The Cultural Hierarchy of Eating Disorders

Let's talk about ED-NOS.

ED-NOS, that is, Eating Disorder Not Otherwise Specified, possibly to be renamed "Feeding and Eating Conditions Not Elsewhere Classified" in the DSM-V.

"[T]he problems of individuals with feeding or eating problems not meeting criteria for currently recognized disorders can be more appropriately described and categorized."  This aim of refining and specifying eating disorder variants is not dissimilar (as this page notes) to the changes proposed for the Mood Disorders (and it seems to me, to some extent, the Personality Disorders).  The point is that "these Conditions may be associated with levels of distress and/or impairment similar to those associated with the recognized Feeding and Eating Disorders, and may require intensive clinical intervention."

Recognition of eating disorders that you can't see with your eyeballs is one of the traditional problems that those in the field have been trying to correct over the last 15 or so years.  Originally, anorexia got all the attention and therefore all the study.  It was decades before bulimia nervosa was even its own diagnosis.  Then, classic anorexia and classic bulimia got all the attention and therefore all the study.   With a major emphasis still on anorexia, though.

(Here's an interesting example.  It's great - it is effing fantastic - to see coverage of eating disorders in men.  And the struggles that men with eating disorders undergo within our acute gender binary are just... I can't even imagine the layer of crap that piles on top o' the other crap.  But this could have been an article about men with eating disorders: not just anorexia, but anorexia, bulimia, binge eating disorder, purging disorder, and more.)

I have Thoughts about that.  One of my Thoughts is that this seems sensible, since anorexia is the deadliest psychiatric disorder.  But another of my Thoughts is that anorexia is relatively so rare.  Comparable to anorexia, a huge portion of the ED population is bulimic, but bulimia isn't as pretty or as alluring, both from a study POV and from a cultural POV.  And comparable to bulimia, a huge portion of the ED population is ED-NOS, but only now is there really beginning to be serious study into ED-NOS, and then the only cultural currency ED-NOS receives is through attention to Binge Eating Disorder, currently categorized under ED-NOS.

So my Thoughts are that we seem to be witnessing a gradual slide from attention to the peak: unattainable, alluring eating disorders -- the low weight restrictive ones that is; the saints live up there.  That attention started trickling its way down the research and the cultural slopes, down to the valley where reside the ugly eating disorders, the disorders that for decades and decades weren't even acknowledged as eating disorders at all.  (This isn't to say that anorexia isn't ugly.  Anorexia nervosa is horrifying.  However, it is approached with a reverence and an envy with which bulimia, binge eating disorder, and other eating disorders are not, at a cultural level.)

It's great that there is finally recognition that just because you're not at 85% or lower of your minimum acceptable body weight, or just because you don't binge and purge a minimum of once a week for at least three months, doesn't mean you don't have an eating disorder.  But there is still such vast misunderstanding of anything that isn't visible Anorexia Nervosa or Bulimia Nervosa at a cultural level.  And truly, there is still a hierarchy within the professional realm, at least as far as studies and diagnostics are concerned.

At a macro level, you can look over things and see the progress, and that sure does feel encouraging.  But at a micro level it is still very, very disheartening that physicians who are trained to observe and evaluate data don't recognize eating disorders in patients whose weight is not at a certain shocking level, or who aren't obviously or admittedly bulimic, mostly because the information and the cultural acknowledgement of what is disordered just isn't there yet.

At the macro level, there is a nebulous knowledge that eating disorders are more than anorexia nervosa or bulimia nervosa, and that perhaps binge eating disorder is A Real Thing, rather than Lazy People.  But at the micro level, the cultural hierarchy of eating disorders keeps so many individuals trapped in disordered eating and disordered living, unaware that they could ask for, and often even find help, if only they knew they deserved it.