Eating Disorders 441
Some people with anorexia may have such distorted thinking about their weight
and body that they may come to believe that there’s really nothing wrong with their
weight or restricted food intake (Csipke & Horne, 2007; Gavin, Rodham, & Poyer,
2008). A minority may come to view anorexia as a lifestyle choice rather than a dis-
order. Unfortunately, anorexia has serious physical and mental health consequences,
which are swept under the rug by such attempts to reframe the condition.
Problems With the DSM-IV-TR Defi nition
of Anorexia Nervosa
Criticisms of the DSM-IV-TR defi nition of anorexia focus on the specifi c criteria
and the classifi cation of the two types: restricting and binge-eating/purging. In this
section we fi rst consider problems with the diagnostic criteria and then examine
problems with the classifi cation into the two types of anorexia.
Problems With the Diagnostic Criteria
Researchers and clinicians point to signifi cant problems with three of the four DSM-
IV-TR criteria for anorexia nervosa:
- Refusal to maintain a healthy body weight (Criterion A). Research suggests that this
criterion may be of little value in predicting an individual’s medical status, prognosis,
or outcome (Garfi nkel, Kennedy, & Kaplan, 1995). The extent to which someone is
underweight does not accurately predict the degree or type of medical problems she
will develop or how she will fare over time. Moreover, the body weight cutoff point
of “85% of that expected” doesn’t take into account the range of healthy weights in
the population, changes in growth due to puberty, or cultural factors that can lead a
person’s weight to vary (Franko et al., 2004; Herzog & Delinsky, 2001).- Fear of becoming fat or of gaining weight (Criterion B). Such fear may not char-
acterize people with anorexia in non-Western cultures such as that of Hong Kong.
Rather, a fear of gaining weight appears to be a by-product of a Western cul-
tural value of thinness (Keel & Klump, 2003; Lee, Ho, & Hsu, 1993; Walsh &
Kahn, 1997). Some researchers and clinicians propose that this criterion should
instead highlight the overemphasis on the importance of controlling eating rather
than focus on weight (Palmer, 2003). Further research can clarify whether people
who are preoccupied with controlling eating (rather than being afraid of gaining
weight) and meet the other three DSM-IV-TR criteria for anorexia are different in
any other way from people who meet all four of the DSM-IV-TR criteria.- Amenorrhea(Criterion D).Many researchers suggest that this diagnostic criterion
should be deleted because it is not reliably associated with the degree of weight loss
or the outcome of the eating disorder. Some women continue to menstruate at low
weights; other women develop amenorrhea before losing a signifi cant amount of
weight (Cachelin & Maher, 1998; Garfi nkel et al., 1996). Moreover, among females
diagnosed with anorexia, those who have amenorrhea are similar to menstruating
females with anorexia in terms of body image problems, depression, personality
disorders, and the severity of the eating disorder (Garfi nkel et al., 1996).Problems With the Types
The goal of delineating types or subtypes of a disorder is to identify and organize
useful information, such as distinguishing the prognosis or course of one type from
another. The two types of anorexia in DSM-IV-TR do not achieve this goal. Patients
diagnosed with one type often shift to the other type over time (Eddy et al., 2008).
For example, at an 8-year follow-up, one study found that 62% of those with the
restricting type had changed to the binge-eating/purging type; in fact, only 12% of
those who had been restrictors never developed any binge/purge symptoms. These
fi ndings suggests that the restricting type may be an earlier phase of the disorder for
some patients (Eddy et al., 2002).