Wilson Island mouth needs regular feeding

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Try out PMC Labs and tell us what you think. Learn More. Current classification of eating disorders is failing to classify most clinical presentations; ignores continuities between child, adolescent and adult manifestations; and requires frequent changes of diagnosis to accommodate the natural course of these disorders. The classification is divorced from clinical practice, and investigators of clinical trials have felt compelled to introduce unsystematic modifications. Classification of feeding Wilson Island mouth needs regular feeding eating disorders in ICD requires substantial changes to remediate the shortcomings.

We review evidence on the developmental and cross-cultural differences and continuities, course and distinctive features of feeding and eating disorders. The deficiencies of these systems are most evident in four facts. Third, most recent clinical trials Wilson Island mouth needs regular feeding used modified diagnostic criteria that may better reflect clinical practice, but deny the purpose of the classification as a means for communication between clinicians and researchers.

Fourth, although childhood feeding disorders are typically described in the history of adolescents and adults with eating disorders, there is little research on the developmental continuity between childhood, adolescent and adult disorders that involve aberrant eating behaviours. Issues have also been raised about developmental and cultural dependencies of feeding and eating disorders as currently conceptualized. Given these problems, it is not surprising that the World Health Organization WHO and the American Psychiatric Association are contemplating ificant changes in classification.

A of proposals for changes have been made. The purpose of this article is to summarize the issues in the classification of feeding and eating disorders, review relevant aspects of evidence, and make proposals for modifications in the context of the development of ICD The primary purpose of the International Classification of Diseases ICD is to facilitate the work of health professionals in various clinical settings across the world.

Therefore, the primary requisite for ICD diagnostic is clinical utility, and evidence from clinical and epidemiological research is given more weight than data from basic and etiological research 1. Attention is paid to global cross-cultural validity and the needs of health professionals from medium and low income countries 1.

Several conceptual directions have been proposed for the ICD 2. First, to reflect the growing evidence on continuity between child, adolescent and adult psychopathology, it has been proposed that the grouping of disorders with onset usually occurring in childhood and adolescence should be removed. Instead, disorders should be organized in groupings by psychopathology and a life-course approach should be adopted to conceptualize child, adolescent and adult manifestations of the same disorders.

It has been proposed that evidence is required not just for changing or adding diagnostic but also for retaining existing ones. Third, to best serve the clinical use, the ICD takes a prototypic approach in which presentations characteristic of each diagnostic category are described in a narrative format, which most health professionals find easier to use in practice 34.

The ICD avoids the use of exact count, frequency and duration criteria to modulate diagnostic thresholds. Since most duration criteria for various disorders are not based on evidence and are difficult to memorize and apply, it has been proposed that a uniform duration criterion of four weeks should be adopted, with qualified exceptions for disorders which require rapid clinical attention e.

Fourth, it has been proposed that with some evidence of clinical usefulness, but insufficient evidence for validity of specific criteria, should be included in the main body of the ICD, but posted as that require further testing. Fifth, to reflect the evidence that most mental disorders are multifactorial, it is proposed to remove the distinction between organic and functional forms of disorders. The most important reason against changing the current diagnostic criteria is that it could invalidate available evidence.

It is therefore important to assess the clinically relevant evidence and its relationship to classification. We have reviewed recent clinical trials on treatments of eating disorders published in six influential child and general psychiatry journals Journal of the American Academy of Child and Adolescent Psychiatry, Journal of Child Psychology and Psychiatry, American Journal of Psychiatry, Archives of General Psychiatry, British Journal of Psychiatry and Psychological Medicine between January and May Seven trials tested treatments for anorexia nervosa.

Eleven trials tested treatments for bulimia and related conditions. Eight of these trials published between and used broader criteria, including bulimic-type eating disorders not otherwise specified or all eating disorders without underweight in addition to bulimia nervosa.

Wilson Island mouth needs regular feeding

We conclude that the clinical trial literature reflects the deficiencies of the current diagnostic systems by broadening the diagnostic criteria in attempts to reflect clinical reality. The result is that inclusion criteria differ between trials and the classification has effectively lost its purpose in defining the same group of patients across research studies and clinical settings. We conclude that changes in classification will not invalidate useful evidence, because most recent evidence is based on modified diagnostic criteria.

Wilson Island mouth needs regular feeding

An important issue is the relationship between feeding and eating disorders. Feeding problems and selective eating in childhood have been described in the history of patients with eating disorders since the early case reports 23but there has been little research on the continuity between feeding and eating disorders. The available research suggests a degree of continuity of eating problems from infancy to adulthood 2425 For example, in a large prospective study, feeding problems in infancy and undereating in childhood predicted anorexia nervosa in adulthood with odds ratios of 2.

For bulimia nervosa, the evidence is limited to a retrospective study showing that history of overeating and rapid eating in childhood was more common in women with bulimia nervosa than in their unaffected sisters However, long-term follow-ups of individuals diagnosed with feeding disorders in childhood are lacking. At the same time, clinical trends indicate that the boundary between feeding disorders of childhood and eating disorders is problematic. On the other hand, many adults presenting with underweight, restrictive and selective eating lack the typical body-weight and shape related psychopathology that characterizes eating disorders and may be better described by criteria of feeding disorders 282930 It has been pointed out that similarity between child and adult manifestations of eating-related psychopathology might have been obscured by the fact that existing criteria are rigidly applied without sensitivity to developmental stage 283233 This is most apparent in the requirement for self-reported cognitions regarding weight, shape and body image.

It has been argued that children and some adolescents may not be able to formulate and communicate such concerns due to incompletely developed capacity for abstract thinking 283233 It has been proposed that behavioural indicators of such concerns should be accepted as a basis for diagnosis, whether they are observed by clinicians or reported by parents, teachers or other adults 3235 In the case of anorexia nervosa, it has also been suggested that restrictive and binge-purge subtypes often represent developmental stages of the same disorder — children and younger adolescents usually present with the restrictive type, and binge-purging behaviours develop in a proportion of individuals at later stages 3235 The summary of evidence suggests that a single classification applied across age groups and sensitive to developmentally specific manifestations would more accurately describe the course of these disorders and reflect the continuity between child, adolescent and adult manifestations than the current system.

Eating plays an important role in most cultures. Acceptable eating habits vary widely between religious and ethnic groups, and eating disorders have been conceptualized as culture-bound syndromes In this context, it is notable that most published research is based on North American and European populations. In the last decade, reports on eating disorders and related conditions from various countries, including low income countries and countries undergoing sociocultural transitions 394041have accumulated which may Wilson Island mouth needs regular feeding a classification that is sensitive to local variation Anorexia nervosa occurs in all cultures, but the incidence is higher among individuals who have been exposed to Western culture and values and those who live in relative affluence 4041 Anorexia nervosa is relatively rare among black women in Africa, the Caribbean, and the USA 4546 In the Czech Republic, the incidence of anorexia nervosa increased sharply after the fall of the iron curtain, that was associated with exposure to Western-style media and values In addition to influence on prevalence, culture also shapes the manifestation of anorexia nervosa.

For example, in South-East Asia, a larger proportion of patients with anorexia nervosa report abdominal discomfort and other factors as a rationale for restrictive eating 28 However, typical presentations with weight and shape-related preoccupations and fear of gaining weight have also been recorded in most non-Western cultures 28484950and the rates of full-syndrome anorexia nervosa in South East Asia are intermediate between Western countries and African populations There is evidence that patients who initially present with other rationales often develop intense fear of weight gain 51 and that the proportion of patients reporting fear of weight gain increases with exposure to Western cultural values This suggests that weight-phobic and non-weight-phobic anorexia are context-dependent manifestations of the same disorder.

Therefore, it is recommended that fear of weight gain is not required for the diagnosis of anorexia nervosa, provided that behaviours maintaining underweight or other psychopathology suggestive of eating disorder are present. Bulimia nervosa has been conceptualized as strongly bound to Western culture The disorder is more common among individuals who were exposed to Western culture and who grew up in relative affluence 3841 Although all component symptoms of bulimia nervosa occur in non-Western low income countries, the syndrome appears to be less common in those countries than in North America and Western Europe 434950 The incidence of bulimia nervosa increases in parallel with exposure to Western media and values and correlates with the degree of acculturation 414352 Therefore, the manifestation of bulimia nervosa and its separation from normality have to be considered within cultural context.

For example, culturally sanctioned feasting followed by the use of indigenous purgatives in Pacific islands should not be medicalized, but the use of the same herbal purgatives in the context of typical psychopathology and outside the culturally sanctioned events is a symptom of an eating disorder 39 The motives for pursuing a thin body shape may also depend on socioeconomic context. For example, in societies undergoing socioeconomic transition, a thin body can be perceived as a valuable commodity that may help obtain a lucrative job and guarantee career success 4256 There is little evidence on whether such cultural variations in manifestation have an impact on the long-term prognosis and treatment response.

In the USA, patients with bulimia nervosa belonging to ethnic minorities appear to respond to the same psychological treatments as European Americans Binge eating disorder is relatively equally distributed across countries and ethnic groups, but details of manifestation vary in culture-dependent manner. Black women with binge eating disorder are on average heavier, have fewer concerns related to body weight, shape and eating, a less frequent history of bulimia nervosa, but similar levels of depressive symptoms and impairment compared to white women with the same diagnosis In general, the associations between binge eating, obesity, weight and shape dissatisfaction, and general psychopathology hold across ethnic groups 60 While no modifications of diagnostic criteria are required, the lower rates of treatment among black women with binge eating disorder suggest that increased alertness of clinicians to eating disorders in non-European ethnic groups is warranted Longitudinal follow-up studies of anorexia and bulimia nervosa have found that a ificant proportion of subjects change diagnostic status to another eating disorder 6263646566 Diagnostic crossovers are more common in the initial years of illness and follow a predictable sequence.

Crossover in the opposite direction is less common. Larger proportions of subjects with an initial diagnosis of Wilson Island mouth needs regular feeding nervosa develop binge eating disorder or eating disorder not otherwise specified EDNOS 65 There are also numerous transitions between specific eating disorder and EDNOS, with the latter often representing an intermediate state on Wilson Island mouth needs regular feeding way to recovery 6873 The diagnostic transitions may also extend to a relationship between feeding disorders in childhood and eating disorders in adolescence and adulthood.

Restrictive eating and hyperactivity are often present in children and adolescents who deny any motivation of these behaviours by fear of gaining weight, but who later demonstrate weight phobia and receive a diagnosis of an eating disorder 2833 Importantly, a ificant minority of cases show repeated diagnostic crossovers. In long-standing eating disorders, diagnostic transitions are the rule, with most patients who remain ill for at least several years changing diagnostic status one or more times 6870 Comorbid depression and alcohol abuse are associated with more diagnostic instability in eating disorders With these rates of transitions, it is clear that the sequential diagnoses represent stages of the same disorder rather than separate disorders.

Wilson Island mouth needs regular feeding

The apparent sequential comorbidity of various eating disorders is probably an artefact of applying a system of overly specified diagnostic with overlapping psychopathology. However, there is no such restriction for sequential diagnoses, and neither ICD nor DSM-IV takes the longitudinal Wilson Island mouth needs regular feeding of psychopathology into. This state of affairs is clearly unsatisfactory. On the one hand it creates an impression of an overly complex pattern of sequential comorbidity, on the other hand it misses important prognostic information.

For example, it was shown that, among patients with current bulimia nervosa, a history of anorexia nervosa is associated with reduced chance of recovery and much larger risk of transiting into anorexia nervosa It has been proposed that bulimia nervosa should be subtyped according to history of anorexia nervosa A more radical solution to the problem of spurious sequential comorbidity may require restrictions on frequent changes of diagnostic e. This classification has serious problems as it includes one heterogeneous condition with unclear boundaries from eating disorders and two less common and more specific conditions that occur in both children and adults 76 The problems are that the specific subtypes leave a large of clinical presentations unclassified and some require allocation of a single etiology to disorders that are multifactorial.

As a result, none of these proposals has been accepted. The situation is clearer for pica and regurgitation, which are relatively distinct syndromes. However, both of these are frequent in adults and in the context of other mental disorders e. It is proposed that pica and regurgitation disorder should be diagnosed based on behaviour and irrespective of age ARFID overlaps with anorexia nervosa in terms of restrictive food intake and the resulting underweight, but differs in psychopathology and motives for restrictive eating.

ARFID is typically not associated with gross disturbance of body image. Since there is vast normal variation in eating habits among children and adults, differentiation from normality is important. Dietary practices that are endorsed by large groups of people, such as vegetarianism or religious fasting, do not constitute a basis for diagnosing ARFID. The proposed ARFID category conforms with the general direction of merging feeding and eating disorders and opening diagnostic to all age groups.

Wilson Island mouth needs regular feeding

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