Clinical Handbook of Eating Disorders

An Integrated Approach

Timothy D. Brewerton

• Publisher: CRC Press
• Year: 2004
• eBook ISBN: 9781135540623
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

Emphasizing that accurate diagnosis is the foundation for effective treatment regimens, this reference reviews the most current research on the assessment, epidemiology, etiology, risk factors, neurodevelopment, course of illness, and various empirically-based evaluation and treatment approaches relating to eating disorders-studying disordered eati

1
Diagnostic Issues in Eating Disorders Historical Perspectives and Thoughts for the Future

D.Blake Woodside
Toronto General Hospital and University of Toronto
Toronto, Ontario, Canada
Richelle Twose
University of Toronto
Toronto, Ontario, Canada

Diagnostic issues have always been important in the field of eating disorders, whether debating the role of gender in these conditions or examining possible etiologic factors. With recent advances in areas as diverse as culture and genetics, reexamining thinking about diagnosis in anorexia nervosa, bulimia nervosa, and binge eating disorder becomes increasingly important.

This chapter will review some of the historical issues in the diagnosis of eating disorders and examine diagnostic schemas for special populations. A final section will address some thoughts about possible revisions to the diagnostic criteria in the light of recent developments in the field. A sample clinical diagnostic interview schedule is attached as an appendix.

DIAGNOSTIC CRITERIA

Anorexia Nervosa

The essential diagnostic criteria for anorexia nervosa has undergone more gradual and subtle shifts over time relative to bulimia nervosa. The Diag nostic and Statistical Manual of Psychiatric Disorders (DSM) criteria (Table 1) are largely reflective of Russell’s 1970 description of three essential factors: (a) purposeful loss of body weight, (b) amenorrhea in females, and (c) psychopathology expressed as an intense fear of becoming fat (1,2). Many of the successive alterations are merely semantic in nature.

TABLE 1 DSM-III Diagnostic Criteria for Anorexia Nervosa

The weight loss threshold for diagnosis of anorexia nervosa has become less strict and severe with each revision of the DSM. In the DSM-III, a loss of 25% of original body weight (or loss of original body weight plus projected weight gain if an adolescent) is required (3). In subsequent versions, this threshold falls to 15% and becomes only a “rough” guideline. In fact, the relevant text in the DSM-IIIR (Table 2) states that weighing 85% of that expected is merely an “arbitrary but useful guide” (4).

In contrast, the evolution of the requirement for amenorrhea has become increasingly stringent over time. Contrary to Russell’s description (1970), the DSM-III does not list amenorrhea as part of the diagnostic criteria but merely mentions it in the relevant text on the section (3). In later versions, this aspect of the disorder becomes mandatory for diagnosis, and the nature of amenorrhea itself is further specified (4,5). However, the presence of this criterion continues to spark controversy among experts in the field, since in approximately 15% of cases menstruation ceases prior to weight loss, and in some individuals amenorrhea persists for a period of time following restorative weight gain (1). One group (6) compared women who meet all DSMIIIR criteria for anorexia nervosa to women who met all criteria except amenorrhea and found no significant differences on a wide variety of clinical and psychometric variables. The final issue that is relevant is the increasingly common use of oral contraceptives in this population, either for contraception or as a treatment for osteoporosis. Most experts suggest that in the presence of oral contraceptive use this criterion should be waived.

While the usefulness of this feature appears to be less and less important, it may be some time before it is abandoned.

Successive versions of the DSM have increasingly emphasized the psychopathological aspects of the illness. For example, criterion C in the DSM-IV, (Table 3) was expanded to include a description of three different examples of how one’s body weight or shape is cognitively experienced in a pathological way. Here the mental “disorder” is said to likely involve body image distortion, its disproportionate influence on self-esteem, and the failure to recognize the dangers of a low body weight (5). Denial of the illness is also included in DSM-IV for the first time. DSM-III states only in the surrounding text on the disorder that individuals with anorexia nervosa “steadfastly deny the illness and are…resistant to therapy” (3). The DSM-IV, however, notes “denial of the seriousness of the current low body weight” as an essential diagnostic criterion (5).

TABLE 2 DSM-IHR Diagnostic Criteria for 307.10 Anorexia Nervosa

Another recent change has been the shift away from percent average weight to body mass index (BMI), which is weight in kilograms divided by height in meters squared. DSM-IV suggests a BMI of 17.5 as an appropriate standard for the diagnosis of anorexia nervosa. This change has a number of benefits both in terms of diagnostic homogeneity across different countries and with the adolescent age group. However, it does not take into account ethnocultural differences and these require further study.

The increasing importance of recognizing both the physical and psychological effects of starvation has been recognized in DSM-IV, where sections have been added identifying common associated physical and psy chological symptoms. This allows for increased sophistication in the diagnosis of comorbid axis I disorders, some of which may be confused with starvation effects. This allows for distinguishing between anorexia nervosa and depression, obsessive-compulsive disorder, and specific phobias.

There have been several attempts to deal with the diagnosis of comorbid bulimia nervosa and/or purging behaviors. In DSM-IIIR, if both conditions were present, both diagnoses were made. However, DSM-IV introduced a change in the way this was handled, allowing a diagnosis of anorexia nervosa to “trump” a diagnosis of bulimia nervosa. In DSM-IV, anorexia is subclassified into the restricting and binge-purge subtypes. This distinction remains somewhat controversial, particularly in the light of some of the recent genetic findings in anorexia and bulimia, which will be reviewed below. It remains to be seen as to whether this is the optimal way in which to proceed with this area of comorbidity.

TABLE 3 DSM-IV Diagnostic Criteria for 307.1 Anorexia Nervosa

Bulimia Nervosa

Bulimia was not recognized as a mental disorder in the DSM until the publication of the third edition in 1980 (Table 4) (3). This followed its identifi cation by Russell during the previous year (7). The original diagnostic criteria in DSM-III were overinclusive and led to some confusion among clinicians and researchers. The publication of the DSM-IIIR and, later, the DSM-IV addressed many of the original version’s shortcomings (4,5).

Bulimia, or “ox-like eating,” the original term for the illness itself, paints an incomplete picture of the syndrome it is meant to characterize. It does not depict the patient’s characteristic psychopathology regarding her intense fear of fatness and obsession with body shape and weight, nor the presence of compensatory behaviors that are so important in the illness. The renaming of the condition as bulimia nervosa in DSM-IV helped to clarify that the illness included important psychopathological features as well as abnormal eating.

TABLE 4 DSM-III Diagnostic Criteria for Bulimia

The DSM-III criteria for bulimia is composed of both “monothetic and polythetic criteria,” i.e., both essential and optional symptoms, respectively, which complicates diagnosis of this disorder (8). The subsequent elimination of the optional indicators in the DSM-IIIR (Table 5) functioned to create a more homogeneous description (and thus a homogeneous group to research/study) and greatly simplified the task of diagnosing this disorder.

The original description of binge eating in DSM-III, “the consumption of a large amount of food in a discrete period of time” (3), was insufficient to characterize this phenomenon. DSM-IIIR added the requirement for lack of control, differentiating bingeing qualitatively from normal eating (4). Provisions governing the time restrictions defining a binge have also evolved over time. Originally, a binge was temporally restricted to “usually under two hours” (3). The DSM-IIIR, on the other hand, abandoned the requirement of a time limit, favoring a less restrictive “discrete period of time” to define the binge event (4). The most recent criteria (5) simply provide a 2-hour period as a useful guideline. More importantly, the criterion defines the context in which a binge would occur. It is characterized as an amount of food that is “definitely larger than most people would eat during a similar period of time under similar circumstances” (5). The use of this specification distinguishes binge eating from instances in which non-disordered individuals may overeat (i.e., at a holiday party).

TABLE 5 DSM-IIIR Diagnostic Criteria for 307.51 Bulimia Nervosa

In addition, the frequency with which binge episodes and inappropriate compensatory strategies must occur was not established until publication of the DSM-IIIR (and DSM-IV; Table 6), where a minimum of two episodes per week over 3 months is required for diagnosis (4,5). However, it is not clear that the current frequency requirement of twice per week for 3 months is meaningful (9). One group compared a sample of bulimia nervosa patients who differed only in whether they binged once or twice per week on average and found no differences across a wide spectrum of variables. It is not clear at present what frequency of bingeing is associated with the typical psychopathology of the condition.

Psychopathologically, the original diagnostic criteria for bulimia did not require the presence of a preoccupation with weight and shape. The accompanying text merely mentions that “individuals with bulimia usually exhibit great concern about their weight” (3). This statement decreased the emphasis on the individual’s pathological disturbance in attitudes, beliefs, and cognitions, and their resulting distress—attributes that distinguish mental pathology. This weakness is corrected in the DSM-IIIR, where a “persistent overconcern with body shape and weight” is listed as an essential criterion required for diagnosis, thereby addressing the sufferer’s abnormal attitudes (criterion E) (4). This criterion was then strengthened in DSM-IV to include wording related to evaluation of self (criterion D) (5).

The original formulation of compensatory behaviors in DSM-III focused on physiology, i.e., the relief of fullness as opposed to the psychological significance of the behavior. Induced vomiting is also mentioned last in a series of physiological factors, such as abdominal pain and sleep, that terminate a binge (criterion B) (3). Behaviors designed to counteract the effects of binge eating did not become a mandatory requirement for diagnosis until the DSM-IIIR (4), where compensatory behaviors were linked to a fear of weight gain (4) or to modulating affect, suggesting the multiple purposes of the behaviors.

TABLE 6 DSM-IV Diagnostic Criteria for 307.51 Bulimia Nervosa

In the DSM-IV, the diagnosis of bulimia nervosa becomes more specific, as the disorder is further divided into two s...

Table of contents

• COVER PAGE
• TITLE PAGE
• COPYRIGHT PAGE
• FOREWORD
• PREFACE
• CONTRIBUTORS
• 1 DIAGNOSTIC ISSUES IN EATING DISORDERS HISTORICAL PERSPECTIVES AND THOUGHTS FOR THE FUTURE
• 2 PSYCHOMETRIC ASSESSMENT OF EATING DISORDERS JACQUELINE C.CARTER, TRACI L.MCFARLANE, AND MARION
• 3 FEEDING DISORDERS IN INFANCY AND EARLY CHILDHOOD
• 4 EPIDEMIOLOGY OF EATING DISORDERS AND DISORDERED EATING: A DEVEIOPMENTAL OVERVIEW
• 5 LONG-TERM OUTCOME, COURSE OF ILLNESS AND MORTALITY IN ANOREXIA NERVOSA, BULIMIA NERVOSA, AND BINGE EATING DISORDER
• 6 AN OVERVIEW OF RISK FACTORS FOR ANOREXIA NERVOSA, BULIMIA NERVOSA, AND BINGE EATING DISORDER
• 7 ROLE OF GENETICS IN ANOREXIA NERVOSA, BULIMIA NERVOSA, AND BINGE EATING DISORDER
• 8 PSYCHIATRIC COMORBIDITY ASSOCIATED WITH ANOREXIA NERVOSA, BULIMIA NERVOSA, AND BINGE EATING DISORDER
• 9 PERSONALITY TRAITS AND DISORDERS ASSOCIATED WITH ANOREXIA NERVOSA, BULIMIA NERVOSA, AND BINGE EATING DISORDER
• 10 MEDICAL COMORBIDITY OF ANOREXIA NERVOSA, BULIMIA NERVOSA, AND BINGE EATING DISORDER
• 11 NEUROTRANSMITTER DYSREGULATION IN ANOREXIA NERVOSA, BULIMIA NERVOSA, AND BINGE EATING DISORDER
• 12 NEUROENDOCRINE AND NEUROPEPTIDE DYSREGULATION IN ANOREXIA NERVOSA, BULIMIA NERVOSA, AND BINGE EATING DISORDER
• 13 NEUROIMAGING OF THE EATING DISORDERS
• 14 MOLECULAR BIOLOGY OF ANOREXIA NERVOSA, BULIMIA NERVOSA, BINGE EATING DISORDER, AND OBESITY
• 15 MANAGEMENT OF EATING DISORDERS: INPATIENT AND PARTIAL HOSPITAL PROGRAMS
• 16 NUTRITION COUNSELING FOR ANOREXIA NERVOSA, BULIMIA NERVOSA, AND BINGE EATING DISORDER
• 17 AN OVERVIEW OF COGNITIVE-BEHAVIORAL APPROACHES TO EATING DISORDERS
• 18 AN OVERVIEW OF FAMILY EVALUATION AND THERAPY FOR ANOREXIA NERVOSA, BULIMIA NERVOSA, AND BINGE EATING DISORDER
• 19 INTERPERSONAL PSYCHOTHERAPY FOR ANOREXIA NERVOSA, BULIMIA NERVOSA, AND BINGE EATING DISORDER
• 20 USE OF DIALECTICAL BEHAVIOR THERAPY IN THE EATING DISORDERS
• 21 PSYCHOPHARMACOLOGY OF ANOREXIA NERVOSA, BULIMIA NERVOSA, AND BINGE EATING DISORDER
• 22 EATING DISORDERS, VICTIMIZATION, AND COMORBIDITY: PRINCIPLES OF TREATMENT
• 23 FUTURE DIRECTIONS IN THE MANAGEMENT OF EATING DISORDERS