Imagine that your doctor told you that you suffered from a disorder that was "not otherwise specified." How would you feel about the seriousness of your condition? Would you feel nervous? Or maybe you would dismiss it as unimportant? These are the questions that confront nearly 70 percent of patients with eating disorders. We have all heard of anorexia and bulimia, but what you may not know is that there is a class of eating disorders called Eating Disorder Not Otherwise Specified (EDNOS).
EDNOS causes more deaths than either anorexia or bulimia (1). Currently, patients are diagnosed with EDNOS if they fail to meet all the requirements for anorexia and bulimia. However, the newest revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM), a cornerstone of psychiatry, plans to address this vagueness so that current EDNOS patients will no longer struggle with that uncertainty.
In our image-obsessed society -- where fashion models are fired for not being skinny enough and a clothing company can cause uproar by featuring the slogan "Eat Less" on a t-shirt -- eating disorders are a dangerous reality. More Americans suffer from eating disorders than Alzheimer's disease and schizophrenia combined (2). In addition, more than a third of normal dieters develop an eating disorder (3).
Eating disorders often point to more serious underlying mental illnesses, like body image issues or depression. Disrupted eating patterns are the common sign, but there are other signs that suggest that someone is suffering from an eating disorder. These include never wanting to eat, uncontrollable eating tied to emotional states, repeatedly chewing and spitting out food without swallowing, frequently using laxatives or enemas, and self-evaluation heavily dependent on body image (4).
To address the high number of EDNOS cases, DSM-5 (the latest version of the manual) will better specify illnesses like Binge Eating Disorder, for example. This is useful because many disorders that are grouped together under EDNOS are not very similar; they have different characteristics and require separate attention and treatment. By doing this, both doctors and patients have a clearer understanding of which eating behaviors need to be treated, instead of shrugging it off as "unspecified."
If you were a patient, wouldn't you feel more positive about the outcome of your disease knowing that it is more than just "non-anorexia" or "non-bulimia?" Also, doctors will be able to choose more suitable strategies for how to treat these behaviors.
This change is not without controversy, though, as some doctors think that "over-specifying" these disorders in DSM-5 means patients will be diagnosed with disorders that they don't truly have (5). Will this really happen? We don't know, but I believe it will allow for eating disorders in patients to be identified more clearly and treated more effectively.
Eating disorders are a serious medical condition. If you notice these signs in yourself or someone you know, get help. Speak with a doctor about counseling. Join a local support group or one on the internet. Educate yourself on the signs of eating disorders and learn how to prevent them.
As updates to the DSM show, these disorders are legitimate mental illnesses and they require treatment; they don't just go away on their own. The medical community is doing its part to deal with unspecified eating disorders by revising its guidelines, and we each need to do our parts by educating ourselves and intervening when we suspect eating disorders in friends or loved ones.
Showing posts with label EDNOS. Show all posts
Showing posts with label EDNOS. Show all posts
Thursday, July 1, 2010
Tuesday, June 8, 2010
ADVICE TO DSM5: DON'T DEVALUE THE NOS CATEGORIES
The DSM5 first draft has proposed many new diagnoses that would create enormous problems (especially false positive "epidemics" and forensic misuse). Two perceived needs have driven the DSM5 Work Groups in this unhappy direction:1- therapeutic zeal not to miss patients who might benefit from treatment; and, 2-an aversion toward using the Not Otherwise Specified (NOS) categories. I will argue that these NOS categories impart a great deal of useful clinical information and are essential to the flexible and effective use of the manual. Giving every presentation a specific name and code in order to reduce the use of NOS would create much worse problems than it would solve.
The common prejudice against NOS diagnosis is that it puts psychiatry in a bad light. Why should as many as a third of our patients not qualify for anything more definitive? How do we explain this to them, their families, to referral sources, and to ourselves? How can we plan a specific treatment if the patient doesn't have a specific diagnosis? And so on.
It may be useful to answer these questions in the act of exploring the different ways patients actually qualify for a NOS diagnosis:
1-There is simply not enough information to be more specific. Sometimes, this occurs because there was insufficient time for a complete evaluation or the patient is uncooperative and there is no informant or chart. Often, though, it comes from the inherent uncertainties of the situation. I have, for example, rarely felt comfortable with any label other than Psychotic Disorder NOS for psychotic teenagers who have only short track records There is usually just too much uncertainty about the etiology (i.e., role of drugs) and their future course to be more definitive. There is nothing to be defensive about in using NOS in these situations. The designation Psychotic Disorder NOS conveys a great deal of information, while keeping tentative what deserves to be kept tentative. The immediate treatment target is clear without imposing a premature closure on long term treatment needs or prognosis. This can easily and productively be explained to patients and families.
2- The presentation clearly belongs in the section, but does not fit the prototype of any of the specific disorders defined there. For example, in DSM4 we included binge eating disorder as an example of Eating Disorder NOS, rather than elevating it to a separate coded category. This allows the clinician the flexibility to diagnose an individual patient when this is deemed necessary without prematurely reifying a category that has yet to pass its risk benefit test and might have unfortunate unintended consequences.
3-The condition is subthreshold to the specific criteria sets- but nonetheless causes obvious clinically significant distress or impairment. There is no bright line between mental disorder and normality. The decision whether a mental disorder is or is not present inherently has to be made on a case by case basis. The NOS categories provide needed flexibility in diagnosing the many people who present at the boundary with normality. Clinicians can use the appropriate NOS category for the early diagnosis of subthreshold conditions (eg "prepsychotic risk") when this clearly warranted for that particular person. This is far preferable to introducing a specific category for "psychosis risk" that would inevitably misidentify many individuals who would be much better off without diagnosis and treatment.
4-The condition presents a mixture of symptoms from different specific disorders that are individually subthreshold but jointly causative of clinically significant distress or impairment. The proposal for a Mixed Anxiety Depressive Disorder is a perfect example and is best handled as an NOS. If made an official category, it would immediately become one of the most popular diagnoses in DSM5 without any proof that treatment would provide more good than harm for the millions of people who would get the diagnosis. In all these ways, the NOS categories are indispensable. They should be celebrated, rather than denigrated and used whenever they are the best description of the less than typical patient. The designation NOS is never really nonspecific or noninformative because it places the patient in a suitable section of the manual without providing more certainty or specificity than the situation allows.
Advice to DSM5
1-Accept the fact of life that a certain degree of diagnostic uncertainty and heterogeneity is inherent in the definition of mental disorder. Do not seek to attain an unattainable and pseudoprecise total specificity.
2-Appreciate that each NOS designation provides considerable information (for example, Psychotic Disorder NOS is very different in its treatment and prognostic connotations from Mood Disorder NOS or Eating Disorder NOS).
3-List the most common examples under each NOS category and allow these to be subtypes of that NOS- eg "Eating Disorder NOS, binge eating presentation" or "Mood Disorder NOS, premenstrual dysphoric presentation".
4- Clinicians using the NOS diagnoses are dealing with non prototypical boundary cases. They must therefore be especially careful in determining that the presentation is accompanied by sufficient clinically significant distress or impairment to warrant a diagnosis of mental disorder.
5-Do not create new diagnoses in a vain attempt to replace NOS. The suggestions for new DSM5 diagnoses should instead be available as examples under the most appropriate NOS ("minor neurognitive" under Cognitive Disorders NOS etc). There are two exceptions among the proposed new diagnoses- "paraphilic coercive" and "hypersexuality"- both of which are harmful constructs whose use should be discouraged altogether, even within the NOS rubric.
The common prejudice against NOS diagnosis is that it puts psychiatry in a bad light. Why should as many as a third of our patients not qualify for anything more definitive? How do we explain this to them, their families, to referral sources, and to ourselves? How can we plan a specific treatment if the patient doesn't have a specific diagnosis? And so on.
It may be useful to answer these questions in the act of exploring the different ways patients actually qualify for a NOS diagnosis:
1-There is simply not enough information to be more specific. Sometimes, this occurs because there was insufficient time for a complete evaluation or the patient is uncooperative and there is no informant or chart. Often, though, it comes from the inherent uncertainties of the situation. I have, for example, rarely felt comfortable with any label other than Psychotic Disorder NOS for psychotic teenagers who have only short track records There is usually just too much uncertainty about the etiology (i.e., role of drugs) and their future course to be more definitive. There is nothing to be defensive about in using NOS in these situations. The designation Psychotic Disorder NOS conveys a great deal of information, while keeping tentative what deserves to be kept tentative. The immediate treatment target is clear without imposing a premature closure on long term treatment needs or prognosis. This can easily and productively be explained to patients and families.
2- The presentation clearly belongs in the section, but does not fit the prototype of any of the specific disorders defined there. For example, in DSM4 we included binge eating disorder as an example of Eating Disorder NOS, rather than elevating it to a separate coded category. This allows the clinician the flexibility to diagnose an individual patient when this is deemed necessary without prematurely reifying a category that has yet to pass its risk benefit test and might have unfortunate unintended consequences.
3-The condition is subthreshold to the specific criteria sets- but nonetheless causes obvious clinically significant distress or impairment. There is no bright line between mental disorder and normality. The decision whether a mental disorder is or is not present inherently has to be made on a case by case basis. The NOS categories provide needed flexibility in diagnosing the many people who present at the boundary with normality. Clinicians can use the appropriate NOS category for the early diagnosis of subthreshold conditions (eg "prepsychotic risk") when this clearly warranted for that particular person. This is far preferable to introducing a specific category for "psychosis risk" that would inevitably misidentify many individuals who would be much better off without diagnosis and treatment.
4-The condition presents a mixture of symptoms from different specific disorders that are individually subthreshold but jointly causative of clinically significant distress or impairment. The proposal for a Mixed Anxiety Depressive Disorder is a perfect example and is best handled as an NOS. If made an official category, it would immediately become one of the most popular diagnoses in DSM5 without any proof that treatment would provide more good than harm for the millions of people who would get the diagnosis. In all these ways, the NOS categories are indispensable. They should be celebrated, rather than denigrated and used whenever they are the best description of the less than typical patient. The designation NOS is never really nonspecific or noninformative because it places the patient in a suitable section of the manual without providing more certainty or specificity than the situation allows.
Advice to DSM5
1-Accept the fact of life that a certain degree of diagnostic uncertainty and heterogeneity is inherent in the definition of mental disorder. Do not seek to attain an unattainable and pseudoprecise total specificity.
2-Appreciate that each NOS designation provides considerable information (for example, Psychotic Disorder NOS is very different in its treatment and prognostic connotations from Mood Disorder NOS or Eating Disorder NOS).
3-List the most common examples under each NOS category and allow these to be subtypes of that NOS- eg "Eating Disorder NOS, binge eating presentation" or "Mood Disorder NOS, premenstrual dysphoric presentation".
4- Clinicians using the NOS diagnoses are dealing with non prototypical boundary cases. They must therefore be especially careful in determining that the presentation is accompanied by sufficient clinically significant distress or impairment to warrant a diagnosis of mental disorder.
5-Do not create new diagnoses in a vain attempt to replace NOS. The suggestions for new DSM5 diagnoses should instead be available as examples under the most appropriate NOS ("minor neurognitive" under Cognitive Disorders NOS etc). There are two exceptions among the proposed new diagnoses- "paraphilic coercive" and "hypersexuality"- both of which are harmful constructs whose use should be discouraged altogether, even within the NOS rubric.
Monday, May 24, 2010
MSNBC: Anorexia and bulimia the most familiar, but not the most common
Anorexia and bulimia are probably the most familiar types of eating disorders, but they are not the most common. Some 50 to 60 percent of patients don't quite make the cut to be diagnosed with full-blown anorexia or bulimia, and are instead classified as having an eating disorder "not otherwise specified" (EDNOS).
But this group is so vast, and the cases within it so diverse, that many in the field believe it creates more problems than it does solutions in terms of treating patients and understanding the syndromes. Patients lumped into this unspecified group can also have misperceptions about their condition, thinking it is not as serious as anorexia or bulimia. But in fact, recent studies have found that there really isn't a medical difference between the three recognized types of eating disorders.
Now, physicians and psychiatrists are taking action to remedy the situation. They are proposing revisions to the psychiatric "bible," the Diagnostic and Statistical Manual of Mental Disorders, or DSM, for the newest version (DSM-5) to be published in 2013. The suggested changes include relaxing the strict criteria for anorexia and bulimia somewhat, and giving other conditions, such as binge eating, their own official labels.
Read the full article here!
But this group is so vast, and the cases within it so diverse, that many in the field believe it creates more problems than it does solutions in terms of treating patients and understanding the syndromes. Patients lumped into this unspecified group can also have misperceptions about their condition, thinking it is not as serious as anorexia or bulimia. But in fact, recent studies have found that there really isn't a medical difference between the three recognized types of eating disorders.
Now, physicians and psychiatrists are taking action to remedy the situation. They are proposing revisions to the psychiatric "bible," the Diagnostic and Statistical Manual of Mental Disorders, or DSM, for the newest version (DSM-5) to be published in 2013. The suggested changes include relaxing the strict criteria for anorexia and bulimia somewhat, and giving other conditions, such as binge eating, their own official labels.
Read the full article here!
Tuesday, January 19, 2010
NTY: Narrowing an Eating Disorder By ABBY ELLIN
The year was 1988, and I was a college student on my junior year abroad, traveling aimlessly through the Middle East and Europe. My backpack was crammed with shorts and T-shirts, bathing suits and sarongs, my Walkman and Grateful Dead tapes. And oh, yes, a scale, buried deep beneath layers of socks. Having been a chubby adolescent — and having spent six summers at fat camp — I was terrified of gaining weight.
Unfortunately, nothing gave me as much pleasure as eating, which I did with abandon.
To maintain some semblance of control, I divided my eating into Food Days and Nonfood Days: that is, days when I consumed vast amounts, and days when I policed my caloric intake with military precision. The routine kept my weight in check, more or less. Never mind that it was insane.
No one at my college health center knew what to do with me. Clearly, I wasn’t anorexic; I was slightly round, in fact. I didn’t purge, so bulimia was out. To my distress, the counselors told me there was nothing they could do for me and sent me on my way.
Today, I would probably qualify for a diagnosis of “eating disorder not otherwise specified,” usually known by its acronym, Ednos. In the current edition of the Diagnostic and Statistical Manual of Mental Disorders, it encompasses virtually every type of eating problem that is not anorexia or bulimia.
Though its name is less familiar, it is diagnosed more often than those two disorders — in 4 percent of American women each year, according to the National Eating Disorders Association. (The association does not have statistics on men.) Subsets of Ednos include binge eating disorder, purging disorder, night eating syndrome, chewing and spitting out food, and even picky eating.
But the diagnosis baffles many clinicians, who call it ambiguous, vague and unwieldy. And so the American Psychiatric Association is overhauling its definition of Ednos for the next edition of the diagnostic manual, known as D.S.M.-5, to be published in 2013.
“The consensus is that Ednos is ‘too big,’ meaning it is being used more frequently than is desirable, as that label does not convey much specific information,” said Dr. B. Timothy Walsh, a professor of psychiatry at Columbia who is chairman of the eating disorders work group for the new manual.
Dr. Walsh said the panel was “considering a range of ways to reduce the frequency with which that very broad category is used.” For now, though, Ednos remains the nation’s the most common eating disorder. A September 2009 study in The International Journal of Eating Disorders found that Ednos was often a way station between an eating disorder and recovery or, less commonly, from recovery to a full-blown eating disorder.
While traveling with a scale in your backpack is not one of the criteria, preoccupation with weight and food is. So are severe chronic dieting, frequent overeating, night eating syndrome, purging disorder and possibly compulsive exercising. If that sounds a little vague — find me one woman who isn’t preoccupied with her body size — psychologists make a distinction.
“The eating has to be disordered in some way, as does the behavior relating to eating,” said Ruth H. Striegel-Moore, a professor of psychology at Montana State University. “Also, it has to lead to some kind of impairment. For instance, some women will not go to parties because they’re worried about eating.
“If you’re restricting yourself so much that it affects your work negatively, you would meet the criteria for Ednos.”
Even so, many clinicians say the diagnosis is just too roomy.
“One of the difficulties with Ednos is that there’s a lot of diversity within that category,” said Craig Johnson, director of the eating disorders program at Laureate Psychiatric Clinic and Hospital in Tulsa, Okla. “Because there are different presentations that not all clinicians are familiar with, there’s a risk that people who have disordered eating who could benefit from clinical attention won’t know that they have a problem.”
Indeed, one reason the panel wants to change the guidelines is to help patients with eating problems recognize them even if they do not exhibit any of the traditional symptoms.
Kris Shock, for example, used laxatives and restricted her food for years, but she never threw up or binged, and her weight was average. She did not seek psychiatric help for what she and her husband called her “eating problem” until age 31, when she became addicted to the diet pill ephedra, she said in a recent interview.
Now 37 and the director of a child care center in Atlanta, Ms. Shock said that when she finally got her diagnosis of Ednos, “it was like, ‘Ah, I am sick enough to get help and have the recovery experience.’ ”
Most health insurance policies do not cover Ednos. (Ms. Shock refinanced her home to pay for her week-and-a-half-long stay at a residential treatment center.) Yet people with it are at risk for many of the same medical problems that afflict anorexics or bulimics, including osteoporosis, heart attacks, hormone imbalance and even death. A study in the Oct. 15 issue of The American Journal of Psychiatry reported that the mortality rate associated with Ednos exceeded that for anorexia nervosa and bulimia.
With that in mind, many doctors blur the diagnostic lines just so their patients can get insurance coverage. A chewer and spitter might be classified as bulimic, Dr. Striegel-Moore said; an almost-anorexic would fall under binge eating disorder.
Clinicians say patients like these often need to feel they have a “real” eating disorder.
“A lot of patients feel this stigma if they know they’re diagnosed with Ednos: ‘Obviously, I’m not good enough to be anorexic,’ ” said Nicole Hawkins, director of clinical services at Center for Change, an eating disorder treatment center in Orem, Utah. “I’ve had many patients feel that they need to lose more weight so they lose their period so they can change the diagnosis. Patients really feel they have to get ‘better’ at their eating disorder to deserve treatment.”
That is how Stacey Taylor felt. Ms. Taylor, 26, a prekindergarten teacher in Alexandria, La., said she had been dieting since age 7; at 16, she lost 70 pounds, and from then until age 25 she purged and abused diet pills, diuretics and laxatives. Although she vomited 3 to 11 times a day, she was never classified as bulimic because she did not binge, and her weight was never low enough to be anorexic.
“The doctors would look at me and say, ‘You don’t look like you have an eating disorder — go home and get something to eat,’ ” she recalled, adding that she didn’t think she was “sick enough” to need help, either.
Some doctors say weight requirements should be eliminated for all eating disorders in the new diagnostic manual. Deb Burgard, an eating disorder specialist in Los Altos, Calif., notes that people of any weight and body mass index may binge, purge or diet excessively.
“I have worked with plenty of restricting average-sized and fat patients who really should be diagnosed with anorexia nervosa,” said Dr. Burgard, a founder of Health at Every Size, an approach that focuses on health rather than weight. “But there is confusion based on the current D.S.M. whether they meet the criteria for the diagnosis if they are not at a low B.M.I. — even if their current weight is extremely low for them individually and they’re showing signs of starvation.”
Perhaps the most difficult part of treating Ednos is that “normal” eating is such an elusive concept. Thinness tends to be the ideal, no matter what lengths people go to get there.
“What Ednos really demonstrates,” said Dr. Johnson, at Laureate in Tulsa, “is that we don’t have empirically derived diagnoses in psychiatry.
“Think about the diagnosis of depression. When does someone have a clinical syndrome versus a mood fluctuation? At what point should it be regarded as a condition that needs treatment? When you talk about food habits, it becomes extraordinarily complicated, because everybody has a relationship with food, and it’s usually a somewhat complicated one."
Unfortunately, nothing gave me as much pleasure as eating, which I did with abandon.
To maintain some semblance of control, I divided my eating into Food Days and Nonfood Days: that is, days when I consumed vast amounts, and days when I policed my caloric intake with military precision. The routine kept my weight in check, more or less. Never mind that it was insane.
No one at my college health center knew what to do with me. Clearly, I wasn’t anorexic; I was slightly round, in fact. I didn’t purge, so bulimia was out. To my distress, the counselors told me there was nothing they could do for me and sent me on my way.
Today, I would probably qualify for a diagnosis of “eating disorder not otherwise specified,” usually known by its acronym, Ednos. In the current edition of the Diagnostic and Statistical Manual of Mental Disorders, it encompasses virtually every type of eating problem that is not anorexia or bulimia.
Though its name is less familiar, it is diagnosed more often than those two disorders — in 4 percent of American women each year, according to the National Eating Disorders Association. (The association does not have statistics on men.) Subsets of Ednos include binge eating disorder, purging disorder, night eating syndrome, chewing and spitting out food, and even picky eating.
But the diagnosis baffles many clinicians, who call it ambiguous, vague and unwieldy. And so the American Psychiatric Association is overhauling its definition of Ednos for the next edition of the diagnostic manual, known as D.S.M.-5, to be published in 2013.
“The consensus is that Ednos is ‘too big,’ meaning it is being used more frequently than is desirable, as that label does not convey much specific information,” said Dr. B. Timothy Walsh, a professor of psychiatry at Columbia who is chairman of the eating disorders work group for the new manual.
Dr. Walsh said the panel was “considering a range of ways to reduce the frequency with which that very broad category is used.” For now, though, Ednos remains the nation’s the most common eating disorder. A September 2009 study in The International Journal of Eating Disorders found that Ednos was often a way station between an eating disorder and recovery or, less commonly, from recovery to a full-blown eating disorder.
While traveling with a scale in your backpack is not one of the criteria, preoccupation with weight and food is. So are severe chronic dieting, frequent overeating, night eating syndrome, purging disorder and possibly compulsive exercising. If that sounds a little vague — find me one woman who isn’t preoccupied with her body size — psychologists make a distinction.
“The eating has to be disordered in some way, as does the behavior relating to eating,” said Ruth H. Striegel-Moore, a professor of psychology at Montana State University. “Also, it has to lead to some kind of impairment. For instance, some women will not go to parties because they’re worried about eating.
“If you’re restricting yourself so much that it affects your work negatively, you would meet the criteria for Ednos.”
Even so, many clinicians say the diagnosis is just too roomy.
“One of the difficulties with Ednos is that there’s a lot of diversity within that category,” said Craig Johnson, director of the eating disorders program at Laureate Psychiatric Clinic and Hospital in Tulsa, Okla. “Because there are different presentations that not all clinicians are familiar with, there’s a risk that people who have disordered eating who could benefit from clinical attention won’t know that they have a problem.”
Indeed, one reason the panel wants to change the guidelines is to help patients with eating problems recognize them even if they do not exhibit any of the traditional symptoms.
Kris Shock, for example, used laxatives and restricted her food for years, but she never threw up or binged, and her weight was average. She did not seek psychiatric help for what she and her husband called her “eating problem” until age 31, when she became addicted to the diet pill ephedra, she said in a recent interview.
Now 37 and the director of a child care center in Atlanta, Ms. Shock said that when she finally got her diagnosis of Ednos, “it was like, ‘Ah, I am sick enough to get help and have the recovery experience.’ ”
Most health insurance policies do not cover Ednos. (Ms. Shock refinanced her home to pay for her week-and-a-half-long stay at a residential treatment center.) Yet people with it are at risk for many of the same medical problems that afflict anorexics or bulimics, including osteoporosis, heart attacks, hormone imbalance and even death. A study in the Oct. 15 issue of The American Journal of Psychiatry reported that the mortality rate associated with Ednos exceeded that for anorexia nervosa and bulimia.
With that in mind, many doctors blur the diagnostic lines just so their patients can get insurance coverage. A chewer and spitter might be classified as bulimic, Dr. Striegel-Moore said; an almost-anorexic would fall under binge eating disorder.
Clinicians say patients like these often need to feel they have a “real” eating disorder.
“A lot of patients feel this stigma if they know they’re diagnosed with Ednos: ‘Obviously, I’m not good enough to be anorexic,’ ” said Nicole Hawkins, director of clinical services at Center for Change, an eating disorder treatment center in Orem, Utah. “I’ve had many patients feel that they need to lose more weight so they lose their period so they can change the diagnosis. Patients really feel they have to get ‘better’ at their eating disorder to deserve treatment.”
That is how Stacey Taylor felt. Ms. Taylor, 26, a prekindergarten teacher in Alexandria, La., said she had been dieting since age 7; at 16, she lost 70 pounds, and from then until age 25 she purged and abused diet pills, diuretics and laxatives. Although she vomited 3 to 11 times a day, she was never classified as bulimic because she did not binge, and her weight was never low enough to be anorexic.
“The doctors would look at me and say, ‘You don’t look like you have an eating disorder — go home and get something to eat,’ ” she recalled, adding that she didn’t think she was “sick enough” to need help, either.
Some doctors say weight requirements should be eliminated for all eating disorders in the new diagnostic manual. Deb Burgard, an eating disorder specialist in Los Altos, Calif., notes that people of any weight and body mass index may binge, purge or diet excessively.
“I have worked with plenty of restricting average-sized and fat patients who really should be diagnosed with anorexia nervosa,” said Dr. Burgard, a founder of Health at Every Size, an approach that focuses on health rather than weight. “But there is confusion based on the current D.S.M. whether they meet the criteria for the diagnosis if they are not at a low B.M.I. — even if their current weight is extremely low for them individually and they’re showing signs of starvation.”
Perhaps the most difficult part of treating Ednos is that “normal” eating is such an elusive concept. Thinness tends to be the ideal, no matter what lengths people go to get there.
“What Ednos really demonstrates,” said Dr. Johnson, at Laureate in Tulsa, “is that we don’t have empirically derived diagnoses in psychiatry.
“Think about the diagnosis of depression. When does someone have a clinical syndrome versus a mood fluctuation? At what point should it be regarded as a condition that needs treatment? When you talk about food habits, it becomes extraordinarily complicated, because everybody has a relationship with food, and it’s usually a somewhat complicated one."
Wednesday, January 13, 2010
Binge Eating: Why an Official Diagnosis Is Crucial
“A half-gallon of ice cream was only the beginning. I was capable of consuming 3,000 calories at a sitting. Many mornings I awakened to find partly chewed food still in my mouth….My despair was profound, and one night in the midst of a binge I became suicidal. I had lost control of my eating; it was controlling me, and I couldn’t go on living that way.” Reporter Jane Brody described her binge eating experience in an article for The New York Times.
According to National Institute of Mental Health, binge eating affects from 2 to 5 percent of the population, more than anorexia and bulimia combined. Yet it does not have a formal diagnosis. How can the medical community find treatments for binge eating if it is not elevated to at least the status of a disorder?
In fact, in an article written by Melissa Healy in latimes.com, the author of “Crave: Why You Binge Eat and How to Stop,” researcher and eating disorder specialist, Cynthia Bulik Ph.D., claimed the medical community won’t produce the studies to discover the genetic components of binge eating and therapy won’t be covered if we don’t have a firm definition of binge eating. Definitions are serious business in the medical world.
Even though, it is not officially considered a disorder there is a Binge Eating Disorder Association (BEDA). On their website, bedaonline.com, they list binge eating as one of the leading causes of obesity with a plethora of complications including type 2 diabetes, high blood pressure, high blood cholesterol, gallbladder disease, heart disease, certain types of cancer, osteoarthritis, joint and muscle pain, gastrointestinal problems, depression, anxiety and sleep apnea.
Sounds serious, but in the Diagnostic and Statistical Manual of Mental Disorders (DSM), binge eating is now listed as an eating disorder not otherwise specified (EDNOS).
Furthermore, Michael D Anestis, M.S of psychotherapybrownbag.com writes that “…between 50 to 70 percent of eating disorder diagnoses are EDNOS.” Explaining why this is a bad idea he said, “…knowing that somebody has EDNOS tells us very little about… what symptoms are causing them distress and/or impairment.” However, Anestis states “… this diagnosis [EDNOS] is…what we are most likely to see listed in the case file.”
Just imagine, you’ve spent the night binging. You feel like you’re going to die so you call 911. By the time the EMTs arrive you’ve passed out. They rush you to the Emergency Room of your hospital and when the ER doctor opens your medical file, he sees the diagnosis of “eating disorder not otherwise specified.” What does that tell the doctor and how will the doctor begin to know how to effectively treat you?
According to Anestis there is hope. Several researchers are working to group together eating disorders with similar symptoms so that there will be less EDNOS diagnoses and a clearer explanation of what the patient is actually suffering from.
Hopefully, placing larger numbers of patients in official eating disorder categories may prompt additional financial coverage and, as importantly, the further studies needed to find effective treatments for the victims who suffer from eating disorders.
http://www.nytimes.com/2007/02/20/health/20brod.html
http://www.nimh.nih.gov/health/publications/the-numbers-count-mental-dis...
http://www.bedaonline.com/aboutBED.html
http://www.psychotherapybrownbag.com/psychotherapy_brown_bag_a/2009/11/e...
According to National Institute of Mental Health, binge eating affects from 2 to 5 percent of the population, more than anorexia and bulimia combined. Yet it does not have a formal diagnosis. How can the medical community find treatments for binge eating if it is not elevated to at least the status of a disorder?
In fact, in an article written by Melissa Healy in latimes.com, the author of “Crave: Why You Binge Eat and How to Stop,” researcher and eating disorder specialist, Cynthia Bulik Ph.D., claimed the medical community won’t produce the studies to discover the genetic components of binge eating and therapy won’t be covered if we don’t have a firm definition of binge eating. Definitions are serious business in the medical world.
Even though, it is not officially considered a disorder there is a Binge Eating Disorder Association (BEDA). On their website, bedaonline.com, they list binge eating as one of the leading causes of obesity with a plethora of complications including type 2 diabetes, high blood pressure, high blood cholesterol, gallbladder disease, heart disease, certain types of cancer, osteoarthritis, joint and muscle pain, gastrointestinal problems, depression, anxiety and sleep apnea.
Sounds serious, but in the Diagnostic and Statistical Manual of Mental Disorders (DSM), binge eating is now listed as an eating disorder not otherwise specified (EDNOS).
Furthermore, Michael D Anestis, M.S of psychotherapybrownbag.com writes that “…between 50 to 70 percent of eating disorder diagnoses are EDNOS.” Explaining why this is a bad idea he said, “…knowing that somebody has EDNOS tells us very little about… what symptoms are causing them distress and/or impairment.” However, Anestis states “… this diagnosis [EDNOS] is…what we are most likely to see listed in the case file.”
Just imagine, you’ve spent the night binging. You feel like you’re going to die so you call 911. By the time the EMTs arrive you’ve passed out. They rush you to the Emergency Room of your hospital and when the ER doctor opens your medical file, he sees the diagnosis of “eating disorder not otherwise specified.” What does that tell the doctor and how will the doctor begin to know how to effectively treat you?
According to Anestis there is hope. Several researchers are working to group together eating disorders with similar symptoms so that there will be less EDNOS diagnoses and a clearer explanation of what the patient is actually suffering from.
Hopefully, placing larger numbers of patients in official eating disorder categories may prompt additional financial coverage and, as importantly, the further studies needed to find effective treatments for the victims who suffer from eating disorders.
http://www.nytimes.com/2007/02/20/health/20brod.html
http://www.nimh.nih.gov/health/publications/the-numbers-count-mental-dis...
http://www.bedaonline.com/aboutBED.html
http://www.psychotherapybrownbag.com/psychotherapy_brown_bag_a/2009/11/e...
Wednesday, December 2, 2009
High Mortality Risk for Bulimia Nervosa and Unspecified Eating Disorders
Acknowlegement about the seriousness of EDs other than AN. All EDs kill!
A large, long-term study extends the finding of high death rates in anorexia nervosa to bulimia nervosa and other eating disorders. Crow et al. (p. 1342) determined diagnoses for 1,885 outpatients with eating disorders evaluated between 1979 and 1997 and searched the National Death Index for matches through 2004. The crude mortality rates for the patients with diagnoses of anorexia nervosa, bulimia nervosa, and "eating disorder not otherwise specified" were 4.0%, 3.9%, and 5.2%, respectively. Compared to national mortality data for demographically similar groups, the rate for eating disorder not otherwise specified was significantly elevated, suggesting that this diagnosis does not indicate a less severe disorder. In addition, 13 of the 84 deaths identified were due to suicide, and eight of these were among the patients with bulimia nervosa. These findings are discussed by Dr. Walter Kaye in an editorial on p. 1309.
A large, long-term study extends the finding of high death rates in anorexia nervosa to bulimia nervosa and other eating disorders. Crow et al. (p. 1342) determined diagnoses for 1,885 outpatients with eating disorders evaluated between 1979 and 1997 and searched the National Death Index for matches through 2004. The crude mortality rates for the patients with diagnoses of anorexia nervosa, bulimia nervosa, and "eating disorder not otherwise specified" were 4.0%, 3.9%, and 5.2%, respectively. Compared to national mortality data for demographically similar groups, the rate for eating disorder not otherwise specified was significantly elevated, suggesting that this diagnosis does not indicate a less severe disorder. In addition, 13 of the 84 deaths identified were due to suicide, and eight of these were among the patients with bulimia nervosa. These findings are discussed by Dr. Walter Kaye in an editorial on p. 1309.
Wednesday, September 16, 2009
Rethinking the Freshman 15 by Johannah Cornblatt
Haley Hogan, a recent Yale graduate who has suffered from anorexia, got used to seeing nutrition facts displayed at New York chain restaurants when she took a semester off last fall. But when she returned to Yale in the spring, she was shocked to find cards detailing calorie information all over her residential dining hall. "They're very triggering if you're in recovery from an eating disorder," Hogan says of calorie counts. "I felt almost violated that Yale had done this."
With more than 30 percent of college students falling into the American College Health Association's obese or overweight categories, Yale is not the only school trying to help students make smart food choices. But experts say the emphasis on calorie counts can backfire and lead to disordered eating, even among students with no history of food issues.
Dr. Richard Kreipe, a specialist in adolescent medicine whose research centers on eating disorders, says that while he has seen fewer cases of classic eating disorders like restrictive anorexia nervosa and bulimia nervosa in the past several years, the number of patients with eating disorders not otherwise specified (EDNOS) has "almost doubled" nationally in the midst of America's obesity epidemic. (An EDNOS, also called disordered eating, is an eating disorder that doesn't meet the strict diagnostic criteria for a full-blown eating disorder, but may include drastic weight loss, caloric restriction, binging, and purging.) Since 2000, the number of college students dieting, vomiting, or taking laxatives to lose weight has jumped from about 28 to 38 percent, according to the American College Health Association's annual surveys. Well-balanced caloric intake, with regular meals and physical activity—not dieting—is the best way to avoid obesity, says Kreipe, a professor at the University of Rochester Medical Center. That's why, in his view, calorie information doesn't benefit students. "Nutrition is not a simple thing that can be distilled down into a label," he says. "There's a tendency for people to overinterpret what a specific number means."
Last fall, Harvard removed cards with calorie information from dining halls. Writing about the decision on his blog, Ted Mayer, executive director of Harvard's dining services, noted that his staff needed to address "the challenge a quiet and surprisingly large contingent of our community faces with eating disorders." The dining staff now makes the information available on the Internet and at kiosks in the dining halls.
Going away to college makes all students vulnerable to weight gain and disordered eating, often at the same time. Students tend to experience a loss of structure when they go from high school to college. Studies have found that college students are less likely to eat breakfast or regular meals, and snack foods account for many often-unrecognized calories. All-you-can-eat dining halls and easy access to alcohol also make college students more susceptible to weight gain. At the same time, anxiety about gaining the "freshman 15" can trigger disordered eating—often well beyond the freshman year. Kreipe says that in a new setting surrounded by new people, college students are more likely to develop body-image issues, which can also lead to disordered eating.
Even overweight students, the prime targets of obesity-awareness programs, may get the wrong message. In a recent study, Dianne Neumark-Sztainer, a professor at the University of Minnesota School of Public Health, found that about 40 percent of overweight college-age women and roughly 20 percent of overweight college-age men engaged in disordered eating behaviors in an attempt to get thin. "People are concerned about the fat kids being fat and the thin kids having anorexia," she says. "But people aren't concerned about the disordered eating among the overweight kids." For under- and overweight people alike, eating disorders can lead to a host of health issues, including electrolyte imbalances, fertility problems, impaired brain development, bone loss, and, in severe cases, death. The study also showed that disordered eating behavior leads to further weight gain over time.
Colleges that focus solely on calorie counts are over-simplifying nutrition, says Neumark-Sztainer, who encourages collaboration between the eating disorder and obesity fields. More comprehensive information—like a nutrient density score—would better serve students. Such data would distinguish between items like a Coke, which is high in calories but low in nutrients, and avocado, which is rich in both calories and nutrients. Neumark-Szainer says the focus at college should be less on what people eat then how they eat. For example, students who eat with others are more likely to make healthy food choices and less likely to develop disordered eating—either eating too much or too little—than those who eat alone, she says.
There are other ways that schools can help students avoid unhealthy weight gain without provoking eating disorders. Colleges should provide opportunities for healthy physical activity that don't necessarily involve being on a sports team or going to the gym, Kreipe says. For example, schools might create walking trails or organize activities and social groups that focus on physically activity. Kreipe also recommends that schools make more healthy options—both in dining halls and vending machines—available. Above all, he says, colleges should be emphasizing portion size.
Some schools have tried to do just that. Last fall, Penn State converted one of its all-you-can-eat dining halls into a so-called "healthy dining hall," free from French fries, deep-fried chicken, or white bread. For each meal, Penn State's healthy dining hall features a model-portion plate, which consists of 50 percent fruits and vegetables, 25 percent grains, and 25 percent proteins. (The program is modeled on one at the University of North Texas.)
Still, Penn State provides caloric breakdowns in its healthy dining hall and in all other cafeterias on campus. "Healthy entrees," designated as those that container fewer than 400 calories and 10 grams of fat, are identified by a special check on the cards. Lisa Wandel, Penn State's residential-dining director, says it's the college's responsibility to notify students about what's in their food. "Would you pull labels off all the items in a grocery store?" she says. "We can't hide the fact that food has calories. I think it's better to provide that information so students can make educated choices."
Despite objections from students like Haley Hogan, Yale also plans to continue posting calorie counts in its dining halls this year. Rafi Taherian, executive director of Yale dining, says he expects that students will one day have access to real-time information about food through their cell phones or laptops. "I don't think we can hold the information back from them," he says. In fact, Rafi predicts that colleges, like some states and cities, will soon be required to provide students with nutritional data.
More important, it seems, is giving students the context to understand that information and making sure their education focuses on healthy behavior, not numbers on a scale.
With more than 30 percent of college students falling into the American College Health Association's obese or overweight categories, Yale is not the only school trying to help students make smart food choices. But experts say the emphasis on calorie counts can backfire and lead to disordered eating, even among students with no history of food issues.
Dr. Richard Kreipe, a specialist in adolescent medicine whose research centers on eating disorders, says that while he has seen fewer cases of classic eating disorders like restrictive anorexia nervosa and bulimia nervosa in the past several years, the number of patients with eating disorders not otherwise specified (EDNOS) has "almost doubled" nationally in the midst of America's obesity epidemic. (An EDNOS, also called disordered eating, is an eating disorder that doesn't meet the strict diagnostic criteria for a full-blown eating disorder, but may include drastic weight loss, caloric restriction, binging, and purging.) Since 2000, the number of college students dieting, vomiting, or taking laxatives to lose weight has jumped from about 28 to 38 percent, according to the American College Health Association's annual surveys. Well-balanced caloric intake, with regular meals and physical activity—not dieting—is the best way to avoid obesity, says Kreipe, a professor at the University of Rochester Medical Center. That's why, in his view, calorie information doesn't benefit students. "Nutrition is not a simple thing that can be distilled down into a label," he says. "There's a tendency for people to overinterpret what a specific number means."
Last fall, Harvard removed cards with calorie information from dining halls. Writing about the decision on his blog, Ted Mayer, executive director of Harvard's dining services, noted that his staff needed to address "the challenge a quiet and surprisingly large contingent of our community faces with eating disorders." The dining staff now makes the information available on the Internet and at kiosks in the dining halls.
Going away to college makes all students vulnerable to weight gain and disordered eating, often at the same time. Students tend to experience a loss of structure when they go from high school to college. Studies have found that college students are less likely to eat breakfast or regular meals, and snack foods account for many often-unrecognized calories. All-you-can-eat dining halls and easy access to alcohol also make college students more susceptible to weight gain. At the same time, anxiety about gaining the "freshman 15" can trigger disordered eating—often well beyond the freshman year. Kreipe says that in a new setting surrounded by new people, college students are more likely to develop body-image issues, which can also lead to disordered eating.
Even overweight students, the prime targets of obesity-awareness programs, may get the wrong message. In a recent study, Dianne Neumark-Sztainer, a professor at the University of Minnesota School of Public Health, found that about 40 percent of overweight college-age women and roughly 20 percent of overweight college-age men engaged in disordered eating behaviors in an attempt to get thin. "People are concerned about the fat kids being fat and the thin kids having anorexia," she says. "But people aren't concerned about the disordered eating among the overweight kids." For under- and overweight people alike, eating disorders can lead to a host of health issues, including electrolyte imbalances, fertility problems, impaired brain development, bone loss, and, in severe cases, death. The study also showed that disordered eating behavior leads to further weight gain over time.
Colleges that focus solely on calorie counts are over-simplifying nutrition, says Neumark-Sztainer, who encourages collaboration between the eating disorder and obesity fields. More comprehensive information—like a nutrient density score—would better serve students. Such data would distinguish between items like a Coke, which is high in calories but low in nutrients, and avocado, which is rich in both calories and nutrients. Neumark-Szainer says the focus at college should be less on what people eat then how they eat. For example, students who eat with others are more likely to make healthy food choices and less likely to develop disordered eating—either eating too much or too little—than those who eat alone, she says.
There are other ways that schools can help students avoid unhealthy weight gain without provoking eating disorders. Colleges should provide opportunities for healthy physical activity that don't necessarily involve being on a sports team or going to the gym, Kreipe says. For example, schools might create walking trails or organize activities and social groups that focus on physically activity. Kreipe also recommends that schools make more healthy options—both in dining halls and vending machines—available. Above all, he says, colleges should be emphasizing portion size.
Some schools have tried to do just that. Last fall, Penn State converted one of its all-you-can-eat dining halls into a so-called "healthy dining hall," free from French fries, deep-fried chicken, or white bread. For each meal, Penn State's healthy dining hall features a model-portion plate, which consists of 50 percent fruits and vegetables, 25 percent grains, and 25 percent proteins. (The program is modeled on one at the University of North Texas.)
Still, Penn State provides caloric breakdowns in its healthy dining hall and in all other cafeterias on campus. "Healthy entrees," designated as those that container fewer than 400 calories and 10 grams of fat, are identified by a special check on the cards. Lisa Wandel, Penn State's residential-dining director, says it's the college's responsibility to notify students about what's in their food. "Would you pull labels off all the items in a grocery store?" she says. "We can't hide the fact that food has calories. I think it's better to provide that information so students can make educated choices."
Despite objections from students like Haley Hogan, Yale also plans to continue posting calorie counts in its dining halls this year. Rafi Taherian, executive director of Yale dining, says he expects that students will one day have access to real-time information about food through their cell phones or laptops. "I don't think we can hold the information back from them," he says. In fact, Rafi predicts that colleges, like some states and cities, will soon be required to provide students with nutritional data.
More important, it seems, is giving students the context to understand that information and making sure their education focuses on healthy behavior, not numbers on a scale.
Tuesday, August 11, 2009
NPR Piece: Minneapolis writer chronicles her eating disorder
Listen Here
St. Paul, Minn. — Nicole Johns doesn't look like she has an eating disorder, and for a long time that was a problem. She was diagnosed as having EDNOS, or an Eating Disorder Not Otherwise Specified.
She has now written a book about her experience in the hope she can help others.
"Even when I was at my worst, you probably wouldn't have been able to pick me out as someone with an eating disorder if I was just walking down the street," Johns said.
"It's one of the misconceptions I am trying to correct in my book -- that if someone isn't underweight or they aren't visibly sick, they don't have an eating disorder and they don't need help," said Johns. "You can have an eating disorder at any weight, you can be overweight, underweight, average weight. It doesn't matter. It's not all about the weight."
Now in recovery, Johns describes her experiences in her new book, "Purge: Rehab Diaries."
Johns binged and purged for more than a decade. She obsessed about calories, and would weigh herself 10 or 15 times a day. Sometimes she drank bottles of maple syrup and soy sauce, only to bring it all up again.
Yet she remained at an appropriate weight for her size. It was only after she collapsed and went into treatment she was diagnosed as having EDNOS, an Eating Disorder Not Otherwise Specified.
Johns told MPR's Euan Kerr she hopes the book will help people understand the realities of the condition.
Broadcast Dates
All Things Considered, 08/06/2009, 5:54 p.m.
St. Paul, Minn. — Nicole Johns doesn't look like she has an eating disorder, and for a long time that was a problem. She was diagnosed as having EDNOS, or an Eating Disorder Not Otherwise Specified.
She has now written a book about her experience in the hope she can help others.
"Even when I was at my worst, you probably wouldn't have been able to pick me out as someone with an eating disorder if I was just walking down the street," Johns said.
"It's one of the misconceptions I am trying to correct in my book -- that if someone isn't underweight or they aren't visibly sick, they don't have an eating disorder and they don't need help," said Johns. "You can have an eating disorder at any weight, you can be overweight, underweight, average weight. It doesn't matter. It's not all about the weight."
Now in recovery, Johns describes her experiences in her new book, "Purge: Rehab Diaries."
Johns binged and purged for more than a decade. She obsessed about calories, and would weigh herself 10 or 15 times a day. Sometimes she drank bottles of maple syrup and soy sauce, only to bring it all up again.
Yet she remained at an appropriate weight for her size. It was only after she collapsed and went into treatment she was diagnosed as having EDNOS, an Eating Disorder Not Otherwise Specified.
Johns told MPR's Euan Kerr she hopes the book will help people understand the realities of the condition.
Broadcast Dates
All Things Considered, 08/06/2009, 5:54 p.m.
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