I read an interesting opinion piece in the Guardian recently titled: “We need to rethink how we classify mental illness”. Within the article, Tamara Kayali Browne argues that the Diagnostic and Statistical Manual of Mental Disorders (DSM) neglects the context of someone’s mental health disorder when listing diagnostic criteria.
The DSM – the latest version being DSM-5 updated in 2013 – is written by the American Psychiatric Association (APA), and is used by GPs and psychiatrists to assess and diagnose people, and plan for their care. What matters is the fact that GPs and psychiatrists are so often the first port of call when someone is worried they – or someone they know – may have an eating disorder.
Time and time again, I hear from people who are misdiagnosed, or prescribed treatment that barely touches the surface of the issue: anti-depressants or short-term online CBT courses are so frequently offered to people suffering with Binge Eating Disorder. CBT is also recommended for someone suffering with Anorexia, unless their physical health requires hospitalization.
To caveat, I know the NHS has extremely limited resources, so they’re doing the best they can. Instead, I want to focus on the limitations of the DSM, and how context can’t be overlooked when diagnosing and determining treatment for someone with an eating disorder.
What was the purpose the eating disorder was serving?
The problem with treatment prescribed off the back of a DSM-based diagnosis is that it only really deals with the symptoms of the illness: treatment is focused around someone’s harmful relationship with food and eating, and aims to help them to stop “acting out” with food.
For instance, the DSM-5 criteria for Bulimia includes: “The binge eating and inappropriate compensatory behaviours both occur, on average, at least once a week for three months.” And “Eating, in a discrete period of time (e.g. within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances.”
But what about why someone developed an eating disorder in the first place? What was the purpose the eating disorder was serving? Why and what were they having to “cope” with via the eating disorder? This is what needs to be treated.
By neglecting the context for why someone develops an eating disorder, there’s a higher potential for relapse. This is because the original cause hasn’t necessarily been given the space and appropriate time to be processed and healed.
“An eating disorder doesn’t survive in someone who has been taught how to love themselves.” – Emmy Brunner
For instance, what the DSM doesn’t mention is trauma. If someone has been impacted by trauma at any point in their life and it isn’t treated appropriately, that experience could still shape their reality. Trauma can be overt or covert, it can be physical or mental – it is relative according to the individual. An eating disorder forms as a way of coping with these painful emotions – so whilst someone may rebuild a “normal” way of eating again, they may still have a very destructive critical voice (for instance) that impacts their day-to-day.
What this means is that someone may finish their CBT course but go on to develop alternative, harmful coping mechanisms that just aren’t related to food – but they still need help.
This is why food is not the issue, and why at The Recover Clinic we don’t focus our treatment solely around it. As Emmy, CEO and Director of The Recover Clinic, has said time and time again: “An eating disorder doesn’t survive in someone who has been taught how to love themselves.” This could be the case for some other mental health disorders too.
By understanding of a person’s history, you can determine effective treatment based off their particular needs. Treatment might be focused around discovering or empowering their sense of identity, healing from abuse, learning how to value and care for themselves…it depends on what they’ve been missing up until now.
One last thing to add regarding to social context: the latest update to the DSM was published in 2013. This was a time when Instagram had only been available on Android devices for 1 year…imagine!