WEIGHT LOSS: DIAGNOSTIC CRITERIA FOR ANOREXIA NERVOSA
A. Refusal to maintain body weight over a minimal normal weight for age and height, e.g.,
weight loss leading to maintenance of body weight 15 percent below that expected; or failure
to make expected weight gain during period of growth, leading to body weight 15 percent
below that expected.
B. Intense fear of gaining weight or becoming fat, even though underweight.
Ñ Disturbance in the way in which one’s body weight, size, or shape is experienced, e.g., the
person claims to “feel fat” even when emaciated, believes that one area of the body is “too
fat” even when obviously underweight.
D. In females, absence of at least three consecutive menstrual cycles when otherwise expected
to occur (primary or secondary amenorrhea). (A woman is considered to have amenorrhea if
her periods occur only following hormone, e.g., estrogen, administration.)
The first guideline, Criterion A, gives physicians an objective means of measuring the degree to which a person is emaciated: 15 percent below minimum normal body weight. This 15 percent figure (a somewhat arbitrary number, but still useful) is considerably less than the 25 percent given in the earlier edition. The change reflects the reality: Like other clinicians, I have seen numerous patients who seem to have anorexia but who, like Paula, haven’t lost enough weight to meet the criteria.
You might be puzzled by the use of the term “refusal to maintain body weight.” Doesn’t the word “refusal” suggest that the patient has made a conscious decision to act (or not act) in a certain way?
Yes, that’s true, but it still doesn’t mean that the anorexia is the patient’s fault. You have to think of the “decision” to lose weight as one made under duress. In a sense, the brain is held hostage to the disease and can’t think clearly. Anorexia is not a well-thought-out, rational plan; it’s more like a compulsion.
Still, such refusal makes life difficult for doctors as well as patients. Many a hospitalized patient declares war on the doctors and the staff. She sees them as members of a conspiracy whose evil aim is to force her to become fat. Patients may feel that they are being hunted down and annihilated by the “fat-doctors.” The patients, who see themselves as valiant rebels fighting to preserve freedom, will do anything to thwart this scheme: hide butter under the tray, spit out bites of food into their milk glass, exercise frantically while lying in bed, even run away from the hospital. Naturally, it’s hard to build a sense of trust and mutual cooperation under such circumstances.
One more point. The first diagnostic guideline lets us think of body weight in one of two ways: either as weight actually lost or weight never gained. The difference is important. Some anorexics feel fat now, and thus want to shed pounds. Others, particularly the younger ones, fear becoming fat in the future, and thus starve themselves to keep from gaining weight in the first place. It’s not necessary for a woman to reach a certain weight and then lose it in order to be considered an anorexic.
Criterion  mentions the intense fear of becoming fat. The earlier DSM specified that this fear doesn’t diminish even as weight loss progresses. The new version lets us acknowledge the presence of anorexia even in those cases where the woman reports that the fear does lessen as her weight shrinks.
Criterion Ñ expands the concept of disturbed body image. The disturbance might now reflect the patient’s perception of her body size or shape, as well as her weight. It also identifies a common anorexic symptom: the tendency to isolate and focus on one part of the body in particular.
Not long ago I visited a patient named Caitlin in her room at the hospital. In the course of our conversation, I indicated that she was making progress and was now eligible to go for short walks outside the hospital.
“I can’t do that!” she wailed. She threw back the bedclothes to reveal her legs, each of which wasn’t much thicker than a baseball bat. She pinched the skin between her fingers-she had to try a couple of times before she could actually grab anything-and shouted, “Look at this fat thigh! I can’t go out in public looking like this!”
The final criterion, D, acknowledges a feature of anorexia that the previous guidelines ignored: the loss of menses (menstrual periods), specifically three periods in a row, at some time during the course of the illness. In about four out of five cases, the loss of menses (also called amenorrhea) occurs as a direct result of starvation. Without proper nutrition, the brain senses that there is not sufficient energy for menstruation and doesn’t supply the “on” signal to the reproductive organs. (In male anorexics the equivalent problem is a loss of interest in sex, usually due to a reduction in the amount of testosterone produced.)
In another 20 percent of female patients, however, amenorrhea occurs before significant weight loss-that is, before starvation takes its toll. Sometimes a report of skipped periods is nothing more than a figment of the patient’s faulty memory. But not always.
The fact that some anorexics stop having periods before they lose weight may be evidence of a biological problem, at least in some cases. Because the hypothalamus regulates both eating and the reproductive system, any malfunction may affect both systems.
Other problems can also cause the loss of menses before weight loss occurs. In order to menstruate, a woman’s body needs not just sufficient weight, but a certain reserve of energy as well. Female athletes, for example, may eat adequate meals and maintain proper weight. But they may expend so much energy during exercise that they deplete their reserves. Menstruation then stops. Also, through chemical changes we don’t yet fully understand, emotional stress can interrupt the monthly cycle.
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