Genuine Disorder or Diagnostic Fad?

A number of new eating disorders syndromes are being considered for inclusion in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). Among these are disorders that were first discussed on the Internet, including purging disorder, bigorexia, and pregorexia, for example.

Dr. Walter Vandereycken and his colleagues at Catholic University of Leuven in Belgium wondered which proposed eating disorders might survive the process to formally become “new” eating disorders. Dr. Vandereycken, a longtime member of the EDR Editorial Board, and his colleagues developed a study to see if four new proposed eating disorders were familiar to other eating disorders professionals (Eat Disord 2011; 91:145)in press).

A group of 472 Dutch-speaking professionals involved in the research, prevention, or treatment of eating disorders were mailed an email questionnaire; they could remain anonymous. The four newly proposed eating disorders selected for the survey were: night eating syndrome, orthorexia, muscle dysmorphia, and emetophobia. Of the 172 responses received, 111 were complete enough to be included in the study results.

Night eating syndrome, which was described more than 50 years ago by Stunkard, Grace, and Wolfe, resurfaced with the discussion around binge eating disorder and the DSM-V. There are proponents and opponents of the validity of night eating syndrome as a stand-alone diagnosis. Orthorexia was first described in an article by Bratman in 1997, who wrote about “health food junkies” who are so obsessed with healthy food that their selective eating pattern may lead to malnutrition and underweight. Because this eating pattern resembled that seen in anorexia nervosa, it was termed orthorexia nervosa. It has been largely ignored in the professional eating disorders literature but its behavioral traits are very recognizable. Muscle dysmorphia, which is sometimes referred to “reverse anorexia nervosa,” has been used to describe people who are obsessed with the idea of being too skinny, in the sense that they are not muscular enough. Although this resembles body dysmorphic disorder, it has been offered as a separate diagnosis under the name of “muscle dysmorphia.” The fourth proposed disorder, emetophobia, has been used to describe avoidance of certain foods due to fear of choking; some individuals avoid foods out of fear of vomiting.

The eating disorders professionals polled in the study were psychologists (51%), physicians (17%) and others, mainly nurses and social workers (32%). The professionals had a wide range of experience with eating disorders, from fewer than 5 years to more than 20 years.

Overall, opinions about the “new disorders” did not vary widely. Psychologists were slightly more familiar with emetophobia than were physicians and other professionals, and the psychologists less often viewed emetophobia as a creation of the popular media. Professionals who spent more than 60% of their time working with people with eating disorders were more familiar with the night eating syndrome, and also thought that muscle dysmorphia deserved more attention.

Whereas three-fourths of the respondents were familiar with the concept of muscle dysmorphia, fewer than 10% had actually observed it in their practices. This disorder was viewed as the “most fashionable,” a creation of the popular media, and not deserving more attention. The opposite was true for emetopobia: nearly half the professionals reported having seen cases in their practice and here the popular media was seen as having almost no influence on shaping this disorder. The other disorders seemed to be taken rather seriously, according to Dr. Vandereycken, in the sense of constituting “genuine” syndromes, which deserve more attention in research and clinical practice. The researchers also found some mixed opinions in the results; for example, 39% of the respondents considered night eating syndrome to represent just a variant of another disorder, and one-fourth of the professionals interpreted orthorexia as a product of the popular media. Perhaps most surprising was the professionals’ opinion about emetophobiaa disorder on its own, often described in clinical practice but too much neglected in the scientific press.

Finally Dr. Vandereycken noted that the results forced him and his group of researchers to think about whether, by publishing their study, they were also becoming part of the social construction of “new” disorders. Although the study did reveal information about how familiar the proposed disorders were among eating disorder professionals, it also raised questions about the “media-ization” of these proposed but not yet fully validated disorders.