Eating Disorders and Body Image Interest Group members:
Anne Kubal, PhD, CEDS-C
Licensed Clinical Psychologist at Anne Kubal, Phd, LLC Private Practice
Certified Eating Disorder Specialist; iaedp approved consultant
Andrea Seefeldt, PsyD, CEDS
Licensed Clinical Psychologist and Certified Eating Disorder Specialist (CEDS)
Seefeldt Psychotherapy
On October 1, 2024, the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM; World Health Organization [WHO], 2024) codes were updated, requiring clinicians to include a severity specifier for diagnoses of anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). Specifically, clinicians must now use one of the following severity specifiers: mild, moderate, severe, extreme, unspecified or in remission. The severity specifiers for AN are based on weight, frequency of compensatory behaviors for BN and frequency of binges for BED. The transition to a severity specifier requirement in conjunction with a paucity of empirical evidence supporting the validity of eating disorder severity specifiers is troubling; however, it also provides the opportunity to reexamine the complexity of eating disorders in general and to reinforce why all psychologists—regardless of specialty—should be knowledgeable on the complexities involved with the diagnosis and treatment of eating disorders.
Eating disorders are complex mental health conditions that can lead to severe medical complications and increased mortality. It is well established that AN has historically had the highest mortality rate among mental health disorders due to the elevated risk of death from both medical complications and suicide. Other eating disorders also share a heightened mortality rate because of similar complications. Longstanding misconceptions about who is at risk for an eating disorder, the ego-syntonic nature of AN, and a lack of required training on eating disorders for behavioral health and medical providers contribute to the under-diagnosis of eating disorders. If eating disorder treatment is sought, it is often well after the onset of the disorder. Early detection and accurate diagnosis are critical for timely intervention and improved prognosis.
The transition from the Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition (DSM-IV; American Psychiatric Association [APA], 1994) to the DSM – Fifth Edition (DSM-5; APA, 2013) brought important changes to the eating disorders diagnostic criteria, including the recognition of BED as an official diagnosis; the inclusion of pica, rumination disorder, and avoidant restrictive food intake disorder (ARFID) within the chapter on feeding and eating disorders; and revisions to the diagnostic criteria for AN and BN. Two major changes to the diagnostic criteria for AN are noteworthy. First, the amenorrhea criterion was dropped in recognition that many individuals who meet criteria for AN do not experience amenorrhea (including children and biological males, for example). Second, the body weight criterion was changed to allow clinicians more autonomy in determining what a “significantly low body weight” means in the context of the person being treated. This is in contrast to the DSM-IV criteria requiring “refusal to maintain body weight at or above a minimally normal weight,” defined as at or below 85% of the ideal body weight according to a person’s body mass index (BMI) (APA, 1994). The DSM-IV criteria also excluded individuals who were struggling with AN but had not lost enough weight to be officially diagnosed. Atypical AN was also added to the DSM-5 under other specified feeding or eating disorder (OSFED) to provide a more accurate diagnosis for individuals who meet all criteria for AN but whose weight is in the normal or above normal range despite significant weight loss (APA, 2013). The changes to AN criteria and addition of atypical AN in the DSM-V are positive steps towards decreasing weight, gender, and age bias when diagnosing AN.
The new ICD-10-CM requirement for severity ratings was intended to enhance diagnostic specificity and mirrors the addition of severity specifiers for eating disorders that was introduced in the DSM-V. However, it is important to acknowledge the severity criteria for eating disorders in the DSM-V were established without sufficient empirical support (Smith et al., 2017). Dang and colleagues (2022) conducted a systematic review of studies and meta-analysis and concluded that the severity specifiers have limited clinical utility for BN and lack clinical utility for AN and BED. Mora-Maltas and colleagues (2023) argued for illness duration as a more informative indication of severity, and Dakanalis and colleagues (2017) found support for the severity specifier for BED as a means of addressing within-group variability for outpatient adults. Again, the current empirical evidence suggests that adding specifiers to the DSM-5 and ICD-10-CM codes does little, if anything, to improve clinical care.
In addition to providing little clinical utility to those treating eating disorders, the severity specifiers for AN (based on BMI and weight status), has the potential to harm patients through the perpetuation of weight bias. A specifier of extreme AN requires a BMI below 15 while a specifier of mild AN requires a BMI of 17 or above, with moderate (16-16.99) and severe (15-15.99) specifiers in between these BMI ranges. This is inherently problematic as it fuels the misconception that eating disorder severity is correlated with body size. BMI categories do not reliably differentiate the intensity of AN symptoms and comorbidities (Billman et al., 2025).
Anyone can suffer from an eating disorder regardless of body size, shape or weight, and that the type of eating disorder and severity of symptoms are not correlated with body weight. AN symptoms actually occur more often in people who are not underweight than people who are underweight (Harrop et al., 2021). A special February 2024 issue of the International Journal of Eating Disorders was dedicated to examining the differences between AN and atypical AN. Most of the studies found few differences between the two disorders with the exception of weight status (Golden & Walsh, 2024). In fact, in a systematic review and meta-analysis, Brennan and colleagues (2023) reported that rapid weight loss among adolescents with both AN and atypical AN was a key factor leading to medical instability and hospital admission regardless of initial weight status.
The scope of psychopathology associated with AN, BN, and BED is not adequately represented by the current severity ratings. The continued use of weight status as an indicator of severity can potentially further perpetuate weight stigma against people in larger bodies through under-identification of eating disorders, invalidation of their experiences, and missing potential acute secondary medical complications. Eating disorders are complex, disorders and it is important that attempts to improve diagnostic specificity do not inadvertently oversimplify the complexity of these disorders and reinforce misperceptions about who is at risk for significant medical complications or even death. The American Psychological Association’s Society for Health Psychology’s (Division 38) newly established Eating Disorders and Body Image Interest Group can serve as a resource for psychologists to continue learning about the nuances and complexities of eating disorder diagnoses and treatment, and ultimately enhance the quality of care provided to this population.
References
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th.). American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Billman Miller, M. G., Abber, S. R., Hamilton, A., Ortiz, S. N., Jacobucci, R. C., Essayli, J. H., Smith, A. R., & Forrest, L. N. (2025). Data mining identifies meaningful severity specifiers for anorexia nervosa. Journal of Psychopathology and Clinical Science, 134(2), 162-172. https://doi.org/10.1037/abn0000962
Brennan, C., Illingworth, S., Cini, E. & Bhakta, D. (2023). Medical instability in typical and atypical adolescent anorexia nervosa: A systematic review and meta-analysis. Journal of Eating Disorders, 11(1), 58. https://doi.org/10.1186/s40337-023-00779-y
Dakanalis, A., Riva, G., Serino, S., Colmegna, F., & Clerici, M. (2017). Classifying adults with binge eating disorder based on severity levels. European Eating Disorders Review, 25(4), 268-274. https://doi.org/10.1002/erv.2518
Dang, A. B., Giles, S., Fuller-Tyszkiewicz, M., Kiropoulos, L., & Krug, I. (2022). A systematic review and meta-analysis on the DSM–5 severity ratings for eating disorders. Clinical Psychology: Science and Practice, 29(4), 325-344. https://doi.org/10.1037/cps0000078
Golden, N. H., & Walsh, B. T. (2024). Time to revisit the definition of atypical anorexia nervosa. International Journal of Eating Disorders, 57(4), 757-760. https://doi.org/10.1002/eat.24174
Harrop, E. N., Mensinger J. L., Moore M., & Lindhorst T. (2021). Restrictive eating disorders in higher weight persons: A systematic review of atypical anorexia nervosa prevalence and consecutive admission literature. International Journal of Eating Disorders. 54(8), 1328-1357. https://doi.org/10.1002/eat.23519
Mora-Maltas, B., Lucas, I., Granero, R., Vintró-Alcaraz, C., Miranda-Olivos, R., Baenas, I., Sánchez, I., Jiménez-del Toro, J., Sánchez-González, J., Krug, I., Tapia, J., Jiménez-Murcia, S., & Fernández-Aranda, F. (2023). Cognitive flexibility and DSM-5 severity criteria for eating disorders: Assessing drive for thinness and duration of illness as alternative severity variables. Journal of Eating Disorders, 11(1), 155. https://doi.org/10.1186/s40337-023-00875-z
Smith, K. E., Ellison, J. M., Crosby, R. D., Engel, S. G., Mitchell, J. E., Crow, S. J., Peterson, C. B., Le Grange, D., & Wonderlich, S. A. (2017). The validity of DSM-5 severity specifiers for anorexia nervosa, bulimia nervosa, and binge-eating disorder. International Journal of Eating Disorders, 50(9), 1109-1113. https://doi.org/10.1002/eat.22739
World Health Organization (WHO). (2024). The ICD-10-CM classification of mental and behavioural disorders. World Health . https://www.google.com/url?q=https://ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/ICD10CM/2025/&sa=D&source=docs&ust=1741828245911824&usg=AOvVaw2NhwqkIMeOWZzJ_gfPGIpP