Classification of Feeding and Eating Disorders
Classification of Feeding and Eating Disorders
Classification of Feeding and Eating Disorders
Current classification of eating disorders is failing to classify most clinical presentations; ignores continuities between child, adolescent and
adult manifestations; and requires frequent changes of diagnosis to accommodate the natural course of these disorders. The classification is
divorced from clinical practice, and investigators of clinical trials have felt compelled to introduce unsystematic modifications. Classification
of feeding and eating disorders in ICD-11 requires substantial changes to remediate the shortcomings. We review evidence on the developmen-
tal and cross-cultural differences and continuities, course and distinctive features of feeding and eating disorders. We make the following
recommendations: a) feeding and eating disorders should be merged into a single grouping with categories applicable across age groups; b)
the category of anorexia nervosa should be broadened through dropping the requirement for amenorrhoea, extending the weight criterion to
any significant underweight, and extending the cognitive criterion to include developmentally and culturally relevant presentations; c) a sever-
ity qualifier “with dangerously low body weight” should distinguish the severe cases of anorexia nervosa that carry the riskiest prognosis; d)
bulimia nervosa should be extended to include subjective binge eating; e) binge eating disorder should be included as a specific category de-
fined by subjective or objective binge eating in the absence of regular compensatory behaviour; f) combined eating disorder should classify
subjects who sequentially or concurrently fulfil criteria for both anorexia and bulimia nervosa; g) avoidant/restrictive food intake disorder
should classify restricted food intake in children or adults that is not accompanied by body weight and shape related psychopathology; h) a
uniform minimum duration criterion of four weeks should apply.
Key words: Feeding disorder, eating disorder, classification, diagnostic stability, cross-cultural psychiatry, developmental psychopathology
The classification of feeding and eating disorders in the THE INTERNATIONAL CLASSIFICATION OF DISEASES
ICD-10 and DSM-IV is unsatisfactory. The deficiencies of
these systems are most evident in four facts. First, the major- The primary purpose of the International Classification of
ity of patients presenting with eating-related psychopathol- Diseases (ICD) is to facilitate the work of health profession-
ogy do not fulfil criteria for a specific disorder and are classi- als in various clinical settings across the world. Therefore, the
fied in the residual “other” or “not otherwise specified” cat- primary requisite for ICD diagnostic categories is clinical
egories. Second, most individuals with an eating disorder utility, and evidence from clinical and epidemiological re-
sequentially receive several diagnoses instead of a single di- search is given more weight than data from basic and etio-
agnosis that would describe the individual’s problems at logical research (1). Attention is paid to global cross-cultural
various developmental stages. Third, most recent clinical tri- validity and the needs of health professionals from medium
als have used modified diagnostic criteria that may better and low income countries (1).
reflect clinical practice, but deny the purpose of the classifi- Several conceptual directions have been proposed for the
cation as a means for communication between clinicians and ICD-11 (2). First, to reflect the growing evidence on continu-
researchers. Fourth, although childhood feeding disorders ity between child, adolescent and adult psychopathology, it
are typically described in the history of adolescents and has been proposed that the grouping of disorders with onset
adults with eating disorders, there is little research on the usually occurring in childhood and adolescence should be
developmental continuity between childhood, adolescent removed. Instead, disorders should be organized in group-
and adult disorders that involve aberrant eating behaviours. ings by psychopathology and a life-course approach should
Issues have also been raised about developmental and cul- be adopted to conceptualize child, adolescent and adult
tural dependencies of feeding and eating disorders as cur- manifestations of the same disorders.
rently conceptualized. Second, it has been agreed that the ICD-10 and DSM-IV
Given these problems, it is not surprising that the World contain an excessively large number of over-specified diag-
Health Organization (WHO) and the American Psychiatric noses, leading to artificially high rates of comorbidity and
Association are contemplating significant changes in classi- frequent use of the uninformative “not otherwise specified”
fication. A number of proposals for changes have been made. and “other” categories (2). It has been proposed that evi-
The purpose of this article is to summarize the issues in the dence is required not just for changing or adding diagnostic
classification of feeding and eating disorders, review relevant categories but also for retaining existing ones. The overuse of
aspects of evidence, and make proposals for modifications in the “not otherwise specified” categories should be reduced
the context of the development of ICD-11. by revising the boundaries of specific disorders to include
most clinically significant presentations.
Third, to best serve the clinical use, the ICD takes a pro-
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Author Year Treatment Comparator N Age group Target group Inclusion diagnostic criteria
CBT - Cognitive behaviour therapy; BMI - body mass index; ED - eating disorder; EDNOS - eating disorder not otherwise specified
tally specific manifestations would more accurately describe pean populations. In the last decade, reports on eating disor-
the course of these disorders and reflect the continuity be- ders and related conditions from various countries, including
tween child, adolescent and adult manifestations than the low income countries and countries undergoing sociocul-
current system. tural transitions (39-41), have accumulated which may in-
form a classification that is sensitive to local variation (42).
Anorexia nervosa occurs in all cultures, but the incidence
CULTURAL CONTEXT is higher among individuals who have been exposed to West-
ern culture and values and those who live in relative afflu-
Eating plays an important role in most cultures. Acceptable ence (40,41,43). For example, in the Caribbean island of
eating habits vary widely between religious and ethnic groups, Curaçao, all identified cases of anorexia nervosa were among
and eating disorders have been conceptualized as culture- young women of mixed ethnicity who had spent time in the
bound syndromes (38). In this context, it is notable that most USA or the Netherlands; there were no cases of anorexia
published research is based on North American and Euro- nervosa among the majority of young women in the island,
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CONCLUSIONS
References
We have reviewed published evidence relevant to the clas-
1. International Advisory Group for the Revision of ICD-10 Mental
sification of feeding and eating disorders, with particular em- and Behavioural Disorders. A conceptual framework for the revi-
phasis on clinical utility, response to treatment, prognosis, sion of the ICD-10 classification of mental and behavioural disor-
and developmental and cultural context. Based on this evi- ders. World Psychiatry 2011;10:86-92.
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