Anorexia Nervosa and the DSM

Emily H. Cohen, M.A.

Ideally, knowing a person’s diagnosis makes it easier for a therapist to know what is likely to be a successful treatment than not knowing the diagnosis. Understanding how Anorexia Nervosa is described in the current DSM illuminates the extent to which use of this label does and does not live up to that ideal.

The Category

The DSM-IV-TR lists four criteria for anorexia nervosa (APA, 2000):

* Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g. weight loss leading to 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).
* Intense fear of gaining weight or becoming fat, even though underweight.
* 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.
* In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles.

Concerns about Defining the Problem

It is difficult to define “normal” eating behavior and body image, because constant dieting is widely presumed to be the norm in Western culture. The National Institute of Mental Health reports that an estimated 0.5 to 3.7 percent of females at some point in their lifetimes suffer from Anorexia Nervosa, using the DSM criteria, yet only a minority of people who exhibit disordered eating receive treatment. In a recent study of 1501 Canadian women, Gauvin et al (2009) found that, while none of these women met full DSM criteria for Anorexia Nervosa, nearly 15% reported having various disturbed eating patterns. While not everyone who displays concern about their weight needs help, clearly there are a significant number of people who slip through the cracks and receive no help, because they fail to meet the requisite DSM criteria. Preoccupation with one’s weight is not always cause for alarm, but it can be difficult to pinpoint where concern about weight becomes problematic. Because there is a culture-bound association between beauty and thinness that frequently leads to negative evaluations of self-worth, it would do more harm than good to label everyone who is a chronic dieter or who voices distress over their appearance as abnormal. So how does one decide where to draw the line in defining Anorexia Nervosa? And are there problems with the way it is defined in the DSM?

Problems with the DSM definition

Although it is worrying when people who need help are not given the right kinds of assistance or when suggested treatments fail to be effective, it is also worrying when people who need help are offered no assistance of any kind. Individuals who fail to meet the DSM criteria for Anorexia Nervosa, i.e., who do not receive this official diagnosis, are often denied access to treatment services, especially if they are deemed, for example, as not thin enough. Because the guidelines for diagnosing eating disorders, as defined in the Diagnostic and Statistical Manual of Mental Disorders-IV-TR, are so stringent, it is easy to miss significant problems that do not fit neatly into a specific category. The DSM description for Anorexia Nervosa illustrates how adhering to the criteria can, and often does, result in countless people whose suffering goes undetected.

The DSM authors do not account for some significant features of eating problems, such as strict and obsessive control over food intake and emotional distress, and they fail to recognize that not everyone who suffers from eating problems will fit their criteria. One cannot assume that failing to meet all four DSM criteria means that the distress is mild and inconsequential, to be brushed off as body consciousness. Furthermore, no distinction is made between someone who meets none of the four criteria and someone who meets three criteria, even though there is often no substantial difference between two such people with regard to behavior and attitudes towards food and body image. For example, one may use extreme dieting to hover just over the DSM weight threshold, and therefore would not be considered to be anorexic. Is there really a significant difference between someone who is at the 85% of healthy body weight that the DSM authors give as the cutoff point and someone whose weight is 86% of that figure? In addition, Fairburn and Bohn (2005) found that eating disordered patients who did not meet DSM criteria and those who received the clinical diagnosis shared a similar duration of eating disorder, severity of associated psychiatric features, and degree of psychosocial impairment. Clinicians who depend heavily on codified systems rather than on the specific aspects of a person’s suffering disregard the fact that each individual suffers in a unique way. Someone who is not yet emaciated still may exhibit intense self-criticism, severe anxiety about gaining weight, and physical health deficiencies (Cohen, 2004). There are also serious problems with amenorrhea as a criterion, because it means that premenarcheal girls, postmenopausal women, and of course males could never officially be diagnosed as anorexic, regardless of how serious their eating problems might be.

Unfortunately, insurance companies only provide coverage for treatment deemed necessary by a DSM diagnosis. Those who fall short of the current DSM criteria may nevertheless experience enough distress and interference with daily life to warrant attention, help, and support. Additionally, it has been shown that treatment is most likely to be successful when it is administered early. However, by the time most individuals seek professional help, they are already submerged in an unrelenting cycle of harm (Herzog et al., 1999; Halmi et al., 2005).

Problems in Treatment

Eating problems are notoriously difficult to treat, due to denial and resistance to change, and most people with these problems only seek help due to urging by relatives or friends. It is difficult to know what helps and, indeed, Fairburn (2005) points out that there is “barely” any evidence from well-done research about successful treatment. Psychotherapy is usually the first line of treatment and cognitive-based therapies tend to be most successful, particularly in adults, as they help to address and modify negative thinking. Unfortunately, the success rates are still low. Although some report that 50% of patients regain healthy eating habits (e.g., Pike, 1998), it is hard to know what to make of such conclusions, given that some programs involve extremely restrictive and punitive measures such as force-feeding and extensive rules that parents or inpatient staff are urged to impose in order to get patients to eat more healthily.[i] And Schmidt (1989) found that behavioral reinforcements showed only short-term effectiveness.

It is also a thorny problem to consider how to define “cure” for something that is pandemic and thus for which the distinction between normality and disorder is so unclear. Other problems in trying to determine what is helpful include researchers’ lack of agreement about appropriate terminology to use (e.g., Pike, 1998) and the fact that research about group therapy for eating problems has primarily been focused on people with bulimia. Furthermore, there have been few scientific inquiries into alternative treatment for anorexia. Since our society is also one that tends to look for a quick fix, some psychiatrists may prescribe medication to an eating disordered patient, even though there have been few studies to show any beneficial effect of this (Fairburn & Harrison, 2003; Halmi et al., 2005). Unfortunately, these medications often carry detrimental side effects that can negate any potential benefits

Partial Solutions

In light of the unclear boundaries between culturally normative attitudes towards body image and what, according to the DSM authors, becomes pathological behavior, several factors need to be used to determine who should receive help, whether formal psychotherapy or support among family, friends and peers. These include people who suffer from preoccupation with food and body shape, distorted body image, intense unwarranted fear of weight gain, and severe food restrictions and/or excessive exercise (Cohen, 2004). In order to provide better care and treatment to those who might be denied services otherwise, it would be especially helpful to address some of the underlying social factors, such as intense pressure on girls and women to be thin and on boys and men to be very muscular. Greater efforts need to be made to include people at all points on the continuum of eating problems, so that they may receive help before it is too late.


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[i] Although medical intervention might be necessary for those who are at life-threatening weights, forcing one to gain weight will almost always backfire. Weight gain is one of the biggest fears of the eating-disordered, causing one to be even more hesitant to seek out help. Compulsory treatment tends to be only a temporary solution; although a few pounds might be added, the person feels even less in control and more in distress, and their pervasive distorted thinking has not been addressed.

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