Capturing the anorexia nervosa phenotype: Conceptual and normative issues in ICD-11

Area of Science:

• Psychiatry
• Medical Ethics
• Philosophy of Medicine

Background:

• The International Classification of Diseases, 11th Revision (ICD-11) provides diagnostic criteria for anorexia nervosa (AN).
• Existing diagnostic frameworks for AN may contain conceptual limitations and normative implications.
• Understanding the underlying assumptions and ethical considerations of AN diagnoses is crucial.

Purpose of the Study:

• To critically examine the conceptual lacunae and normative implications of the ICD-11's diagnostic definition of AN.
• To analyze the ethical implications of assumptions related to voluntary agency, definitions of low weight, and disorder boundaries in AN diagnosis.
• To identify areas requiring further research for a comprehensive understanding of AN.

Main Methods:

• Philosophical analysis was employed to examine the assumptions and ethical implications of the ICD-11 definition of AN.
• Specific focus was placed on voluntary agency in caloric restriction, definitions of "dangerously low weight," and disorder boundaries.
• The analysis considered contested aspects such as excessive exercise and the aetiology of AN.

Main Results:

• The ICD-11 definition's handling of voluntary agency in AN behavior, particularly excessive exercise, remains unresolved and requires understanding AN motivation.
• Uncertainty in AN aetiology impacts the definition of sub-threshold states and the determination of morbidly low body weight, posing risks of medicalizing normal variation.
• Efforts to minimize reliance on subjective motivation in ICD-11 exclusion criteria reveal limitations, highlighting the need for better understanding of AN motivation.

Conclusions:

• A complete characterization of the AN phenotype necessitates reference to psychological states of motivation, which are not fully understood.
• Further research encompassing clinical, genetic, neurobiological, conceptual, and ethical dimensions is required to address the challenges in diagnosing and understanding AN.
• The current diagnostic criteria for AN, while not necessarily mistaken, require careful consideration of false positives and complex cost-risk assessments in clinical practice.