Diagnostic Comparison of DSM-5-TR and ICD-11 for Binge-Eating Disorder
ICD-11 demonstrates superior clinical utility for diagnosing binge-eating disorder by reducing subthreshold diagnoses from 21% to 5% compared with DSM-5-TR, primarily through its inclusion of subjective binge episodes, while maintaining equivalent convergent validity across demographic features, clinical severity, and mental health-related quality of life. 1
Strengths of ICD-11
Diagnostic Inclusivity and Clinical Utility
ICD-11 captures 95% of patients within full-threshold BN or BED categories, compared with only 79% using DSM-5 criteria, reducing "other specified" diagnoses by 16 percentage points. 1
In a multinational field study of 2,288 practitioners, ICD-11 achieved higher diagnostic accuracy and greater perceived clinical utility for feeding and eating disorders compared with ICD-10. 2
Clinician satisfaction ratings were high: 82.5–83.9% rated ICD-11 as "quite" or "extremely" easy to use, accurate, clear, and understandable. 2, 3
Inclusion of Subjective Binge Episodes
ICD-11 includes subjective binges (episodes perceived as excessive by the patient but objectively smaller in quantity) in the definition of BED, whereas DSM-5 requires objectively large amounts of food. 4
Among 3,863 eating disorder inpatients, 121 patients (approximately 3%) received an ICD-11 diagnosis of BN or BED specifically because of subjective binges, preventing misclassification as subthreshold disorders. 4
In an Australian community sample of 2,977 individuals, the estimated prevalence of BED was lower when applying DSM-5 criteria than ICD-11 criteria, largely due to DSM-5's stricter Criterion B binge-eating specifiers, indicating that DSM-5 may miss clinically significant cases in epidemiological surveys. 5
Longitudinal Monitoring Capabilities
ICD-11 permits coding of episodicity (first episode, multiple episodes, continuous course) and current clinical status (currently symptomatic, partial remission, full remission), enabling tracking of disease patterns over time. 2
Course qualifiers allow differentiation between episode types, facilitating longitudinal monitoring that is absent in DSM-5-TR's categorical framework. 2
Weaknesses of ICD-11
Lack of Dimensional Specifiers for BED
- ICD-11 does not provide specific dimensional qualifiers for binge-eating disorder, despite having such capabilities for other disorder categories, limiting granular symptom tracking. 2
Methodological Limitations of Validation Studies
Field studies used self-selected online participants, introducing selection bias that may inflate utility ratings because clinicians favorable toward ICD-11 were more likely to enroll. 6, 2, 7
Study vignettes were prototypic and lacked real-world complexity (e.g., comorbidities), raising concerns about generalizability to routine clinical practice. 6, 2, 7
When new diagnostic categories (including ARFID and other novel entities) were excluded from analysis, ICD-11 showed no statistically significant advantage over ICD-10 in diagnostic accuracy, goodness-of-fit, or clarity, suggesting that improvements may be limited to newly introduced disorders rather than established categories like BED. 6, 2, 7
Absence of Neurobiological Validation
Like DSM-5-TR, ICD-11 remains symptom-based without neurobiological markers or genetic risk data, limiting biologically-targeted interventions. 2, 3, 7
The lack of biological grounding produces diagnostically heterogeneous groups within the same category that cannot guide treatment selection based on underlying mechanisms. 2, 3, 7
Strengths of DSM-5-TR
Administrative Efficiency
- The categorical framework of DSM-5-TR streamlines administrative processes such as insurance reimbursement, treatment authorization, and billing, which remain the dominant workflow in most healthcare systems. 2, 3
Specificity of Binge-Episode Criteria
DSM-5 Criterion B specifies five associated features of binge episodes (eating rapidly, eating until uncomfortably full, eating large amounts when not hungry, eating alone due to embarrassment, feeling disgusted/depressed/guilty afterward), providing operational definitions that may enhance diagnostic specificity. 8
In a community sample of 80 individuals, "feeling disgusted/depressed/guilty" was the only unique predictor of distress regarding bingeing (p = 0.001), and receiver-operating characteristic curves identified three features as the optimal threshold for predicting clinically significant distress. 8
Weaknesses of DSM-5-TR
Exclusion of Subjective Binges
DSM-5-TR's requirement for objectively large amounts of food excludes patients who experience subjective loss of control over smaller quantities, resulting in underdiagnosis of clinically significant BED. 5, 4
In an Australian epidemiological sample, cases of BED were missed when using the stricter DSM-5 criteria compared with ICD-11, particularly in community surveys where subjective binges are common. 5
High Rate of Subthreshold Diagnoses
The strict categorical approach leads to 21% of patients being classified as "other specified feeding or eating disorder" (OSFED), compared with only 5% using ICD-11. 1
Approximately 60% of anxiety-disorder presentations are similarly uncategorized in DSM-5, a limitation that extends to eating-disorder diagnoses including BED. 2
Limited Dimensional Assessment
- DSM-5-TR provides limited dimensional assessment of symptom severity or longitudinal course, restricting monitoring of treatment response over time. 2
Low Internal Consistency of Associated Features
- In a community-based validation study, internal consistency reliability for the five Criterion B indicators was low, and several features demonstrated low or nonsignificant associations with distress and clinical diagnosis, raising questions about their collective validity. 8
Shared Limitations of Both Systems
Absence of Overvaluation of Shape and Weight as a Criterion
Neither DSM-5-TR nor ICD-11 includes overvaluation of shape and weight as a diagnostic criterion for BED, despite systematic review evidence (N = 93 studies) showing that overvaluation is more severe in BED than in individuals with similar high BMI alone, is comparable in severity to that in anorexia nervosa and bulimia nervosa, and predicts poorer treatment outcomes. 9
Overvaluation of shape and weight is a risk factor for the onset of binge eating in adolescents and is positively associated with other psychiatric symptoms, yet its omission from diagnostic criteria may lead to failure to address this construct during treatment. 9
Lack of Neurobiological Validation
- Both classification systems lack neurobiological validation, resulting in diagnostically heterogeneous groups that cannot guide treatment based on underlying mechanisms. 2, 3, 7
Cultural Insensitivity
Symptom specifications may be culturally insensitive, potentially producing false-negative diagnoses in populations whose binge-eating patterns differ from Western constructs. 2
Both systems may miss culturally variant conceptualizations of binge eating, risking misclassification of culturally appropriate eating patterns as pathological. 2
Insufficient Treatment-Outcome Data
- Neither system has robust treatment-outcome data to validate diagnostic boundaries or inform evidence-based intervention selection for BED. 2
Algorithmic System Selection Strategy
Choose ICD-11 When:
Clinical utility, dimensional symptom tracking, and longitudinal monitoring are paramount for treatment planning. 2
You are conducting epidemiological research or community screening where subjective binges are prevalent and must be captured. 5
You need to reduce the proportion of subthreshold diagnoses and maximize full-threshold diagnostic capture. 1
Choose DSM-5-TR When:
Administrative priorities (insurance billing, reimbursement, treatment authorization) dominate clinical workflow. 2, 3
You require operational specificity of binge-episode features to guide structured assessment. 8
Your practice setting mandates DSM-5-TR for regulatory or institutional compliance.
Hybrid Documentation Approach:
- Record symptom severity and episode status using ICD-11 longitudinal qualifiers at each assessment while retaining the DSM-5-TR categorical label for billing purposes. 3
Critical Pitfalls to Avoid
Do not exclude patients who report subjective loss of control over smaller food quantities from a BED diagnosis; these presentations are clinically significant and meet ICD-11 criteria. 5, 4
Do not rely solely on unstructured clinical interviews; use structured screening tools to improve detection reliability, particularly for the five DSM-5 Criterion B features. 2, 8
Do not overlook overvaluation of shape and weight during assessment and treatment planning, even though it is not a formal criterion; failure to address this construct predicts poorer outcomes. 9
Avoid forcing a categorical BED diagnosis when presentations are partial or atypical; consider "other specified" or "unspecified" feeding/eating disorder categories in DSM-5-TR, recognizing that ICD-11 reduces the need for such classifications. 2, 1
Actively assess for culturally variant manifestations of binge eating that may not fit standard criteria, as both systems risk pathologizing culturally appropriate eating patterns. 2
Do not assume that meeting three of the five DSM-5 Criterion B features is sufficient; receiver-operating characteristic analysis indicates this is the optimal threshold for predicting distress, but individual features vary in predictive validity. 8