On February 25th, Erikka Taylor, MD, MPH, DFAACAP, DFAPA, presented “Changing the Criteria, Changing Lives: The Case for Inclusive Eating Disorder Diagnoses,” examining how current and proposed diagnostic criteria shape who is identified, who receives care, and who may be overlooked in the eating disorder field. 

Eating disorders do not present in one body, one gender, or one cultural context. Yet diagnostic frameworks have historically reflected a narrow image of who is “most likely” to struggle. When criteria and screening tools center thinness, weight, or stereotypical presentations, they can unintentionally delay recognition and treatment for individuals across diverse racial, socioeconomic, and gender identities. 

This session explored how evolving diagnostic standards, greater cultural awareness, and intentional self-examination can help clinicians move toward more equitable identification and access to care. 

Key Takeaways

• Diagnostic frameworks directly shape access to care. Narrow, weight-centered criteria can delay identification for patients across diverse racial, gender, and body-size groups.
  
  
• Delayed or missed diagnoses have measurable consequences. Increased mortality, chronicity, medical instability, and treatment resistance underscore the stakes of diagnostic accuracy.
  
  
• Implicit bias and screening limitations contribute to inequities. Research shows disparities in recognition, and many tools fail to capture culturally and gender-diverse presentations.
  
  
• Evolving DSM criteria create an opportunity for reform. Removing weight-based severity markers and reexamining screening practices can improve equitable identification and outcomes.
  

The impact of delayed or missed eating disorder diagnoses 

Eating disorders are among the psychiatric conditions commonly misdiagnosed. When diagnosis is delayed, the consequences are significant and far-reaching. 

Delayed or missed eating disorder diagnoses are associated with: 

• Increased mortality 

• Increased medical instability 

• Increased chronicity 

• Increased comorbidity 

• Increased treatment resistance 

• Increased healthcare costs 

• Decreased full recovery rates 

These outcomes underscore that diagnostic accuracy is not merely administrative. It is directly tied to long-term health and survival. 

Who is more likely to receive an eating disorder diagnosis? 

Patterns in identification reveal disparities. Individuals are more likely to receive an eating disorder diagnosis if they are: 

• Underweight 

• White 

• Affluent 

• Female 

• Diagnosed with anorexia nervosa or sub-threshold anorexia nervosa 

This reflects a narrow and historically reinforced image of who “looks like” they have an eating disorder. Presentations outside that stereotype may be overlooked, even when symptoms are clinically significant. 

A data slide reviewing perceived need, diagnosis, and treatment rates across diagnostic categories further illustrates variability in recognition and service utilization. These discrepancies highlight gaps between experiencing symptoms, receiving a diagnosis, and accessing treatment. 

Where inequities occur in the diagnostic pathway 

The diagnostic process unfolds in stages: detection of bodily changes, perceived reasons to seek help, consultation with providers, diagnosis, and treatment planning. Each stage presents potential barriers. 

Factors influencing this pathway include: 

• Health literacy 

• Health care avoidance 

• Cultural factors 

• Stigma and privacy concerns 

• Trust in health care systems 

• Organizational health literacy 

• Fragmented health systems 

• Administrative burden 

• Cultural competence 

• Patient-provider relationship 

• Cognitive bias 

• Knowledge of the disease 

Barriers to timely diagnosis can be grouped into: 

• Socioeconomic factors 

• Sociocultural factors 

• Clinician factors 

• Systemic barriers 

These overlapping influences shape whether someone is screened, believed, diagnosed, and connected to appropriate care. 

Bias in eating disorder symptom recognition 

Research presented in the webinar demonstrated how implicit bias may influence identification. When clinicians were shown identical case studies describing disordered eating symptoms in white, Hispanic, and Black women, they identified the eating behavior as problematic at different rates: 

• 44% for the white woman 

• 41% for the Hispanic woman 

• 17% for the Black woman 

These findings suggest that recognition of eating pathology is not purely symptom-driven. Perception may be shaped by racial stereotypes and assumptions. 

The presentation included full references for this and related research in the closing reference slide. 

A historical evolution of DSM eating disorder criteria 

Understanding how DSM criteria have evolved provides context for current limitations. 

• DSM-I (1952): Anorexia classified under “Psychophysiologic Gastrointestinal Reaction” without formal criteria. 

• DSM-II (1968): Listed under Feeding Disturbances. No bulimia diagnosis. 

• DSM-III (1980): Creation of an Eating Disorders category. Bulimia introduced. Amenorrhea required for anorexia nervosa. 

• DSM-IV (1994): EDNOS introduced and became the most common diagnosis. Binge Eating Disorder provisional. Amenorrhea retained. 

• DSM-5 (2013): Amenorrhea removed. Binge Eating Disorder formalized. OSFED replaced EDNOS. Atypical anorexia recognized. 

• Proposed DSM changes (2025): Removal of weight criterion from severity specifiers. 

The historical arc reflects gradual expansion of diagnostic inclusion. Yet weight-based and frequency-based severity frameworks continue to shape clinical decision-making. 

DSM-5 updates and severity specifiers 

Slides reviewing DSM-5 criteria for anorexia nervosa, bulimia nervosa, and binge eating disorder highlighted how severity has traditionally been determined. 

• Anorexia nervosa severity was previously tied to BMI ranges. 

• Bulimia nervosa severity has been based on frequency of inappropriate compensatory behaviors [CITE: Slide 15]. 

• Binge eating disorder severity has been based on frequency of binge episodes. 

Proposed changes include removing weight-based criteria from severity specifiers in anorexia nervosa. 

Severity measures grounded primarily in weight or behavior frequency may not fully capture: 

• Functional impairment 

• Psychological distress 

• Cultural and contextual drivers 

• Medical instability at higher weights 

These concerns underscore the need to evaluate whether current frameworks reflect lived clinical reality across diverse populations. 

The limits of current eating disorder screening tools 

Screening and assessment tools play a central role in early identification. Common measures include: 

• SCOFF 

• EDE-Q 

• EDE-QS 

• Eating Disorder Screen for Primary Care 

• Screen for Disordered Eating 

• Binge Eating Disorder Screener-7 

However, current eating disorder measures: 

• Focus heavily on the thin body ideal or drive for thinness 

• Do not account for gender dysphoria-related body image disturbances 

• Do not incorporate cultural factors 

• Do not assess drivers of eating disorder pathology 

When assessment tools center thinness as the primary marker of pathology, presentations influenced by muscularity ideals, cultural body norms, or gender-related body distress may not be adequately captured. 

The slide reviewing screening questionnaires includes citations for the original validation studies, which should be referenced directly from the presentation’s reference list. 

Moving toward inclusive diagnostic frameworks 

The webinar concluded with practical considerations for clinicians and organizations seeking to reduce diagnostic inequities. 

Recommended actions included: 

• Research: Ensure marginalized community voices are included. 

• Training: Strengthen cultural competency, pluralism, and inclusivity. 

• Self-evaluation: Examine how privilege and implicit bias influence care. 

• Screening: Reevaluate tools and interventions for inclusivity. 

• Accountability: Hire clinicians and leaders from diverse backgrounds. 

• Culturally inclusive spaces and modalities: Incorporate culturally relevant practices and community and social supports. 

Inclusive diagnostic frameworks are not about broadening criteria indiscriminately. They are about increasing diagnostic accuracy across age, gender, body size, and cultural background to ensure equitable access to evidence-based care [CITE: Slide 2]. 

Diagnostic criteria shape treatment access. Changing those criteria, and the ways they are applied, is one meaningful step toward changing outcomes. 

Explore more continuing education sessions from Monte Nido.

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