Should amenorrhea be a diagnostic criterion for anorexia nervosa?

Department of Psychiatry, College of Physicians and Surgeons of Columbia University, New York, New York, USA.
International Journal of Eating Disorders (Impact Factor: 3.13). 11/2009; 42(7):581-9. DOI: 10.1002/eat.20720
Source: PubMed


The removal of the amenorrhea criterion for anorexia nervosa (AN) is being considered for the fifth edition of The Diagnostic and Statistical Manual (DSM-V). This article presents and discusses the arguments for maintaining as well as those for removing the criterion.
The psychological and biological literatures on the utility of amenorrhea as a distinguishing diagnostic criterion for AN and as an indicator of illness severity are reviewed.
The findings suggest that the majority of differences among patients with AN who do and do not meet the amenorrhea criterion appear largely to reflect nutritional status. Overall, the two groups have few psychological differences. There are mixed findings regarding biological differences between those with AN who do and do not menstruate and the relationship between amenorrhea and bone health among patients with AN.
Based on these findings, one option is to describe amenorrhea in DSM-V as a frequent occurrence among individuals with AN that may provide important information about clinical severity, but should not be maintained as a core diagnostic feature. The possibilities of retaining the criterion or eliminating it altogether are discussed.

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    • "In order to better define and limit EDNOS, DSM-5 lowers thresholds for AN and BN, and establishes binge eating disorder (BED) as a separate diagnosis. These changes are supported by research [4-6] and will likely decrease EDNOS to some extent [7-9]. However, many patients will still be classified under a “residual” or unspecified diagnostic category. "
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    ABSTRACT: Background DSM-IV eating disorder (ED) diagnoses have been criticized for lack of clinical utility, diagnostic instability, and over-inclusiveness of the residual category “ED not otherwise specified” (EDNOS). Revisions made in DSM-5 attempt to generate a more scientifically valid and clinically relevant system of ED classification. The aim with the present study was to examine clinical characteristics and distinctiveness of the new DSM-5 ED diagnoses, especially concerning purging disorder (PD). Methods Using a large naturalistic Swedish ED database, 2233 adult women were diagnosed using DSM-5. Initial and 1-year follow-up psychopathology data were analyzed. Measures included the Eating Disorder Examination Questionnaire, Structural Eating Disorder Interview, Clinical Impairment Assessment, Structural Analysis of Social Behavior, Comprehensive Psychiatric Rating Scale, and Structured Clinical Interview for DSM-IV Axis I Disorders. Results Few meaningful differences emerged between anorexia nervosa binge/purge subtype (ANB/P), PD, and bulimia nervosa (BN). Unspecified Feeding and Eating Disorders (UFED) showed significantly less severity compared to other groups. Conclusions PD does not appear to constitute a distinct diagnosis, the distinction between atypical AN and PD requires clarification, and minimum inclusion criteria for UFED are needed. Further sub-classification is unlikely to improve clinical utility. Instead, better delineation of commonalities is important.
    Journal of Eating Disorders 07/2013; 1. DOI:10.1186/2050-2974-1-31
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    • "Although com - monly associated with AN , amenorrhea is now understood to be an epiphenomenon for many , but certainly not all , individuals with AN . Moreover , menstrual functioning is not relevant for males and young children , and the empirical data suggest that amenorrhea does not provide significant clinical value in terms of diagnosis or prognosis ( Attia & Roberto , 2009 ) . "
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    ABSTRACT: TheWorld Health Organization is currently revising the International Classification of Diseases and Related Health Problems (ICD-10). A central goal for the revision of the ICD classification of mental and behavioural disorders is to improve its clinical utility. Global representation and cultural sensitivity and relevance are important across all mental disorders, but are especially critical to advancing our understanding, diagnosis and treatment of feeding and eating disorders (FED). This paper summarises the current status of the Eating Disorders Consultation Group (EDCG) considerations regarding diagnostic categories for FEDs in ICD-11 and represents work in progress. The recommendations of the EDCG are informed by relevant research evidence, and the consultation group is striving to find a balance between clinical utility and diagnostic purity. Provisional recommendations of the EDCG include: (1) merger of previous FEDs categories in one group; (2) inclusion of six main FED categories that include anorexia nervosa (AN), bulimia nervosa (BN), pica, regurgitation disorder, binge-eating disorder (BED) and avoidant/restrictive food intake disorder, the last two representing new categories; (3) broadening of categories with the aim of reducing the use of the unspecified ED category (e.g. dropping the amenorrhea requirement, increasing the body mass index cut-off for low weight and rewording the cognitive and behavioural features of AN to be more culturally-sensitive). In line with this last recommendation, one point that require further analysis pertains to severity of the binge-eating and purging behaviours in BN and BED, as the EDCG is considering reducing or eliminating the frequency criterion and broadening the binge-eating criterion to include ‘subjective’ binge episodes.
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    • "1) AN(ABC): AN criteria are met except for amenorrhea, as proposed by Attia et al. [17]; 2) sAN: AN criteria are met with a less severe BMI level for criterion A (BMI = 18.5 kg/m 2 ); and 3) sAN(ABC): AN criteria are met, except for amenorrhea, with a less severe BMI level for criterion A (BMI = 18.5 kg/m 2 ). For boys, only one AN definition and one sub-threshold sAN(ABC) could be defined because there was no amenorrhea criterion. "
    Open Journal of Epidemiology 01/2013; 03(02):53-61. DOI:10.4236/ojepi.2013.32009
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