Eating disorder not otherwise specified in an inpatient unit: the impact of altering the DSM-IV criteria for anorexia and bulimia nervosa

European Eating Disorders Review
Eur. Eat. Disorders Rev. 15, 340–349 (2007)
Eating Disorder Not OtherwiseSpecified in an Inpatient Unit: TheImpact of Altering the DSM-IVCriteria for Anorexia and BulimiaNervosa

*Correspondence to: Riccardo Dalle Grave,of Eating Disorder and Weight DisordHospital, Via Montebaldo 89, 37016 GARTel: þ39-045-8103915. Fax: þ39-051-6364502E-mail: [email protected]

Copyright # 2007 John Wiley & Sons, Ltd a

Published online 26 July 2007 in Wiley InterS

Riccardo Dalle Grave* and Simona CalugiDepartment of Eating and Weight Disorder, Villa Garda Hospital, Garda (VR),Italy

Objective: To evaluate (1) the Eating Disorder Not OtherwiseSpecified (EDNOS) prevalence in an eating disorder inpatient unit;(2) the impact of altering the diagnostic criteria for anorexia nervosaand bulimia nervosa on the prevalence of EDNOS.Method: One hundred and eighty six eating disorder patientsconsecutively hospitalised were included in the study. The preva-lence of anorexia nervosa, bulimia nervosa and EDNOS was eval-uated with the Eating Disorder Examination (EDE). The EDNOSprevalence was recalculated after the alteration of three diagnosticcriteria for anorexia nervosa and one for bulimia nervosa.Results: Seventy eight patients (41.9%) met the diagnostic criteriafor anorexia nervosa, 33 (17.8%) for bulimia nervosa and 75 (40.3%)for EDNOS. The alteration of the DSM-IV diagnostic criteriareduced the prevalence of EDNOS to 28 cases (15%).Conclusion: EDNOS is a very frequent diagnostic category in aninpatient setting. Altering the diagnostic criteria for anorexia ner-vosa and bulimia nervosa reduced significantly the prevalence ofEDNOS. Copyright # 2007 John Wiley & Sons, Ltd and EatingDisorders Association.

Keywords: DSM-IV; NOS; eating disorder; diagnosis; classification; anorexia nervosa; bulimia nervosa

INTRODUCTION

The DSM-IV classification of eating disorders in-cludes anorexia nervosa, bulimia nervosa andEDNOS (American Psychiatric Association, 1994).Eating Disorder Not Otherwise Specified (EDNOS)

MD, Departmenter, Villa GardaDA (VR), Italy..

nd Eating Disorders

cience (www.interscie

is a diagnostic category reserved for individualssuffering from an eating disorder of clinical severitythat does not meet the diagnostic criteria foranorexia nervosa or bulimia nervosa.The diagnosis of EDNOS, as the other NOS

category in DSM-IV (American Psychiatric Associ-ation, 1994), was intended to indicate a categorywithin a class of disorders that is residual to thespecific categories in that class (American Psychia-tric Association, 1980). Nevertheless, recent studieshave found that EDNOS is the most common eatingdisorder diagnosismade in outpatient settings, with

Association.

nce.wiley.com) DOI: 10.1002/erv.805

EDNOS in an Inpatient Unit 341

a prevalence ranging from 50 to 70% of patients(Martin, Williamson, & Thaw, 2000; Ricca et al.,2001; Turner & Bryant-Waugh, 2004). Previousstudies in inpatient samples found a slightly lowerprevalence of EDNOS ranging from 23% (Solen-berger, 2001) to 30% (Andersen, Bowers, & Watson,2001), but they did not use stringent diagnosticcriteria, such as those evaluated by ope-rational-based Eating Disorder Examination(EDE) interview (Fairburn & Cooper, 1993).Although EDNOS is a common eating disorder

diagnosis treated by clinicians, it has been largelyignored by researchers and there are no studiesregarding its treatment. It has been suggested thatresearchers have neglected to study EDNOS fortwo reasons: first, due to its NOS status (Fairburn &Bohn, 2005), since NOS diagnoses are in generalrarely studied (Pincus, Davis, & McQueen, 1999),and second, due to the absence of positive diag-nostic criteria to delineate these disorders (Fairburn& Bohn, 2005).One possible strategy for resolving these two

problems associated with the diagnosis EDNOS(i.e. its anomalous nosological status and its neglect)is to modify the DSM-IV diagnostic criteria for an-orexia nervosa and bulimia nervosa to determinewhether most EDNOS cases are ‘subthreshold’forms of anorexia nervosa or bulimia nervosa(Fairburn & Bohn, 2005; Fairburn, Cooper, Bohn,O’Connor, Doll, & Palmer, 2007; Thaw, Williamson,& Martin, 2001).Three main suggestions have been made to

modify the diagnostic criteria for anorexia nervosa(Fairburn & Bohn, 2005). The first was to delete theamenorrhoea criterion, since individuals with allthe diagnostic features of anorexia nervosa exceptamenorrhoea have few statistically significant dif-ferences in terms of demographics, psychiatriccomorbidity, family history or early experiences(Garfinkel et al., 1996), body-image disturbance,psychopathology (Cachelin & Maher, 1998), illnesshistory, treatment response and bone density (Wat-son & Andersen, 2003). The second was to adjustupward the weight threshold criterion (Garfinkel,Kennedy, & Kaplan, 1995; Watson & Andersen,2003), and to substitute the actual criterion whichis based on weight loss percentage from expectedweight, with the more objective and widely usedmeasure of Body Mass Index (BMI) (Fairburn &Cooper, 1993). The third was to redefine the ‘corepsychopathology’ of anorexia nervosa includingalso the patients with eating restraint without theconcerns about shape andweight (Fairburn & Bohn,2005; Palmer, 1993, 2005; Rieger, Touyz, Swain, &

Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders A

Beumont, 2001). This proposal comes from severalauthors questioning the centrality of requiring bothweight phobia and body-image disturbance, basedon their study of accounts regarding the nosologicalhistory of anorexia nervosa (Casper, 1983; Haber-mas, 2005; Van Deth & Vandereycken, 1991). Theabsence of body-weight phobia and body-imagedisturbance in the patients with low body weight,noted by the epidemiological and clinical accountsof non-Western countries, is another proof advo-cated by supporters of this proposal (Lee, Ho, &Hsu, 1993).For bulimia nervosa the main suggestion was

to lower the minimum and arbitrary twice-weeklythreshold for frequency of binge eating and purging(Fairburn & Bohn, 2005; Garfinkel et al., 1995;Herzog, Norman, Rigotti, & Pepose, 1986; Wilson &Eldredge, 1991). This proposal arose from the evi-dence that individuals with once-weekly bingeeating are not different in coexisting psychopathol-ogy and clinical outcome than those who bingemore often (Garfinkel et al., 1995).The impact of altering the anorexia nervosa and

bulimia nervosa diagnostic criteria on the preva-lence of EDNOS has been systematically evaluatedin only two studies. The first investigated a hetero-geneous sample of eating disorders patientsrecruited from both clinical and community settings(Thaw et al., 2001). Omitting the amenorrhoeacriterion and adjusting the weight loss thresholdcriterion from 15 to 10% produced a modest reduc-tion in the EDNOS prevalence (from 55.9 to 44%).While reducing the frequency for binge eating fromat least twice per week to once weekly produced aminimal reduction in the clinical prevalence ofEDNOS (from 55.9 to 51.3%). The second studyevaluated the impact of altering the diagnosticcriteria for anorexia nervosa and bulimia nervosa,along the lines described above, in a sampleof 170 eating disorder patients recruited for anoutpatient psychotherapy research trial (Fairburnet al., 2007). Here as well, the impact of adjusting thediagnostic criteria for anorexia nervosa and bulimianervosa criteria (delete criteria) on the clinicalprevalence of EDNOS was modest (from 60 to50%) (Fairburn et al., 2007).Aims of this study were: (1) to determine the

prevalence of EDNOS in an inpatient unit special-ised in the treatment of eating disorders using theoperational-based EDE interview, (2) to evaluate theimpact of altering the DSM-IV diagnostic criteriafor anorexia nervosa and bulimia nervosa on theprevalence of inpatient EDNOS; (3) to compareconverted patients and the other eating disorder

ssociation. Eur. Eat. Disorders Rev. 15, 340–349 (2007)

DOI: 10.1002/erv

342 R. Dalle Grave and S. Calugi

patients and (4) to describe the residual EDNOSafter modifications.

METHODS

Participants

One hundred and eighty six patients (age 26.0�7.8 years; 173 females and 13 males) with an eatingdisorder of clinical severity participated in thestudy. Twenty three of one hundred and eighty sixpatients (12.4%) were under 18 years of age. All thepatients were consecutively admitted to the eatingdisorder inpatient unit of Villa Garda Hospitalof Northern Italy between November 2003 andOctober 2005. The patients were referred from allover Italy by general practitioners or by outpatients’eating disorder specialists. All the patients hadfailed less intensive treatment (e.g. outpatient treat-ment) or had an eating disorder of clinical severitynot manageable in an outpatient setting. Patientswith active substance abuse, schizophrenia andother psychotic disorders were not included in thestudy.The research was reviewed and approved by the

institutional review board, and all participants gavewritten informed consent (or by the legal guardianfor the 23 patients less than 18 years old).

Measures

Assessment took place the first day of inpatientadmission. Data collection included weight andheight measurement, a detailed Medical Record, aface-to-face structured eating disorder diagnosticinterview and a package of questionnaires to eva-luate general psychopathology.

Weight and heightWeight was measured on a medical-balance and

height by a stadiometer by a physician. Patientswere dressed in underwear without shoes.

Medical recordThe medical record was completed by a physician

by directly interviewing patients, and it includeddemographic data, a detailed medical and eatingdisorder history, with specific information on theage of eating disorder onset, and on maximum andminimum weight.


Eating disorder psychopathology and diagnosisThe EDE 12.OD (Fairburn & Cooper, 1993) was

used to evaluate the eating disorder specific psycho-pathology and to elicit the diagnosis of eating dis-order. The interview was completed by a seniorspecialist in the field (RDG). The EDE is an investi-gator-based interview that assesses the frequencyof key behavioural and attitudinal aspects of eatingdisorders during the preceding 4 weeks (28 days).The EDE evaluates the major areas of eating dis-order psychopathology on four subscales: Restraint,Eating Concern, Shape Concern and Weight Con-cern. Interrater reliability for Global EDE score hasbeen estimated to be 0.97–0.99 (Wilson & Smith,1989). The four subscales have good discriminantvalidity in distinguishing between individuals witheating disorders and controls (Cooper, Cooper, &Fairburn, 1989; Fairburn & Cooper, 1993), and theWeight Concern and Shape Concern subscaleshave good discriminant validity in distinguishingbetween women with eating disorders and rest-rained eaters (Wilson & Smith, 1989). The EDEwas used to generate operational definitions ofthe DSM-IV diagnoses anorexia nervosa, bulimianervosa and Binge Eating Disorder (BED; exactdefinitions available on request). In male patientsthe amenorrhoea criterion was not used for thediagnosis of anorexia nervosa. Those eating dis-orders that did not meet the operational definitionsof anorexia nervosa or bulimia nervosa wereclassed as cases of EDNOS. All the patientswith EDNOS had an eating disorder of clinicalseverity, as defined by Fairburn and Walsh(2002), not conforming to the diagnostic criteriafor anorexia nervosa or bulimia nervosa. In thepresent study we used a validated EDE Italiantranslation (Mannucci, Ricca, Di Bernardo, &Rotella, 1996).

General psychopathologyThe Beck Depression Inventory (BDI) (Beck, Ward,

Mendelson, Mock, & Erbaugh, 1961) was used toassess the presence and severity of depressionand personal distress. This measure has excellentinternal reliability, reasonably good test–retestreliability and good criterion validity (Beck et al.,1961). The State-Trait Anxiety Inventory (STAI FormY-1) (Spielberg, Gorsuch, & Lushene, 1970) wasused tomeasure trait levels of anxiety. This measurehas good internal consistency (Ramanaiah, Franzen,& Schill, 1983) and good concurrent validity(Spielberger & Vagg, 1984). Both BDI and STAIhave been validated in their Italian version (Baggio,


DOI: 10.1002/erv


Ferrari, Partinico, Vidotto, & Visentin, 1997; Lazzari& Pancheri, 1980).

Procedures

To evaluate the impact of altering the DSM-IVeating disorder diagnostic criteria for anorexianervosa and bulimia nervosa on the clinical pre-valence of EDNOS we adopted the following pro-cedures.First, we calculated the clinical prevalence of

anorexia nervosa, bulimia nervosa and EDNOSusing the EDE interview with the operationaldefinitions of the DSM-IV diagnoses. Second, werecalculated the clinical prevalence of EDNOSdetermined by modification of the four DSM-IVdiagnostic criteria alone and in combination. Foranorexia nervosa we altered the following threediagnostic criteria: (1) the amenorrhoea criterionwas deleted in females; (2) the EDE DSM-IV BMIthreshold criterion was raised from a BMI below orequal to 17.5 kg/m2 to a BMI below to 18.5 kg/m2, avalue indicated by the World Health Organizationfor defining underweight (WHO, 1998); (3) the ‘corepsychopathology’ of the disorder was redefined toinclude patients with eating restraint without theconcerns about shape and weight. To be includedin this category patients had a BMI below or equalto 17.5 kg/m2 (DSM-IV criterion A), a rating 1 onthe EDE item ‘Maintained low weight’ (DSM-IVcriterion A) and a rating 0 or 7 on the EDE itemmenstruation (no periods in the 3 month beforeassessment or oral contraceptive) (DSM-IV criterionD). For bulimia nervosa we changed the minimumDSM-IV threshold frequency for binge eating andpurging from twice weekly to once weekly in thepast 3 months.Finally, to evaluate the validity of the reconsti-

tuted diagnostic groups we compared the patientsconverted to anorexia and bulimia nervosa with the‘core’ sample of anorexia and bulimia nervosa, andthe retained EDNOS samples.

Statistical Analysis

Univariate analysis of variance (ANOVA) withBonferroni analyses as post hoc test, tested the signi-ficance of differences between anorexia nervosa,bulimia nervosa and EDNOS patients or Kruskal–Wallis Test when the variables had no normaldistribution. Significant changes in the clinical pre-valence of EDNOS before/after altering the diag-nostic criteria of anorexia nervosa were tested bycomparing the prevalence with the McNemar Chi-square tests.


RESULTS

Prevalence of EDNOS Using the EDEInterview With the Operational Definitionsof the DSM-IV

Table 1 presents the clinical data, eating disorderand general psychopathology for the 186 patients byeating disorder diagnosis. Seventy eight patients(41.9%) met diagnostic criteria for anorexia nervosa,33 (17.8%) met criteria for bulimia nervosa and75 (40.3%) met criteria for eating disorder NOS.The group of patients did not differ significantlyregarding age, and age of eating disorder onset, anddifferences between groups were found in regardto BMI, to maximum and minimum BMI and topremorbid BMI. The patients with anorexia nervosahad significantly lower BMI and higher numberof previous inpatient treatments than those withbulimia nervosa and those with EDNOS. Patientswith bulimia nervosa had a significantly higher BMIcompared with those with EDNOS. Patients withbulimia nervosa had significantly higher maximumBMI, minimum BMI and premorbid BMI thanthose with anorexia nervosa and those withEDNOS. Significant differences between groupswere found in relation to eating disorder clinicalmanifestations and to severity of eating disorderpsychopathology evaluated using the EDE. Patientswith bulimia nervosa had more frequent objectivebulimic and self-induced vomiting episodes in thelast 28 days than patients with anorexia nervosaand EDNOS. Patients with anorexia nervosa hadmore frequent days of driven exercise in the last28 days than the patients with bulimia nervosaand EDNOS. Patients with anorexia nervosascored significantly higher than those with EDNOSpatients on all of the subscales of the EDE andon Global EDE. Patients with bulimia nervosascored significantly higher than EDNOS on theEating Concern, Weight Concern and ShapeConcern subscales and on Global EDE, and higherthan anorexia nervosa patients on the EatingConcern subscale. There was no significant differ-ence between groups in the scores of BDI, andSTAI.

Clinical Prevalence of EDNOS AfterModifications

Table 2 presents the prevalence of anorexia nervosa,bulimia nervosa and EDNOS with and without theDSM-IV criteria modifications.First, we evaluated the impact of omitting

the diagnostic criterion of amenorrhoea as a


DOI: 10.1002/erv

Table 1. Clinical data, eating disorder and general psychopathology by eating disorder diagnosis (mean� SD ormedian [interquartile range])

AN (n¼ 78) BN (n¼ 33) EDNOS (n¼ 75) F p�

Age (years) 25.7� 8.8 25.1� 6.0 26.6� 7.4 0.6 NSCurrent BMI (kg/m2) 14.5� 1.6a 20.8� 2.7b 17.5� 3.4c 71.9 0.001Maximum BMI (kg/m2)y 21.3� 3.7a 26.2� 6.6b 22.0� 3.9a 14.4 0.001Minimum BMI (kg/m2)y 13.3� 1.6a 16.4� 2.2b 14.6� 2.2c 28.5 0.001Premorbid BMI (kg/m2) 20.5� 3.2a 22.5� 3.7b 20.5� 3.3a 4.7 0.05Age of eating disorder onset 17.1� 4.4 20.4� 2.7 17.5� 3.4 1.8 NSNo. of previous inpatient treatment 2 [5] 1 [2] 1 [3] 7.6 0.05EDE objective bulimic episodesz,x 0 [6.2] 28 [56] 0 [28] 54.1 0.001EDE subjective bulimic episodesz,x 6 [28] 8 [20] 3 [17] 7.5 0.05EDE episodes of self-induced vomitingz,x 0 [25] 28 [56] 0.5 [30] 15.2 0.001EDE episodes of laxative misusez,x 0 [0] 0 [12.5] 0 [0] 2.4 NSEDE episodes of diuretic misusez,x 0 [0] 0 [0] 0 [0] 0.2 NSEDE days of driven exercisez,x 20 [28] 0 [20] 0 [12] 16.4 0.001EDE Restraint 4.0� 1.4a 3.5� 1.4a,b 3.1� 1.7b 7.8 0.01EDE Eating Concern 3.5� 1.3a 4.3� 1.2b 3.0� 1.7c 11.6 0.001EDE Weight Concern 4.0� 1.4a 4.4� 1.3a 2.9� 1.8b 16.6 0.001EDE Shape Concern 4.1� 0.9a 4.2� 1.1a 3.0� 1.5b 24.9 0.001EDE Global Score 3.9� 9.1a 4.1� 0.9a 2.9� 1.4b 19.8 0.001BDI 30.9� 13.6 27.0� 11.6 28.4� 15.1 1.4 NSSTAI 57.6� 14.6 56.6� 13.3 57.8� 14.7 0.1 NS

Note: AN, anorexia nervosa; BN, bulimia nervosa, EDNOS, Eating Disorder Not Otherwise Specified; BMI, Body Mass Index; EDE,Eating Disorder Examination; BDI, Beck Depression Inventory; STAI, State-Trait Anxiety Inventory—Form Y.Superscripts that differ represent significant differences of p< 0.05 between groups.�ANOVA.y Since menarche occurred.zOver the last 28 days before admission.xKruskal–Wallis Test.


requirement for a diagnosis of anorexia nervosa.Nine of the seventy five EDNOS patients (12.0%)were reclassified as anorexia nervosa.Second, we evaluated the impact of adjusting

upward the BMI threshold criterion for anorexia

Table 2. Clinical prevalence of anorexia nervosa, bulimia nmodifications

EDE diagnosisAdjustment to AN criteria(a) AN no amenorrhea(b) AN <18.5(c) AN psychopathology(d) Adjustment a, b and c combined

Adjustment to BN criteriaBN binge eating and purging frequency

Adjustment of AN and BN criteria combined

Note: AN, anorexia nervosa; BN, bulimia nervosa, EDNOS, EatExamination; AN no amenorrhea¼ removal amenorrhea criteria fr(BMI) to<18.5 kg/m2 as the threshold criterion for the diagnosis of Aby also including in the diagnosis of AN the patients with eating restrand purging frequency¼ reduction of the minimum frequency for biof BN.The numbers in parentheses are percentages.


nervosa to a BMI< 18.5 kg/m2. The result wasthat only 2 of the 75 EDNOS patients (2.7%)were reclassified as anorexia nervosa. Five of thethirty three bulimia nervosa patients (15.1%) werereclassified as anorexia nervosa.

ervosa and EDNOS with and without the DSM-IV criteria

AN BN EDNOS

78 (41.9) 33 (17.8) 75 (40.3)

87 (46.8) 33 (17.8) 66 (35.5)85 (45.7) 28 (15.1) 73 (39.2)102 (54.8) 33 (17.8) 51 (27.4)132 (71.0) 25 (13.4) 29 (15.6)

78 (41.9) 34 (18.3) 74 (39.8)132 (71.0) 26 (14.0) 28 (15.0)

ing Disorder Not Otherwise Specified; EDE, Eating Disorderom the diagnosis of AN; AN <18.5¼ increase Body Mass IndexN; AN psychopathology¼ redefinition of ‘core psychopathology’aint without the concerns about shape andweight; BN binge eatingnge eating and purging to at least once per week for the diagnosis


DOI: 10.1002/erv


Third, we evaluated the impact of redefiningthe ‘core psychopathology’ of anorexia nervosa andalso including in this diagnostic category, patientswith eating restraint without the concerns aboutshape and weight. Twenty four of the seventy fiveEDNOS patients (32%) were reclassified as anorexianervosa. This change had the biggest effect on therelative prevalence of EDNOS.Fourth, we evaluated the impact of the adjust-

ments of anorexia nervosa criteria combined.Forty six of the seventy five EDNOS patients (61.3%),and 8 of the 33 bulimia nervosa patients (10.7%)were reclassified as anorexia nervosa (see Table 2for the impact on the three diagnostic categories).Fifth, we evaluated the impact of reducing the

minimum frequency of binge eating and purgingfor the diagnosis of bulimia nervosa from twice perweek to once per week. No patients with anorexianervosa changed diagnostic category while onepatient with EDNOS (1.3%) obtained a diagnosis ofbulimia nervosa.The combination of all DSM-IV criterion modifi-

cations significantly reduced the number of patientsgiven a diagnosis of EDNOS (from 75 to 28 cases,p< 0.001). These modifications increased signifi-cantly the number of patients with a diagnosis ofanorexia nervosa (from 78 to 132 cases, p< 0.001)though did not decrease significantly the number ofpatients with a diagnosis of bulimia nervosa (from33 to 26 cases, p¼NS). Twenty eight patients (37.3%of the total EDNOS and 15% of the total sample)maintained their original diagnosis of EDNOS afterthe DSM-IV manipulation, and are considered to be‘residual cases’.

Comparison Between Converted Patients andthe Other Eating Disorder Patients

Table 3 shows the comparison between core anorexianervosa, converted anorexia nervosa patients, resi-dual bulimia nervosa and residual EDNOS.Converted anorexia nervosa patients had signi-

ficantly lower scores on EDE Restraint, WeightConcern, Shape Concern subscales and on GlobalEDE than core anorexia nervosa patients. They hadalso significant lower BMI, and lower frequency ofobjective bulimic episodes and self-induced epi-sodes in the last 28 days than patients with residualbulimia nervosa and residual EDNOS. Patients withresidual bulimia nervosa had significantly highermaximum BMI, minimum BMI, premorbid BMI,and significantly higher scores on EDE EatingConcern,Weight Concern, Shape Concern subscalesand on Global EDE than patients converted to


anorexia nervosa. Finally, core anorexia nervosapatients had higher frequency of driven exercise inthe last 28 days than the other three samples.No significant differences emerged on Global

EDE score between core anorexia nervosa patientsand converted anorexia nervosa patients withBMI between 17.5 and 18.5 kg/m2 and absence ofamenorrhoea (3.9� 0.9 vs. 3.7� 1.0, F¼ 0.4; p¼NS).Patients converted to anorexia nervosa withoutconcern on shape and weight had a significantlylower score on Global EDE than core anorexianervosa patients (2.1� 1.1 vs. 3.9� 0.9, F¼ 60.3,p< 0.001) and than patients converted to anorexianervosa with BMI between 17.5 and 18.5 kg/m2

and without amenorrhoea (2.1� 1.1 vs. 3.7� 1.0,F¼ 20.8, p< 0.001).Since only one EDNOS patient converted to buli-

mia nervosa, no statistical comparisons were madebetween these two groups.

Clinical Description of the Residual EDNOSAfter Modifications

The 28 residual cases of EDNOS had heterogeneousclinical features. One (3.7%) met the diagnosis ofBED according to DSM-IV criteria (American Psy-chiatric Association, 1994). Ten (35.7%) had thebehavioural features of bulimia nervosa withoutthe concerns about shape and weight. Three (10.7%)showed the clinical features of bulimia nervosa butwith a frequency of binge eating and compensatorybehaviours greater than the twice a week thresholdin the last month but lower than once a week in thetwo previous months. Two (7.1%) were slightlyunderweight but missed the maintenance of lowweight required by the EDE. Six (21.4%) had a BMIgreater than 18.5kg/m2, and recurrent purging in theabsence of objectively large binge episodes. Six(21.4%) had clinical features of anorexia nervosaand bulimia nervosa combined in a different way tothat seen in the two recognised syndromes.

DISCUSSION

The study has three principal findings: (1) EDNOSis common in an adult eating disorder inpatientsample; (2) most of the EDNOS cases are subthres-hold forms of anorexia nervosa and (3) the mainreason these cases do not get diagnosed as anorexianervosa is that the characteristic psychopathologyof anorexia nervosa as described in DSM-IV ismissing.


DOI: 10.1002/erv

Tab

le3.

Comparisonbetweencore

anorexia

nervosa

patients,residual

bulimia

nervosa

patients,residual

EDNOSpatientsan

dpatientsconvertedto

anorexia

nervosa

onclinical

andpsych

opathological

variables(m

ean�SD

ormed

ian[interquartile

range])

Core

AN

(n¼78

)Convertedto

AN

(n¼54

)Residual

BN

(n¼26

)Residual

EDNOS(n

¼28

)F

p�

Age(years)

25.7�8.8

25.9�7.1

25.5�6.1

27.6�6.1

0.5

NS

Curren

tBMI(kg/m

2)

14.5�1.6a

15.8�1.9b

21.7�2.4c

20.8�2.8c

129.3

0.00

1Max

imum

BMI(kg/m

2)

21.3�3.7a

21.1�3.6a

27.2�6.9b

23.7�3.7a

15.1

0.00

1Minim

um

BMI(kg/m

2)

13.3�1.6a

14.3�1.5b

16.6�2.3c

15.5�2.9b

,c21

.50.00

1Premorbid

BMI(kg/m

2)

20.5�3.2a

20.3�3.4a

23.1�4.0b

21.0�2.9a

,b4.5

0.01

Ageofeatingdisord

eronset(years)

17.1�4.4

18.2�6.1

21.3�18

.515

.4�5.8

2.2

NS

Durationofeatingdisord

er(m

onths)

60[144

]84

[171

]96

[132

]12

6[168

]7.5

NS

Previousinpatienttreatm

ents

2[5]

1[3]

1[2]

1[2.7]

7.9

NS

EDEobjectivebulimic

episodes

y,z

0[6.2]

0[26.5]

28[51.5]

3[50]

33.7

0.00

1EDEsu

bjectivebulimic

episodes

y,z

8[56]

3[22]

16[48]

1.5[15.2]

10.6

0.05

EDEep

isodes

ofself-inducedvomitingy,z

0[25]

0[48.5]

25.5

[51.5]

4[56]

11.0

0.05

EDEep

isodes

oflaxativemisuse

y,z

0[0]

0[0]

0[24.2]

0[3.7]

3.6

NS

EDEep

isodes

ofdiureticmisuse

y,z

0[0]

0[0]

0[0]

0[0]

5.1

NS

EDEday

sofdriven

exercise

y,z

20[28]

0[12.5]

0[14.5]

0[17]

16.1

0.00

1EDERestraint

4.0�1.4a

2.9�1.5b

3.6�1.5a

,b3.3�1.7a

,b5.8

0.00

1EDEEatingConcern

3.5�1.3a

,b3.1�1.7a

4.4�1.1b

2.9�1.7a

6.4

0.00

1EDEW

eightConcern

4.0�1.4a

,b2.7�1.5b

4.7�1.2c

3.1�2.1a

,b12

.20.00

1EDEShap

eConcern

4.1�0.9a

2.8�1.4b

4.4�1.0a

3.2�1.5b

16.9

0.00

1EDEGlobal

Score

3.9�0.9a

2.9�1.3b

4.3�0.8a

3.1�1.5b

13.2

0.00

1BDI

30.9�13

.626

.1�14

.229

.7�11

.729

.1�15

.61.4

NS

STAI

57.6�14

.657

.7�14

.358

.0�12

.955

.3�15

.40.2

NS

Note:Core

AN,anorexia

nervosa

withcore

EDEdiagnosis;Residual

BN,residual

bulimia

nervosa

patientsafterdiagnosticconversion;R

esidual

EDNOS,residual

eatingdisord

ernot

otherwisesp

ecified

patients;C

onvertedto

AN:convertedto

anorexia

nervosa

patientsafterdiagnosticconversion;BMI,BodyMassIndex;E

DE,E

atingDisord

erExam

ination;BDI,

BeckDep

ressionInven

tory;STAI,State-TraitAnxiety

Inven

tory

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Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 15, 340–349 (2007)

DOI: 10.1002/erv


The study has two principal strengths. First, itpresents data from a large sample of clinicallysevere eating disorder patients treated in an inpatientsetting. Second, it applied leading measures of psy-chopathology and the same operational EDE-baseddiagnostic criteria adopted in a previous outpatientstudy that evaluated the impact of relaxing thediagnostic criteria of anorexia nervosa and bulimianervosa on EDNOS prevalence (Fairburn et al.,2007). The operational EDE-based diagnosticcriteria enabled diagnostic thresholds to be adjustedin a systematic and replicable way.Previous studies evaluated the clinical prevalence

of EDNOS mainly in the outpatient setting. Theoutpatient studies found a prevalence of EDNOSranging from 50.3 to 70.5%with a weighted averageprevalence around 60.0% (Fairburn & Bohn, 2005).Our study found a prevalence of EDNOS of 40.3%that is lower than those observed in outpatient set-tings, but higher than the 23% (Solenberger, 2001) to30% (Andersen et al., 2001) rate found in previousstudies in inpatient samples that did not use thestringent EDE operational-based diagnostic criteria.Our data indicate that even in a specialist inpatientsetting, where the patients admitted are the mostsevere eating disorder cases, EDNOS is a very fre-quent diagnosis. These data confirmprevious obser-vations that the actual DSM-IV diagnostic systemhas a major nosologic problem, since it definesEDNOS as a residual eating disorder categoryalthough it is a very frequent eating disorder diag-noses made in both outpatient and inpatient set-tings.The impact of altering four DSM-IV criteria

was to create a significant reduction in theprevalence of inpatient EDNOS. Redefining the‘core psychopathology’ of anorexia nervosa madethe greatest reduction on EDNOS prevalence: 32%of EDNOS were rediagnosed as anorexia nervosa.This observation highlights that there is a significantpercentage of patients admitted to a unit specialis-ing in eating disorders that lack detectable Shapeand Weight Concern, and supports the hypothesisthat in anorexia nervosa eating restraint can bemotivated by concerns other than weight and shapecontrol (Palmer, 2005). After dropping the amenor-rhoea criterion, 12.0% of EDNOS were reclassifiedas anorexia nervosa. These data show that a sub-group of eating disorder patients maintain a regularmenstrual cycle in a condition of severe under-weight. Increasing the BMI threshold to BMI<18.5 kg/m2 had a modest impact on decreasing theprevalence of eating disorder NOS, and reduced thediagnosis of bulimia nervosa (15.1% of the patients


with this diagnosis were reclassified as anorexianervosa). Reducing theminimum frequency of bingeeating and purging had an insignificant impact onthe prevalence of inpatient EDNOS diagnosis.The combined impact of the four criteria modi-

fications reduced significantly the total prevalenceof EDNOS from 40.3 to 15%. This reduction isgreater than those observed in a previous study thatevaluated the sameDSM-IV alterations in a researchoutpatient setting (Fairburn et al., 2007) and in astudy that used a heterogeneous eating disordersample (Thaw et al., 2001). This greater effect isexplained by the fact that the majority of ourEDNOS patients had a ‘subthreshold’ eating dis-order with clinical features similar to anorexia ner-vosa while in research outpatient treatment settingsmost of the EDNOS had an eating disorder of‘mixed’ variety (Fairburn & Bohn, 2005).The small sample size of converted patients

limits any definitive conclusion on the validity ofthe reconstituted diagnostic groups. However, itis important to underline that no significant dif-ferences emerged between patients converted toanorexia nervosa and the core anorexia nervosapatients with regards to age, age of eating disorderonset, duration of eating disorder, maximum andpremorbid BMI, BDI and STAI scores. The twosamples also showed a similar frequency in epi-sodes of binge eating, self-induced vomiting, laxa-tive and diuretic misuses in the last 28 days. Coreanorexia nervosa patients displayed higher severityof eating disorder psychopathology than patientsconverted to anorexia nervosa. However, the dif-ference in the severity of eating disorder psycho-pathology between the two groups was determinedby the large number of converted EDNOS patientsthat did not report concerns with regards to shapeand weight. In fact, no significant differences oneating disorder psychopathology emerged amongcore anorexia nervosa patients and the other twogroups of patients converted to anorexia nervosa(i.e. the patients with all the diagnostic featuresof anorexia nervosa except amenorrhoea and thepatients with all the diagnostic features of anorexianervosa except a BMI from 17.5 to <18.5 kg/m2).Many authors consider the absence of Shape andWeight Concern in motivating eating restraint anon-valid criterion to exclude these cases from thediagnosis of anorexia nervosa (Fairburn & Bohn,2005; Palmer, 1993, 2005; Rieger et al., 2001). In thesepatients, the concern of shape and weight could bedenied or the restraint eating could be motivated byother ideas and preoccupations (e.g. religious ideas,ideas of fitness, ideas of asceticism and concern over


DOI: 10.1002/erv


digestion) (Palmer, 2005). In our clinical experience,the main reasons for eating restraint reported byhospitalised eating disorder patients without con-cern on shape and weight include concerns overdigestive function or abdominal pain associatedwith eating.The reduction of the rate of EDNOS diagnosis

with DSM-IV alteration has practical implications. Itincreases the chances that a larger number of thepatients with eating disorders will be considered byresearchers. It facilitates the process of reimburse-ment by public health system. It helps the patients toimprove the awareness of having a disorder that hasan ‘accepted’ diagnosis.The study has some limitations. First, it evaluated

a single inpatient unit that treats mainly adultpatients. Replication using other inpatient sample isneeded. Second, the patients evaluated belong toa distinctive subgroup of severe eating disorderpatients hospitalised in a specialist inpatient unit. Itis therefore important to be cautious in generalisingthe findings about EDNOS clinical features andeating disorder psychopathology. Third, the num-ber of patients converted to anorexia nervosa withall the diagnostic features of anorexia nervosaexcept amenorrhoea or except a BMI from 17.5 to<18.5 kg/m2 was small. Studies with larger samplesizes are needed to assess further the utility ofamenorrhoea and a higher BMI threshold as diag-nostic criteria. Based on the previous studies andour findings, we suggest that amenorrhoea is notan essential criterion for the diagnosis of anorexianervosa. More data are indeed needed to establishthe utility to adjust upward the BMI threshold forthe diagnosis of anorexia nervosa. Fourth, the studydid not included patients with active substanceabuse, schizophrenia and other psychotic disorders.However, the number of patients with these dis-orders excluded during the recruitment interviewwas small (two with active substance abuse and onewith schizophrenia) and it is unlikely that they willhave an impact on the clinical representativeness ofthe relative prevalence of anorexia nervosa, bulimianervosa and EDNOS.In conclusion, the data of this study make clear

that EDNOS is a very common diagnosismade in aneating disorders specialising inpatient unit. Alter-ing the diagnostic criteria for anorexia nervosa andbulimia nervosa reduces significantly the clinicalprevalence of EDNOS from 40.3 to 15%. These datasupport the alteration of DSM-IV criteria for anor-exia nervosa as a valid solution for reducing theprevalence of inpatient EDNOS to a true residualcategory.


ACKNOWLEDGEMENTS

We are indebted to Prof. Chris Fairburn for his com-ments of this paper.

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Eating disorder not otherwise specified in an inpatient unit: the impact of altering the DSM-IV criteria for anorexia and bulimia nervosa