The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) classifies eating disorders into eight distinct disorders. Of these eight, most attention is often focused to anorexia nervosa, bulimia nervosa, and binge eating disorder (the latter disorder new to the DSM-5). However, an individual who suffers from one of these eating disorders is likely to also develop another eating disorder later in life, even after recovering from the previous disorder. This trend strongly suggests there may be some sort of unifying, underlying factor among the eating disorders or, in other words, a common etiology that is simply being expressed through varied groups of symptoms that people have chosen to assign various names to. If this is the case though, is it useful to make such specific and rigid diagnostic criteria for each eating disorder within the group?

One of the criteria for anorexia nervosa is a significantly low body weight (below BMI of 18.5). So if an individual diagnosed with anorexia has been forced to eat an amount of food sufficient to bring their body weight back up to normal range, they are now, technically speaking, no longer suffering from anorexia nervosa. These are the kind of classification measures that would be used in studies looking at the effectiveness of treatment for anorexia. But then what if, after being “cured,” this individual still suffers from an excessive influence of body weight on self-evaluation and then as a result develops bulimia nervosa? Clearly the core root of the issue has not been remedied. What would be more useful are studies, and consequently, therapeutic approaches, that focus on the deeper underlying etiology of an eating disorder.

A statistic that stands out when beginning to approach this question is that 10%-20% of patients with anorexia nervosa and 25% to 35% of patients with bulimia nervosa have a history of at least one suicide attempt (Dalle-Grave, 2007). Reaching the point at which someone feels they have no way out but to end their life suggests rather severe internal struggles that are manifesting through a disordered relationship with the body and food. Another informative statistic is that two out of every three people with eating disorders have also had an anxiety disorder at some point in their life (Rodriguez, 2009), indicating a possible underlying link between anxiety disorders and eating disorders. Similarly, another study of individuals with eating disorders found that 64% of these individuals also possessed at least one anxiety disorder (Kaye et al., 2004). Leslie Lipton, a patient in New York with anorexia, offers a personal account of this relationship: “I had been dealing with (anxiety) for a good portion of my life” she says, “and then the eating disorder was sort of my outlet, my way of dealing with those feelings” (Rodriguez, 2009). She goes on to say that, upon reflection, she feels she developed an eating disorder almost as a “socially acceptable way of acting out the anxiety that (she) was feeling internally” (Rodriguez, 2009). Leslie’s account is just one of many that suggest that a particular eating disorder that develops in an individual could actually be a manifestation of the struggle to control things in his/her life.

Many studies have shown that there is no significant difference in co-morbid psychopathology, recovery, or relapse rates based on the specific types of eating disorders (Goyal, 2012). This begs the question of what the usefulness is of distinguishing between each of the eating disorders. According to Fairburn (2008), in the majority of cases of anorexia nervosa, patterns of extreme dietary restriction often lead at some point to the development of binge eating disorder (BED), bulimia nervosa, or a mixed form of eating disorder “not otherwise specified,” with the latter two occurring in about half of all cases. Statistics like this that show half of patients going on to develop a secondary disorder point to an underlying core issue behind the various eating disorders, and if the core issue is something more fundamental than a person’s patterns of disordered eating, than this fundamental issue should be the focus of diagnosis and treatment rather than the categorization of the various eating disorders.

So then the problem lies in reconceptualizing what it means to have an eating disorder. Diagnosis is based on reported/observed (and possibly medical records, in the case of low BMI in anorexia nervosa) symptoms, so the clinician must take time and effort to get at the core of the problem based on what they’re observing on the surface. This is where I believe the use of functional magnetic resonance imaging (fMRI) or single-photon emission computed tomography (SPECT) can assist clinicians by offering an objective tool for understanding what is taking place in cases where it is difficult to pinpoint the fundamental underlying issue. Additionally, substantial background research to support fMRI use clinically could potentially lead to more directed and more successful treatment techniques. Research on the activation of certain brain areas in relation to certain psychological disorders is already taking place. A study at Columbia University found that, for individuals with anorexia nervosa, decisions about what to eat were associated with activation in the dorsal striatum, a brain region known to be involved in the habitual control of actions (Foerde et al., 2015). Interestingly, this provides evidence that may link anorexia nervosa not just to other eating disorders, but to disorders like substance abuse that involve excessive activity in the dorsal striatum (Foerde et al., 2015). Additionally, this kind of approach toward eating disorders also promotes new avenues for treatment, both in terms of psychotherapy and medication (Foerde et al., 2015). If research such as this can also be implemented clinically in terms of innovating techniques for diagnosis, psychiatrists and psychologists would have an objective tool to help them more quickly understand and treat the underlying malignancy for the symptoms they are seeing on the surface.

This is not to say that patient interviewing should not continue to play a crucial role in diagnosis and influence treatment, but if mental disorders are being treated as a medical issue that involves a visit to a doctor, then efforts should be made to take the grey area out of mental health. Imagine a person comes to the hospital and describes a list of symptoms that match the symptoms experienced in an individual with leukemia so then the doctor immediately prescribes chemotherapy without any further testing. This scenario would never happen. So why does it happen with eating disorders (and mental illnesses in general)? An issue that comes up in regards to this is misdiagnoses of eating disorders in people with Crohn’s disease. Crohn’s disease is a chronic inflammatory bowel disease that affects the lining of the digestive tract. As a result of the bowel inflammation, eating is often associated with great pain and discomfort and so individuals with Crohn’s will tend to avoid food as a result. This type of avoidant behavior in children and adolescents may be confused with an eating disorder. In fact, looking through sites and forums for the Crohn’s community will quickly tell you that this apparently happens quite often. One example from Crohn’s Forum is that of a woman diagnosed with an eating disorder when she was a teenager due to her extremely low weight and phobia of eating (which was actually due to the discomfort she associated with food). According to her, even the diarrheas she was experiencing was attributed to laxative use and no one thought to diagnose something other than a mental illness until she was very physically ill despite the extensive treatment she’d received. This and other stories of patients on these forums helps point out the more general issue of jumping to conclusions based on expected diagnoses and a list of symptoms that have not been matched to an underlying cause. Child health specialist Professor Ian Booth warns that proper treatment can be delayed for months as a result of this common misdiagnoses (BBC, 2005). Another example of where this type of issue can occur is the under-diagnosis of eating disorders in men, which results partially from the fact that male’s expression of symptoms can be different from that of females. Body ideals for men are different than for women and so a man struggling with an eating disorder might be perceived as a fit guy who’s obsessed with the gym simply because he doesn’t fit the stereotypical profile of an eating disorder patient.

Yet another strong case for going beyond reported symptoms and using fMRI or other more rigorous diagnostic techniques is the idea of prevention and screening in certain situations such as, for example, diabulimia. Diabulimia, which is not recognized as an official disorder, refers to a disorder in which people with Type 1 diabetes purposely give themselves less insulin than they need for the purpose of weight loss. This condition is distinct from other eating disorders in that it involves a special case within a specific demographic, and so screening for individuals in this demographic may be useful to identify those at risk of developing an eating disorder before it begins. If there is a way to go beyond symptoms and identify underlying patterns that occur before symptoms arise, then there could be more careful monitoring of a diabetic patient’s administration of insulin and more education provided to the family of the patient if the patient has been identified as someone at risk for developing this maladaptive behavior.

Thus, as evidence suggests, the items that fill the lists of the current criteria in the DSM-5 for each eating disorder should be seen as the varied symptomatic consequences of an underlying disorder, rather than distinct disorders. For this to be the case, more research should be done with focus on what is actually going on inside the brains of individuals with eating disorders and what is a common thread that influences their behavior. This approach would more successfully target the central issue rather than the symptoms of the issue and, as a result, improve understanding and treatment of eating disorders.

Sources for This Article:

Crohn's 'Mistaken for Anorexia' (2005, March 20). BBC.

Dalle-Grave R, Calugi S, Brambilla F. et al. The effect of inpatient cognitive-behavioral therapy for eating disorders on temperament and character. Behaviour Research Therapy. 2007;45:1335–1344

Fairburn, C. G. (2008). Cognitive Behavioral Therapy and Eating Disorders. New York, New York: The Guilford Press.

Foerde, K, Joanna E Steinglass, Daphna Shohamy, B Timothy Walsh. Neural mechanisms supporting maladaptive food choices in anorexia nervosa. Nature Neuroscience, 2015; DOI: 10.1038/nn.4136

Goyal, S., Balhara, Y., & Khandelwal, S. K. (2012). Revisiting Classification of Eating Disorders-toward Diagnostic and Statistical Manual of Mental Disorders-5 and International Statistical Classification of Diseases and Related Health Problems-11. Indian Journal of Psychological Medicine.

Kaye WH, Bulik CM, Thornton L, Barbarich N, Masters K, “Comorbidity of anxiety disorders with anorexia and bulimia nervosa.” Am J Psychiatry, 2004; 161 2215-2221. 2. Yaryura-Tobias JA, & Neziroglu F (1983). “Obsessive Compulsive Disorders Pathogenesis Diagnosis and Treatment.” New York Marcel Dekker

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