Contents
Key concepts
Classifications
Diagnosis danger?!
Key concepts
The term “eating disorder” refers to any abnormal psychological state associated with a disturbance in a person’s eating habits, which often serves as a means of expressing difficult emotions (1).
To an outsider this is a very strange way of coping, yet to a sufferer it makes perfect sense, and it may become their “normal” until somebody suggests otherwise. A person with an eating disorder may not even be aware that there’s a problem, and so this makes it all the more difficult when any attempt to discuss the issue is met with defensiveness or anger, as they may struggle to understand what on earth the other person is concerned about (2)!
In my case, I percieved the changes in my eating & exercise habits as being healthy. Prior to the development of my eating disorder I was slightly chubby, and being as awkward as I was this eventually became incorporated into my personality. My sense of humour was very self-depreciating, but over time I came to view myself as the “chubby useless one” in a less than humorous way, which eventually spiralled down into shame about my body weight. I wasn’t really unfit; I could jog for miles and I took part in judo weekly, but my physique didn’t seem to reflect that, and I wasn’t satisfied. Losing weight seemed to be my only opportunity to shake off this part of me, “If I can re-shape my body I can re-shape myself”, I thought. Unfortunately I didn’t go about this sensibly - fortunately the people around me were able to recognise this when I couldn’t.
Imagine living in a society where you were told that the water was toxic, and that you need to drink less of it. But you need water, right? People might take to drastically reducing their water intake to avoid being poisoned, others might drink loads of water & purge themselves of it in the hope that it gets rid of any toxicity.
Then imagine somebody comes along one day, and they tell you that you can actually drink the water as long as you drink it properly. Yet you wonder what “properly” is supposed to mean when water has been pegged as the enemy for so long. You understand that you must drink water, but the quantities and methods they’re teaching you don’t feel safe.
That’s sort of what it’s like having an ED, or having anorexia nervosa (AN)/bulimia nervosa (BN) at least. Food feels like a necessary evil. You need it, but being around it doesn’t feel safe, and you might feel like you’ve lost control. Any analogy for EDs is likely to fall short, because no two experiences are the same. In my “water analogy” the emphasis is placed on the impressions society gives you about that water (in place of food), and though the role society plays in EDs is important it is by no means the sole cause of their development (see ED Science #4: Risk Factors).
Classifications
The standards for the diagnosis of mental health disorders are set out by 2 main publications, and which system you use depends mainly on the country you live in:
The International Classification of Diseases (ICD) published by the World Health Organisation (WHO). The 10th edition is currently used, although a version of the 11th edition has been published in preparation for its implementation in 2019 (3).
The Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association (APA). Since 2013, the 5th edition (DSM-5) has been in use (4).
While the ICD-10 is most commonly used by over 100 countries throughout Europe, the DSM-5 is mainly used in Canada & the USA (5). While the ICD-10 covers diseases of every kind, the DSM-5 is specific to mental health disorders, and in 2013 it made some pretty hefty changes to the classification of eating disorders!
First of all, the EDs were moved from the “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence” category to its own category: “Feeding and Eating Disorders” (6, 7). This represented an important change in thinking, as EDs were no longer recognised as a disorder that only young people get; they can affect anybody at any age. Although EDs such as AN are most common in young girls, this does not mean they are exclusive to young girls.
Secondly, the criteria for AN & BN was changed slightly (6):
The diagnosis for AN did not rely on the cessation of periods (amenorrhea).
The term “refusal” of food was removed from AN criteria.
The criteria for AN no longer relied only on a fear of weight gain, but also factors impeding weight gain.
BN saw a decrease in threshhold, from a frequency of 2 episodes per week to just 1 episode per week (this would constitute mild BN) (7).Finally, whereas the DSM-4 recognised only 3 EDs, namely (8)…
Finally, whereas the DSM-4 recognised only 3 EDs, namely (8)…
AN
BN
Eating disorder not otherwise specified (EDNOS)
… the DSM-5 recognised 5 EDs, which are illustrated in the mind-map below (7).
Note that binge eating disorder (BED) was introduced as a standalone classification, and that EDNOS was replaced by other specified feeding or eating disorder (OSFED) and unspecified feeding or eating disorder (UFED). The EDNOS category was associated with quite a bit of stigma and self-doubt, because if you don’t fall into the “main” eating disorder categories then it can’t be that bad, right?
Well, actually, no. Amanda Henkel (a psychology student who has posted several videos about mental health disorders) sums this up very nicely in a video titled “EDNOS/OSFED: “I’m not sick enough."”.
OSFED & UFED may still carry some stigma, but hopefully we as a society can understand that a mental illness is a mental illness, whether or not you have a “label” or a specific diagnosis. These EDs can be just as dangerous, and until the publication of the DSM-5 these disorders actually made up around half of all ED cases,
This is a subject that I could ramble on about for days, so I won’t discuss the actual criteria themselves here, but Eating Disorders Victoria has published a webpage listing the disorders classified by the DSM-5 and their criteria, which you can access via. this hyperlink.
Eating disorders are covered alongside feeding disorders in the DSM-5, which will also be the case in the ICD-11. Although feeding & eating disorders have some overlapping behaviours (and anecdotal evidence suggests that feeding disorders in youth predispose a person to developing an ED in later life) they are not the same thing, and the link between them is poorly researched (9). The main feeding disorders listed are:
Pica - where a person consumes non-food materials.
Rumination disorder - where a person chews their food, brings it back up, and re-chews it. The name is derived from “ruminant”, a term used to describe animals such as cows that also eat their food in this way.
Avoidant-restrictive food intake disorder (ARFID) - a person
The key feature that distinguishes EDs from feeding disorders is that EDs are often associated with a distorted body image, a drive to lose weight, or a feeling of loss of control around food (9). These attitudes & behaviours are generally not associated with feeding disorders, for example, a person with pica does not eat non-food material to lose weight, but often (not always) is sufferring from a developmental disability.
Diagnosis danger?!
A diagnosis in mental health is not as simple as a diagnosis in general medicine, which also isn’t that simple, although that’s another topic altogether! What we call autism is actually a spectrum of conditions, and who’s to say that all of these conditions should all be classified under the same umbrella term? Would it be more beneficial to separate them all out completely?
This debate can get very philosophical; humans have been classifying things since our very early days, and the way we identify things can be quite arbitrary. Do we distinguish trees from shrubs, or do we just say that shrubs are small trees?
Thankfully, science has stepped in here. With the development of genetic sequencing, we are able to say that one species does not belong to the same category as another based on its molecular features, which is more accurate than making the same judgement by looking at the appearance of 2 things.
Medical tests such as X-rays can be very handy, but even then they aren’t the be all and end all. In psychiatry there is very little physical evidence to go off, which can make diagnosis that bit more difficult, and somewhat controversial. Image source.
Unlike X-rays or genetic analysis, we can’t rely on brain scans as a method of diagnosing mental health conditions (10). Although research has seen success in identifying patterns in brain activity associated with specific mental health disorders, it is more difficult to use these patterns to determine what mental health disorder somebody is suffering from, because (10):
There is variation in brain activity between individuals.
There is variation in brain activity between 2 people with the same disorder.
Many mental health conditions display similar patterns to eachother in the brain.
So psychiatrists have to rely on a set of guidelines established by current wisdom & their own intiution to make a diagnosis, which might not be the best way of doing things,. A diagnosis in mental health has its benefits; it suggests what treatments might best work for you based on the outcomes of patients with similar symptoms & it can make it easier to access services (11). Yet these are not great when somebody can’t get a diagnosis. Maybe they don’t quite meet the criteria, or their case is too complex. The lack of a diagnosis might see them fall by the wayside, despite the fact that their issue may be just as distressing as anybody else’s.
The diagnosis of AN was a relief to me; I did see it as a helpful thing, and still do. Having a known mental health disorder allowed me to know what I was up against, and allowed the people around me to understand how I might be feeling. It was much easier to communicate my needs with my care team & several teachers at school who knew about my condition. Yet sometimes I wonder if things would have been the same if I hadn’t been given this diagnosis. Before AN was even mentioned friends and family showed concern for my health, but perhaps the connection between my mental state and my eating habits wasn’t so easy to make. At my first GP appointment I was told I was “malnourished” & another appointment was made for a month’s time. Looking back I completely understand his decision. My local health board is under immense pressure, as many others throughout the UK are, and to refer a teenager who had not been showing symptoms for very long is a risky move. Thankfully, I started seeing my local CAHMS team in under a month!
Diagnosis has its obvious perks (e.g. by enhancing communication & letting a patient know that they are not alone), but we run the risk of forgetting the people behind the diagnosis (12). You may know somebody has depression, and that might clue you into why they have developed this disorder based on the common risk factors, but the only way to know for certain is to learn more about them & their history, which plays largely into their treatment.
One alternative to a diagnostic approach is formulation, which uses the patient’s background, history & presenting symptoms to “formulate” their diagnosis (13). This method also uses diagnoses, but makes no assumption of a diagnosis based on the initial presentation & instead builds up a diagnosis from the patient’s story.
Again, however, a diagnosis is not definitive nor defining. You may feel trapped by it, and certainly I felt that it was a part of me that I would never shake off. I was encouraged to name it something other than AN, and when prompted to imagine the worst possible person I came up with the name Donald Trump.
Which also means that I beat Donald Trump. Pretty hardcore!
Most importantly, you control your ED and it does not control you. Statistics may say that this percentage of sufferers recover in a year, or that percentage of sufferers remain chronically ill, but those are not cut-off points. We can’t give up on people, regardless of how complex their issue seems. While attending Beat’s “Tip of the Iceberg” event, one health care professional recalled a patient that she did not believe would ever recover. Yet the very same patient did just that. Ever since, she says, she believes that every person has the potential to recover.
Last in series: ED Science #1: Introduction
Next in series: ED Science #3: Symptom Spotting
References
(1) Mind. Types of Eating Disorders. Available from: https://www.mind.org.uk/information-support/types-of-mental-health-problems/eating-problems/types-of-eating-disorders/#.XBi9kM3grIU. [Accessed 18th December 2018].
(2) Ferentz, L. Six Signs to Assess an Eating Disorder. Available from: https://www.psychologytoday.com/us/blog/healing-trauma-s-wounds/201703/six-signs-assess-eating-disorder. [Accessed 18th December 2018].
(3) World Health Organisation. International Classification of Diseases. Available from: https://www.who.int/health-topics/international-classification-of-diseases. [Accessed 20th December 2018].
(4) American Psychiatric Association. DSM History. Available from: https://www.psychiatry.org/psychiatrists/practice/dsm/history-of-the-dsm. [Accessed 20th December 2018].
(5) Thomas Engelthaler. Are there countries in which references other than the DSM are used for psychological diagnosis? Available from: https://www.quora.com/Are-there-countries-in-which-references-other-than-the-DSM-are-used-for-psychological-diagnosis/answer/Thomas-Engelthaler.[Accessed 20th December 2018].
(6) Grohol, J. M. DSM-5 Changes: Feeding & Eating Disorders. Available from: https://pro.psychcentral.com/dsm-5-changes-feeding-eating-disorders/. [Accessed 20th December 2018].
(7) Psychiatry Online. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Available from: https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596. [Accessed 21st December 2018].
(8) Psychiatry Online. DSM-IV-TR. Available from: https://dsm.psychiatryonline.org/doi/abs/10.1176/appi.books.9780890420249.dsm-iv-tr. [Accessed 21st December 2018].
(9) Ekern, J. Understanding the Difference Between a Feeding and Eating Disorder in Your Child. Available from: https://www.eatingdisorderhope.com/blog/understanding-the-difference-between-a-feeding-and-eating-disorder-in-your-child. [Accessed 21st December 2018].
(10) Gillihan, S. J. Using Brain Scans to Diagnose Mental Disorders. Available from: https://www.psychologytoday.com/gb/blog/think-act-be/201605/using-brain-scans-diagnose-mental-disorders. [Accessed 21st December 2018].
(11) British Psychological Society. Understanding Psychiatric Diagnosis in Adult Mental Health. Available from: https://www1.bps.org.uk/system/files/user-files/Division%20of%20Clinical%20Psychology/public/DCP%20Diagnosis.pdf. [Accessed 21st December 2018].
(12) Craddock, N. and Mynors-Wallis, L. Psychiatric diagnosis: impersonal, imperfect and important. British Journal of Psychiatry. 2014; 204(2): 93-95. Available from: https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/psychiatric-diagnosis-impersonal-imperfect-and-important/C29813EAC72CCC801F4F17AC96126093/core-reader. [Accessed 21st December 2018].
(13) Rege, S. Psychiatric Formulation Demystified – The Sherlock Holmes Way. Available from: https://psychscenehub.com/psychinsights/psychiatric-formulation-demystified-sherlock-holmes-way/. [Accessed 21st December 2018].
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