Eating Disorders: DSM-VEssay

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Why the DSM 5's current method of diagnosis/conceptualization of Eating Disorders is wrong

An argument against the DSM diagnostic criteria for eating disorders

The Diagnostic and Statistical Manual (DSM) of Mental Disorders has the appearance of an authoritative text in terms of how mental disease are defined. However, there has been considerable debate over what constitutes a mental disorder over the years. For example, for many years Asperger Syndrome was defined as a separate category from other autism spectrum disorders (ASD). Now individuals who once were thought to have Asperger's are simply viewed as being 'on the autistic spectrum.' Similarly homosexuality was once classified as a disorder, now it no longer is while severe PMS has made its way (controversially) into the DSM. Thus, when the definition of a mental illness does not seem to be effective or serving the population it is intended to serve, questioning the definition of that disorder seems wise. This should be the case with eating disorders, particularly given the troublesome reputation for treating these conditions. This alone should be a red flag regarding the questionable nature of the diagnostic criteria.

The word 'anorexia' is often colloquially and inaccurately used to describe someone who is very thin or on an extreme diet. According to the DSM-IV and revised DSM-V, the primary characteristic is "a refusal to maintain body weight at or above a minimally normal weight for age and height (e.g. weight loss leading to a maintenance of body weight less than 85% of that expected, or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected)." However this is immediately problematic because the severity of the disorder is almost completely defined according to the subject's weight. True, an extremely underweight anorexic may be at greater physical risk than a less extremely underweight anorexic. But that does not mean that the more underweight sufferer has a more severe mental disturbance. An anorexic who is older, has a slower metabolism, or less ability to engage in highly restrictive eating and extreme exercise may be less technically underweight than another but still have the same obsessive thinking about weight and body issues. An older woman with family obligations may not be able to 'get away' with as much restrictive eating or to be physically able to lose as much weight as a teenage girl who plays sports.

This calls for emphasizing the second component of the DSM criteria to a greater degree which is "intense fear of gaining weight or becoming fat, even though underweight." The fear of gaining weight, more than the weight should be emphasized in the treatment of the mental illness. Presumably the reference to 'even though underweight' is an attempt to distinguish between an anorexic and someone who genuinely needs to lose weight. However, the fear and anxiety more so than the underweight status would seem to be the 'mentally ill' component of the disorder. Someone who was technically underweight might be very obsessed with their weight because they were competing in a sport, for example, which required a lower body weight than is typical, but still would not be willing to compromise their health or to lose weight past a certain point -- nor exhibit significant fear.

The third criteria for anorexia in the DSM-V is "disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight." Once again, this is problematic in distinguishing anorexics from the rest of the population, given that many people, particularly women, seem to place an undue emphasis on body weight in terms of self-evaluation. Women who are lawyers, doctors, or otherwise professionally established may question their abilities simply because they are overweight or perceived to be overweight by society. But they may not have the extreme emaciation that is deemed to be characteristic of anorexics. There is also the question of the 'seriousness' of current low body weight: when is a body weight low enough to be medically serious? If the anorexic is medically stable, not extremely emaciated, but still obsessed with weight to the point that it dominates her life, does she still merit a diagnosis? Similarly, does someone who is underweight but is balanced in other aspects of her life and simply is very focused on healthy eating warrant being diagnosed with a mental disorder? Some individuals at least claim to eat very little for health-related reasons, using caloric restriction or periods of fasting to prolong their health. Regardless of whether this actually accomplishes this health-related objective, should they be characterized as having an eating disorder?

At least the most recent edition of the DSM eliminated the criteria of cessation of menses as a criterion for anorexia. This stipulation was obviously extremely problematic, given that it effectively eliminated males and older, postmenopausal female from the definition. Also, some women do continue to menstruate at very low body weights and some women do not menstruate even though they are of normal body weight and body fat percentage for other reasons. The excessive focus on this category was gender-specific but anorexia can occur in all populations. Finally, women on the pill will often continue to menstruate because of hormonal reasons, regardless of body fat percentage.

There is also a division of anorexia into 'restricting' and 'purging' types. Once again, weight is given emphasis: the only difference between a purging anorexia and a bulimic (who by definition purges) is that an anorexic has an 'anorexic' BMI. This also highlights the degree to which the definition of bulimia is also problematic. According to the DSM-V, bulimia nervosa is characterized by "eating, in a discrete period of time (e.g. within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances." Does this include Thanksgiving? Competitive eating? The new norm for supersizing meals? It is also said to be coupled with inappropriate compensatory mechanisms such as vomiting but also excessive exercise. Is someone who runs a marathon after eating a massive amount of pasta (or is training for a marathon, running 60 miles a week and eating a great deal) a possible candidate for the disorder? Similar problems arise with the criteria for binge eating disorder that there is the use of "recurrent inappropriate compensatory behaviour in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, or excessive exercise." Given the popularity of many exercise regimes (such as CrossFit) which might easily be interpreted as excessive, the subjectivity of the criteria is once again highlighted. Similarly, the newly-added binge eating disorder which identifies overeating to the point of discomfort on a repeated basis as a mental disorder raise the question of what constitutes a normative amount of food, particularly in a culture where portion sizes are out of control, but also due to the fact that metabolic rates may vary as may physical builds.

Focusing instead upon the attitude towards eating might ultimately be more fruitful. Regarding obsessive thoughts about food and weight might make eating disorders better classified under obsessive-compulsive disorders rather than in their own special category. This might also serve to place the focus on the root cause of the behavior (obsession and anxiety) versus the food-related aspect of it. Although we live in a culture where many people (particularly women) are focused on body image and weight, not all individuals become anorexic or bulimic. Shifting the diagnostic criteria to the thought processes behind the behavior and the extent to which they impact social functioning would be more valuable. An individual who was socialized to eat too much may not have a mental disorder, merely an unproductive habit, versus someone who uses food like alcohol to distress from his or her day. Interestingly enough, and in another contradiction in terms of diagnostic criteria, while weight remains a very significant determinant of diagnosis in anorexia (and in bulimia, too, given that an underweight bulimic may gain the diagnosis of 'anorexic, purging type), it is not so in binge eating disorder. A person may engage in binge eating, not compensate with purging, and still receive the diagnosis, although there is obviously a stereotype that persons who overeat must be overweight.

In actual practice, very few people perfectly embody the clinical type of an eating disorder in an enclosed fashion. "Eating disorder diagnoses are snapshots in the course of an eating disorder. It is not uncommon to encounter individuals who initially met the diagnostic criteria for anorexia nervosa, then those of bulimia nervosa and now have a mixed state. Technically speaking, they have had three distinct psychiatric disorders (anorexia nervosa, then bulimia nervosa and now eating disorder NOS), whereas both common sense and the individual's subjective experience suggest that they have had a single eating disorder that has evolved over time" (Fairburn &… [END OF PREVIEW]

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