Saturday, August 25, 2012

With Rise of Gene Sequencing, Ethical Puzzles -

Dr. Arul Chinnaiyan stared at a printout of gene sequences from a man with cancer, a subject in one of his studies. There, along with the man's cancer genes, was something unexpected — genes of the virus that causes AIDS.

It could have been a sign that the man was infected with H.I.V.; the only way to tell was further testing. But Dr. Chinnaiyan, who leads the Center for Translational Pathology at the University of Michigan, was not able to suggest that to the patient, who had donated his cells on the condition that he remain anonymous.

In laboratories around the world, genetic researchers using tools that are ever more sophisticated to peer into the DNA of cells are increasingly finding things they were not looking for, including information that could make a big difference to an anonymous donor.

The question of how, when and whether to return genetic results to study subjects or their families "is one of the thorniest current challenges in clinical research," said Dr. Francis Collins, the director of the National Institutes of Health. "We are living in an awkward interval where our ability to capture the information often exceeds our ability to know what to do with it."

The federal government is hurrying to develop policy options. It has made the issue a priority, holding meetings and workshops and spending millions of dollars on research on how to deal with questions unique to this new genomics era.

The quandaries arise from the conditions that medical research studies typically set out. Volunteers usually sign forms saying that they agree only to provide tissue samples, and that they will not be contacted. Only now have some studies started asking the participants whether they want to be contacted, but that leads to more questions: What sort of information should they get? What if the person dies before the study is completed?

The complications are procedural as well as ethical. Often, the research labs that make the surprise discoveries are not certified to provide clinical information to patients. The consent forms the patients signed were approved by ethics boards, which would have to approve any changes to the agreements — if the patients could even be found.

Sometimes the findings indicate that unexpected treatments might help. In a newly published federal study of 224 gene sequences of colon cancers, for example, researchers found genetic changes in 5 percent that were the same as changes in breast cancer patients whose prognosis is drastically improved with a drug, Herceptin. About 15 percent had a particular gene mutation that is common inmelanoma. Once again, there is a drug, approved for melanoma, that might help. But under the rules of the study, none of the research subjects could ever know.

Other times the findings indicate that the study subjects or their relatives who might have the same genes are at risk for diseases they had not considered. For example, researchers at the Mayo Clinic in Rochester, Minn., found genes predisposing patients to melanoma in cells of people in a pancreatic cancer study — but most of those patients had died, and their consent forms did not say anything about contacting relatives.

One of the first cases came a decade ago, just as the new age of genetics was beginning. A young woman with a strong family history of breast and ovarian cancer enrolled in a study trying to find cancer genes that, when mutated, greatly increase the risk of breast cancer. But the woman, terrified by her family history, also intended to have her breasts removed prophylactically.

Her consent form said she would not be contacted by the researchers. Consent forms are typically written this way because the purpose of such studies is not to provide medical care but to gain new insights. The researchers are not the patients' doctors.

But in this case, the researchers happened to know about the woman's plan, and they also knew that their study indicated that she did not have her family's breast cancer gene. They were horrified.

"We couldn't sit back and let this woman have her healthy breasts cut off," said Barbara B. Biesecker, the director of the genetic counseling program at the National Human Genome Research Institute, part of the National Institutes of Health. After consulting the university's lawyer and ethics committee, the researchers decided they had to breach the consent stipulations and offer the results to the young woman and anyone else in her family who wanted to know if they were likely to have the gene mutation discovered in the study. The entire family — about a dozen people — wanted to know. One by one, they went into a room to be told their result.

"It was a heavy and intense experience," Dr. Biesecker recalled.

Around the same time, Dr. Gail Jarvik, now a professor of medicine and genome science at the University of Washington, had a similar experience. But her story had a very different ending.

She was an investigator in a study of genes unrelated to breast cancer when the study researchers noticed that members of one family had a breast cancer gene. But because the consent form, which was not from the University of Washington, said no results would be returned, the investigators never told them, arguing that their hands were tied. The researchers said an ethics board — not they — made the rules.

Dr. Jarvik argued that they should have tried to persuade the ethics board. But, she said, "I did not hold sway."

Such ethical quandaries grow more immediate year by year as genome sequencing gets cheaper and easier. More studies include gene sequencing and look at the entire genome instead of just one or two genes. Yet while some findings are clear-cut — a gene for colon cancer, for example, will greatly increase the disease risk in anyone who inherits it — more often the significance of a genetic change is not so clear. Or, even if it is, there is nothing to be done.

Researchers are divided on what counts as an important finding. Some say it has to suggest prevention or treatment. Others say it can suggest a clinical trial or an experimental drug. Then there is the question of what to do if the genetic findings only sometimes lead to bad outcomes and there is nothing to do to prevent them.

"If you are a Ph.D. in a lab in Oklahoma and think you made a discovery using a sample from 15 years ago from a subject in California, what exactly are you supposed to do with that?" asked Dr. Robert C. Green, an associate professor of medicine at Harvard. "Are you supposed to somehow track the sample back?"

Then there are the consent forms saying that no one would ever contact the subjects.

"If you go back to them and ask them to re-consent, you are telling them something is there," Dr. Green said. "There is a certain kind of participant who doesn't want to know," he added, and if a researcher contacts study subjects, "you are kind of invalidating the contract."

Other questions involve the lab that did the analysis. All labs providing clinical results to patients must have certification ensuring that they follow practices making it more likely that their results are accurate and reproducible. But most research labs lack this certification, and some of the latest genetic tests are so new that there are no certification standards for them.

"I find it really hard to defend the notion that we are not going to give you something back because it was not done" in a certified lab, "even though we are 99 percent certain it is correct," Dr. Jarvik said.

Gloria M. Petersen, a genetic epidemiologist at the Mayo Clinic, and her colleagues ran into a disclosure problem in a study of genes that predispose people to pancreatic cancer. The 2,000 study patients had signed consents indicating whether they wanted to know about research findings that might be important to them. But the forms did not ask about sharing findings that might be important to their families, or about what the researchers should do if they discovered important information after the patients were dead.

Seventy-three of the study patients, almost all of whom are now dead, had one of three clinically important mutations. One predisposed them mostly to melanoma but also to pancreatic cancer. A second predisposed them primarily to breast and ovarian cancer. The third, a cystic fibrosis gene, can increase the risk of pancreatic cancer and can also be important in family planning. If a man and a woman each have this gene, they have a one-in-four chance of having a child with the disease.

When it comes to the family members, "I don't know what my obligation is," Dr. Petersen said. "There is an incredible burden to track down the relatives. Whose information is it, and who has a right to that information?"

Dr. Petersen, along with Barbara Koenig, a professor of medical anthropology and bioethics at the University of California, San Francisco, and Susan M. Wolf, a professor of law, medicine and public policy at the University of Minnesota, got a federal grant to study the effects of offering to return the genetic results to the families of those 73 patients. The questions involved are tricky, Dr. Koenig said. Finding patients and their families can be expensive, and labs do not have money set aside for it. How would you find them? Even if they were found, whom would you tell? What if there had been a divorce, or if family members were estranged?

"My gut feeling is that there is a moral obligation to return results," Dr. Koenig said. "But that comes at an enormous cost. If you were in a study 20 years ago, where does my obligation end?"

Old bones - Mireille Silcoff, National Post

Sometimes I wonder whether these pages are the right platform for writing about illness. Nobody wants sick cells in their coffee on a Saturday morning. But then I think: there is writing lugubriously about illness and there is writing about illness the way you might write about anything else. You try to be honest, see some bigger picture. There are only a few things everyone in the universe can relate to: birth, death, love, loss, and somewhere in all that, illness.

I live with more of it than anyone else I know. By "know" I mean people in my immediate circling of family and friends. My grandfather is 104 and, on paper, much healthier than me. If there is a spare nook or cranny in my life, it will, guaranteed, soon be filled by some crazy syndrome that is so rare most GPs need to look it up, brows knit.

My nature abhors a vacuum. So I have trained myself to become something like the opposite of hypochondriac. I am somebody who is often unwell but uses a good deal of her available strength not to succumb to it, or at least, to succumb creatively. I have stated before that I cannot go into a doctor's office without coming out with something fascinating and I am about to repeat that idea now, albeit with new, troubling details:

This past June, I sat before a Montreal neuroendocrinologist who looked at some results and then looked at me and said:

"You know you have the bones of a 95-year-old woman."

Let's take a moment here to discuss delivery. There are many, many ways a doctor can tell a happy, hopeful 39-year-old woman with a new baby at home, a person considering a second child, a person who already has medical issues that impinge her on a daily basis, that she also has severe osteoporosis.

He could say, simply:

"You have osteoporosis, and it is not a mild case. That is rare for someone of your age."

He could say:

"Do you know you have osteoporosis? Let me explain it to you. And then I will tell you what we can do about it."

But no. It's "a 95-year-old woman." So I now have some spectre of an old lady living inside me. I get a new haircut; I put on a nice dress. I look in the mirror, and I think, "Hey! Pretty damn good!" and then a gravelly inner voice - one that sounds uncannily like my doctor's - rises up and says, "Don't kid yourself. On the inside, you are a withering nonagenarian."

A doctor giving bad news needs to employ artistry, but he does not need to employ drama. Usually, there is enough drama in the information (compared with a healthy adult Canadian, I am missing 36% of my bone mass). A doctor employing needless drama in the transmission of bad diagnoses has lost his heart, and should go somewhere and do something to retrieve it.

Last weekend, I listened to a wonderful conversation, one from 2000, between CBC Radio's Eleanor Wachtel and the writer and thinker Susan Sontag, who died of cancer in 2004. Over the span of her life, Ms. Sontag had cancer three times. Here she spoke of the first time she had it, in the 1970s, and then of having another kind of cancer in the late 1990s. Ms. Sontag said that in the '70s, most patients didn't even know the names of the drugs they were on, while in the 1990s, people were much better informed, constantly "pulling out their printouts from the computer," and "exchanging hot tips" on treatment. The knowledge was gleaned from the Internet. The information, she said, gave the patients power.

In my experience, doctors do not love it when you pull out printouts. In my experience, with so many time-strapped doctors in Canada, corroded by the demands of the breaking system, there is not much choice. I have a long-standing, highly unusual spinal cord condition - the tissue tears, causing spinal fluid leaks - which required treatment outside of Canada a few years ago.

In the United States, I paid through the nose, paid enough to go bankrupt in fact, but I got what I paid for: clarity, information, nothing falling between cracks, lateral thinking, every effort expended in treatment. In terms of my own understanding of my spinal cord tissue, it was a big turning point. And from there, I learned how to live well with the condition.

I am sure that the Montreal doctor who dispensed my most recent diagnosis is a man with normal sensitivities and sensibilities outside his office. But the entirety of the information I have so far received from his bureau, where the average face time with the MD during an appointment is five minutes, and where the doctor spends half those minutes talking to the interns he is teaching (Specimen A: 95-year-old trapped in body of 39-year-old.) is:

a. I have severe osteoporosis, which is rare for someone in her thirties.

b. The doctor suspects an underlying genetic tissue disorder called Ehlers-Danlos syndrome. It could be the source of my porous bones and also my strangely tearing spinal cord.

c. I need to go on a drug, for osteoporosis.

d. The drug is called Forteo. I will have to inject it daily.

e. It will cost $20, 000 a year.

f. The people from Eli Lilly, the pharmaceutical company that makes Forteo, will be telephoning me to discuss. They will tell me everything I need to know about my treatment.

And so, to the Internet. I soon find out that nobody knows how Forteo builds bone. It can improve bone mass, but the method in which it does so is a complete mystery. In lab rodents, it has caused bone cancer. It has caused tumours in rats to the extent that in Canada, a human being is only allowed to take Forteo for two years in a lifetime. Forteo has a large range of side effects, including nausea, dizziness, weakness and joint pain. Some of these are noted in an astonishing 14% of those taking the drug. You must not conceive while on Forteo. You must be off the drug for months before trying.

Lately, the folks from the Eli Lilly Company have been phoning me. I get calls from customer care, as if from the Hoover man. Sometimes it's a nurse, sometimes it's a person calling to talk about a medic coming to my house to show me how to use the drug, and sometimes it's someone who is there solely to help me get insured. In the wild world of Quebec medicare, if you have severe osteoporosis and you are a woman of 70, you are worthy of coverage. But if your bone mass is disintegrating when you are pre-menopausal? Contrary to all good sense, you are most likely on your own.

At present I speak to someone from Eli Lilly about once a day. Once a day I pick up the receiver and it's Big Pharma phoning. Given my proximity to embarking on a possibly carcinogenic treatment, a treatment for a bone condition that likely has an underlying tissue disorder at its root, a disorder for which I have not even had the genetic tests yet, a disorder that is heritable, heritable from one side, meaning there is a not-tiny chance that I have passed it down to my child, and given that this fact alone keeps me up all night, hankie-twisting, once a day seems about as often as I should be speaking to a real doctor right about now.

But I am not speaking to my doctor. I am speaking to salespeople. And their main, perhaps sole, interest in me, is that I take a total of $40, 0000 worth of a drug with a gratingly superheroic name.

In general, I have had more esteem than complaint for our Canadian healthcare system. I have often seen it as a group of people - doctors and patients - doing their best in a highly imperfect situation. But I only need to glance at my current state of affairs to know that the way it is being handled is wrong - all of it, perverted. A corporation with specific interests has usurped my doctor in my treatment.

But I refuse to go elsewhere to treat osteoporosis, the way I went for spinal fluid leaks. Spinal fluid leaks required a specific expert, but osteoporosis can be cared for perfectly well in my hometown. And so of course I will look for more doctors, and of course I will continue asking my current doctor for more information, for any information, for genetic tests that he doesn't think are urgent, and which I do. I learned a long time ago to ask that desperate question of my doctors: If it were your child what would you do, doctor? What would you do? If it were your child?

But for now, I submit to the care of the world wide web, and that of a pharmaceutical company. The Hoover salesmen have entered my home. At the moment, the only thing I can do is welcome them.

Tuesday, August 21, 2012

U.S. Physicians Commonly Have Symptoms Of Burnout

At least 45.8% of physicians have one symptom of burnout, according to a national survey of burnout in physicians from all specialty disciplines. The study is published Online First by Archives of Internal Medicine.

According to other studies, burnout may have an impact on the quality of care and elevate the risk for medical errors in addition to having adverse effects on physicians, such as problem drinking, broken relationships and thoughts of suicide.

For their study, Tait D. Shanafelt, M.D., of the Mayo Clinic, Rochester, Minn., and her team involved 7,288 physicians from the American Medical Association Physician Masterfile and for comparison, a sample of 3,442 working U.S. adults from the general population as control group. 26.7% of physicians responded to the survey.

According to the findings, 37.9% of U.S. physicians reported high emotional exhaustion, 29.4% had high depersonalization, and 12.4% felt a low sense of personal accomplishment. The risk of having symptoms of burnout was 27.8% in the control group compared with 37.9% of the physicians. In addition, 40.2% of physicians reported to be dissatisfied with their work-life balance compared with only 23.2% in those in the control group.

The team also noted differences in burnout depending on special sectors of emergency medicine. For instance, the highest burnout rates were noted amongst physicians working in general internal medicine, neurology and family medicine, whilst those working in pathology, dermatology, general pediatrics and preventive medicine displayed the lowest burnout rates.

The team concludes: 

"Collectively, the findings of this national study indicate that (1) the prevalence of burnout among U.S. physicians is at an alarming level, (2) physicians in specialties at the front line of care access (emergency medicine, general internal medicine and family medicine) are at greatest risk, (3) physicians work longer hours and have greater struggles with work-life integration than other U.S. workers and (4) after adjusting for hours worked per week, higher levels of education and professional degrees seem to reduce the risk for burnout in fields outside of medicine, whereas a degree in medicine (M.D., or D.O.) increases the risk. The fact that almost 1 in 2 U.S. physicians has symptoms of burnout implies that the origins of this problem are rooted in the environment and care delivery system rather than in the personal characteristics of a few susceptible individuals. Policy makers and health care organizations must address the problem of physician burnout for the sake of physicians and their patients."

They indicate that more research needs to be conducted in order to gain more insight into physician burnout and to develop interventions.

Coming Next - Doctors Prescribing Apps to Patients -

Before long, your doctor may be telling you to download two apps and call her in the morning.

Smartphone apps already fill the roles of television remotes, bike speedometers and flashlights. Soon they may also act as medical devices, helping patients monitor their heart rate or manage their diabetes, and be paid for by insurance.

The idea of medically prescribed apps excites some people in the health care industry, who see them as a starting point for even more sophisticated applications that might otherwise never be built. But first, a range of issues — around vetting, paying for and monitoring the proper use of such apps — needs to be worked out.

"It is intuitive to people, the idea of a prescription," said Lee H. Perlman, managing director of Happtique, a subsidiary of the business arm of the Greater New York Hospital Association. Happtique is creating a system to allow doctors to prescribe apps, and Mr. Perlman suggested that a change in the way people think about medicine might be required: "We're basically saying that pills can also be information, that pills can also be connectivity."

Simple apps that track users' personal fitness goals have already gained wide traction. Now medical professionals and entrepreneurs want to use similar approaches to dealing with chronic ailments like diabetes or heart disease.

If smartphone-based systems can reduce the amount of other medical care that patients need, the potential benefit to the health care system would be enormous; the total cost of treating diabetes alone in 2007 was $174 billion, according to the most recent statistics from the Centers for Disease Control and Prevention.

But unlike a 99-cent game, apps dealing directly with medical care cannot be introduced to the public with bugs that will be fixed later. The industry is still grappling with how to ensure quality and safety.

One of the pioneers in the prescription-app field is a company called WellDoc. Its DiabetesManager system, which patients can use through a smartphone app, standard cellphone or desktop computer, collects information about a patient's diet, blood sugar levels and medication regimen. Patients can enter this data manually or link their devices wirelessly with glucose monitors.

DiabetesManager then gives advice to a patient, perhaps suggesting the best food after recording a low midday blood-sugar reading. It also uses an algorithm to analyze the medical data and send clinical recommendations to the doctor.

WellDoc says that in a clinical trial, DiabetesManager was shown to reduce significantly the blood sugar levels in diabetes patients.

Those results persuaded the Food and Drug Administration to give the system clearance to operate as a medical device. At over $100 a month, the cost is more akin to diabetes drugs than to most smartphone apps. But two insurance companies have already agreed to pay the bill for patients whose doctors ask them to use the system when it is available early next year, said Anand K. Iyer, the company's president. He declined to name the companies.

When Mr. Iyer began planning an app for WellDoc, he had something simple in mind. But as the company pursued it he realized that it would have to build something much more ambitious, in a process that ended up taking years and millions of dollars in investment.

"As I learned more and more about the health care system, I realized that the way to monetize this wasn't as a 5-cent app in the app store, but as a high-value system," he said. "It wasn't going to be a quick ride."

The app is one of fewer than 10 to date that has gained clearance from the F.D.A.

Sailesh Chutani, the co-founder of MobiSante, which created a smartphone-based ultrasound system, said that his company initially considered marketing it as a veterinary tool, or selling it only overseas, to avoid an expensive vetting process. But the company chose to ask to be regulated, in part because it made it easier to attract investment. Last year the F.D.A. approved the system, which includes an app and an ultrasound device that connects to the phone.

"Suddenly you're sending a market signal that you have been vetted and cleared by the toughest regulatory agency in the world," Mr. Chutani said.

It is still not completely clear how far regulation over medical apps will extend. The F.D.A. plans to release guidelines later this year outlining its approach to apps, while other agencies will be in charge of privacy and data security.

Continua Health Alliance, an industry group, is also working on standards so that medical apps collect data in compatible formats, allowing patients to move their data from one app to another. There are also questions of what happens when a prescribable app is available only on certain types of phones.

At the same time, many apps being marketed as medical tools are being designed to skirt federal regulation, in part by piling on the disclaimers. Still, there is wide acknowledgment that many apps violate current regulations by making dubious or untested medical claims. The F.D.A. has shied away from going after such apps until its guidelines are in place. The agency, which does not want to choke innovation, will regulate only applications that act as medical devices by making clinical or diagnostic decisions, said Bakul Patel, an F.D.A. policy adviser.

Mr. Perlman of Happtique says he believes that doctors will soon prescribe both clinically tested apps and more modest apps, like those that track physical activity or remind patients to take their pills. The company has established its own set of guidelines to determine the quality of health care-related apps, and helps doctors integrate them into their medical practice.

The company evaluates apps in several areas — diabetes, cardiology, rheumatoid arthritis and physical therapy — and allows doctors to prescribe apps to their patients from selected lists. It monitors whether the patient has downloaded the app, and can send automated reminders to those who have not done so. The company is opening its system to doctors this week.

Skeptics, including John Moore, a physician at the M.I.T. Media Lab's new media medicine project, say that Happtique is ahead of its time, since there are relatively few apps that are worth prescribing.

"Making a clearinghouse for apps today is a tough job because you're just filtering through a lot of stuff that doesn't do much," said Dr. Moore. "But as a long-term vision, it's an interesting idea."

But the company says that it is setting up a framework so that it can persuade insurance companies to pay for apps that doctors recommend. It is also lobbying federal regulators to allow patients to use flexible spending accounts to buy prescribed apps through its system.

"This is the transition from something that is superficial to serious health care delivery," Mr. Perlman said. "The health care system is going to need somebody to help organize this."

Sunday, August 19, 2012

Feeding the illness industry machine thanks to DSM5 | Robert Fulford | National Post

Once again the armies of psychiatry are on the move, marching like imperial legions into unconquered territories of the human spirit. Psychiatrists do excellent work as individuals but when they join international bureaucracies they can cause trouble and look foolish.
The evidence is the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, known as DSM-5. It's now in final draft, scheduled for release during the American Psychiatric Association annual meeting next May.
Authors of the various DSM editions appear anxious to demonstrate that just about every trace of emotional discomfort deserves professional attention. Sadness is being reclassified as sickness. The medicalization of everyday life is progressing with astonishing speed.
People not directly involved may view this with a light heart, as fresh intellectual confusion created by pretentious, over-confident experts. It's more serious for patients. A medical label that's invented by an ambitious theorist and carelessly applied by an untrained doctor can erode self-confidence. A diagnosis takes on a life of its own.
Habitually, the DSM volumes lead to over-diagnosing and over-prescribing. Grief, for instance, receives special DSM attention. Humanity traditionally regards sorrow as a part of life but in the DSM it indicates depression. In DSM-5, reactions to grief lasting longer than two weeks may be diagnosed as depression, perhaps requiring antidepressants.
Kenneth S. Kendler, a Virginia psychiatrist who serves on the DSM mood disorder committee, has answered criticism of the grief proposal — but answered it in a way that suggests he doesn't understand the impact of what he's doing. He says we needn't worry that grieving individuals will be automatically treated as depressives. In psychiatry, watchful waiting is an important tool, and a psychiatrist with a patient who appears depressed after a bereavement will start with a careful diagnostic evaluation.
But DSM-5 will be used by many family doctors who have no time for watchful waiting and no training for a diagnostic evaluation. It's been credibly estimated that in the U.S. about 80% of drugs for mood disorders are prescribed by non-psychiatrists, usually GPs.
In the current round of controversy, critics of DSM-5 have a surprising champion — Allen J. Frances, former head of psychiatry at Duke University.
He chaired DSM-4, the current edition, published in 1994. He admits it got out of control. Unjustified expansion of illness categories happened on his watch and he's campaigning by speeches and blogs to get it right this time.
The case of Attention Deficit Hyperactivity Disorder (ADHD) is one of his concerns. Earlier versions of the DSM have encouraged excessive diagnosis, creating the appearance of an international epidemic of ADHD.
And now, Frances says, DSM-5 is about to lower the threshold for diagnosis, which means there will be still more kids given Ritalin and more articles about ungovernable, badly reared children.
A University of British Columbia study, released earlier this year, shows how this works. Over 11 years, researchers surveyed the records of 937,943 children, searching for factors that lead to the ADHD diagnosis. They discovered that the youngest children in any classroom are the likeliest to be identified as suffering from ADHD.
Given the schedules of Canadian schools, children born in December are roughly a year younger than their oldest classmates. They likely suffer from greater frustration and anxiety, producing ADHD-like symptoms. Those born in December, compared to those born in January, are 39% more likely to be classified ADHD and 48% more likely to receive ADHD medication. Clearly, many children being medicated for ADHD are in truth being medicated for their age.
Why is the DSM so anxious to uncover new categories of mental illness and inflate the more familiar categories? Drug companies hope to develop new drugs and expand the market for old ones but lobbying by psychiatrists with specialized interests carries more weight. As Allen Frances says, "Experts always overvalue their pet area and want to expand its purview."
Some disorders even have their own lobbies. This month Eating Disorder Hope, an on-line publication, celebrated the news that DSM-5 will elevate the status of binge-eating disorder (BED), shifting it from the appendix (where rookie disorders nervously await acceptance as proper illnesses) to a distinct category of eating disorder. Patients who binge once a week for three months will be officially BED. Eating Disorder Hope says this means their treatments will be covered by their insurance.
Frances considers that section another DSM mistake. But, like everything else in this vast catalogue of sorrows, it satisfies at least one corner of the steadily increasing illness industry.