DSM: Does It Matter How We Diagnose Eating Disorders?

The public doesn't need help describing anorexia and bulimia and other eating disorders. Ask most people "What is anorexia?" and they'll have an answer, an opinion, and a list of people they know who have it. We can define it, but unfortunately our ideas are often wrong. That's why we need the "DSM," which stands for the Diagnostic and Statistical Manual published by the American Psychiatric Association.

Eating Disorders Diagnosis and The American Psychiatric Association's DSM

There are other documents and resources to define how to diagnose an eating disorder, but the DSM is so widely used around the world that it serves as an almost universal standard. Unfortunately, psychiatric illness is difficult to diagnose. There are no blood tests, brain scans, or eye charts. Mental illnesses are recognized by the way they make people think and act. Some, like depression for example, are diagnosed by the patient's description of their thoughts and feelings. Others, like eating disorders, are based on actions and medical repercussions of those actions. Unlike illnesses like diabetes, where one can test at any time of the day or night, mental illness requires far more time and length of symptoms to meet a diagnosis. Like diabetes, however, the tests determine how well the disease is managed rather than the presence of the illness itself.

DSM V and My Feelings About How Eating Disorders Are Defined

The DSM is a changing document. The version currently being vetted by professionals and the public will result in the fifth version, commonly called "DSM-V." This is an interesting time, in that the public can comment on and influence the final DSM-V document.

I have strong feelings on what the DSM should include and how eating disorders should be categorized and defined. So do many, many other people. Personally, I'd like to see eating disorder diagnosis separated from the process of deciding severity. As it stands now, anorexia is diagnosed according to measures of malnourishment instead of the mental symptoms that lead to that malnourishment. This means, in practice, that when a patient starts to move toward recovery, they lose insurance coverage, urgency on the part of loved ones, and access to treatment providers; patients are punished for getting better. This is also true for bulimia, where you are no longer diagnostically suffering from an eating disorder as soon as your symptoms abate - and right when the most important phase of treatment for the eating disorder begins.

An example of the difference in thinking on this would be the diagnosis of Obsessive Compulsive Disorder, which is based on the thoughts and compulsions and not how badly those symptoms have hurt the body. Another way to frame this is to look at depression: if the symptom of depression abates, the person feels and functions better. But with eating disorders, the patient feels worse as they approach medical recovery and their core mental illness is then in full swing.

I think we need to stop looking at eating disorders as a problem of weight or eating behaviors, but rather as a mental illness where the brain is creating these self-perpetuating symptoms. Restricting, bingeing and purging are all symptoms of the illness and serve to exacerbate and perpetuate the thoughts and behaviors. This vicious cycle isn't likely to be interrupted when one loses support and treatment at the very time we need to offer the most help.