Thursday, February 11, 2010

Ditching the concept of "refusal"

The editors of the venerable Diagnostic and Statistical Manual of Mental Disorders, otherwise known as DSM, have just released proposed revisions for the fifth edition of the book, due out in 2013. And WOO-HOO! They've taken out the word refusal in their criteria for anorexia nervosa.

That word has always bugged the crap out of me. It embodies everything I've come to dislike and distrust about conventional eating disorders treatment. It assumes that the person with anorexia is making a choice--a conscious choice--to not eat. It reinforces Hilde Bruch's characterization of anorexia and the people who suffer from it and the whole psychodynamic theory of AN--a theory that has absolutely no basis in scientific evidence or fact. A theory that has kept ED treatment in the 18th century, in my opinion, and condemned sufferers to years of ineffective treatment and torment.

So three cheers to the editors. I hope their proposed revisions make the final cut.

6 comments:

Jane Cawley said...

I was glad to see this, too : )

KristineM said...

This is good news! When my 11 year-old ED daughter's weight was dropping like a stone, mere "refusal" didn't cut it. She was "unable" to start eating right without enormous support from clinicians and family. The inner mental beating she was taking was too much for her to face alone.

Harriet said...

Exactly, Kristine.

kallista93 said...

I always felt like "refusal" re-enforced this idea of the AN patient being a spoiled brat, which is how they tend to be treated. "Oh hurry up & eat aleady so we can help some real patients." It doesn't address the paralyzing fear.
On a different note, I'm still diappointed that you have to qualify as underweight to be diagnosed with AN. This requirement prevents early treatment, and also allows insurance companies to stop paying in treatment centers as soon as the patient is on the low side of normal, which for many people is no guarantee of healthy, I can assure you. To me, that is a big issue that keeps a lot of people on the sub-clinical level from getting help or even admitting they have a problem, because they won't be taken seriously.

Harriet said...

You're absolutely right, Kallista. Thanks for making that point. The research is clear that early intervention is best and can prevent a full-blown eating disorder, but if you can't get treatment until you have a full-blown disorder . . .

Cathy (UK) said...

I found the previous term 'refusal' very condescending. When I was stuck in anorexia nervosa, for many years, I simply couldn't bring myself to change my eating and exercise behaviours. These behaviours were rituals which I felt bound to keep because I was terrified of life outside of anorexia nervosa. There was no deliberate 'rebellion' on my part (and I write 'rebellion' - because this is the notion that the term 'refusal' conjures up).

However, I am disappointed at the (over-) emphasis on weight and body image in the new criteria. I know many individuals with anorexia nervosa (or histories of this illness) for whom weight and shape control were NOT at the heart of their ED behaviours. Many (most) individuals with anorexia (and bulimia) nervosa use ED behaviours to regulate mood and control anxiety. Unfortunately EDs have become synonymous with 'dying to be thin'....