The impact of revised DSM-5 criteria on the relative distribution and inter-rater reliability of eating disorder diagnoses in a residential treatment setting.

This study evaluated the relative distribution and inter-rater reliability of revised DSM-5 criteria for eating disorders in a residential treatment program. Consecutive adolescent and young adult females (N=150) admitted to a residential eating disorder treatment facility were assigned both DSM-IV and DSM-5 diagnoses by a clinician (n=14) via routine clinical interview and a research assessor (n=4) via structured interview. We compared the frequency of diagnostic assignments under each taxonomy and by type of assessor. We evaluated concordance between clinician and researcher assignment through inter-rater reliability kappa and percent agreement. Significantly fewer patients received either clinician or researcher diagnoses of a residual eating disorder under DSM-5 (clinician-12.0%; researcher-31.3%) versus DSM-IV (clinician-28.7%; researcher-59.3%), with the majority of reassigned DSM-IV residual cases reclassified as DSM-5 anorexia nervosa. Researcher and clinician diagnoses showed moderate inter-rater reliability under DSM-IV (κ=.48) and DSM-5 (κ=.57), though agreement for specific DSM-5 other specified feeding or eating disorder (OSFED) presentations was poor (κ=.05). DSM-5 revisions were associated with significantly less frequent residual eating disorder diagnoses, but not with reduced inter-rater reliability. Findings support specific dimensions of clinical utility for revised DSM-5 criteria for eating disorders.

Motivation to change among residential treatment patients with an eating disorder: assessment of the multidimensionality of motivation and its relation to treatment outcome.

OBJECTIVE: To examine the multidimensional nature of motivation to change in an adolescent sample in residential eating disorder (ED) treatment and relate it to outcome. METHOD: To determine whether different dimensions of motivation (benefits, burdens, and functional avoidance) are differentially associated with symptom severity and outcome, we assessed eating pathology and motivation to change in consecutively admitted female patients (n = 67) with AN, BN, and EDNOS in a residential ED program with the Eating Disorder Examination Questionnaire (EDE-Q) and the Decisional Balance Scale (DB). RESULTS: Pretreatment DB benefits and functional avoidance subscales were correlated with ED and comorbid psychopathology. Admission to discharge change in DB benefits-but not other measured dimensions of motivation was significantly associated with post-treatment EDE-Q global scores. DISCUSSION: Our findings support that motivation to change is a multidimensional construct among ED patients. A reduction in perceived benefits of illness is associated with less severe post-treatment eating pathology.

How do eating disorder specialist clinicians apply DSM-IV diagnostic criteria in routine clinical practice? Implications for enhancing clinical utility in DSM-5.

The clinical utility of the DSM-IV eating disorder (ED) diagnostic criteria among practicing clinicians has not been formally evaluated, despite the considerable diagnostic challenges these disorders present. This study evaluated inter-rater reliability between research and clinical diagnoses, identified discrepantly rated diagnostic criteria, and evaluated ED subtype use in a naturalistic treatment setting. Seventy-six adolescent and young adult female patients consecutively admitted to a residential ED program were evaluated independently by clinicians (unstructured clinical interview) and research assessors (Structured Clinical Interview for DSM-IV). Clinicians and research assessors conferred concordant ED diagnoses in 80.3% of cases (kappa=0.70), thus highlighting the clinical utility of the extant DSM-IV diagnostic scheme in this specialty ED treatment setting. All but two discordant cases included a diagnosis of ED not otherwise specified (EDNOS). Clinicians applied ED subtypes in just 20.4% of eligible cases, and were significantly more likely to apply subtypes to major depressive disorder. Although clinical and research interviews yielded substantial reliability, EDNOS had the lowest reliability among the ED diagnoses. Moreover, infrequent subtype application on this specialty unit raises questions about the clinical utility of DSM-IV anorexia nervosa and bulimia nervosa subtypes, even in the context of clinically useful overarching categories.