Why are Eating Disorder Diagnoses so Fluid?

Diagnoses in psychiatry change over years and even generations to reflect the role mental illness plays in our culture. Some changes are due to a better understanding of an illness. Other times the diagnoses reflect a new social construct around a mental disorder, changes in the social structure or treatment trends that lead to increases in specific diagnoses.

Eating disorder diagnoses change over time as well. More recent trends include the misdiagnosis of depression or anxiety as an eating disorder or the expansion of the diagnoses to accommodate the larger number of treatment centers seeking to fill their beds. The ease of access of GLP-1 medications leads to more self-diagnosis of “food noise” as a different kind of eating disorder and as a way to justify taking these new drugs.

These are just examples of how diagnosis changes over time and how the concept of eating disorders remains fluid rather than a fixed concept, largely due to changing external circumstances rather than a fundamental change in the illness.

The borderline between an eating disorder and a supposedly healthy person is narrow in our culture. The drive for thinness implies that health, beauty and success are synonymous with a low weight. However, the line between these purportedly positive attributes and an illness is not always easy to define.

Psychiatrists try to define an eating disorder diagnosis based on the number on the scale, a certain amount of disordered behavior or the overall level of disordered thoughts about food and weight. However, many people who seem to fall into the socially admirable category don’t seem all that different from the people who are deemed sick.

Often the difference is context. Does the person have family who assess the situation as an illness or an achievement? What is the opinion of the pediatrician or primary care doctor who does the first assessment? What is the role of that person in their family of origin? The answers to these questions can determine the outcome: either a functional person with disordered thoughts and behaviors or extended stays in eating disorder treatment. The difference is not diagnosis but context. Few mental illnesses rely on external circumstances as the crux of the issue.

With current trends leaning towards extreme thinness again, there is much more acceptance of thinness as the goal rather than a sign of being sick. Because so many people are underweight due to the GLP-1’s, it is harder to differentiate the unwell versus the well. Without other markers for achievement, weight has become the default indicator of wellness again. There is no medical justification that people losing weight are healthier, but all cultural trends overvalue size and health, so anyone losing weight receives accolades across the board.

Eating disorder diagnosis is as much a cultural construct as it is a psychiatric disorder. There are many people who clearly have eating disorders and struggle to get well. The clearest diagnoses involve addictive-like behavior around food, intractable intrusive thoughts, trauma and often primary medical illness like MCAS. However, the number of people who don’t fit these categories but also dilute the severity and understanding about eating disorders is vast.

In trying to be clearer about diagnosis, the term eating disorder ought to reflect the cause of the illness, the severity of the symptoms and the types of experiences more specifically. These changes involve further research into possible underlying causes and incorporating changing trends around food and weight.