Categories
Eating Disorders

Hiding in the Shadows: The “Other” Eating Disorders

Anorexia nervosa, bulimia nervosa, binge eating disorder: the three most well-known eating disorders. Avoidant/restrictive food intake disorder, pica,  rumination disorder: the less commonly known but still discussed eating disorders. Regardless of how well-known an eating disorder is, the psychological distress that stems from a distorted relationship with food can be severely impairing.

In addition, these eating disorders have been formally identified by the American Psychiatric Association’s fifth edition of the Diagnostic and Statistic Manual of Mental Disorders (DSM-V), which means that people who have eating disorders can be clinically diagnosed based on a set of criteria. The webpage to the manual even states that “diagnostic criteria are provided for pica, rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, and binge-eating disorder.” What about the “other” eating disorders, the unidentified, unknown eating disorders that hide in the shadows of clinically diagnosable ones. What are they?

People who have disordered relationships with food are often grouped together in an obscure category of eating disorders called “other specified feeding or eating disorder” (OSFED). Formerly known as “eating disorder otherwise not specified” (EDNOS), OSFED is the broadest category of eating disorders that, according to the DSM-V, includes atypical anorexia nervosa, bulimia nervosa of low frequency and/or limited duration, binge-eating disorder of low frequency and/or limited duration, purging disorder, and night eating syndrome (American Psychiatric Association, 2013). Some of these OSFED eating disorders appear to be better known because they contain the words “anorexia,” “bulimia,” “binge-eating,” and “purging,” but why are they classified under OSFED?

Based on other information provided by the DSM-V, the category “applies to presentations in which symptoms characteristic of a feeding and eating disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the feeding and eating disorders diagnostic class” (American Psychiatric Association, 2013). For this reason, OSFED is the most common diagnosis given to individuals. However, individuals seeking help and not knowing what they need to get better may get frustrated with being labeled as “other.”

According to multiple scholarly sources, OSFED comprises from forty to sixty percent of treatment-seekers at eating disorder specialty clinics, with OSFED prevalence of up to ninety percent in non-specialty settings (Rockert, Kaplan, & Olmsted, 2007; Fairburn et al., 2007; Zimmerman, Francione-Witt, Chelminski, Young, & Tortolani, 2008). One prevalence study showed that seventy-five percent of young women received OSFED diagnoses. OSFED also touches upon men, ethnic minority groups, athletes, children and adolescents, and the elderly (Thomas, Vartanian, & Brownell, 2009). Based on these extensive studies, the OSFED category continues to be too broad for use as a diagnostic criterion in each individual case.

To ameliorate some of the concerns associated with grouping individuals under OSFED, a group of researchers and clinicians characterized a large sample of adult outpatients diagnosed in the “other” category (Rockert, Kaplan, & Olmsted, 2007). They classified individuals into six subtypes (i.e., anorexia nervosa (AN) restricting, AN binge-purge, bulimia nervosa (BN) purging, BN non-purging, normal-weight restrictors, and subthreshold AN, BN, and BED) to specify the experiences of these participating individuals. What they found was that of 1,449 participants, forty percent were classified under OSFED, and that the percentage of patients who meet the full criteria of DSM-V feeding and eating disorders was greater than that reported in other literature in outpatient community settings (Rockert, Kaplan, & Olmsted). For instance, the most frequent subtypes were reported to be normal-weight restrictors, patients who purged in the absence of binge-eating, and patients with subthreshold BN, which accounted for seventy-five percent of the OSFED group (Rockert, Kaplan, & Olmsted).

Another research group (Sysko & Walsh 2011) conducted 267 telephone interviews between April and December 2009 using the Broad Categories for the Diagnosis of Eating Disorders (BCD-ED) criteria scheme. The group found that 247 of the individuals met criteria for an eating disorder, particular 97 individuals who were classified to have OSFED (i.e., 39.3% of the interview participants had an OSFED diagnosis), and 97.6% of the OSFED-diagnosed individuals were reclassified under this scheme. If reclassification has proven to successfully guide individuals with OSFED into treatment, therapy, and recovery more appropriate for them, then what about the remaining 2.4% of individuals who never get reclassified?

According to the National Eating Disorders Collaboration website, the most effective way to help individuals who had not had their eating disorder reclassified is by following the treatments for the disorder that most closely resembles the individual’s symptoms. For example, if a person presents with many of the symptoms of anorexia nervosa, that person will be recommended to seek the same or similar treatment approaches. Some of the most popular treatments include psychotherapy (CAT, CBT, DBT), family therapy (support, intervention, and education), self-help, nutrition management (via dietitian or nutritionist to adopt optimal lifestyle modifications), and medication (vital especially in cases of comorbid disorders or illnesses, e.g., depression). These are tried-and-true therapies that work best in concert with each other, and when offered to individuals with OSFED, can benefit their symptoms and experiences.

For individuals with OSFED who can be re-diagnosed for more well-known eating disorders, the treatment and recovery options may be more available within their reach. For those who remain under the OSFED diagnosis, the most optimal approach to treatment and recovery would be to individualize treatment based on the services described above. Being diagnosed with an unknown eating disorder may be daunting, especially when the disorder is unknown to its fullest extent, but the more aware we become about these unknown eating disorders, the more awareness we can spread to help those in need of finding answers for themselves.

References:

American Psychiatric Association. (2013). Feeding and Eating Disorders. Other Specified Feeding or Eating Disorders. http://dx.doi.org/10.1176/appi.books.9780890425596.dsm10

Machado, P. P. P., Machado, B. C., Gonçalves, S., & Hoek, H. W. (2007). The prevalence of eating disorders not otherwise specified. International Journal of Eating Disorders, 40(3), 212–217. https://doi.org/10.1002/eat.20358

National Eating Disorders Collaboration. (2016). Treatment approaches. Retrieved from http://www.nedc.com.au/treatment-approaches. Accessed 27 April, 2017.

Rockert, W., Kaplan, A. S., & Olmsted, M. P. (2007). Eating disorder not otherwise specified: The view from a tertiary care treatment center. International Journal of Eating Disorders, 40(S3), S99–S103. https://doi.org/10.1002/eat.20482

Sysko, R., & Walsh, B. T. (2011). Does the broad categories for the diagnosis of eating disorders (BCD-ED) scheme reduce the frequency of eating disorder not otherwise specified? International Journal of Eating Disorders, 44(7), 625–629. https://doi.org/10.1002/eat.20860

Thomas, J. J., Vartanian, L. R., & Brownell, K. D. (2009). The relationship between eating disorder not otherwise specified (EDNOS) and officially recognized eating disorders: meta-analysis and implications for DSM. Psychological Bulletin VO  – 135, (3), 407.

Categories
Eating Disorders

Elephant in the Room: There Are More Than Three

You are sitting in a room filled with people. Your next door neighbor Kevin, best friend Melissa, and your cousins from down South even decided to stop by. Everyone is playing a friendly game of Taboo until your mother calls everyone in for dinner in the next room over. You are the last one to go in because you do not want anyone to know. You are afraid that everyone, even Melissa, will never look at you the same way again.

Because you do not eat at all. Not because you cannot, but because you will not. And if you do, you might eat more than you can control. Not because you want to, but because you cannot stop once it is happening. You are inherently afraid of the elephant always lurking behind you. Why introduce it into the room now, at the dinner table, when everyone is enjoying their meals? Sometimes the elephant unexpectedly introduces itself, mostly because your frame has become thin enough for the elephant to extend itself. Or maybe, your frame has stayed the same, and the elephant has stayed alongside to accompany you.

Telling friends and family about a constant struggle with food is not an easy topic of discussion, but many people realize that a support system exists for their distressed relationship with eating; however, several other people are still left behind tumbling in the dust, stranded away from guidance or intervention. As a society, I think time has come for the elephant in the room to be identified.

Anorexia nervosa, bulimia nervosa, and binge eating disorder are the three elephants in the room that have been discussed and addressed extensively, but there exists a bigger elephant in the room than you might think. While all three are serious disorders, many others on the wide spectrum of eating disorders are not being given the attention they deserve. The media covers mainly anorexia, followed by bulimia and then binge eating disorder; however, according to the 2008-2012 Mental Health Surveillance Study conducted by the Center for Behavioral Health Statistics and Quality, anorexia is less common than bulimia and binge eating disorder in individuals aged 18 and over, occurring in less than 0.1% of the adult population.

An article published by Smink and Hoeken (2012) in the peer-reviewed medical journal known as Current Psychiatric Reports revealed that when younger women aged 15-19 years are included in the data and statistical analysis, the “lifetime prevalence of anorexia increases to 0.9 percent of women in the population…” and “…0.3 percent of men exhibit the disorder at some point in their lives.” Smink and Hoeken (2012) also suggested that the prevalence rates of anorexia, bulimia, and binge eating disorder are 1.2%, 1.6%, and 5.7%, respectively, in the population aged 15 and older.

Unlike many eating disorders studies, this study also included a comprehensive meta-analysis of 125 other studies to collect the epidemiological data of all eating disorders, and found that eating disorder not otherwise specified (EDNOS), which has most recently been termed other specified eating or feeding disorder (OSFED), had the highest population prevalence and is associated with psychological and physiological risks comparable to specified eating disorders, such as anorexia, bulimia, and binge eating disorder. While this group of researchers’ goal was to reduce the size of the EDNOS/OSFED category, what about the rest? You may not have even known they existed.

“Sweetheart, eat your peas, Al. They are not going to eat themselves.” This theoretical exchange between a mother and her “picky” child Al is not enough to represent avoidant/restrictive food intake disorder (ARFID), when a person is conflicted by food or foods, resulting in inadequate nutrition (“Avoidant/Restrictive Food Intake Disorder,” 2013). What Al’s mother does not know is that he is choosing not to eat the peas because he fears eating green-colored foods in the shape of spheres. Two doors down from Al’s house, Jane takes her plate of dinner to her room to “eat,” but what her family does not know is that she goes to the backyard and empties her plate into the trash can, pretending she ate everything. The truth? She is afraid of eating any food as a result of her growing fear of vomiting or choking.

“Teacher, Tim is chewing on his pencil again.” This theoretical situation in which a young student alerts her teacher about her classmate’s “weird” habit of eating the wood of pencils may be an understatement of pica, an eating disorder usually defined by a persistent ingestion of non-nutritive substances (e.g. rocks, wood, or even glass) “for at least one month at an age for which this behavior is developmentally inappropriate” (“Pica,” 2013). Consuming these substances over the course of a long period of time can potentially cause unwarranted physiological consequences (e.g. digestive issues), and especially in individuals who have autism spectrum disorder or schizophrenia where pica can manifest itself more seriously.

“Just a midnight snack, that’s all.” Meanwhile, Charlie consistently does not feel hungry until the very peak of the night around 4 A.M., which may be the result of night eating syndrome (NES) disorder characterized by a “delayed circadian pattern of food intake” (“Other Specified Eating or Feeding Disorders,” 2013). Charlie may be consuming a lot of food during unusual times of the evening or night, which is typically uncontrollable and causes individuals to become physically and mentally distressed by both the disturbed sleep cycle episodes of late-night feeding.

Before reading this article, you may have known about only three of the six, seven, or eight plus eating disorders that have been officially recognized on the spectrum of eating disorders. When people think eating disorders they usually assume a discussion of anorexia or bulimia, and sometimes acknowledge binge eating. By introducing EDNOS/OFSED, ARFID, pica, and NES into the playing field we can begin to understand that eating disorders can affect anyone and in a multitude of ways, and not necessarily the ways in which we have been taught in school and the media to accept.

With the elephant in the room that there are more than three, we need to create a society that is open to discussion about and accepting of these many other disordered relationships with eating. The elephant that was once invisible is now ready to be painted with perspective about these once hidden, invisible eating disorders.

References:

American Psychiatric Association. (2013). Feeding and Eating Disorders. Avoidant/Restrictive Intake Disorder. http://dx.doi.org/10.1176/appi.books.9780890425596.dsm10

American Psychiatric Association. (2013). Feeding and Eating Disorders. Other Specified Eating or Feeding Disorders. http://dx.doi.org/10.1176/appi.books.9780890425596.dsm10

American Psychiatric Association. (2013). Feeding and Eating Disorders. Pica. http://dx.doi.org/10.1176/appi.books.9780890425596.dsm10

Karg, R.S., Jonaki, B., Batts, K.R., Forman-Hoffman, V.L., Liao D., Hirsch E., Pemberton, M.R., Colpe, L.J., & Hedden S.L. (2014). Past Year Mental Disorders Among Adults in the United States: Results from the 2008–2012 Mental Health Surveillance Study. CBHSQ Data Review.

Smink, F. R. E., van Hoeken, D., & Hoek, H. W. (2012). Epidemiology of Eating Disorders: Incidence, Prevalence and Mortality Rates. Current Psychiatry Reports, 14(4), 406–414.

Categories
Eating Disorders

A Victim of Anorexia: How to Tell

As outlined by DSM-5 guidelines, anorexia nervosa includes restrictive energy intake even lower than daily requirements, extreme fear of gaining weight or becoming fat, and denial of increasingly lower body weight. What does a victim of anorexia look like and how can you tell?

Easy. Look at what is on magazine covers, television screens, and fashion runways: a severely underweight, starving young woman.What is more shocking is that over 1 million women in the United States suffer from anorexia in their lifetime, with 1 in 5 anorexia deaths resulting from suicide (Arcelus et al. 2011; Hudson et al. 2007). While database statistics can better represent an affected population, popular media continues to emphasize that most people who suffer from anorexia are women, women who are young, white, and middle-to-upper class. Elders, minority groups, men, gender non-conforming, the poor–all silently suffering, and current statistics are not enough to emphasize the prevalence of anorexia in these subgroups of society.

Still trying to figure out how to tell if someone is a victim of anorexia? In a world domineered by Western culture, the face is a young white woman. A mere Google search shows you almost nothing else. If other subgroups are affected by this mental disorder, why are we only beaming our eyes towards one angle and averting all other angles?

Media. One of the most influential powers of Western society, media comes in a variety of flavors, from television to Internet to the radio. In between all the sitcoms, news, and movies, commercials can subliminally speak to our hidden insecurities and inner fears, particularly those that target women’s physical appearance. What we do not realize is that others that are not directly targeted are also deeply affected.

TJ’s “nine-year nightmare” ended at the age of 22, when he died in the middle of doing sit-ups. The 2015 tragedy flooded news stations and circulated on the Internet, claiming that he was the “New Face of Anorexia.” TJ, a young white college-student with excellent grades, dreams, and manners did not “want to be skinny. He wanted to have muscles. He wanted to have a six-pack, like the health magazine covers that he had, about 100 of those under his bed. He wanted to be quicker and faster and stronger, and look good,” his mother, Susan, explained. People might be quick to blame Susan for her lack of intervention, but she did monitor him for years until he went off to college. He began lying to her because he was afraid of showing weakness or worry and giving up on his goal. TJ’s demise can be perfectly attributed to the influence of media, those magazines eventually convincing him that he had to be muscular and thin or that he would not be considered a man.

On the other hand, Ahani Ortega, a 25-year-old Latina woman, had found herself trapped in the shadows of the “white anorexia.” Ortega shares with us that as part of her traditional Mexican lifestyle, her family would only eat two meals a day, and skipping meals was even easier at her California high school because no one was watching. Her anorexia escalated into self-harm and bulimia, and at the age of 15, she was hospitalized for overdosing on diet pills and nearly suffering a stroke. She began group therapy, but she was the only Latina “in a room full of white girls.” Her group therapy failed, and her doctors then diagnosed her with EDNOS (eating disorder not otherwise specified) because she did not meet the standards for anorexia, bulimia, or binge eating disorder. Surprisingly, EDNOS is the most common diagnosis in Latina women because like Ortega, many are not focused maintaining “the perfect thin,” defined as curvy, but not too much; thus, because anorexia’s diagnostic requirement is a “preoccupation with thinness,” she fell away from the possibility of receiving the treatment appropriate for her.

Darcy, too, found herself battling with anorexia after her husband died. She stopped eating, dropped fifty pounds, and, one day, the 66-year-old widow living in an “active retirement community” found herself hospitalized after a fainting spell on the golf course. The events leading up to her collapse were a mix of her depression, other women complimenting her on her figure the more weight she lost, and her own desire to lose her “chubby belly,” although she was a 5-foot-5, 90-pound woman. Who was telling her that she was “chubby,” and who knew that she was no longer eating?

More advertisements portray what young white women should represent, but nobody talks about TJ’s starving himself to death, Anahi’s misdiagnosis because she is Latina, or Darcy’s mid-life struggle with her husband’s sudden passing. Nobody talks because the facts are wrong. Most statistics we have are recorded based on self-reported questionnaires, with questions that target specific populations and create the young white woman bias we see (Streigel-Moore and Franko, 2003).

Given what I have discussed in previous other articles I have published about eating disorders, you can recognize that the experiences of eating disorders are spectral and range from one extreme to the other. To solve part of the bias portrayed in the media, Favaro et al. 2004 suggests to conduct personal interviews across several communities; furthermore, population-based data are needed to ascertain the prevalence in not only anorexia nervosa, but also bulimia nervosa and binge eating disorder (Favaro et al. 2004). From these interviews, we will be better able to assort the data on age-of-onset, duration of the illness, and association with sociodemographic factors (e.g. race, gender, class).

Note that many of the sources in this article date back to approximately ten or more years ago, which demonstrates the evident knowledge gap in anorexia prevalence, pathology, and treatment. On the greener side of research, data analyzed from the National Comorbidity Survey Replication (NCS-R) by Hudson et al. 2007 identifies a wider range of factors to consider, such as the association of anorexia with other mental disorders, the degree of disability, and the history of mental health treatment (Hudson et al. 2007). Other work contributed to the National Institutes of Mental Health (NIMH) reveals that researchers have found that, on the whole, eating disorders are caused by “a complex interaction of genetic, biological, behavioral, psychological, and social factors.” Just from these studies alone, we can start to understand that anorexia does not look the same for every person who lives with the illness.

We like to think that we know the in’s and out’s of anorexia, but we only know what anorexia should look like because the media tells us what to believe. As serious as anorexia nervosa is, a black cloud of social issues still hovers over the mental disorder. Media portrayal of positive body image, self-love and acceptance, and mental health wellness and awareness can lead to profound changes in how we view others and ourselves. TJ, Ahani, and Darcy did not get the help they needed when they were most vulnerable, all because they were not young white women, but emphasizing the level of destruction that a disorder such as anorexia can sustain on an individual can aid in the advocacy of urgent intervention, treatment, and management.

As Gayle Brooks, vice president and chief clinical officer of the Renfrew Center, the country’s first residential treatment facility for eating disorders, says, “When eating disorders were first being recognized, people seeking treatment were young white girls, so the belief developed early that nobody else suffers from them. When that became the core of our understanding, we stopped looking at diversity being an issue. We missed a lot.”

If you or someone you know is struggling with an eating disorder, the National Eating Disorders Association has useful information and resources. Do not hesitate to get help.

References:

American Psychiatric Association. (2013). Feeding and Eating Disorders. Retrieved from http://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425596.dsm10

Arcelus J, Mitchell AJ, Wales J, Nielsen S. (2011). Mortality Rates in Patients With Anorexia Nervosa and Other Eating Disorders: A Meta-analysis of 36 Studies. Arch Gen Psychiatry, 68(7):724-731.doi:10.1001/archgenpsychiatry.2011.74

Cartwright, Martina M. (2013). Does Grandma Have an Eating Disorder? Psychology Today. Retrieved from https://www.psychologytoday.com/blog/food-thought/201310/does-grandma-have-eating-disorder

Favaro A, Ferrara S, Santonastaso P. (2004). The Spectrum of Eating Disorders in Young Women: A Prevalence Study in a General Population Sample. Psychosom Med, (65):701–708.

George, J. B. E., & Franko, D. L. (2010). Cultural Issues in Eating Pathology and Body Image Among Children and Adolescents. Journal of Pediatric Psychology, 35(3), 231-242. doi: 10.1093/jpepsy/jsp064

Hudson, J. I., Hiripi, E., Pope, H. G., & Kessler, R. C. (2007). The Prevalence and Correlates of Eating Disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 61(3), 348–358. http://doi.org/10.1016/j.biopsych.2006.03.040

Kloepfer, Chivon. (2015). Friends for Life: Nine-Year Nightmare. WLNS 6 News. Retrieved from http://wlns.com/2015/11/23/friends-for-life-nine-year-nightmare/

Konstantinovsky, Michelle. (2014). Eating Disorders Do Not Discriminate. Slate. Retrieved from http://www.slate.com/articles/double_x/doublex/2014/03/eating_disorders_and_women_of_color_anorexia_and_bulimia_are_not_just_white.html

National Association of Anorexia Nervosa and Associated Disorders. (2016). Eating Disorder Statistics. Retrieved from http://www.anad.org/get-information/about-eating-disorders/eating-disorders-statistics/

National Institutes of Mental Health. (2016). Eating Disorders. Retrieved from https://www.nimh.nih.gov/health/topics/eating-disorders/index.shtml