Diagnosing a Nation

“Therefore I tell you, do not worry about your life, what you will eat or drink; or about your body, what you will wear. Is not life more than food, and the body more than clothes?” Matthew 6:25

Eating Disorders (ED) have become an epidemic.

In order to see the number of people suffering from EDs diminish, we must better understand the causes, the warning signs, the all-consuming nature, and dynamic evils at the core of EDs.

EDs have the highest mortality rate among mental illnesses.

Every 62 minutes at least one person dies as a direct result of an eating disorder. (1)

But, let us not simply focus on mortality rates – we must acknowledge the walking dead among us: people who are living a numb existence because EDs have stolen “life to the fullest” from them (John 10:10).

Countless individuals are experiencing a zombie-like existence because their minds are anchored in self-hatred, they are running on minimal calories, and they have sold their energy to their workouts.

I have qualms with how the Diagnostic Statistical Manual (DSM) defines EDs.

The DSM is a large, fancy book mental health professionals use to identify a diagnosis. Much like a medical doctor would study symptoms and say, “this is not pneumonia, this is the flu,” and thereby prescribe appropriate medication or interventions, mental health clinicians use the DSM to identify atypical baseline behaviors, formulate a treatment plan, and measure the progress of patients.

As one who has worked in mental health and who has battled an ED, I feel frustrated with how confined ED diagnoses are assumed to be among the general population.

While I do not embrace the way the DSM outlines EDs, I must acknowledge the progressive changes that were made in the newest edition of our DSM (DSM-V):

No longer is amenorrhea a qualifier for anorexia (that prevented a male diagnosis and sometimes anorexic women still have a menstrual cycle, anyway.) Also, Binge Eating Disorder has been added and expanded upon as its own category (a widespread, deadly illness in our society). And no longer do people have to purge 2 times a week in order to be diagnosed as bulimic – a whopping 1 time will do the trick…(2)

But is it really this black and white?

Eating Disorders are not tidy. They are not easily described, experienced, or treated. Eating Disorders are not confined to the pages of the DSM. They are actually infuriatingly ambiguous and can parade around disguised as all sorts of conditions and common behaviors.

So why is labeling important?

Labeling is important because the language of the DSM lays a foundation and framework for important research and dialogue in the United States. Dialogue that can prompt change. “Kingdom on earth” kind of change – a change we desperately need.

Anorexia was first added to the DSM in the 1950’s, though the condition has been observed since the middle-ages (formally in the medical community since the 1600s).

Bulimia was officially defined in 1979 and Binge Eating Disorder was added to the DSM in 2013. Other Eating Disorders that are less common, but relevant to the discussion include Pica, Rumination, and Night Eating Syndrome.

The general population associates EDs with the classic-cinema depiction of Anorexia and Bulimia. It is widely assumed that Anorexia means an individual is starving himself or herself, and bulimia means a person is compensating for calorie consumption through purging foods via vomiting or laxatives.

While these assumptions are true, they are dangerously simplistic. By assigning such a simple definition to these very broad conditions, we have normalized eating disorders among our population and overlooked hundreds, likely thousands, of victims. Perhaps this is why EDs continue to run rampant and steal life from people.

Unless an individual is vomiting up his or her every meal, skipping multiple meals a day, exercising excessively, visibly appearing unhealthy (skin and bones/morbidly obese), or using substances to alter physical performance and physique, we typically assume all is well and that an ED is not present. We wait until “the extreme, measurable behavior” has occurred to label an individual with a diagnosis and put them in treatment.

The truth is, many people in our culture dabble in these behaviors because it has become acceptable, even applaudable, to do so.

The (often overlooked and under discussed) reality is, according to the DSM… 

  • Calorie compensation in bulimia is not just purging through laxatives or self-induced vomiting, it can also include excessive exercising.
  • Anorexia actually has two subtypes: Binge eating/purging type and restricting type. Meaning some people who purge after meals would be considered anorexic, not bulimic. 
  • Most ED victims participate in all ED subtype behaviors simultaneously, not just one, tidy subcategory.

EDs are anchored in the spirit, the heart, and the mind far before behavior ever takes place. They are heart-centered and spiritually rooted. In fact, the very first observations of Eating Disorders were tied to spiritual practices. (3)

We need to identify the issues of the heart and mind before extreme behavior is even present. We need to recognize that the toxic ED condition of the heart and mind is just as worthy of our attention and intervention as the behaviors outlined by the DSM. We need not wait for certain behaviors to manifest before acknowledging the issue.

“Above all else, guard your heart, for everything you do flows from it.” Proverbs 4:23

Our society has an unhealthy relationship with food and body. It’s no secret that every aspect of society is hyper-sexualized and body-centered. They now sell exercise clothes for preschoolers. We have seven year olds dieting. Thirteen percent of women over age 50 engage in eating disorder behaviors.” (4)

dress-sizing-chart^ This is an image of a sizing chart I received to take measurements of myself for a bridesmaid dress. It depicts the bridal shop’s “average size” customer.

A man or woman may have a completely healthy appearance and seem to eat “clean,” but the truth is, we do not know their thought life. The majority of their thoughts may be devoted to food and body shape. We can assume nothing through observation, because the real problem is unseen.

“‘I am allowed to do anything’–but not everything is good for you. And even though ‘I am allowed to do anything,’ I must not become a slave to anything. 1 Corinthians 6:12

Obsessive and compulsive behaviors around food and exercise are no longer abnormal. Unfortunately, they have become the norm in our culture and are often esteemed as impressive, healthy and responsible.

Recognizing that life is more than what we eat or drink or wear (Matthew 6:25) is incredibly important in light of this epidemic. We need to be reminded of this truth. We need to know that our obsessive thoughts regarding food intake and exercise are not normal.

Unfortunately, these obsessions have become so embedded in our society that we do not even realize we are participating in a culture of EDs.

Of course there is always a healthy balance. The Lord calls us to care for our bodies as they are temples of the living God. Gifts to us from Him. He cautions us against binging (gluttony) and encourages us to choose a healthy lifestyle.

But the healthy lifestyle endorsed in the Scriptures is holistically healthy, not solely physically healthy.

“Or do you not know that your body is a temple of the Holy Spirit within you, whom you have from God? You are not your own.” 1 Corinthians 6:19

So, as our culture leans more toward “clean” ways of eating and more “natural” ways of living, let us never lose sight of our core identity and subtle psychological messages that may accompany our choices. Let us never disqualify ourselves as ones who may be participants in the ED culture. We must constantly challenge one another to look beyond the kitchen table and treadmill.

Just because one’s experience is not precisely the behaviors as outlined in the DSM, does not mean that he or she is not engaging in a dangerous and life stealing position of the mind and heart. We must be transparent with one another regarding how and when obsessive and compulsive thoughts around food and our bodies imprison our souls.

The dialogue around EDs needs to change because, at this point, the United States has an Eating Disorder. And the change process begins with the subtle ways we think about ourselves and the ways we influence our friends and family to think as well.

“Love the Lord your God with all your heart and with all your soul and with all your mind and with all your strength.” Mark 12:30
















Appendix: 


Stages of Change:

1) Precontemplation Stage (It isn’t that we can’t see the solution. We are simply oblivious to the problem)

2) Contemplation Stage (Acknowledging the existence of a problem and considering solutions. “Over it” but not quite ready to take active steps)

3) Preparation Stage (Planning to take action but still resolving uncertainty toward change process)

4) Action stage (people actively involved in modifying behavior and environment. Attempts to change are most visible to public)

5) Maintenance Stage (continual self-check and involvement of community for accountability.)


DSM 5 Criteria:

Anorexia Nervosa

According to the DSM-5 criteria, to be diagnosed as having Anorexia Nervosa a person must display:

  • Persistent restriction of energy intake leading to significantly low body weight (in context of what is minimally expected for age, sex, developmental trajectory, and physical health) .
  • Either an intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain (even though significantly low weight).
  • Disturbance in the way one’s body weight or shape is experienced, undue influence of body shape and weight on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.
Subtypes:
Restricting type
Binge-eating/purging type

Bulimia Nervosa

According to the DSM-5 criteria, to be diagnosed as having Bulimia Nervosa a person must display:

  • Recurrent episodes of binge eating. An episode of binge eating is characterised by both of the following:
    • Eating, in a discrete period of time (e.g. within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances.
    • A sense of lack of control over eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating).
  • Recurrent inappropriate compensatory behaviour in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, or excessive exercise.
  • The binge eating and inappropriate compensatory behaviours both occur, on average, at least once a week for three months.
  • Self-evaluation is unduly influenced by body shape and weight.
  • The disturbance does not occur exclusively during episodes of Anorexia Nervosa.
Binge Eating Disorder

According to the DSM-5 criteria, to be diagnosed as having Binge Eating Disorder a person must display:

  • Recurrent episodes of binge eating. An episode of binge eating is characterised by both of the following:
    • Eating, in a discrete period of time (e.g. within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances.
    • A sense of lack of control over eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating).
  • The binge eating episodes are associated with three or more of the following:
    • eating much more rapidly than normal
    • eating until feeling uncomfortably full
    • eating large amounts of food when not feeling physically hungry
    • eating alone because of feeling embarrassed by how much one is eating
    • feeling disgusted with oneself, depressed or very guilty afterward
  • Marked distress regarding binge eating is present
  • Binge eating occurs, on average, at least once a week for three months
  • Binge eating not associated with the recurrent use of inappropriate compensatory behaviours as in Bulimia Nervosa and does not occur exclusively during the course of Bulimia Nervosa, or Anorexia Nervosa methods to compensate for overeating, such as self-induced vomiting.
Note: Binge Eating Disorder is less common but much more severe than overeating. Binge Eating Disorder is associated with more subjective distress regarding the eating behaviour, and commonly other co-occurring psychological problems.

Pica

According to the DSM-5 criteria, to be diagnosed with Pica a person must display:

  • Persistent eating of non-nutritive substances for a period of at least one month.
  • The eating of non-nutritive substances is inappropriate to the developmental level of the individual.
  • The eating behaviour is not part of a culturally supported or socially normative practice.
  • If occurring in the presence of another mental disorder (e.g. autistic spectrum disorder), or during a medical condition (e.g. pregnancy), it is severe enough to warrant independent clinical attention.
Note: Pica often occurs with other mental health disorders associated with impaired functioning.

Rumination Disorder

According to the DSM-5 criteria, to be diagnosed as having Rumination Disorder a person must display:

  • Repeated regurgitation of food for a period of at least one month Regurgitated food may be re-chewed, re-swallowed, or spit out.
  • The repeated regurgitation is not due to a medication condition (e.g. gastrointestinal condition).
  • The behaviour does not occur exclusively in the course of Anorexia Nervosa, Bulimia Nervosa, BED, or Avoidant/Restrictive Food Intake disorder.
  • If occurring in the presence of another mental disorder (e.g. intellectual developmental disorder), it is severe enough to warrant independent clinical attention.
Avoidant/Restrictive Food Intake Disorder (ARFID)

According to the DSM-5 criteria, to be diagnosed as having ARFID a person must display:

  • An Eating or Feeding disturbance as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following:
  1. Significant loss of weight (or failure to achieve expected weight gain or faltering growth in children).
  2. Significant nutritional deficiency
  3. Dependence on enteral feeding or oral nutritional supplements
  4. Marked interference with psychosocial functioning
  • The behavior is not better explained by lack of available food or by an associated culturally sanctioned practice.
  • The behavior does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way one’s body weight or shape is experienced.
  • The eating disturbance is not attributed to a medical condition, or better explained by another mental health disorder. When is does occur in the presence of another condition/disorder, the behavior exceeds what is usually associated, and warrants additional clinical attention.
Other Specified Feeding or Eating Disorder (OSFED)

According to the DSM-5 criteria, to be diagnosed as having OSFED a person must present with a feeding or eating behaviors that cause clinically significant distress and impairment in areas of functioning, but do not meet the full criteria for any of the other feeding and eating disorders.

A diagnosis might then be allocated that specifies a specific reason why the presentation does not meet the specifics of another disorder (e.g. Bulimia Nervosa- low frequency). The following are further examples for OSFED:

  • Atypical Anorexia Nervosa: All criteria are met, except despite significant weight loss, the individual’s weight is within or above the normal range.
  • Binge Eating Disorder(of low frequency and/or limited duration)All of the criteria for BED are met, except at a lower frequency and/or for less than three months.
  • Bulimia Nervosa(of low frequency and/or limited duration): All of the criteria for Bulimia Nervosa are met, except that the binge eating and inappropriate compensatory behaviour occurs at a lower frequency and/or for less than three months.
  • Purging Disorder:Recurrent purging behaviour to influence weight or shape in the absence of binge eating
  • Night Eating Syndrome:Recurrent episodes of night eating. Eating after awakening from sleep, or by excessive food consumption after the evening meal. The behavior is not better explained by environmental influences or social norms. The behavior causes significant distress/impairment. The behavior is not better explained by another mental health disorder (e.g. BED).
Unspecified Feeding or Eating Disorder (UFED)

According to the DSM-5 criteria this category applies to where behaviours cause clinically significant distress/impairment of functioning, but do not meet the full criteria of any of the Feeding or Eating Disorder criteria. This category may be used by clinicians where a clinician chooses not to specify why criteria are not met, including presentations where there may be insufficient information to make a more specific diagnosis (e.g. in emergency room settings).


Footnotes:
  1. Eating Disorders Coalition. (2016). Facts About Eating Disorders: What The Research http://eatingdisorderscoalition.org.s208556.gridserver.com/couch/uploads/file/fact-sheet_2016.pdf
  2. American Psychiatric Assoiation (2013). Feeding and Eating Disorders. http://www.dsm5.org/documents/eating%20disorders%20fact%20sheet.pdf (may need to click “Eating Disorders” on this link to get to appropriate page: http://www.dsm5.org/psychiatrists/practice/dsm/educational-resources/dsm-5-fact-sheets)
  3. Plotkin, M. (2016). A Brief History of Eating Disorders & Binge Eating Disorder. http://bedaonline.com/a-brief-history-of-eating-disorders-binge-eating-disorder/
  4. Gagne, D. A., Von Holle, A., Brownley, K. A., Runfola, C. D., Hofmeier, S., Branch, K. E., & Bulik, C. M. (2012). Eating disorder symptoms and weight and shape concerns in a large web‐based convenience sample of women ages 50 and above: Results of the gender and body image (GABI) study. International Journal of Eating Disorders45(7), 832-844.
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