- Email: [email protected]
Classification of the eating disorders
0022.3956185 13.00+ .OO Pcrgamon Press Ltd.
J psychrsr. Res.. Vol. 19, No. Z/3. pp. 113-119. 1985 Primed m Great Brxan
CLASSIFICATION OF THE EATING DISORDERS KATHERINE A. HALMI CornellUniversity MedicalCollege,NewYork ANOREXIA
nervosa and bulimia nervosa are appetitive behavioral disorders that have been studied comprehensively and with systematic methodologies only in the last 20 years. In the past decade an explosion of investigations of the eating disorders has produced epidemiological, clinical and physiological information necessary for devising a classification of the eating disorders. These eating behavior conditions are entities and not diseases with a common cause, common course, and a common pathology. The eating disorders are best conceptualized as syndromes and therefore must be classified on the basis of the cluster of symptoms that are present. Schizophrenia is another example of a behavioral syndrome. It is important to remember that the final outcome of a classification represents an arbitrary procedure even though research data are used to formulate the classification. The most useful classification will be one that will satisfy several purposes; mainly, (1) facilitate meaningful communication among clinicians, (2) facilitate research so that investigative findings can be replicated, (3) facilitate research by steering the direction of research and (4) facilitate treatment by assessing treatment efficacy through the use of careful classifying criteria. These principles of classification should be considered in the criticisms and revisions of the classification of the eating disorders. The term “anorexia nervosa” immediately brings to the minds of most clinicians a cluster of signs and symptoms that represents a familiar disorder to them. Although there are unsatisfactory aspects to this term (very few patients with this disorder have lost their appetite) the term which has been used for over 100 years is immediately recognizable as a specific disorder and therefore it’s common usage has an advantage in communication. In an effort to be both precise and comprehensive, the Feighner criteria for anorexia nervosa were devised (Table 1, FEIGHNER et al., 1972). Although the goals of this effort were admirable, studies over the past 10 years have shown these criteria to be restrictive and not representative of the anorexia nervosa population. Specifically, epidemiological studies (HALMI et al., 1975; MORGAN and RUSSELL, 1975; THEANDER, 1970; Hsu et al., 1979) have shown that the occurrence of anorexia nervosa in patients over the age of 25 or even 30 is not uncommon. It no longer seems reasonable to use age as an exclusion criteria. Currently, there is no concensus as to how weight loss should be calculated for a diagnostic criterion for anorexia nervosa. Some investigators emphasize a total weight loss and others emphasize a weight loss below a normal weight for age and height. The Diagnostic and Statistical Manual of Mental Disorders (DSM-III, 1980) requires a weight loss of 25% of original body weight as a necessary criterion for anorexia nervosa (Table 2). No one has shown that anorexia nervosa patients can be differentiated on other clinical 113
114
KATHERINE A. HALMI TABLE 1. FEJGHNER CRITERIA FOR ANOREXIA NERVOSA A.
Age at onset prior
B.
Anorexia
C.
A distorted, implacable attitude toward eating, food, or weight that overrides hunger, admon itions, reassurance, and threats: e.g. (1) denial of illness with a failure to recognize nutritional needs; (2) apparent enjoyment in losing weight with overt manifestation that food refusal is a pleasurable indulgence; (3) a desired body image of extreme thinness with overt evidence that it is rewarding to the patient to achieve and maintain this state; and (4) unusual hoarding or handling of food.
D.
No known
E.
No other known psychiatric disorder with particular reference to primary affective disorders, schizophrenia, obsessive-compulsive and phobic neuroses. (The assumption is made that even though it may appear phobic or obsessional, food refusal alone is not sufficient to qualify for obsessivecompulsive or phobic disease).
F.
At least 2 of the following manifestations: (1) amenorrhea, (2) lanugo. (3) bradycardia (persistent resting pulse of 60 or less), (4) periods of overactivity, (5) episodes of bulimia, (6) vomiting (may be self-induced).
to 25.
with accompanying
medical
weight
illness that could
TABLE 2. DSM-III fear of becoming
account
for the anorexia
body weight.
and weight
loss.
DIAGNOSTICCRITERIA FOR ANOREXIA NERVOSA
A.
Intense
B.
Disturbance
C.
Weight loss of at least 25% of original body weight or, if under 18 years of age, weight loss from original body weight plus projected weight gain expected from growth charts may be combined to make the 25%.
D.
Refusal
E.
No known
of body
to maintain physical
obese.
loss of at least 25% of original
image,
which does not diminish
e.g. claiming
body weight
to “feel
over a minimal
illness that would account
fat”
normal
as weight
loss progresses.
even when emaciated.
weight
for the weight
for age and height.
loss.
variables by degree of weight loss. This observation has always been respected by RUSSELL who has used the criterion “self-induced loss of weight” as a comprehensive criterion covering the weight loss (Table 3). The criterion “no known physical illness that would account for weight loss” is unnecessary. The diagnosis of anorexia nervosa should be made on positive criteria. Obviously there is always a chance that some physical weight-losing disease will coexist with anorexia nervosa. Treatment of the specific physical entity does not mean that the eating behavior and typical anorexic attitudes will change. (1970)
TABLE 3. RUSSELL CRITERIA FOR ANOREXIA N~RVOSA 1.
Self-induced loss of weight patient to be fattening).
2.
A characteristic
3.
A specific endocrine disorder a delay of events of puberty
(resulting
psychopathology
mainly
consisting
from the studied
avoidance
of foods considered
of an overvalued
idea that fatness
which in the postpubertal girl causes the cessation in the prepubertal or early pubertal female.
is a dreadful of menstruation,
by the state. or
CLASSIFICATION OF EATING DISORDERS
115
In the past, investigators used the exclusion criterion “no other psychiatric disorder with particular reference to primary affective disorders, schizophrenia, obsessivecompulsive neurosis,” for the diagnosis of anorexia nervosa. The DSM-III criteria for anorexia nervosa do not contain a psychiatric diagnosis exclusion criterion. The descriptive and axial system of classification in DSM-III allows the possibility of more than one diagnosis on Axis I and an additional diagnosis on the personality disorder Axis II. The relationship of major affective disorder (an Axis I diagnosis) with anorexia nervosa is not clearly elucidated at this time. A recent study by GERSHWIN et al. (1983) showed that 13 of 24 anorexia nervosa patients had a history of major affective disorder (12 unipolar, 1 bipolar); nine of this sample had a minor affective disorder. In this same study, major affective disorder was found to be significantly more frequent in relatives of anorexics than in relatives of controls. According to the authors the proposition that anorexia nervosa is a manifestation of affective disorder is not supported because they did not find an excess of anorexics and bulimics among relatives of affective disorder probands. The issue of whether amenorrhea should be a necessary criterion for the diagnosis of anorexia nervosa remains controversial. RUSSELL (1%9) has advocated that amenorrhea be a necessary criterion for diagnosis of anorexia nervosa on the basis of his hypothesis that amenorrhea is caused by a primary disturbance of hypothalamic function: “the full expression of this disturbance is brought about with psychological stress and the malnutrition only perpetuates the amenorrhea of anorexia nervosa”. Russell’s hypothesis has stimulated much research in the past 15 years and his use of amenorrhea as a criterion for the diagnosis of anorexia has also emphasized a direction of research. As mentioned earlier, criteria in the classification of a disorder do have an influence on the direction of research. Russell’s hypothesis and criterion concerning amenorrhea have generated significant research, some of which supports his hypothesis. The question to be answered is whether amenorrhea seen in anorexia nervosa is a reflection solely of weight loss or whether it may indicate a primary impairment of hypothalamic function. Several studies have shown that the resumption of menses in anorexia nervosa occurs not just with the restoration to a normal weight but more significantly is associated with marked psychological improvement (MORGAN and RUSSELL, 1975; FALK and HALMI, 1982). WEINER (1983) points out that if 78% of the variance in LH levels must be accounted for by factors other than weight loss, then there can be no simple relationship between weight loss, LH levels and amenorrhea. His calculations were taken from the study by BROWN(1977) in which only 22% of the variance in LH levels was accounted for by the degree of weight loss or percentage below ideal body weight. In this same article Weiner points out that amenorrheic runners in a study by SCHWARTZet al. (1981) had increased LH levels when compared to exercising women who retained their menses. Weiner suggests evidence against a relationship between weight and gonadotrophin levels is that women who lose weight but do not develop anorexia nervosa and have secondary amenorrhea can have normal LH levels. Some normal weight bulimics have low LH and FSH levels and some patients with “psychogenic amenorrhea” have no weight loss but have low LH and FSH levels compared with normal controls. Post-pubertal bulimic women with a normal weight can be amenorrheic and have ageinappropriate patterns of gonadotrophin secretion. Full recovery of ideal body weight but the persistence of symptoms of anorexia nervosa or bulimia still show age-inappropriate
KATHERINEA. HALMI
116
gonadotrophin secretion patterns (KATZ et al., 1978). There seems to be sufficient evidence at this time to retain amenorrhea as a criterion for anorexia nervosa. The identification of the psychology behind the physical symptomatology is also fraught with difficulty. BRUCH (1962) identifies the relentless pursuit of thinness, denial of cachexia and the general ineffectiveness of these patients as being the core psychological symptoms. Other investigators have focused on the fear of becoming obese (BRADY and RIEGER, 1972) or the fear of sexuality and an adult-female sexual body (CRISP and ULUCY, 1974). The criterion “intense fear of becoming obese, which does not diminish as weight loss progresses” seems to be accepted by all clinicians and all researchers. The disturbance of body image is described by anorexia nervosa patients as “claiming to feel fat even when they are emaciated”. Although the research investigation of this has been fraught with methodological problems and perhaps inappropriate ways of trying to measure this phenomenon, none the less, most clinicians and researchers recognize that the anorexic patients have a “body conceptualization disturbance”. Another area of difficulty in the classification of anorexia nervosa is the diagnosis of personality disorders. The diagnosis of schizoid personality disorder, borderline personality disorder, histrionic personality disorder and anti-social personality disorder have been made in patients with anorexia nervosa (BRAM et al., 1982). Anorexic patients who have bulimia are likely to have personality disorder diagnoses (STROBER, 1981). Since a higher association of impulsive behaviors such as suicide attempts, self mutilation, stealing and substance including alcohol abuse, are present in the bingeing and purging anorexics, one may expect a higher prevalence of well defined personality disorders in the bulimic anorexics (CASPER et al., 1980; GARFINKEL et al., 1980). Longitudinal and follow-up studies are needed to determine if anorexic patients who binge and vomit are a separate clinical entity, and should be classified differently from the exclusive starving anorexic. Although there is not enough evidence to justify bulimic anorectics as a separate clinical entity there is enough evidence as mentioned above, to justify subtyping anorexia nervosa patients into those who exclusively starve, those who starve and purge but do not binge and those who binge and purge (Table 4). Since there are specific medical complications with bingeing and purging, it would be helpful for the clinician to subtype the anorexia nervosa patients. TABLE 4. PROPOSED REVISION OF DSM-III CRITERIA FORANOREXIA NERVOSA
Anorexia nervosa A.
Intense fear of becoming obese, which does not diminish as weight loss progresses.
B.
Body conceptualization
disturbance,
e.g. claiming to “feel fat” even when emaciated.
C.
Refusal to maintain body weight over a minimal normal weight for age and height.
D.
Amenorrhea
(in females).
Type I-for patients who solely restrict food intake and who do nor binge or purge (induce vomiting or abuse laxatives or diuretics). Type II-for
patients who restrict food intake and purge but do not binge.
For patients who binge and purge and who may restrict intake as well, give additional diagnosis of bulimia nervosa.
CLASSIFICATION OF EATING DISORDERS
117
The multiaxial method of diagnosis, as demonstrated in the DSM-III, provides the possibility of having several concurrent diagnoses on Axis I and personality diagnoses on Axis II. Thus in this system of classification, a patient with anorexia nervosa could have an Axis I diagnosis of anorexia nervosa, and Axis I diagnosis of alcohol abuse, an Axis I diagnosis of major depressive disorder and an Axis II diagnosis of histrionic personality disorder. This method of diagnosing is useful because it does not interfere with the major diagnostic criteria in the classification of anorexia nervosa, and accommodates those patients that express different behavioral problems. BRUCH (1966) preferred to deal with this heterogeneity by classifying the anorexic patients with secondary psychiatric diagnoses as atypical anorexics. She includes not only the personality disorders in this category but also the anorexics who meet criteria for schizophrenia. The DSM-III method of classification is more precise and eventually should be more useful. Table 4 is a proposed revision of DSM-III criteria for anorexia nervosa based on the above discussion. The term bulimia merely means binge-eating. This is a behavior that has become a common practice among otherwise normal young female students at American universities and has spread to high school age students. Bulimia is a behavior that occurs in anorexia nervosa patients and can also occur in those of normal weight, associated with psychological symptomatology. In the DSM-III the latter condition is simply referred to as bulimia and can be only diagnosed if anorexia nervosa is not present (Table 5). TABLE5. DSM-III DIAGNOSTIC CRITERIA FORBULIMIA A.
Recurrent episodes of binge eating (rapid consumption of a large amount of food in a discreet period of time, usually less than 2 h).
B.
At 1. 2. 3.
least three of the following: Consumption of high-caloric, easily ingested food during a binge. Inconspicuous eating during a binge. Termination of such eating episodes by abdominal pain, sleep, social interruption or self-induced vomiting. 4. Repeated attempts to lose weight by severely restrictive diets, self-induced vomiting, or use of cathartics or diuretics. 5. Frequent weight fluctuations greater than 10 pounds due to alternating binges and fasts.
C.
Awareness that the eating pattern is abnormal and fear of not being able to stop eating voluntarily.
D.
Depressed mood and self-deprecating
E.
The bulimic episodes are not due to anorexia nervosa or any known physical disorder.
thoughts following eating binges.
RUSSELL (1979) coined the term bulimia nervosa. At that time Russell conceptualized bulimia nervosa as an “aftermath of chronic phase of anorexia nervosa”. Only six of the 30 patients he studied had no history of preceding anorexia nervosa. Russell’s criteria for bulimia nervosa (Table 6) are ambiguous because a patient with anorexia nervosa could also meet criteria for bulimia nervosa. Does such a patient receive both diagnoses or does one take precedence over the other? Giving everyone who binges the diagnosis of bulimia is fraught with problems. There are distinct physiological differences that occur with weight loss that must be identified separately. This cannot be done if everyone is clustered under the same diagnosis of bulimia. The successful maintenance of an emaciated state is associated with differences in
KATHERINEA. HALMI
118
TABLE 6. RUSSELLCRITERIA FORBULIMIANERVOSA
1.
A powerful and intractible urge to overeat resulting in episodes of overeating.
2.
Avoidance of “fattening”
3.
A morbid fear of becoming fat.
effects of food by inducing vomiting or abusing purgatives or both.
physiological, and behavioral signs and symptoms. The DSM-III criteria (Table 5) for bulimia imply these patients are within a normal weight range. These criteria are merely a description of the process of binge eating because at the time they were written, there was virtually no information on demographic variables, course of illness, and effective treatment on this disorder. Although a surge of information is currently being obtained on the epidemiology, endocrinology and treatment of this disorder, there is not enough firm evidence for strong recommendations for any specific set of criteria. It is useful to separate students who binge occasionally for a lark, from binge eaters who have a distinct psychiatric impairment. The term bulimia nervosa implies a psychiatric impairment and therefore is a better label for the binge eating disorder. Additional criteria regarding frequency of binge eating and maintenance of body weight within 10% of a normal weight range are useful for differentiating the disorder from a casual behavior and from anorexia nervosa. A proposed revision of DSM-III criteria for bulimia is presented in Table 7. We need longitudinal studies on normal weight bulimics to compare their long-term outcome with the outcomes of exclusively dieting anorexics and bulimic anorexics in order to determine if separate classifications are justified for these disorders. Until more definitive information is available it seems useful both from the points of clinical care and research to subtype the bulimia nervosa patients into those who have had a previous history TABLE 7. PROPOSEDREVISION OF DSM-III CRITERIA FORBULIMIA
Bulimia nervosa A.
Recurrent episodes of binge eating (rapid consumption of a large amount of food in a discreet period of time, usually less than 2 h).
B.
At least three of the following: I. Consumption of high-caloric, easily ingested food during a binge. 2. Inconspicuous eating during a binge. 3. Termination of such eating episodes by abdominal pain, sleep, social interruption or self-induced vomiting. 4. Repeated attempts to lose weight by several restricted diets, self-induced vomiting or use of cathartics or diuretics. 5. Frequent weight fluctuations greater than ten pounds due to alternating binges and fasts.
C.
Awareness that the eating pattern is abnormal and fear of not being able to stop eating voluntarily.
D.
Frequency of binge eating must be at least an average of twice per week for a chronicity of three months. If both the above criteria and anorexia nervosa criteria are currently present, give both diagnoses; anorexia nervosa and bulimia nervosa.
E.
Type I-for Type II-for
patients who have not had a previous history of anorexia nervosa. patients with a previous history of anorexia nervosa.
CLASSIFICATIONOF EATINGDISORDERS
119
of anorexia nervosa and those who have not had preceeding anorexia nervosa. It is likely these subtypes will also have a different course and it is reasonable to expect that those with a history of anorexia nervosa will have a course with more frequent anorexic episodes than those who have never had anorexia nervosa. The proposed criteria for anorexia nervosa and bulimia nervosa in Tables 4 and 7 were compiled with the intention of suiting the needs of both clinicians and researchers. Variations of these criteria that cannot be encompassed by other Axis I and Axis II DSM-III diagnoses could be placed under the term atypical eating disorders. The most useful information for the future revision of diagnostic criteria of the eating disorders will come from carefully conducted, systematic, longitudinal studies. REFERENCES BRADY,A. P. and RIEGER, W. (1972) Behavior treatment of anorexia nervosa. In Proceedings of the International Symposium on Behavior Modification. Appleton-Century-Crofts, New York. BRAM,S., EGER, D. and HALMI, K. (1982) Anorexia nervosa and personality type: a preliminary report. Inf. J. eat. Disord. 2, 67-73. BROWN,G. M., GARFINKEL,P. E., JEUNIEWIC,N., MOLDOFSKY,H. and STANCER,H. C. (1977) Endocrine profiles in anorexia nervosa. In Anorexia Nervosa (Edited by VIGERSKY,R. A.), pp. 123-125. Raven Press, New York. BRUCH,H. (1962) Perceptual and conceptual disturbance in anorexia nervosa. Psychosom. Med. 24, 187-193. BRUCH, H. (1966) Anorexia nervosa and it’s differential diagnosis. J. nerv. menf. Dis. 141, 555-673. CASPER, R., ECKERT,E., HALMI, K., GOLDBERG,S. and DAVIS, J. (1980) Bulimia: it’s incidence and clinical importance in patients with anorexia nervosa. Archs gen. Psychiaf. 37, 1030-1035. CRISP, A. H. and KALUCY,R. S. (1982) Aspects of perceptual disorder in anorexia nervosa. Br. J. med. Psycho/. 47, 349-360. FEIGHNER,J. P., ROBINS,E., GUZE, S., WOODRUFF,R. A., WINOKUR,G. and MUNOZ, R. (1972) Diagnostic criteria for use in psychiatric research. Archs gen. Psychiat. 26, 57-63. GARFINKEL,P., MOLDOFSKY,H. and GARNER,D. (1980) The heterogeneity of anorexia nervosa; bulimia as a distinct group. Archs gen. Psychiat. 37, 1036-1040. GERSHON.E. S., HAMOVIT,J. R., SCHREIBER,J. L., DIBBLE,E. D., KAYE,W., NURNBERGER, J. l., ANDERSEN, A. and EBERT,M. (1983) Anorexia nervosa and major affective disorders associated in families: a preliminary report. In Childhood Psychopathology andDevelopment (Edited by GUZE, S. B., EARLES, F. J. and BARRETT, J. E.), pp. 279-287. Raven Press, New York. HALMI, K. A., BRODLAND, G. and RIGAS, C. (1975) A follow-up study of 79 patients with anorexia nervosa: an evaluation of prognostic factors and diagnostic criteria. Life Hist. Res. Psychopath. 4, 290-298. Hsu, L. K., CRISP, A. H. and HARDING,B. (1979) Outcome of anorexia nervosa. Lancer i, 65-73. KATZ, J. L. (1983) Weight and circadian LH secretory pattern in anorexia nervosa. Psychosom. Med. 40, 549-567. MORGAN,H. G. and RUSSELL,G. F. M. (1975) Value of family background in clinical features as prediction of long-term outcome in anorexia nervosa. Psychof. Med. 5, 355-371. RUSSELL,G. F. M. and BEARDWOOD, C. J. (1970) Amenorrhea in the feeding disorders: anorexia nervosa and obesity. Psychother. Psychosom. 18,358-364. RUSSELL,G. F. M. (1979) Bulimia nervosa: an ominous variant of anorexia nervosa. Psychol. Med. 9,429-448. SCHWARTZ,B.,CUMMING,D. C., RIORDAN,E., SELYE,M., YEN, S. C. C. and REBOR, R. W. (1981) Exercise associated amenorrhea: a distinct entity? Am. J.obstet. Gynecol. 141, 662-670. STROBER,M. (1981) The significance of bulimia in juvenile anorexia nervosa: an exploration of possible etiological factors. Int. J. eat. Disord. 1,28-43. THEANDER,S. (1970) Anorexia nervosa. Acta psychiat. Stand. Suppl. 214. WEINER, H. (1983) Hypothalamic-pituitary-ovarian axis in anorexia and bulimia nervosa. Int. J. ear. Disord. 2, 109-l 16.
J psychrsr. Res.. Vol. 19, No. Z/3. pp. 113-119. 1985 Primed m Great Brxan
CLASSIFICATION OF THE EATING DISORDERS KATHERINE A. HALMI CornellUniversity MedicalCollege,NewYork ANOREXIA
nervosa and bulimia nervosa are appetitive behavioral disorders that have been studied comprehensively and with systematic methodologies only in the last 20 years. In the past decade an explosion of investigations of the eating disorders has produced epidemiological, clinical and physiological information necessary for devising a classification of the eating disorders. These eating behavior conditions are entities and not diseases with a common cause, common course, and a common pathology. The eating disorders are best conceptualized as syndromes and therefore must be classified on the basis of the cluster of symptoms that are present. Schizophrenia is another example of a behavioral syndrome. It is important to remember that the final outcome of a classification represents an arbitrary procedure even though research data are used to formulate the classification. The most useful classification will be one that will satisfy several purposes; mainly, (1) facilitate meaningful communication among clinicians, (2) facilitate research so that investigative findings can be replicated, (3) facilitate research by steering the direction of research and (4) facilitate treatment by assessing treatment efficacy through the use of careful classifying criteria. These principles of classification should be considered in the criticisms and revisions of the classification of the eating disorders. The term “anorexia nervosa” immediately brings to the minds of most clinicians a cluster of signs and symptoms that represents a familiar disorder to them. Although there are unsatisfactory aspects to this term (very few patients with this disorder have lost their appetite) the term which has been used for over 100 years is immediately recognizable as a specific disorder and therefore it’s common usage has an advantage in communication. In an effort to be both precise and comprehensive, the Feighner criteria for anorexia nervosa were devised (Table 1, FEIGHNER et al., 1972). Although the goals of this effort were admirable, studies over the past 10 years have shown these criteria to be restrictive and not representative of the anorexia nervosa population. Specifically, epidemiological studies (HALMI et al., 1975; MORGAN and RUSSELL, 1975; THEANDER, 1970; Hsu et al., 1979) have shown that the occurrence of anorexia nervosa in patients over the age of 25 or even 30 is not uncommon. It no longer seems reasonable to use age as an exclusion criteria. Currently, there is no concensus as to how weight loss should be calculated for a diagnostic criterion for anorexia nervosa. Some investigators emphasize a total weight loss and others emphasize a weight loss below a normal weight for age and height. The Diagnostic and Statistical Manual of Mental Disorders (DSM-III, 1980) requires a weight loss of 25% of original body weight as a necessary criterion for anorexia nervosa (Table 2). No one has shown that anorexia nervosa patients can be differentiated on other clinical 113
114
KATHERINE A. HALMI TABLE 1. FEJGHNER CRITERIA FOR ANOREXIA NERVOSA A.
Age at onset prior
B.
Anorexia
C.
A distorted, implacable attitude toward eating, food, or weight that overrides hunger, admon itions, reassurance, and threats: e.g. (1) denial of illness with a failure to recognize nutritional needs; (2) apparent enjoyment in losing weight with overt manifestation that food refusal is a pleasurable indulgence; (3) a desired body image of extreme thinness with overt evidence that it is rewarding to the patient to achieve and maintain this state; and (4) unusual hoarding or handling of food.
D.
No known
E.
No other known psychiatric disorder with particular reference to primary affective disorders, schizophrenia, obsessive-compulsive and phobic neuroses. (The assumption is made that even though it may appear phobic or obsessional, food refusal alone is not sufficient to qualify for obsessivecompulsive or phobic disease).
F.
At least 2 of the following manifestations: (1) amenorrhea, (2) lanugo. (3) bradycardia (persistent resting pulse of 60 or less), (4) periods of overactivity, (5) episodes of bulimia, (6) vomiting (may be self-induced).
to 25.
with accompanying
medical
weight
illness that could
TABLE 2. DSM-III fear of becoming
account
for the anorexia
body weight.
and weight
loss.
DIAGNOSTICCRITERIA FOR ANOREXIA NERVOSA
A.
Intense
B.
Disturbance
C.
Weight loss of at least 25% of original body weight or, if under 18 years of age, weight loss from original body weight plus projected weight gain expected from growth charts may be combined to make the 25%.
D.
Refusal
E.
No known
of body
to maintain physical
obese.
loss of at least 25% of original
image,
which does not diminish
e.g. claiming
body weight
to “feel
over a minimal
illness that would account
fat”
normal
as weight
loss progresses.
even when emaciated.
weight
for the weight
for age and height.
loss.
variables by degree of weight loss. This observation has always been respected by RUSSELL who has used the criterion “self-induced loss of weight” as a comprehensive criterion covering the weight loss (Table 3). The criterion “no known physical illness that would account for weight loss” is unnecessary. The diagnosis of anorexia nervosa should be made on positive criteria. Obviously there is always a chance that some physical weight-losing disease will coexist with anorexia nervosa. Treatment of the specific physical entity does not mean that the eating behavior and typical anorexic attitudes will change. (1970)
TABLE 3. RUSSELL CRITERIA FOR ANOREXIA N~RVOSA 1.
Self-induced loss of weight patient to be fattening).
2.
A characteristic
3.
A specific endocrine disorder a delay of events of puberty
(resulting
psychopathology
mainly
consisting
from the studied
avoidance
of foods considered
of an overvalued
idea that fatness
which in the postpubertal girl causes the cessation in the prepubertal or early pubertal female.
is a dreadful of menstruation,
by the state. or
CLASSIFICATION OF EATING DISORDERS
115
In the past, investigators used the exclusion criterion “no other psychiatric disorder with particular reference to primary affective disorders, schizophrenia, obsessivecompulsive neurosis,” for the diagnosis of anorexia nervosa. The DSM-III criteria for anorexia nervosa do not contain a psychiatric diagnosis exclusion criterion. The descriptive and axial system of classification in DSM-III allows the possibility of more than one diagnosis on Axis I and an additional diagnosis on the personality disorder Axis II. The relationship of major affective disorder (an Axis I diagnosis) with anorexia nervosa is not clearly elucidated at this time. A recent study by GERSHWIN et al. (1983) showed that 13 of 24 anorexia nervosa patients had a history of major affective disorder (12 unipolar, 1 bipolar); nine of this sample had a minor affective disorder. In this same study, major affective disorder was found to be significantly more frequent in relatives of anorexics than in relatives of controls. According to the authors the proposition that anorexia nervosa is a manifestation of affective disorder is not supported because they did not find an excess of anorexics and bulimics among relatives of affective disorder probands. The issue of whether amenorrhea should be a necessary criterion for the diagnosis of anorexia nervosa remains controversial. RUSSELL (1%9) has advocated that amenorrhea be a necessary criterion for diagnosis of anorexia nervosa on the basis of his hypothesis that amenorrhea is caused by a primary disturbance of hypothalamic function: “the full expression of this disturbance is brought about with psychological stress and the malnutrition only perpetuates the amenorrhea of anorexia nervosa”. Russell’s hypothesis has stimulated much research in the past 15 years and his use of amenorrhea as a criterion for the diagnosis of anorexia has also emphasized a direction of research. As mentioned earlier, criteria in the classification of a disorder do have an influence on the direction of research. Russell’s hypothesis and criterion concerning amenorrhea have generated significant research, some of which supports his hypothesis. The question to be answered is whether amenorrhea seen in anorexia nervosa is a reflection solely of weight loss or whether it may indicate a primary impairment of hypothalamic function. Several studies have shown that the resumption of menses in anorexia nervosa occurs not just with the restoration to a normal weight but more significantly is associated with marked psychological improvement (MORGAN and RUSSELL, 1975; FALK and HALMI, 1982). WEINER (1983) points out that if 78% of the variance in LH levels must be accounted for by factors other than weight loss, then there can be no simple relationship between weight loss, LH levels and amenorrhea. His calculations were taken from the study by BROWN(1977) in which only 22% of the variance in LH levels was accounted for by the degree of weight loss or percentage below ideal body weight. In this same article Weiner points out that amenorrheic runners in a study by SCHWARTZet al. (1981) had increased LH levels when compared to exercising women who retained their menses. Weiner suggests evidence against a relationship between weight and gonadotrophin levels is that women who lose weight but do not develop anorexia nervosa and have secondary amenorrhea can have normal LH levels. Some normal weight bulimics have low LH and FSH levels and some patients with “psychogenic amenorrhea” have no weight loss but have low LH and FSH levels compared with normal controls. Post-pubertal bulimic women with a normal weight can be amenorrheic and have ageinappropriate patterns of gonadotrophin secretion. Full recovery of ideal body weight but the persistence of symptoms of anorexia nervosa or bulimia still show age-inappropriate
KATHERINEA. HALMI
116
gonadotrophin secretion patterns (KATZ et al., 1978). There seems to be sufficient evidence at this time to retain amenorrhea as a criterion for anorexia nervosa. The identification of the psychology behind the physical symptomatology is also fraught with difficulty. BRUCH (1962) identifies the relentless pursuit of thinness, denial of cachexia and the general ineffectiveness of these patients as being the core psychological symptoms. Other investigators have focused on the fear of becoming obese (BRADY and RIEGER, 1972) or the fear of sexuality and an adult-female sexual body (CRISP and ULUCY, 1974). The criterion “intense fear of becoming obese, which does not diminish as weight loss progresses” seems to be accepted by all clinicians and all researchers. The disturbance of body image is described by anorexia nervosa patients as “claiming to feel fat even when they are emaciated”. Although the research investigation of this has been fraught with methodological problems and perhaps inappropriate ways of trying to measure this phenomenon, none the less, most clinicians and researchers recognize that the anorexic patients have a “body conceptualization disturbance”. Another area of difficulty in the classification of anorexia nervosa is the diagnosis of personality disorders. The diagnosis of schizoid personality disorder, borderline personality disorder, histrionic personality disorder and anti-social personality disorder have been made in patients with anorexia nervosa (BRAM et al., 1982). Anorexic patients who have bulimia are likely to have personality disorder diagnoses (STROBER, 1981). Since a higher association of impulsive behaviors such as suicide attempts, self mutilation, stealing and substance including alcohol abuse, are present in the bingeing and purging anorexics, one may expect a higher prevalence of well defined personality disorders in the bulimic anorexics (CASPER et al., 1980; GARFINKEL et al., 1980). Longitudinal and follow-up studies are needed to determine if anorexic patients who binge and vomit are a separate clinical entity, and should be classified differently from the exclusive starving anorexic. Although there is not enough evidence to justify bulimic anorectics as a separate clinical entity there is enough evidence as mentioned above, to justify subtyping anorexia nervosa patients into those who exclusively starve, those who starve and purge but do not binge and those who binge and purge (Table 4). Since there are specific medical complications with bingeing and purging, it would be helpful for the clinician to subtype the anorexia nervosa patients. TABLE 4. PROPOSED REVISION OF DSM-III CRITERIA FORANOREXIA NERVOSA
Anorexia nervosa A.
Intense fear of becoming obese, which does not diminish as weight loss progresses.
B.
Body conceptualization
disturbance,
e.g. claiming to “feel fat” even when emaciated.
C.
Refusal to maintain body weight over a minimal normal weight for age and height.
D.
Amenorrhea
(in females).
Type I-for patients who solely restrict food intake and who do nor binge or purge (induce vomiting or abuse laxatives or diuretics). Type II-for
patients who restrict food intake and purge but do not binge.
For patients who binge and purge and who may restrict intake as well, give additional diagnosis of bulimia nervosa.
CLASSIFICATION OF EATING DISORDERS
117
The multiaxial method of diagnosis, as demonstrated in the DSM-III, provides the possibility of having several concurrent diagnoses on Axis I and personality diagnoses on Axis II. Thus in this system of classification, a patient with anorexia nervosa could have an Axis I diagnosis of anorexia nervosa, and Axis I diagnosis of alcohol abuse, an Axis I diagnosis of major depressive disorder and an Axis II diagnosis of histrionic personality disorder. This method of diagnosing is useful because it does not interfere with the major diagnostic criteria in the classification of anorexia nervosa, and accommodates those patients that express different behavioral problems. BRUCH (1966) preferred to deal with this heterogeneity by classifying the anorexic patients with secondary psychiatric diagnoses as atypical anorexics. She includes not only the personality disorders in this category but also the anorexics who meet criteria for schizophrenia. The DSM-III method of classification is more precise and eventually should be more useful. Table 4 is a proposed revision of DSM-III criteria for anorexia nervosa based on the above discussion. The term bulimia merely means binge-eating. This is a behavior that has become a common practice among otherwise normal young female students at American universities and has spread to high school age students. Bulimia is a behavior that occurs in anorexia nervosa patients and can also occur in those of normal weight, associated with psychological symptomatology. In the DSM-III the latter condition is simply referred to as bulimia and can be only diagnosed if anorexia nervosa is not present (Table 5). TABLE5. DSM-III DIAGNOSTIC CRITERIA FORBULIMIA A.
Recurrent episodes of binge eating (rapid consumption of a large amount of food in a discreet period of time, usually less than 2 h).
B.
At 1. 2. 3.
least three of the following: Consumption of high-caloric, easily ingested food during a binge. Inconspicuous eating during a binge. Termination of such eating episodes by abdominal pain, sleep, social interruption or self-induced vomiting. 4. Repeated attempts to lose weight by severely restrictive diets, self-induced vomiting, or use of cathartics or diuretics. 5. Frequent weight fluctuations greater than 10 pounds due to alternating binges and fasts.
C.
Awareness that the eating pattern is abnormal and fear of not being able to stop eating voluntarily.
D.
Depressed mood and self-deprecating
E.
The bulimic episodes are not due to anorexia nervosa or any known physical disorder.
thoughts following eating binges.
RUSSELL (1979) coined the term bulimia nervosa. At that time Russell conceptualized bulimia nervosa as an “aftermath of chronic phase of anorexia nervosa”. Only six of the 30 patients he studied had no history of preceding anorexia nervosa. Russell’s criteria for bulimia nervosa (Table 6) are ambiguous because a patient with anorexia nervosa could also meet criteria for bulimia nervosa. Does such a patient receive both diagnoses or does one take precedence over the other? Giving everyone who binges the diagnosis of bulimia is fraught with problems. There are distinct physiological differences that occur with weight loss that must be identified separately. This cannot be done if everyone is clustered under the same diagnosis of bulimia. The successful maintenance of an emaciated state is associated with differences in
KATHERINEA. HALMI
118
TABLE 6. RUSSELLCRITERIA FORBULIMIANERVOSA
1.
A powerful and intractible urge to overeat resulting in episodes of overeating.
2.
Avoidance of “fattening”
3.
A morbid fear of becoming fat.
effects of food by inducing vomiting or abusing purgatives or both.
physiological, and behavioral signs and symptoms. The DSM-III criteria (Table 5) for bulimia imply these patients are within a normal weight range. These criteria are merely a description of the process of binge eating because at the time they were written, there was virtually no information on demographic variables, course of illness, and effective treatment on this disorder. Although a surge of information is currently being obtained on the epidemiology, endocrinology and treatment of this disorder, there is not enough firm evidence for strong recommendations for any specific set of criteria. It is useful to separate students who binge occasionally for a lark, from binge eaters who have a distinct psychiatric impairment. The term bulimia nervosa implies a psychiatric impairment and therefore is a better label for the binge eating disorder. Additional criteria regarding frequency of binge eating and maintenance of body weight within 10% of a normal weight range are useful for differentiating the disorder from a casual behavior and from anorexia nervosa. A proposed revision of DSM-III criteria for bulimia is presented in Table 7. We need longitudinal studies on normal weight bulimics to compare their long-term outcome with the outcomes of exclusively dieting anorexics and bulimic anorexics in order to determine if separate classifications are justified for these disorders. Until more definitive information is available it seems useful both from the points of clinical care and research to subtype the bulimia nervosa patients into those who have had a previous history TABLE 7. PROPOSEDREVISION OF DSM-III CRITERIA FORBULIMIA
Bulimia nervosa A.
Recurrent episodes of binge eating (rapid consumption of a large amount of food in a discreet period of time, usually less than 2 h).
B.
At least three of the following: I. Consumption of high-caloric, easily ingested food during a binge. 2. Inconspicuous eating during a binge. 3. Termination of such eating episodes by abdominal pain, sleep, social interruption or self-induced vomiting. 4. Repeated attempts to lose weight by several restricted diets, self-induced vomiting or use of cathartics or diuretics. 5. Frequent weight fluctuations greater than ten pounds due to alternating binges and fasts.
C.
Awareness that the eating pattern is abnormal and fear of not being able to stop eating voluntarily.
D.
Frequency of binge eating must be at least an average of twice per week for a chronicity of three months. If both the above criteria and anorexia nervosa criteria are currently present, give both diagnoses; anorexia nervosa and bulimia nervosa.
E.
Type I-for Type II-for
patients who have not had a previous history of anorexia nervosa. patients with a previous history of anorexia nervosa.
CLASSIFICATIONOF EATINGDISORDERS
119
of anorexia nervosa and those who have not had preceeding anorexia nervosa. It is likely these subtypes will also have a different course and it is reasonable to expect that those with a history of anorexia nervosa will have a course with more frequent anorexic episodes than those who have never had anorexia nervosa. The proposed criteria for anorexia nervosa and bulimia nervosa in Tables 4 and 7 were compiled with the intention of suiting the needs of both clinicians and researchers. Variations of these criteria that cannot be encompassed by other Axis I and Axis II DSM-III diagnoses could be placed under the term atypical eating disorders. The most useful information for the future revision of diagnostic criteria of the eating disorders will come from carefully conducted, systematic, longitudinal studies. REFERENCES BRADY,A. P. and RIEGER, W. (1972) Behavior treatment of anorexia nervosa. In Proceedings of the International Symposium on Behavior Modification. Appleton-Century-Crofts, New York. BRAM,S., EGER, D. and HALMI, K. (1982) Anorexia nervosa and personality type: a preliminary report. Inf. J. eat. Disord. 2, 67-73. BROWN,G. M., GARFINKEL,P. E., JEUNIEWIC,N., MOLDOFSKY,H. and STANCER,H. C. (1977) Endocrine profiles in anorexia nervosa. In Anorexia Nervosa (Edited by VIGERSKY,R. A.), pp. 123-125. Raven Press, New York. BRUCH,H. (1962) Perceptual and conceptual disturbance in anorexia nervosa. Psychosom. Med. 24, 187-193. BRUCH, H. (1966) Anorexia nervosa and it’s differential diagnosis. J. nerv. menf. Dis. 141, 555-673. CASPER, R., ECKERT,E., HALMI, K., GOLDBERG,S. and DAVIS, J. (1980) Bulimia: it’s incidence and clinical importance in patients with anorexia nervosa. Archs gen. Psychiaf. 37, 1030-1035. CRISP, A. H. and KALUCY,R. S. (1982) Aspects of perceptual disorder in anorexia nervosa. Br. J. med. Psycho/. 47, 349-360. FEIGHNER,J. P., ROBINS,E., GUZE, S., WOODRUFF,R. A., WINOKUR,G. and MUNOZ, R. (1972) Diagnostic criteria for use in psychiatric research. Archs gen. Psychiat. 26, 57-63. GARFINKEL,P., MOLDOFSKY,H. and GARNER,D. (1980) The heterogeneity of anorexia nervosa; bulimia as a distinct group. Archs gen. Psychiat. 37, 1036-1040. GERSHON.E. S., HAMOVIT,J. R., SCHREIBER,J. L., DIBBLE,E. D., KAYE,W., NURNBERGER, J. l., ANDERSEN, A. and EBERT,M. (1983) Anorexia nervosa and major affective disorders associated in families: a preliminary report. In Childhood Psychopathology andDevelopment (Edited by GUZE, S. B., EARLES, F. J. and BARRETT, J. E.), pp. 279-287. Raven Press, New York. HALMI, K. A., BRODLAND, G. and RIGAS, C. (1975) A follow-up study of 79 patients with anorexia nervosa: an evaluation of prognostic factors and diagnostic criteria. Life Hist. Res. Psychopath. 4, 290-298. Hsu, L. K., CRISP, A. H. and HARDING,B. (1979) Outcome of anorexia nervosa. Lancer i, 65-73. KATZ, J. L. (1983) Weight and circadian LH secretory pattern in anorexia nervosa. Psychosom. Med. 40, 549-567. MORGAN,H. G. and RUSSELL,G. F. M. (1975) Value of family background in clinical features as prediction of long-term outcome in anorexia nervosa. Psychof. Med. 5, 355-371. RUSSELL,G. F. M. and BEARDWOOD, C. J. (1970) Amenorrhea in the feeding disorders: anorexia nervosa and obesity. Psychother. Psychosom. 18,358-364. RUSSELL,G. F. M. (1979) Bulimia nervosa: an ominous variant of anorexia nervosa. Psychol. Med. 9,429-448. SCHWARTZ,B.,CUMMING,D. C., RIORDAN,E., SELYE,M., YEN, S. C. C. and REBOR, R. W. (1981) Exercise associated amenorrhea: a distinct entity? Am. J.obstet. Gynecol. 141, 662-670. STROBER,M. (1981) The significance of bulimia in juvenile anorexia nervosa: an exploration of possible etiological factors. Int. J. eat. Disord. 1,28-43. THEANDER,S. (1970) Anorexia nervosa. Acta psychiat. Stand. Suppl. 214. WEINER, H. (1983) Hypothalamic-pituitary-ovarian axis in anorexia and bulimia nervosa. Int. J. ear. Disord. 2, 109-l 16.