In the first part of this essay I am going to be discussing the DSM-5 diagnosis criteria of eating disorders; Anorexia Nervosa, Bulimia Nervosa and Binge Eating Disorder. I will also differentiate the diagnosis and discuss the hallmark features of each disorder.
In the second part of the essay I will discuss eating disorders in South Africa, will also talk about the “African body” and how black South African females are no longer “immune” to eating disorders.
When one thinks of eating disorders, the first thought that comes to mind is of a person who has a problem with food. The person either eats too much or eats little to no food. However, Taylor et al (2006) defines eating disorders as being marked by extremes, “they are persistent when a person experiences very extreme disturbances in their eating behaviour”, for example, the person may reduce their food intake or may start overeating, some people tend to experience feelings of extreme fear and distress about their body size and shape. According to Wilson and Shafran (2005), a person who has eating disorders may have at one point started eating smaller portions of food than normal, but then at some point the urge to eat less or more food became out of control. Taylor et al (2006) states that for many people, eating disorders rear its head during the stage of adolescents or young adulthood, it also seems that women and girls are more prone to eating disorders compared to their male counterparts.
Eating disorders are real and treatable medical illnesses with complex underlying psychological and biological causes (Taylor et al, 2006). Taylor et al (2006) further adds that these disorders usually co-exist with other mental problems such as depression, anxiety and many more. The diagnosis of eating disorders can be very complex to say the least as some symptoms that are present in the person being diagnosed can be as a result of other underlying problems and not necessarily that of eating disorders. The diagnosis of eating disorder is done using the DSM-5 criteria. According to APA (2013), the DSM-5 criteria contains a set of diagnostic criteria, these are the symptoms being experienced by the individual. Using the DSM-5 diagnosis criteria, I am going to list the diagnostic criteria of Anorexia Nervosa, Bulimia Nervosa and Binge Eating Disorder. I will also include the Hallmark features and the differential diagnosis.
According to the APA (2013), Anorexia Nervosa primarily affects adolescents and women in early adulthood. Anorexia is characterised by a distorted body image and excessive dieting that leads the person to severe weight loss and an extreme fear (phobia) of becoming fat (Jones et al, 2012).
According to the DSM-5 criteria, for a person to be diagnosed as having anorexia the person must display the following:
• The person will have a persistent restriction of energy intake which will lead to a significantly low body weight (in the context of what is expectable for the persons age, gender, developmental trajectory and their physical health).
• The person will either have an intense fear of gaining weight or becoming “fat”, or persistent behaviour that interferes with weight gain even if its just a little weight gain.
• There will be disturbances in the way the person experiences their body weight and shape, undue influence of body shape and weight on self-evaluation, the person will also have a lack of recognition or be in denial on the seriousness of their current body weight.
Anorexia Nervosa has two subtypes, which are:
1. Restricting type
2. Binge-eating/purging type
According to Lock et al (2015), the DSM-5 suggests that the severity of Anorexia Nervosa be rated in levels from mild to extreme. In adults, the rate will be based on their body mass index (BMI) and in young children and adolescents will be based on their age, and gender norms according to the BMI percentile (Couturiet and Lock, 2006).
Hallmark features of Anorexia Nervosa
According to Keys et al (1950), the mail psychological features of anorexia is the persons extreme over evaluation of body shape and weight. People who have anorexia also have the physical capacity to tolerate extreme imposed weight loss (Keys et al, 1950). Food restriction is not the only aspect that anorexic people use to lose weight, they also tend to exercise excessively for them to lose weight, they also gravitate more towards activities that keep them active, such as participating in sports like athletics. Purging practices include self-induced vomiting, the misuse of laxatives and diet products like pills. According to Keys et al (1950), patients practice body checking rituals like constantly weighing and measuring themselves, they also use mirror gazing and many other obsessive behaviours to reassure themselves that they are still thin.
There are many possible reasons that may cause a person to lose a lot of weight. Many people may have a low or a complete loss of appetite because of being ill causing them to refuse to eat. According to Bryan-Waugh and Kriepe (2012), the differential diagnosis for anorexia include avoidant restrictive food intake disorder and rumination disorder, when these disorders have resulted in the person having low weight. Many medical and psychiatric conditions that lead to changes in a person’s appetite, weight or changes in their food intake are likely to develop into eating disorders (Lock et al, 2015). Other aspects that may complicate the diagnosis of anorexia are the persistence of psychiatric disorders such as depression, anxiety and obsessive-compulsive disorder (OCD), substance use and abuse disorder and many others can be diagnosed (Godart et al, 2002). According to Lock et al (2015), anorexia and OCD share the same obsessive preoccupations such as over eating, weight and shape checking, compulsive behaviours such as restricting as well as counting calories, exercising excessively and the like, this makes it difficult to differentiate these two disorders.
According to APA (2013), bulimia is characterised by the frequent episodes of binge eating which is then followed by inappropriate behaviours such as self-induced vomiting to avoid gaining weight. Unlike anorexia, people who have bulimia fall within the normal range of weight for their age and gender (Taylor et al, 2006).
According to the DSM-5 criteria, for a person to be diagnosed with bulimia, they must display the following:
• The person must have recurrent episode of binge eating, these episodes are characterised by the following:
1. The person will eat in a discrete period of time (for example, within any two-hour period) an amount of food that is larger than what most people would it in the same time period and under the same circumstances.
2. The person will have a sense of lack of control over their eating during these episodes (for example, the person feels like they cannot stop eating or control what or how much they are eating).
• The person has recurrent inappropriate compensatory behaviours to prevent them from gaining any weight, these include self-induced vomiting, the misuse of laxatives, diuretics or other medications, fasting and or exercising excessively.
• The binge eating and inappropriate compensatory behaviours both usually occur on average at least once a week for a period of three months.
• Self-evaluation is always influenced by the persons body shape and weight.
• The disturbances do not occur exclusively during episodes of anorexia.
Hallmark Features of Bulimia Nervosa
People wo have bulimia tend to be slightly overweight or of a normal body weight compared to those with anorexia (Taylor et al. 2006). According to Varcarolis (2011), the hallmark features of bulimia are excessive intake of food (binge eating), with some behaviours of purging to maintain body weight. Purging behaviours include self-induced vomiting, using laxatives, diuretics and other medications (APA, 2013). Other behaviours that involve maintaining body weight may include fasting for a prolonged period of time, exercising excessively and even using diet pills wrongly. Purging is used by approximately 80% to 90% of people who present for treatment at eating disorder clinics (Varcarolis, 2011).
According to Lock et al (2015), the differential diagnosis of bulimia usually includes anorexia, binge/purging type, binge eating disorder, purging disorder and the like. There are many other psychiatric disorders that may be associated with bulimia, these disorders include anxiety disorders, the use and abuse of substance disorders as well as personality disorders (Godart et al, 2002).
Binge Eating Disorder
Binge eating disorder was approved for inclusion in the DSM-5 criteria as its own category of eating disorder, whereas before it in DSM-IV it was not recognised as a disorder but fell under the category of “eating disorders not otherwise specified” (APA, 2013). Taylor et al (2006) says that binge eating disorders are characterised by recurrent binge eating episodes, whereby the person feels they do not have any control over their eating, because of this, people who binge are usually overweight. Once the person has binged the have feelings of guilt and shame towards what they have done.
According to the DSM-5 criteria, for a person to be diagnosed with binge eating disorder they must display the following:
• The person must have recurrent episodes of binge eating. An episode of binge eating can be characterised by the following:
1. Eating in a discrete period of time (usually within a two-hour period) an amount of food that is larger than most people would actually eat during the same period of time and under the same circumstances.
2. The person feels like they have a lack of control over their eating during these episodes (for example, feeling like they cannot stop eating or they cannot control what or how much they eat).
• The binge eating episodes are usually associated with three or more of the following:
1. Eating much more rapidly than usual.
2. Eating to the point where one feels uncomfortably full.
3. Eating too much food even when the person does not does not feel physically hungry.
4. Eating alone because the person feels embarrassed about the amount of food they are eating.
5. The person feeling disgusted with themselves, depressed or feeling very guilty after eating.
• Marked distress regarding binge eating is present in the person.
• The person binge eats on average once a week for a period of three months.
• Binge eating is not associated with the recurrent use of inappropriate compensatory behaviours as in bulimia and it does not occur exclusively during the course of bulimia or anorexia methods to compensate for over eating such as self-induced vomiting.
Hallmark Features of Binge Eating Disorder
In binge eating disorders, eating binges are much like those of bulimia, but the main hallmark features distinguishing bulimia and binge eating disorder is the inappropriate compensatory behaviours subsequent to binge eating (Fishman, 2005).
Lock et al (2015) talks about the differential diagnosis of binge eating disorder being inclusive of bulimia, anorexia, night eating syndrome and noncontinuable sleep related eating disorders. Hudson et al (2007) states that when diagnosing BED other medical reasons for binge eating should be considered like CNS tumours, gastrointestinal pathology, to name a few. In adults the presence of binge eating disorder is associated with significant comorbid psychopathology, including control disorders, substance use and abuse disorders as well as personality disorders (Hudson et al, 2007).
Similarities and Differences
In many ways one can say that Bulimia and Binge eating disorder are very much similar to one another, they both have to do with eating too much food at short intervals of time where as in bulimia the person is worried about their weight and participates in compensatory behaviours that ensure that the person does not gain any weight. In binge eating disorder the person does not use any compensatory behaviours to ensure weight is gained, instead, people who binge eat tend to be overweight. Anorexia is completely different to bulimia and binge eating, a person with anorexia tends to eat little and to use compensatory behaviours to lose weight, people with anorexia are obsessed with being thin and have ab extreme fear of being fat. These three disorders are similar in the sense that they are usually underlined by other mental and physical disorders.
In conclusion, as it has been mentioned before, eating disorders are very much but are also treatable, and that a person who has an eating disorder might also have other underlying psychological and biological disorders. In many ways the three eating disorders discussed in this essay are similar to one another and yet so unique. One aspect that makes them similar to each other is the fact that other disorders tend to be present in their presence, so it is therefore important to take not of past history of disorders that a patient might have before actually diagnosing the person with and eating disorder.
Eating disorders, a phenomenon that many in south Africa would consider as being a strictly white girl illness, Le Grange et al (2004) says that in South Africa, eating disorders are typically viewed as being an exclusive domain of white South African women, these are women who are in the economic elite and are linked to the Western cultural ideals. However, surveys that were conducted in racially diverse groups of women in South Africa suggested that non-white South African women may in fact not be immune to eating disorders. In South Africa, eating disorders among black women were first reported in 1995, having it previously documented among white South African women since the 1970s (Szabo et al, 1995).
The African Body
In Africa, the African body can be defined by a fuller and curvier figure, which can at times be considered as overweight.