Skip to main content
SpringerLink
Log in

The diagnostic classification of eating disorders: current situation, possible alternatives and future perspectives

  • Review
  • Published:
Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity Aims and scope Submit manuscript

Abstract

The current nosography of eating disorders (ED) has various limitations in terms of validity and accuracy. The changes adopted in the DSM-5 limit some of the current problems, such as excessive prevalence of ED not otherwise specified (EDNOS) and the lack of longitudinal stability, but are unlikely to adequately capture the clinical complexity of ED. Many authors suggest the need for a thorough review of the current nosography to support evidence-based classification. In this paper, we discuss the validity of the current diagnostic categories and their possible reorganization. Furthermore, we review the main empirical models of classification and the diagnostic approach from a personality perspective, with particular attention to research and to the prognostic and therapeutic implications.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders, 5th edn. American Psychiatric Publishing, Arlington

  2. Striegel-Moore R, Wonderlich SA, Walsh BT, Mitchell JE (eds) (2011) Developing an evidence-based classification eating disorders: scientific findings for the DSM-5. American Psychiatric Publishing, Arlington

  3. Rojo Moreno L, Plumed Domingo J, Conesa Burguet L, Vaz Leal F, Diaz Marsá M, Rojo-Bofill L, Livianos Aldana L (2012) Eating disorders: considerations on nosology, etiology and treatment in the XXI century. Rev Psiquiatr Salud Ment 05:197–204

    Article  Google Scholar 

  4. Crow SJ, Agras WS, Halmi K, Mitchell JE, Kraemer HC (2002) Full syndromal versus subthreshold anorexia nervosa, bulimia nervosa, and binge eating disorder: a multicenter study. Int J Eat Disord 32:309–318

    Article  PubMed  Google Scholar 

  5. Garfinkel PE, Kennedy SH, Kaplan AS (1995) Views on classification and diagnosis of eating disorders. Can J Psychiatry 40:445–456

    CAS  PubMed  Google Scholar 

  6. Martin CK, Williamson DA, Thaw JM (2000) Criterion validity of the multiaxial assessment of eating disorders symptoms. Int J Eat Disord 28:303–310

    Article  CAS  PubMed  Google Scholar 

  7. Ramacciotti CE, Dell’Osso L, Paoli RA, Ciapparelli A, Coli E, Kaplan AS (2002) Characteristics of eating disorder patients without a drive for thinness. Int J Eat Disord 32:206–212

    Article  PubMed  Google Scholar 

  8. Thaw JM, Williamson DA, Martin CK (2001) Impact of altering DSM-IV criteria for anorexia and bulimia nervosa on the base rates of eating disorder diagnoses. Eat Weight Disord 6:121–129

    Article  CAS  PubMed  Google Scholar 

  9. Keel PK, Brown TA, Holland LA, Bodell LP (2012) Empirical classification of eating disorders. Annu Rev Clin Psychol 8:381–404

    Article  PubMed  Google Scholar 

  10. Uher R, Rutter M (2012) Classification of feeding and eating disorders: review of evidence and proposals for ICD-11. World Psychiatry 11(2):80–92

    Article  PubMed Central  PubMed  Google Scholar 

  11. Fairburn CG, Cooper Z, Bohn K, O’Connor ME, Doll HA, Palmer RL (2007) The severity and status of eating disorder NOS: implications for DSM-V. Behav Res Ther 45(8):1705–1715

    Article  PubMed Central  PubMed  Google Scholar 

  12. Fairburn CG, Harrison PJ (2003) Eating disorders. Lancet 361:407–416

    Article  PubMed  Google Scholar 

  13. Fairburn CG, Cooper Z (2007) Thinking afresh about the classification of eating disorders. Int J Eat Disord 40:107–110

    Article  Google Scholar 

  14. Fairburn CG, Bohn K (2005) Eating disorder NOS (EDNOS): an example of the troublesome “not otherwise specified” (NOS) category in DSM–IV. Behav Res Ther 43:691–701

    Article  PubMed Central  PubMed  Google Scholar 

  15. Walsh BT, Sysko R (2009) Broad categories for the diagnosis of eating disorders (BCD-ED): an alternative system for classification. Int J Eat Disord 42:754–764

    Article  PubMed Central  PubMed  Google Scholar 

  16. Keel PK, Striegel-Moore RH (2009) The validity and clinical utility of purging disorder. Int J Eat Disord 42:706–719

    Article  PubMed  Google Scholar 

  17. Striegel-Moore RH, Franko DL, Garcia J (2009) The validity and clinical utility of night eating syndrome. Int J Eat Disord 42:720–738

    Article  PubMed  Google Scholar 

  18. Becker AE, Thomas JJ, Pike KM (2009) Should non-fat-phobic anorexia nervosa be included in DSM-V? Int J Eat Disord 42:620–635

    Article  PubMed  Google Scholar 

  19. Goyal S, Balhara YP, Khandelwal SK (2012) 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. Indian J Psychol Med 34(3):290–296

    Article  PubMed Central  PubMed  Google Scholar 

  20. Janas-Kozik M, Zejda J, Stochel M, Brozek G, Janas A, Jelonek I (2012) Orthorexia—a new diagnosis? Psychiatr Pol 46(3):441–450

    PubMed  Google Scholar 

  21. Koch S, Quadflieg N, Rief W, Fichter M (2013) Purging Disorder—a distinct diagnosis? Review about the current state of research. Psychother Psychosom Med Psychol. doi:10.1055/s-0032-1331212

  22. Keel PK, Brown TA, Holm-Denoma J, Bodell LP (2011) Comparison of DSM-IV versus proposed DSM-5 diagnostic criteria for eating disorders: reduction of eating disorder not otherwise specified and validity. Int J Eat Disord 44(6):553–560

    Article  PubMed  Google Scholar 

  23. Fairburn CG, Cooper Z (2011) Eating disorders, DSM–5 and clinical reality. Br J Psychiatry 198(1):8–10

    Article  PubMed Central  PubMed  Google Scholar 

  24. Meehl PE (1992) Factors and taxa, traits and types, differences of degree and differences of kind. J Pers 60:117–174

    Article  Google Scholar 

  25. Gleaves D, Brown J, Warren C (2004) The continuity/discontinuity models of eating disorders: a review of the literature and implications for assessment, treatment, and prevention. Behav Modif 28:739

    Article  PubMed  Google Scholar 

  26. Wonderlich SA, Joiner TE Jr, Keel PK, Williamson DA, Crosby RD (2007) Eating disorder diagnoses: empirical approaches to classification. Am Psychol 62(3):167–180

    Article  PubMed  Google Scholar 

  27. Olatunji BO, Broman-Fulks JJ, Ciesielski BG, Zawilinski LL, Shewmaker S, Wall D (2012) A taxometric investigation of the latent structure of eating disorders. Psychiatry Res 197(1–2):97–102

    Article  PubMed  Google Scholar 

  28. Williamson DA, Womble LG, Smeets MA, Netemeyer RG, Thaw JM, Kutlesic V, Gleaves DH (2002) Latent structure of eating disorder symptoms: a factor analytic and taxometric investigation. Am J Psychiatry 159:412–418

    Article  PubMed  Google Scholar 

  29. Fairburn CG (2008) Eating disorders: the transdiagnostic view and the cognitive behavioral theory. In: Fairburn CG (ed) Cognitive behavior therapy and eating disorders. The Guilford Press, New York, pp 7–22

    Google Scholar 

  30. Castellini G, Lo Sauro C, Mannucci E, Ravaldi C, Rotella CM, Faravelli C, Ricca V (2011) Diagnostic crossover and outcome predictors in eating disorders according to DSM-IV and DSM-V proposed criteria: a 6-year follow-up study. Psychosom Med 73:270–279

    Article  PubMed  Google Scholar 

  31. Wade TD, Crosby RD, Martin NG (2006) Use of latent profile analysis to identify eating disorder phenotypes in an adult Australian twin cohort. Arch Gen Psychiatry 63:1377–1384

    Article  PubMed  Google Scholar 

  32. Striegel-Moore RH, Franko DL, Thompson D, Barton B, Schreiber GB, Daniels SR (2005) An empirical study of the typology of bulimia nervosa and its spectrum variants. Psychol Med 35:1563–1572

    Article  PubMed  Google Scholar 

  33. Keel PK, Fichter M, Quadflieg N, Bulik CM, Baxter MG, Thornton L et al (2004) Application of a latent class analysis to empirically define eating disorder phenotypes. Arch Gen Psychiatry 61:192–200

    Article  PubMed  Google Scholar 

  34. Bulik CM, Sullivan PF, Kendler KS (2000) An empirical study of the classification of eating disorders. Am J Psychiatry 157:886–895

    Article  CAS  PubMed  Google Scholar 

  35. Castellini G, Fioravanti G, Lo Sauro C, Rotella F, Lelli L, Ventura L, Faravelli C, Ricca V (2012) Latent profile and latent transition analyses of eating disorder phenotypes in a clinical sample: a 6 year follow-up study. Psychiatry Res. doi:10.1016/j.psychres.2012.08.035

  36. Crow SJ, Swanson SA, Peterson CB, Crosby RD, Wonderlich SA, Mitchell JE (2012) Latent class analysis of eating disorders: relationship to mortality. J Abnorm Psychol 121(1):225–231

    Article  PubMed  Google Scholar 

  37. Williamson DA, Gleaves DH, Stewart TM (2005) Categorical versus dimensional models of eating disorders: an examination of the evidence. Int J Eat Disord 37:1–10

    Article  PubMed  Google Scholar 

  38. Peterson CB, Crow SJ, Swanson SA, Crosby RD, Wonderlich SA, Mitchell JE, Agras WS, Halmi KA (2011) Examining the stability of DSM-IV and empirically derived eating disorder classification: implications for DSM-5. J Consult Clin Psychol 79(6):777–783

    Article  PubMed  Google Scholar 

  39. Von Lojewski A, Boyd C, Abraham S, Russell J (2012) Lifetime and recent DSM and ICD psychiatric comorbidity of inpatients engaging in different eating disorder behaviours. Eat Weight Disord 17(3):85–93

    Google Scholar 

  40. Rojo L, Barriguete A, Livianos L (2006) Factores de riesgo socioculturales de los trastornos alimentarios. Monogr Psiquiatr 18:65–70

    Google Scholar 

  41. Thomas JJ, Crosby RD, Wonderlich SA, Striegel-Moore RH, Becker AE (2011) A latent profile analysis of the typology of bulimic symptoms in an indigenous pacific population: evidence of cross-cultural variation in phenomenology. Psychol Med 41:195–206

    Article  CAS  PubMed  Google Scholar 

  42. Bennet D, Sharpe M, Freeman C, Carson A (2004) Anorexia nervosa among female secondary school students in Ghana. Br J Psychiatry 185:312–317

    Article  Google Scholar 

  43. Taylor JY, Caldwell CH, Baser RE, Matusko N, Faison N, Jackson JS (2013) Classification and correlates of eating disorders among Blacks: findings from the National Survey of American Life. J Health Care Poor Underserved 24(1):289–310

    Article  PubMed Central  PubMed  Google Scholar 

  44. Fairburn CG, Cooper Z, Shafran R (2003) Cognitive behaviour therapy for eating disorders: a “transdiagnostic” theory and treatment. Behav Res Ther 41:509–528

    Article  PubMed  Google Scholar 

  45. Brooks SJ, Rask-Andersen M, Benedict C, Schiöth HB (2012) A debate on current eating disorder diagnoses in light of neurobiological findings: is it time for a spectrum model? BMC Psychiatry 12:76

    Article  PubMed Central  PubMed  Google Scholar 

  46. Van Kuyck K, Gerard N, Van Laere K, Casteels C, Pieters G, Gabriels L, Nuttin B (2009) Towards a neurocircuitry in anorexia nervosa: evidence from functional neuroimaging studies. J Psychiatr Res 43(14):1133–1145

    Article  PubMed  Google Scholar 

  47. Kaye WH, Wagner A, Fudge JL, Paulus M (2011) Neurocircuitry of eating disorders. Curr Top Behav Neurosci 6:37–57

    Article  PubMed  Google Scholar 

  48. Pietrini F, Castellini G, Ricca V, Polito C, Pupi A, Faravelli C (2011) Functional neuroimaging in anorexia nervosa: a clinical approach. Eur Psychiatry 26(3):176–182

    Article  CAS  PubMed  Google Scholar 

  49. Brooks SJ, O’Daly OG, Uher R, Friederich HC, Giampietro V, Brammer M, Williams SC, Schioth HB, Treasure J, Campbell IC (2011) Differential neural responses to food images in women with bulimia versus anorexia nervosa. PLoS ONE 6(7):e22259

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  50. Brooks SJ, O’Daly O, Uher R, Friederich HC, Giampietro V, Brammer M, Williams SC, Schioth HB, Treasure J, Campbell IC (2012) Thinking about eating food activates visual cortex with reduced bilateral cerebellar activation in females with anorexia nervosa: an fMRI study. PLoS ONE 7(3):e34000

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  51. Hollmann M, Hellrung L, Pleger B, Schlogl H, Kabisch S, Stumvoll M, Villringer A, Horstmann A (2011) Neural correlates of the volitional regulation of the desire for food. Int J Obes 36(5):648–655

    Article  Google Scholar 

  52. Burger KS, Stice E (2011) Relation of dietary restraint scores to activation of reward-related brain regions in response to food intake, anticipated intake, and food pictures. NeuroImage 55(1):233–239

    Article  PubMed Central  PubMed  Google Scholar 

  53. Weygandt M, Schaefer A, Schienle A, Haynes JD (2012) Diagnosing different binge-eating disorders based on reward-related brain activation patterns. Hum Brain Mapp 33(9):2135–2146

    Article  PubMed  Google Scholar 

  54. Bohon C, Stice E (2011) Reward abnormalities among women with full and subthreshold bulimia nervosa: a functional magnetic resonance imaging study. Int J Eat Disord 44(7):585–595

    Article  PubMed Central  PubMed  Google Scholar 

  55. Van den Eynde F, Claudino AM, Mogg A, Horrell L, Stahl D, Ribeiro W, Uher R, Campbell I, Schmidt U (2010) Repetitive transcranial magnetic stimulation reduces cue-induced food craving in bulimic disorders. Biol Psychiatry 67(8):793–795

    Article  PubMed  Google Scholar 

  56. Tseng MC, Hu FC (2012) Latent class analysis of eating and impulsive behavioral symptoms in Taiwanese women with bulimia nervosa. J Psychosom Res 72(1):65–72

    Article  PubMed  Google Scholar 

  57. Wildes JE, Marcus MD (2013) Alternative methods of classifying eating disorders: models incorporating comorbid psychopathology and associated features. Clin Psychol Rev 33(3):383–394

    Article  PubMed  Google Scholar 

  58. Westen D, Harnden-Fischer J (2001) Personality profiles in eating disorders: rethinking the distinction between axis I and axis II. Am J Psychiatry 158:547–562

    Article  CAS  PubMed  Google Scholar 

  59. Westen D, Shedler J (1999) Revising and assessing axis II, Part I: developing a clinically and empirically valid assessment method. Am J Psychiatry 156(2):258–272

    CAS  PubMed  Google Scholar 

  60. Westen D, Shedler J (1999) Revising and assessing axis II, Part II: developing a clinically and empirically valid assessment method. Am J Psychiatry 156(2):273–285

    CAS  PubMed  Google Scholar 

  61. Thompson-Brenner H, Eddy KT, Franko DL, Dorer DJ, Vashchenko M, Kass AE, Herzog DB (2008) A personality classification system for eating disorders: a longitudinal study. Compr Psychiatry 49(6):551–560

    Article  PubMed  Google Scholar 

  62. Thompson-Brenner H, Westen D (2005) Personality subtypes in eating disorders: validation of a classification in a naturalistic sample. Br J Psychiatry 186:516–524

    Article  PubMed  Google Scholar 

  63. Steiger H, Richardson J, Schmitz N, Israel M, Bruce KR, Gauvin L (2010) Trait-defined eating-disorder subtypes and history of childhood abuse. Int J Eat Disord 43(5):428–432

    PubMed  Google Scholar 

  64. Wonderlich SA, Crosby RD, Joiner T, Peterson CB, Bardone-Cone A, Klein M, Crow S, Mitchell JE, Le Grange D, Steiger H, Kolden G, Johnson F, Vrshek S (2005) Personality subtyping and bulimia nervosa: psychopathological and genetic correlates. Psychol Med 35(5):649–657

    Article  PubMed  Google Scholar 

  65. Wonderlich SA, Crosby RD, Engel SG, Mitchell JE, Smyth J, Miltenberger R (2007) Personality-based clusters in bulimia nervosa: differences in clinical variables and ecological momentary assessment. J Pers Disord 21(3):340–357

    Article  PubMed  Google Scholar 

  66. Espelage DL, Mazzeo SE, Sherman R, Thompson R (2002) MCMI-II profiles of women with eating disorders: a cluster analytic investigation. J Pers Disord 16:453–463

    Article  PubMed  Google Scholar 

  67. Goldner EM, Srikameswaran S, Schroeder M, Livesley MJ, Birmingham CL (1999) Dimensional assessment of personality pathology in patients with eating disorders. Psychiatry Res 85:151–159

    Article  CAS  PubMed  Google Scholar 

  68. Strober M (1983) An empirically derived typology of anorexia nervosa. In: Darby P, Garfinkel P, Garner DM, Coscina D (eds) Anorexia nervosa: recent developments in research. Alan R. Liss, New York, pp 185–196

    Google Scholar 

  69. Holliday J, Landau S, Collier D, Treasure J (2006) Do illness characteristics and familial risk differ between women with anorexia nervosa grouped on the basis of personality pathology? Psychol Med 36:529–538

    Article  PubMed  Google Scholar 

  70. Krug I, Root T, Bulik C, Granero R, Penelo E, Jiménez-Murcia S et al (2011) Redefining phenotypes in eating disorders based on personality: a latent profile analysis. Psychiatry Res 188:439–445

    Article  PubMed  Google Scholar 

  71. Fassino S, Abbate-Daga G, Amianto F, Leombruni P, Boggio S, Rovera GG (2002) Temperament and character profile of eating disorders: a controlled study with the Temperament and Character Inventory. Int J Eat Disord 32(4):412–425

    Article  PubMed  Google Scholar 

  72. Speranza A (2009) La complessità della diagnosi: il caso dei disturbi alimentari. In: Dazzi N, Lingiardi V, Gazzillo F (eds) La diagnosi in psicologia clinica. Personalità e psicopatologia. Raffaello Cortina Editore, Milano

    Google Scholar 

  73. Westen D (2000) Integrative psychotherapy: integrating psychodynamic and cognitive behavioral theory and technique. In: Snyder CR, Ingram R (eds) Handbook of psychological change: psychotherapy processes and practices for the 21st century. Wiley, New York, pp 217–242

    Google Scholar 

Download references

Conflict of interest

None.

Author information

Authors and Affiliations

  1. Marconi University, Rome, Italy

    F. Dazzi

  2. Department of Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy

    F. G. Di Leone

Authors
  1. F. Dazzi
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. F. G. Di Leone
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to F. Dazzi.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Dazzi, F., Di Leone, F.G. The diagnostic classification of eating disorders: current situation, possible alternatives and future perspectives. Eat Weight Disord 19, 11–19 (2014). https://doi.org/10.1007/s40519-013-0076-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40519-013-0076-1

Keywords

Search

Navigation