Feeding and Eating Conditions Not Elsewhere Classified (NEC) inDSM-5 Tiffany A. Brown, MS; Pamela K. Keel, PhD; and Ruth H. Striegel, PhD long with changes to the formally recognized eating disorders, the ADiagnostic and Statistical Man- ual, Fifth Edition Eating Disorder Work Group has recommended that the DSM- IV eating disorder not otherwise specified category be renamed: Feeding and eating conditions not elsewhere classified. This change reflects the inclusion of childhood feeding disorders within the eat- ing disorder classification scheme, as well as the focus on reducing the ambiguous and “catch-all” nature of eating disorder not otherwise specified (EDNOS). While there is not currently enough rigorous sci- Tiffany A. Brown, MS, is a doctoral candi- date in Clinical Psychology, Department of Psychology, Florida State University. Pamela K. Keel, PhD, is Professor of Psychology, De- partment of Psychology, Florida State Uni- versity. Ruth H. Striegel, PhD, is Professor of Psychology, Department of Psychology, Wes- leyan University. Address correspondence to: Ruth H. Strie- gel, PhD, Department of Psychology, Wesley- an University, 207 High Street, Middletown, CT 06459; email: [email protected]. Disclosure: The authors have no relevant financial relationships to disclose. Copyright ©2012, American Psychiatric Association. All rights reserved. doi: 10.3928/00485713-20121105-08 © Shutterstock PSYCHIATRIC ANNALS 42:11 | NOVEMBER 2012 Healio.com/Psychiatry | 421 entific evidence to categorize the proposed category. The inclusion of BED as a for- specified nature of the residualDSM-IV conditions as disorders, a diagnosis of not mally recognized disorder, along with the EDNOS category itself has been a major elsewhere classified (NEC) is warranted expansion of the AN and BN categories, roadblock to initiating research and pro- if the individual has an eating disturbance has helped reduce what conditions remain viding useful guidelines for clinical prac- that is clinically significant, but does not in the “residual” diagnostic group by re- tice. With this issue in mind, further reor- meet criteria for any other feeding or eat- allocating what were formerly several ganization and specification was needed ing disorder. Thus, the NEC category is atypical or subthreshold presentations within this category to facilitate greater not meant to capture disordered eating, (eg, AN without amenorrhea or BN with understanding regarding some of the al- which can be present among the general once per week binge/purge episodes). ternative syndromes that have been iden- population, but rather, eating conditions tified in research and clinical practice. that may cause significant distress, inter- Consistent with the broader change ference with daily life, and/or increased in the nomenclature from “not otherwise risk of death or disability. specified” to “not elsewhere classified,” From a practitioner’s standpoint, in- the DSM-5 work group has focused dividuals seeking treatment for eating on specifying and defining subgroups problems are likely either experiencing within EDNOS. While DSM-IV EDNOS distress and/or impairment that are clini- included several examples of unnamed cally significant. Proposed conditions in- syndromes, DSM-5 will include several cluded in NEC are: atypical anorexia ner- named syndromes with brief descriptions vosa (atypical AN); subthreshold bulimia (but without formal diagnostic criteria) nervosa (subthreshold BN); subthresh- within three categories: (1) atypical, old binge eating disorder (subthreshold mixed, or subthreshold syndromes; (2) BED); purging disorder (PD); and night other specific syndromes; and (3) condi- eating syndrome (NES). Treatment-seek- Several studies have shown tions with insufficient information. Nota- ing samples of bulimic-related EDNOS bly, for all NEC conditions, no minimum syndromes, which would include many, that with these revisions, the frequency or duration requirements are if not most, of the conditions proposed designated. This decision was made, in for NEC, are at increased risk of death by proportion of NEC diagnoses large part, because there is no available suicide,1 supporting the severity of illness will decrease dramatically. research that would have guided more among patients who will fall within the specific frequency or duration thresh- NEC category. olds. Thus, it is left to clinical judgment Unlike the clear hierarchy proposed for Indeed, several studies have shown to distinguish a clinically significant eat- diagnoses of AN, BN, and BED, there is that with these revisions, the proportion ing disorder from disordered eating. currently no specified diagnostic hierarchy of NEC diagnoses will decrease dramati- for NEC conditions. With this understood, cally.2,3 In a community-based sample, Atypical and Subthreshold practitioners should only diagnose an indi- the use of DSM-IV vs. DSM-5 criteria Presentations vidual with a single NEC condition, based resulted in 63% EDNOS versus 53% Regarding the first category of NEC on the best match between the description NEC, respectively (P < .001).2 Similarly, (atypical AN, subthreshold BN, sub- of NEC conditions and that individual’s among a treatment-seeking sample, esti- threshold BED), descriptive changes specific constellation of symptoms. mates of EDNOS decreased from 53% were warranted based on revisions to to 25% for NEC (P < .001).3 As evident diagnostic criteria for full threshold CLINICAL UTILITY OF NEC from these studies, while proposed revi- disorders. Given that the changes to A large emphasis for revisions of sions will reduce the “catch-all” nature of diagnostic criteria for AN and BN and DSM-5 was to reduce the preponderance the EDNOS category somewhat, DSM-5 the inclusion of BED as a formal diag- of DSM-IV EDNOS diagnoses without NEC is still likely to represent a sizeable nosis reallocated a substantial propor- reducing diagnostic validity of recog- minority of patients in clinical settings tion of patients from DSM-IV EDNOS nized categories, such as AN and BN. and the majority of clinically significant to DSM-5 full-threshold diagnoses, the Perhaps the largest revision is the recom- eating disorders in community settings. definitions of what constitute atypical or mendation that BED be “promoted” from In addition to the need to reduce the subthreshold presentations were in need a form of EDNOS to a formal diagnostic profusion of EDNOS diagnoses, the un- of modification. 422 | Healio.com/Psychiatry PSYCHIATRIC ANNALS 42:11 | NOVEMBER 2012 Purging Disorder contributed to the chronicity of obesity Given that increased freedom has been Regarding other specific syndromes, among a case series of 23 obese individu- designated to the practitioner to define purging disorder (PD), which reflects the als.14 While NES has not been mentioned what qualifies as “low weight” when di- most commonly used specific name for in any iteration of the DSM, advocacy agnosing AN, diagnoses of AN among this symptom configuration across recent from researchers led to a rigorous scien- those who are underweight will largely ex- studies,4 was first introduced as a poten- tific evaluation of NES to determine how clude them from being assigned to NEC. tial description of an atypical eating dis- it may be addressed within DSM-5. Because a central feature of AN is low order in 1986.5 An unnamed version of The largest limitation within the NES weight, the descriptor of “atypical” ap- PD was added as an example descriptor research literature has been lack of agree- pears appropriate for this NEC condition. of EDNOS in DSM-III-R,6 and as Ex- ment on a definitive syndromal definition The other two conditions in this sub- ample 4 in DSM-IV7 (“the regular use of and some debate regarding whether the category of NEC include subthreshold inappropriate compensatory behavior by condition described as NES best repre- conditions. Example 3 from DSM-IV individuals with normal body weight af- sents a syndrome or a set of symptoms.15 EDNOS has been aptly named sub- ter eating small amounts of food”). More Several studies have found support for in- threshold BN, which accurately reflects detailed and rigorous studies of the con- creased pathology on a number of psycho- a syndrome identical to DSM-5 BN, al- dition have produced a clearer descrip- logical correlates for NES as compared to beit with a frequency of less than once tion and name for purging disorder. healthy controls; however, the variables per week or less than 3 months in dura- Several studies have demonstrated examined have differed across research tion. Since the designation of BED as a the clinical significance of PD and its studies (eg, depressive symptoms, anxiety full-threshold eating disorder, subthresh- distinction from non-eating disordered symptoms, substance-use problems, psy- old BED also will be included within the individuals.8-10 A lesser number of stud- chiatric diagnoses) making it difficult to NEC conditions (with identical frequen- ies have demonstrated physiological and draw definitive conclusions overall.15 cy criteria as for subthreshold BN). psychological differences between PD Further, several other methodological Reflecting the definition used in re- and BN;11,12 however, these differences issues exist within the NES research lit- search on PD in recent years, PD will be have been less consistently studied and erature, including lack of data regarding described by recurrent purging behaviors found.13 Finally, studies examining the the prevalence and course of NES, and