Critiquing DSM Diagnostic Criteria for Eating Disorders

Introduction: Questioning the DSM's Authority on Eating Disorders

The Diagnostic and Statistical Manual (DSM) of Mental Disorders has the appearance of an authoritative text in terms of how mental diseases are defined. However, there has been considerable debate over what constitutes a mental disorder over the years. For example, for many years Asperger Syndrome was defined as a separate category from other autism spectrum disorders (ASD). Now, individuals who were once thought to have Asperger's are simply viewed as being "on the autistic spectrum." Similarly, homosexuality was once classified as a disorder but no longer is, while severe PMS has made its way — controversially — into the DSM. Thus, when the definition of a mental illness does not seem to be effective or to be serving the population it is intended to serve, questioning that definition seems wise.

This should be the case with eating disorders, particularly given the troublesome reputation for treating these conditions. The persistent difficulty in treating them should itself be a red flag regarding the questionable nature of the diagnostic criteria.

Problems with the Anorexia Nervosa Criteria

The word "anorexia" is often colloquially and inaccurately used to describe someone who is very thin or on an extreme diet. According to the DSM-IV and the revised DSM-5, the primary characteristic is "a refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to a maintenance of body weight less than 85% of that expected, or failure to make expected weight gain during a period of growth, leading to body weight less than 85% of that expected)." However, this is immediately problematic because the severity of the disorder is almost completely defined according to the subject's weight.

It is true that an extremely underweight anorexic may be at greater physical risk than a less severely underweight anorexic. But that does not mean that the more underweight sufferer has a more severe mental disturbance. An anorexic who is older, has a slower metabolism, or has less ability to engage in highly restrictive eating and extreme exercise may be less technically underweight than another sufferer but still harbor the same obsessive thinking about weight and body image. An older woman with family obligations may not be able to "get away" with as much restrictive eating or to physically lose as much weight as a teenage girl who plays sports.

This calls for greater emphasis on the second component of the DSM criteria: "intense fear of gaining weight or becoming fat, even though underweight." The fear of gaining weight — more than weight itself — should be emphasized in the treatment of the mental illness. Presumably the phrase "even though underweight" attempts to distinguish between an anorexic and someone who genuinely needs to lose weight. However, the fear and anxiety, more so than the underweight status, would seem to constitute the "mentally ill" component of the disorder. Someone who was technically underweight might be very focused on their weight because they were competing in a sport that required a lower body weight than is typical, yet would still not be willing to compromise their health or to lose weight past a certain point — nor would they exhibit significant fear.

The third criterion for anorexia in the DSM-5 is "disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight." Once again, this is problematic in distinguishing anorexics from the broader population, given that many people — particularly women — appear to place undue emphasis on body weight in terms of self-evaluation. Women who are lawyers, doctors, or otherwise professionally established may question their abilities simply because they are overweight or perceived to be overweight by society, yet they may not display the extreme emaciation deemed characteristic of anorexia. There is also the question of what constitutes a "seriously" low body weight: if an anorexic is medically stable, not extremely emaciated, but still obsessed with weight to the point that it dominates her life, does she still merit a diagnosis? Similarly, does someone who is underweight but balanced in other aspects of life and simply very focused on healthy eating warrant being diagnosed with a mental disorder? Some individuals claim to eat very little for health-related reasons, using caloric restriction or periods of fasting to promote longevity. Regardless of whether this actually accomplishes the intended health objective, should they be characterized as having an eating disorder?

The Menses Criterion and Gender Exclusion

At least the most recent edition of the DSM eliminated the cessation of menses as a criterion for anorexia. This stipulation was obviously extremely problematic, given that it effectively excluded males and older, postmenopausal women from the diagnosis. Moreover, some women continue to menstruate at very low body weights, while others do not menstruate despite having a normal body weight and body fat percentage for entirely unrelated reasons. The excessive focus on this criterion was gender-specific, yet anorexia can occur across all populations. Finally, women taking oral contraceptives will often continue to menstruate for hormonal reasons, regardless of body fat percentage.