Thanks for posting these new criteria Carrie. I could write reams but I won't...

The main point I would make is that the criteria for AN still focus heavily (forgive the pun..) on weight and body image - suggesting cause and effect. In other words, the patients' behaviours are focused on getting/remaining thin.

Yet, some (many?) people with AN restrict food (and perhaps also purge and over-exercise) to regulate MOOD and to control anxiety. Sometimes being thin is simply the end-result of behaviours which the patient has become dependent upon to control mood.

So now people will continue to equate anorexia nervosa with that dreadful cliche 'dying to be thin'.

Gah.

Very interesting. Thanks for posting as I don't know if I would have been aware otherwise. I'm glad they took out the amenorrhea criteria, as I think it's possible to be very sick and get a period. Have they always separated anorexia as restricting vs. binge eating/purging? I didn't know about that...

Also, I agree with Cathy that much of the focus on anorexia is still on weight/body image. Personally, I never related to this. Restricting for me was not about wanting to be thin, and I was never really afraid of getting fat. I felt like my anxiety went way down when I restricted, and I think that was the driver.

I still think they need a classification for AN in remission, etc. . .

When someone with AN regains enough weight to no longer meet the 85% criteria, but thoughts/eating/behaviours are still messed up, they may be on the way to recovery, but they are not recovered. Classifying these people as EDNOS is a diservice because it does not say anything about their past history and risk for relapse back into AN.

From what I have read, there is no one definition of what constiutes AN in partial remission or AN in remission vs, recovery.

Ideally it would be nice if it almost like being in remission from cancer -- where the ED patient is "in remission" for the first 2-3 years and then considered recovered afterward.

A:)

Perhaps we should stage an uprising! I agree, the concentration on ideas of shape and weight sounds wrong to me, and although it MUST be sensible to remove the necessity of amenorrhoea for diagnosis both because many women still menstruate at low weights and because ALL men never menstruate at any weight and yet can suffer from AN, apart from that there doesn't seem to be much improvement. I heard one definition of recovery as "an end to preoccupation about weight and shape" Well, apart from the cruel observation that people who die of the illness can therefore qualify as recovered, what about those who never had a preoccupation with weight and shape or for whom that was a minor side effect of the illness rather than a major factor. Does that mean they can't be sick. No way. Does it mean they aren't offered treatment? All too often.

I think all criterias body shape related need to be removed. The APA is in the business of evaluating people's mental health, not in the business of telling people how much to weigh.

The way they phrase this "85% below normal weight" criteria makes it sound like they're encouraging EDNOS folks to try harder so they qualify for treatment and medical attention.

I know that's how I took it. I wasn't good enough of an anorexic so I needed to try harder so I can finally earn the label I felt I deserved.

I'm still very confused about the difference between anorexia-binge/purge type, and bulimia....what do you think, Carrie?

Oh dear, non fat-phobic anorexics miss out on recognition again! I guess my diagnosis would still be as it was under DSM-IV, a-typical anorexia nervosa. It doesn't seem so a-typical to me though, I know a lot of other people now who were at anorexic weights for reasons other than a deathly fear of being overweight. Like Cathy ;) the things that kept me ill were very similar to hers.

C-G - I hope you don't mind my thoughts on the subject, but I know a lot of people with purging anorexia, and they tend to come in several different subtypes. All meet the weight criteria for anorexia, but either purge small or normal amounts of food without bingeing; mainly restrict but binge and purge occasionally; or binge and purge often multiple times a day and barely keep anything down aside from that. I think people with purging anorexia are different to people with 'typical' bulimia in that they suffer from all the medical and cognitive problems of being at a low weight AND all the medical complications of bingeing and purging. It's one of the most immediately medically dangerous sets of behaviours. People can live for decades at anorexic weights (although quality of life is pretty crappy) but bingeing and purging combined with being at a low weight often results in organ damage/failure very quickly.

I agree with A that there should be a remission diagnosis. It doesn't seem quite right that weight restored anorexics would be categorised as EDNOS somehow.

My, I'm opinionated today :P

I don't think this helps, as long as BMI is still in the criteria for diagnosis. I also wonder at the wisdom of making such differences between all the eating disorders, since so many of us have different symptoms at different times in our lives. I think what often happens is when weight is restored, or doesn't ever get "too" low, not enough treatment is available or affordable, so the root of the problem, where all the food related behaviors are coming from, never really gets addressed, which is why eating disorders tend to be a lifelong challenge.
I don't have a better answer myself. Maybe when I've learned more and have some credentials I will, but for now I guess we'll have to work with the flawed system we have.

I was glad to see "refusal" removed from criteria A. The Rationale section reads: "The word “refusal” in DSM-IV was viewed as possibly pejorative and difficult to assess, as it implies intention. Rewording of the criterion to focus on behaviors is recommended."

The new wording of criteria B includes "OR persistent behavior to avoid weight gain, even though underweight" so fear of weight gain is not necessary for diagnosis. It seems they are attempting to consider non-fat phobic AN.
The Rationale section reads: "In DSM-IV, 'fear of weight gain' is required. A significant minority of individuals with the syndrome explicitly deny such fear. Therefore, the addition of a clause to focus on behavior is recommended."

As a recovering ED-NOSer (ED-NOSee?) I am somewhat naively (no, optimistically! optimistically!) hoping that adding BED and removing the amenorrhea criterion will help clinicians understand ED-NOS more so that its sufferers will recognize themselves. I'm not sure where I stand on the continuum vs. on/off switch of eating disorders, but ED-NOS does qualify for treatment under my insurance, and others. So being diagnosed with ED-NOS after beginning physical recovery from anorexia does not necessarily mean that the care will end.

(I wrote more at length about this at http://velvet-steamroller.blogspot.com)

To Jane: it is criteria C which discounts non fat-phobic anorexics, not B - if diagnosis depends on the presence of all three criteria, at my worst I would have met A and B but not C. I did not perceive myself as overweight, my self esteem was not based on my weight and I knew that I was dangerously underweight and could suffer health problems. I don't mind being a-typical now because I'm weight restored and doing well, but on principle and for all the other non fat-phobic anorexics out there, I still object to criteria C not having something relating to the fact that not ALL anorexics are driven by a fear of being overweight.

I don't have any special wish to defend the DSM but I wonder if tweaking the "or persistent lack of recognition of the seriousness of the current low body weight" part of criteria C might help. It seems to me that if recognition of seriousness of low body weight doesn't outweigh drive to restrict then that's a problem (rather than an absolute blindness to the perils of low weight status.)

Good point, and I guess I'm being a bit pedantic - it just doesn't really capture the thought processes very well. Not that this revised definition will make any difference to my life or my recovery, but the constant barrage of messages that all anorexics want to emulate Victoria Beckham drives me right up the wall so it would be nice to see a real understanding of the different things that can drive anorexia. It doesn't matter in the grand scheme of things, it just bugs me!

I know what you mean.

If one should binge on food, let it be on fruits and vegetables. Doing so will be beneficial for the body because these foods are rich in essential nutrients, so it will not really harm much if you stock up on it.

The concern about including non-fat phobic self-induced starvation under AN is that people, for example, on political hunger strike, fussy eaters, people who are always rushing around too busy to eat or are just get too bored to eat, and more, would qualify for anorexia nervosa, even though the treatment and research they would need is vastly different.

Well, the solution should come from the word 'compulsive' in my opinion. Maybe in the first criterion. Not just 'restriction', but COMPULSIVE restriction would indicate that the person for whatever reason feels irrationally and specifically driven to not take action necessary for weight gain, as opposed to failing to take such action as a rational means to an end (e.g. hunger strike) or as a result of lack of motivation and cynicism about doctors' advice (e.g. those indifferent to and impatient with food), or as a result of avoiding sensory displeasure (e.g. fussy eaters). In none of the above cases is the starvation itself the compulsion, where there is a compulsion at all.

Underweight fussy eaters and people with phobias of swallowing or vomiting might be described as compulsively avoiding most food and trying new foods, but they're not compulsively STARVING because no aspect of starvation - neither body image, the euphoric neurological effects, nor self-esteem derived from self-control - is what compels the behaviour. Starvation is just a side effect.