Eating Disorder Not Otherwise Specified: The DSM-IV-TR Diagnostic Criteria
Because of the diversity of individual presentations associated with any diagnostic class in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev., or DSM-IV- TR-, American Psychiatric Association [ APA], 2000a), including the EDs, it is impossible for the formal categories alone to cover every possible client situation (APA, 2000a; Schwitzer, Bergholtz, Dore, & Salimi, 1998). Therefore, each diagnostic class, including the EDs, offers at least one NOS category. The NOS category is used under several different conditions. Two of these conditions are especially relevant when identifying clients' eating-related difficulties. First, a person's presentation may conform to the general guidelines for the types of concerns covered in a diagnostic class but without fully meeting all of the exact criteria for a specific disorder. Second, symptoms may cause “clinically significant distress or impairment” (APA, 2000a, p. 4) but without conforming to any formal diagnostic category found in the manual.
Under these conditions – when a client's presentation does not fully meet the criteria for anorexia or bulimia but clearly consists of disordered eating patterns and experiences of distress or impairment in daily life – the EDNOS category is used (APA, 2000a; Schwitzer et al., 1998). For example, a person might be experiencing a scenario in which the behavioral features of a formal ED are only partially met. As an illustration, the EDNOS category is suggested when an individual exhibits normally expected body weight and normal menstrual patterns but is experiencing all of the other diagnostic features of anorexia (such as intense fear of gaining weight, disturbed body image, and severely restrictive dieting). Likewise, an individual might be experiencing a situation in which duration or frequency criteria are not met. As an illustration, the EDNOS category is again suggested when a person presents with all of the associated features of bulimia (self-evaluation that is unduly influenced by body and appearance considerations), but recurrent binging and compensating behaviors (purging, laxative use, etc.) occur at below-threshold levels (Schwitzer et al., 1998). A prominent example of the EDNOS category is the situation in which a client's behavior fits the criteria for binge eating disorder, a diagnosis currently under further study for possible future use in the DSM, indicating that the person is engaging in recurrent episodes of binge eating without regular use of the compensatory behaviors that would make up bulimia (APA, 2000a).
In sum, EDNOS is a moderate, heterogeneous group of “less severe problems centering on weight preoccupation and dissatisfaction with body image and sub-threshold problems with eating and compensatory behavior” (Schwitzer et al., 2008, p. 608; see also Ash & Piazza, 1995; Klemchuck, Hutchinson, & Frank, 1990;).
Naturally, counseling professionals should be aware of the current trends and future directions regarding ED best practices, including the trends concerning diagnosis. As readers can see, the framework for practice presented in this chapter is based on the DSM-IV TR's criterion-referenced approach to the categorical diagnosis of EDs. Other writers have persuasively made the case for alternative approaches, including transdiagnostic and continuum methods of classifying eating-related concerns (Cleaves, Lowe, Green, Cororve, & Williams, 2000; Peck & Lightsey, 2008; Shisslak et al., 1995; Wonderlich et al., 2007). In turn, some readers may want to explore the benefits of these alternatives in comparison with, or as a supplement to, the approach used in this chapter.
In addition, some writers have raised a concern that overuse of the NOS approach has the potential to reduce diagnostic and predictive validity (Keel, Brown, Holm-Denoma, & Bodell, 2011). For practitioners, this means these writers believe overuse of EDNOS might possibly reduce the power of categorical diagnosis to meaningfully describe client situations. To address this potential problem, some of the new diagnostic criteria currently being proposed for the DSM-5 include not only EDNOS, but also the addition of a formal binge eating disorder diagnosis (APA, 2010). Down the road, therefore, it is possible that offering both options (EDNOS and binge eating disorder), along with revised criteria sets for anorexia and bulimia, might reduce to some degree the prevalence of the EDNOS diagnosis. Practitioners with an interest in EDs should follow these developments; however, Keel et al. (2011), on the basis of their recent clinical trial studies, concluded that even though adding the binge eating disorder option would be a constructive step to take, “it appears likely that EDNOS may [still] continue to be the most common diagnosis” (p. 559).
