• arielprag

When the Bible is Wrong: Eating Disorders and Failings of the DSM-V

Updated: Mar 14, 2019

Like the limitless ways we suffer as humans, there are various defined and undefined eating disorders. The general public and medical community are most familiar with anorexia nervosa (AN) and bulimia nervosa (BN). Many have little information about the nuances of each of the "big two." Worse still, the most prevalent eating disorders are rarely acknowledged, let alone the rarer and ill-defined types.

The "Other" 4 Specific Diagnoses

Let's just jump right in:

  • Pica – a condition defined by "eating items that are not typically thought of as food and that do not contain significant nutritional value, such as hair, dirt, and paint chips."

  • Avoidant/restrictive food intake disorder (ARFID) – "previously referred to as “selective eating disorder,” involves limitations in the amount and/or types of food consumed but does not involve any distress about body shape or size, or fears of fatness."

  • Rumination disorder - "the regular regurgitation of food that occurs for at least one month. Regurgitated food may be re-chewed, re-swallowed, or spit out." It may be diagnosed as its own condition or as a part of another eating disorder, particularly anorexia and bulimia. Many sufferers know the condition as "chewing and spitting," often abbreviated as c/s, c&s, or other variants.

  • Binge Eating Disorder - "Binge eating disorder, the most common eating disorder in the United States, is characterized by recurrent episodes of eating large quantities of food; a feeling of a loss of control during the binge; experiencing shame, distress or guilt afterwards; and not regularly using unhealthy compensatory measures to counter the binge eating."

The DSM-V also recognizes two "umbrella" disorders: Otherwise Specified Feeding or Eating Disorder (OSFED, formerly EDNOS) and Unspecified Feeding or Eating Disorder (UFED).

OSFED means that a person presents "with feeding or eating behaviors that cause clinically significant distress and impairment, but do not meet the full criteria for any of the other disorders." This does not mean the condition is less serious.

A diagnosis of UFED is made when a patient does not meet full criteria for other specified disorders, as with OSFED, but "is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for a specific feeding and eating disorder, and includes presentation in which there is insufficient information to make a more specific diagnosis (e.g., in emergency room settings)." In other words, when a doctor can’t identify the type of eating disorder or whether the person meets full criteria, they will use this diagnosis to ensure the patient’s condition is addressed when it is possible.

(Definitions from NEDA.) [1]

Not Just Those Two!

Most people with eating disorders do not have textbook anorexia or bulimia. In the United States, the most widespread eating disorder by far is Binge Eating Disorder (BED).

After BED, OSFED is the second most frequently diagnosed type of eating disorders.

Just like AN and BN, Binge Eating Disorder is a serious condition with extreme psychological symptoms and dangerous physical complications. Despite affecting approximately 3% of the US population (3.5% of women, 2% of men), BED was only formally recognized as a DSM diagnosis in 2013 (DSM-V). Until then, it was listed as a subtype of OSFED, or Otherwise Specified Feeding or Eating Disorder(s). After BED, OSFED is the second most frequently diagnosed type of eating disorders. [1]

This includes sub-threshold bulimia nervosa, sub-threshold binge eating disorder, and sub-threshold anorexia nervosa. While the distinction "sub-threshold" implies that these subtypes are less severe conditions, they are as dangerous as their parent disorders. The first two diagnoses imply that the patient engages in the characteristic behaviors – e.g., binging – less frequently than in the threshold disorder. However, diagnosis of sub-threshold anorexia (or atypical anorexia) entails all the same behaviors as anorexia nervosa but without meeting the low weight criterion.

The Problem with the DSM (and Stubborn Clinicians)

In my opinion, these sub-threshold diagnoses are the DSM’s ill-considered interpretations of eating disorders in patients that have common variations in human physiology. Some individuals may have a chronic condition, like hypothyroidism, that limits weight loss; thus they may present at a normal weight, while suffering from severe anorexia and on the brink of death. As for low-frequency bulimia and binge eating disorder – does it really matter that the patient is engaging in these dangerous behaviors on a less frequent basis? [1] It may be more reasonable to include low-frequency presentations as sub-categories of each diagnosis. This allows the patient to receive proper care and prevents insurance companies from denying coverage. Furthermore, sub-categories would create an inclusive environment that promotes healing rather than competition or denial as are so often seen in eating disorders. [2] There are already enough patients who believe that they are not sick enough.

When my eating disorder was at its worst, the DSM-IV diagnostic criteria prevailed. I personally refused to believe that I was actually anorexic because at my lowest weight,

I wasn't underweight according to BMI or height-weight charts; I never lost a significant amount of weight in a short time, because I started out at a normal weight at 12 and at 17 was just 12 pounds lighter; I never lost my period; I never developed lanugo; I was never admitted to an eating disorder treatment center.

[Note: do NOT click the following link if you are easily triggered. I only post the second picture to demonstrate how ridiculous is is that because I wasn't severely underweight according to inaccurate charts, I never received treatment for my eating disorder. No emaciation is shown.]

I'm currently in treatment for an ED and those who see my pictures from that time are shocked by how sick I looked. My therapist at the time asserted that I was only suffering from Body Dysmorphic Disorder. I still have a hard time understanding that I don't look "better" that way.

Clinicians and some sufferers may argue that sub-threshold diagnoses have their place in the DSM. I believe that the differences between the sub-threshold and "full" disorders are often negligible. In fact, a 2002 psychiatric study at University of Minnesota studied the differences in clinical presentations between threshold and sub-threshold AN, BN, and BED. The study found that while it was possible to differentiate between full and partial BN, the sub-threshold presentations of AN and BED were indistinguishable from those in patients determined threshold cases. [3]

In addition to sub-threshold AN/BN/BED, Night Eating Syndrome and Purging Disorder are formally recognized as OSFEDs by the DSM-V. The following conditions (not exhaustive) exist without formal recognition under the OSFED umbrella:

  • diabulimia

  • orthorexia

  • compulsive exercise

  • laxative abuse

These conditions are similar to Rumination Disorder in that they can be their own conditions, or they can be part of another eating disorder.

Unfortunately, due to limited volume of medical research and even sparser acknowledgement, several OSFEDs (including the above) remain in limbo without official DSM recognition.


[1] Information by Eating Disorder. (2018, February 21). National Eating Disorders Association. Retrieved March 5, 2019, from https://www.nationaleatingdisorders.org/information-eating-disorder

[2] Chapa, D. A., Bohrer, B. K., & Forbush, K. T. (2018). Is the diagnostic threshold for bulimia nervosa clinically meaningful? Eating Behaviors,28, 16-19. doi:10.1016/j.eatbeh.2017.12.002

Abstract consulted.

[3] Crow, S. J., Agras, W. S., Halmi, K., Mitchell, J. E., & Kraemer, H. C. (2002). Full syndromal versus subthreshold anorexia nervosa, bulimia nervosa, and binge eating disorder: A multicenter study. International Journal of Eating Disorders, 32(3), 309-318. https://doi.org/10.1002/eat.10088

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