Archive for the ‘Body dysmorphic disorder’ Category

This reprinted here in full, making it easier to read. Thank you to Helen Razer for putting it so well and so correctly about eating disorders and the current ‘DIS’ campaign. To read her original please go to: http://www.crikey.com.au/2015/05/07/were-making-ourselves-sick-with-the-publicity-of-eating-disorders/

I will follow in a while with my own post and thoughts on where Butterfly are and aren’t heading and the damage they do because they heavily mix body image campaigns with eating disorder awareness.


To survive the current calendar, health advocacy groups must claim a month and shake it. January starts with glaucoma and thyroid conditions, and the year ends with Alzheimer’s and AIDS.  This month is given over to a number of health campaigns with notable new May player The Butterfly Foundation currently raising funds and awareness for eating disorders (ED).

Theirs is a well-regarded organisation providing outpatient services to ED sufferers who, in the case of an anorexia nervosa diagnosis, face what is estimated to be the highest standardised mortality figures of any psychiatric disorder. The help they offer is practical and based in firm research. But, like so many other advocacy groups, the public messages broadcast are entirely theoretical and based on flimsy hope.

With the achievable aim of funding itself and the rather more incredible one of stopping ED at its source, the foundation has launched Don’t DIS My Appearance campaign. Let’s set aside the antique hip-hop language that had passed its best before date before Snoop Dogg had packed his first bowl. Let’s also overlook the decision to ask ambassadors to display a middle finger, which I imagine may seem less like a moment of cheeky defiance than a bleak reminder of the toilet bowl to those who suffer from bulimia. Let’s look instead at how this organisation, and others, can so easily extinguish the very awareness they seek to create with crude messaging.

We spend much of the year in a tangle of awareness ribbons and there are those who reasonably argue that we’re bound to stop noticing the meaning of such decoration at all. But even if a public health campaign is good enough to cut through all this shiny bunting, it may achieve the terrible opposite of its intention.

In a study undertaken to assess the effectiveness of the famous breast cancer pink, researchers unexpectedly found that the women have become both more likely to underestimate their risk of the disease and less likely to donate to charities. The marketing professor who undertook the study concluded that in an effort to make the matter of breast cancer seem less taboo, organisers had also drained the matter of its urgency. After all, it’s pink like Barbie.

In a literature review on gender-based violence awareness, authors found that such campaigns can end up describing a standard of behaviour. If audiences believe that violence is very prevalent, as they reasonably might when viewing such ads, the message can license “violent behavior rather than activating behavior to reduce [it]”. In other words, violence is normalised through its depiction.

The Butterfly Foundation runs a similar risk of normalisation with its campaign. It’s a high-profile, celebrity-studded effort that posits EDs as normal and as prevalent enough to ask us all to change our behaviour in order to prevent them.

The thing is, though, this campaign is really not aimed at anorexia patients.”

Of course, all reasonable people would like to see a reduction in the incidence of anorexia nervosa. This disorder, which has a lifetime prevalence of between 0.3% and 1.5% in females and between 0.1% and 0.5% in males, is horrifying. That treatment, if accessible, promises a very high rate of recovery would seem to make the task of “awareness raising” all the more urgent.

If we can save a few lives by making death and extreme disordered eating seem a lot more common than they are — and the campaign absolutely does this by conflating EDs, a diverse group of mental illnesses, many of which have no extreme physical side effects, with anorexia in stating they collectively “kill more Australians than any other psychiatric illness” — then what of it?

The thing is, though, this campaign is really not aimed at anorexia patients. Professor Susan Rossell, a highly regarded expert in EDs with qualifications and associations too several to cite, sees “awareness” of this type aimed chiefly at people with “super anxious body consciousness” rather than an actual illness.

Rossell says that campaigns that demand an end to bullying might have some benefit for some ED patients. But the at-risk anorexia patients whose mortality statistic is used as a call to action are unlikely to be rescued by the injunction not to “dis”.

While there are accounts of anorexia patients who suffered chiding for overweight in early life, this is just one tiny potential element of a complex range of influences, including biological and genetic ones, which can provoke ED. While some patients may report bullying as a factor in their disease, others may report endorsement. Just as the so-called “Pro Ana” and “thinspiration” online community of extreme dieting normalises anorexia, campaigns of the Butterfly type can do exactly the same. To the potentially anorexic mind, the “everybody’s doing it” nature of this campaign is as much of a catalyst as a “dis” or a size 4 pair of skinny jeans.

Scholars in anorexia and all ED commonly use the biopsychosocial model to explain this disorder range. While it might be nice to end the “dis”, it might be also of great benefit to legitimate patients, as opposed to the simply body conscious, to understand that their disease has more of the “bio” and less of the “social” than most of us suspect.

“All eating disorders have a strong biological component,” said Richard Newton, Austin Health’s medical director of mental health and board member of The Butterfly Foundation.  When I suggest that the foundation’s newest campaign continues to situate ED entirely in the realm of the social, he explains that the illness-shaping or “pathoplastic” effects of the culture can switch the disease on. There are, he says, historical accounts that describe anorexia some 3000 years old. The “Holy Anorexia” of ascetic women who sought to become pure through fasting was, says Newton, “apparently epidemic in the Middle Ages”. The culture can turn this genetic predisposition on and off.

But what this awareness campaign does not give us is any indication that the disease may be genetic. Researcher in risk factors for ED at the University of Melbourne Isabel Krug rattles off a list of studies on potential endophenotypes, heritability, genome wide association and other data that we lay people can trust to mean that these disorders, particularly anorexia, involve a genetic predisposition.

There are even emerging biomarkers for anorexia, and Rossell was lately involved in a study on a particular eye movement called the “square wave jerk”. It is my lay understanding that imaging for anorexia shows more evolved promise than for those in the study of all other psychiatric disorders. It’s odd that common wisdom, and a great deal of general medicine, treats a common mental illness like depression as a case of “chemical imbalance” or genes, and anorexia as purely the result of social factors like bullying or super-skinny ladies in magazines.

Depression, despite its lack of biomarkers and clear prevalence among those poor in social capital, is read as biological. Anorexia, despite great evidence of its biological basis, is read as social and The Butterfly Foundation certainly overplays this by recommending being nice to people as a cure for death.

I asked Rossell about our willingness to see anorexia as an entirely manufactured disorder and she said: “It’s because it occurs so often in young girls”. She is unwilling to elaborate much further but when I asked her if it was due to the assumption that young women are empty vessels whose untainted bodies just wait to be filled by the culture she makes an ambivalent noise.

She is not ambivalent, however, on the enduring refusal to study and describe anorexia as having a biological basis. “There are papers I have tried to publish and these have been refused on the grounds that I am trying to overly medicalise anorexia,” she said. “Of course the biopsychosocial model is one that should be observed. But if you continually refuse to acknowledge the ‘bio’ in that complex, then you will end up with no idea of how the different elements interact.”

With medicine so reluctant to commit itself to an explanation for ED, it’s hardly surprising that groups like The Butterfly Foundation would follow suit. But even if we agree that it’s better to take the potential social catalysts for EDs out of the picture, the “dis” campaign fails miserably on that score.

Let’s even allow that the foundation’s normalisation of extreme ED and selective mortality statistic will do no harm and just think about the phrase “don’t DIS my appearance”. Given that the most at-risk ED sufferers are those who are underweight and gain at least as much momentum from the compliments their tiny silhouettes routinely attract as they may have from an early life “DIS”, perhaps “don’t praise my appearance” might be a more effective tactic.

Approbation is, perhaps, even more hazardous to ED patients than condemnation. As Rossell suggests, many public conversations that purport to address ED patients are really just intended for gals who feel like they might be a bit unattractive. And even if making the super body conscious feel a bit better about their flab is considered a good outcome, the “don’t DIS” edict doesn’t even really work here.

If women, both those who suffer an ED and those who just feel a bit shit about their bodies, want to be liberated from the primacy of the image, then surely an obvious solution is to detonate the power of the image.

Here’s my campaign, free of charge, to The Butterfly Foundation next May. How about you try “completely DISregard my appearance”? And instead of using attractive ambassadors and expensive manicures to underscore the lack of importance of the image, try a picture of me after 24 straight hours of researching EDs in my pyjamas. I’ll show you just how visual perfection has very little currency in one adult human woman’s working life.



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black and white thinkingWhilst black and white thinking can make decisions and life simple, it stunts both growth as a person, expression, communication and the ability to perceive or discern what is around us. Another way of explaining black and white is polarised thinking.

I have been watching my two. Both are black and white. What I didn’t appreciate is there are levels of black and white. You would think black is the extreme end, but no, we get black black and white white. One child is black/white – the other is black black/white white on the same things.

Being unique beings, my two also have differing things that trigger the black/white thinking. Communication can be difficult and understanding each other’s perception is challenged because one is polarised on an issue the other isn’t. Then in trying to find common ground, they try another tactic which can trigger a polarised position in the other child.

Frustrating yes, confusing yes. For all of us. I mostly see all the shades of grey when dealing with others which in itself can be disabling. Procrastination and indecision haunt me, because I am always seeing all the different sides and choices. When dealing with myself, I am more black and white, hence the depression.

For good reading on black/white thinking, polarised thinking the links below are very good at explaining what it is and how to change thinking patterns. Those with Asperger, eating disorders, depression, anxiety, BDD etc, all suffer from this pattern of thinking and it challenges the recovery process.






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I wanted to share this lovely post from one of my readers. As a mum with two children struggling with an eating disorder she gives some great advice, hope and strength to those of use following a similar path. The reality of living with an eating disorder in the house is different for everyone. It is tough, frightening, painful and like living in some private, hellish parallel universe. What is also frightening is how strong a link there is from eating disorders developing and fathers who are absent, abusive and neglectful.


Hello everyone,

A swift update. My son Jordan [who likes to be called just J] ended up being sectioned and spending nearly two and a half months in the Huntercombe hospital, Stafford, UK. It was a nightmare trying to get him in the ambulance to take him on the 3 hour journey – his resistance and strength was superhuman – quite surprising for someone so weak with starvation. The dents in my freezer where he punched it is testament. I’d even struggled to disarm him when he’d grabbed a couple of bread knives and tried to stab the social workers. Once inside the hospital, he protested violently, kicked the furniture and finally fell to his knees, sobbing and breaking down totally. It was heartbreaking, but necessary. I was relived that he was finally where he needed to be. He was admitted weighing 8 1/2 stone after losing around 1/3 of his body weight. After admission his blood pressure dropped dangerously low. Thankfully the hospital staff saved his life and put him on the road to recovery. He hated it there, but was determined to do whatever it took to get himself out and he quickly and steadily gained weight. He was discharged weighing 10 stone, which is still very low for his height, but he is terrified of getting any heavier.

He is still firmly in the grip of anorexia and doesn’t really want to recover [although he tries to convince us that he has recovered.] Just like Sophie, for the first month he seemed to be doing well; he was perky and chatty, controlling his own food intake and maintaining his discharge weight. However he is now slowly losing weight again, even though he eats somewhere between 1700 and 2000 cals per day. He goes through periods of food obsession. At first he would only eat a variety of just a handful of ‘healthy’ foods; that changed and his calorie intake came largely from ‘healthy’ fluids, including lots of milk; now he’s gone to the extreme of eating mainly unhealthy food and drink, such as energy drinks, kitkats, fish and chips from the chippy and black coffee. He sees the CAMHS team regularly, but under duress. He refuses to co-operate and will only agree to being weighed and having a very brief consultation. He began haphazardly taking his anti depressants, just before stopping them completely, insisting he doesn’t need them. He refuses to see the medics and have tests re his curved spine and sleep paralysis, saying that he can’t stand being touched during examinations. Despite all of this, the old happy ‘normal’ J that we used to know – the one that used to joke around and the one who you could have an intelligent conversation with – does still exist and emerges fairly frequently. He is very changeable though, one minute he’s laughing and feeling optimistic about the future and making plans/setting goals and the next he’s angry and depressed and saying he didn’t ask to be born. He is frequently argumentative, aggressive, verbally abusive, selfish … it’s as if he’s possessed by the devil. I’ve learnt to keep my composure and walk away from him when he’s being nasty, telling him I refuse to talk to that other voice/creature. After a short time he will calm down and be nice and reasonable again and all the harsh words will have been forgotten. He never apologises though and has a complete lack of empathy for anyone else. The good thing is, he is truthful and admits his dieting had got out of hand, that it was all about control, that he does hear the ‘anorexic voice’ [saying, for example, that he used to grab a handful of cereal, put it in his mouth, but was then compelled to spit it out], that we had all been right, but that he had refused to listen, believing that we were all lying to him… He says he forces himself to ignore the Ana voice as he has no intention of ever getting sectioned again. He jokes that he’ll be visiting his younger sister Melissa in hospital when she gets sectioned. He tells me to stop worrying and that although he hates food, he knows he has to eat. He is aware that there is a strong chance of relapse and says he’s not going to let that happen. How can any parent not worry? Due to being malnourished for so long he now has low bone density and a curved spine and he has weakened his heart. He also has very poor short-term memory and constantly repeats himself. The hope is that he will settle at college next year, build up his confidence and find some happiness [he did try a college course this September but it was all too soon – all the anxieties and doubts flooded back and overwhelmed him and he had to drop out]. Thankfully he has a lovely supportive friend.

Melissa [now 15] is sliding down the same slope as J. After battling with her E.D and, for months being able to maintain her weight of around 8 1/2 stone [which is very low for her height of 5ft 8″], she is now losing weight again and struggles to tip the scales at 8 stone, fully clothed. She used to be a healthy 10 stone and a perfect size 10, but thought she was fat. She is very rigid in the handful of different foods that she allows herself and in her calorie intake, which is now only a few hundred per day. She still thinks she’s fat even though she is very thin. Thankfully she has a lovely CAMHS counsellor, who sees her weekly and her teachers/mentors at Bryn Elian school in North Wales are bending over backwards to support her – she is allowed to leave early and go in late on some days, has been able to drop unnecessary subjects and is allowed to learn maths at home. So the reduced school stress has resulted in an improvement in her confidence and mood. She is motivated to complete year 11 and pass her GCSEs and go to college next year. Hopefully she can stay healthy enough. Frequently though she gets so depressed, tearful, argumentative, nasty and even violent. Her eyes glare and something ugly speaks. It really isn’t her as the real Melly is gentle, loving, caring, helpful, beautiful and a joy to have around. Ana-Melissa sometimes threatens to self-harm. We have spent endless hours just talking and cuddling and crying together. [She’s so different to J who doesn’t do hugs]. Despite the fact she has many lovely supportive friends and lots of male admirers, she struggles to be happy. She feels constantly cold and her hair is falling out.

Their older brother and sister Andy and Shelly seem to have given up and feel that Mel is just an attention seeking difficult teen. It is difficult trying to convince them that neither J or M want to be this way, that they cannot help it, nor can they fight it alone. At least Mel had the strength to ask her school teachers and everyone else for help. I try to stay calm and understanding and supportive and positive thinking, however I’m not supermum and I sometimes can’t help raging and effing and blinding back at them. And yes, I’ve told them both to just grow up. I do get over my angry outbursts and frustration quickly though and both J & M know that I’m just releasing tension and that I’ll always be there for them, will always love them and will do whatever it takes to help them both back to health and happiness. My GP and the CAMHS team have told me to expect to be the punching bag and that this will be an up/down struggle for years, maybe a lifetime. There was only one time when I totally lost control, and that was when after the millionth time of going round and round in circles with Melissa I finally blew my top and yelled that I couldn’t take it any more. She had been my rock during our worst times with J and now she was sapping all my energy. Rather than hurt her or smash up the house as I so deeply desired at that moment, I stomped my way upstairs to my room, sat on my bed, gripped the quilt and, from the pit of my stomach, just screamed and sobbed and rocked backwards and forwards, yelling “why, why why”. This went on for a good 10 minutes until I had burst blood vessels in my face and I had nothing left inside of me. Shelly came up with a cup of sweet tea, spoke soothing words to me, told me everything’s going to be ok and helped me pull myself together. Meanwhile Melly ran outside and we found her sitting and just staring into space. Anorexia is an ugly powerful destructive demon. Daily I pray that J & M find the strength to overcome it.

If I could offer any parent advice I would say get your GP [pressure him/her if need be] to refer your child into the psychiatric services as soon as you know he/she is showing signs of a worrying eating pattern, and once there, if things don’t improve, push for admittance into an inpatient eating disorder unit/hospital. Remember, our kids will not/cannot just ‘snap out of it’. I was so angry with the old GP [we’re with a much more sympathetic and helpful one now] because he just dismissed us, saying nothing could be done unless J wanted help. He had a mocking, couldn’t-care-less attitude and told me I had no choice but to just wait until J got so ill that he’d be rushed into hospital, but by then it might be too late. I just sat there, stared at him with a look of shock horror and told him he has to get us some help. I didn’t move from my seat and just kept repeating that he has to help us. Eventually he said he would have a word with his colleagues at the local hospital and see what could be done. A few days later he phoned me to say that he had put a referral through to the Child and Adolescent services, but warned me that the waiting list was long and that we could be waiting weeks. Thankfully it only took 2 weeks.

My love and prayers go out to all who struggle with an eating disorder and all the families involved. It really is tough on everyone with all the stress and worry and constant walking on egg shells, not to mention the endless meetings with all sorts of professionals – psychiatric nurses, psychiatrists, doctors, family therapists, dieticians, school teachers/mentors/educational welfare officers… all this on top of having to earn a living.

Sorry I’ve gone on a bit! It helps to get the thoughts down. Mel also finds it therapeutic to diarise stuff that has happened in her life in relation to her father and what led to her eating disorder. She says that when she is older she will publish it on my website http://www.sharonkilby.co.uk/site/ The site exposes corruption in North Wales and the people responsible for forcing my children to live with their abusive father almost half their lives.

I have been shocked to learn that eating disorders are not so uncommon anymore. It seems that everyone knows someone who is suffering with one. Melissa knows 4 people in her school year who are sufferers. My boss knows 2 people who are anorexic, a friend of mine knows 2 anorexics [one of them fully recovered and went on to be happily married with child, the other person didn’t recover], my solicitor has an anorexic in her family… My God what is happening to our youngsters? Maybe EDs are symptomatic of the sick insane, evil society that we are forced to live in [more on that in my site.]

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Body Dysmorphia And Its Relationship With Eating Disorders

Article Contributed by Sharon McConville, MB, BCh, BAO (Eating Disorder Hope)

Body Dysmorphic Disorder (BDD), or Body Dysmorphia, is a condition that affects a person’s body image.  It is diagnosed when three criteria are met.  First, the sufferer must be either preoccupied with an imagined defect in their appearance or excessively concerned about a slight physical anomaly.  Secondly, the sufferer must be significantly distressed by their preoccupation or excessive concern with their appearance and/or be impaired in terms of what work-related and social activities they can participate in.  Finally, their preoccupation must not be better diagnosed under the heading of a different mental illness, such as anorexia, where body image is also a factor1.

What are the symptoms?

A person with BDD may be concerned about any part of their body, although skin, hair and facial features being involved most frequently2.  While many sufferers are preoccupied with their eyes, eyelids, nose, mouth or chin, it is also fairly common for the breasts or genitalia to be the site of the perceived defect3.  Some people have a very precise complaint about a particular feature; others have a vaguer perception of ugliness2.  Either way, people with BDD frequently attach strong personal meanings to their beliefs about their appearance.  For example, one man thought that his nose made him look like an unlovable crook; another thought that tiny flaws in his skin made him dirty2.  People with these kinds of beliefs usually expect other people to have the same beliefs about them and to evaluate them negatively because of their appearance, which is very disabling socially2.  Other people with BDD may realise –often having been told many times – that others do not perceive them to have a disfigurement; however, the perceived defect remains very real to them personally3.

Because people with BDD are so consumed with thinking about an aspect of their appearance, they often spend a lot of time either examining the perceived defect or trying to disguise it2.  For example, a sufferer may gaze at the mirror for excessive periods of time, engage in long personal grooming rituals, or attempt to camouflage the perceived defect with heavy make-up.  People with BDD may also attempt ‘DIY surgeries’ such as flattening the nose with tape or reshaping it by placing tissue paper inside, and many go on to seek cosmetic surgery2.  When surgery goes ahead, it is frequently perceived to be unsuccessful, while in cases where satisfaction is achieved, 50% of people with BDD have been shown to develop a preoccupation with a previously unaffected body part2.

People with BDD are at a high risk for depression and suicide, and have been shown to have a greater degree of distress than people with depression, diabetes, or bipolar disorder4.  They tend to avoid social situations because they do not want others to see and judge them, and because their perceived defect causes them to be afraid of dating or intimacy2.  They may employ unhelpful strategies to help them endure such situations, such as drinking alcohol to excess, or they may become housebound.  Because of this, attempts at following a course of study or taking part in paid employment are frequently disrupted.  All of these factors may lead to interpersonal difficulties with family members who cannot understand the extent of the disability which the person with BDD faces2.

Who gets Body Dysmorphic Disorder?

The proportion of adults living with BDD in the United States has been found to be 2.4%, with men and women affected equally5.  It commonly begins in adolescence at the time when people are most sensitive about their appearance, but many sufferers live with it for years before seeking help for fear that they will be considered vain2,3.  What is more, BDD is often under-diagnosed, partly because treating physicians are not good at recognising it6 and partly because patients tend to talk to healthcare professionals about other related symptoms such as anxiety or depression rather than revealing their underlying concern3.  Children can get BDD too, but they are often unable to articulate their problems; instead, signs that they are ill can include refusing to attend school and making plans for suicide2.

What causes Body Dysmorphic Disorder?

BDD is under-researched compared with other disorders of body image such as eating disorders.  There are both biological and psychological explanations for the development of BDD3.  In the biological model, a person has a genetic predisposition to the condition, which emerges after they are exposed to certain life stressors such as bullying or abuse.  Once BDD has developed, an imbalance in neurotransmitters such as serotonin may perpetuate the problem3.  In the psychological model, BDD is related to low self-esteem and a tendency to judge oneself according to appearance.  A person may develop false beliefs linking a perceived defect in their appearance to their worth as a person:  “If I am unattractive my life is not worth living”.  In this model, the BDD is then maintained by extreme self-focused behaviours such as appearance checking and comparing the feature perceived to be defective with that of other people3.  As further research is carried out, it is likely that a more inclusive bio-psycho-social model of illness causation will be developed.

Is Body Dysmorphic Disorder an eating disorder?

There is some overlap between characteristics of BDD and eating disorders including, for example, body image dissatisfaction and disturbance, rituals and behaviours relating to appearance, and a tendency to compare7.  However, although dieting can be a feature of BDD that involves a body part perceived to be large, eating and weight are not usually disturbed, and BDD is not diagnosed if an eating disorder is thought to be present.  People with an eating disorder can also be diagnosed with BDD and individuals who have both have been found to have more severe psychopathology7.  They may therefore require a more aggressive treatment plan.

How is Body Dysmorphic Disorder best treated?

At present, it is accepted that the treatment with the best evidence-base in BDD is a combination of an SSRI antidepressant with cognitive behavioural therapy (CBT)8.  A form of “exposure with response prevention” is usually included in CBT for BDD3.  This means that the patient is exposed to their fear – for example, of looking in the mirror or being seen in public without make-up – without being able to respond in the usual way, such as by covering up, so that he or she becomes used to the experience and begins to find it less distressing.  CBT can be delivered equally successfully to individuals or to a group of patients with BDD9.


Clearly, Body Dysmorphic Disorder is a complex and devastating illness that requires specialist treatment.  Problems occur when people are reluctant to ask for help or when health professionals fail to recognize the condition, so education and awareness campaigns are crucial.  While BDD is not an eating disorder, it can present to eating disorder professionals, who should be aware of the appropriate treatment and referral pathways.


  1. American Psychiatric Association, 2000. Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision. American Psychiatric Association.
  2. Veale, D: Body dysmorphic disorder. Postgraduate Medical Journal 2004;80:67-71
  3. Mind. Body dysmorphic disorder. Web address: http://www.mind.org.uk/mental_health_a-z/7990_body_dysmorphic_disorder Accessed May 29th, 2013
  4. Philips, KA: Quality of life for patients with body dysmorphic disorder. Journal of Nervous and Mental Disorders 2000;188:170-175
  5. Koran, LM et al: The prevalence of body dysmorphic disorder in the United States adult population. CNS Spectrums 2008;13:316-322
  6. Grant, JE, Kim, SW, Crow, SJ: Prevalence and clinical features of body dysmorphic disorder in adult and adolescent psychiatric inpatients. Journal of Clinical Psychiatry 2001;62:517-522
  7. Dingemans, AE et al: Body dysmorphic disorder in patients with an eating disorder: prevalence and characteristics. International Journal of Eating Disorders 2012;45:562-569
  8. Ipser, JC et al: Pharmacotherapy and psychotherapy for body dysmorphic disorder. Cochrane Database Systematic Review 2009;21:CD005332
  9. Prazeres, AM et al: Cognitive-behavioral therapy for body dysmorphic disorder: a review of its efficacy. Neuropsychiatric Disease and Treatment 2013;9:307-316
  10. Daily Mail (UK) http://www.dailymail.co.uk/femail/beauty/article-1195336/Body-dysmorphic-disorder-Four-beautiful-women-distorted-way-THEY-themselves.html Accessed May 30th, 2013

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I have been thinking more about the non-communication of my daughter’s medical diagnosis labels. One thing I do remember is our psychiatrist is not into labels. She rarely points out the obvious, prefering to focus on the person not the label. Good therapists will always do this. Remember you are not whatever eating disorder, mental health illness you have.

I also go through my Tumblr site reading the different entries. Some girls put up their diagnosis labels. One poor girl had 6. I find the girls are divided into two camps. One is proud of all their levels, put them out there like some sort of competition as to who is the most screwed up. The other lot are so weighed down by their labels, they have lost their identity and don’t see a way out of the labels. Regardless of what camp the girls are in, the two camps both have the same outcome. Recovery is impossible for me, cause I have so many labels.

Humans love to box things and label them. It is part of all our natures. We happily stuff everything into boxes, label it, put it away. It annoys and challenges us when we find something slightly different to the boxes and labels we already have. So we created another box with another label. Soon we have so many boxes and labels that we need another label to organise all the original boxes and labels. For example there any now so many ‘exoria’ labels, that it is hard to tell what is acknowledge by the medical profession and what isn’t.

Categorical labeling is a tool that humans use to resolve the impossible complexity of the environments we grapple to perceive. Like so many human faculties, it’s adaptive and miraculous, but it also contributes to some of the deepest problems that face our species. (http://www.psychologytoday.com/blog/alternative-truths/201005/why-its-dangerous-label-people)

Sophie, as you all know, is anxiety ridden and the more things wrong with her the heavier the weight. Just finding out she has haemochromatosis and asperger was enough to flatten her for a while. Thinking through our psychiatrist’s omission, I know she is right. Sophie did not need to know at a younger age that she is BDD and has a social anxiety disorder. But now as an adult I do think she needs to know at some stage – lets at least wait until after HSC. I also think as the parent, I should have been told. There were enough times when I was the sole occupant of the therapy room when that information could have been imparted.

Medical labels are important, they let medical professionals know what is wrong, how to treat, how to provide appropriate care and understanding to the patient. In the mental health world though, care needs to be take just how much we fling labels around. The labels themselves can contribute negatively and stigmatise a person. It shapes the perception of not only the person themselves, but of those interacting with the person. Some labels we give those with mental health illness are short-term things and would bring more pain and negativity than needed if known. Anorexia in its most intense stages, mimics other illnesses and also brings out other ‘behaviours’ that could be interpreted as another comorbid illness. Often once the anorexia is brought under reasonable control, weight is restored and the mind recovers to some extent, some of the other behaviours disappear. Sophie’s OCD is a good example. It only presents when she is very sick with anorexia.

It is a wise medical professional who only diagnosis anorexia until further therapy and recovery is underway before considering other medical diagnosis.

I hope this all makes sense, it is hard to express in an intelligent way exactly what I am trying to say. Research also backs up the negativity of labelling and being careful how we apply them and when.

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It has always been made clear verbally that Sophie has only ever suffered from anorexia. She has anxiety but not a disorder. She has no other co-morbidity illnesses or addictions, only the high functioning aspergers.

Until …

Filling in the equity assessment forms for university entrance, each need a statement from her psychiatrist. We have got these types of statements before for getting her through the HSC and school certificate exams. This time was different.

There clearly on the page was … “suffered from anorexia nervosa, body dysmorphia disorder, and social anxiety disorder“. Umm, hello!? Was anyone ever going to tell her parent, if not the patient herself.

We are over 3.5 years after diagnosis of the anorexia itself, surely somewhere along the line somebody could have mentioned the other two.

When were these diagnosis made and why. Understanding and learning from our end would have been beneficial. I assume Sophie’s counsellor knows of the labels as she keeps in close weekly contact with the psychiatrist.

So another ‘talk’ with the psych to find out ‘what the …’ and get a full explanation. That will happen in a couple of weeks. Sophie saw her counsellor today and I think they actually tackled how to express her feelings – particularly to her dad. In a positive way not a negative way that immediately breaks down communication. Thankfully her counsellor has given her several sessions from now to the end of year. Leave it up to Sophie and no appts would have been made.

mental health labels

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              With thanks from the NEDC website


1. Background to DSM-5

2. Overview of changes

3What does this mean?

4. Where to find out more

1. Background to DSM-5

eating disorders clinician

The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association (APA), is the manual used by many clinicians and researchers to diagnose and classify mental disorders.

Since it was first published in 1952, the DSM has been the diagnostic benchmark for many psychiatrists and psychologists. Each time the manual is updated, new conditions are introduced and some are removed, often amid controversy.

The previous version of the DSM was completed nearly two decades ago and since that time there has been a wealth of new research and knowledge about mental health. The publication of the fifth edition of the DSM (DSM-5) has been a much anticipated event for mental health professionals and marks the end of more than a decade’s journey in revising the criteria for the diagnosis and classification of mental health disorders.

The revision process, coordinated by the APA, brought together over 500 clinicians and researchers in designated Task Forces and Working Groups. The DSM-5 Eating Disorders Work Group was charged with improving the diagnostic categories and classification of the eating disorders based on the best available empirical data. A Scientific Review Committee of mental health experts reviewed and provided guidance on the strength of the evidence of proposed changes.

This most recent revision of the DSM was formally launched in May 2013.

2. Overview of Changes

clinician male

During debates on the Diagnostic and Statistical Manual of Mental Disorders (DSM) revision there were various proposals for eating disorders. The American Psychiatric Association (APA) has indicated that one of the primary goals in the changes made in this version of the DSM is for more people experiencing eating disorders to have a diagnosis that accurately describes their symptoms and behaviours.

The DSM-5 approach to eating disorders has ultimately been relatively conservative: to retain anorexia nervosa and bulimia nervosa with more inclusive criteria and to introduce binge-eating disorder as a distinct diagnosis. The manual has also organised feeding and eating disorders together.

Below, we overview the changes in this latest version of the DSM.

What diagnostic categories are included in the DSM-5?

The DSM-5 includes the following diagnostic categories:

  • Anorexia nervosa (AN)
  • Bulimia nervosa (BN)
  • Binge-eating disorder (BED)
  • Avoidant/restrictive food intake disorder (ARFID)
  • Pica
  • Rumination disorder.

For each specific eating disorder diagnostic category a clinician is now required to specify state of remission if applicable:

  • A person may be considered in partial remission where after full criteria were previously met, some but not all criteria have been met for a sustained period of time
  • A person may be considered in full remission if full criteria were previously met but no criteria have been met for a sustained period of time.

Two new categories have also been included to capture clinically significant feeding and eating behaviours which do not meet the criteria for the disorders above.

Other Specified Feeding or Eating Disorder (OSFED) refers to situations where a person has clinically significant feeding and eating disorder symptoms but does not meet the full criteria for another diagnostic category. Examples of this category include;

  1. Atypical anorexia nervosa (e.g. weight is within normal range)
  2. Bulimia nervosa (e.g. low frequency and/or limited duration)
  3. Binge-eating disorder (e.g. low frequency and/or limited duration)
  4. Purging disorder (e.g. purging in the absence of binging)
  5. Night-eating syndrome
  6. Bulimia nervosa (e.g. low frequency and/or limited duration of inappropriate compensatory behaviours)
  7. Binge-eating disorder (e.g. low frequency and/or limited duration of binge eating episodes)

Unspecified Feeding and Eating Disorders (UFED) are clinically significant feeding or eating disorders that do not meet the criteria for another eating or feeding disorder.

What are the changes to anorexia nervosa (AN)?

Several minor but important changes have been made to the physical and cognitive criteria for AN:

  • Criteria no longer require the patient’s weight for height to be less than 85% of that expected
  • Cognitive criteria, such as fear of weight gain and shape and weight overvaluation, no longer need to be self-reported and can be inferred by behaviour or by parent report for young people
  • The DSM-IV Criterion D requiring amenorrhea or the absence of at least three menstrual cycles has been deleted.

Body Mass Index (BMI) has been used to specify the level of severity; based on BMI for adults and BMI percentile for children and adolescents. In adults, severity is indicated by:

  • Mild; BMI less than or equal to 17
  • Moderate; BMI between 16 and 16.99
  • Severe; BMI between 15 and 15.99
  • Extreme; BMI less than 15

What are the changes to bulimia nervosa (BN)?

DSM-5 criteria have reduced the frequency of binge eating and compensatory behaviours that people with bulimia nervosa must exhibit from twice a week to once a week. In addition, the purging and non-purging subtypes have been removed.

Frequency of inappropriate compensatory behaviours has been used to specify the level of severity for BN. Severity is indicated by:

  • Mild; An average of 1-3 episodes per week
  • Moderate; An average of 4 – 7 episodes per week
  • Severe; An average of 8-13 episodes per week
  • Extreme; An average of 14 or more episodes per week

What are the changes for binge eating disorder?

Binge Eating Disorder has been included in DSM-5 as its own category of eating disorder. In DSM-IV, binge-eating disorder previously fell under the general category of Eating Disorder Not Otherwise Specified (EDNOS).

Binge eating disorder is defined as recurring episodes of eating significantly more food in a short period of time than most people would eat under similar circumstances, with episodes marked by feelings of lack of control. A person will be distressed and may have feelings of guilt, embarrassment, or disgust. This disordered binge-eating behaviour occurs, on average, at least once a week over three months.

Frequency of binge eating episodes has been used to specify the level of severity for Binge Eating Disorder. Severity is indicated by:

  • Mild; An average of 1-3 episodes per week
  • Moderate; An average of 4 – 7 episodes per week
  • Severe; An average of 8-13 episodes per week
  • Extreme; An average of 14 or more episodes per week

Where has EDNOS gone?

DSM-5 has replaced the ‘not otherwise specified’ (NOS) designation throughout the entire manual.

People who have previously been diagnosed with EDNOS may now meet the full criteria for one of the other DSM-5 eating disorders. Alternatively, they will be assessed as having either OSFED or UFED as detailed above.

What is avoidant/restrictive food intake disorder (ARFID)?

ARFID is characterised by restrictive or inadequate eating that is not due to medical or psychiatric co-morbidity and cannot be attributed to disturbances in the perception of shape and weight. There are three common clinical presentations to ARFID;

  • individuals appear to lack interest in food or to have a blunted response to physiological hunger
  • individuals avoid eating because they do not like the smell, taste, texture, temperature, or appearance of food and will only eat a narrow range of foods
  • individuals restrict intake as a reaction to a previous upsetting event, usually a gastrointestinal experience such as choking.

ARFID occurs predominantly in children but can also occur in adults.

3. What does this mean?

Many of the changes in DSM-5 attempt to better characterise symptoms and behaviours of groups of people currently seeking clinical help who did not meet definitions in DSM-IV.

Although the DSM-5 criteria appear to capture clinical variance better than DSM-IV, an important question remains concerning the prognostic validity of the DSM-5 categories. Moving forward, there is a call to adhere to an open and transparent process so that feedback can enhance the validity and clinical utility of the DSM-5.

Should I start using DSM-5 for diagnosis?

DSM-5 can be used immediately for diagnosis. It contains the most up-to-date criteria for diagnosing mental health disorders. It is recommended that clinicians learn about diagnostic and coding changes and transition to the new manual. This may mean that clinical, research, and administrative forms require updating too.

How does DSM-5 relate to ICD-10?

The International Classification of Diseases (ICD) is the World Health Organisation’s (WHO) standard diagnostic tool for epidemiology, health management and clinical purposes. It is used to monitor the incidence and prevalence of diseases and other health problems. ICD-10 was endorsed by the Forty-third World Health Assembly in May 1990 and came into use in WHO Member States as from 1994. The 11th revision of the classification has already started and will continue until 2015.

The DSM and ICD have much in common, but they are not identical. They should be thought of as companion publications.

The DSM-5 includes coding for ICD-9-CM and ICD-10-CM, to allow ‘cross-walking’ to the corresponding code in ICD. Government-funded health settings in Australia use ICD-10-AM, the Australian modification.

Are there diagnostic and assessment tools for DSM-5?

The Eating Disorder Examination has been validated as a diagnostic instrument for some DSM-5 eating disorders. At present, no comprehensive diagnostic or assessment measures for DSM-5 exist. Until these become available, clinicians are advised to continue using previous validated diagnostic interviews, such as the EDE, Structured Clinical Interview for DSM (SCID), and the Structured Interview for Anorexic and Bulimic Disorders (SIAB-EX), and assessment instruments, such as the Eating Disorder Examination-Questionnaire (EDE-Q), Eating Disorder Inventory (EDI), and Eating Attitudes Test (EAT).

How will this affect different sectors?

We have asked individuals from a few different affected health sectors how they anticipate these changes will impact on their professional practice.

Gabriella Heruc, Accredited Practicing Dietician
“The changes in DSM-5 will likely result in more individuals meeting diagnostic criteria for feeding and eating disorders. In dietetic practice, this highlights the importance of early identification and appropriate management of these conditions, with particular focus on ARFID, binge eating disorder and anorexia nervosa. The ARFID diagnosis is significant for dietetic practice, with ‘fussy eating’ and food avoidance being common concerns in both paediatric and adult settings, often resulting in growth and weight concerns, as well as nutritional deficiencies. Dietitians also see many overweight individuals struggling to lose weight, often due to binging and comfort eating. In anorexia nervosa, the removal of the amenorrhoea criteria and clarification of the low body weight criterion are also significant in nutritional management. Improved education around identification and treatment of feeding and eating disorders is now even more important for both specialist and non-specialist dietitians.”

Kirsty Greenwood, National Manager, Support, Education and Collaboration, The Butterfly Foundation
“For consumers and their loved ones, while the changes to the DSM V criteria for eating disorders might in the longer term assist with more accurate diagnosis and treatment of new cases, in the short term they are likely to bring up a degree of confusion and stress. Consumers with current eating disorders may now be unsure of what category their disorder is now in, and how this impacts on their diagnosis, services and supports they may have been accessing. For many consumers there is an identity factor in the diagnosis they hold, and so they may find it difficult to make the transition into whatever new diagnosis now best reflects their presentation. There may also be an impact on how they explain their illness to others, both to clinicians who may not specialise in eating disorders, and family and friends for whom this relabelling might cause further confusion in understanding an already complex and very misunderstood set of disorders.”

4. Where to find out more

We are interested in your thoughts and questions about the DSM-5 and what these changes might mean to you. If you have any questions, comments or thoughts about the DSM, or would like more information please contact us at info@nedc.com.au. Your feedback will help us develop more relevant resources about diagnosis and treatment of eating disorders. We will also endeavour to help you find the information you need about eating disorders diagnosis.

You can find out more about diagnostic tools online. The ICD-10 diagnostic tool is freely available from the World Health Organisation and the American Psychiatric Association (APA) has a dedicated website for the DSM-5, including a form to provide feedback. You can also purchase the DSM from the APA, online book stores and professional associations such as the Australian Psychological Society.

If you’re interested in further reading on the DSM-5 and its implications for eating disorders, you can access the following articles in our online Knowledge Hub:

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