Big changes proposed in eating disorder diagnoses

10th February 2010

Big changes proposed in eating disorder diagnoses

posted in Anorexia, Binge Eating Disorder, Bulimia, ED-NOS, Eating Disorders, Mental Health, New Research, Purging Disorder, Rachel |

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.

Purging Disorder

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.

Anorexia

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.

Bulimia

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.

Obesity

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.

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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.

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This entry was posted on Wednesday, February 10th, 2010 at 3:21 pm and is filed under Anorexia, Binge Eating Disorder, Bulimia, ED-NOS, Eating Disorders, Mental Health, New Research, Purging Disorder, Rachel. You can follow any responses to this entry through the RSS 2.0 feed. Both comments and pings are currently closed.

1 On February 10th, 2010, Kataphatic said:

I have had concerns about a BED diagnosis because of the potential for BMI to be included in the diagnostic criteria, but as proposed, this looks very good. I do admit I still worry that some (many?) health care professionals will use fatness as a determinant (assuming that someone who is fat has BED even if all criteria are not met, or assuming that because someone is thin she cannot have BED).

I also still have the same concerns I’ve had before about the eating disorders being over (and under) diagnosed in folks based on their body weight and also how it’s a bit of a cop-out to call what is often a really normal response to social pressure to be thin a “mental illness.” I wish that we were addressing the social issues related to this alongside looking at ways to help individuals experiencing these disorders.

posted on February 10th, 2010 at 4:23 pm

2 On February 10th, 2010, Holly said:

The proposed changes to the ED diagnostic criteria have been nagging at me all day. While I agree with you that the proposed removal of amenorrhea from the criteria is cause for celebration, the fact that they have kept the weight requirements for anorexia (“…maintenance of a body weight less than a minimally normal weight for age and height”) is troubling at best.

At one point, I met all criteria for AN other than the weight cutoff and loss of my period (my “starting weight” was similar to yours and I also lost XXX pounds in a short time), and later was severely bulimic yet clinically “overweight” (BMI 27ish, perhaps). I feel that my weight was a major hindrance to my access to appropriate treatment, and prevented many medical professionals from accepting that I had a problem, period. Certainly this is an experience shared my many others. Maybe I have failed to do my research here, but I am at a loss for what evidence exists that shows weight is a valid indicator of an ED patient’s mental or physical status. Maybe I am just bitter to think of all of the years I wasted because no one thought I could possibly be sick, leading me to try and prove it.

posted on February 10th, 2010 at 4:42 pm

3 On February 10th, 2010, Rachel said:

@Kataphonic: I share some of your same concerns re: BMI. I know there was a push to have BMI removed from the anorexia criterion, but unfortunately the panel refused to budge on that one. I disagree however that eating disorders represent a “normal response to social pressure to be thin.” While I sometimes wonder if society itself is inherently disordered for its pervasive idolization of thinness, I have to point out that not everyone goes on to develop an eating disorder in response. New research in the past few decades, especially in the area of anorexia, indicates strong evidence of a biological component. As well, many an eating disorder may start as a plan to lose weight, but the weight soon becomes but a proxy for larger emotional issues, and in cases like anorexia and bulimia, physiological responses to starvation often drive and reinforce disordered behaviors.

posted on February 10th, 2010 at 4:59 pm

4 On February 10th, 2010, Rachel said:

@Holly: Yes, same situation here. One of the reasons I think I was misdiagnosed with bulimia is because I didn’t meet the weight requirement for anorexia (had the doctor taken into consideration the 25 pounds of loose skin from my rapid and significant weight loss, I might have qualified). I don’t know why they kept the weight requirement. With all the evidence showing early intervention to be the key in treating eating disorders, you’d think that when you reached a low enough body weight to finally warrant the diagnosis that it would be too late.

posted on February 10th, 2010 at 5:02 pm

5 On February 10th, 2010, Annie said:

I’m cautiously optimistic about the BED designation. I’ve suffered with this disease for years, and have yet to see a doctor or therapist who knew how to treat it – including those specializing in eating disorders. Hopefully this will lead to more knowledge among health professionals on the subject.

It’s funny that you mention Wellbutrin as a possible drug treatment choice. I’ve been on and off the drug for years (currently on) and my greatest recovery efforts were while I was on but being treated for depression. I hypothesized that Wellbutrin has helped me fight BED, but no doctor or therapist agreed. They all wanted to treat me like a Bulimic. In my research I’ve found little information available to sufferers of BED on possible treatments.

posted on February 10th, 2010 at 6:05 pm

6 On February 10th, 2010, Twistie said:

Okay, it’s definitely imperfect, but it’s also an amazing step forward. I certainly agree that we need to keep pushing for taking the weight requirement out of anorexia, obviously. It’s a diagnostic tool that’s keeping a lot of people from getting the help they need.

OTOH, the breakthroughs here are something to celebrate. I’ll head over and put in my two cents’ worth. If nothing else, there are sure to be a lot of people who know nothing about EDs commenting, and we need to get informed opinions heard.

posted on February 10th, 2010 at 6:09 pm

7 On February 10th, 2010, JennyRose said:

Overall I think this is good news. I am so glad to see the inclusion of BED. It recognizes the drive to overeat can exist without the drive to purge. It regards this problem as a disorder rather than the inability to control oneself/diet. I know EDs are a touchy subject for fat people but I find it helpful that they are recognizing that a fat person can even have an ED. Of course that does not mean all people who are fat have EDs or that fat is theb sole evidence of an ED.

I think the problem with the an diagnosis criteria is that many sufferers have a sub-clinical type of the disease. They may not meet all the physical requirements but they restrict food while being deep in the obsessive part of the disease.

posted on February 10th, 2010 at 6:29 pm

8 On February 10th, 2010, Merricat said:

I don’t know, I’m too disappointed about the BMI requirements for AN myself. I think that it’s underdiagnosed because of it, and that many people don’t get treatment or are considered cured because of it. I also have a personal stake in that, because my “normal” weight is the only thing that keeps me from having an AN diagnosis, even with the loss of my period. There is still time, and I do understand the logic of not putting everyone on a diet into treatment, but it’s a bit disappointing. The binge eating part is good though, and a lot of us have probably experienced the trading of one disorder for another in the course of our lives and experienced all of these at different periods. Perhaps there will one day be a more holistic form of treatment that addresses deeper causes of EDs, but that could require such a shift in our health care system as to be unlikely. Babbling now – good work APA. I’ll see you in a decade or so when I’m Dr. Merricat and have more factual and less anecdotal things to add.

posted on February 10th, 2010 at 8:31 pm

9 On February 10th, 2010, Revising Book on Disorders of the Mind « Follow Me Here… said:

[...] Big changes proposed in eating disorder diagnoses (the-f-word.org) [...]

posted on February 10th, 2010 at 11:17 pm

10 On February 10th, 2010, Rachel said:

Annie wrote: It’s funny that you mention Wellbutrin as a possible drug treatment choice. I’ve been on and off the drug for years (currently on) and my greatest recovery efforts were while I was on but being treated for depression.

Ha, the same thing kind of happened to my dad. Welbutrin is also marketed as Zyban, a smoking cessation drug. My dad went on it after he and my mom separated to help him stop smoking. It didn’t really do much for his habit, but helped immensely with his depression! He went off of it though since he rationalized that it wasn’t working.

posted on February 10th, 2010 at 11:41 pm

11 On February 11th, 2010, All Women Stalker said:

I don’t really have much to say about this. I do wish otherwise, though. Anyway, it’s a really good thing that they’re clearing up a lot of things in the manual. If it will help people get correct diagnosis and treatment, then I’m all for it.

posted on February 11th, 2010 at 1:55 am

12 On February 12th, 2010, Rachel said:

I don’t really have much to say about this. I do wish otherwise, though.

Exactly what is it that you wish otherwise?

posted on February 12th, 2010 at 12:12 pm

13 On February 12th, 2010, Bronwyn said:

One thing that I am really happy to see is the reconsideration of the language for AN- “Refusal” vs “inability.” Because frankly, it has always bugged me. This may be personal bias, but when I was in treatment for my ED, I always felt like I was being blamed any time that sort of language got bandied around- which I felt was always a little snag in recovery. I know that it probably stems from those ED sufferers who are “unwilling” in their recovery, but I would personally love to see that language reconsidered.

Also, I really hope that BED makes the final cut as a separately classified mental illness; I’m also not crazy about weight as part of the criteria, because it sort of buys into that “treatment as a last resort” type thing, when really ED is something you need to nip in the bud. I also think that in relation to BED- it will be really good to have it separate, because I can’t tell you how shocked i was when I finally heard this from my psychiatrist (No one had ever said ANYTHING about it to me before so I wonder who was just taking the warning at face value) “Now I’m not really supposed to put you on Wellbutrin because you have an eating disorder, but that is really only if you purge- you don’t purge, right?” I think a separate diagnosis for BED will be incredibly helpful to those who are perhaps a tad less knowledgeable about the specific reasoning behind certain drugs.

posted on February 12th, 2010 at 2:12 pm

14 On February 13th, 2010, Jackie said:

Purposing Obesity as a mental illness you say? Really, I wish I could feel some surprise. It’s just more of the same craziness surrounding the Obesity Hysteria. I mean, I don’t know, like if someone was too fat would they send them to a mental hospital to be locked in a room eating less calories than a victim of a German concentration camp? I have heard of that happening in the past.

posted on February 13th, 2010 at 10:59 am

15 On February 13th, 2010, Blimp said:

Why make such conditions an object of litigation by or against insurance companies? Insurance policies are legally binding contracts, and (in any state worth considering) such contracts always assume that the signer is of sound mind; insurance companies should be advised that any contract that is signed by one who is not of sound mind is null and void, and that it is illegal to collect any insurance premiums from such a person.

Eating disorders are a kind of self-harm which must surely be the result of a serious mental disorder, albeit perhaps not so severe as to require confinement in a mental institution. Both mental institutions, and outpatient clinics for the less severely insane are, or should be, the responsibility of the state. Likewise, the care of the health of all persons not able to pay for it. And any state worth considering must ban the Goth sub-culture. It’s insane! Promoting self-harming insanity as a life-style is a crime!

The only unresolved question is, should an eating-disordered adult be considered legally competent in matters not related to their eating disorder? I say yes, as long as we don’t pretend that a person whose eating disorder has yet to be brought under control is competent for any position of leadership, or can be trusted with any financial obligations that require maintaining one’s employment, or for which the lender needs to investigate one’s employment to determine credit-worthiness. Competent for testimony in court-of-law? Yes. Allowed to vote? Yes.

Of course, “obesity” is no eating disorder, but a condition that is harmless. Even in the most extreme cases, the problem is not too much weight or fat, but not enough bone or muscle.

posted on February 13th, 2010 at 10:11 pm

16 On February 17th, 2010, All Women Stalker said:

I wish that I had something more to say. Because it’s all so big and highfalutin for me. All those ideas. My little understanding of those technicalities make my thoughts trivial in comparison to what everyone else has to say. I wish I had more of an opinion because the issue of eating disorders is something I’ve been dealing with personally for the past 5-6 years.

That’s it…..

posted on February 17th, 2010 at 2:05 am