Given the blog’s focus, it’s not often that I have good news to report, so I tend to get a little giddy when the cosmos align in our collective favor. I blogged back in December, 2008 about proposed changes under consideration by the American Psychiatric Association to the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM). Considered the psychiatric bible of the field, the DSM is used by doctors to make a diagnosis and provides insurance companies with diagnostic codes without which the insurers will not reimburse patients’ claims for treatment. Among the conditions up for debate included making binge eating disorder (BED) an independent diagnosis (BED is currently lumped into the vague catch-all category of ED-NOS, which encompasses those who don’t meet one or more of the criteria for anorexia or bulimia).
You’d think that a condition estimated to eclipse both anorexia and bulimia combined would be a no-brainer for inclusion, right? You’d think wrong. Some mental health professionals actually protested classifying BED as a disorder, suggesting it to be a “normal behavior.” Luckily for those who suffer from decidedly abnormal binge eating behaviors, the duh truck must have finally arrived at the APA, because when they released a draft of its recommendations today, it included recognizing BED as an official independent diagnosis — read the recommended criteria for diagnosis here. This is awesome news, for in addition to psychotherapy, there are medications that have been shown to help people with binge eating disorder (Topamax and Wellbutrin, for example). If binge eating disorder were included in the manual as a legitimate eating disorder, those people who struggle with it might have an easier time getting insurers to cover the treatment and medication they so desperately need.
The recommendation of BED as an independent diagnosis is certainly the biggest change for eating disorders in the DSM, but there are other proposals under consideration that I think are pretty fabulous, too.
The work group is considering whether it may be useful and appropriate to describe other eating problems (such as purging disorder–recurrent purging in the absence of binge eating, and night eating syndrome) as conditions that may be the focus of clinical attention. Measures of severity would be required, and these conditions might be listed in an Appendix of DSM-5. If these recommendations are accepted, the examples in Eating Disorder Not Otherwise Specified will be changed accordingly.
As someone who suffered from what would be considered purging disorder with anorexic tendencies and was misdiagnosed with bulimia, I’m excited to see this relatively newly-popularized condition being entertained by the panel. Pamela Keel, an associate professor of psychology in the UI College of Liberal Arts and Sciences, has made great inroads in research indicating purging disorder to be a significant problem in women that is distinct from bulimia.
Many eating disorder activists are critical of the phrasing in the criteria for anorexia of a “refusal to maintain body weight at or above a minimally normal weight for age and height.” Refusal here, being the key word as myself and others argue that it’s not so much a refusal as it is an inability. For more on this, read Harriet Brown’s critique of the semantics. In its draft, the APA recommended clarifying the criterion to focus instead on behaviors, acknowledging that the word “refusal” implies intention and is “possibly pejorative and difficult to assess.” The panel also recommended deleting the criterion of amenorrhea, thus opening up the diagnosis to a broader range of sufferers, including a growing number of men reporting anorexic behaviors.
In DSM-IV, amenorrhea is required. However, individuals have been clearly described who exhibit all other symptoms and signs of Anorexia Nervosa but who report at least some menstrual activity. In addition, this criterion cannot be applied to pre-menarchal females, to females taking oral contraceptives, to post-menopausal females, or to males. However, there are some data that women who endorse amenorrhea have poorer bone health than do women who fail to meet this criterion. Deletion of this criterion is recommended.
The current DSM-IV requires episodes of binge eating and inappropriate compensatory behaviors both occur on average twice a week for three months. The panel cited a literature review that found that the clinical characteristics of individuals reporting a lower frequency of once/week were similar to those meeting the current criterion, so they recommended that the required minimum frequency be reduced to once/week over the last three months. The bulimia diagnosis also currently includes two subtypes: purging and non-purging. People with non-purging bulimia often try to purge calories via exercise or fasting, but do not use enemas, self-induced vomiting, laxatives, etc.. The panel found that non-purgers more closely resembled people with BED, and so they recommended deleting this subtype altogether.
Despite reports from the Boston Globe that the APA was considering classifying obesity a mental illness, I see nothing in the draft indicating that it would be included. The sheer ridiculousness of such a proposal simply blows my mind and at first I thought the Globe perhaps erroneously conflated obesity with binge eating disorder, since those with BED tend to be overwhelmingly overweight or obese, but it appears as if the idea was at least introduced. A study released last summer examined the evidence for making obesity a mental disorder and found it significantly lacking, acknowledging only “evidence that obesity is related to mental disorder and many of the medications used to treat psychiatric illness.” Considering that the latter evidence has been around since the 1990s, the study basically only confirmed the obvious.
Before we pop the cork on the champagne, keep in mind that this is only a draft, and is subject to change and that’s where you come in. In a new twist for the APA, the organization has posted the draft online and is seeking feedback via the Internet from both psychiatrists and the general public about whether the changes will be helpful before finalizing them. The draft manual, posted at www.DSM5.org, is up for public debate through April. The final version is expected to be released in 2013.