Evaluation of the DSM‐5 Severity Indicator for Anorexia Nervosa
Open accessAbstract
Objective: This study tested the new DSM‐5 severity criterion for anorexia nervosa (AN) based on proposed body mass index (BMI) cut‐points. Method: Participants were a clinical sample of 201 treatment‐seeking patients diagnosed with DSM‐5 AN in Portugal. Participants were categorised based on DSM‐5 severity levels and were compared on demographic and clinical variables assessed with the Eating Disorder Examination‐Questionnaire. Results: Based on DSM‐5 severity definitions for AN, 73 (36.3%) participants were categorised as mild (≥17.0 BMI), 40 (19.9%) as moderate (16–16.99 BMI), 30 (14.9%) as severe (15–15.99 BMI) and 58 (28.9%) as extreme (<15 BMI). The severity groups did not differ significantly in age or gender. Analyses comparing the severity groups on measures of eating‐disorder psychopathology revealed no significant differences on the Eating Disorder Examination‐Questionnaire global or subscale scores. The groups also did not differ significantly on the frequency of binge eating or purging episodes within the past 28 days. Conclusions: Our findings, in this clinical sample of patients with AN in Portugal, provide no evidence for the new DSM‐5 severity ratings based on BMI level. Further research on the validity of the DSM‐5 specifiers is needed and should test additional clinical or functional variables and especially prognostic utility for course and outcome across eating disorders. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.
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Written from the paper’s full text.
TL;DR
This study tested whether DSM-5 BMI-based severity levels for anorexia nervosa correspond to differences in clinical presentation in a Portuguese treatment-seeking sample. It found no significant differences across severity groups on eating-disorder psychopathology or binge/purging frequency, providing little support for the BMI-based severity indicator.
Key findings
- Among 201 patients with DSM-5 anorexia nervosa, 73 (36.3%) were mild (≥17.0 BMI), 40 (19.9%) moderate (16–16.99 BMI), 30 (14.9%) severe (15–15.99 BMI), and 58 (28.9%) extreme (<15 BMI).
- Severity groups did not differ significantly in age or gender; they differed significantly on BMI, as expected from the cut-points.
- There were no significant differences across severity groups on EDE-Q global or subscale scores, nor on frequency of binge eating or purging episodes in the past 28 days.
- The authors conclude there is “very little support” for the DSM-5 severity ratings for anorexia nervosa based on BMI level.
Methods
- Clinical sample of 201 treatment-seeking patients diagnosed with DSM-5 anorexia nervosa in Portugal: 193 women and 8 men; 109 AN-restricting subtype and 92 AN-binge-eating/purging subtype. Mean age was 22.4 years (SD = 9.5, range 11–61), and mean BMI was 16.2 kg/m² (SD = 1.9, range 11.7–20.0).
- Diagnosis used diagnostic items from the Eating Disorder Examination interview; eating-disorder psychopathology was assessed with the Portuguese EDE-Q, including global and four subscale scores and past-28-day binge eating and purging frequencies.
- Analyses used ANOVA with Tukey’s HSD post hoc comparisons and chi-square with follow-up pairwise comparisons; effect sizes were partial η² for ANOVAs and phi coefficients for chi-square.
Limitations
- The paper states that findings are based on cross-sectional analyses focused primarily on eating psychopathology, and calls for further research testing additional clinical or functional variables and prognostic utility for course and outcome.
- Evident from the text: the sample is a single-country, treatment-seeking group that is predominantly female, limiting generalizability and leaving long-term outcome unexamined.
- Evident from the text: the authors considered age-appropriate weight criteria for participants under 18 but used a single BMI criterion for all ages because the younger subgroup was relatively small (N = 73).
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Claims the paper makes
0 of 9 cited sources checked · 0 supported · 0 flagged
- Findingown data
The DSM-5 severity groups did not differ significantly in age.
“The severity groups did not differ significantly in age or gender.”
- Also stated in: § Results · plain
“The severity groups did not differ significantly in age or sex”
Quote in the paperNot a substantial claim - Also stated in: § Results · plain
- Findingown data
The clinical sample consisted of 201 treatment-seeking patients diagnosed with DSM-5 AN in Portugal (193 women and 8 men).
“The sample consisted of 193 women and eight men seeking treatment and diagnosed with AN at specialised eating disorder treatment units in Portugal.”
- Also stated in: § Method: · plain
“Participants were a clinical sample of 201 treatment-seeking patients diagnosed with DSM-5 AN in Portugal.”
Quote in the paperSubstantial claim - Also stated in: § Method: · plain
- Findingreasoning
The DSM-5 severity groups differed significantly on BMI, as expected from the cut-points.
“BMI — as expected per the cut-points — the groups did differ significantly on BMI.”
Quote in the paperNot a substantial claim - Findingown data
The DSM-5 severity groups did not differ significantly on frequency of binge eating episodes within the past 28 days.
“The groups also did not differ significantly on the frequency of binge eating or purging episodes within the past 28 days.”
- Also stated in: § Results · plain
“The groups also did not differ significantly on the frequency of binge eating and purging episodes within the past 28 days.”
Quote in the paperSubstantial claim - Also stated in: § Results · plain
- Findingown data
The DSM-5 severity groups did not differ significantly on EDE-Q global or subscale scores.
“Analyses comparing the severity groups on measures of eating-disorder psychopathology revealed no significant differences on the Eating Disorder Examination-Questionnaire global or subscale scores.”
- Also stated in: § Results · plain
“Analyses comparing the severity groups on measures of eating-disorder psychopathology revealed no significant differences on the EDE-Q global or subscale scores.”
Quote in the paperSubstantial claim - Also stated in: § Results · plain
- Findingown data
The DSM-5 severity groups did not differ significantly in sex/gender.
“The severity groups did not differ significantly in age or gender.”
- Also stated in: § Results · plain
“The severity groups did not differ significantly in age or sex”
Quote in the paperNot a substantial claim - Also stated in: § Results · plain
- Findingown data
The DSM-5 severity groups did not differ significantly on frequency of purging episodes within the past 28 days.
“The groups also did not differ significantly on the frequency of binge eating or purging episodes within the past 28 days.”
- Also stated in: § Results · plain
“The groups also did not differ significantly on the frequency of binge eating and purging episodes within the past 28 days.”
Quote in the paperSubstantial claim - Also stated in: § Results · plain
- Interpretationown data
In this clinical sample of patients with AN in Portugal, the findings provide no evidence for the new DSM-5 severity ratings based on BMI level.
“Our findings, in this clinical sample of patients with AN in Portugal, provide no evidence for the new DSM-5 severity ratings based on BMI level.”
- Also stated in: § Discussion · hedged
“Findings from this clinical group of patients diagnosed with AN in Portugal provide very little support for the new DSM-5 severity ratings for AN based on BMI level.”
Quote in the paperSubstantial claim- Rests on an assumption: A valid DSM-5 severity indicator for AN should be associated with differences in eating-disorder psychopathology and binge/purge frequency as measured by the EDE-Q.
- Rests on an assumption: The study had adequate statistical power to detect clinically meaningful differences between DSM-5 severity groups.
- Also stated in: § Discussion · hedged
- Classified as probably not a substantial claim. 8
- May combine two claims. 5
Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
Findingown dataIn the sample, mean age was 22.4 years (SD = 9.5, range 11-61) and mean BMI was 16.2 kg/m2 (SD = 1.9, range 11.7-20.0).
“Overall, mean age was 22.4 (SD = 9.5, range = 11–61) with a mean BMI (kg/m2) of 16.2 (SD = 1.9, range = 11.7–20.0).”
Quote in the paperNot a substantial claimMay combine two claims.
Findingown dataIn this clinical sample, the DSM-5 severity distribution was 73 (36.3%) mild (≥17.0 BMI), 40 (19.9%) moderate (16-16.99 BMI), 30 (14.9%) severe (15-15.99 BMI), and 58 (28.9%) extreme (<15 BMI).
“Based on DSM-5 severity definitions for AN, 73 (36.3%) participants were categorised as mild (≥17.0 BMI), 40 (19.9%) as moderate (16–16.99 BMI), 30 (14.9%) as severe (15–15.99 BMI) and 58 (28.9%) as extreme (<15 BMI).”
- Also stated in: § Results · plain
“Based on DSM-5 severity definitions for AN, 73 (36.3%) participants were categorised as mild (≥17.0 BMI), 40 (19.9%) as moderate (16–16.99 BMI), 30 (14.9%) as severe (15–15.99 BMI) and 58 (28.9%) as extreme (<15 BMI).”
Quote in the paperSubstantial claim- Also stated in: § Results · plain
Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
Findingown dataOf the 201 participants, 109 were diagnosed with AN-Restricting subtype and 92 with AN-Binge-Eating/Purging subtype.
“Participants met DSM-5 (APA, 2013) criteria for anorexia nervosa (n = 109 diagnosed as AN-Restricting subtype and n = 92 as AN-Binge-Eating/Purging subtype).”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites APA, 2013
Not checked in the free run.
May combine two claims.
InterpretationcitationThese findings for AN generally parallel those for other eating disorder diagnoses (BN and binge eating disorder), suggesting that the new DSM-5 severity specifiers based on BMI intervals may not contribute much.
“These findings for AN generally parallel those emerging for other eating disorder diagnoses, including BN (Grilo et al., 2015a; Jenkins et al., 2016) and binge eating disorder (Grilo et al., 2015b, 2015c), suggesting that the new DSM-5 severity specifiers based on BMI intervals may not contribute much.”
Quote in the paperSubstantial claim0 of 3 sources checked- cites Grilo et al., 2015a
Not checked in the free run.
- cites Jenkins et al., 2016
Not checked in the free run.
- cites Grilo et al., 2015b, 2015c
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationThe Portuguese-language version of the EDE-Q used in this study has demonstrated good psychometric properties.
“The Portuguese-language version of the EDE-Q (Machado et al., 2014) used in this study has demonstrated good psychometric properties (Machado et al., 2014) much like that reported for other translated versions (Elder & Grilo, 2007) and the literature for the English version (Berg, Pterson, Frazier, & Crow, 2012).”
Quote in the paperNot a substantial claim0 of 3 sources checked- cites Machado et al., 2014
Not checked in the free run.
- cites Elder & Grilo, 2007
Not checked in the free run.
- cites Berg, Pterson, Frazier, & Crow, 2012
Not checked in the free run.
Classified as probably not a substantial claim.
PremisecitationThe DSM-5 severity specifiers are intended to provide information regarding clinical severity for each eating disorder diagnosis.
“The DSM-5 made a number of changes to the classification of eating disorders, which included severity specifiers intended to provide information regarding clinical severity for each of the diagnoses (Regier, Kuhl, & Kupfer, 2013).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Regier, Kuhl, & Kupfer, 2013
Not checked in the free run.
Classified as probably not a substantial claim.
PremisecitationIn the DSM-5, BMI intervals are used to define the minimum level of severity for anorexia nervosa.
“Although the level of severity may be increased by clinicians to reflect clinical symptoms, levels of disability, or the need for supervision, body mass index (BMI), intervals are used to define the minimum level of severity in the case of anorexia nervosa (AN) in the DSM-5 (APA, 2013).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites APA, 2013
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
Study design and conductnone givenThe research was IRB-approved and all participants provided written informed consent.
“The research was IRB-approved and all participants provided written informed consent.”
Quote in the paperNot a substantial claimClassified as probably not a substantial claim.
Study design and conductnone givenThe findings are based on cross-sectional analyses focused primarily on eating psychopathology.
“Our findings, however, are based on cross-sectional analyses focused primarily on eating psychopathology.”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductown dataIn the current sample, internal consistency reliability (Cronbach's alpha) for the EDE-Q global score and subscales was good or excellent (global α = 0.96; restraint α = 0.86; eating concern α = 0.84; shape concern α = 0.91; weight concern α = 0.82).
“Internal consistency reliability, Cronbach’s alpha, for the current sample of EDE-Q global score and subscales was either good or excellent (global, α = 0.96; restraint, α = 0.86; eating concern, α = 0.84; shape concern, α = 0.91; and weight concern, α = 0.82).”
Quote in the paperNot a substantial claim
The paper relies on this without support.
A valid DSM-5 severity indicator for AN should be associated with differences in eating-disorder psychopathology and binge/purge frequency as measured by the EDE-Q.
“Analyses comparing the severity groups on measures of eating-disorder psychopathology revealed no significant differences on the EDE-Q global or subscale scores.”
“Our findings, in this clinical sample of patients with AN in Portugal, provide no evidence for the new DSM-5 severity ratings based on BMI level.”
The paper relies on this without support.
No published studies have tested the DSM-5 severity specifier for AN based on BMI using treatment-seeking samples.
“For AN, no published studies have tested the DSM-5 severity specifier based on BMI using treatment seeking samples.”
The paper relies on this without support.
The study had adequate statistical power to detect clinically meaningful differences between DSM-5 severity groups.
“The sample consisted of 193 women and eight men seeking treatment and diagnosed with AN at specialised eating disorder treatment units in Portugal.”
“Analyses comparing the severity groups on measures of eating-disorder psychopathology revealed no significant differences on the EDE-Q global or subscale scores.”
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Research has provided limited support for the DSM-5 low BMI specifier ratings across both European and US samples.
“To date, research has provided limited support for the DSM-5 low BMI specifier ratings across both European [81–84] and US [85, 86] samples.”
From Mental, behavioral and neurodevelopmental disorders in the ICD-11: an international perspective on key changes and controversies (2020) · cites this paper as [83]
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“The Portuguese-language version of the EDE-Q (Machado et al., 2014) used in this study has demonstrated good psychometric properties (Machado et al., 2014) much like that reported for other translated versions (Elder & Grilo, 2007) and the literature for the English version (Berg, Pterson, Frazier,…”
MethodInfluentialSelf-citationEvaluation of the DSM-5 severity indicator for binge eating disorder in a community sample
Grilo, C. M., Ivezaj, V., & White, M. A. (2015) · Behaviour Research and Therapy · doi:10.1016/j.brat.2015.01.004 · Cited by 67 · cited 3× · see citing works
“These findings for AN generally parallel those emerging for other eating disorder diagnoses, including BN (Grilo et al., 2015a; Jenkins et al., 2016) and binge eating disorder (Grilo et al., 2015b, 2015c), suggesting that the new DSM-5 severity specifiers based on BMI intervals may not contribute…”
BackgroundSelf-citationGianini, L., Roberto, C. A., Attia, E., Walsh, B. T., Thomas, J. J., Eddy, K. T., Grilo, C. M., Weigel, T., & Sysko, R. (2017) · International Journal of Eating Disorders · doi:10.1002/eat.22728 · Cited by 64 · cited 1× · see citing works
“Sysko et al. (2016) recently presented findings for a clinical sample of 162 patients diagnosed with AN suggesting that the BMI-based severity categories did not differ significantly on measures of eating-disorder psychopathology, depression, or psychosocial functioning; however, number of…”
BackgroundSelf-citationEvaluation of the DSM-5 severity indicator for binge eating disorder in a clinical sample
Grilo, C., Ivezaj, V., & White, M. (2015) · Behaviour Research and Therapy · doi:10.1016/j.brat.2015.05.003 · Cited by 54 · cited 3× · see citing works
“These findings for AN generally parallel those emerging for other eating disorder diagnoses, including BN (Grilo et al., 2015a; Jenkins et al., 2016) and binge eating disorder (Grilo et al., 2015b, 2015c), suggesting that the new DSM-5 severity specifiers based on BMI intervals may not contribute…”
BackgroundSelf-citationElder, K. A., & Grilo, C. M. (2006) · Behaviour Research and Therapy · doi:10.1016/j.brat.2006.08.012 · Cited by 53 · cited 1× · see citing works
“…version of the EDE-Q (Machado et al., 2014) used in this study has demonstrated good psychometric properties (Machado et al., 2014) much like that reported for other translated versions (Elder & Grilo, 2007) and the literature for the English version (Berg, Pterson, Frazier, & Crow, 2012).”
MethodSelf-citationEvaluation of the DSM-5 severity indicator for bulimia nervosa
Grilo, C. M., Ivezaj, V., & White, M. A. (2015) · Behaviour Research and Therapy · doi:10.1016/j.brat.2015.02.002 · Cited by 36 · cited 3× · see citing works
“These findings for AN generally parallel those emerging for other eating disorder diagnoses, including BN (Grilo et al., 2015a; Jenkins et al., 2016) and binge eating disorder (Grilo et al., 2015b, 2015c), suggesting that the new DSM-5 severity specifiers based on BMI intervals may not contribute…”
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“These findings for AN generally parallel those emerging for other eating disorder diagnoses, including BN (Grilo et al., 2015a; Jenkins et al., 2016) and binge eating disorder (Grilo et al., 2015b, 2015c), suggesting that the new DSM-5 severity specifiers based on BMI intervals may not contribute…”
BackgroundAssessment of eating disorders: interview or self-report questionnaire
Fairburn, C. G., & Beglin, S. J. (1994) · International Journal of Eating Disorders · doi:10.1002/1098-108x(199412)16:4
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Cited by
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Ambwani, S., Cardi, V., Albano, G., Cao, L., Crosby, R. D., Macdonald, P., Schmidt, U., & Treasure, J. (2020) · International Journal of Eating Disorders · doi:10.1002/eat.23246 · Cited by 109 · see citing works
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“In a treatment-seeking sample of individuals with AN, Machado and colleagues (Machado, Grilo, and Crosby, 2017) found that the severity groups did not differ on cross-sectional measures of eating pathology or frequency of binge eating or purging.”
Self-citationSmith, 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) · International Journal of Eating Disorders · doi:10.1002/eat.22739 · Cited by 59 · see citing works
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“…our DSM-5 severity frequency results agree with previous studies that found that more than 50% of their AN (Dakanalis, Timko, et al., 2018; Machado et al., 2017; Smith et al., 2017), BN (Jenkins et al., 2016), and BED (Dakanalis, Zanetti, Colmegna, Riva, & Clerici, 2018; Gianini et al.,…”
BackgroundResultEngelhardt, C., Föcker, M., Bühren, K., Dahmen, B., Becker, K., Weber, L., Correll, C. U., Egberts, K. M., Ehrlich, S., Roessner, V., et al. (2020) · European Child & Adolescent Psychiatry · doi:10.1007/s00787-020-01595-4 · Cited by 37 · see citing works
Evaluation of the DSM-5 severity ratings for anorexia nervosa in a clinical sample
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“Interestingly, no relationship has been found between the severity of the disease and mood disorder outcomes, although lower bone mass density was observed in more severe cases (41, 42, 45).”
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“However, a couple of caveats should be considered: first, BMI could not be an effective proxy for AN severity, as already proposed [46,47]; second, a higher BMI could be also related to the greater presence of patients with BPAN in the PTSD group.”
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Investigating the DSM‐5 severity specifiers based on thinness for adults with anorexia nervosa
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“Overall, findings are consistent with a recent investigation of adolescents and adults with AN (of which 40% were<18 years) by Machado et al. (2017), who found that BMI-based severity groups did not differ significantly in terms of age, gender, eating-disorder psychopathology, or binge eating or…”
ResultTajadura‐Jiménez, A., Crucianelli, L., Zheng, R., Cheng, C. M., Ley-Flores, J., Mas, M. D. L. M. B., Bianchi‐Berthouze, N., & Fotopoulou, A. (2022) · Scientific Reports · doi:10.1038/s41598-022-24452-7 · Cited by 29 · see citing works
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“Among patients with AN (96% female), there were no differences in ED psychopathology across severity groups (Machado et al., 2017).”
BackgroundResultRiquin, É., Raynal-Tacquet, A., Mattar, L., Lalanne, C., Hirot, F., Huas, C., Duclos, J., Berthoz, S., Godart, N. T., & EVHAN group (2021) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2021.658416 · Cited by 30 · see citing works
“(48), this single criterion is not a good reflection of the overall severity of AN because it does not take into account the pathophysiology of the specific expression of symptoms of the ED, its developmental profile or its impact on daily life.”
BackgroundDSM-5 severity specifiers for anorexia nervosa and treatment outcomes in adult females
Dalle Grave, R., Sartirana, M., El Ghoch, M., & Calugi, S. (2018) · Eating Behaviors · doi:10.1016/j.eatbeh.2018.07.006 · Cited by 27 · see citing works
Body Mass Index Specifiers in Anorexia Nervosa: Anything below the “Extreme”?
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“This trend of marked psychopathology in non-emaciated patients resembles only one study on outpatients [7], but is not in keeping with the available reports on inpatients that reported no differences across groups with different BMIs on the EDE-Q [2,3].”
BackgroundInfluentialDang, A. B., Kiropoulos, L. A., Castle, D. J., Jenkins, Z., Phillipou, A., Rossell, S. L., & Krug, I. (2023) · European Eating Disorders Review · doi:10.1002/erv.2969 · Cited by 24 · see citing works
Assessment of Family Functioning and Eating Disorders – The Mediating Role of Self-Esteem
Kroplewski, Z., Szczęśniak, M., Furmańska, J., & Gójska, A. (2019) · Frontiers in Psychology · doi:10.3389/fpsyg.2019.00921 · Cited by 20 · see citing works
“Although the weight criterion used to diagnose EDs should be grounded in BMI (Hebebrand et al., 2004), more recent studies give no evidence (Machado et al., 2017) or modest support (Dakanalis et al., 2018) for the new DSM-5 severity ratings based on BMI level.”
Management of anorexia nervosa in pregnancy: a systematic and state-of-the-art review
Galbally, M., Himmerich, H., Senaratne, S., Fitzgerald, P., Frost, J., Woods, N., & Dickinson, J. E. (2022) · The Lancet Psychiatry · doi:10.1016/s2215-0366(22)00031-1 · Cited by 21 · see citing works
Diagnostic Categories for Eating Disorders
Walsh, B. T. (2018) · Psychiatric Clinics of North America · doi:10.1016/j.psc.2018.10.001 · Cited by 20 · see citing works
Hemmingsen, S. D., Jensen, N. A., Larsen, P. V., Sjögren, J. M., Lichtenstein, M. B., & Støving, R. K. (2022) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2022.939225 · Cited by 17 · see citing works
“However, it has been argued that the DSM-5 severity ratings based on BMI levels do not reflect actual AN severity of eating disorder symptomatology (46).”
BackgroundICD-11-Sonderserie: Fütter- und Essstörungen in der ICD-11
Gradl-Dietsch, G., Herpertz‐Dahlmann, B., Degenhardt, F., & Hebebrand, J. (2020) · Zeitschrift für Kinder- und Jugendpsychiatrie und Psychotherapie · doi:10.1024/1422-4917/a000772 · Cited by 15 · see citing works
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“In this line, several studies assessing individuals with AN did not find significant variation among the different DSM-5 severity groups regarding distress, psychiatric comorbidity or further attitudinal eating disorder (ED) symptoms (i.e., shape concerns/weight) [5, 6, 9, 14–18].”
BackgroundResultPurcell, J. B., Winter, S. R., Breslin, C. M., White, N. C., Lowe, M. R., & Coslett, H. B. (2018) · Journal of the International Neuropsychological Society · doi:10.1017/s1355617718000371 · Cited by 11 · see citing works
Systematic Review and Meta‐Analysis of Mortality in Patients With Anorexia Nervosa
Lai, E. T. H., Lai, B.-X., Wong, C. S. M., Wong, L. Y., Cheng, K., Cheng, C. P.-W., Lo, H. K. Y., Tse, G., Chan, W. C., Chang, W. C., et al. (2025) · International Journal of Eating Disorders · doi:10.1111/eat.70002 · Cited by 15 · see citing works
“These negative findings, along with other studies demonstrating that lower BMI is not associated with more severe eating psychopathology (Machado et al. 2017; Smith et al. 2017; Zayas et al. 2018), question the utility of BMI as a primary severity indicator for AN (Dang et al. 2022, 2023).”
Todisco, P., Meneguzzo, P., Garolla, A., Antoniades, A., Vogazianos, P., & Tozzi, F. (2023) · International Journal of Psychiatry in Clinical Practice · doi:10.1080/13651501.2023.2221318 · Cited by 11 · see citing works
“Indeed, previous data have already reported a more severe presentation of patients with AN in different places (Haripersad et al., 2021) that is not linked exclusively to their weight (Machado et al., 2017) – as in our sample.”
BackgroundKrug, I., Granero, R., Giles, S., Riesco, N., Agüera, Z., Sánchez, I., Jiménez‐Múrcia, S., del Pino‐Gutiérrez, A., Codina, E., Baenas, I., et al. (2020) · European Eating Disorders Review · doi:10.1002/erv.2769 · Cited by 12 · see citing works
Analysis of symptom clusters amongst adults with anorexia nervosa: Key severity indicators
Li, Z., Leppänen, J., Webb, J., Croft, P., Byford, S., & Tchanturia, K. (2023) · Psychiatry Research · doi:10.1016/j.psychres.2023.115272 · Cited by 10 · see citing works
Shibata, M., Iwane, T., Higuchi, R., Suwa, K., & Nakajima, K. (2018) · Medicine · doi:10.1097/md.0000000000010729 · Cited by 10 · see citing works
Different clusters of perfectionism in inpatients with anorexia nervosa and healthy controls
Longo, P., Aloi, M., Delsedime, N., Rania, M., Garcia, C. S., Abbate-Daga, G., & Marzola, E. (2021) · Eating Disorders · doi:10.1080/10640266.2021.1938937 · Cited by 10 · see citing works
“This “mismatch” between BMI and global psychopathological severity could be read in the light of those lines of research questioning BMI as a measure of patients’ severity (Gianini et al., 2017; Machado et al., 2017).”
BackgroundBarney, J. L., Barrett, T. S., Lensegrav-Benson, T., Quakenbush, B., & Twohig, M. P. (2021) · Body Image · doi:10.1016/j.bodyim.2021.04.012 · Cited by 9 · see citing works
“Although it is the case that in the current study the restrictive behaviors group did indeed have a lower average BMI relative to the binge/purge group, recent research suggests that lower BMI is frequently not associated with more severe ED symptomology (Grilo et al., 2015; Machado et al., 2017).”
Body appearance values modulate risk aversion in eating restriction.
Jenkinson, P. M., Koukoutsakis, A., Panagiotopoulou, E., Vagnoni, E., Demartini, B., Nisticò, V., Gambini, O., Christakou, A., & Fotopoulou, A. (2023) · Journal of Experimental Psychology General · doi:10.1037/xge0001445 · Cited by 8 · see citing works
Ortiz, S. N., Forrest, L. N., Kinkel‐Ram, S. S., Jacobucci, R., & Smith, A. R. (2021) · Journal of Affective Disorders · doi:10.1016/j.jad.2021.08.049 · Cited by 7 · see citing works
Muzi, L., Tieghi, L., Franco, A., Rugo, M. A., & Lingiardi, V. (2021) · Frontiers in Psychology · doi:10.3389/fpsyg.2021.688924 · Cited by 8 · see citing works
Do risk factors differentiate DSM-5 and drive for thinness severity groups for anorexia nervosa?
Dang, A. B., Kiropoulos, L. A., Anderluh, M. B., Collier, D. A., Fernández‐Aranda, F., Karwautz, A. F. K., Treasure, J. L., Wagner, G., & Krug, I. (2024) · Journal of Eating Disorders · doi:10.1186/s40337-024-00966-5 · Cited by 5 · see citing works
“In relation to AN, which comprised five studies [18–22], the review did not find significant differences in ED psychopathology across the DSM-5 BMI severity groups.”
BackgroundRienecke, R. D., Blalock, D. V., Duffy, A., Johnson, C., Riddle, M. C., Grange, D. L., Mehler, P. S., & Brandt, H. (2024) · Journal of Eating Disorders · doi:10.1186/s40337-024-01150-5 · Cited by 3 · see citing works
“We acknowledge the limitations of using BMI as an indicator of diagnostic severity [20].”
Krug, I., Dang, A. B., Sánchez, I., Granero, R., Agüera, Z., Gaspar‐Pérez, A., Jiménez‐Múrcia, S., & Fernández‐Aranda, F. (2023) · Eating Disorders · doi:10.1080/10640266.2023.2259682 · Cited by 2 · see citing works
“…recent findings from meta-analyses (Dang et al., 2022), treatment-seeking almost-all-female studies (e.g., Dang et al., 2023; Krug et al., 2021; Machado et al., 2017), and gender-specific studies (Zayas et al., 2018) that have evaluated the usefulness of DSM-5 severity indices in predominantly…”
BackgroundSeverity levels of anorexia nervosa and atypical anorexia nervosa in a Korean cohort
Kim, Y., An, Z., & Treasure, J. L. (2024) · European Eating Disorders Review · doi:10.1002/erv.3145 · Cited by 2 · see citing works
“…of < 15 kg/m 2 as an indicator of extreme AN, various studies have suggested that the parameters used to define the term “extreme” are too broad and have raised concerns regarding the validity of this criterion (e.g., Machado et al., 2017; Reas & Rø, 2017; Smith et al., 2017; Toppino et al., 2022).”
Trastornos de alimentación en la infancia y adolescencia. Nuevas perspectivas para nuevos tiempos
Graell-Berna, M. (2020) · Revista de Psiquiatría Infanto-Juvenil · doi:10.31766/revpsij.v37n3a1 · Cited by 2 · see citing works
Stein, D. J., Szatmari, P., Gaebel, W., Berk, M., Vieta, E., Maj, M., de Vries, Y. A., Roest, A. M., de Jonge, P., Maercker, A., et al. (2020) · BMC Medicine · doi:10.1186/s12916-020-1495-2 · Cited by 264 · see citing works
Self-citationHenriet, E., Norton, J. L., Sénèque, M., Maı̈moun, L., Courtet, P., & Guillaume, S. (2025) · International Journal of Eating Disorders · doi:10.1002/eat.24542 · Cited by 1 · see citing works
“…differences in eating disorder psychopathology across DSM-5 severity categories, consistent with earlier reports (Gianini et al. 2017; Krug et al. 2021; Machado et al. 2017), and some studies have even shown greater psychopathology in higher BMI categories (Dang et al. 2023; Nakai et al. 2017).”
Dyląg, K. A., Skowron, K. P., Kurnik‐Łucka, M., Drzewiecki, Ł., Przybyszewska, K., Król, M., Dumnicka, P., Gawlik, Z., Gawlik, J., Sikora, S., et al. (2024) · Nutrients · doi:10.3390/nu16234112 · Cited by 1 · see citing works
The Classification of Feeding or Eating Disorders in the ICD-11
Pike, K. M., Claudino, D. A., & Claudino, A. M. (2024) · Springer eBooks · doi:10.1007/978-3-031-46096-8_10 · Cited by 1 · see citing works
The Classification of Feeding or Eating Disorders in the ICD-11
Pike, K. M., Claudino, D. A., & Claudino, A. M. (2024) · Springer eBooks · doi:10.1007/978-3-030-97416-9_10-1
Friedman, J. I., & Lowe, M. R. (2024) · European Eating Disorders Review · doi:10.1002/erv.3162
Dang, A. B., Fuller‐Tyszkiewicz, M., Kiropoulos, L. A., & Krug, I. (2025) · European Eating Disorders Review · doi:10.1002/erv.70032
“Within this review, five studies on AN (Dalle Grave et al. 2018; Gianini et al. 2017; Machado et al. 2017; Smith et al. 2017; Zayas et al. 2018) evaluated the DSM‐5 severity specifiers based on BMI and found limited support for their validity as indicators of ED psychopathology in AN.”
Carr, B., Dang, A. B., Kiropoulos, L. A., & Krug, I. (2025) · European Eating Disorders Review · doi:10.1002/erv.70036
“BMI was included in the AN analysis due to it being a diagnostic criterion of AN in the DSM‐5 (American Psychiatric Association 2013; Machado et al. 2017), and because starvation (a low BMI) impacts cognition (Spettigue et al. 2025).”
Dang, A. B., Kiropoulos, L. A., Anderluh, M. B., Collier, D. A., Fernandez-Aranda, F., Karwautz, A., Treasure, J., Wagner, G., & Krug, I. (2024) · Figshare · doi:10.6084/m9.figshare.24987780
A person-centred and data-driven approach to phenotyping anorexia nervosa
Bovenberg, C., Keeler, J. L., Cardi, V., Ambwani, S., Morris, R., Rowlands, K., & Treasure, J. (2026) · Journal of Eating Disorders · doi:10.1186/s40337-026-01632-8
“BMI-derived severity thresholds do not meaningfully differentiate individuals in terms of frequency of ED behaviours or psychological distress [15, 17].”
- Authors
- Machado, P. P. P., Grilo, C. M., & Crosby, R. D.
- Affiliations
- University of Minho (PT)
- Yale University (US)
- University of North Dakota (US)
- Corresponding author
- Machado, Paulo P.P.
- Venue
- European Eating Disorders Review
- Publisher
- Wiley
- Published
- 2017-04-12
- Volume
- 25
- Issue
- 3
- Pages
- 221-223
- ISSN
- 1072-4133 (ISSN-L)
- 1099-0968
- PMC
- PMC8674740
- OpenAlex
- W2605587109
- Semantic Scholar
- eeefa8b0b27143aff1a2d1488bcf7a1776297eef
- Cited by
- 51
- References
- 15
- Citations by year
- 2026: 2 · 2025: 4 · 2024: 8 · 2023: 6 · 2022: 5 · 2021: 5 · 2020: 9 · 2019: 1 · 2018: 7 · 2017: 4
- FWCI
- 7.10
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- European Eating Disorders Review (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Portuguese National Funding Agency for Science, Research and Technology (RCAAP Project by FCT) (submittedVersion)
- Portuguese National Funding Agency for Science, Research and Technology (RCAAP Project by FCT) (submittedVersion, cc-by-nc-nd)
- Funders
- National Institutes of Health (K24 DK070052)
- Fundação para a Ciência e a Tecnologia (POCI‐01‐0145‐FEDER‐007653)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Eating Disorders and Behaviors
- Health Sciences › Medicine › Psychiatry and Mental health › Child Nutrition and Feeding Issues
- Health Sciences › Nursing › Nutrition and Dietetics › Nutrition, Health and Food Behavior
- Keywords
- anorexia nervosa, body mass index, severity classification, Eating Disorder Examination Questionnaire, binge eating, purging, eating disorder psychopathology, treatment-seeking patients
- MeSH terms
- Adolescent, Adult, Anorexia Nervosa, Female, Humans, Male, Severity of Illness Index, Reproducibility of Results, Body Mass Index, Diagnostic and Statistical Manual of Mental Disorders, Young Adult
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