The Diagnostic and Statistical Manual of Mental Disorders (DSM) is designed primarily as a clinical tool. Yet high rates of diagnostic “crossover” among the anorexia nervosa subtypes and bulimia nervosa may reflect problems with the validity of the current diagnostic schema, thereby limiting its clinical utility.
Revision the DSM-IV is to increase clinical and research utility by improving diagnostic validity through reliance on empirical evidence. Currently defined eating disorder (ED) categories have limited validity and require refinement based on data.
The available scientific evidence is considered in evaluating the current ED nosology. Specific recommendations include modifying ED classification by retaining categories but adding a dimensional component; removing the amenorrhea criterion for anorexia nervosa (AN); removing the subtypes for AN and bulimia nervosa (BN); making binge eating disorder (BED) an official diagnosis; and unifying the frequency and duration cut-points for BN and BED to once per week for 3 months. There are significant issues to address in revising ED nosology as we move toward a more valid and useful DSM-V.
Eating disorder not otherwise specified (EDNOS)
Eating disorder not otherwise specified (EDNOS) is the most prevalent eating disorder (ED) diagnosis. Diagnostic and Statistical Manual of Mental Disorders revisions by comparing the psychopathology of EDNOS with that of the officially recognized EDs: anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). A comprehensive literature search identified 125 eligible studies (published and unpublished) appearing in the literature from 1987 to 2007. Random effects analyses indicated that whereas EDNOS did not differ significantly from AN and BED on eating pathology or general psychopathology, BN exhibited greater eating and general psychopathology than EDNOS. Moderator analyses indicated that EDNOS groups who met all diagnostic criteria for AN except for amenorrhea did not differ significantly from full syndrome cases. Similarly, EDNOS groups who met all criteria for BN or BED except for binge frequency did not differ significantly from full syndrome cases. Results suggest that EDNOS represents a set of disorders associated with substantial psychological and physiological morbidity. Although certain EDNOS subtypes could be incorporated into existing Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) categories, others-such as purging disorder and non-fat-phobic AN-may be best conceptualized as distinct syndromes.
Subthreshold presentations in women with lifetime AN and BN were common, resembled the initial diagnosis, and were associated with modest improvements in psychosocial functioning. For most with lifetime AN and BN, subthreshold presentations seem to represent part of the course of illness and to fit within the original AN or BN diagnosis.
- Wilfley DE, et al. Classification of eating disorders: toward DSM-V. Int J Eat Disord. 2007 Nov;40 Suppl:S123-9.
- The relationship between eating disorder not otherwise specified (EDNOS) and officially recognized eating disorders: meta-analysis and implications for DSM. Thomas JJ, et al. Psychol Bull. 2009 May;135(3):407-33
- Eddy KT, et al. How should DSM-V classify eating disorder not otherwise specified (EDNOS) presentations in women with lifetime anorexia or bulimia nervosa? Psychol Med. 2010 Oct;40(10):1735-44.
- Eddy KT, et al. Diagnostic crossover in anorexia nervosa and bulimia nervosa: implications for DSM-V. Am J Psychiatry. 2008 Feb;165(2):245-50.
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