A change in the way anorexia is diagnosed may make it easier to help more teens, not just thin ones, with the illness. Previously, overweight or obese teens were more likely to fall through the cracks when they developed anorexic behaviors. Now, the release of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has broadened the disorder criteria by taking away the weight requirement. The change shifts the focus of the diagnosis from “being thin” to the behaviors of those with the illness.
The previous criteria perpetuated the idea that anorexia is a weight disorder—rather than a psychological one. “A lot of people need help even if they don’t narrowly fit the definition of an illness,” says David Hahn, medical director of The Renfrew Center of Philadelphia. “This criteria makes clear that the behaviors, even without a very low weight, are pathologic and need to be addressed. The criteria may very much help pediatricians catch an eating disorder sooner and may teach the public and families to intervene more quickly if it’s understood that anorexia doesn’t only mean underweight.”
Anorexia nervosa most often begins in adolescence and affects approximately 0.3 percent of teens. An additional 0.8 percent were found in one large study to have “subthreshold anorexia nervosa”—they showed the symptoms but did not meet all the criteria. Overall, about 6 percent of teens suffer from some kind of eating disorder, such as bulimia, binge-eating and other eating issues previously classified in the DSM-IV as “Eating Disorder—Not Otherwise Specified” (ED-NOS).
Now the DSM-5 changes have led experts to express optimism that adolescents who may not “look” anorexic might start getting treatment they need rather than being overlooked entirely or diagnosed with ED-NOS. More than 55 percent of teen girls and 30 percent of boys report some kind of “disordered eating” symptoms, such as fasting, diet pills, vomiting or using laxatives. The challenge is catching those who will take it too far. “Before, patients were very sick before meeting criteria, and the evidence is pretty clear that if you interfere in anorexia before there’s been significant weight loss, the outcomes are much better and the illness is easier to treat in an outpatient setting,” says Kimberli McCallum, founder and medical director of eating disorder clinic McCallum Place in Saint Louis.
Reducing the ambiguity of diagnoses
Most overweight or obese teens with eating disorders have been diagnosed up to now with ED-NOS, regardless of whether they were binge eating or showing anorexic behaviors such as starving themselves or purging. In fact, under the DSM-IV more than half of all diagnosed eating disorders were classified as ED-NOS. “We had too many atypicals,” says Ovidio Bermudez, medical director of child and adolescent services at Eating Recovery Center in Denver. “That reflects that the other criteria were weak, not matching what we see at a clinical level.”
ED-NOS was also not always taken as seriously by families, patients or insurance companies. “A lot of the changes in the DSM-5 have been geared toward decreasing ED-NOS as a diagnosis for folks who don’t fit into the other categories because it’s a catch-all bin,” says Espra Andrus, a licensed clinical social worker who specializes in eating disorder treatment. “If I’m sitting in an appointment with a parent and I say ‘Your child has Eating Disorder Not Otherwise Specified,’ it doesn’t carry the punch of seriousness with them, and it tends to be a little tougher to get insurance coverage, especially for inpatient care.”