Diagnosing Eating Disorders

Abstract

    This article will examine the history of diagnosis of Eating Disorder listed in the DSM-TR-IV (APA, 2000) including: When Eating Disorders were first considered a diagnosable disorder by clinicians, and when it was added to the DSM. I will also investigate how society has contributed to an increase of Eating Disordered clients, the biological causes of Eating Disorders. Additionally, the common symptoms of Eating Disorders will be listed.

    Mental Diagnosis has evolved as society and science has evolved, and successive versions of the Diagnostic and Statistical Manual (DSM) has reflected this growth process. Conversely, inclusion or exclusion from the DSM has influenced society’s perceptions of what is “acceptable and normal” behavior, and what is deviant. Case in point: When the American Psychiatric Association excluded homosexuality as a mental disorder in 1973, this decision heavily influenced the public’s opinion about the issue. The DSM has undergone many changes which reflect both social and medical advances in mental health.

   

    “The first standardized classification manual was the Statistical Manual for the Use of Institutions for the Insane” (National Committee for Mental Hygiene, 1918). It described 22 major diagnostic categories. Of the 22 categories, only one was directly acknowledged as “essentially psychogenetic in nature” (p. 26). There was an emphasis on medical etiology into the 1940s. During World War 11, many psychiatrists involved in treating traumatized soldiers applied psychodynamic therapies and found success. This lead to a restructuring and reconceptualization of treatment for mental disorders.

    

    The DSM-1 (APA, 1952) was considered an updated version of the Statistical Manual (1918) but used psychodynamic philosophy and language. The DSM-11 (APA, 1968) represented a move towards similarity with the International Classification of Diseases (ICD) (World Health Organization). The DCM-111 (APA, 1980) was, “A profound break from these previous classification systems” (Clegg, 2012). It was re-medicalized: “The use of specific diagnostic criteria for virtually all of the disorders-the major innovation of the DSM-111” (Spitzer, 1991, p. 294). The DSM 1V (APA, 1994) included cultural aspects of diagnosis. The current version of DSM-1V-TR (APA, 2000) made no changes to diagnostic criteria or codes.

   In 1980 the DSM (APA, 1980) added two categories for the diagnosis of Eating Disorders: Anorexia Nervosa (AN) and Bulimia Nervosa (BN). In the DSM-1V (APA, 2000) all other Eating Disorders were assigned to the category of Eating Disorders Not Otherwise Specified (EDNOS), which included Binge Eating Disorder (BED). In the DSM-V (APA, 2013), BED may be a distinct and separate diagnosis apart from EDNOS (Walsh, Sysko, 2009).

   

    Not only has the APA determined what is abnormal or normal functioning, but the media has also influenced society’s ideas about what is ideal. “Many scholars have concluded that thin-ideal media can have an appreciable impact on viewers. “A meta-analysis of 204 studies indicated little evidence for media effects in males, and generally minimal in females” (Ferguson, 2013). However, author Naomi Wolfe (The Beauty Myth, 2002) argue that due to observational learning, body dissatisfaction and Eating Disorders have been on the increase. “The National Eating Disorders Association confirms that 1-2% of American women are anorexic…and Anorexia is the biggest killer of teenage girls” (NIH, 2002). Male cosmetic surgery has hit record highs: “Men are now 33% of the market for cosmetic surgical procedures, and 10% of college students suffering from Eating Disorders are men” (Wolfe, 2002). There seems to be a discrepancy between these reports-perhaps in the decade between them, body dissatisfaction has declined. The NIH (2011) reports, “About 3% of U.S. adolescents are affected by an Eating Disorder, but most do not receive treatment for their specific eating condition.” This may suggest that of the academic analysis conducted on Eating Disorders, a percentage of the population are not being treated and thus have not reported Eating Disorders. Therefore, numbers are under-represented in studies. “Eating Disorders rank among the 10 leading causes of disability among young women” (Mathers, Vos, Stevenson, Begg, 2000). Given the negative impact and mortality of these diagnoses, the causal factors are important to understand.

   

    “Too often, discussions of the etiology of Eating Disorders becomes polarized into “cultural” versus “biological” explanations that ignore the fact that biological and environmental variables are inextricably linked” (Streigel-Moore, Bulik, 2007).  Having already addressed here some cultural risk factors, we turn now to the biochemical abnormalities. “Anorexia Nervosa has been shown to be associated with abnormalities in the serotonergic system” (Kaye, Bailer, Frank, Wagner, Henry, 2005). Additionally, extensive family history studies have shown familial transmission of Anorexia Nervosa, Bulimia Nervosa, and BED” (Fowler, & Bulik, 1997; Hudson, Pope, Jonas, Yurgelun-Todd, Frankenburg, 1987). Heritability estimates for Anorexia Nervosa from twin studies have been 48% on the low side (Kortegaard, Hoerder, Joergensen, Gillberg, Kyrik, 2001) and 76% on the high side (Klump, Miller, Keel, McGue, Iacono, 2001). It can be reasonably deduced from these studies that there is a genetic predisposition to Eating Disorders. Finally, having discussed the history of the DSM and Eating Disorders, we turn to the diagnostic criteria of an Eating Disorder as identified by the DSM-1V-TR (APA, 2000). As mentioned previously, there are three categorizations for Eating Disorders: Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Binge Eating Disorder (BED), found under the category: Eating Disorder Not Otherwise Specified (EDNOS).

    
Anorexia Nervosa (AN) has a lifetime prevalence among females of .05%. Diagnostic criteria are:

A. Refusal to maintain healthy body weight (less than 85% of that expected)

B. Intense fear of gaining weight or being fat

C. Body Dysmorphia or denial of low body weight

D. Amenorrhea (3 consecutive menstrual cycles missed).

Bulimia Nervosa (BN) has a lifetime prevalence among females of 1-3%. Diagnostic criteria are:

A. Binge Eating

B. Recurrent compensatory behavior (such as: vomiting, fasting, excessive exercise, laxatives, enemas or diet medications)

C. Binge Eating and Compensatory behaviors both occur at least twice a week for 3 months

D. Self-evaluation is unduly influenced by weight

E. Disturbance does not occur during episodes of AN.

Binge Eating Disorder (BED)-Recurrent episodes of binge eating in the absence of behaviors characteristic of Bulimia Nervosa.

   

    In conclusion, as advances in neuroscience and society have progressed, the DSM has endeavored to keep pace. Eating Disorders were at one time not included in the DSM; today, there are three types of Eating Disorders. With the publication of the much-awaited DSM-V (APA, 2013), the Eating Disorders category will undergo yet another revision, as rates of Eating Disorders rise. I selected Eating Disorders because they have become a prevalent problem in mental health, and mental health counselors will be asked to diagnose and treat them throughout their careers.

References:

American Psychiatric Association. (2000). The Diagnostic and Statistical Manual of Mental Disorders (DSM-1V-TR). American Psychiatric Association, Arlington, VA

National Committee for Mental Hygiene. (1918). Statistical Manual for the Use of Institutions for the Insane. New York, NY: Author.

Spitzer, R.L. (1991) An outsider-insider views about revising the DSMs. Journal of Abnormal Psychiatry, 100, p. 294-296.

Walsh, B.J., Sysko, R. (2009). Broad categories for the diagnosis of eating disorders. An alternative system for classification. International Journal of Eating Disorders, Vol. 42 (8), p. 754-764. US: John Wiley & Sons.

Ferguson, C.J. (2013). In the eye of the beholder: Thin-ideal media affects some, but not most, viewers in a meta-analytic review of body dissatisfaction in women and men. Psychology of Popular Media Culture. Vol 2, No. 1, p. 20-37. American Psychological Association, 2013.

Wolfe, N. (2002). The Beauty Myth: How Images of Beauty Are Used Against Women. William Morrow & Company.

National Institutes of Health (NIH). (2001). Annual Report of Eating Disorders.

National Institutes of Health (NIH). (2011). Most Teens with Eating Disorders Go Without Treatment. Retrieved From: www.nimh.nih.gov

Streigel-Moore, R.H., Bulik, C.M. (2007). Risk factors for eating disorders. American Psychologist, Vol. 62 (3), p. 181-198

Mathers, C.D., Vos, E.T., Steveson, C.E., Begg, S.J. (2000). The Australian burden of disease study: Measuring the loss of healthy from diseases, injuries and risk factors. Medical Journal of Australia, 172, p. 592-596

Kaye, W.H., Frank, G.K., Bailor, U.F., Henry, S.E., Meltzer, C.C., Price, J.C. et al. (2005). Serotonin alterations in anorexia and bulimia nervosa: New insights from imaging studies. Physiology and Behavior, 85, 86, p. 15-17

Fowler, S. Bulik, C. (1997). Family environment and psychiatric history in women with binge eating disorder and obese controls. Behavior Change, 14, 1

Hudson, J.I., Pope, H.G., Jonas, J.M., Yurgelun-Todd, D., Frankenburg, F.R. (1987). A controlled family history study of bulimia. Psychological Medicine, 17, p. 883-890

Kortegaard, L.S., Hoerder, K., Joergensen, J., Gillberg, C., Kyrik, K.O. (2001). A preliminary population-based twin study of self-reported eating disorder. Psychological Medicine, 31, p. 361-365

Klump, K.L., Miller, K.B., Kell, P.K., McGue, M., Iacano, W.G. (2001). Genetic and environmental influences in anorexia nervosa syndromes in population-based twin sample. Psychological Medicine, 31, p. 737-740.