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Thoughts on DSM-V: Anorexia

Posted Feb 22 2010 3:04pm 1 Comment

A few weeks ago, I posted on the draft criteria for eating disorders proposed for the DSM-V, and I promised you my thoughts on the changes (or lack thereof). I spent several days mulling over my thoughts, and then I spent the rest of the time following the ongoing discussion on an eating disorders listserv. The discussion still hasn't concluded, but since it doesn't show any signs of slowing, I decided to bite the bullet and get on with it.

As an overly brief summary, the three most major changes to the current DSM diagnostic criteria for eating disorders were:

  • removing amenorrhea as a criteria for anorexia
  • removing the purging/non-purging subtypes for bulimia (non-purging bulimia would be considered, essentially, binge eating disorder)
  • the addition of binge eating disorder as a stand-alone diagnosis
First off, I want to credit some other awesome bloggers for their thoughts on these changes. Both Rachel and Kim had some thoughts that are well worth reading, and I highly encourage you to do so.

Since I have many thoughts, I decided to break this post into several parts. I decided to start with anorexia, since that's where I have the majority of my thoughts, and I will post the next part on other diagnoses tomorrow.

Anorexia Nervosa

The removal of the amenorrhea criteria is, in my mind, a really good thing. I have no quibbles with that. What is rather interesting is what stayed the same. Both my regular readers Cathy and Katie pointed out that the "overvaluation of weight and shape" isn't universal to anorexia, nor is it necessarily what is driving anorexia. In Kim's blog on the DSM-V criteria, she writes
In my opinion, the DSM doesn't really do service to the underlying drivers of anorexia. I think most self-destructive behaviors are a way to self-medicate, and I'm very aware that my anxiety went way, way down when I was heavily involved with my eating disorder. Everything seemed very peaceful and quiet when my mind was just tallying calories. For me, recovery is about learning to manage anxiety in a healthy way. It has very little to do with appreciating the Dove beauty campaign. Yes, there are days when I "feel fat," but this mostly translates to "I feel stressed." Somehow, they got linked in my mind (stress-->fat-->eat less-->less stress), but that doesn't mean the driver is for me to be thin; the driver is for me to be calm, and thinness was the result.

The DSM sort of supports the idea of Ralph Lauren ads and anorexia being paired. I just don't see this. This direct linkage seems to fuel the fire that eating disorders are adolescent obsessions with looking good. That fuels another fire -- that treatment is simple: Just eat, write body affirmations, paint your nails, you'll be fine. This starts a whole other inferno of self-hate and shame for the sufferer who feels like, "Why can't I just get better then? Am I just a vain, stubborn idiot?" The only thing that has extinguished all this has been to realize (with the help of Carrie's blog) that this is an illness.

All I can add to this is: amen!

What generated the most discussion on the listserv was the "85% of ideal body weight" criteria for anorexia. Laura Collins pointed out that anything under an individuals ideal body weight was a sign of malnutrition, so it almost seems like the 85% criteria was written by anorexia, for anorexia. Others have pointed out that these criteria leave out people who started restricting at a higher body weight, indicating that they don't have anorexia when all other signs say that they do, indeed, have anorexia. One could say that this is what EDNOS is for, but there are several problems with this. The first is that if they really do have anorexia, numbers on a chart be damned, they should be diagnosed with anorexia. The second has to do with EDNOS and mental health parity. Technically, there's mental health parity in the United States, which means mental illnesses need to be treated on par with physical illnesses (why they're even separated is beyond me, but that's another post). It's a step, and I'm happy it's a step, but let's be honest: everyone knows that mental health care gets the short end of an already very short stick. And in some states, EDNOS is not a parity diagnosis; only anorexia and bulimia are. So these semantics can have huge effects on who gets treatment.

Another issue is that people with eating disorders get very fixated on the 85% "rule." The psychology of EDs works like this: people with lower ideal body weights are somehow "better" and they "deserve" treatment. So if you don't meet that 85% cutoff, many people's thoughts are to lose more weight. I'm not saying we should change the diagnostic criteria to make sufferers happy--this thinking is an issue with ED psychology and not so much the diagnosis. But I'm not so sure what is "magic" about the 85% cutoff. It's not like I hit X pounds and I went from not-anorexic to anorexic, nor did I stop having anorexia once I crept over that 85% mark.

I have almost conflicting feelings on the focus on weight in the ED world. On the one hand, if everyone is weighing me all the freaking time, it's hard to stop focusing on weight. On the other hand, being weighed regularly gives me some comfort because I know I'm not constantly gaining weight. And for someone with a long history of anorexia, tracking weight can be a useful tool. It's not the be all, end all of my treatment and recovery, but if my weight starts slipping, that would be a useful thing to know. Part of the reason I find weight monitoring* helpful is that I'm not necessarily the brightest lightbulb in the box when it comes to recognizing relapse. How can not eating be a problem when it seems like a solution?

I do believe (and evidence suggests) that our bodies gravitate towards our set point weights, but getting there is far from just letting "gravity" do the work. After this past relapse, it took me almost half of my time re-feeding to get the last five pounds on because my metabolism started seriously fighting back. I would have much preferred not to bother with that, but I was lucky to have a team that absolutely insisted. I don't necessarily want people to totally ignore my weight, to just let nature sort itself out. Long-term, ongoing malnutrition wrecks havoc with your body, and that's not something on which I want to take a let's-just-throw-the-dice-and-see-what-happens approach.

That being said, "ideal weights" and "target weights" may not be stagnant, and they may not be one particular number. One treatment center told me my ideal weight down to the half pound, which made me laugh even then. Weight isn't the sole indicator of health. I don't think weight should be ignored, but it's just one factor in an overall picture.

And on that note, I will transition to the last part of my thoughts on the anorexia criteria in DSM-V. The entire DSM was altered slightly to have a dimensional aspect to diagnosis rather than a categorical. Click here for a more in-depth discussion. Take depression. In order to be diagnosed with depression, you have to meet five of nine symptoms. If you don't meet all five, technically, you don't have depression. That's the categorical diagnosis: you have it, or you don't. (Talk about black-or-white thinking!) The problem is that people can suffer from four of the criteria in very severe forms that impact their life. So now the DSM is also looking at severity of symptoms when using the diagnostic criteria so that the hypothetical person in the above example will be diagnosed and treated for depression. Which is good.

As part of this, the draft criteria for anorexia included a "severity" section. You know how severity of anorexia is likely to be calculated? Wait for it...wait for it...BMI. That's right. From the professionals who are constantly saying "it's not about the weight" are the ones telling you that the less you weigh, the sicker you are.

I'm not going to say that health and weight have nothing to do with each other. People with anorexia nervosa and very low body weights are clearly ill. I'm not disputing that. But weight is not the sole indicator of health or severity of anorexia!! There are so many other ways to measure severity, ways that don't collude with the I'm-not-that-sick mentality so common in eating disorders. I have been very, very sick at relatively normal weights, and some of the sickest people I met weren't those with the lowest weights. Anorexia is a mental illness, no? It's not primarily a disorder of low body weight; it's a disorder of self-starvation. Yes, weight loss is part of that, I'm not denying it, but perhaps severity could be measured by things like bradycardia and orthostasis, by body temperature and cyanosis, by energy imbalance and Eating Disorders Inventory scores, by how much of your thinking is dominated by food and weight and how frightened you are of gaining weight. But not weight itself. The severity of binge eating disorder isn't measured by BMI, it's measured by number of binge episodes per week. It can't be that hard to come up with a similar criteria for anorexia...can it?

I am actually shocked that more people haven't noticed and discussed this. It seems like such a huge issue (no pun intended), and it's basically been overlooked.

*Currently, I do weekly weigh-ins and I would imagine these will be spaced out as I continue to do well in recovery.
Comments (1)
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Anorexia diagnosis needs to be totally re-addressed. There is no magic number on the scales, nor any magic halting of menstruation which suddenly deems a person 'anorexic'.

The diagnosis is a combination of mental and physical issues which are measurable on a CONTINUUM. This hypothetical continuum is flexible and different for every sufferer. 

Health professionals need also, to be far better informed of this nature of, and manifestation of anorexia.  

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