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(4) Anorexia

My doctor said I have “atypical anorexia.” What does that mean?

Recall from the previous question that a diagnosis of anorexia requires that a person’s symptoms meet a number of specific diagnostic criteria, as specified in the DSM-IV-TR. However, what happens when someone has symptoms of an eating disorder that do not meet all of these criteria?

This occurs more frequently than you might imagine. Nancy Kolodnyclinical social worker and author of “The Beginner’s Guide to Eating Disorders Recovery”, states that as many as 10–20% of adolescent girls and young women display some, but not all, of the clinical symptoms of anorexia.

Indeed, research findings indicate that at least half of all people diagnosed with an eating disorder do not meet the full criteria for either of the two primary eating disorders: anorexia nervosa and bulimia nervosa. In such cases, an alternative diagnosis is given.

According to the DSM-IV-TR, “eating disorder not otherwise specified” (EDNOS) is the diagnostic term used to describe clinically significant eating disturbances that meet some, but not all, of the diagnostic criteria of either anorexia nervosa or bulimia nervosa. In the ICD-10, the corresponding term used is “atypical anorexia” (see Exhibit 2). Some of those diagnosed with EDNOS may have symptoms that closely align with diagnostic criteria of anorexia but fall outside of this diagnosis based on just one criterion.

The differences between the diagnoses of anorexia and EDNOS are often a matter of fluctuating body weight and symptom severity. Indeed, a 2007 study showed that up to 70% of those diagnosed with EDNOS moved to a diagnosis of either anorexia or bulimia over a 30-month period.

Therefore, it is important to note that a diagnosis of EDNOS is no less clinically significant than that of anorexia, nor is it necessarily of less concern. EDNOS can be quite serious and requires the same attention and level of treatment as another eating disorder diagnosis.

Examples of instances when a diagnosis of EDNOS (or atypical anorexia) might be given include:

• An individual who formerly met the diagnosis for anorexia nervosa returns to a normal weight, yet retains some, but not all, of the associated symptoms.

• An individual who does not express a fear of gaining weight, but nevertheless displays other symptoms of anorexia nervosa, including food restriction, weight-reducing behaviors, and substantial weight loss that is not due to any known physical illness.

• An individual of normal body weight who regularly uses inappropriate compensatory behavior (such as vomiting) after eating small amounts of food (two cookies, for example).

• An individual who repeatedly chews and spits out, but does not swallow, large amounts of food.

Perhaps case examples will serve as helpful illustrations. Let’s begin with Barbara: Barbara is a 5’ 3”, 26 -year-old, recently married, Caucasian woman. Up until a month before her wedding day, Barbara weighed between 120 and 125 pounds, but she wanted to lose a few pounds before that day, thinking she would feel more comfortable wearing a bathing suit during her Hawaiian honeymoon. Barbara ended up losing a few pounds more than she planned, yet she liked the fact that her clothes fit a bit more loosely. Her husband made several comments about how much he liked her body when on their honeymoon, remarking that she was not “chunky,” like his ex-girlfriend. When they returned from their honeymoon, several of Barbara’s friends made comments about how “great” she looked. In fact, it seemed like the more weight she lost, the more her husband and acquaintances complemented her appearance. After losing 15 additional pounds, Barbara’s mother grew concerned and told Barbara that she was “thin enough,” yet Barbara did not change her diet. Instead, she became terrified that if she put any weight back on, her husband would no longer find her attractive. His verbal reassurances did not convince her otherwise. By the time Barbara came in for treatment, she weighed 89 pounds. Barbara had severe, self-imposed food restrictions and stated that if she varied from these rules about food it made her feel “nervous for days afterward.” Barbara has a serious eating disorder. However, although her symptoms met most of the diagnostic criteria for anorexia nervosa, she was still having regular menses and therefore did not meet all of the diagnostic criteria for the disorder. Thus, Barbara was diagnosed with EDNOS.

Here is another case example: Marc, an avid swimmer, is a 16-year-old Caucasian male with a history of childhood obesity. During the summer between his freshman and sophomore year of high school, Marc got a job as a construction assistant. He spent many hours carrying heavy loads of lumber, moving large bags of concrete, and climbing multiple flights of stairs. All of this activity left Marc 30 pounds lighter than when the summer began. Marc liked his new, slimmer appearance and vowed to maintain his weight loss after his summer job ended, but the methods he chose were not healthy. Marc severely restricted his calorie intake for days at a time and would frequently exercise to the point of exhaustion. Altogether, Marc lost about 20% of his body weight. In addition, he grew increasingly preoccupied with his weight and developed an intense fear of gaining weight. Marc’s symptoms are part of the diagnostic criteria for anorexia nervosa. However, Marc’s current weight was still within the normal range. Therefore, his clinical presentation did not meet the full diagnostic requirements specified for anorexia nervosa. Instead, Marc’s diagnosis was EDNOS.

Exhibit 2: ICD-10 Classification of Atypical Anorexia

Disorders that fulfill some of the features of anorexia nervosa but in which the overall clinical picture does not justify that diagnosis. For instance, one of the key symptoms, such as amenorrhea or marked dread of being fat, may be absent in the presence of marked weight loss and weight-reducing behavior.

This diagnosis should not be made in the presence of known physical disorders associated with weight loss.

SOURCE: World Health Organization. (2007). The international classification of diseases and related health problems, 10th Rev. (Electronic Version). Retrieved. July 22, 2008 from ICD-10 Online: www.who.int/classifications/apps/icd/icd10online

Terms:

Bulimia nervosa - An eating disorder characterized by recurrent episodes of binge eating followed by inappropriate compensatory behavior, such as vomiting, misuse of laxatives, diuretics, enemas, or other medications; and/or fasting or excessive exercise. There are two subtypes of bulimia nervosa: purging type and non-purging type.

EDNOS - A diagnostic classification for several varieties of eating disorder symptoms classified in the DSM-IV-TR.

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