In this issue, Dr. Pierre Leichner, an experienced eating disorders clinician and researcher, offers a thoughtful and somewhat provocative perspective in his presentation of the program that he and his colleagues are evolving in Vancouver. His concerns about the limitations of the DSM system for categorizing so-called comorbidities in patients with anorexia nervosa will be sympathetically received by many clinicians. Multiple DSM-IV labels offer descriptive glyphs with which to characterize the variety of patients’ clinical complexities but, to my mind, assigning multiple diagnostic labels does not really indicate that a patient has several distinct diseases. She is who she iseach person has her unique set of features and characteristics. Each person makes her own sets of waves, but some of the waves reach sufficient height and threshold to trigger different descriptive labels. Clearly, one person’s anorexia nervosa is not another person’s anorexia nervosa, but until the DSM-V comes alongwith greater appreciation for dimensionality for examplethe DSM-IV is the administrative tool we use to communicate these variations on a theme.

Just as interesting is the forceful statement Dr. Leichner makes regarding nasogastric feeding. Obviously, his program is designed for voluntary patients who are not at grave risk for physiological collapse. But, even in Vancouver, in the event that a patient with anorexia nervosa was starving to the point of physiological instability, she would undoubtedly be hospitalized on a general medical service where, if circumstances required and she did not eat enough by mouth, it’s highly likely that nasogastric feeding would be utilized as a safety measure. However, she would not be eligible for Dr. Leichner’s program until she chose to voluntarily eat without the aid of nasogastric feeding. Dr. Leichner’s argument that some of the pressures to use nasogastric feeding are directly connected to economically driven desires to reduce the length of hospital care is well taken, and there is probably some validity to it. However, I don’t believe that’s the entire story.

From my perspective, nasogastric tube feeding continues to be a matter of some controversy. Experienced eating disorders clinicians would agree that nasogastric tube feeding should never be used coercively, as a “negative reinforcer” or punishment, and that with patients who defiantly refuse to eat at all, nasogastric feedings should be used in as humane a manner as possible to sustain life. More controversy revolves around questions regarding the utility of nasogastric feeding to hasten weight gain, particularly when this stems from pressures to severely reduce lengths of hospital stays. With voluntary patients, who accept the idea that supplemental nasogastric feeding might help weight gain and reduce hospital stay, several programs at National Children’s Hospital and at Remuda Ranch, have now shown a modest weight advantage for adding supplemental nasogastric feedings to patients who are willing to accept this protocol, and no major acute disadvantages have been reported (Robb AS, Am J Psychiatry 2002;159:1347; Zuercher JN et al, J Parenteral and Enteral Nutrition 2003; 27:268). However, these studies may have pre-selected more highly motivated patients in the first place (those who want to get out faster). Furthermore, no post-hospital follow-up data are available yet, so we do not know if there are any longer-term differences in relapse or weight loss between those treated with supplemental nasogastric feedings during hospitalization. The conservative interpretation of available data would suggest that for patients who fully understand and buy into the rationale for supplemental nasogastric feedingnot to replace eating usual foodsthese programs may help a bit and don’t appear to hurt, at least in the short run. One rationale is that although some individuals are incapable of actively feeding themselves, they may find it easier, psychologically, to allow themselves to be fed, even by nasogastric tube.

I invite readers to share their experiences and perspectives, and suggest that additional empirical study of short-term outcomes and longer-term impact would help shed additional light on this controversial area.

J.Y.