What are the diagnostic changes for anorexia nervosa across DSM‑III, DSM‑III‑TR, DSM‑IV, DSM‑5, DSM‑5‑TR, ICD‑10, and ICD‑11?

Diagnostic Evolution of Anorexia Nervosa Across DSM and ICD Versions

DSM-5 (2013) Represents the Most Clinically Relevant Diagnostic Framework

The most significant diagnostic change across DSM versions was the removal of the amenorrhea criterion in DSM-5, which expanded diagnostic applicability to males, prepubertal females, women using hormonal contraceptives, and postmenopausal women. 1

Core DSM-5 Diagnostic Criteria (Current Standard)

The American Psychiatric Association established three essential criteria in DSM-5 (2013): 2, 1

• Criterion A: Persistent restriction of energy intake leading to significantly low body weight (in context of age, sex, developmental trajectory, and physical health) 2, 1
• Criterion B: Either intense fear of gaining weight or becoming fat, OR persistent behavior that interferes with weight gain despite significantly low weight 2, 1
• Criterion C: Disturbance in the way one's body weight or shape is experienced, undue influence of body shape/weight on self-evaluation, OR persistent lack of recognition of the seriousness of current low body weight 2, 1

Key Changes from DSM-IV to DSM-5

Amenorrhea Criterion Removed

The most impactful revision was eliminating DSM-IV's Criterion D, which required absence of at least three consecutive menstrual cycles. 1 This change:

• Allowed diagnosis in males, prepubertal females, women using hormonal contraceptives, and postmenopausal women 1
• Research demonstrated that women meeting all other AN criteria except amenorrhea showed similar eating disorder behaviors, psychiatric comorbidity, and temperament characteristics 3

Weight Criterion Flexibility

DSM-5 replaced the rigid "less than 85% of expected weight" threshold with more flexible language specifying "significantly low body weight," enabling clinicians to consider multiple factors including growth charts, BMI percentiles in youth, and clinical context. 1

DSM Subtype Classifications

DSM-IV Through DSM-5-TR Subtypes

Both restricting and binge-eating/purging subtypes have been retained across DSM-IV, DSM-5, and DSM-5-TR: 4, 5

• Restricting type: Weight loss achieved primarily through dietary restriction, fasting, and/or excessive exercise 4
• Binge-eating/purging type: Regular engagement in binge eating and/or purging behaviors (self-induced vomiting, misuse of laxatives, diuretics, or other medications) 4

Critical distinction: Unlike bulimia nervosa, the binge-eating/purging subtype maintains significantly low body weight. 4

Subtype Validity Concerns

Research from the 1990s through 2010s questioned the clinical utility of these subtypes, as studies found minimal differences in personality characteristics, temperament, or eating disorder attitudes between restricting and binge/purging subtypes. 6, 7 However, the subtypes have been retained through DSM-5-TR.

DSM-III and DSM-III-R Historical Context

While the provided evidence does not detail specific DSM-III or DSM-III-R criteria, the evolution toward DSM-IV included: 5

• Introduction of the binge eating and severe food restriction subgroups in DSM-IV 5
• Recognition that different personality characteristics and behaviors warranted subtype classification 5

ICD Classification Systems

ICD-10 (1990s)

The evidence does not provide specific ICD-10 diagnostic criteria for anorexia nervosa, though ICD-10 predates the introduction of ARFID as a distinct category. 8

ICD-11 (2022)

While ICD-11 introduced ARFID as a new diagnostic entity distinct from anorexia nervosa, the specific anorexia nervosa criteria in ICD-11 are not detailed in the provided evidence. 8 ICD-11 emphasizes that ARFID differs from AN by the absence of body-image distortion and fear of weight gain. 8

Clinical Implications and Diagnostic Pitfalls

Broadening Criteria Increases Heterogeneity

Research demonstrates that broadening AN diagnostic criteria beyond DSM-IV standards results in: 3

• More heterogeneous samples with regard to eating disorder symptoms 3
• Increased psychiatric comorbidity variability 3
• Decreased heritability point estimates 3
• Women with broader AN definitions reported significantly fewer eating disorder behaviors than those meeting strict DSM-IV criteria 3

Differential Diagnosis Requirements

Clinicians must distinguish AN from: 1, 8

• Bulimia nervosa: AN patients maintain significantly low body weight 1, 4
• ARFID: Lacks body image disturbance or fear of weight gain 1, 8
• Binge eating disorder: No compensatory behaviors and no significantly low weight 1
• Medical causes: Inflammatory bowel disease, hyperthyroidism, malignancy lack the psychological features (fear of weight gain, body image disturbance) 1

Gastroenterological Presentations

Patients presenting to gastroenterologists often lack typical AN presentations, with delayed gastric emptying of solids and delayed small/large bowel transit commonly described. 2 Mega-duodenum and absent propagating MMCs have been reported, improving with increased nutritional intake. 2