EDNOS

The term EDNOS was used in the Diagnostic and Statistical Manual of Mental Disorders (DSM) until 2013. Changes were made to the DSM classification system in 2013 to ensure more people with eating disorders received an accurate diagnosis. The diagnostic criteria no longer uses the term and people will be diagnosed with anorexia, bulimia or binge-eating disorder.

Eating disorders are incredibly complex by nature, and in many cases diagnosis is not clear-cut. It is believed that most people suffering from disordered eating do not in fact fit the criteria for anorexia or bulimia - instead they have what is known as an eating disorder not otherwise specified (or EDNOS).

This category of eating problems accounts for those who have behaviours linked to anorexia and/or bulimia but do not fit the specific criteria for either disorder. An example of this would be someone who has anorexic or bulimic behaviours, but still weighs a 'normal' amount for his or her height.

Receiving this diagnosis can be hard to cope with for the sufferer, with many feeling as if they are not 'ill' enough to receive treatment. This makes EDNOS a particularly dangerous disease, and indeed some studies suggest that it has the highest mortality rate of all psychological disorders.

On this page we will be looking at what constitutes an atypical eating disorder or EDNOS, as well as looking at other eating problems such as pica and orthorexia.

What is EDNOS?

EDNOS stands for eating disorder not otherwise specified, a catch-all term for those with eating problems that do not fit the criteria entirely for anorexia or bulimia. Another term that is becoming more widely used for this category is 'other specified feeding and eating disorder' or simply 'atypical eating disorder'.

Whatever term is used, this category of eating problems has a wide range of behaviours making it difficult to diagnose. The following behaviours may be spotted when making the diagnosis:

• All the criteria for anorexia are met, however the individual still has regular menses (if female).

• All the criteria for anorexia are met, but despite weight-loss the individual's weight is within the normal range.

• All the criteria for bulimia are met, however binges occur less than twice a week or for a duration of less than three months.

• An individual whose weight is within the normal range who regularly engages in unhealthy behaviour after eating small amounts of food (for example, vomiting after eating two biscuits).

• An individual who chews and spits out food rather than swallowing it.

Sufferers of atypical eating disorders may appear outwardly healthy (especially if their weight is considered within the normal range), making it harder for those around them to spot the signs. The common thread between all eating problems however is the psychological suffering. Those with eating problems are likely to have a warped relationship with food and/or their body image, and may use food (or the restriction of food) as a coping mechanism. Common thoughts and feelings experienced by those with eating problems include the following:

• feeling overweight even when at a normal (or below normal) weight
• hearing voices that encourage disordered eating habits
• feelings of self-hatred
• low self-confidence and low self-esteem
• feelings of guilt and shame surrounding eating
• distorted perception of self
• feelings of depression and anxiety.

Effects of EDNOS

Those with EDNOS will suffer the same consequences as those with other eating problems. Even though the criteria for anorexia or bulimia are not met in entirety, there are still several serious conditions that can affect those with an atypical eating disorder.

Medically speaking, risks include: osteoporosis, kidney problems, dental problems, ulcers, heart failure and death. Most eating problems arise out of emotional distress, and often other mental health problems are experienced alongside EDNOS, including: self-harm, depression, anxiety and suicidal thoughts.

Diagnosing EDNOS

Eating problems tend to breed an atmosphere of secrecy and deceit. This makes diagnosing any sort of eating disorder difficult, and because those with EDNOS may not fit the typical 'mould' of someone with an eating disorder, they often become even more difficult to diagnose.

A doctor will look at the psychological symptoms as well as the physical symptoms before making a diagnosis.

Psychological impact of the diagnosis

Being diagnosed with an eating disorder not otherwise specified can result in complex emotions for the sufferer. In some cases, sufferers feel like they are not ill enough to receive help or treatment. This could stop them from reaching out in times of need - consequently allowing their symptoms to worsen.

If someone with EDNOS has been diagnosed as such due to a 'normal' bodyweight, they may feel distressed and want to lose more weight in order to be considered either anorexic or bulimic. The way such atypical eating disorders are assessed is beginning to change however, because of these associated issues.

The DSM-5 (the American Diagnostic and Statistical Manual of Mental Disorders) is looking to minimise the use of catch-all diagnoses like EDNOS and instead want to instill diagnoses that more accurately describe the symptoms and behaviours of people with eating problems.

In the UK, the National Institute of Health and Care Excellence (NICE) say that atypical eating disorders (including binge eating disorder) may affect more than half of all people with an eating disorder - acknowledging its prevalence in those with disordered eating. Several campaigns are helping to raise awareness of EDNOS, in the hope that the way eating problems are assessed and diagnosed can change so that everyone with disordered eating receives the same amount of care and attention.

Other eating problems

Anorexia, bulimia and binge-eating disorder are the most well known eating disorders - however there are other variations surfacing. Two such disorders are pica and orthorexia.

Pica

Pica is a condition that causes compulsive cravings for eating, licking or chewing non-food items. The word itself comes from the Latin word for magpie - a bird that is known for eating anything and everything. The majority of cases of pica are seen in children, however adults and pregnant women can also develop the condition.

A link between autism and pica has also been noted, with an estimated 30% of children with autism also having pica. The reasons behind this are largely unknown, however it is thought to have something to do with the development of the brain.

Sometimes pica is linked to deficiencies of minerals (such as iron or zinc), but more often than not it is deemed a mental health condition. The non-food items that are craved will differ from person to person, but common culprits include:

• paint chips
• rust
• glue
• chalk
• clay
• dirt
• sand
• fabrics
• ice.

Due to the nature of the items being consumed, the medical risks associated can be serious. Medical conditions that can occur as a result of pica include: lead poisoning, intestinal obstruction, dental damage, malnutrition, mercury poisoning and phosphorus intoxication.

Treatment for pica will likely involve the help of mental health professionals and potentially a dietitian. Close medical monitoring is also advised for those being treated for pica to ensure none of the above conditions occur.

Orthorexia

A condition that is gaining more steam in recent years is orthorexia - an unhealthy fixation on eating only healthy or 'pure' foods. While the idea of someone being diligent with their eating habits may sound like no bad thing, when the person involved develops an obsession - both mental and physical health are at risk.

Differing from eating disorders like anorexia and bulimia, a person with orthorexia may not be preoccupied with their body image - or indeed believe that he or she is overweight - instead they are more concerned with the quality of food they are eating.

Beliefs about which foods are 'pure' dominate the sufferer's eating patterns and can see them restricting their diet to only include such foods. Typically, acceptable foods include those that are organic, healthy and totally unprocessed. The progressive and obsessive nature of the disorder is similar to that of anorexia, and often sees the sufferer eliminating entire food groups in the quest for a 'perfect' diet.

When entire food types are eliminated, it can be difficult to get all the nutrients you require. Those suffering from orthorexia may believe that what they are eating is inherently good for them - but in reality they could be missing out on key nutrients.

Getting help

If your relationship with food and/or body image is causing you distress, or you feel as if you use your eating habits as a coping mechanism - it is important to tell someone you trust. All types of eating disorders are isolating conditions and it can be incredibly hard to admit to yourself and others that you have a problem with food. Taking that step to telling someone how you feel can help you feel less alone and may lead the way to recovery.

It is important to realise that even if you don't think you meet the criteria for having anorexia or bulimia, you still need and deserve help. If you feel comfortable doing so, talking to a friend or family member about your feelings is a fantastic first step. When you feel ready, speaking to a doctor will ensure you receive the support and help you need.

If you feel unable to do this, speaking to a professional in confidence (such as a counsellor) is another ideal option. In many cases, your doctor will recommend counselling to help you learn more about your issues surrounding food and to help you develop healthier ways of coping.

There are several different treatment options for those with EDNOS and your plan will be based on your specific symptoms. Examples of the types of treatments you may be offered include:

Cognitive behavioural therapy (CBT) - This therapy type combines both cognitive and behavioural therapies to help change the way you think and how you respond to such thoughts.

Interpersonal psychotherapy (IPT) - This therapy model focuses on interpersonal relationship issues that may contribute to psychological distress.

Modified dialectical therapy (DBT) - This therapy combines techniques from cognitive behavioural therapy with mindfulness to help sufferers reduce stress levels and change their way of thinking.

If your illness is threatening your health, you may be required to stay in a hospital or treatment centre on an inpatient basis. Here you will receive ongoing support to protect your health and help you through your recovery.

Relapses

Whether you have recovered from an eating disorder or an EDNOS, the risk of relapse is very real. During your treatment your therapist should talk you through relapses and help you devise a coping strategy should it happen.

If you find yourself slipping back into old habits or old thinking patterns, consider visiting your therapist or counsellor for additional support. Group therapy and self-help groups can also offer emotional support during difficult times.

What to do if you suspect a loved one has an eating problem

It can be incredibly hard to spot the signs of an eating problem, especially if the person you suspect tells you they're fine. The following signs may point to an eating problem:

• avoiding social situations that include food
• eating small amounts or 'playing' with food
• being very picky about what they eat
• lying about the amount/frequency of food consumption
• hiding food
• complaining of feeling/looking overweight
• frequent trips to the bathroom after eating.

It is important to address the issue - even if the person you suspect of having a problem is of a healthy weight. Try to bring up the topic in a calm manner and not during meal time. The person you suspect may not think they have a problem and may react in anger.

Simply letting them know you are there for them when/if they want to talk is sometimes all that is necessary. If you are worried about their physical or mental well-being, try to encourage them to speak to a doctor or a counsellor.

What should I be looking for in a counsellor or psychotherapist?

Whilst there is no law in place specifying the level of training a counsellor must have in order to treat individuals with EDNOS or other eating problems, the National Institute for Health and Care Excellence have developed a set of clinical guidelines that issue advice on types of psychological treatment, medication and available services.

Key points within the information include the following:

• Of the atypical eating disorders, most is known about the treatment of binge eating disorder (BED).

• If you have an eating disorder that is not easily categorised as anorexia nervosa or bulimia nervosa (often called an atypical eating disorder), your healthcare professional should usually follow the guidance for the eating problem that is most similar to the one from which you are suffering.

For more information, please visit the full NICE guidelines:

Eating disorders - information for the public

Further help

• National Association of Anorexia Nervosa and Associated Disorders