The Impact of Changes in the Diagnosis of Binge Eating Disorder

| November 26, 2013 | 0 Comments

This column is dedicated to covering a variety of topics relevant to the multidisciplinary care of the bariatric surgical patient.

Column Editor: Karen Schulz, RN, CBN, MSN
President of the Integrated Health Section of the ASMBS; Clinical Nurse Specialist, Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, Ohio.

This Month: The Impact of Changes in the Fiagnosis if Binge Eating Disorder

by Dene Berman, PhD, ABPP

Dr. Berman is a Board Certified Clinical Psychologist. He is the Clinical Director of Lifespan Counseling Associates in Beavercreek, Ohio and Clinical Professor in the School of Professional Psychology, Wright State University, Dayton, Ohio.

Financial disclosures: The author reports no conflicts of interest relevant to the content of this article.

With the introduction of Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, there is a change from Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition in the diagnostic criteria for binge eating disorder from two or more incidences per week over six months to one or more incidences per week for at least three months. These changes are likely to result in the diagnosed incidence rate of binge eating disorder. Moreover, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition diagnosis for binge eating disorder may conflict with the Health Insurance Portability and Accountability Act of 1996 mandate of using The International Classification of Diseases, Ninth Revision, Clinical Modification now and The International Classification of Diseases, Tenth Revision, Clinical Modification in the forthcoming year.

Binge eating was first described in 1957 as a condition that involved eating large amounts of food without a regular pattern and in an orgiastic manner.[1] Following this early attempt to define binge eating, views of the phenomenon ranged from overindulgence to “a true problem, something that has a negative impact on many aspects of life.”[2]

In 1994, with the publication of Diagnostic and Statistical Manual of Mental Disorders, Fourth Editon (DSM-IV),[3] binge eating disorder (BED) was classified as an eating disorder, not otherwise specified (NOS), with its criteria in an appendix as a proposed new category with recommended diagnostic criteria. Those criteria included the following: eating a larger than average amount of food over a distinct period of time accompanied by a feeling of loss of control over eating. In addition, these incidences were specified to meet three of the five following conditions: rapid eating; feeling uncomfortably full; eating large amounts when not feeling physically hungry; eating alone because of embarrassment over the amount one is eating; and feelings of disgust, depression, or guilt over one’s overeating. Two other criteria were also required to be present: marked distress and an ongoing pattern of binge eating at least twice a week for six months.

With the very recent publication of DSM-5,[4] BED is offered as a new, stand-alone category of psychiatric disturbance. While many of the criteria have not changed from DSM-IV, the main change is in the frequency and duration of bingeing. The new criteria require an ongoing pattern of at least once a week (as opposed to twice a week) for a duration of three months (versus six months).

The implications of adopting this change in the assessment of prospective bariatric surgery patients is that a much greater percentage of patients is likely to receive the diagnosis of BED than ever before. Although some studies suggest that there is no relationship between pre-surgery binge eating and post-surgery weight loss,[5,6] others report a negative relationship between BED and post-surgical weight loss.[7–9] To the extent that some sources call for pre-surgical counseling for patients with BED,[10] loosening the criteria for BED may well delay surgery for many patients. Moreover, it could also add a barrier to surgery for some patients.

If DSM-5 criteria for BED were more reliable or valid than other criteria, a case could be made for adopting the new criteria. However, the new criteria are not without controversy in this regard. For example, Allen Frances, the chairperson of the Taskforce for DSM-IV, was recently quoted at the American Psychiatric Association meeting as saying, “DSM-V will result in the mislabeling of potentially millions of people who are basically normal… and turn gluttony into binge eating disorder.”[11]

Prior to the release of DSM-5, the director of the National Institute of Mental Health (NIMH) rejected DSM-5, saying, “patients with mental disorders deserve better.”[12] He went on to announce a framework that NIMH will be using to create a new diagnostic system. The British Psychological Association has also been highly critical of the DSM-5, in part claiming that DSM-5 labels some behaviors that “do not meet the criteria for categorization demanded for a field of science or medicine.”[13]

There are other guidelines for diagnosing BED. For example, the National Institute for Clinical Excellence in the United Kingdom has published a clinical guideline on the treatment of eating disorders. Regarding BED, this guideline makes reference to DSM-IV, but omits any reference to the frequency or duration of episodes.14 By omitting the number of episodes per week or the number of months necessary for a diagnosis of BED, this guideline maintains some, but not all, of the DSM-IV and DSM-5 criteria.

There is no mandate for mental health practitioners to use DSM-IV or DSM-5. In fact, in the United States, ICD-9 Clinical Modification (CM) codes have been mandated by the Health Insurance Portability and Accountability Act of 1996 (HIPAA; Public Law 104-191) for HIPAA standard transactions, including third-party billing and reporting.[15] While consistent with DSM-IV, the two sets of codes are not identical. In October of 2014, all healthcare providers will be required to use ICD-10 CM codes.[16] The codes for BED are identical for DSM-IV (eating disorder, NOS) and ICD-9 CM (eating disorder, unspecified)—307.50. With DSM-5, the new code for eating disorder is 307.51, and for ICD-10 CM, the diagnostic category of overeating associated with other psychological disturbances has the code F50.4.17

Thus, the current state of changing diagnostic systems leaves many questions unanswered. While there is currently consistency between DSM-IV and ICD-9 CM, the publication of DSM-V results in diagnostic ambiguity until the mandated change to ICD-10 CM codes in 2014. It is now up to the clinician to base the diagnosis of BED on episodes of binge eating once or twice a week and three or six months in duration depending on whether one continues to use DSM-IV and ICD-9 CM or the new DSM-5.[18]

The prudent clinician might want to wait for a body of research to answer questions about the comparative validity and reliability of the differing diagnostic criteria. A second approach might be for one to follow ICD-9 CM for the next year, and switch to ICD-10 CM when it is mandated in the United States in October 2014. Another approach would be to look at emerging research that examines the number of people that a change in criteria includes or excludes from a diagnosis of BED, and the effect that such a change makes on those people’s lives in terms of their ability to get bariatric surgery or the effectiveness of bariatric surgery for those meeting differing diagnostic criteria.

My own approach is to look at the percentage of prospective bariatric surgery patients who meet the DSM-IV and DSM-5 criteria. In this vein, I administered a questionnaire consistent with the DSM-IV/ICD-9 CM criteria for six months prior to the publication of DSM-5. Of 50 patients completing this questionnaire, six (12%) met the criteria for BED. With the publication of DSM-5, I modified the questionnaire to meet the new diagnostic criteria and will track the number of patients who meet the criteria for BED for the next 50 prospective bariatric surgery patients. I will look at the percentage of patients meeting the new criteria. Of critical interest will be follow-up data on how many patients in each of those groups went on to have surgery and their post-surgical success. In time, the impact of the change in the diagnosis of BED will emerge, along with evidence-based recommendations. Until then we, and our patients will remain in some state of diagnostic limbo.

1.    Stunkard A. Eating patterns and obesity. Psychiat Quart. 1957;33(2):284-295.
2.    Fairburn CG. Overcoming Binge Eating. New York, Guilford Press; 1995:4.
3.    American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: American Psychiatric Association;1994.
4.    American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Association;2013.
5.    Powers PS, Perez A, Boyd F, Rosemurgy A. Eating pathology before and after bariatric surgery: a prospective study. Int J Eat Disorder. 1999;25(3):293–300.
6.    Wadden TA, Faulconbridge LF, Jones-Corneille LR, et al. Binge eating disorder and the outcome of bariatric surgery at one year: a prospective, observational study. Obesity. 2011;19(6):1220–1228.
7.    de Zwaan M, Lancaster KL, Mitchell JE et al. Health-related quality of life in morbidly obese patients: effect of gastric bypass surgery. Obes Surg. 2002;12:773–780.
8.    Pekkarinen T, Koskela K, Huikuri K, Mustajoki P. Long-term results of gastroplasty for morbid obesity: binge-eating as a predictor of poor outcome. Obes Surg. 1994;4:248–255.
9.    Sallet PC, Sallet JA, Dixon JB, et al. Eating behavior as a prognostic factor for weight loss after gastric bypass. Obes Surg. 2007;17:445–451.
10.    Ashton K, Drerup M, Windover A, Heinberg L. Brief, four-session group CBT reduces binge eating behaviors among bariatric surgery candidates. Surg Obes Relat Dis. 2009;5:257–262.
11.    Cassels C. DSM-5 officially launched, but controversy persists. Medscape Medical News, May 18, 2013. Accessed from Accessed August 2, 2013.
12.    Insel T. Director’s Blog: Transforming Diagnosis. National Institute of Mental Health. April 29, 2013. Accessed from Accessed August 2, 2013.
13.    British Psychological Society. Response to the American Psychiatric Association: DSM-5 development. Accessed  from Accessed August 2, 2013.
14.    The British Psychological Society and The Royal College of Psychiatrists. Eating Disorders: Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa, and related eating disorders. National Clinical Practice Guideline Number CG9. Accessed from Accessed August 2, 2013.
15.    Center for Medicare and Medicaid Services. Transaction & Code Sets Standards. Accessed from Accessed August 2, 2013.
16.    American Psychological Association. Transition to the ICD-10-CM: What does it mean for psychologists? Accessed  from Accessed August 2, 2013.
17.    World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders. Geneva, World Health Organization; 1993.
18.    Center for Medicare and Medicaid Services. Frequently Asked Questions. Accessed from Accessed August 2, 2013.
Funding: No funding was provided.

Category: Hot Topics in Integrated Health, Past Articles

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