Understanding mental health is becoming increasingly essential in dietetic practice.
As dietitians, we often encounter clients whose eating habits are influenced by underlying mental health conditions. Whether it’s a client struggling with an eating disorder, a patient whose anxiety impacts their appetite, or someone managing depression with the help of food, the connection between mental health and nutrition is undeniable.
But we don’t learn about this stuff in school.
This is where the DSM-V, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, comes into play. While it’s primarily used by mental health professionals to diagnose and classify mental disorders, having a basic understanding of DSM-V can empower dietitians to better support their clients’ overall well-being.
Dietitians may not typically use the DSM-V in their day-to-day practice, but having a basic understanding of this important resource can be invaluable when working with clients who have co-occurring mental health issues.
In this post, we’ll explore the DSM-V, its structure, and how the mental health disorders listed in the manual are relevant to dietitians’ work.
Table of Contents
What is DSM-V-TR?
The Diagnostic and Statistical Manual of Mental Disorders is a guide used by mental health professionals to diagnose mental illness. At its bare bones, it is a list of symptoms and other diagnostic criteria.
It is NOT a guide to causes of, or treatments for, psychiatric disorders.
First published in 1952 and updated every 10-15 years, the current version is the DSM-V-TR (DSM-5-Text Revision). Every revision involves updating symptoms and adding and removing diagnoses as research is updated.
The DSM-V-TR was published in 2022. It added three diagnoses, as well as free-standing symptom codes (the presence or history of suicidal behavior and nonsuicidal self-injury) meant to allow clinicians to better record and track these behaviors.
Significantly, this revision involved not only the typical literature reviews and over 20 review groups for the clinical aspects of the book but also special attention to special and marginalized groups.
Three Review Groups (Sex and Gender, Culture, and Suicide) evaluated each chapter for appropriateness and missing information. A forensic review of each chapter followed this. Lastly, an Enthoracial Equity and Inclusion Work Group evaluated the entire text to ensure that “explanations of ethno‐racial and cultural differences in symptomatic presentations and prevalence took into consideration the impact of experiences such as racism and discrimination.”
Structure of DSM-V-TR
The DSM-5 and DSM-V-TR consist of 20 disorder chapters. Each chapter progresses according to the developmental lifespan, starting with disorders typically diagnosed in childhood and ending with those typically diagnosed in later life.
Below is a sampling of some of the disorders groups you may encounter.
Keep in mind that this is meant to be an overview and introduction, not a deep dive. There is so much information; there’s no way to cover it all in one blog post!
Neurodevelopmental Disorders
Sample Diagnoses: Autism Spectrum Disorder, Attention Deficit Hyperactivity Disorder, Tourette’s Disorder, Oppositional Defiant Disorder, Separation Anxiety Disorder
Signs and Symptoms: The criteria vary depending on the diagnosis. However, these disorders show symptoms initially in early childhood, though sometimes evaluation and diagnosis don’t occur until adulthood.
Parents or other caregivers may generally notice difficulties with language and speech, delayed motor skills, and problems with socialization, memory, learning, and behavior.
Nutritional Implications: Children and adults with neurodevelopmental disorders may have sensory processing problems, leading to very picky eating or refusal to eat anything other than very specific, safe foods. While a dietitian experienced in these problems is important, an occupational therapist is crucial.
Autism, in particular, is strongly linked to gastrointestinal disorders.
Overall, nutrition research is in its early days. Common social media recommendations, such as gluten-free, dye-free, and/or sugar-free diets, are not supported by research and may lead to malnutrition, especially if safe foods are omitted.
Schizophrenia Spectrum and Other Psychotic Disorders
Sample Diagnoses: Schizophrenia, Schizoaffective Disorder, Substance/Medication-Induced Psychotic Disorder, Catatonia
Signs and Symptoms: Changes in thinking and behavior, suspiciousness or paranoia, social withdrawal, sleep disruptions, catatonia, decline in hygiene, confused sleep, sudden decrease in performance at work or school.
Nutritional Considerations: Individuals with psychosis may be paranoid about food. Consider keeping packaged food on hand so they can monitor the preparation. Schizophrenia is strongly tied to general GI upset. Small studies suggest that probiotic supplementation may help with the somatic symptoms of schizophrenia and may shorten the psychotic period.
This population is susceptible to abuse and food insecurity. Your first focus must be evaluating for malnutrition and treating it if necessary.
All healthcare team members should also be on the lookout for excessive water intake. A small subset of individuals with schizophrenia will develop psychogenic polydipsia. They will need to be monitored at all times to prevent hyponatremia.
Bipolar and Related Disorders
Sample Diagnoses: Bipolar I Disorder, Bipolar II Disorder, Cyclothymia
Signs and Symptoms: Characterized by alternating periods of depression and either mania or hypomania. Some individuals with bipolar disorder will also experience psychosis during manic periods. These individuals may be diagnosed with Major Depressive Disorder that is either unresponsive to antidepressant medications or are induced into a manic phase on antidepressants.
Nutritional Considerations: Depressive episodes can lead to appetite disturbances. Mania and hypomania tend to cause increased activity and less demand for sleep, which they may or may not choose to eat. Evaluation for malnutrition is essential.
Small studies suggest that probiotic supplementation can lessen the chance of recurrence of mania requiring hospitalization or shorten the length of stay if hospitalization becomes necessary.
Depressive Disorders
Sample Diagnoses: Major Depressive Disorder, Premenstrual Dysphoric Disorder, Dysthymia (aka Persistent Depressive Disorder), Seasonal Affective Disorder, Perinatal Depression
Signs and Symptoms: persistent sad or empty mood; feelings of hopelessness, guilt, worthlessness, or helplessness; fatigue; difficulty concentrating or making decisions; sleep disturbances; appetite disturbances; physical pain with no evident cause
Nutritional Considerations: IBS-like symptoms and appetite dysregulation are very common, with associated rapid weight changes. The majority of nutritional psychology research is on depressive disorders. Magnesium, zinc, folate, and B12 deficiency is common and should be evaluated (likely in all psychiatric disorders).
Gut disorders should be addressed and managed, as the two conditions can worsen or improve each other. Probiotics can be helpful initially but should not be the primary management effort.
Anxiety Disorders
Sample Diagnoses: Generalized Anxiety Disorder, Panic Disorder, Phobias, Social Anxiety Disorder, Selective Mutism
Signs and Symptoms: Fear or anxiety that is out of proportion to the situation and hinders their ability to function normally. These patients may also experience GI upset and generalized pain.
Nutritional Considerations: Anxiety Disorders don’t appear to respond to nutrition interventions in the same way that depressive disorders do. However, reduction or elimination of caffeine and/or alcohol, adequate nutrition throughout the day, and high doses of fish oil (EPA) may help.
Feeding and Eating Disorders
Sample Diagnoses: Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder, Pica, Avoidant Restrictive Food Intake Disorder
Signs and Symptoms: This is highly variable, and we will barely touch the surface here. You may see frequent trips to the bathroom after eating, hiding food, rapid weight changes, fear of certain foods or nutrients, frequently voicing low body image, dizziness or fainting, cold intolerance, eating very rapidly, disinterest in food, avoidance of social interactions they may involve food, and more
Nutritional Considerations: Again, this can be highly variable, depending on the ED presentation. Generalized and severe malnutrition is always a big concern. As is refeeding syndrome in restrictive-type eating disorders. If you are not familiar with eating disorder treatment, please refer these cases to someone who is.
Substance-Related and Addictive Behavior
Sample Diagnoses: Alcohol Use Disorder, Stimulant Use Disorder, Opioid Use Disorder, Benzodiazepine Use Disorder, Cannabis Use Disorder, Gambling Disorder
Signs and Symptoms: inability to stop the behavior (even when they want to), intense cravings (especially in locations where the behavior occurred), neglecting responsibilities, risky behavior to obtain the substance, increased tolerance of the substance, physiological symptoms of withdrawal, secretive behavior, stealing to fund the substance.
Nutritional Considerations: All substances of abuse negatively impact the gut function and can lead to food insecurity. GI symptoms range based on the substance, such as extreme pain and bloating from opioid withdrawal; constipation in opioid use; diarrhea, nausea, and vomiting in alcohol abuse; etc. Detox periods are particularly hard on the gut, and patients generally do not want to eat. After the detox period, intense sugar cravings are common, especially with alcohol and opioids. Rapid weight loss can occur. However, many patients deny recent weight loss if they have been malnourished for a long time.
Other Chapters
- Neurocognitive Disorders
- Personality Disorders
- Disruptive, Impulse-Control, and Conduct Disorders
- Gender Dysphoria
- Sexual Dysfunctions
- Sleep-Wake Disorders
- Elimination Disorders
- Somatic Symptoms and Related Disorders
- Dissociative Disorders
- Trauma- and Stressor-Related Disorders
- Obsessive-Compulsive and Related Disorders
Criticisms of the DSM
Obviously, there are opinions on either side of this, but some of the criticisms and worries seem valid.
The main criticism is due to the number of behaviors added to the latest additions. This was meant to help prevent false and missed diagnoses, but opponents worry that this can lead to pathologizing normal behavior or inappropriately medicating individuals.
The counterargument argues that the DSM is a guide and a document. Diagnosis and treatment are still the responsibility of the treatment team. Some worry that this criticism takes the blame for inappropriate care and diagnoses from the healthcare team. This argument states that you shouldn’t treat the diagnosis anyway. You should treat the patient.
Others argue that some of the behaviors included in the DSM are based on cultural norms, which change over time. For instance, homosexuality used to be considered a “pathological sociopathic personality trait” caused by poor relationships between parents and children.
The one that I personally find the most substantial is that the DSM focuses only on signs and symptoms. While the DMS-V-TR attempted to incorporate stigma and discriminatory factors into the diagnosis, there is little attention on biopsychosocial and physiological factors for psychiatric conditions.
However, we also have to understand that we likely don’t know all of the biological processes in the brain that can lead to certain symptoms. For instance, we don’t exactly know why people react to traumatic experiences differently. Why does one experience long-term trauma, such as PTSD, and the person right next to them doesn’t? Even if they’re twins?
If we don’t know that, how can it be in the DSM?
How the DSM-V relates to dietetics
The research is pretty clear now that nutrition can impact mental health. Inadequate nutrition does not appear to cause mental illness, nor does nutrition therapy act as a primary treatment for mental illness.
However, we can use nutrition to help clients feel better overall and improve their response to primary mental healthcare, such as medications and talk therapy.
Additionally, because dietitians are trained to assess all aspects of a person that can affect nutrition, we can target the needs of each individual rather than give generic nutrition information that a client may or may not be able to act on.
And since we’re trained to aid clients in behavior changes, we can effectively help the client meet their goals, rather than giving a handout and moving on.
No other profession has that combination of skills and education!
Using the DSM-V in dietetic practice
In essence, we can use the DSM to learn what to expect when we have a client referred with a condition we are not familiar with. While this won’t give us all the information we need to help, it can get us started before we even see the client.
Dietitians obviously cannot diagnose a patient, but the DSM is an excellent reference, and it can help us understand psychiatric disorders a bit better. However, nothing compares to actually interacting with your client or patient!
The Role of Dietitians in Mental Health
Interdisciplinary Approach: Remember to make yourself part of the team! Report your findings and recommendations to your patient’s or client’s other healthcare professionals. This ensures that all aspects of the individual’s care are addressed.
Screening and Referral: Dietitians can (and should be) screen for a variety of factors that affect or signal mental health disorders. Does your intake paperwork address alcohol, caffeine, and other substance use? Do you ask about their top stressors, food security, and ability (or willingness) to cook? The intake paperwork for my private practice asks if their stress negatively affects their life and if they feel like their life has meaning and purpose.
Do you know who to refer to if your client shows signs of mental illness? I strongly recommend you have a referral list for therapists, psychiatrists, psychologists, and more.
Know their specialties, whether or not they take insurance, and if they speak a second language.
Counseling Techniques: Most of us learn some counseling techniques in school. Motivational interviewing is particularly effective at finding the motivation and initial goals to make a small but impactful change in one’s food choices.
Challenges and considerations for dietitians
As dietitians, our education regarding mental illness is pretty limited. We learn the fundamental definitions of eating disorders, the effects of alcohol on B vitamin metabolism, and the management of liver cirrhosis.
But really, that’s about it.
For those of us who choose to work in the behavioral health field, the vast majority of our knowledge comes after we graduate. Those wanting to work in eating disorder treatment have a clear pathway to specialization.
But the rest of us learn as we go, interacting with mental health professionals and behavioral health patients. We read, we learn from those who came before us, and we ask lots of questions.
Conclusion
As dietitians, our role extends beyond simply providing dietary advice or education. We are integral members of a multidisciplinary team that supports clients’ overall health, which includes their mental well-being.
By understanding the basics of DSM-V, we can enhance our ability to recognize when a client may need additional mental health support, facilitate more effective collaboration with mental health professionals, and tailor our nutritional counseling to meet better the needs of those living with mental health disorders.
The intersection of nutrition and mental health is a powerful space, and our awareness of tools like the DSM-V ensures that we are equipped to make a meaningful impact on our clients’ lives. To continue building your knowledge in this area, I encourage you to explore the resources provided and consider further education in nutritional psychology.
