and compensatory behaviors as an average of once per week, over the past 3 months.
Binge eating disorder
Binge eating disorder was identified as worthy of further study in DSM-IV-TR and is officially recognized in DSM-5. However, although widely accepted as a diagnosis, binge eating disorder is not recognized in ICD-10, and individuals would receive a diagnosis of F50.8 under other eating disorders. Binge eating disorder criteria include recurrent binge eating at the frequency threshold of at least an average of once per week, over the past 3 months, and the presence of at least 3 of the following 5 criteria:
• Eating much more quickly than usual
• Eating until uncomfortably full
• Eating a lot when not physically hungry
• Eating alone because of embarrassment
• Feeling very bad or guilty after eating
In DSM-5, individuals who meet significant criteria for an eating disorder but do not meet criteria for 1 of the 3 disorders described above may receive a diagnosis of other specified feeding and eating disorder, or OSFED. This includes individuals who may not meet the weight threshold for anorexia nervosa, or the frequency and duration of bulimia nervosa or binge eating disorder. In addition, purging disorder (ie, recurrent purging in the absence of bingeing) and night eating syndrome (ie, recurrent episodes of consciously eating at night) may be specified under an OSFED diagnosis. In ICD-10, diagnoses of atypical anorexia nervosa (F50.1) and atypical bulimia nervosa (F50.3) are specified as unique disorders, but any other eating disorder may receive the code of F50.8 for other eating disorders.
Dr Eichen is a Postdoctoral Fellow at the University of California, San Diego. Dr Wilfley is The Scott Rudolph University Professor of Psychiatry, Medicine, and Psychological and Brain Sciences at the Washington University School of Medicine in St Louis. Dr Eichen reports no conflicts of interest concerning the subject matter of this article; Dr Wilfley reports that she is a consultant for Shire Pharmaceuticals.
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