Diluting the DSM
I’m finally catching up on some of my “must read” articles. Tonight I got a chance to read an article on a new possible diagnostic system for eating disorders in the DSM-V. “Broad Categories for the Diagnosis of Eating Disorders (BCD-ED): An Alternative System for Classification.” You could go ahead and download it – the full text is available online for free – but I can sum the whole thing up in a couple of words:
Take the DSM-IV and add water.
Basically the new system expands each eating disorder category to be more inclusive, therefore reducing the percentage of sufferers in the EDNOS category.
How do they suggest doing this? Well…
- decrease the specificity of each diagnostic category
- remove concrete diagnostic criteria
- rely primarily on clinical judgment for diagnosis
I think that by broadening each eating disorder type, they are creating more heterogenous patient populations. Isn’t this a major criticism of the EDNOS diagnosis that they are trying to resolve? I’m all for being more lax on the 85% of IBW rule (your diagnosis shouldn’t change just because you gain to 88%) and the frequency of binge/purge episodes, but as I said in my last post, diagnoses are meant to guide treatment. Even from just a medical perspective, the anorexia diagnosis implies certain hallmark concerns – anemia, osteoporosis, low blood pressure, refeeding syndrome, etc. Physicians know what to look for. Research can be more accurate. I think there are identifiable types of EDNOS patients and they should be classified as such, rather than getting lumped into another diagnostic category that only kind of fits.
I also take issue with their increased emphasis on clinical judgment:
“This scheme also offers an advantage for diagnosing individuals with eating disorders outside of specialist settings, where a comprehensive psychiatric assessment may not be feasible (e.g.. primary care)”
PCPs already often miss eating disorders… even with defined criteria and many present symptoms! How will removing guidelines going to help them better diagnose patients?
What else bugged me about the study? Well…
- Individuals with a “lifetime eating disorder diagnosis” were excluded from the study
- Course of illness, treatment approach, and treatment outcome were not considered
- Anorexia was declared the most serious type of eating disorder, and therefore has the “highest position in the hierarchy.”
- Diagnoses require significant functional impairment
- Individuals are lumped into broad categories based on just BMI and functional impairment.
- No definition of “recovery” or guidelines for when a patient is ready to end treatment.
I feel like this system takes current issues in eating disorder research, diagnosis, and treatment, and magnifies them. Issues like specificity, chronicity, and the definition of “recovery.”
I couldn’t agree more!
While ‘legitimizing’ the needs of many who may now fall under the no-man’s-land of EDNOS, this approach does everything BUT address the main flaw with the current diagnostic system. In other words, it still ignores the level of impact on psychosocial functioning and places the utmost importance squarely on BMI. Mind you, NEDA, AED, BEDA, and others recently spoke out against the use of BMI as an indicator of “health status”: (statement can be viewed here: http://www.news-medical.net/news/20091211/Eating-disorder-groups-say-BMI-fuels-weight-prejudice-and-urge-to-focus-on-health-and-lifestyle.aspx ).
We wrote our own response to this, asking that this position should include both ends of the spectrum: http://www.facebook.com/pages/edit/?id=60817118582#!/note.php?note_id=407411203687&id=60817118582&ref=mf
Regardless, I’m glad to see that they’re starting to budge……but will they change the things that really matter?
Joy,
Thanks for including those articles – great information! And I agree… this new diagnostic system is completely missing the point.
Hey
I haven’t read the article so I don’t want to pretend to have done so. I think the new guidelines in general are good because people need to get access to treatment and often the DSM is used to DENY people treatment. HOWEVER…. I am aware of some work in the “staging” of eating disorders (for both AN and BN types) where illness severity is considered.
Now, that has allll sorts of implications regarding treatment access too and also for those suffering from an eating disorder (aka competitiveness, the idea of being “sick enough” etc) but I am starting to wonder whether it might me more useful to have a more psychologically focussed DSM-V but then have staging in the clinical arena to pick up on treatment issues and target treatment appropriately.
I am just aware that I’ve never met the criteria for AN simply due to continuing to menstruate but I’ve been told that I’ve been as sick as many other people… I’m aware of a good friend who didn’t meet the weight criteria for AN or at the time the b/p for BN (even though that is her usual dx) but was literally dying when she was amazingly admitted to the IP unit… I’m aware that if she was in a different state then she would NOT have been admitted and that clinical severity doesn’t always present according to the text book… so for the purposes of diagnosis, I think that such specific details may not be useful or helpful…but I also agree with you that for purposes of treatment and research, we need SOME indications of what is going on…
Anyway, these are just my thoughts and I have (purposefully) not thought too much about it all for my own personal reasons.
Anyway, just sharing, feel free to ignore too
Telstarr,
These are really good points! I think the menstruation criteria will go away regardless. I know that some treatment professionals unofficially use subcategories like AN-P, AN-R, BN-R, etc…. and I think there is definitely some utility in that. I’m also not completely attached to the 85% IBW line, for example. I just don’t like the wishy-washy “patient weighs less than they should” criteria.
I actually wrote a post awhile ago (wow, it’s been two years… maybe I should revisit this and give it more attention, because the journal article really was awesome) with my favorite ED diagnostic system (doesn’t everyone have a favorite ED diagnostic system??
). If you’re interested: Better eating disorder diagnosis
wow, like AN isn’t already glamorized in ED world hierarchy.
on a separate note, I am bulimic, not anorexic, but I have anemia and osteopenia, and low blood pressure (was around 90/60 for a long time, but Adderall is raising it), etc.
Hi Laur,
I’d say that AN is more glamorized in the media, sure… but do you feel that it’s more “glamorized” in a treatment setting? That has never been my experience, but I’m curious to hear your thoughts.
YES, AN is always taken more seriously, seen as the preferred diagnosis, less shameful.
I’m not talking about treatment professionals as much, but those of us being treated.
Which diagnosis do you see some sick pride in, in some individuals? NOT bulimia! WE KNOW we are looked upon with disgust.
Even non ED people will sometimes say to an anorexic that they WISH they had the willpower, but no one has ever told me they WISH they could have spent thousands of dollars on binge food and cleaning up vomit.
I was told IN TREATMENT that my behaviors were disgusting and out of control.
I couldn’t agree more!
While ‘legitimizing’ the needs of many who may now fall under the no-man’s-land of EDNOS, this approach does everything BUT address the main flaw with the current diagnostic system. In other words, it still ignores the level of impact on psychosocial functioning and places the utmost importance squarely on BMI. Mind you, NEDA, AED, BEDA, and others recently spoke out against the use of BMI as an indicator of “health status”: (statement can be viewed here: http://www.news-medical.net/news/20091211/Eating-disorder-groups-say-BMI-fuels-weight-prejudice-and-urge-to-focus-on-health-and-lifestyle.aspx ).
We wrote our own response to this, asking that this position should include both ends of the spectrum: http://www.facebook.com/pages/edit/?id=60817118582#!/note.php?note_id=407411203687&id=60817118582&ref=mf
Regardless, I’m glad to see that they’re starting to budge……but will they change the things that really matter?
I couldn’t agree more!
While ‘legitimizing’ the needs of many who may now fall under the no-man’s-land of EDNOS, this approach does everything BUT address the main flaw with the current diagnostic system. In other words, it still ignores the level of impact on psychosocial functioning and places the utmost importance squarely on BMI. Mind you, NEDA, AED, BEDA, and others recently spoke out against the use of BMI as an indicator of “health status”: (statement can be viewed here: http://www.news-medical.net/news/20091211/Eating-disorder-groups-say-BMI-fuels-weight-prejudice-and-urge-to-focus-on-health-and-lifestyle.aspx ).
We wrote our own response to this, asking that this position should include both ends of the spectrum: http://www.facebook.com/pages/edit/?id=60817118582#!/note.php?note_id=407411203687&id=60817118582&ref=mf
Regardless, I’m glad to see that they’re starting to budge……but will they change the things that really matter?
Keep posting stuff like this i really like it