It was recently brought to my attention through an online discussion forum that a significant impasse could well exist concerning the diagnosis of anorexia nervosa.

The problem pertains to the first symptom listed in the DSM-IV`s diagnostic criteria for anorexia – that, “body weight is maintained at 15% below that expected”. The contention in question forces consideration of a hypothetical pertaining to an obese individual who begins suffering from anorexia. In such a scenario, it would presumably take a far longer than usual time for this patient`s body weight to drop to 85% of “that expected”, and hence, the diagnosis of anorexia nervosa cannot be made. The antecedence of this discussion focused on the factor of early treatment intervention, and whether or not the patient in question would be denied the concession of this all-important anticipatory attention.

The diagnostic criteria for anorexia nervosa is comprised of four parts. For a successful diagnosis to be made it is a requisite that the whole criteria be met, which means it is expedient that the patient must also satisfy the first criterion pertaining to body weight. However, when presented with the extenuating circumstance of an obese patient, a considerable obstruction now exists. I have never read any literature pertaining to the diagnostic differential of an obese patient. Although one may justifiably assume, that in the case of a five-faceted criteria such as this, when it is also specified that each and every criterion must be met in order to conclude the diagnosis, then any given anorexic individual – obese or not – is going to also be exhibiting the other four of the five symptoms that structure the criteria embodiment. Therefore, in the case of the obesity sufferer, it should be blatantly apparent to friends and family that there is a significant problem afoot – even though a successful diagnosis, at this time, cannot be made. Let us remember, that it is by no means a requisite for a person to acquire a diagnosis before he or she becomes eligible for psychiatric care. A hospital does not refuse to provide treatment for an individual admitted with severe stomach pains simply because they are unable to locate, and diagnose, the cause of the pain. And the psychiatric system would never behave in such a coequal manner.

For the sake of reference, and for the benefit of the interested reader, I shall now provide a brief overview of the remaining criteria for anorexia nervosa, as dictated by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV):

– “There is weight loss that is self-induced by avoidance of “fattening foods” and one or more of the following: self-induced vomiting; self-induced purging; excessive exercise; use of appetite suppressants and/or diuretics”.

– “There is body-image distortion in the form of a specific psychopathology whereby a dread of fatness persists as an intrusive, overvalued idea and the patient imposes a low weight threshold on himself or herself.”

– “A widespread endocrine disorder involving the hypothalamic-pituitary-gonadal axis is manifest in women as amenorrhoea and in men as a loss of sexual interest and potency. (An apparent exception is the persistence of vaginal bleeds in anorexic women who are receiving replacement hormonal therapy, most commonly taken as a contraceptive pill.) There may also be elevated levels of growth hormone, raised levels of cortisol, changes in the peripheral metabolism of the thyroid hormone, and abnormalities of insulin secretion.”

– “If onset is prepubertal, the sequence of pubertal events is delayed or even arrested (growth ceases; in girls the breasts do not develop and there is a primary amenorrhoea; in boys the genitals remain juvenile). With recovery, puberty is often completed normally, but the menarche is late.”

In the case of the obese patient then, the doctor may formulate a diagnosis that looks something like this:

Axis 1. Self-induced vomiting secondary to a marked distortion of body image (rule out anorexia nervosa, bulimia nervosa, body dysmorphic disorder)
Axis 2. None.
Axis 3. Intermittent gastric pain secondary to repeated vomiting (rule out gastric disorder)

You will have to forgive my lack of knowledge on the following matter, but at present I am actually unsure as to whether or not there is an existing `borderline` diagnosis with regards to eating disorders. If this was the case, however, then the obese patient could, in theory, be given a diagnosis of `borderline anorexia nervosa`.

We have now concluded a brief overview of the diagnostic criteria for anorexia nervosa. It may now be of value to pay particular attention to the symptoms we have just looked at, some of which were `objective`, others being `subjective`. By subjective we mean the symptoms of which we must rely upon the patient to relate to us; such as a distortion of body image. Objective symptoms are those symptoms that we can see for ourselves, as with weight-loss or inhibited pubic development. In the diagnostic criteria we have just reviewed we have seen a total of two objective symptoms, one subjective symptom, and one both objective and subjective symptom. Therefore, when we consider also our primary objective symptom (pertaining to body weight), we now have a criteria comprised largely of objective symptoms, with the exception of one – of which, incidentally, the remaining four become secondary – and one more symptom which has the potential to manifest itself to us in an objective form. In our hypothetical of the obese patient, however, it is unfortunate that we do lose one of these objective symptoms. Though this should exist as no crimp in the smooth functioning of our ever-objective eye… A rapid, unexplained weight loss, in whatever circumstance, should always point towards the possibility that there is an underlying abnormality at large. We should still be capable of detecting the problem.