The Dangerous Downside to the DSM-IV

For many who suffer from deadly eating disorders, the Diagnostic Standards Manual (DSM-IV) has become a bible of sorts.

Let me explain.

The DSM-IV is the official diagnostic tool that standardizes how to diagnose and address certain sets of symptoms for healthcare professionals the world over. So, for instance, if you are diagnosed with anorexia nervosa in Nevada, but then travel to Singapore, the healthcare professionals in Singapore will be able to reference your diagnosis and treat you appropriately. And if you then travel on to Canada, the healthcare professionals there will be able to take up where your Singapore team left off.

This is the upside to the DSM-IV.

However, as I write this post, the DSM-IV is once again undergoing scrutiny and tremendous revision, and a new version is anticipated by May 2012. While revision to the DSM is normal and does happen every so often when new information becomes available and our knowledge of mental illness increases, for those of us with eating disorders, and those of us who treat eating disorders, the revisions simply cannot come fast enough.

If you have an eating disorder, or suspect you have an eating disorder, you are likely all too familiar already with the stringent diagnostic criteria the DSM-IV outlines to categorize the severity of your illness and the impact it is likely to have on your overall health and wellbeing. For instance, a diagnosis of anorexia nervosa comes only when the individual can meet the following criteria:

Refusal to maintain body weight at or above a minimally normal weight for age and height (weight drops beneath 85% of ideal or fails to achieve expected body weight for age and growth rate)
Intense fear of gaining weight or becoming fat, even though underweight
Undue influence of body weight or shape on self-evaluation or denial of the seriousness of the current low body weight
Amenorrhea (the absence of at least three consecutive cycles), with periods reappearing only with hormone administration

From the very first bullet point we can see where the problems begin. Insurance companies look to the DSM-IV to determine whether they are required to pay for care, and how much care they must pay for. Doctors cannot provide care (for the most part) without the promise of reimbursement, and they frequently must rely on insurance coverage for that reimbursement. So an individual suffering from restricting-type disordered eating is literally forced to lose 15% of his or her body weight before being eligible for care! Furthermore, it is very common for individuals suffering from restricting-type to label themselves as “not sick enough” to even reach out for help or support until they can meet all four of these diagnostic criteria.

After my own eight-year battle against an eating disorder and almost two decades treating individuals for disordered eating and eating disorders, I can assert with utmost authority that eating disorders come in all shapes and sizes, and that eating disorders can be deadly at any stage of illness…and the dangerous downside to the DSM-IV is that current standards do not reflect that*.

I will give you just one final example to prove my point. The DSM-IV currently lists the following criteria as a prerequisite for a medical diagnosis of bulimia nervosa:

Recurrent episodes of binge eating: Eating, within any 2-hour period, an amount of food that is definitely larger than most people would eat under similar circumstances; A sense of lack of control over eating during the episode; Inappropriate compensatory behavior in order to prevent weight gain (vomiting, laxatives, diuretics, enemas, fasting, excessive exercise, etc.)
The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months
Self-evaluation is unduly influenced by body shape and weight
The disturbance does not occur exclusively during episodes of anorexia

Yet there have been documented instances of death due to cardiac arrest after only three purge incidents. The DSM-IV criteria gives individuals who suffer from purging – and their insurance companies – free rein to assume that they are not in need of critical care until they have been purging at least twice a week for 3 months.

Some individuals who suffer won’t make it that long.

If you are suffering from any level of disordered eating, if food has taken a place in your life beyond simply giving your body the nutrition it needs to function, if you feel trapped or imprisoned by your food-related thoughts and behaviors, and if you know, deep down on the inside where no one else but you can see or hear that you are struggling regardless of what the DSM-IV criteria are, then you need to get help.

You deserve help. Life is too short to live with an eating disorder as your constant companion. And life is too precious to lose it to an eating disorder when help and hope is available.

Here at The Southlake Center, we know what it feels like to live through an eating disorder. We know how dangerous eating disorders are, and how deadly they can be. If you will let us, we can help you say a permanent “no” to your eating disorder, and say YES to your own unique and precious life!

Be Well.


* There is a diagnostic category in the DSM-IV called “eating disorders not otherwise specified (EDNOS)” that allows for less severe symptoms that do not fit into the three major categories of eating disorders (anorexia, bulimia, binge-eating disorder). However, many insurance companies have been slow to recognize this category and incorporate it into coverage provided to policy-holders.

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