Diagnosing an eating disorder comes with an intense, complicated, and often tragic history. (We touch on it a bit in our history of diet culture if you’re curious.) In the last couple of centuries, modern medicine has necessitated a structured approach to medical diagnoses so treatment can have a scientific approach. The Diagnostic and Statistical Manual of Mental Disorders (DSM) has been the answer to this need. But hasn’t always been the most helpful. However, the most recent edition, the DSM-5, allows for a more inclusive diagnosis of eating disorders compared to previous versions. Here, we go into some of the history of the DSM and provide context on why this text is important to treatment providers, your loved ones and caregivers, and the patients themselves.
What Is the DSM-5
The DSM-5, or the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, is a comprehensive classification system published by the American Psychiatric Association (APA). Released in 2013, it serves as a resource for clinicians, researchers, and policymakers in diagnosing and treating mental health disorders. The current iteration of the DSM is just the most recent in a long line of efforts to provide classification guidelines for mental illnesses, including eating disorders.
Context of the DSM
The first edition of the DSM came to fruition in the post-WWII era when the publication of the International Classification of Diseases (ICD) included its first section on mental disorders. However, the U.S. government has been collecting information on the prevalence of mental health issues since the 1800s. Most other countries still rely on the ICD to provide diagnostic criteria for mental illnesses because it is internationally funded and recognized by the World Health Association. However, many psychologists believe that the DSM allows for more effective diagnosis because it offers more clarity, and it’s the standard text for clinicians to use in the United States.
It’s worth noting that previous versions of the DSM used Roman numerals to distinguish the editions, but the most current version transitioned to Arabic numbers. Moving forward, the APA will use a decimal system similar to software versions to clarify iterations of the DSM. The most current edition is the DSM-5 TR, which is a text revision of the DSM-5 with diagnostic clarifications and updates to the medical diagnosis code.
Should We Put People in Boxes? The Pros and Cons of Mental Health Diagnoses
At its core, the DSM is a tool to assign a diagnosis to a person suffering from a mental disorder. But this brings into question the value of diagnoses. An accurate diagnosis can be integral to helping a patient access the proper care and start their recovery journey. However, an improper diagnosis or lack of a diagnosis can prevent them from getting help or even make their condition worse. The revisions of the DSM are continually trying to improve the accuracy and inclusivity of mental health diagnoses, and the DSM-5 is the most recent attempt to bring more balance to this issue. Because this tool is used so broadly, it’s important to acknowledge both the pros and cons of mental health labels. Here, we provide context for the variety of stakeholders that use the DSM-5 and what it means for them.
The DSM and Policymakers
Many different stakeholder groups use the DSM for a variety of reasons. At a macro-scale, policymakers use the DSM-5 as reference material to gauge the prevalence and economic impact of mental health disorders. They may use this data and diagnostic guidelines to inform healthcare policy decisions. By analyzing data on disease burden and healthcare delivery, they can allocate resources more effectively and advocate for improved mental health services. By working toward better quality and accessibility of care, policymakers rely on resources like the DSM to support their constituents’ well-being.
The Value of DSM Diagnoses to Healthcare Providers
A proper diagnosis helps people get treatment. Many mental illnesses exist on a nuanced spectrum, with the symptoms and presentation differing between cases. Historically, this lack of clarity has made it easy to misdiagnose or even ignore mental illness. With eating disorders, this trend has caused harm. For example, assuming that someone must be “underweight” to have an eating disorder overlooks the 94% percent of people with EDs who aren’t clinically underweight. Trying to create clear boxes for each diagnosis is a tricky task. As past iterations of the DSM have shown, overly detailed criteria leave people out. Plus, a labeled diagnosis of a mental health condition doesn’t help the patient or doctor explain the underlying cause. It merely gives a place to start.
However, when diagnosed properly, a provider can more confidently prescribe effective treatment to a patient. Additionally, the DSM-5 provides a common language for clinicians and mental health professionals to be able to communicate about their patient’s conditions and treatments.
DSM-5 Diagnoses and Insurance
Beyond the value of diagnoses for healthcare providers to prescribe the most appropriate treatment, a DSM diagnosis is often necessary for a patient to bill insurance. Because the DSM is the most prevalent diagnostic criteria for mental illness in the United States, insurance companies often require a medical diagnosis for coverage. With the high costs of therapies and other forms of medical treatment, insurance coverage can make or break someone’s treatment journey. The changes to the DSM in the fifth edition allow clinicians to more effectively work within this system, getting patients insurance coverage to help pay for their treatment.
The Impact of A Diagnosis on Patients
A diagnosis of an eating disorder can cause mixed reactions. On one hand, they may feel isolated or ashamed. But on the other hand, a diagnosis can offer those suffering with some relief. A diagnosis can explain why they are feeling or behaving a certain way which can alleviate some anxiety associated with the unknown. Additionally, a diagnosis can help someone connect with others who are experiencing the same thing, providing a sense of community. Our support groups at the Alliance are a great example of the power of peer support.
The DSM-IV to the DSM-5: Major Shifts in Eating Disorder Diagnosis
Despite some of the criticisms of the DSM, it’s often the key to getting treatment for all types of mental illnesses, including eating disorders. Revisions to the DSM are key to improving access to quality research and support for eating disorder recovery.
The DSM-IV only recognized two eating disorders in adults: anorexia nervosa and bulimia nervosa. At least half of adults seen for eating disorder treatment were then given the diagnosis “eating disorder not otherwise specified.” This diagnosis is unclear and doesn’t have a well-researched set of treatments due to its vagueness.
Currently, the DSM-5 recognizes eight types or categories of eating disorder diagnoses. The restructuring and loosening of criteria to meet a diagnosis mark a significant step forward. The DSM-5 allows for a bit more clinician discretion and includes more options for diagnoses.
The DSM-5 also includes sections on pica and rumination disorder, as well as a section called “Unspecified feeding and eating disorder” to round out the diagnostic categories of the eight types of Feeding and Eating disorders. Here, we highlight the major changes in diagnoses between the DSM-IV and the DSM-5 criteria for common eating disorders.
Anorexia Nervosa
AN received a broader, more inclusive definition in the DSM-5. Rather than requiring patients to be at or under 85% of their ideal body weight, a person can be diagnosed with AN if their treatment professional states they have reached a “significantly low weight.” By steering away from using body mass index (BMI is a misleading measure of health) as the primary indicator, diagnoses can be more effective and inclusive. Additionally, patients are no longer required to have skipped menstruation (amenorrhea) to qualify for an AN diagnosis. While this is a symptom some people with uteruses experience with this eating disorder, it doesn’t apply to everyone.
Bulimia Nervosa
The diagnosis for BN had a few changes, including broadening the frequency guidelines of binging and purging behaviors and getting rid of subtypes of BN. This recognizes that someone with BN may engage in a variety of compensatory behaviors and experience a range in frequency of binge eating.
Binge Eating Disorder
Previous editions of the DSM only listed BED as a subject for further research, but the DSM-5 lists it as a diagnosable disorder. Including BED as a clear diagnosis will hopefully get individuals who live with this disorder validation and access to treatment.
ARFID
Another big change in the DSM-5 saw the reorganization of Avoidant/Restrictive Food Intake Disorder (ARFID). Previously this was characterized under “feeding and eating disorders of infancy or early childhood,” but now it’s placed under “Feeding and Eating Disorders,” allowing for a more general diagnosis of ARFID in adolescents and adults.
OSFED
While a bit of a catchall group, Other Specified Feeding and Eating Disorders (OSFED) now lists subtypes of EDs for a more nuanced diagnosis. For example, the DSM-5 includes atypical anorexia nervosa, bulimia nervosa or BED with low frequency, purging disorder, and night eating syndrome.
The DSM-5 is Step One to Recovery
The DSM has a complicated history, but researchers and clinicians are constantly trying to create a more accurate and inclusive manual for mental health diagnoses. When living with a mental illness like an eating disorder, getting a diagnosis from the DSM-5 is often the first step to getting treatment. With a diagnosis, your providers can collaborate on a holistic treatment plan based on your specific needs and the most current research on eating disorder recovery. This plan may include a range of tactics, from mental health support and clinical specialists to both inpatient and outpatient care.
At the Alliance, our team of mental health professionals will connect you with the best-fit treatment for your situation. By calling our helpline at +1 (866) 662-1235, we can put you in touch with providers in your area that can meet your recovery needs. You don’t even need a DSM diagnosis to call! We’d love to talk to you about how we can offer support no matter where you are in your recovery journey.