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Disorders without
classification pose problems
(April 2005
Issue)
By Ami Albernaz
Imagine a woman who is five-foot-six and weighs175 pounds, and
who has torn her esophagus from vomiting after eating. The woman
no longer vomits, but has begun using laxatives instead, and has
lost 50 pounds over a short time span. Yet because her pattern of
eating and purging does not meet the "classic" criteria for anorexia
or bulimia (she does not "volume binge," as is specified under the
classic definition of bulimia), her insurance will not cover hospitalization.
The example, while severe, is not hypothetical, and points to some
of the difficulties of treating disorders that elude neat classification,
says Diane Mickley, M.D., director of the Wilkins Center for Eating
Disorders in Greenwich, Conn. Eating disorders is one area in which
these "not otherwise specified" (NOS) conditions abound, owing to
the many ways in which disordered eating manifests itself. Psychotherapy
for NOS conditions generally is covered by insurance because NOS
categories are included for many disorders in the diagnostic and
statistical manual. However, at least within eating disorders, being
in the NOS grab bag does present challenges in understanding these
conditions, says Mickley.
"Since EDNOS (eating disorder not otherwise specified) is such
a hodgepodge, it's hard to get data on one group [within it]," Mickley
says. "If you don't have a clear population to reach, you can't
get data on it." Syndromes lumped in the EDNOS grouping include
night eating, purging disorder (which, unlike bulimia, does not
include binge-eating) and subsyndromal disordered eating - conditions
so different from each other that being contained in one catch-all
category reveals very little about any one of them.
According to Mickley, some conditions that are currently lumped
within NOS may eventually be accorded their own specific diagnoses
(binge-eating disorder, for instance, will be accorded a separate
diagnosis in the next DSM, which will appear in 2012). Meanwhile,
patients whose conditions are classified as NOS might perceive themselves
as less in need of treatment, even though they are legitimately
distressed, Mickley says.
"Patients will say, 'I think about food all the time, but I'm not
throwing up, so I must not be bulimic, and I'm not skinny enough,
so I must not be anorexic.' They will say it must not be that bad."
Some eating disorders specialists, meanwhile, do not see the EDNOS
classification as a problem within their practices because therapy
is covered by insurance and each course of treatment is highly individualized
regardless of diagnosis. "So many people are atypical; they don't
fall into a set category," says Denise Lamothe, Psy.D., a specialist
in Epping, N.H. "It all depends on the person."
Michelle Friedman, Psy.D., a psychologist in Salem, Mass. agrees,
but adds that some clients prefer to have a clear label by which
to define their disorder.
"Patients usually define the disorder for themselves, as anorexia
or bulimia, and if you take the label away from them, they might
try harder to fit to it," she says. "Some people need to hold onto
their identity, so challenging it is counterproductive."
Before a condition is taken out of the NOS grab bag and named a
disorder in its own right, three criteria must be met: many patients
must be affected by the condition; there must be an effective existing
treatment for it; and the condition must be judged as sufficiently
distinct from behavior that could be considered normal, according
to Michael First, M.D., as associate professor of clinical psychology
at Columbia University and the text and criteria editor of the DSM-IV.
Because this process is slow, however, Mickley would like to see
some preliminary steps in considering EDNOS conditions. She says
the classification could be broken down into isolated subsets: binge
eating, night eating, and subsyndromal disordered eating, for instance.
The latter condition is especially important to understand for adolescents
who might be in the early stages of what could become a full-fledged
eating disorder. Focusing on this subset could be critical for prevention.
"We could be really aggressive and nip it in the bud," Mickley says.
A breaking down of EDNOS could also help elucidate for the public
what is now a murky topic. "You might see articles on night eating
in the paper, but you don't see them on EDNOS, because it's so vague,"
she says. "It's hard to inform people about something that's such
a mixed bag."
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