Eating Disorder Not Otherwise Specified

Eating Disorder Not Otherwise Specified

Widodo Judarwanto

EDNOS is a very frequent diagnostic category in an inpatient setting. Altering the diagnostic criteria for anorexia nervosa and bulimia nervosa reduced significantly the prevalence of EDNOS. The evidence map highlights the absence of intervention studies investigating EDNOS treatments in adolescents and young adults. This is concerning given that data suggest more than 50% of those diagnosed with an eating disorder have EDNOS and it being the most common diagnosis reported in clinical and community populations with eating disorders. Additionally, those with EDNOS follow a similar course to those diagnosed with AN and BN in terms of the nature, symptom severity, eating pathology and outcome of disorder. The DSM-IV diagnosis “Eating Disorder Not Otherwise Specified” (eating disorder NOS) is much used by clinicians yet largely ignored by researchers. It is the most common category of eating disorder seen in outpatient settings yet there have been no studies of its treatment. Indeed, little has been written about eating disorder NOS.

“Not otherwise specified” (NOS) diagnoses within DSM-IV are designed for disorders of clinical severity that fall outside the specified diagnoses (American Psychiatric Association, 1994). For example, within the diagnostic classes of anxiety disorders and mood disorders are the diagnoses anxiety disorder NOS and mood disorder NOS respectively, and these exist alongside the specified individual anxiety disorder and mood disorder diagnoses. Thus, NOS diagnoses are by definition residual categories and, possibly as a result, they tend to be neglected.

Eating disorder not otherwise specified (EDNOS) is an eating disorder that does not meet the criteria for anorexia nervosa or bulimia nervosa. Individuals with EDNOS usually fall into one of three groups: sub-threshold symptoms of anorexia nervosa or bulimia nervosa, mixed features of both disorders, or extremely atypical eating behaviors that are not characterized by either of the other established disorders. The symptoms and behaviors of people with EDNOS are similar to those with anorexia and bulimia. People with EDNOS can face the same dangerous risk as people with anorexia and bulimia.EDNOS is the most prevalent eating disorder; about 60% of adults treated for eating disorders are diagnosed with EDNOS. EDNOS occurs in both men and women.

Eating Disorder Not Otherwise Specified (EDNOS) is a diagnostic category used when an individual’s symptoms are problematic and definitely represent disordered eating but do not fit neatly within the strict criteria for anorexia or bulimia. Though many people have never heard of it, EDNOS is by far the most commonly diagnosed eating disorder. Approximately 40-60% of cases in eating disorder treatment centers fall into the EDNOS category. About 75% of individuals with eating disorders seen at non-specialty community settings have EDNOS.

An anomalous situation exists within the eating disorders in that “eating disorder NOS” is the most common eating disorder diagnosis encountered in routine clinical practice: it is considerably more common than the two specified eating disorders, anorexia nervosa and bulimia nervosa. Despite this, there have been very few systematic descriptions of the clinical characteristics of patients with eating disorder NOS, and those that exist have had shortcomings including the use of relatively small and unrepresentative patient samples, the collection of a limited range of descriptive information, and reliance on weak or unstandardised measures. Two exceptions are of note. Ricca et al. recruited 95 first referrals with eating disorder NOS and assessed them using the Eating Disorder Examination (EDE) interview. Their sample was likely to have been biased, however, as it came in part from referrals to a private clinic and as patients taking antidepressant medication were excluded. Turner and Bryant-Waugh also used the EDE to characterise cases of eating disorder NOS but their sample excluded those with binge eating disorder and those with co-existing obesity. Also the clinical description was confined to current eating disorder psychopathology.

Eating disorder not otherwise specified (EDNOS) is the most prevalent eating disorder (ED) diagnosis. The study of meta-analysis, the authors aimed to inform 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 Disorde

“Eating disorder NOS” is the most common eating disorder encountered in outpatient settings yet it has been neglected. The aim of this study was to describe the characteristics of eating disorder NOS, establish its severity, and determine whether its high relative prevalence might be due to the inclusion of cases closely resembling anorexia nervosa or bulimia nervosa. One hundred and seventy consecutive patients with an eating disorder were assessed using standardised instruments. Operational DSM-IV diagnoses were made and eating disorder NOS cases were compared with bulimia nervosa cases.

Although EDNOS (formerly called atypical eating disorder) was originally introduced in DSM-III to capture unusual cases, it accounts for up to 60% of cases in eating disorder specialty clinics. EDNOS is an especially prevalent category in populations that have received inadequate research attention such as young children, males, ethnic minorities, and non-Western groups

Due to the similarities EDNOS shares with AN and BN, and problems recruiting sufficient sample sizes in eating disorder research, it can be common for researchers to include participants with EDNOS within trials investigating interventions for AN or BN, either by including EDNOS diagnosis or by using relaxed AN/BN inclusion criteria which facilitates entry of EDNOS participants. This may explain the lack of trials specifically targeting those with EDNOS, potentially masking the evidence base for effective EDNOS intervention. However, only a small number of trials explicitly reported doing so and those that did failed to provide the adequate sub-group analysis required to determine intervention effects according to eating disorder diagnosis.

Given the similarities between EDNOS and AN/BN categories and in line with guideline recommendations indicating treatment of EDNOS follow the disorder-symptom profile most closely resembled (either AN or BN, those treatments which have previously shown promise in the AN and BN area (e.g., FBT, CBT) should be prioritised in future EDNOS intervention research.

Clinical manifestation

  • Because individuals with EDNOS represent such a heterogeneous group, symptoms could look very different even among individuals with the same EDNOS diagnosis.
  • Reviewing the signs and symptoms listed for anorexia, bulimia and binge eating disorder would be helpful if you suspect someone you love may have EDNOS.
  • In general warning signs related to 1) weight and shape concerns, 2) food & eating behaviors and 3) changes in personality and social behavior.
  • Clinical descriptions of eating disorder NOS are consistent in stressing that most cases have clinical features that closely resemble those seen in anorexia nervosa and bulimia nervosa albeit at slightly different levels or in different combinations. They also indicate that the majority of cases are young women, just as in anorexia nervosa and bulimia nervosa.
  • It is helpful to distinguish two subgroups within eating disorder NOS, although there is no sharp boundary between them. In the first are cases that closely resemble anorexia nervosa or bulimia nervosa but just fail to meet their diagnostic thresholds; for example, their weight may be marginally above the limit for anorexia nervosa or their frequency of binge eating may be just too low for a diagnosis of bulimia nervosa. These cases may be viewed as “subthreshold” instances of anorexia nervosa or bulimia nervosa respectively. In the second group are cases in which the clinical features of anorexia nervosa and bulimia nervosa are combined in a different way to that seen in the two recognised syndromes. These cases are best described as “mixed”. Other terms have been used to describe such subgroups within eating disorder NOS including “subclinical” for the former subgroup, a term that is inappropriate given that these states are of clinical severity by definition; and “atypical” or “partial” for the second subgroup. Both the latter terms are problematic; the first because these states are not unusual and the second because of the implication that they are less severe than the full syndromes.
  • A recent development of relevance is the proposal that a third specific eating disorder be recognised in addition to anorexia nervosa and bulimia nervosa, effectively removing eligible cases from eating disorder NOS. This new diagnostic concept is termed “binge eating disorder” (BED) and is intended for people who experience recurrent episodes of binge eating in the absence of the extreme methods of weight control seen in bulimia nervosa and anorexia nervosa (American Psychiatric Association, 1994). This proposal was controversial when it was first suggested and divergent views on its merits still persist. As matters stand BED is not an established DSM-IV diagnosis and therefore eating disorders of this type remain under the rubric of eating disorder NOS.
  • There have been few systematic attempts to characterise the clinical features of patients with eating disorder NOS and compare them with those seen in anorexia nervosa and bulimia nervosa. Notable exceptions are three recent studies that have used the “gold standard” Eating Disorder Examination (EDE) for this purpose. All three have confirmed that the characteristic clinical features of anorexia nervosa and bulimia nervosa are present and to a similar degree. Thus it has been found that patients with eating disorder NOS have the same distinctive behaviour and attitudes as patients with anorexia nervosa and bulimia nervosa, even to the extent that most individual EDE item ratings are remarkably similar. Our data show that this similarity extends to the duration of the eating disorder, severity of associated general psychiatric features and degree of secondary psychosocial impairment, especially when bulimia nervosa and eating disorder NOS are compared.

Characteristics

Rather than providing specific diagnostic criteria for EDNOS, the fourth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) listed six non-exhaustive example presentations, including individuals who:

  1. Meet all criteria for anorexia nervosa except their weight falls within the normal range
  2. Meet all criteria for bulimia nervosa except they engage in binge eating or purging behaviors less than twice per week or for fewer than three months
  3. Purge after eating small amounts of food while retaining a normal body weight
  4. Repeatedly chew and spit out large amounts of food without swallowing
  5. Meet criteria for binge eating disorder

Despite its subclinical status in DSM-IV, available data suggest that EDNOS is no less severe than the officially recognized DSM-IV eating disorders. In a comprehensive meta-analysis of 125 studies, individuals with EDNOS exhibited similar levels of eating pathology and general psychopathology to those with anorexia nervosa and binge eating disorder, and similar levels of physical health problems as those with anorexia nervosa. Although individuals with bulimia nervosa scored significantly higher than those with EDNOS on measures of eating pathology and general psychopathology, EDNOS exhibited more physical health problems than bulimia nervosa.

Diagnosis

  • The “Not Otherwise Specified” (NOS) category within DSM-IV is designed for disorders of clinical severity that are not specified within broad diagnostic classes. “NOS” diagnoses are intended to be residual categories and they tend to be neglected by researchers. This can be inappropriate. The problems associated with certain NOS diagnoses are well illustrated by “Eating Disorder NOS” (sometimes termed EDNOS), which is the most common category of eating disorder encountered in routine clinical practice yet it has barely been studied. Indeed, there has been no research on its treatment. Interim and longer-term conceptual and practical solutions to the anomalous status of eating disorder NOS are proposed including the creation of a new diagnosis termed “mixed eating disorder”. Several of these solutions are of relevance to NOS categories in general. All the solutions should fulfil criteria for clinical utility.

The EDNOS diagnosis usually captures the following three general categories of symptoms:

  • Subthreshold symptoms of anorexia or bulimia
  • Mixed features of both anorexia and bulimia
  • Atypical eating behaviors that are not characterized by either anorexia or bulimia

The three general categories for an EDNOS diagnosis are subthreshold symptoms of anorexia or bulimia, a mixture of both anorexia or bulimia, and eating behaviors that are not particularized by anorexia and bulimia. Diagnostic criteria were then adjusted to determine the impact on the prevalence of eating disorder NOS. Cases of eating disorder NOS comprised 60.0% of the sample. These cases closely resembled the cases of bulimia nervosa in the nature, duration and severity of their psychopathology. Few could be reclassified as cases of anorexia nervosa or bulimia nervosa. The findings indicate that eating disorder NOS is common, severe and persistent. Most cases are “mixed” in character and not subthreshold forms of anorexia nervosa or bulimia nervosa. It is proposed that in DSM-V the clinical state (or states) currently embraced by the diagnosis eating disorder NOS be reclassified as one or more specific forms of eating disorder.

The Diagnostic & Statistical Manual (DSM-IV) currently lists six clinical examples of EDNOS.  It’s important to note that this list in not exhaustive, and there are other situations and variations of symptoms that would also warrant an EDNOS diagnosis:

  1. All criteria for anorexia nervosa are met except the individuals has regular menstrual cycles
  2. All criteria for anorexia nervosa are met except that, despite significant weight loss, the individual’s current weight falls within the normal range
  3. All criteria for bulimia nervosa are met except that binge eating or purging behaviors occur less than twice per week or for fewer than three months
  4. An individual purges after eating small amounts of food while retaining a normal body weight
  5. Repeatedly chewing and spitting out large amounts of food without swallowing
  6. All criteria are met for binge eating disorder

EDNOS is sometimes referred to as a “subclinical” or “sub-threshold” diagnosis. This can be misleading in terms of severity, and some individuals may interpret it as being a less serious illness than anorexia or bulimia. This is far from the truth. Many studies have shown that individuals with the EDNOS diagnosis experience eating pathology and medical consequences that are just as, if not more, severe than individuals who receive a formal anorexia or bulimia diagnosis. Furthermore, one recent study found that 75% of individuals with EDNOS had co-occurring psychiatric disorders and 25% endorsed suicidality

Eating disorder NOS is an example of the “Not Otherwise Specified” (NOS) category in DSM-IV (American Psychiatric Association, 1994). Since the publication of DSM-III (American Psychiatric Association, 1980), the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders has included either “atypical” (in DSM-III) or “not otherwise specified” categories (in DSM-III-R (American Psychiatric Association, 1987) and DSM-IV), respectively in each broad diagnostic class in view of the difficulty covering every presentation encountered in clinical practice. These diagnoses are intended to “indicate a category within a class of disorders that is residual to the specific categories in that class…”.

An external file that holds a picture, illustration, etc.
Object name is gr1.jpg

Eating disorder NOS is the category in DSM-IV reserved for eating disorders of clinical severity that do not meet diagnostic criteria for either one of the two eating disorders recognised in DSM-IV, anorexia nervosa and bulimia nervosa. In common with other NOS diagnoses, it is a residual category. Thus, there are two steps in making a diagnosis of eating disorder NOS: first, it must be determined that there is an eating disorder of clinical severity; and then, it must be established that the diagnostic criteria of anorexia nervosa and bulimia nervosa are not met. This second step therefore involves diagnosis by exclusion: no positive diagnostic criteria for eating disorder NOS need to be fulfilled.

It is helpful to illustrate diagrammatically the relationship between the diagnoses anorexia nervosa, bulimia nervosa and eating disorder NOS . The two overlapping inner circles represent anorexia nervosa (the smaller circle) and bulimia nervosa (the larger circle) respectively, the area of potential overlap being that occupied by those people who would meet the diagnostic criteria for both disorders but for the DSM-IV “trumping” rule whereby the diagnosis of anorexia nervosa takes precedence over that of bulimia nervosa. Surrounding these two circles is an outer circle which defines the boundary of eating disorder “caseness”; that is, the boundary between having an eating disorder, a state of clinical significance, and having a lesser, non-clinical, problem with eating. It is this boundary that demarcates what is, and is not, an eating disorder. Within the outer circle, but outside the two inner circles, lies eating disorder NOS.

This diagnosis is not to be taken lightly, and individuals with EDNOS often require the same level of treatment and support as those with anorexia or bulimia. Unfortunately, some insurance companies still resist coverage for the EDNOS diagnosis despite the fact that without treatment, a significant number of individuals with EDNOS will go on to meet full criteria for anorexia or bulimia at some point during the course of their illness.

The DSM-IV is scheduled for updated publication in 2013.  It is expected that the DSM-5 will include expanded diagnostic criteria for anorexia nervosa and bulimia nervosa, and elevate binge eating disorder to a formally recognized diagnosis. Furthermore, DSM-5 plans to rename the EDNOS category Feeding or Eating Disorder Not Elsewhere Classified, and to provide named descriptions of example presentations. Professionals are hopeful that these changes will address some of the concerns related to the expansive EDNOS category, increase opportunities for research on effective treatment for more people, and improve insurance approvals for those individuals who need treatment.

References

  • Fairburn CG, Cooper Z: Thinking afresh about the classification of eating disorders. Int J Eat Disord 2007, 40(Suppl 3):107-110.
  • Fairburn CG, Harrison PJ: Eating disorders. Lancet 2003, 361(9355):407-416.
  • Fairburn CG, Bohn K (June 2005). “Eating disorder NOS (EDNOS): an example of the troublesome “not otherwise specified” (NOS) category in DSM-IV”. Behav Res Ther 43 (6): 691–701. 
  • “Eating Disorder Not Otherwise Specified (EDNOS)”. National Alliance of Mental Illness. Retrieved December 21, 2014.
  • Thomas JJ, Vartanian LR, Brownell KD (May 2009). “The relationship between eating disorder not otherwise specified (EDNOS) and officially recognized eating disorders: meta-analysis and implications for DSM”. Psychol Bull 135 (3): 407–33. 
  • American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association.
  • American Psychiatric Association (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: American Psychiatric Association.[page needed]
  • Becker AE, Thomas JJ, Pike KM (November 2009). “Should non-fat-phobic anorexia nervosa be included in DSM-V?”. Int J Eat Disord 42 (7): 620–35. 
  • Dalle-Grave R, Calugi S: Eating disorder not otherwise specified in an inpatient unit: the impact of altering the DSM-IV criteria for anorexia and bulimia nervosa. Eur Eat Disord Rev 2007, 15(5):340-349
  • Rockert W, Kaplan AS, Olmsted MP: Eating disorder not otherwise specified: the view from a tertiary care treatment center. Int J Eat Disord 2007, 40(Suppl 3):99-103. OpenURL
  • Crow SJ, Peterson CB, Swanson SA, Raymond NC, Specker S, Eckert ED, Mitchell JE: Increased mortality in bulimia nervosa and other eating disorders. Am J Psychiatry 2009, 166(12):1342-1346.
  • Fairburn CG, Cooper Z, Bohn K, O’Connor ME, Doll HA, Palmer RL: The severity and status of eating disorder NOS: implications for DSM-V. Behav Res Ther 2007, 45(8):1705-1715.
  • Le Grange D, et al (2012). Eating disorder not otherwise specified presentation in the US population.
    Int J Eat Disord. 2012 Jul;45(5):711-8.
  • Thomas JJ, Vartanian LR, Brownell KD: The relationship between eating disorder not otherwise specified (EDNOS) and officially recognized eating disorders: meta-analysis and implications for DSM. Psychol Bull 2009, 135(3):407-433.
  • Agras WS, Brandt HA, Bulik CM, Dolan-Sewell R, Fairburn CG, Halmi KA, Herzog DB, Jimerson DC, Kaplan AS, Kaye WH: Report of the national institutes of health workshop on overcoming barriers to treatment research in anorexia nervosa. Int J Eat Disord 2004, 35(4):509-521.

www.pickyeatersclinic.com

supported by

PICKY EATERS AND GROW UP CLINIC (Klinik Khusus Kesulitan Makan dan Gangguan Berat Badan) GRoW UP CLINIC JAKARTA Yudhasmara Foundation GRoW UP CLINIC I Jl Taman Bendungan Asahan 5 Bendungan Hilir Jakarta Pusat 10210, phone (021) 5703646 – 085100466103 – 085101466102. GRoW UP CLINIC II MENTENG SQUARE Jl Matraman 30 Jakarta Pusat 10430, phone (021) 29614252 – 08131592-2013 08131592-2012 email : judarwanto@gmail.com drnarulitadewi@gmail.com http://pickyeatersclinic.com . Professional Healthcare Provider “GRoW UP CLINIC” Dr Narulita Dewi SpKFR, Physical Medicine & Rehabilitation curriculum vitae HP 085777227790 PIN BB 235CF967 Clinical – Editor in Chief : Dr Widodo Judarwanto, Pediatrician Editor: Audi Yudhasmara email : judarwanto@gmail.com Mobile Phone 089683015220 PIN BBM 76211048 Komunikasi dan Konsultasi online : twitter @widojudarwanto facebook dr Widodo Judarwanto, pediatrician Komunikasi dan Konsultasi Online Alergi Anak : Allergy Clinic Online Komunikasi dan Konsultasi Online Sulit makan dan Gangguan Berat Badan : Picky Eaters Clinic Komunikasi Profesional Pediatric: Indonesia Pediatrician Online
“GRoW UP CLINIC” Jakarta Focus and Interest on: *** Allergy Clinic Online *** Picky Eaters and Growup Clinic For Children, Teen and Adult (Klinik Khusus Gangguan Sulit Makan dan Gangguan Kenaikkan Berat Badan)*** Children Foot Clinic *** Physical Medicine and Rehabilitation Clinic *** Oral Motor Disorders and Speech Clinic *** Children Sleep Clinic *** Pain Management Clinic Jakarta *** Autism Clinic *** Children Behaviour Clinic *** Motoric & Sensory Processing Disorders Clinic *** NICU – Premature Follow up Clinic *** Lactation and Breastfeeding Clinic *** Swimming Spa Baby & Medicine Massage Therapy For Baby, Children and Teen ***

Curriculum Vitae Dr Widodo judarwanto, Pediatrician

Information on this web site is provided for informational purposes only and is not a substitute for professional medical advice. You should not use the information on this web site for diagnosing or treating a medical or health condition. You should carefully read all product packaging. If you have or suspect you have a medical problem, promptly contact your professional healthcare provider
Copyright © 2015, Picky Eaters and Grow Up Clinic, Information Education Network. All rights reservedxz

Tinggalkan Balasan

Isikan data di bawah atau klik salah satu ikon untuk log in:

Logo WordPress.com

You are commenting using your WordPress.com account. Logout / Ubah )

Gambar Twitter

You are commenting using your Twitter account. Logout / Ubah )

Foto Facebook

You are commenting using your Facebook account. Logout / Ubah )

Foto Google+

You are commenting using your Google+ account. Logout / Ubah )

Connecting to %s