Patients Who Are Underweight But Not Overly Concerned About Shape and Weight

Some patients fit nearly all the criteria for a diagnosis of anorexia nervosa (AN), but are not concerned about shape and weight. A recent study has drawn attention to these patients, who are placed in the category of eating disorder not otherwise specified (EDNOS-W). In addition to lack of concern about shape and weight, their self-evaluation is largely based on their ability to control their eating and to avoid certain gastrointestinal symptoms (Int J Eat Disord. 2008; 41:705).

As  Riccardo Dalle Grave, MD, and colleagues at the University of Bologna point out, only one naturalistic study has reported the outcome of treatment for these patients. In that study, patients recovered more rapidly, were less likely to lose weight after discharge, and had a lower cumulative risk for developing binge eating compared to patients with classic AN (Int J Eat Disord. 1999; 25:135).

Study and subjects

Eighty-eight consecutive patients (81 women, 7 men) admitted to the eating disorder inpatient unit at Villa Garda Hospital in northern Italy were included in the study. These patients had been referred for treatment from all over Italy and were included in the study if they had body mass indexes (BMIs) ≥ 17.5 kg/m.2 The women had to be amenorrheic for 3 months before the study and did not use oral contraceptives.

The authors assessed the patients with the Beck Depression Inventory, an Italian translation of the Eating Disorders Examination, the State-Trait Inventory, and the Temperament and Character Inventory, along with measurement of weight and height.

How the EDNOS-W patients differed from AN patients

The EDE-based operational DSM-IV diagnosis of participants was AN in 71 cases (80.7%), and EDNOS-W in 17 cases (19.3%). Most of the EDNOS-W patients were female, single, and in their 20s, and had had their eating disorder for several years (mean: 70 months). Although the 17 patients were severely underweight, their EDE scores indicated the absence of over-evaluation of shape and weight, which contrasted with the 71 patients diagnosed with AN.

The most common reason for restricting intake reported by those with EDNOS-W was gastric or colonic symptoms, such as bloating, nausea, a feeling of fullness, abdominal pain, constipation, and diarrhea, which were worsened by eating. Two patients reported that their excessive restriction of food intake and fear of food began soon after they were tested for food intolerance and were following their doctors’ advice to eliminate a few specific foods from their diets. The EDNOS-W patients also had lower scores in all four EDE subscales and in global EDE. A significantly lower number of bulimic episodes were reported by individuals in the EDNOS-W cases.

Twelve patients with EDNOS-W (71%) and 54 patients with AN (76%) completed treatment and achieved normal body weights (BMI ≥ 18.5 kg/m2). None of the patients with EDNOS-W over-evaluated the change in their weight or shape.  (-32).

Implications for DSM-V

Dr. Dalle Grave and co-workers note that the onset of gastric or colonic symptoms in this group might be associated with some form of psychological distress. One mechanism might be through corticotrophin-releasing hormone, at least in those with irritable bowel disease. The authors suggest that when individuals with a need for self-control start to cut back their food intake to alleviate gastrointestinal symptoms, the control over eating represents success in the face of perceived failure in other, uncontrollable areas.

The absence of significant clinical differences between patients with EDNOS-W and AN and the similar response to treatment shown by the two groups lends some early support to include EDNOS-W patients in the broader diagnosis of AN in the coming DSM-V. Doing so may improve research in this area, reduce the high prevalence of EDNOS within the spectrum of eating disorders, and may lead to inpatient treatment of most severe cases. Finally, it may also improve patient awareness of the disorder, giving it a community-accepted diagnosis, not an uncertain diagnosis.