The body, the book and the organisation: Towards a post-structuralist understanding of anorexia nervosa and its treatment in a clinical setting

Content and FocusA brief post-structuralist analysis of recent changes to the criteria for anorexia nervosa in the DSM-5 is presented. These changes are examined in the context of the political and social forces described in existing literature. The main idea that emerges from the analysis is that the creation of diagnostic criteria is a value-driven practice which, in the case of anorexia nervosa, encourages a somatic and controlling clinical approach. A clinical example is then used to illustrate how social and therapeutic discourses might affect therapists and clients in an inpatient setting. A tentative formulation of how post-structuralist theory can be applied in a way which considers how therapist and client are positioned by discourses is also advanced.ConclusionIn the context of the changing diagnostic criteria for anorexia nervosa, it is concluded that poststructuralist theory can be applied usefully for therapists and clients in inpatient settings. This necessitates a degree of reflexive practice which may suit counselling psychologists well. Such an application may also fit in with and improve understanding of existing therapeutic approaches rather than simply deconstructing them.

To evaluate (1) the Eating Disorder Not Otherwise Specified (EDNOS) prevalence in an eating disorder inpatient unit; (2) the impact of altering the diagnostic criteria for anorexia nervosa and bulimia nervosa on the prevalence of EDNOS. One hundred and eighty six eating disorder patients consecutively hospitalised were included in the study. The prevalence of anorexia nervosa, bulimia nervosa and EDNOS was evaluated with the Eating Disorder Examination (EDE). The EDNOS prevalence was recalculated after the alteration of three diagnostic criteria for anorexia nervosa and one for bulimia nervosa. Seventy eight patients (41.9%) met the diagnostic criteria for anorexia nervosa, 33 (17.8%) for bulimia nervosa and 75 (40.3%) for EDNOS. The alteration of the DSM-IV diagnostic criteria reduced the prevalence of EDNOS to 28 cases (15%). EDNOS is a very frequent diagnostic category in an inpatient setting. Altering the diagnostic criteria for anorexia nervosa and bulimia nervosa reduced significantly the prevalence of EDNOS.

Eating Disorders

DSM-5 revised the diagnostic criteria for anorexia nervosa (AN) by eliminating the amenorrhea requirement, liberalizing weight and psychological criteria, and adding the formal diagnosis of "atypical AN" for individuals with AN psychological symptoms without low weight. We sought to determine whether bone density (BMD) is impaired in women diagnosed with AN using the new, more liberal, DSM-5 criteria. Cross-sectional study of 168 women, 18 - 45y: (1) AN by DSM-IV (DSM-IV AN) (n = 37), (2) AN by DSM-5 but not DSM-IV criteria (DSM-5 AN) (n = 33), (3) atypical AN (ATYPICAL AN) (n = 77), (4) healthy comparison group (HC) (n = 21). Measurements included dual energy X-ray absorptiometry, Eating Disorder Examination-Questionnaire, Eating Disorder Inventory-2, Hamilton Depression and Anxiety Rating Scales. BMD Z-score <-1.0 was present in 78% of DSM-IV, 82% of DSM-5, and 69% of ATYPICAL. Mean Z-scores were comparably low in DSM-IV and DSM-5, intermediate in ATYPICAL, and highest in HC. Lack of prior low weight or amenorrhea was, but history of overweight/obesity was not, protective against bone loss. Mean lean mass and percent fat mass were significantly lower in all AN groups than HC. DSM-IV, DSM-5, and ATYPICAL had comparable psychopathology. Despite liberalizing diagnostic criteria, many women diagnosed with AN and atypical AN using DSM-5 criteria have low BMD. Presence or history of low weight and/or amenorrhea remain important indications for DXA. Loss of lean mass, in addition to fat mass, is present in all AN groups, and may contribute to low BMD. The deleterious effect of eating disorders on BMD extends beyond those with current low weight and amenorrhea. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2017; 50:343-351).

Amenorrhea is currently a criterion in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., Text rev. [DSM-IV-TR]) for the diagnosis of anorexia nervosa (AN). Recently, there has been increased interest in examining the utility of this criterion. This article reviews the historical rationale for inclusion of amenorrhea in the DSM criteria for AN, clinical evidence evaluating amenorrhea as a diagnostic criterion for AN, and the nursing practice implications of amenorrhea as a diagnostic criterion for AN. Data suggest there is limited support for amenorrhea as a diagnostic criterion for AN. J Am Psychiatr Nurses Assoc, 2008; 14(3), 209-215. DOI: 10.1177/1078390308320288.

This guideline watch reviews new evidence and highlights salient developments since the 2006 publication of APA’s Practice Guideline for the Treatment of Patients With Eating Disorders, 3rd Edition. The authors of this watch constituted the work group that developed the 2006 guideline. We find the guideline to remain substantially correct and current in its recommendations. The sole exception is a recommendation (with moderate-level confidence) for sibutramine for binge-eating disorder. In 2010, the U.S. Food and Drug Administration (FDA) withdrew approval for sibutramine because clinical trials showed increased risk of heart attack and stroke, and the manufacturer, Abbott Laboratories, subsequently withdrew this medication from the U.S. market. Noteworthy recent publications about the treatment of eating disorders include systematic reviews by the Agency for Healthcare Research and Quality (Berkman et al. 2006; Bulik et al. 2007); practice guidelines from international groups, including the Catalan Agency for Health Information, Assessment and Quality (Working Group of the Clinical Practice Guideline for Eating Disorders 2009), the World Federation of Societies of Biological Psychiatry (Aigner et al. 2011), and the German Society of Psychosomatic Medicine and Psychotherapy and the German College for Psychosomatic Medicine (Herpertz et al. 2011); and a 2011 guidance statement by the Academy for Eating Disorders, which was written by some of the authors of this

This article reviews issues with the diagnostic criteria for anorexia nervosa, which is a controversial topic. It discusses how the criteria can be vague and exclude certain populations who can be affected by this eating disorder. After this discussion, some suggestions to improve the diagnostic criteria are made in order to ensure more inclusivity in the diagnosis of anorexia nervosa. This article is meant to provide a new perspective on how the current diagnostic criteria has some limitations which may imply that all the affected individuals who need help are not receiving it. The current criteria is directed towards a very specific subset of the population who lives with anorexia nervosa, and it does not include other subsets who present with different symptoms.

Diagnosing eating disorders -- AN, BN and the others.

Anorexia nervosa (AN) is a psychiatric disorder defined by anthropometric symptoms, such as low body weight, and cognitive-behavioral symptoms, such as restricted eating, fear of weight gain, and distorted body image. Recent studies have identified a genetic association between AN and metabolic/anthropometric factors, including body mass index (BMI). Although the reported associations may be under pleiotropic genetic influences, they may represent independent risk factors for AN. Here we examined the independent contributions of genetic predisposition to low body weight and polygenic risk (PRS) for AN in a clinical population (Vanderbilt University Medical Center biobank, BioVU). We fitted logistic and linear regression models in a retrospective case-control design (123 AN patients, 615 age-matched controls). We replicated the genetic correlations between PRSBMI and AN (p = 1.12 × 10−3, OR = 0.96), but this correlation disappeared when controlling for lowest BMI (p = 0.84, OR = 1.00). Additionally, we performed a phenome-wide association analysis of the PRSAN and found that the associations with metabolic phenotypes were attenuated when controlling for PRSBMI. These findings suggest that the genetic association between BMI and AN may be a consequence of the weight-related diagnostic criteria for AN and that genetically regulated anthropometric traits (like BMI) may be independent of AN psychopathology. If so, individuals with cognitive-behavioral symptomatology suggestive of AN, but with a higher PRSBMI, may be under-diagnosed given current diagnostic criteria. Furthermore, PRSBMI may serve as an independent risk factor for weight loss and weight gain during recovery.

BackgroundAnorexia nervosa is an eating disorder characterized by a distorted self-image, an intense desire for weight loss, anxiety, and strict dieting. The disorder primarily affects children, adolescents, and young adults. It leads to serious health consequences and increases the risk of depression, suicidal thoughts, and addiction. The causes of the disorder are multifactorial, including genetic influences, social pressures, and emotional problems. Eating disorders are now considered a serious public health problem that requires special supervision by specialists and the development of long-term measures to reduce their incidence.ObjectiveThe objectives of the study were to determine the prevalence of anorexia nervosa among school adolescents aged 15–19; to determine the relationship between the prevalence of anorexia nervosa and the severity of school stress, the severity of family stress, the use of psychoactive substances, and the occurrence of auto-aggressive and self-destructive behavior.Materials and methodsThe group of respondents consisted of individuals aged 15 to 19 years (secondary school students). The study utilized a diagnostic interview method, along with an additional questionnaire. The author’s survey questionnaire was developed based on the diagnostic criteria for anorexia nervosa in the International Classification of Diseases, 11th Revision and Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, as well as information from scientific sources regarding stressors and auto-aggressive and self-destructive behaviors. In the statistical analysis, a significance level of α = 0.05 was adopted.ResultsThe diagnostic criteria for anorexia nervosa were met by 13.3% of respondents. 37.1% of respondents admitted to engaging in self-injurious behavior, and 13.9% reported having suicidal thoughts. The greatest risk factors for developing anorexia nervosa were female gender, high maternal education, and high levels of physical activity.ConclusionIndividuals who could be diagnosed with anorexia nervosa experienced higher levels of school stress and a greater sense of family stress compared to those who did not meet the diagnostic criteria for the disorder. Auto-aggressive and self-destructive behaviors were much more common among those with a possible diagnosis of anorexia nervosa than among those who did not meet the criteria for the disorder.

The literature often describes medical complications that are a result of the malnutrition and weight loss that define anorexia nervosa. The comorbidity of anorexia nervosa with other independent medical disorders associated with weight loss is unusual. Case reports have described anorexia nervosa coincident with, for example, lymphocytic leukemia (1), chronic pancreatitis (2), celiac disease (3), and cerebral meningioma (4). In the present report we describe the case of a young man who met diagnostic criteria for anorexia nervosa and gastrointestinal stromal tumors. This case presentation emphasizes the importance of making a diagnosis based on positive criteria. Distinguishing features of the two disorders are highlighted in the process of differential diagnosis. Treatment decisions and relapse issues are presented for both conditions. The patient is given the name Alex in this report to protect his identity.

Treatment of Eating Disorders in Children, Adolescents, and Young Adults

Optimizing bone health in anorexia nervosa and hypothalamic amenorrhea: new trials and tribulations

Despite evidence from a number of long-term follow-up studies of anorexia nervosa that nearly 50% of patients eventually make a full recovery, controlled trials of psychotherapy for anorexia nervosa are lacking. Those with severe and enduring problems represent a considerable therapeutic challenge. Thirty-four consecutive adult referrals to the inpatient treatment unit who fulfilled Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnostic criteria for anorexia nervosa were examined pre-admission, post-discharge and 4 years after admission. Characteristics of remitted and non-remitted patients were examined. Secondary analyses considered the differences between patients with anorexia nervosa, restricting type and anorexia nervosa binging/purging type. The findings highlight a number of differences between patients with anorexia nervosa (restricting type) versus anorexia nervosa (binging/purging type) as well as remitted versus non-remitted patients. The use of a comprehensive battery of assessments found that resolution of eating disorder symptomatology was paralleled by improvements in emotional and psychological distress and improvement in body image perception and coping skills. Better results were obtained for those who had continuity of care on an outpatient basis. This pattern is particularly significant given the more 'chronic' nature of the sample that were older, with a higher incidence of binge-eating and purging than previous samples. Results provide some encouragement for the treatment of those adults with anorexia nervosa who typically have less favourable outcomes.

Few studies have examined the characteristics of atypical restrictive anorexia nervosa (AN) with a well-powered design. The study aims to explore this issue, with particular attention paid to psychopathology and response to outpatient treatment. The sample consists of 365 participants with restrictive AN and 204 with atypical AN. Three types of atypical AN were included: subthreshold (all the criteria except weight); partial (AN without amenorrhea); and participants with AN without fear of gaining weight. Participants with AN without fear of weight gain reported the lowest lifetime BMI and subthreshold AN the highest. Participant with partial AN reported the highest levels of psychiatric symptoms and novelty seeking. All types of atypical AN showed high rates of dropout, whereas participants with subthreshold AN showed the highest level of full remission after treatment. Before considering a revision of the diagnostic criteria of AN, further studies on adequately large samples are needed.