Classification of feeding and eating disorders: review of evidence and proposals for ICD‐11

The classification of feeding and eating disorders in the ICD-10 and DSM-IV is unsatisfactory. The deficiencies of these systems are most evident in four facts. First, the majority of patients presenting with eating-related psychopathology do not fulfil criteria for a specific disorder and are classified in the residual “other” or “not otherwise specified” categories. Second, most individuals with an eating disorder sequentially receive several diagnoses instead of a single diagnosis that would describe the individual's problems at various developmental stages. Third, most recent clinical trials have used modified diagnostic criteria that may better reflect clinical practice, but deny the purpose of the classification as a means for communication between clinicians and researchers. Fourth, although childhood feeding disorders are typically described in the history of adolescents and adults with eating disorders, there is little research on the developmental continuity between childhood, adolescent and adult disorders that involve aberrant eating behaviours. Issues have also been raised about developmental and cultural dependencies of feeding and eating disorders as currently conceptualized. Given these problems, it is not surprising that the World Health Organization (WHO) and the American Psychiatric Association are contemplating significant changes in classification. A number of proposals for changes have been made. The purpose of this article is to summarize the issues in the classification of feeding and eating disorders, review relevant aspects of evidence, and make proposals for modifications in the context of the development of ICD-11. The primary purpose of the International Classification of Diseases (ICD) is to facilitate the work of health professionals in various clinical settings across the world. Therefore, the primary requisite for ICD diagnostic categories is clinical utility, and evidence from clinical and epidemiological research is given more weight than data from basic and etiological research 1. Attention is paid to global cross-cultural validity and the needs of health professionals from medium and low income countries 1. Several conceptual directions have been proposed for the ICD-11 2. First, to reflect the growing evidence on continuity between child, adolescent and adult psychopathology, it has been proposed that the grouping of disorders with onset usually occurring in childhood and adolescence should be removed. Instead, disorders should be organized in groupings by psychopathology and a life-course approach should be adopted to conceptualize child, adolescent and adult manifestations of the same disorders. Second, it has been agreed that the ICD-10 and DSM-IV contain an excessively large number of over-specified diagnoses, leading to artificially high rates of comorbidity and frequent use of the uninformative “not otherwise specified” and “other” categories 2. It has been proposed that evidence is required not just for changing or adding diagnostic categories but also for retaining existing ones. The overuse of the “not otherwise specified” categories should be reduced by revising the boundaries of specific disorders to include most clinically significant presentations. Third, to best serve the clinical use, the ICD takes a prototypic approach in which presentations characteristic of each diagnostic category are described in a narrative format, which most health professionals find easier to use in practice 3,4. The ICD avoids the use of exact count, frequency and duration criteria to modulate diagnostic thresholds. Since most duration criteria for various disorders are not based on evidence and are difficult to memorize and apply, it has been proposed that a uniform duration criterion of four weeks should be adopted, with qualified exceptions for disorders which require rapid clinical attention (e.g., delirium, mania and catatonia) or that manifest by relatively brief events (e.g., intermittent explosive disorder). Fourth, it has been proposed that categories with some evidence of clinical usefulness, but insufficient evidence for validity of specific criteria, should be included in the main body of the ICD, but signposted as categories that require further testing. Fifth, to reflect the evidence that most mental disorders are multifactorial, it is proposed to remove the distinction between organic and functional forms of disorders. The most important reason against changing the current diagnostic criteria is that it could invalidate available evidence. It is therefore important to assess the clinically relevant evidence and its relationship to classification. We have reviewed recent clinical trials on treatments of eating disorders published in six influential child and general psychiatry journals (Journal of the American Academy of Child and Adolescent Psychiatry, Journal of Child Psychology and Psychiatry, American Journal of Psychiatry, Archives of General Psychiatry, British Journal of Psychiatry and Psychological Medicine) between January 2000 and May 2011. We identified 18 clinical trials (Table 1). Seven trials tested treatments for anorexia nervosa. Of these, three (published between 2000 and 2003) used “strict” DSM-IV or ICD-10 criteria. Four more recent trials (published between 2005 and 2010) used broader criteria, relaxing the weight and/or the amenorrhoea criterion. Eleven trials tested treatments for bulimia and related conditions. Three of these (published between 2000 and 2003) applied “strict” DSM-IV or DSM-III-R criteria. Eight of these trials (published between 2001 and 2009) used broader criteria, including bulimic-type eating disorders not otherwise specified or all eating disorders without underweight in addition to bulimia nervosa. We conclude that the clinical trial literature reflects the deficiencies of the current diagnostic systems by broadening the diagnostic criteria in attempts to reflect clinical reality. No clinical trial published in the last seven years in the six journals used DSM-IV or ICD-10 criteria exactly. The result is that inclusion criteria differ between trials and the classification has effectively lost its purpose in defining the same group of patients across research studies and clinical settings. We conclude that changes in classification will not invalidate useful evidence, because most recent evidence is based on modified diagnostic criteria. An important issue is the relationship between feeding and eating disorders. Feeding problems and selective eating in childhood have been described in the history of patients with eating disorders since the early case reports 23, but there has been little research on the continuity between feeding and eating disorders. The available research a of continuity of eating problems from to in a large feeding problems in and in childhood anorexia in with of and bulimia the evidence is to a that history of and rapid eating in childhood more in with bulimia than in of individuals with feeding disorders in childhood are the same clinical that the between feeding disorders of childhood and eating disorders is the there is a for and to with eating disorders the adults presenting with and selective eating the and related psychopathology that eating disorders and may be better described by criteria of feeding disorders It has been that between child and adult manifestations of eating-related psychopathology have been by the that existing criteria are applied without to developmental is most in the for and body It has been that and some adolescents may not be to and to for It has been proposed that of should be as a for are by clinicians or by or adults of the child weight and or aspects of in be as of with weight and in the context of eating behaviours. the case of anorexia it has also been that and developmental of the same disorder and adolescents usually with the and in a of individuals at The of evidence that a single classification applied across and to specific manifestations would more describe the of these disorders and reflect the continuity between child, adolescent and adult manifestations than the current an important in most eating between and and eating disorders have been as this it is that most published research is based on American and the last reports on eating disorders and related from various including low income countries and countries have which may a classification that is to in all but the is individuals have been to and and in in the of all identified of anorexia of in the or the there of anorexia the majority of in the are and not been is relatively in the and the the the of anorexia the of the that with to and addition to on also the of anorexia nervosa. in a of patients with anorexia and as a for eating presentations with weight and and of weight have also been in most and the rates of anorexia in are between countries and is evidence that patients with of weight and that the of patients of weight with to cultural that and anorexia are manifestations of the same Therefore, it is that of weight is not required for the diagnosis of anorexia that underweight or psychopathology of eating disorder are has been as to The disorder is more individuals to and in all of bulimia in low income the to be in countries than in and The of bulimia in with to and and with the of Therefore, the of bulimia and its from have to be cultural by the use of in should not be but the use of the same in the context of psychopathology and the events is a of an eating disorder The for a body may also on in a body be as a that may a and is little evidence on cultural in have an on the and the patients with bulimia to to to the same treatments as eating disorder is relatively across countries and but of in with eating disorder are on have related to body and a frequent history of bulimia but of and to with the same diagnosis the between weight and and general psychopathology across modifications of diagnostic criteria are the rates of with eating disorder that of clinicians to eating disorders in is studies of anorexia and bulimia have that a significant of diagnostic to eating disorder are more in the years of and a anorexia anorexia to bulimia in the is of individuals with an diagnosis of anorexia bulimia a of with an diagnosis of bulimia anorexia of with an diagnosis of bulimia eating disorder or eating disorder not otherwise specified are also between specific eating disorder categories and with the an on the to The diagnostic may also to a relationship between feeding disorders in childhood and eating disorders in adolescence and eating and are in and adolescents deny of these by of but weight and receive a diagnosis of an eating disorder a significant of diagnostic of from an anorexia to bulimia a of anorexia a years eating disorders, diagnostic are the with most patients for at several years changing diagnostic or more and are with more diagnostic in eating disorders these rates of it is that the diagnoses of the same disorder than disorders. The comorbidity of various eating disorders is an of a of specified diagnostic categories with ICD-10 and the various eating disorder categories are be at the same there is for diagnoses, and ICD-10 DSM-IV takes the of psychopathology of is unsatisfactory. the it an of an of on the it important it patients with current bulimia a history of anorexia is with reduced of and of anorexia It has been proposed that bulimia should be to history of anorexia A more to the of comorbidity may require on frequent changes of diagnostic categories (e.g., the diagnosis of anorexia may be for a weight or a eating disorder category to that sequentially fulfil criteria for anorexia and bulimia and have a to presentations. Feeding disorders of and eating disorders of are classified in of ICD-10 and Feeding disorders of include of and selective of with or without or eating of classification has problems as it with boundaries from eating disorders and and more specific that in and adults of feeding disorders have been that to this category as four to six specific categories and/or the context of feeding and the of primary The problems are that the specific a large number of clinical presentations and some require of a single to disorders that are a of these proposals has been The is for and which are relatively of these are frequent in adults and in the context of mental disorders (e.g., and and It is proposed that and disorder should be based on and of disorder has been proposed to the category of feeding disorder of or early childhood in include adolescent and adult presenting with for related to the or of eating specific of than on body weight and with anorexia in of and the but in psychopathology and for include of of specific or or to a number of specific of because of health is typically not with of body Since there is in eating and from is a should be the eating is a of that may be with in or in or development of the in that are by large of as or do not a for The proposed category with the general of feeding and eating disorders and diagnostic categories to all It also an category for some that the diagnosis of Since is a that it is included in ICD-11 as a category that further testing. the boundaries between and anorexia including the and between and specific to be It is also that the inclusion of will research on continuity between child and adult presentations. eating of as or or ICD-10 and is included the disorders with onset usually occurring in childhood and and adult presentations are (e.g., as an Since to attention in it is proposed that there are for its diagnosis a diagnosis it is to (e.g., or not events (e.g., or practice (e.g., eating of in and is not by mental disorder (e.g., or disorder). also in and should not be in it is of or health disorder from to the and or It included in ICD-10 and DSM-IV the of Since is used to describe a changing the to to disorder classified in the of disorders with onset specific to childhood, but it to attention in Therefore, it should be without The of eating disorders has the of anorexia and bulimia nervosa. DSM-IV criteria are applied to patients presenting to eating disorders the most diagnosis is The of patients with is across settings and with of patients to child, adolescent or adult eating disorders classified as is between anorexia bulimia eating and eating this not the since the diagnoses of anorexia and bulimia are and of patients receive the “other” or residual diagnoses is also about the of anorexia anorexia is as a that anorexia but not fulfil all of the diagnostic criteria (e.g., there is amenorrhoea or not a of weight the the anorexia is used more to describe an eating disorder with significant underweight but about body or weight these it is that ICD-10 is as as The of the current problems is that criteria for specific eating disorders, as anorexia and bulimia are and the of eating disorders are by the of all criteria, than a number of a of the diagnosis of of but the diagnosis of anorexia four of four of weight body and means that of the four is are as the otherwise anorexia nervosa. A significant of is of of include anorexia without anorexia without of anorexia not the weight bulimia with that are not do not involve an of that is than most would bulimia without bulimia without eating and bulimia with and occurring than a for three in a for eating disorders, anorexia and bulimia for of most patients with is for several First, is a group in of and Second, most of a of an eating disorder in individuals criteria for anorexia or bulimia at Third, the residual of this category that it is a with the and a including in has specific for or has been an to a that would be for most of eating disorders, but the published evidence on this eating disorders with underweight and better a broader category of bulimia A approach has been in recent clinical trials in bulimia which also included We conclude that use of would be and A number of proposals have been to the on proposals include broadening of diagnostic criteria for anorexia and bulimia that a of currently with The proposed of criteria for anorexia the for relaxing the underweight and relaxing the for of weight The proposed broadening of criteria for bulimia include the frequency for and and the criterion that a eating an large of studies in adolescents and adults that the criterion has the on the use of the residual category on the of the categories the use of or its use The of proposals include more specific diagnostic categories. is most for the of eating disorder proposed categories include disorder and eating A category of eating disorder with of anorexia and bulimia has been proposed to the that do not the of specific eating disorder there is a that relaxing the that all defining be to make a diagnosis and a of of which or more needs to be to fulfil a diagnostic criterion all of the proposals and each would the for it is difficult to the of aspects of the various are also problems with some of the proposals the classification proposed by and the from current by the for all to be but it anorexia and it relatively as and to the about it would against disorders from the of eating disorder as an specific category with broadening of diagnostic criteria, to the by and which has been to the use of and is with recent in clinical trial literature (Table 1). It is disorder or eating will be the criteria for anorexia bulimia and eating disorder are The available evidence that most individuals with disorder have therefore the of for an large of to be a may be to most of these as bulimia which not differ from disorder in of and to of eating be the category of eating The issue that and sequentially fulfil criteria for eating disorders. by the use of a to broader specific category for the relatively that fulfil criteria for anorexia and bulimia or category may be more than eating is the eating disorder that has been described since the ICD-10 and it is by four criteria, all of which are required for Three of these are the same in the low body weight at body or of weight for and body and The criterion between the in it is a that low weight is and/or in of weight or is anorexia is further and have been for several First, the of all four criteria a significant of clinical presentations that the of anorexia nervosa. The of low body weight and have all been on this Second, these criteria are to cultural of weight is by a of in Third, it has been that criteria which is a in the of anorexia The problems with diagnostic criteria are in the that most recent clinical trials have used broader inclusion criteria, relaxing the weight and amenorrhoea criteria (Table 1). We will review the for retaining or each specific criterion and to the diagnostic and proposals for as of three is a of anorexia that is with underweight and and may have for and several make amenorrhoea as a diagnostic criterion. First, it is not to to to and The ICD-10 has proposed a of manifest as of and which is or and to the diagnosis is Second, a significant of to in clinical otherwise fulfil criteria for anorexia and require clinical attention and are classified as Third, the of three with diagnosis and is a that amenorrhoea should not be required for the diagnosis of anorexia but should be since it may be an of and may between and anorexia The low weight criterion is the defining of anorexia but its exact has been A number of the of anorexia the weight criterion of body weight than of is for and and are classified as on body the for underweight may be as high or low in Therefore, it has been proposed that this should be and/or to clinical has the of the use of the uninformative but of and important underweight has been to be a of and and is used as an for We relaxing the underweight criterion to the of underweight with a for clinical and a history of underweight (e.g., as a low body body weight is a of anorexia it is the individual's eating than as a or of of weight is required for anorexia in the the of is included the criterion. has been the most criterion. The of of is from a developmental and a cultural of weight is by and may require an of that adolescence with otherwise anorexia in countries of as the reason for in a significant of patients of weight and are classified as It has also been that weight in patients of weight The on and against the of weight as a diagnostic criterion. it has also been that of weight is of the defining psychopathology of anorexia We this criterion to include with body weight and with and and that are to or is a of anorexia and is required in ICD-10 and It the of body or its as than are and the of of the of and its weight has of this criterion has been for and with retaining this criterion of eating with body related psychopathology may better be classified as is a of of anorexia and is a from of is not the criteria in ICD-10 or inclusion the of anorexia has been since is not in all of otherwise anorexia and its may on of to include it as a which may between anorexia and in with the anorexia is further classified and to the of and behaviours. has been since the developmental of the same and do not and adolescents usually with in the majority at has been to in some studies but not in anorexia has a high of diagnostic with bulimia diagnosis that anorexia with and should be classified as eating The proposed category of eating will include that classified as anorexia as as that clinically significant and described in as a of anorexia and as a ICD-10 and bulimia is by three and with body weight or all of which are required for the bulimia is a category that is used in practice and its has a evidence various aspects of the eating criterion have been for the diagnosis and in a of patients with problems classified as The for a broader diagnostic category is in the clinical trial with of the recent trials broader criteria (Table 1). The aspects of the that have been in these trials and in the literature are the of in a eating and the frequency of behaviours. We the of ICD-10 and DSM-IV that eating is an large of is in and the of eating to eating or the or of a number of reports have the that patients eating of that may but are large of eating that are by of but do not involve eating an large of are described as A number of studies have patients presenting with and and little or clinically eating may be with body and and eating a of comorbidity are with of and have a to The literature that of of eating is the defining of eating that is with psychopathology and of of the of in adults and It has therefore been proposed that the for an large of should be the for an large of is the that the use of and most presentations to be classified as bulimia The of the diagnostic criteria is the frequency of and that is required for the criterion is in ICD-10 and ICD-10 eating and to be DSM-IV a frequency of for at three there is a general that the diagnosis should not be applied to with of there is evidence a specific and most and clinicians or the frequency criterion Since there to be between or more a a or of the frequency criterion to be in the frequency to a on its has a relatively in with eating it to a in the use of The for of or an of body weight and on is in most adult but may be in and in It is proposed that this criterion be applied include and and as of specific psychopathology the bulimia is further classified and The is by that are to and and a relatively of patients with bulimia nervosa. practice, of bulimia is little used and there is evidence to its validity or of bulimia to be between bulimia and eating disorder It has been proposed to or to remove the from the of that bulimia the would that classified as bulimia would be as eating An has been to bulimia based on the history of anorexia which has more validity We this be applied as of the eating the of evidence retaining in the of bulimia nervosa. eating by eating without described in but a of clinical and research attention in the last It not included in but in DSM-IV as a diagnosis in of further testing. Since a large body of research has and eating disorder is a and useful category eating disorder is with with of individuals eating disorder with mental disorders, and has been to be from these and not a of general psychopathology The distinction between eating disorder and bulimia is and in the categories may of the same disorder with eating disorder are on than of bulimia and have a history of a diagnosis of bulimia weight and are not required for the diagnosis of eating are of the in bulimia the specific diagnostic criteria for eating disorder have been a of it required that eating in eating an of that is than most individuals would in a and that the of eating to eating or the or of to in bulimia it that of is the defining of the of is it is useful as a defining because eating of that are not large but are large by the are with psychopathology and eating is by eating because of eating of and of and DSM-IV that eating is with and the validity of this criterion is The duration of a of eating last than but eating has been described as The DSM-IV further required that eating be in at for at six to be little evidence this frequency and the Since eating disorder is with rapid weight six the diagnosis may be It has been that relaxing the frequency criterion to a would to in the of eating disorder there is a that eating disorder is a and useful It is proposed that eating disorder be included in ICD-11. It is also proposed that the diagnostic criteria for eating disorder be to include that do not involve eating an large of as as there is of eating is from eating and is specific evidence to the proposed uniform duration criterion. Therefore, the diagnosis of eating disorder may be eating for at four duration may be to clinical addition to the feeding and eating disorders described the ICD-11 should include a to disorders that are classified but may with The most is which is by a of the of a on and is classified in of ICD-10 and with and eating of but also We have reviewed published evidence relevant to the classification of feeding and eating disorders, with on clinical utility, to and developmental and cultural on this evidence, make with the general directions for the development of ICD-11. The are in 2. We that the proposed changes will the clinical of the classification of feeding and eating disorders, will the for uninformative “not otherwise specified” diagnoses, and will research on continuity between child and adult presentations and on in of patients that the majority of presenting with eating related psychopathology in clinical settings. article has been by the of the on Classification of and in and to the International for the of ICD-10 and is the of this for this group as a reflects the work and of the for its The and for on of this

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