Obesity in the DSM-V

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KillerDiller

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I was just wondering what everyone's thoughts are on the proposal to add obesity to the newest version of the DSM. I'm in the process of trying to formulate my own arguments, but would like to hear from others. So let's have at it. Are you for or against this addition? Why?
 
I was just wondering what everyone's thoughts are on the proposal to add obesity to the newest version of the DSM. I'm in the process of trying to formulate my own arguments, but would like to hear from others. So let's have at it. Are you for or against this addition? Why?

I actually hadn't heard that obesity, per se, was being considered for the DSM-V. I know that there is currently debate regarding Binge Eating Disorder (BED) going in or not. My thoughts on BED are that it seems like enough empirical evidence has been accumulated to warrant its inclusion, but from what I've heard from those in the eating disorder circles, it is far from a shoe-in.
 
I was actually wondering about this. I'm reserving judgment for after I see more details.

If they call it "Obesity" I don't think it belongs in the DSM. It can certainly be a symptom of a psychological issue. I place it in the same category as cirrhosis. Its certainly a common result of alcohol abuse and dependence, but that doesn't mean it should be in the DSM.

To some degree, its semantics, but I think we need to be careful about it. If we want to call it something more like "Chronic overeating" (also not ideal for a variety of reasons, but I think closer), I take little issue with that. It will likely have huge comorbidity, but that's nothing we aren't used to. Obesity itself does not belong in the DSM any more than cirrhosis or lung cancer do.

I do look forward to some changes to the ED section as a whole though, since it seems horrendously underdeveloped for all the work out there on the topic. The simple fact that someone can be starving themselves but not meet for AN because they haven't passed the arbitrary weight cutoff yet seems ridiculous.
 
To some degree, its semantics, but I think we need to be careful about it. If we want to call it something more like "Chronic overeating" (also not ideal for a variety of reasons, but I think closer)

I will bet any amount that the sex ratio for such a diagnosis would be something like 10 women to 1 man.

I agree with others who have said that obesity itself doesn't belong in the DSM. Who's making that proposal?

I also think it's interesting that that's coming up as all the Fat/Size Acceptance people are picking up some steam.
 
I will bet any amount that the sex ratio for such a diagnosis would be something like 10 women to 1 man.

I agree with others who have said that obesity itself doesn't belong in the DSM. Who's making that proposal?

I also think it's interesting that that's coming up as all the Fat/Size Acceptance people are picking up some steam.

Well, I think it depends how we define it. If we define it the way we currently define "Binge" than I'm sure you are right. However, if its meant to capture chronic, poor dietary habits I bet it would be roughly equal, or perhaps even more men. Of course, men would probably be far less likely to seek treatment.

I'm not sure where we should draw the line. If its defined too loosely, it could probably capture 95% of the country. If we draw the line where it starts to adversely affect people's health, that's an ENORMOUS group of folks. Do we borrow the "Repeated unsucessful attempts to cut down" criteria from substance use disorders? That has problems too. If it really is going into the DSM, this is going to be an unbelievably difficult judgment call and I don't envy those responsible. I think SOME form of the disorder should go in there. It certainly has psychological roots, its hugely detrimental to many people's lives, and its something there is substantial evidence that we can help with. Although part of the detriment is due to societal judgment, there are very real physical consequences as well. Again, where do we draw the line? If someone is happy with their weight, recognizes the physical consequences and has made a conscious choice, would they be diagnosable? This is a critical issue for the fat/size acceptance groups you mentioned. We still diagnose nicotine dependence even if someone knows they're at greater risk and still wants to smoke. Is diet the same? Similar? Completely different?



Very, very complicated stuff.
 
Do we borrow the "Repeated unsucessful attempts to cut down" criteria from substance use disorders? That has problems too. If it really is going into the DSM, this is going to be an unbelievably difficult judgment call and I don't envy those responsible. I think SOME form of the disorder should go in there. It certainly has psychological roots, its hugely detrimental to many people's lives, and its something there is substantial evidence that we can help with.

Hmmm. I'm very interested in your comment re: "...something there is substantial evidence that we can help with." I assume you mean to imply that psychotherapy can help with weight loss? Do you have citations?

I find this field interesting, and am a strong believer that obesity has no place in the DSM. I'd be interested in reading any studies that show significant MAINTAINED weight loss after psychotherapy... The last study I read on this did not find any strong evidence that intervention could result in significant long-term weight loss.

Citation: Long-term maintenance of weight loss: Current status. Jeffery, Robert W.; Epstein, Leonard H.; Wilson, G. Terence; Drewnowski, Adam; Stunkard, Albert J.; Wing, Rena R.Health Psychology. Vol 19(1, Suppl), Jan 2000, 5-16.
 
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Perhaps substantial was an overstatement, but there certainly are a fair number of positive results out there. I didn't have anything in particular in mind when I posted it, but I know Klesges has done some interesting work with pretty difficult populations. Heard a talk he gave about a year ago - not sure what has been published and what hasn't. I know the MI folks have done some work with this as well.

Certainly any treatments have a LONG way to go, and I'm not sure we're going to see huge treatment effects. I'll be the first to say that evidence is not stellar. I definitely agree that evidence for long-term maintenance is particularly poor right now. I'm not sure how much maintenace we can even expect without follow-up contact, given the nature of weight loss. Given the fact that...well...everyone needs to eat, it complicates things since we're dealing with much more of a continuum.

Of course, I'm also used to smoking cessation treatment, where if 20% of people make it a year without relapsing, that's considered an enormous success🙂
 
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Perhaps substantial was an overstatement, but there certainly are a fair number of positive results out there. I didn't have anything in particular in mind when I posted it, but I know Klesges has done some interesting work with pretty difficult populations. Heard a talk he gave about a year ago - not sure what has been published and what hasn't. I know the MI folks have done some work with this as well.

Certainly any treatments have a LONG way to go, and I'm not sure we're going to see huge treatment effects. I'll be the first to say that evidence is not stellar. I definitely agree that evidence for long-term maintenance is particularly poor right now. I'm not sure how much maintenace we can even expect without follow-up contact, given the nature of weight loss. Given the fact that...well...everyone needs to eat, it complicates things since we're dealing with much more of a continuum.

Of course, I'm also used to smoking cessation treatment, where if 20% of people make it a year without relapsing, that's considered an enormous success🙂

Cool. I'll keep an eye out for Klesges papers... Just PsycInfo'd and he doesn't seem to have anything out yet, which isn't surprising if the conference was only a year ago.

Here's an editorial from the American Psychiatric Association on the issue of 'obesity' as a DSM entry:

http://ajp.psychiatryonline.org/cgi/content/full/164/5/708

Key quote: "Obesity is characterized by compulsive consumption of food and the inability to restrain from eating despite the desire to do so."

I, for one, am pretty happy with my inability to restrain from eating, even if I were to desire to do so. 'Cause, you know, food kind of keeps me alive.

I'd consider supporting a DSM entry for compulsive overeating, depending how it were defined. I'd also support moving binge eating disorder from the ED-NOS to its own entry. But further pathologizing 'obesity', which is ill-defined as is? I'm not seeing how that's necessary or helpful.
 
Be sure to check pubmed and similar stuff. Klesges mostly does large-scale public-health type interventions, so a great deal of what he publishes is outside of traditional psychology journals. The study I'm thinking of was a large behavioral intervention with inner-city youth. MI has been done on adherence to diets and to exercise-regimens. I might be remembering incorrectly, but I think both were weak, but still positive.
Pretty much agree with everything else. Obesity is a medical condition, not a psychological one. We shouldn't confuse the two. There is no doubt that psychological processes can both directly and indirectly contribute to obesity, but we need to make sure any diagnosis focuses on the psychological processes. Making "fat" a mental disorder doesn't make any sense.
 
I actually hadn't heard that obesity, per se, was being considered for the DSM-V. I know that there is currently debate regarding Binge Eating Disorder (BED) going in or not. My thoughts on BED are that it seems like enough empirical evidence has been accumulated to warrant its inclusion, but from what I've heard from those in the eating disorder circles, it is far from a shoe-in.

Yeah, I'm not entirely sure about my sources, but from what I've heard they are considering a category called "obesity". Now whether that means they will simply add "Binge Eating Disorder" to the DSM and that's it (which would be far less controversial) or whether they will subsume BED under obesity, I don't know.
 
One thing I have trouble with is that obesity itself is merely a risk-factor for poor health. Not every obese person is physically unhealthy. However, this addition would suggest that every obese person is psychologically unhealthy.
 
Eh, I actually don't take much issue with that.

Again, I realize smoking is different since there is a clearly defined "Addictive chemical" involved, but I can't help but draw the parallel. Not every smoker will get lung cancer, emphysema, or heart disease, its just a huge risk factor for them. If smoking wasn't bad for your health, would nicotine dependence be in the DSM? I doubt it. If it was, we'd probably treat it very differently from how we do currently. I imagine along similar lines as we do caffeine. Unless I'm mistaken, there is no actual caffeine dependence in the DSM (probably because 3/4 of the field would have met criteria for it😉).

I agree that calling it obesity suggests that every obese person is psychologically unhealthy, which I don't buy. Its one of the biggest problems in the US right now, and psychologists undoubtedly have a role to play in helping change that. I think it makes sense to have an official diagnosis for it. Beyond that, the devil is in the details😉
 
I find this funny given Crandall's (sp?) work on anti-fat attitudes. 😉
 
Eh, I actually don't take much issue with that.

Again, I realize smoking is different since there is a clearly defined "Addictive chemical" involved, but I can't help but draw the parallel. Not every smoker will get lung cancer, emphysema, or heart disease, its just a huge risk factor for them. If smoking wasn't bad for your health, would nicotine dependence be in the DSM? I doubt it. If it was, we'd probably treat it very differently from how we do currently. I imagine along similar lines as we do caffeine. Unless I'm mistaken, there is no actual caffeine dependence in the DSM (probably because 3/4 of the field would have met criteria for it😉).

That's a very interesting parallel to draw, and it's one that I hadn't thought of. I tend to forget about the diagnosis of nicotine dependence because I've never treated someone with that for a primary complaint. I've seen plenty of clients who fit the criteria, and yet that was never even listed as one of their diagnoses or addressed in their treatment plans. Maybe I would need to work more with the "worried well" in order to see the utility of even this existing diagnosis.

It does come back to what you mentioned earlier, though--smoking is an identifiable behavior while the term "obesity" indicates the result of a behavior. Obesity can be arrived at through many different pathways, not all of which indicate pathological behavior.

My guess is that if any of these diagnoses were to survive the editing process and make it into the DSM-V, it would be Binge Eating Disorder.
 
I guess just the huge difference of opinion within the same field: here we have one researcher working on figuring out prejudice towards obese people, and here we have others trying to categorize obesity as a mental illness. 😉

Oh, for those unfamiliar: Crandall studies attitudes towards overweight individuals, including developing questionnaires to measure it. IIRC the questionnaire I'm most familiar with measures people's beliefs that it's a result of laziness, disgust towards overweight people, and also looks at the participant's own fear of fat.
 
I guess just the huge difference of opinion: here we have one researcher working on figuring out prejudice towards obese people, and here we have others trying to categorize obesity as a mental illness. 😉

Oh, for those unfamiliar: Crandall studies attitudes towards overweight individuals, including developing questionnaires to measure it. IIRC the questionnaire I'm most familiar with measures people's beliefs that it's a result of laziness, disgust towards overweight people, and also looks at the participant's own fear of fat.

*nods*. Ah, okay, I get it. Yeah, it's a little strange on the surface, but not all that surprising... Especially when you consider that there are plenty of people out there working on understanding people's prejudices and general social stigma toward mental illness (Corrigan's the name that comes to mind here, though I think Crandall's also done work in this area!).
 
Oh, for those unfamiliar: Crandall studies attitudes towards overweight individuals, including developing questionnaires to measure it. IIRC the questionnaire I'm most familiar with measures people's beliefs that it's a result of laziness, disgust towards overweight people, and also looks at the participant's own fear of fat.

Oh, ok. It sounds similar to Brownell's work at Yale. I've often wondered what his thoughts on the issue are.
 
That's a very interesting parallel to draw, and it's one that I hadn't thought of. I tend to forget about the diagnosis of nicotine dependence because I've never treated someone with that for a primary complaint. I've seen plenty of clients who fit the criteria, and yet that was never even listed as one of their diagnoses or addressed in their treatment plans. Maybe I would need to work more with the "worried well" in order to see the utility of even this existing diagnosis.

Well, as a psychologist working at a cancer center, let me assure you "nicotine dependence" belongs in there😉 Its a very different population than a typical setting and no, you probably are not going to see people coming into a psychology clinic to get treated for smoking cessation. They just wouldn't seek it out there. Its a growing area, and many hospitals now have staff who specialize in it.

I look at it this way...its definitely a behavioral issue, it probably reflects a bigger public health burden than all other psychological disorders combined, behavioral treatments basically doubles treatment efficacy, but almost no one follows practice guidelines even in oncology settings, let alone other settings. It pretty much defines health psychology.

Again, approach is everything. I don't think a "Chronic uncontrollable eating" diagnosis should be at odds with "size acceptance". If we define it as obesity I can see the complaint. There are elements of stigma in pretty much all psychological disorders, that doesn't mean we shouldn't admit they exist and refuse to help people who have them. Being severely overweight carries a significant health risk. If someone is overweight, does not desire to change it, and is willing to accept the health consequences, then I think we need to respect that. I take a similar approach to smoking - I love helping people who genuinely want to quit, and have near-zero interest in working with those who do not. Feeling ambiguous is normal and one thing MI is for, but I'm not out to "make" anyone quit if they don't want to. If someone wants desperately to change for the sake of their health, but needs help doing so, I think we should have a diagnosis for it.
 
I was just wondering what everyone's thoughts are on the proposal to add obesity to the newest version of the DSM. I'm in the process of trying to formulate my own arguments, but would like to hear from others. So let's have at it. Are you for or against this addition? Why?


This idea conflates obesity with psychological pathology of some sort. This is very very tenuouslink and represents poor science . Obesity is a very complex biological condition with multiple etiologies that may have little to do with psychopathology. This is especially true for persons who have been obese since early childhood, many of whom do not actually overeat. Obesity may be an indicator of stress eating, depression, low self-esteem etc... Or the person with obesity may be well adjusted according to any number of psychological measures or criteria. Adding obesity to the DSM-V would be exceptionally problematic. We have enough problems already with the poor validity and reliability of the existing diagnostic categories to begin with. We don't need yet another diagnostic category of questionable validity being added. Creating a psychiatric disorder which over 50% of the American public would meet the criteria for is irresponsible and inappropriate.
 
Well, as a psychologist working at a cancer center, let me assure you "nicotine dependence" belongs in there😉 Its a very different population than a typical setting and no, you probably are not going to see people coming into a psychology clinic to get treated for smoking cessation. They just wouldn't seek it out there. Its a growing area, and many hospitals now have staff who specialize in it.

I look at it this way...its definitely a behavioral issue, it probably reflects a bigger public health burden than all other psychological disorders combined, behavioral treatments basically doubles treatment efficacy, but almost no one follows practice guidelines even in oncology settings, let alone other settings. It pretty much defines health psychology.

Again, approach is everything. I don't think a "Chronic uncontrollable eating" diagnosis should be at odds with "size acceptance". If we define it as obesity I can see the complaint. There are elements of stigma in pretty much all psychological disorders, that doesn't mean we shouldn't admit they exist and refuse to help people who have them. Being severely overweight carries a significant health risk. If someone is overweight, does not desire to change it, and is willing to accept the health consequences, then I think we need to respect that. I take a similar approach to smoking - I love helping people who genuinely want to quit, and have near-zero interest in working with those who do not. Feeling ambiguous is normal and one thing MI is for, but I'm not out to "make" anyone quit if they don't want to. If someone wants desperately to change for the sake of their health, but needs help doing so, I think we should have a diagnosis for it.

Careful... If someone wants desperately to change their lifestyle, behaviour, or habits for the sake of their health, but needs help doing so, then sure, I agree. Behavioural therapy could help with that, just like it helps with smoking (which is a behaviour).

Changing certain habits (increasing exercise, etc.) may or may not impact weight in the short or long-term, depending on the individual. *Obesity* is not a behaviour.
 
*Obesity* is not a behaviour.

I think that in some way sums up the debate.

I agree with those that say it might well be a symptom of another disorder (like BED) but is not a disorder in and of itself.
 
If not behavioral, where would it fall in the DSM?
 
obesity is a disorder.


might not be a behavioral one.

I'm not sure I necessarily agree, but I'm interested in hearing more, especially from someone who's a licensed psychologist at this point (I'm still in graduate school). If it may not be a behavioural disorder, would you consider it to be a mental disorder at all? If so, why/why not? Does it belong in the DSM?
 
Touche. But I believe the spirit of this debate is whether or not it should be an Axis I disorder.
 
Careful... If someone wants desperately to change their lifestyle, behaviour, or habits for the sake of their health, but needs help doing so, then sure, I agree. Behavioural therapy could help with that, just like it helps with smoking (which is a behaviour).

Changing certain habits (increasing exercise, etc.) may or may not impact weight in the short or long-term, depending on the individual. *Obesity* is not a behaviour.

Sure. Sorry, didn't mean to imply it was justification for inclusion of "obesity". Just that it means we should have some sort of diagnosis for situations where help changing those behaviors (diet and exercise) IS what needs to be done. Certainly some people eat great and exercise regularly and still can't lose weight. I have had high cholesterol for years despite working out regularly, and the fact that the "low cholesterol diet" they recommend is substantially higher in cholesterol than what I eat when left to my own devices. I'm well aware that behavior is not always the issue😉

Obesity is certainly a diagnostic "something" - I think we go a bit overboard on being PC with regards to labeling things and I don't much care if we want to call it a disorder, a condition, or whatever else. Obesity absolutely does not belong in the DSM (well, not on Axis I or II, I agree it could go on Axis III). Basically, its something that needs to be acknowledged medically, since its a risk factor for so many things and can play a huge role in medical treatment. What category seems arbitrary to me.
 
westernsky,

i do not think of obesity as a mental disorder. it is a physical disorder listed in the ICD-9 with very specific criteria set by both the NIH and WHO. when a behavioral factor causes a physical symptom, we diagnose that the behavioral disorder. there are several of those types of dx's in the DSM.

for example: person X could be obese because they eat a 20000 kcal diet and do not exercise. IMO, this is dirodered behavior. person Y could be obese because he/she is taking a course of corticosteroids and lithium bicarbonate which have both been associated with weight gain. IMO, person X is behaviorally disordered which has resulted in obesity while person Y is obese due to other variables.


likewise, both of these patients would liekly suffer from hypertension. however, the hypertension is not a behavioral variable in both hypothetical pts.
 
westernsky,

i do not think of obesity as a mental disorder. it is a physical disorder listed in the ICD-9 with very specific criteria set by both the NIH and WHO. when a behavioral factor causes a physical symptom, we diagnose that the behavioral disorder. there are several of those types of dx's in the DSM.

for example: person X could be obese because they eat a 20000 kcal diet and do not exercise. IMO, this is dirodered behavior. person Y could be obese because he/she is taking a course of corticosteroids and lithium bicarbonate which have both been associated with weight gain. IMO, person X is behaviorally disordered which has resulted in obesity while person Y is obese due to other variables.


likewise, both of these patients would liekly suffer from hypertension. however, the hypertension is not a behavioral variable in both hypothetical pts.

Thanks for the elaboration. 🙂
 
I ran obesity/weight loss psychoeducational classes at the VA as part of my health psych internship. From my experience, a huge component of people being overweight/obese has to do with ignorance. You would be shocked at the number of people who just don't know the basics of weight (i.e. 3500 calories = 1 lb, reading food labels, measuring servings, calories burned during exercise). The class I help teach works to increase that knowledge. However, I have noticed that the behavioral changes that are required once they have the knowledge are quite difficult to get people to implement. Some people you see a light bulb go off and they're off and running with their weight loss goals. But the majority continue to struggle, even if the "get it."

I don't think the term "obesity" should be in the DSM-V because it is already stigmatized. I hear that a lot from the vets and it certainly doesn't help to make them feel worse about themselves - especially because emotional eating is a big part of this problem.

I would think this falls more in the addictions category. We get a lot of resistance from people when we talk about eating 1800 calories a day to lose weight or show what a serving of pasta actually should look like. It's similar to what you hear when you tell someone that smoking is bad for them or drinking a case of beer a night might not be so hot for their liver 🙄
 
since when do we not include a diagnosis because it would stigmatize someone? that is one of the most puerile arguments i have heard recently.


using that logic, malingering should be not included because it would stigmatize someone. hell, throw out dementias. people hate those. schizophrenia, anorexia, bulemia, etc. all stigmatize people also.

however, these diagnoses are also a great way to describe someone's behavior to another professional.

accurate diagnosis often hurts people's feeling and stigmatizes them. it is still the job.
 
The point could be made that psychologists have an ethical responsibility to avoid reifying existing social prejudices through the use of questionable diagnostic labels. By giving the imprimatur of scientific respectability to such prejudices we violate the spirit of our ethical principles which call upon psychologists to respect the dignity of the persons we serve and to work for social justice. How many of us use the term "borderline" in a perjorative manner? The broader question is how the varous iterations of the DSM and its diagnostic systems have actually helped the field. Diagnoses are labels intended to provide a clincial description that guide treatments. However, can we really say that treatment planning derived the DSM categories is all that effective. Should we as psychologists accept a practice derived from the medical model or should we develop our own system of classifying clients. The significant problems the DSM regarding the reliability and validity of the diagnostic categories in the DSM suggests that we should use these labels with caution. The complex, nuanced and ideopathic formulations we can derive from psychological testing are of far greater clincial import than the nomothetic labels derived from the DSM. The only value I can see from the DSM is the use of a common nomenclature. The risk however is the imputation of too much significance to the nomenclature.
 
neuropsych2be,



1) the ethical principles you refer to are ASPIRATIONAL in nature. learn the difference.

2) deriving the physical symptom of obesity from a formula created over a HUNDRED YEARS AGO which has thousands of articles supporting its use sounds like decent science to me. your proposed procedures have no science whatsoever.

3) the physical symptom of obesity (NOT THE PROPOSED BINGE EATING DISORDER which no one in this thread seems to understand how to differentiate from) has been associated with higher incidence of neoplastic disorders, cardiac illnesses, etc.

4) i don't see how calling someone obese is a violation of their social justice, etc. what other symptoms are a violation of their rights? hypertension? atrial fibrillation? pulmonary disease? WHO disagrees with you.

i understand you are concerned about this dx making people feel bad about themselves. i also understand there is some concern that including BED will increase bad feeling because those dx'ed with BED will feel responsible.

you know what? those with BED are probably by and large are responsible for their own behavior.

5) how has the DSM helped people? the use of a scientific standard of language has aided all sciences. a common taxonomy has allowed for the systematic study of a wide range of psychiatric illnesses and the treatment thereof. the dsm has also allowed the development of standardized treatment protocols and allowed for the effective study thereof. your proposal for an ideopathic taxonomy has done nothing for society.

6) "should we develop our own system" - LOL. that is a stupid idea that would further fraction psychology away from mainstream healthcare and needlessly complicated pt treatment. AND directly contradict all the literature. but hey, maybe you know better.

7) again with the social justice . accurately diagnosing someone regardless of their SES, etc sounds like promotion of social justice. to suggest anything other then accurate diagnosis sounds like a violation of ethical principles to me. oh look, APA ethics agrees!


all of this sounds like the argument is based off of a few things

a) fear that the diagnosis of obesity might hurt someone's feelings. i don't see how describing someone's physical features in a scientific manner is ever harmful. short, tall, brown haired, blue eyed, amputations, blind, whatever. if a patient can't handle an accurate description of him/herself, that is not their problem. i am 6'. i have never thought twice about it being in my medical chart. along with my weight and BP.

we don't give patients the diagnosis they want. or their would be a lot more "geniuses" walking around.

this fear sounds based in paternalism "oh, i know they can't handle the diagnosis so we just won't tell them" which is one of the most narcissistic things i think i have heard since reading 1940s medical texts.

b) a failure to differentiate OBESITY FROM THE PROPOSED BINGE EATING DISORDER. one has a 150 yrs of science behind it. one does not. i can see how you all are hesitant about the proposed dx of BED. i can't see how calling someone obese is anything other than good science.
 
neuropsych2be,


3) the physical symptom of obesity (NOT THE PROPOSED BINGE EATING DISORDER which no one in this thread seems to understand how to differentiate from) has been associated with higher incidence of neoplastic disorders, cardiac illnesses, etc.

This reads like an unfounded accusation. I think the distinction between BED and obesity is pretty clear and understood. The consensus seems to be that BED is more suitable for inclusion in the DSM than obesity due to its behavioral components...not because of the stigma of obesity.

Also, if you follow the link I posted, it is clear that "obesity" is being discussed by the ED committee separately from BED.
 
killerdiller,


sorry, let me clarify:

i am definitely accusing neuropsych2be of using a terrible basis for scientific debate.

1) " The point could be made that psychologists have an ethical responsibility to avoid reifying existing social prejudices through the use of questionable diagnostic labels. "

to me the diagnostic labels to which neuropsych2be is referring is either a) obesity or b) BED.

A) If he/she is referring to option A (obesity) then the proposal reads one should not use obesity as a label as it is questionable. The literature is 100% against this proposal. there is 150years of literature to support the concept of obesity.

B) if he/she is referring to option B, then the proposal reads something like BED should not be used because it supports existing social prejudices of said label. What prejudices? the diagnostic label is not in existence, so i can't really see their being too many prejudices against a group no one is assigned to.

C) there is also a possibility that neuropsyc2be is stating that we should not assign the obese to the diagnosis of BED. There is a common sense in that not all the obese will meet criteria for BED. however, he/she might be stating we shouldn't call them BED because it might strengthen social prejudices against the obese. in my opinion this is terrible science. the population is pretty prejudiced against tons of mental disorders(e.g., sexual sadism, schizophrenia, MR, etc). However, in describing how these people are suffering by using diagnostic labels we are able to study and create treatments. i also think to not tell a group that their behavior is disordered because telling them reinforces prejudices reeks of paternalism.

2)" How many of us use the term "borderline" in a perjorative manner? "

i see no data to support this claim. anecdotally, my colleagues do not use this label in the pejorative.

3) "The broader question is how the various iterations of the DSM and its diagnostic systems have actually helped the field."

through the systematic study of behavioral disorders using the DSM and ICD-9 taxonomomies we have had randomized studies of effective behavioral and pharmacological treatments. please see CBT literature, SSRI literature, SNRI literature, etc.

4) "Diagnoses are labels intended to provide a clincial description that guide treatments."

says who? neuropsych2be has left out all research and forensic reasons just to think of a few. i am not buying this one use contention one bit.

5) "However, can we really say that treatment planning derived the DSM categories is all that effective"

disorder specific, yes we can. Again, we can pick any disorder and look at the literature. All mjor depressive disorder (i.e., MDD) literature uses DSM criteria to diagnose depression. The intervention of choice is then applied. Symptoms of MDD according to DSM are then remeasured to determine efficacy of teatment. Sounds like the taxonomy was pretty useful. give me a disorder and we can discuss in further depth. i'll bring evidence.

6) "Should we as psychologists accept a practice derived from the medical model or should we develop our own system of classifying clients."

a) you are not a psychologist

b) uhm, my opinion is a resounding "no". multiple taxonomies would, in my opinion, complicate patient treatment. But, how this question is interesting becomes even more interesting in the context of the next sentence... wait for it...

7) "The significant problems the DSM regarding the reliability and validity of the diagnostic categories in the DSM suggests that we should use these labels with caution"

a) so we shouldn't use the taxonomy that has several studies supporting its reliability and validity, but we should create a new taxonomy? huh?

b) where is the evidence that suggests the reliability/validity is low? Brown says you're wrong (2001).


8) "The complex, nuanced and ideopathic formulations we can derive from psychological testing are of far greater clincial import than the nomothetic labels derived from the DSM."

again, an assertion with no evidence. i can provide research demonstrating the clinical import of a BDI score of 30. or a SCID, i can even point to research that demonstrates how this score helped treatment. where is the evidence that a psych test not related to the DSM makes treatment better?


9) "The only value I can see from the DSM is the use of a common nomenclature."

fair enough. that is your opinion. i disagree.

10) "The risk however is the imputation of too much significance to the nomenclature."

the risk to what/who? what risk?
 
since when do we not include a diagnosis because it would stigmatize someone? that is one of the most puerile arguments i have heard recently.

using that logic, malingering should be not included because it would stigmatize someone. hell, throw out dementias. people hate those. schizophrenia, anorexia, bulemia, etc. all stigmatize people also.

however, these diagnoses are also a great way to describe someone's behavior to another professional.

accurate diagnosis often hurts people's feeling and stigmatizes them. it is still the job.

Way to pick out only one of my points and go with it to serve your argument. You seem rather vehement in your opinion about obesity being added to the DSM-V. Which you're entitled to, but I don't agree that it's the correct diagnostic term to use to describe the underlying behavior(s). I'm not sure why you've decided to take the low road and decry my thoughts as childish and silly. But hey, whatever floats your boat. I learned a long time ago not to get into flame wars with random people on the internet.

I think the distinction between BED and obesity is pretty clear and understood. The consensus seems to be that BED is more suitable for inclusion in the DSM than obesity due to its behavioral components...not because of the stigma of obesity.

Complete agree. I reiterate my comments about the behaviors that result in obesity being similar to those of other addictions, and thus should be what we as psychologists are working to understand and treat.
 
Psydr, maybe I was misunderstanding, but I didn't think anyone objected to obesity being included on Axis III. I mean, how could it not be? It would be sheer idiocy to do anything else. That's what Axis III is for. No one likes having cancer either, but it damn sure goes on there if the client has cancer.

I was under the impression the discussion was about including something explicitly called "Obesity" on Axis I, alongside AN, etc. There is not 150 years of science to support that. I'm not sure there is ANY science that would support that. Because it isn't a behavioral disorder, at best its a possible, but not necessary, outcome of what might be a behavioral disorder. Again, its like including cirrhosis as an Axis I disorder. Stigma is one reason not to do this (and I think its a legitimate concern), but I think its just one of many reasons its a horrible idea. Are you arguing FOR the inclusion of Obesity as Axis I? I didn't think you were until the most recent posts. Or just its use as a label in general?

I think everyone here understands the distinction between BED and Obesity perfectly, so I'm not sure where you are getting that. If you read the first couple posts, we're explicitly discussing whether the proposal is to include "Obesity" or if it was a mistake and was meant to be BED. If its the latter, I don't think its all that controversial. I think we need to go a step beyond BED since it probably won't capture a crap-ton of people who would benefit from behavioral intervention.

Based on my reading of this thread, we're discussing whether a clearly defined physical condition (obesity) with well-established, explicit diagnostic criteria, should suddenly be labeled a mental disorder too. I don't think there's any justification for doing so.
 
Well said Ollie.
 
ollie,


my entire thesis is obesity= physical disorder, obesity due to BED or whatever they want to call it= behavioral. Not wanting to use a term because it might hurt people's feelings = big hearted but illogical. i realize i was not clear on this line of thinking. i apologize for my lack of clarity.


to elaborate, i don't really care what term the APA uses to describe disordered eating (e.g., BED, EDNOS, etc). there are many physical symptoms that have an associated behavioral presentation that are cross listed in the DSM and ICD (e.g., DAT and AZ, Parkinsons and dementia of due to...). Additionally, one can have a disease state and not have the behavioral presentation (e.g., Huntington's genotype and no dementia due to...). i can see obesity being listed on axis III and Obesity due to BED or Obesity due to disordered eating or whatever being on Axis I. i fully support this type of taxonomy. rereading my posts, i realize i was less than clear on this point. i apologize for my lack of clarity.


HOWEVER,

i began to lose my cool when i read the discussants write about how they would not like to use the behavioral label of obesity because said label has a stigma and/or might make people feel bad. i pointed out that that many many diagnoses stigmatize people but correctly classify them (e.g., malingering). it is my opinion that scientific nomenclature should not be swayed by public sensibilities. i hold very fast to such an idea.

neuropsych2be, then opined that diagnostic labels were of no use and then questioned when diagnostic labels had ever helped anyone without providing any support for his/her contention. i remain shocked and appalled.

cosmo,

while i very much disagree with your dislike of the behavioral use of obesity, i somewhat agree with your classification of such eating disorders as being addicitive in nature. there is a body of neuroimaging literature that somewhat supports your idea.


i'll stay out of this thread from now on. hospital is full up and i gots things to do.
 
The abstract of a new article in the International Journal of Eating Disorders:

Obesity: Is it a mental disorder?
Marsha D. Marcus, PhD *, Jennifer E. Wildes, PhD
Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
email: Marsha D. Marcus ([email protected])

*Correspondence to Marsha D. Marcus, Western Psychiatric Institute and Clinic, 3811 O'Hara Street, Pittsburgh, Pennsylvania 15213

Abstract

Objective:
Using Wakefield's conceptualization of mental disorder as harmful mental dysfunction (Wakefield, Am Psychol, 47, 373-388, 1992), we examined the evidence for including obesity as a mental disorder in DSM-V.

Method:
We searched computer databases and examined reference lists from review articles published in the last 10 years to identify empirical papers relevant to the present review.

Results:
Obesity is a condition of heterogeneous etiology that is harmful for most individuals. However, there is scant evidence that obesity, in general, is caused by mental dysfunction. Although recent work examining the neurocircuitry of energy balance has suggested that mental dysfunction may be involved in the etiology of specific obesity phenotypes, findings are too preliminary to support classification of obesity as a mental disorder. Nevertheless, there is evidence that obesity is related to mental disorder and many of the medications used to treat psychiatric illness.

Discussion:
There is little evidence for including obesity as a mental disorder in DSM-V. However, results confirm the importance of monitoring adiposity routinely among patients with psychiatric illness. © 2009 American Psychiatric Association. (Int J Eat Disord 2009)
 
I actually hadn't heard that obesity, per se, was being considered for the DSM-V. I know that there is currently debate regarding Binge Eating Disorder (BED) going in or not. My thoughts on BED are that it seems like enough empirical evidence has been accumulated to warrant its inclusion, but from what I've heard from those in the eating disorder circles, it is far from a shoe-in.

exactly. I haven't heard about "obesity" being added but I have heard about BED being added.
 
I was just wondering what everyone's thoughts are on the proposal to add obesity to the newest version of the DSM. I'm in the process of trying to formulate my own arguments, but would like to hear from others. So let's have at it. Are you for or against this addition? Why?

Here's my opinion on this thing...

If "obesity" makes it into the DSM, what's next? "heart disease" ?

I don't quite see the relevance of having "obesity" which is simply (from my understanding) a label describing where a person falls on a chart according to his/her weight/height ratio and BMI. On the other hand, I can totally see BED making it into the DSM because of its behavioral qualities.

How is obesity a mental disorder or related to a mental disorder (if there is no evidence of BED) and therefore acceptable to be added to the diagnostic and statistical manual of mental disorders?
 
exactly. I haven't heard about "obesity" being added but I have heard about BED being added.

The website linked to earlier in this thread clarifies that it is obesity itself that is being considered, not simply BED.
 
Here's my opinion on this thing...

If "obesity" makes it into the DSM, what's next? "heart disease" ?

I don't quite see the relevance of having "obesity" which is simply (from my understanding) a label describing where a person falls on a chart according to his/her weight/height ratio and BMI. On the other hand, I can totally see BED making it into the DSM because of its behavioral qualities.

How is obesity a mental disorder or related to a mental disorder (if there is no evidence of BED) and therefore acceptable to be added to the diagnostic and statistical manual of mental disorders?

Agreed, except it's even worse than that--obesity isn't a disorder in and of itself, it's a symptom and/or a risk factor, and in some cases none of those things, especially when measured by the extremely faulty BMI. Many athletes are obese according to it, because it fails to distinguish between (very dense) lean muscle mass and (less dense) fat. Not to mention that increasingly research suggests that the relationship between fat and poor health outcomes is more complex than previously thought--for instance, the risk of metabolic disorder is more related to body shape (basically, whether or not you have a defined waist) than absolute body size.

If we have no reliable measure for obesity, and if it's not even a clear cut physical health problem, how the hell is anyone making a case for it as a mental/behavioral one, which doesn't even make sense? That's akin to making "having lots of repeated scars on one's body" a disorder, instead of making cutting the criterion.
 
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