ED Hierarchy Followup

Thank you guys so much for your thoughtful comments! I really encourage everyone to o back and read the comments there. Some super important facts and relevant opinions. You all brought up really important points, so here's some additional notes to the last post.

Kafi is correct in pointing out this important detail: my post only is relevant in the United States and places where the DSM is used for diagnosis. Other countries use the ICD. Eating disorders fall under the category of "Mental and behavioural disorders (F00-F99 - Behavioural syndromes associated with physiological disturbances and physical factors (F50-F59)", but that's about all I know. I'll have to look into it more. (Taking a glance, yes, Atypical Anorexia and Bulimia are both present there. It seems like BN can only be diagnosed with weightloss, otherwise it's Atypical? That's really interesting.)

FYI, here is the ICD section on eating disorders: click here to view.

I mention that a number of decisions are left up to the doctor's discretion. As DisenchantED suggests, one reason a person might receive an AN-II as opposed to a dual AN/BP diagnosis involves the individual's "drives" behind the disorders. I've often wondered about this, personally, because it seems like there are two different kinds of "Bulimics" to me, based on personality and function. Definitely something they need to keep working on.

As Tempest said, "I think the bottom line is that no Eating Disorder Name will sum up how much the disorder is affecting your mental OR physical health." Here here!

She continues, "The BMI cutoff is completely arbitrary, as the DSM provides no guideline for what they consider minimally acceptable weight." From what I have read in studies and thesis and such, there is an important and significant difference between the individuals with EDs who can (and therefore do) lose significant weight, and those who do not. Not simply that severe weightloss causes some specific health problems, but that there is some commonality of brain structure within the two groups. I think that brain structure is important to study. But the BMI is a poor substitute to represent whatever "that" is. (And obviously, referring back to your first sentence, weightloss is completely irrelevant to the severity of mental and physical health. You can be both obese and malnourished, for example.)

(A personal note on brain structure versus ED diagnosis: I have always had much more in common with the stereotypical anorexic personality (shy, nervous, harm-avoiding) than the stereotypical bulimic personality (outgoing, impulsive). I confess to EXTREME JEALOUSY when I read the blogs of 70-pound anorexics who sound exactly like me.)

"I think EDNOS, both in the medical and everyday communities, is seen as less severe than AN or BN, which is a load of crap." Indeed. In fact, empirical studies have shown that EDNOS is actually MORE DEADLY than just a primary BN diagnosis!

"Most people in the "pro-ana" and virtual eating disorder community do not have clinically diagnosable anorexia nervosa. I've always known that, and I don't think it matters." I agree wholeheartedly with this.

Miranda points out that I totally forgot to address the "loss of period" issue, because I'm a dope. Yeah, amenorrhea is one of the official criteria. I am under the impression that because "everyone knows" it is a completely shitty indicator of AN that doctors pretty much ignore it as a criteria. This probably depends on the doctor, of course. The criteria is being removed in the DSM-V. (Personally, I sometimes miss my periods during months of severe bulimia, but have never lost it due to just restricting. Part of that is because I'm on the pill. It does get very light, though.)

Posie points out one of the most important things which I totally didn't make clear. There is nothing wrong with self-diagnosing as long as you are both well-informed and reasonable about it. If you've starved yourself to 80 pounds, it's pretty damn reasonable to say you're anorexic, even without an "official" diagnosis. The last time I went to the docs I got an EDNOS Dx, but considering the fact that I binge/pure almost every fucking day, I'd say it's reasonable to say I'm bulimic. If you believe you have an eating disorder, you shoul.d find out as much information about it as possible. I don't want to sound like I'm insulting or not including self-diagnosed people, or calling them liars or wanas or fakes. You don't have to have a doctor's say-so to have a legitimate eating disorder!

Finally, and related to self-diagnosis, I want to reiterate one point: even if you have the behaviors of disordered eating, it does not mean you have an eating disorder, even if it seems like you do. This is the trouble with using criteria-based differential diagnosis, and I hope one day they have a brain-scan style test or whatever to make exact specific diagnoses. Sometimes people who have a lot of bullshit going on in their lives will turn to unhealthy means of dealing with it. Like say

With almost any other topic I would say this is a "forest vs trees" situation. For example, I've been diagnosed with Rheumatoid Arthritis, but I really think I have Lupus because it runs in the family. Both are non-specific disorders which are just diagnosed when other possibilities have been eliminated. But in reality, it doesn't fucking matter whether I have RA or SLE, because the treatment plan is the same: find the proper medication to remove symptoms and halt damage progression. There are no "cures" for RA or SLE.

And Eating Disorders, and other biologically-based mental disorders, are the exact same way. There is no "cure", no permanent removal of these disorders. There is only managing the symptoms to stop future damage, and healing some of the damage that has already been inflicted. That's the only reason a diagnosis is important, to decide what is the proper method of treatment. That's why certain medications and therapies don't seem to do diddlyshit in treating eating disorders, because they're for treating other things.

I personally would not be surprised to find out that the treatment for various clusters of EDs are all the same and that the specific behaviors and symptoms are relevant only to properly categorize people and irrelevant to treatment.

If they asked me (lol) I would make three groups:

An EDNOS-like category of people who deal with their emotional, self-esteem, and trauma issues through food-related behaviors, such as compulsive eating or crash dieting. These are currently "disordered-eating but not eating disordered" people. Their treatment would be based on talk-therapy, DBT, CBT, and whatever else they currently use to treat PTSD or addictions. They would get emotional support and validation, self-esteem and self-identity strengthening, and practical learning to refocus unhealthy behaviors towards healthy ones.

A group for the "implusive" type EDs, certain types binge-eaters and bulimics, those eating disordered people whose disorders seem to take over their brains inexplicably and cause them to do dangerous impulsive behavior. They may want to lose weight and tie in their body-issues to their EDs but the main focus is loss-of-control. They would receive a combo of chemical and behavioral therapy - I think it would be very similar to the treatments for either OCD or Borderline, which combine anxiety/mood stabilization (usually with meds) and therapies which emphasize mindfulness, emotion recognition and acceptance, and practice redirecting behaviors.

A group for the "obsessive" type EDs, the anorexics and bulimics and purgers and exercisers, etc, who have the overwhelming need to control their weight and eating, and have impaired ability in self-viewing similar to Body Dysmorphia. I think it's pretty clear from studies that this group is different than the above, something to do with their neuroticism and lack of self-insight. I don't think talk or behavioral therapy does sweetfuckall for this group (although they may need it for comorbid problems or post-damage healing) and that biological treatments are necessary.

All three groups can get obsessional about their weights and diets, yes, and all three groups use their eating disorders to regulate their emotions. But I think the "origins" for each group are different - or perhaps it's just that the brain structures for each group are different, and so they're all reacting differently to the triggered disorder. I don't know. I still think I'm right, though. (Oh, ego, lol.)


Quick personal update: bulimia has been suddenly bad again, laxatives are too reactive to work right, and I can't get properly empty enough for an accurate weight measurement. It's generally around 110 to 113, full of fluids and post-purging bloat and food from the last X days. Frustrating. Also, I'm thinking of ditching the term "pro-ana" again, but I'll stow that explanation for another post.


I'd love to hear everyone's opinion on my new ED category proposal!