They appear to be Cinderella states. In some countries this has a direct impact on patient care for the marginal status of NOS diagnoses even extends to restrictions on treatment provision or, at least, reimbursement for treatment Herzog et al. This could perhaps be justified were NOS states uncommon or mild but neither could be said to be true of eating disorder NOS.
Below we propose three potential solutions to these problems of nosology and neglect. The first solution is based on the premise that the high prevalence of eating disorder NOS cases is due to the DSM-IV diagnostic criteria for anorexia nervosa and bulimia nervosa being inappropriately strict. If true, some cases within eating disorder NOS would be better designated as cases of anorexia nervosa or bulimia nervosa.
With reference to Fig. Done mindfully, relaxing the diagnostic criteria for anorexia nervosa and bulimia nervosa has much to commend it. Many clinicians and researchers have suggested that the DSM-IV criteria need to be adjusted in various ways Crow et al. Such adjustments seem worth contemplating so long as the two diagnostic concepts are not materially altered. Adjusting upward the weight threshold for anorexia nervosa is another option Garfinkel et al. With regard to bulimia nervosa the main bone of contention concerns the present twice-weekly threshold for the frequency of binge eating: it has been repeatedly argued that a lower minimum frequency would be more appropriate Garfinkel et al.
Changes of this type represent a fine-tuning of the existing diagnostic criteria rather than any radical change. Systematically applying all the above changes to our representative dataset Fairburn, Palmer, et al. Thaw and colleagues came to a similar conclusion, albeit using a convenience sample of eating disorder NOS cases. The second solution is a response to the main shortcoming of the first; namely that it fails to address the fact that many cases within eating disorder NOS are mixed in nature.
This solution is an elaboration and extension of the first. Subthreshold cases of anorexia nervosa and bulimia nervosa would be incorporated within these two diagnoses, respectively, as in the first solution, but in addition the remaining cases of eating disorder NOS would be reclassified as belonging to a new category of eating disorder. The majority of these cases would be mixed in character although a minority would fulfil diagnostic criteria for BED and might be best separated off.
The third solution is the most radical. Thus, rather than focusing on differences between the eating disorders, there is a case for highlighting the many features that are shared by them and are largely peculiar to them. These include extreme dietary restraint and restriction, binge eating, self-induced vomiting and the misuse of laxatives, driven exercising, body checking and avoidance, and the over-evaluation of control over eating, shape and weight. These cross-diagnostic similarities become even more obvious if a longitudinal perspective is taken since, as noted above, patients do not adhere to their DSM-IV diagnosis over time; rather, they move between them Fairburn and Harrison, ; Herzog et al.
A second prerequisite for furthering research on the problems of patients with eating disorder NOS is the development of positive diagnostic criteria to delineate them. At present no specific features have to be present to make the diagnosis: rather, the sole requirement is that the person has an eating disorder of clinical severity other than anorexia nervosa or bulimia nervosa. This situation is quite different to that existing for anorexia nervosa and bulimia nervosa where a specific combination of clinical features must be present for either diagnosis to be made. Defining the outer edges of eating disorder NOS is possible.
In principle, it requires identifying the type and level of eating disorder psychopathology that is typically associated with a clinically significant degree of secondary distress or disability. Good measures of eating disorder psychopathology are available for example, the EDE and we have developed a complementary measure of secondary clinical impairment that addresses the main domains of functioning affected by eating disorders; namely, mood, cognition, relationships, work and physical health. Two misconceptions appear to keep eating disorder NOS on the margins of eating disorders.
The first is the assumption that cases of eating disorder NOS are mild and therefore unimportant. The findings reviewed above indicate that this view is mistaken. The second misconception is that eating disorder NOS is uncommon. We have suggested that two challenges have to be met for the problems of people with eating disorder NOS to get the attention that they deserve.
One is that positive diagnostic criteria are needed and we have described a research strategy whereby they could be developed.
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For example, it would provide a definition of caseness for epidemiological and clinical purposes and it would provide a new and clinically meaningful way of defining outcome for studies of treatment and natural course. At present most such studies ignore eating disorder NOS as a potential outcome thereby possibly inflating recovery rates.
It might therefore make redundant the varied and somewhat inconsistent ways of representing outcome that are in use today. We are also aware that the proposed research strategy has broader implications too for it could be used to define the outer boundaries of other classes of psychiatric disorder. The second challenge involves re-conceptualising the clinical problems that are currently categorised as eating disorder NOS.
This is essential if the nosological anomaly of eating disorder NOS is to be resolved. Three solutions have been proposed. In the short term we favour the second solution because the first ignores the fact that many of the cases within eating disorder NOS are of the mixed variety. It involves relaxing the diagnostic criteria for anorexia nervosa and bulimia nervosa to extract the subthreshold cases from eating disorder NOS, the remaining cases being re-classified as cases of mixed eating disorder or BED.
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The second solution would have the effect of eliminating the concept of eating disorder NOS, at least for the meantime. These cases should be modest in number, rendering eating disorder NOS a small residual category, as NOS categories are intended to be. We acknowledge that this re-classification of the cases within eating disorder NOS is something of a sleight of hand, but it is a sleight of hand with a purpose since it is intended to place these cases in specific and appropriate diagnostic categories.
This might enhance the credibility and usefulness of the scheme for classifying eating disorders and, hopefully, it might also facilitate research on these problems including research on their treatment.
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We believe that this proposal would fulfil the First et al. The existing scheme for classifying eating disorders is a historical accident that is a poor reflection of clinical reality. The transdiagnostic solution would encourage and permit the classification of eating disorders to be examined afresh. The collection of good transdiagnostic data, particularly cross-diagnostic information on course and response to treatment, is needed if new clinically informative subdivisions are to be identified.
We are grateful to the Wellcome Trust for their support. National Center for Biotechnology Information , U. Sponsored Document from. Behav Res Ther. Christopher G. Author information Article notes Copyright and License information Disclaimer. Fairburn: ku. Received Jun 12; Accepted Jun All rights reserved. This article has been cited by other articles in PMC. Open in a separate window. The characteristics of eating disorder NOS 3.
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Prevalence Eating disorder NOS is the most common eating disorder diagnosis made in most outpatient settings other than those that attract highly specialist referrals. Table 1 Prevalence of eating disorder NOS in samples of adult outpatients with eating disorders. Sample restricted to patients with a body mass index between BED 5.
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Bulimia involves eating vast quantities of food, usually in a very short period of time and then inducing vomiting and often using large numbers of laxatives. Binge Eating is Bulimia without the purging and vomiting which results in rapid weight gain. More prevalent in girls, but can affect girls and boys from all Read More ….
You never see anorexics eat Dressing in baggy clothes A significant change in apparent appetite An unnatural preoccupation with food and calories An obsession with clothing sizes, mirrors and scales Routine secrecy, e.
What to do if you suspect a pupil has an Eating Disorder Do not promise to keep it confidential, make it clear what the policy on confidentiality is for the school. Report to the designated child protection officer. This is a concise paperback version of the authoritative and comprehensive Handbook of Eating Disorders, Second Edition, focusing on the most practical elements from that volume.
Ideal for the individual practitioner, this selection of chapters concentrates on the main therapeutic approaches in use, including cognitive behavioural treatments, interpersonal psychotherapy, family interventions, dialectical behaviour therapy and drug treatments. Indispensable for those working in the eating disorders field, such as clinical psychologists, child psychologists, family therapists, psychiatrists, psychiatric nurses, social workers and occupational therapists.
The Essential Handbook of Eating Disorders will also be of interest to researchers, lecturers and those in training in the field. Chapter 2 Epidemiology. Chapter 3 CognitiveBehavioural Models. Chapter 4 Medical Complications.
Chapter 6 Treatment Overview.
Related The Essential Handbook of Eating Disorders
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