DSM–5

View and Comment on Recently Proposed Changes to DSM–5

The following proposal was approved by the DSM Steering Committee and are being posted for a 45-day public comment period.

Comment Period Opens: October 15, 2018

Comment Period Closes: November 29, 2018

Comment on Proposed Changes

Proposal: Text Change to the Diagnostic Criteria and Diagnostic Features for Avoidant/Restrictive Food Intake Disorder

Issue

The DSM Steering Committee received a proposal requesting that changes be made to DSM-5 Criterion A and the "Diagnostic Features" text for Avoidant/Restrictive Food Intake Disorder (ARFID).

ARFID was intended to capture a range of presentations of individuals, often children and adolescents, who substantially restrict their food intake and experience significant associated physiological or psychosocial problems, but do not meet criteria for any other DSM-5 feeding or eating disorder. It has become clear that there is a problem with the wording of Criterion A for ARFID. As written, this criterion violates the basic DSM criteria construction principle that sub-criteria (A.1 through A.4) are manifestations of the "stem" criterion (i.e., the text appearing before the sub-criteria; in this case, the part starting with "An eating or feeding disturbance…"). As written, criterion A.4 ("Marked interference with psychosocial functioning") is not a manifestation of the stem (which, as written, requires "failure to meet appropriate nutritional and/or energy needs"). Thus, whether Criterion A is considered to be fulfilled may depend on whether the DSM user pays attention to the stem and realizes that failure to meet appropriate nutritional or energy needs is required for all cases, or as is likely to be true of many if not most DSM users, just focuses on the sub-criteria as manifestations of the stem and ignores the text of the stem.

The lack of clarity inherent in the current wording of Criterion A creates significant potential problems. From a clinical perspective, individuals who might benefit from receiving this diagnosis for treatment planning and insurance reimbursement may not do so, and there is no recognized category in DSM-5 which might be used instead (other than Other Specified Feeding or Eating Disorder). From a research perspective, emerging data about ARFID may vary depending on research groups’ differing interpretations of Criterion A, leading to confusion about the characteristics, course of illness, and treatment response of individuals with ARFID.

For these reasons, the proposed change to ARFID is to allow individuals who satisfy Criterion A solely on the basis of A.4 to receive a diagnosis of ARFID if their symptoms also fulfill Criteria B-D.

The Fixes

DSM-5 p.334:

Diagnostic Criteria       307.59 (F50.8)

  • A.   An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following:
    1. Significant weight loss (or failure to achieve expected weight gain or faltering growth in children).
    2. Significant nutritional deficiency.
    3. Dependence on enteral feeding or oral nutritional supplements.
    4. Marked interference with psychosocial functioning.
  • B.   The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice.
  • C.   The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced.
  • D.   The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder. When the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention.
  • Specify if:
    In remission: After full criteria for avoidant/restrictive food intake disorder were previously met, the criteria have not been met for a sustained period of time.

DSM-5 p. 334-335:

Diagnostic Features

Avoidant/restrictive food intake disorder replaces and extends the DSM-IV diagnosis of feeding disorder of infancy or early childhood. The main diagnostic feature of avoidant/restrictive food intake disorder is avoidance or restriction of food intake (Criterion A) manifested by clinically significant failure to meet requirements for nutrition or insufficient energy intake through oral intake of food and/or significant social impairment. One or more of the following key features must be present: significant weight loss, significant nutritional deficiency (or related health impact), dependence on enteral feeding or oral nutritional supplements, or marked interference with psychosocial functioning. The determination of whether weight loss is significant (Criterion A1) is a clinical judgment; instead of losing weight, children and adolescents who have not completed growth may not maintain weight or height increases along their developmental trajectory.

Determination of significant nutritional deficiency (Criterion A2) is also based on clinical assessment (e.g., assessment of dietary intake, physical examination, and laboratory testing), and related impact on physical health can be of a similar severity to that seen in anorexia nervosa (e.g., hypothermia, bradycardia, anemia). In severe cases, particularly in infants, malnutrition can be life threatening. "Dependence" on enteral feeding or oral nutritional supplements (Criterion A3) means that supplementary feeding is required to sustain adequate intake. Examples of individuals requiring supplementary feeding include infants with failure to thrive who require nasogastric tube feeding, children with neurodevelopmental disorders who are dependent on nutritionally complete supplements, and individuals who rely on gastrostomy tube feeding or complete oral nutrition supplements in the absence of an underlying medical condition. Inability to participate in normal social activities, such as eating with others, attending school or work or to sustaining relationships as a result of the disturbance would indicate marked interference with psychosocial functioning (Criterion A4). Substantial disruption of family functioning, such as marked restriction of foods permitted in the home or inordinate accommodations to provide foods from specific grocery stores or restaurants, may also satisfy Criterion A4.

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