Friday, June 15, 2007

Fat--it's all in your head

At least according to this editorial in the American Journal of Psychiatry, exploring the question of whether to make obesity a brain disorder in DSM-V.

Of course, it's not really clear what exactly they mean by brain disorder. Anorexia and bulimia are listed in DSM-IV as brain disorders, sorta, and I have to say, I'm not sure what that means, either. Insurers still treat them as mental health issues rather than biologically based illnesses, and use that as a way to skive off covering them (at least in beknighted states like Wisconsin, which have no mental healthy parity laws).

It depends what the rationale is here, really. What we now know about eating disorders like anorexia is that some people are genetically and biologically predisposed to them, and that environment seems to play some kind of role in triggering those who are susceptible. Maybe that's true for obesity. That makes more sense to me than suggesting that all so-called obese people are compulsive eaters, which we know ain't true. Yo-yo dieting might be the environmental trigger, resetting the metabolism over time in ways that result in obesity.

But if an entry in DSM-V is going to result in more stigma attached to being obesity, I think we should say no thanks.

What do you think?


Carrie Arnold said...


Heh. I never thought of that. There are several issues to placing "obesity" in the DSM.

1) Define obesity.
2) We need some data saying that it is, in fact a disease, in that it adversely affects health.

There very well may be chemical imbalances (such as low levels of leptin, etc) that should be classified as an illness, but not obesity itself. It's going to result in a slew of treatments of negligible usefulness but are claimed to be 'curative.'

Sounds a lot like anorexia, come to think of it. But I bet insurance companies will cover obesity as a diagnosis before anorexia.

Don't feel bad- you're not in the only unenlightened state. My mom could give a 100 page dissertation on the ins and outs of the insurance process. Grrr.

Katy said...

I think you can replace "beknighted state" with "beknighted country." Even in states with MHP laws, insurance companies find loopholes. Can you imagine if insurance companies decided that, say, it was too expensive to cover cancer, and argued that those pushing for "cancer parity" would bankrupt the insurance industry and drive up everyone's premiums? People would scream bloody murder! But "mental illness" is seen as volitional, and thus those with "mental illnesses" are somehow less than those with "physical" illnesses. As though the brain was not part of the body.

But I digress.

When diagnoses in the DSM rely on particular physical outcomes to retroactively make the diagnosis, I get nervous. Obesity appears to be the result of multiple factors--many of which we don't understand (though we pretend we do!); the DSM is SUPPOSED to identify behavioral traits that characterize an illness. When diagnoses are made based solely on physical outcome, then we run the risk of 1) lumping together several different problems in one category because they have a similar end result and 2) missing illnesses that DON'T have the requisite physical outcomes. Obesity that results from binge eating is qualitatively different from obesity that results from metabolic issues and genetics. AN (as defined in DSM-IV) is another problematic diagnosis--a significant portion of anorexics don't lose their period, and, according to the DSM-IV, are therefore EDNOS, even if their behaviors and weight are the exact same as someone whose body reacts differently. (I also take issue with the 85% weight requirement--I'm not sure any studies indicate that there is a significant difference b/w those who reduce their weight to 90% IBW as opposed to 85%. Also, two people with the exact same behaviors, same length of illness and same amount or percentage of weight lost, but with different starting weights (one normal and one obese, for example) would have different diagnoses.) If the etiology is the same, the diagnosis should be the same.

To conclude my overly long ramble...

Given the stigmas already attached to both obesity and mental illness (and the general(ly insane) attitude that both are "choices") I can't help but think that less than benign forces are behind the idea of including obesity in the DSM. It's another way to pathologize people as "bad" or "disordered" for being fat when we don't yet understand all of obesity's causal factors. Scarier yet to the fat-o-phobes is the idea that obesity in and of itself may not be an issue at all; if an obese person is "otherwise" healthy--BP, blood sugar, cholesterol, etc--then where is the "disorder?"

And now, I'm truly done.

Harriet said...

I'm sure that's true--about the less than benign forces. Somewhere in the last few years I became a true cynic about the medical profession. Too bad.

Obesity, as I'm hardly the first to point out, is a description, not a disorder. It is possible to be fat and fit, for example, and not be unhealthy. I can't help thinking about those star-bellied sneetches. Talk about pathologizing.

As for mental health parity, the last I heard, the brain was part of the body. Try explaining that to some insurance co. flak whose job it is to find those loopholes.

mary said...

"Obesity, as I'm hardly the first to point out, is a description, not a disorder."

I think you said a mouthful right there Harriet.
We still can't seem to address discrimination in a proper fashion. It's a humanity problem that might not kill but it certainly makes us less for the tolerance of such baloney.
If the professionals can not be trusted to weigh in with intelligent information then it's no wonder some of us do not trust them.