Non-fat-phobic eating disorders : Why we need to investigate implicit associations and neural correlates

Abstract

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) represents a paradigm shift in eating disorder classification: Fear of weight gain is no longer the sine qua non of disordered eating. While two out of three DSM-IV eating disorders featured fat phobia and/or body image disturbance as core diagnostic criteria, only one out of five DSM-5 eating disorders retains this focus. Specifically, while DSM-5 bulimia nervosa (BN) still requires overvaluation of shape and weight; DSM-5 anorexia nervosa (AN) now includes individuals who do not explicitly endorse fat phobia or body image disturbance, as long as they exhibit consistent behaviors that inhibit weight gain and do not fully appreciate the medical consequences of their low weight. Furthermore, DSM-5 avoidant/restrictive food intake disorder (ARFID), binge eating disorder (BED), and feeding and eating disorder not elsewhere classified (FEDNEC) can all be diagnosed in the absence of body image disturbance or fear of weight gain. This shift is important because current etiological theories of eating disorders emphasize the centrality of shape and weight concerns, and many contemporary treatment and prevention efforts target body image specifically. However, approximately 20% of low-weight eating disorder patients present without explicitly endorsing fear of weight gain or overvaluation of shape and weight.1 Will the central tenets and techniques of our field remain relevant in the brave new world of DSM-5? The answer hinges primarily on our understanding of why individuals with eating disorders—and, in particular, those with low-weight, restricting-type eating disorders—present without fear of weight gain.