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Historical Evolution of the Concept of Anorexia Nervosa and Relationships with Orthorexia Nervosa, Autism, and Obsessive–Compulsive Spectrum

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Historical Evolution of the Concept of Anorexia Nervosa and Relationships with Orthorexia Nervosa, Autism, and Obsessive–Compulsive Spectrum Journal name: Neuropsychiatric Disease and Treatment Article Designation: Review Year: 2016 Volume: 12 Neuropsychiatric Disease and Treatment Dovepress Running head verso: Dell’Osso et al Running head recto: Historical evolution of the concept of anorexia nervosa open access to scientific and medical research DOI: http://dx.doi.org/10.2147/NDT.S108912 Open Access Full Text Article REVIEW Historical evolution of the concept of anorexia nervosa and relationships with orthorexia nervosa, autism, and obsessive–compulsive spectrum Liliana Dell’Osso1 Abstract: Eating disorders have been defined as “characterized by persistence disturbance of Marianna Abelli1 eating or eating-related behavior that results in the altered consumption or absorption of food and Barbara Carpita1 that significantly impairs health or psychosocial functioning”. The psychopathology of eating Stefano Pini1 disorders changed across time under the influence of environmental factors, determining the Giovanni Castellini2 emergence of new phenotypes. Some of these conditions are still under investigation and are Claudia Carmassi1 not clearly identified as independent diagnostic entities. In this review, the historic evolution of the eating disorder concept up to the recent Diagnostic and Statistical Manual of Mental Valdo Ricca2 Disorders, Fifth Edition, has been evaluated. We also examined literature supporting the inclu- 1 Psychiatry Section, Department of sion of new emergent eating behaviors within the eating disorder spectrum, and their relation- Clinical and Experimental Medicine, For personal use only. University of Pisa, Pisa, 2Department ship with anorexia, autism, and obsessive–compulsive disorder. In particular, we focused on of Neuroscience, Psychology, what is known about the symptoms, epidemiology, assessment, and diagnostic boundaries of Drug Research and Child Health a new problematic eating pattern called orthorexia nervosa that could be accepted as a new (NEUROFARBA), University of Florence, Florence, Italy psychological syndrome, as emphasized by an increasing number of scientific articles in the last few years. Keywords: anorexia nervosa, autism spectrum disorders, eating disorders spectrum, obsessive–compulsive spectrum, orthorexia nervosa, DSM-5 Introduction Eating disorders have been defined as “characterized by persistence disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food and that significantly impairs health or psychosocial functioning”.1 Neuropsychiatric Disease and Treatment downloaded from https://www.dovepress.com/ by 131.114.71.60 on 19-Oct-2016 The last version of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5),1 places eating disorders in the “Feeding and Eating Disorders” chapter, featuring several modifications of DSM-IV-TR. These changes include the inclusion of three disorders – avoidant/restrictive food intake disorder (ARFID), rumination disorder, and pica – previously described in the “Feeding and Eating Disorder of Infancy or Early Childhood” chapter and subsequently removed with the aim to produce a single chapter for eating disorders in childhood and adulthood. It includes anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder Correspondence: Stefano Pini (BED), ARFID, rumination disorder, pica, other specified feeding or eating disor- Psychiatry Section, Department of der, and unspecified feeding or eating disorder.1 The modifications of the diagnostic Clinical and Experimental Medicine, University of Pisa, Via Roma 67, criteria appearing in the DSM-5 are relatively few, although significant, and involve 56100 Pisa, Italy clarifications to language and adjustments to existing diagnoses.2 In AN, the amenor- Tel +39 336 801 322 Email [email protected] rhea criterion was removed, and in BN, the threshold frequency of binge episodes and submit your manuscript | www.dovepress.com Neuropsychiatric Disease and Treatment 2016:12 1651–1660 1651 Dovepress © 2016 Dell’Osso et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you http://dx.doi.org/10.2147/NDT.S108912 hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php). Powered by TCPDF (www.tcpdf.org) 1 / 1 Dell’Osso et al Dovepress compensatory behaviors were decreased as the two subtypes disorder concept up to the last version of the DSM, to the (purging type and non-purging type) were deleted. Moreover, latest proposal for a new conceptualization of the eating the DSM-5 officially recognized BED as a formal diagnosis.1 disorder spectrum, and the new emergent eating disorders In reviewing and revising these disorders, the DSM-5 Eating and behaviors. In particular, we focused on what is known Disorders Work Group had two objectives: clarify the exist- about the symptoms, epidemiology, assessment, and diag- ing diagnostic criteria, and decrease the frequency with which nostic boundaries of a new problematic eating pattern called individuals, presenting for eating disorder treatment, were orthorexia nervosa (ON) that could be accepted as a new assigned to the heterogeneous category residual category, psychological syndrome, as emphasized by an increasing other specified feeding or eating disorder (or, in DSM-IV, number of scientific articles in the last few years.8–11 eating disorders not otherwise specified [EDNOS]), reas- signing someone to a specific diagnosis. Le Grange et al,3 Before the DSM: historical in a nationwide study in the US, reported that 80.97% of perspective on self-starvation adolescents and 75.38% of adults with an eating disorder Although the symptomatology of AN shows an evolution were classified as having EDNOS, making it the most related to environmental factors across history, it is important common eating disorder diagnosis. not to consider it as a contemporary disorder (Table 1). This “miscellaneous” category provides less clinical The first examples of self-starvation in Western countries utility. Conversely, by using DSM-5 criteria, many of these have been reported as starting from the widespread diffu- individuals will be returned to a diagnosis with a greater sion of Gnostic philosophy and Christianity, both of which clinical utility. promoted a dichotomy between the evil, material world, and The National Comorbidity Survey Replication estimates the holiness of souls.12 Christian hermits researched purifica- the lifetime prevalence of AN, BN, and BED at 0.9%, 1.5%, tion through self-starvation,13 and it seems that Saint Jerome and 3.5% in women and 0.3%, 0.5%, and 2.0% in men, professed the ascetic regime benefits to Roman women, to respectively.4 The new criteria adopted in the last edition the extent that a Roman girl died of self-starvation following For personal use only. of the DSM included in the main diagnoses the majority of his precepts.12–14 patients who were classified as EDNOS, maintaining this During the Middle Age, and in particular from the 13th category as a residual condition. However, several data seem to the 16th century, it is possible to collect various evidence to indicate that the new DSM-5 criteria determine mainly of extreme, self-induced fasting, often leading to premature quantitative changes, and some issues related to the DSM death by starvation, such as Catherina from Siena.15 The categorization of eating disorders were not solved with the characteristic sex difference was already evident, with fasting new edition. For example, it is noteworthy that the major- reported as a peculiar trait of feminine approach to medieval ity of the diagnoses change across time and a considerable asceticism16 and female sainthood ideals were often related number of AN patients develop BN, and vice versa.5,6 The to self-sacrifice practices. Deprivation of food, except for DSM categories can only represent a temporary condition the ritual of Eucharist, was an element of spirituality along that would eventually changes with time. Indeed, several with reclusion, self-flagellation, humble dressing, and other 17 Neuropsychiatric Disease and Treatment downloaded from https://www.dovepress.com/ by 131.114.71.60 on 19-Oct-2016 psychopathological dimensions, such as body image disorder practices. or emotion dysregulation, represent stable markers associated A close relationship between inanition and spirituality in with eating disorders. In this regard, DSM-5 modifications the Middle Age was described, although most of the cases seem to represent quantitative rather than qualitative changes of self-starvation were ascribed to demonic possessions.12,18 to the previous criteria.7 Moreover, the relationship of eating All fasting women were believed suspicious (even in the disorder psychopathology with other conditions outside the case of St Caterina) and only highborn charismatic ladies DSM categories, such as obsessive–compulsive and autism could convince men of the holy nature of their habits.15,18 spectrum, is still far from clarified. Some authors named the common fasting habits reported Indeed, the psychopathology of
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