2 days ago
Time to Update Diagnostic Criteria for Eating Disorders?
Current diagnostic criteria for eating disorders fail to capture a broad range of weight-loss behaviors characteristic of anorexia nervosa, bulimia nervosa, and binge eating disorder that are not captured by current diagnostic criteria, new research suggested.
On the basis of interviews with nearly 1700 patients, investigators identified a wide variety of patient behaviors that are not included in current diagnostic criteria. These range from chewing gum to reduce food intake to more extreme symptoms such as consuming cotton balls to distend the stomach without ingesting calories.
Investigators believe the results highlight the limitations of existing assessment tools and the importance of listening to patients and initiating open discussion about weight-loss behaviors.
'We're proposing an updated eating disorder assessment tool that has a longer, more varied list of behaviors so that there's more flexibility and a more comfortable setting for patients to share their experiences,' lead author Saakshi Kakar, PhD student and lead research assistant, National Institute for Health and Care Research (NIHR) Biomedical Research Centre for Mental Health, and Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, England, told Medscape Medical News .
Saakshi Kakar
The findings were published online on June 17 in the International Journal of Eating Disorders .
Assessing the Assessment Tools
Standard eating disorder assessment tools, which include the Eating Disorder Examination Questionnaire and the Eating Pathology Symptoms Inventory, may capture restriction-based behaviors such as calorie counting, methods to elicit a diuretic or laxative effect, as well as medical interventions such as bariatric surgery. However, these tools often fail to capture the full range of weight-loss tactics used by individuals with eating disorders, said Kakar.
While clinical interviews that employ tools such as the Eating Disorder Examination offer greater flexibility in assessing key behaviors, they are resource intensive and may not provide an environment conducive to revealing sensitive information, she added.
The goal of the study was to identify and categorize the diverse range of weight-loss behaviors that extend beyond traditional diagnostic criteria and highlight the variability in symptom presentation.
The analysis included 1675 mostly female participants, with an average age of 31.7 years, from two ongoing UK studies: the GLAD study and the EDGI UK study.
All participants had an eating disorder that was either self-reported or identified by researchers using algorithms based on responses to the Eating Disorders 100,000 eating disorder questionnaire.
Using this tool, individuals are asked to expand on weight-loss methods and compensatory behaviors they use to control their body shape or weight. Questions are open-ended and are answered in private, which encourages disclosure of sometimes stigmatized behaviors people may hesitate to share in clinical settings.
Four Behavioral Themes
In all, 27% of participants had the binge eating/purging subtype of anorexia nervosa, and 13.8% had the restricting subtype of anorexia nervosa. In addition, 53.9% had bulimia nervosa and 4.8% had a binge eating disorder.
The most frequently cited behaviors included structured weight-loss diets such as Atkins (endorsed by 17.7%), calorie counting (12.1%), and restrictive eating (11.1%). However, some participants used less common behaviors such as compression garments (4.2%) and bariatric surgery (4.2%).
From the data, researchers identified four behavior types. These included:
Restriction-based approaches included weight-loss diets, calorie counting, restrictive eating patterns, participation in weight-loss groups such as Weight Watchers, and limiting fluid intake.
included weight-loss diets, calorie counting, restrictive eating patterns, participation in weight-loss groups such as Weight Watchers, and limiting fluid intake. Medical interventions encompassed bariatric surgery, off-label prescription medications such as metformin used to treat type 2 diabetes, methylphenidate used to treat attention-deficit/hyperactivity disorder, and levothyroxine used to treat hypothyroidism, weight-loss injections such as Ozempic, and appetite suppressants such as caffeine and smoking.
encompassed bariatric surgery, off-label prescription medications such as metformin used to treat type 2 diabetes, methylphenidate used to treat attention-deficit/hyperactivity disorder, and levothyroxine used to treat hypothyroidism, weight-loss injections such as Ozempic, and appetite suppressants such as caffeine and smoking. Body manipulation tactics can include wearing compression garments that restrict the stomach, using stimulants or other illicit drugs, lowering body temperature, inducing sweating, intentionally consuming foods incompatible with known intolerances (eg, gluten) to cause discomfort and suppress appetite, engaging in micro-exercise such as constant fidgeting or leg shaking, chewing gum, depriving oneself of sleep, or overeating to trigger vomiting.
tactics can include wearing compression garments that restrict the stomach, using stimulants or other illicit drugs, lowering body temperature, inducing sweating, intentionally consuming foods incompatible with known intolerances (eg, gluten) to cause discomfort and suppress appetite, engaging in micro-exercise such as constant fidgeting or leg shaking, chewing gum, depriving oneself of sleep, or overeating to trigger vomiting. Food avoidance behaviors may involve chewing and spitting out food without swallowing, hiding food, consuming nonfood items such as cotton balls or tissue to simulate chewing without ingesting calories, or using sleep or smoking as strategies to suppress appetite and avoid eating.
Certain behaviors could be categorized under multiple themes, investigators noted. Smoking, for example, may be considered both a restriction-based approach and a medical intervention, depending on the individual's intent and context.
Kakar noted that, to her knowledge, no previous studies have systematically categorized weight-loss behaviors in this way, making it 'a novel contribution to the literature.'
She added that most of the behaviors her team identified are not explicitly included in the current diagnostic criteria.
'While some of these behaviors may be familiar to experienced clinicians, they are not formally recognized in diagnostic manuals — suggesting a significant gap between clinical practice and diagnostic guidance,' said Kakar.
Time to Update Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition ( DSM-5 ) Criteria?
A key finding was that 81 participants with binge eating disorder engaged in weight-loss and compensatory behaviors typically linked to bulimia nervosa.
Kakar noted DSM-5 criteria for binge eating disorder stipulate that binge eating should not be accompanied by recurrent inappropriate compensatory behaviors.
'This exemplifies the fact that people are possibly missed or misdiagnosed, which means adequate treatment may not be offered,' she said.
Kakar suggested that on the basis of the study's findings, it may be time to update eating disorder criteria in the DSM-5 , although she recognizes this would require further research.
In a secondary analysis, researchers isolated responses from participants with different eating disorders. The most frequently reported weight-loss behaviors and resulting themes did not differ among eating disorders.
In addition, an analysis examining the results according to gender showed weight-loss behaviors endorsed by men closely mirrored the broader sample.
The findings underscored the importance of considering all possibilities when assessing for an eating disorder, Kakar said.
Kakar emphasized the importance of moving beyond brief, proscriptive checklists in clinical assessments. Instead, she said physicians should engage in open-ended conversations with patients about the strategies they use to lose weight or control body shape, noting that this approach can reveal behaviors that might be overlooked by standard screening tools.
Kakar also plans to work with clinicians and individuals with eating disorders to create a more robust list of weight-loss behaviors that can be used by clinicians as well as in research settings.
A limitation of the study was that researchers didn't assess whether the identified behaviors are associated with clinically significant distress or impairment. In addition, the study sample was mostly White, women, heterosexual, and highly educated.
Taking a Broader View
Commenting on the findings for Medscape Medical News , Genevieve Nowicki, a counseling psychology PhD candidate at Northeastern University, Boston, who has studied eating and body image issues for the past 8 years, said the study provides additional evidence of the evolving nature of eating disorder behaviors.
Nevertheless, she added, it might be helpful to 'zoom out' and consider the broader picture including context, motivation, and frequency of a weight-loss behavior. This approach may be less daunting for providers than trying to keep up with an ever-expanding list of behaviors, she said.
'There are potentially an infinite number of things that people with, and without, eating disorders can do to modify weight, shape, or appearance,' Nowicki said.
Nowicki noted that while it's important for clinicians to recognize specific weight-loss behaviors, it can be more effective — and less overwhelming — to take a broader view. Considering the context, motivation, and frequency of these behaviors may provide deeper clinical insight.
She believes current DSM-5 eating disorder criteria are 'intentionally broad' in order to include all potential compensatory or purging behaviors. Self-report tools alone can't be expected to capture the full spectrum of eating disorder behaviors, said Nowicki.
