Underweight Eating Disorder without Over-Evaluationof Shape and Weight: Atypical Anorexia Nervosa?

Riccardo Dalle Grave, MD1

Simona Calugi, PhD1

Giulio Marchesini, MD2*

ABSTRACT

Objective: Underweight patients with

eating disorder not otherwise specified

without the over-evaluation of shape and

weight (EDNOS-W) represent a diagnostic

challenge. We aimed to evaluate their

clinical characteristics and treatment out-

come, compared with anorexia nervosa

(AN) cases.

Method: Eighty-eight consecutive pa-

tients (81 females; age range 13–50 years,

71 AN, and 17 EDNOS-W) were studied.

The differential diagnosis of AN and

EDNOS-W was based on the eating dis-

order examination.

Results: Compared with AN, EDNOS-W

cases had a milder eating disorder

psychopathology, but no differences in

anthropometric and clinical data. The

response to inpatient cognitive behav-

ioral treatment was good and similar

between groups, and no differences in

the dropout rate or time-to-dropout were

observed. The normalization of body

weight in EDNOS-W cases was not associ-

ated with the appearance of the over-

evaluation of shape and weight.

Conclusion: The data gives preliminary

support to the proposal to include

EDNOS-W in the diagnosis of AN. VVC 2008

by Wiley Periodicals, Inc.

Keywords: DSM-IV; eating disorder NOS;

diagnosis; classification; anorexia nervosa

(Int J Eat Disord 2008; 41:705–712)

Introduction

Eating disorder not otherwise specified (EDNOS) isa diagnostic category designed for individuals suf-fering from an eating disorder of clinical severityfalling outside the diagnostic criteria specific forAN or bulimia nervosa. The diagnosis of EDNOS, aswell as the other NOS categories in DSM-IV, wasintended to indicate a category within a class ofdisorders that is residual to the specific categoriesin that class,1 but recent studies have found thatEDNOS is the most common eating disorder diag-nosis, both in outpatient2 and inpatient settings.3

Underweight patients that do not report over-evaluation of shape and weight are a distinctiveand scarcely studied subgroup of EDNOS.4 They donot show the characteristic concern about weightgain and the drive for thinness (DT) of the typical

cases of anorexia nervosa (AN), and their self-eval-uation is largely or exclusively based on their abilityto control their eating per se.4 In these patients,concern about shape and weight could either bedenied or restraint eating could be motivated byother ideas and preoccupations (e.g., religiousideas, drive for fitness, ideas of asceticism, andconcern over digestion)5 or by fear of food, stom-ach bloating, stomach pain, no appetite, and nohunger.6

Reviewers of the history of AN found that weightphobia, a key diagnostic criteria of the disorder,emerged as a principal reason for eating restraintonly around the 1930s.7,8 In recent years, theabsence of weight phobia and body-image disturb-ance in patients with low body weight was princi-pally reported not only in epidemiological and clin-ical studies carried out in nonwestern cultures,6,9

but also in almost 20% of patients treated in West-ern clinical setting.10,11 Accordingly, some authorssuggested that shape and weight concerns are onlyrecent culture-specific elements of the psychopa-thology of AN, and may not be essential features ofthe disorder.4,5,12–14

Underweight patients with low scores on the DTsubscale of the eating disorder inventory (EDI)15

are characterized by less severe eating disorder10,16

and general psychopathology16 than those withhigh DT scores. Reports on nonwestern clinical

Accepted 19 March 2008

1 Department of Eating and Weight Disorder, Villa Garda

Hospital, Garda (Vr), Italy2 Unit of Clinical Dietetics, ‘‘Alma Mater’’ University of Bologna,

Policlinico S. Orsola, Bologna, Italy

*Correspondence to: Giulio Marchesini, Unit of Clinical Dietetics,

‘‘Alma Mater’’ University of Bologna, Policlinico S. Orsola, Via

Massarenti, 9, I-40138 Bologna, Italy.

E-mail: giulio.marchesini@unibo.it

Published online 3 June 2008 in Wiley InterScience

(www.interscience.wiley.com). DOI: 10.1002/eat.20555

VVC 2008 Wiley Periodicals, Inc.

International Journal of Eating Disorders 41:8 705–712 2008 705

REGULAR ARTICLE

samples showed that patients with weight phobiahave a higher premorbid body mass index (BMI)6,9

and are more likely to exhibit binge eating.9 Themain limitations of these studies are the use of self-administered questionnaires (with the risk of denialanswers) or of nonstandardized interviews, andthere are no data on the impact of weight restora-tion on the fear of weight gain and on the concernsabout shape and weight.

The outcome of treatment in underweightpatients without the over-evaluation of shape andweight has been assessed only in one naturalisticprospective study. The study evaluated consecutivepatients treated in an eating disorder inpatientunit, where they received a comprehensive multi-modal treatment including individual psych-otherapy, family therapy, group therapy, nursingmanagement, and nutritional counseling. Patientswithout the morbid fear of weight gain and bodysize distortion at admission recovered more rapidly,were less likely to lose weight after discharge, andhad a lower cumulative risk for developing bingeeating in comparison with classical AN.11

The present report was aimed at describing theclinical characteristics of underweight EDNOSpatients without over-evaluation of shape andweight (EDNOS-W) and at comparing these caseswith people with AN using standardized instru-ments. A second aim was to determine whether theabsence of the over-evaluation of shape and weightpersists after body weight recovery. Finally, wecompared EDNOS-W cases with people with AN interms of treatment outcome.

Method

Participants

The study sample comprises 88 consecutive

patients (81 women and 7 men; age range 13–50),

admitted to the eating disorder inpatient unit of Villa

Garda Hospital (Northern Italy) between November

2003 and November 2005. The patients were referred

from all over Italy by general practitioners or by out-

patient eating disorder specialists. Patients were

included if they met the following criteria: (a) BMI �17.5 kg/m2; (b) no menstrual periods in the three

months before assessment or on oral contraceptives;

(c) aged 12–65 years; (d) either failed less intensive,

outpatient treatment or had an eating disorder of

clinical severity not manageable in an outpatient set-

ting. Patients with daily substance misuse, acute

psychotic disorders, severe weight loss secondary to

severe clinical depression or organic illness were not

included. The inclusion and exclusion criteria listed

above were evaluated during an eligibility interview

completed by a senior specialist in the field (RDG).

The research was reviewed and approved by the insti-

tutional review board of Villa Garda hospital, and all

participants (or their legal guardian for the 17

patients less than 18 years old) gave written informed

consent.

Inpatient Treatment Protocol

The program has been described in details else-

where.17 The treatment was derived from the trans-

diagnostic cognitive behavior theory and treatment of

eating disorders,18 but was adapted to make it suitable

for an inpatient setting. The treatment is manual-

based,19 lasts 20 weeks (13 for inpatients followed by

7 weeks of residential day-hospital), and is divided

into three stages. In Stage 1 (week 1–4) the focus is on

engaging and educating the patient, creating a person-

alized formulation of the disorder, obtaining maximal

early behavior change, including the initiation of

weight regain. In Stage 2 (week 5–17) the content is

dictated by the patient’s psychopathology. In AN cases

the treatment addressed the over-evaluation of control

over eating, shape, and weight, whereas in EDNOS-W

cases it only addressed the over-evaluation of control

over eating together with food avoidance and other

dietary rules. In addition, patients—particularly the

EDNOS-W cases—are encouraged to reduce their

undue attention to abdominal symptoms during and

after meals. External mechanisms maintaining the dis-

ease may also be tackled in subgroups of patients,

using one or more of the following modules: clinical

perfectionism, low self-esteem, mood intolerance,

interpersonal difficulties. During this stage most of the

underweight patients reach their target BMI range and

start the weight maintenance period. In Stage 3 (week

18–20) the focus is on maintaining progress after

treatment end and on organizing the out-patient

follow-up.

The treatment was provided by a multidisciplinary

team composed of physicians, psychologists, dieticians,

and nurses. A unique aspect of treatment is that all the

therapists are trained in the transdiagnostic cognitive

behavior theory and therapy for eating disorders.

Measures

Data collection included weight and height measure-

ment, a detailed medical record on a standardized case

report form, a face-to-face structured eating disorder

diagnostic interview, and a package of questionnaires to

evaluate specific eating disorder psychopathology, gen-

eral psychopathology, and personality. All measurements

DALLE GRAVE ET AL.

706 International Journal of Eating Disorders 41:8 705–712 2008

were done on the first day of admission and were

repeated on the last day of treatment.

The medical records were completed by a physician

during a direct interview. They comprised demographic

and family data and a detailed medical and eating disor-

der history, including specific information on the age of

eating disorder onset, and on maximum and minimum

weight.

Weight (to the nearest 100 g) was measured on a cali-

brated balance and height (to the nearest 0.5 cm) by a

stadiometer. Patients were measured with underwear

and without shoes.

The eating disorder examination (EDE) 12.0 D20 was

used to generate operational definitions of AN and

EDNOS-W according to DSM-IV (Table 1). EDE is an in-

vestigator-based interview that assesses the frequency of

key behavioral and attitudinal aspects of eating disorders

during the preceding 4 weeks (28 days). When EDE is

used to elicit diagnoses, relevant events in the preceding

2 months (months 2 and 3, respectively) should also be

recorded. In the present study we used a validated Italian

translation of EDE,21 completed by a senior specialist in

the field (RDG).

EDE evaluates the major areas of specific eating disorder

psychopathology on four subscales: Restraint, eating con-

cern, shape concern, and weight concern. Inter-rater reli-

ability has been estimated to be 0.97–0.99.22 The four sub-

scales have good discriminant validity in distinguishing

between individuals with eating disorders and controls,23,24

and the weight concern and shape concern subscales have

good discriminant validity in distinguishing between

people with eating disorders and restrained eaters.22

General Psychopathology

The Beck Depression Inventory (BDI)25 was used to

assess the presence and severity of depression and per-

sonal distress. This BDI has excellent internal reliability,

good test–retest reliability, and good criterion validity.25

The state-trait anxiety inventory (STAI Form Y-1)26 was

used to measure trait levels of anxiety. This measure has

good internal consistency27 and good concurrent valid-

ity.28 Both BDI and STAI have been validated in their

Italian version.29,30

The temperament and character inventory (TCI)31 was

used to evaluate personality characteristics. TCI is a

temperament and character inventory based on a psycho-

biologic model of personality. This model includes four

temperament and three character dimensions.31,32 The

temperamental dimensions are novelty seeking, harm

avoidance, reward dependence, and persistence. The

character dimensions are self-directedness, cooperative-

ness, and self-transcendence. The TCI has good internal

consistency,31,33 inter-tester reliability, and test–retest reli-

ability31 and has been validated in its Italian version.34

Statistical Analyses

Statistical analyses were conducted by SPSS Version 11.0

(SPSS, Chicago), StatView 5.0 (SAS Institute, Cary, NC) and

STATA version 9.0. Continuous variables were categorized

as mean6 SD (median for non-normally distributed varia-

bles) and categorical variables as frequency and percent-

age. Weight (in kg) and height (in m) data were trans-

formed into BMI units (kg/m2) to allow comparison

between genders. The basal clinical characteristics of AN

and EDNOS-W cases were tested for differences using

T-test or Mann–Whitney U test for continuous data (for

normally or non-normally distributed data respectively—

Shapiro–Wilk normality test) and v2 tests for categorical

data. Changes between pre and post-treatment values were

tested for significance by Wilcoxon or sign tests. The com-

parison of pre and post-treatment changes between AN

and EDNOS-W cases were tested by v2 tests for categoricaldata and Mann–Whitney U test for continuous data. Since

five sets of variables were tested in the analysis (clinical,

historical, general, and eating disorder psychopathology,

personality), the significance limit was calculated accord-

ing to Duncan’s multiple range to p0 ¼ 1�ffiffiffiffiffiffiffiffiffiffiffiffiffiffiffið1� pÞðn�1Þ

p,35

TABLE 1. Operational definitions of the eating disorder examination for the diagnosis of anorexia nervosaand eating disorder NOS-Wa, according to DSM-IV1

Anorexia Nervosa EDNOS-Wa

A body mass index � 17.5 kg/m2 (DSM-IV criterion A) A body mass index � 17.5 kg/m2 (DSM-IV criterion A)A rating of 1 on the EDE item ‘‘maintained low weight’’

(DSM-IV criterion A)A rating of 1 on the EDE item ‘‘maintained low weight’’ (DSM-IV

criterion A)A rating �4 in the EDE item ‘‘fear of weight gain’’ in each of the 3

months prior assessment (DSM-IV criterion B)A rating\4 in the EDE item ‘‘fear of weight gain’’ in each of the three

months prior assessmentA rating �4 in the EDE item ‘‘importance of weight’’ or ‘‘importance

of shape’’ in each of the of the 3 months prior assessment(DSM-IV criterion C)

A rating\4 in the EDE item ‘‘importance of weight’’ and on the EDEitem ‘‘importance of shape’’ in each of the of the 3 months priorassessment

A rating of 0 or 44 in the EDE item menstruation (no period in the3 months before assessment or on oral contraceptives)(DSM-IV criterion D)

A rating of 0 or 44 on the EDE item menstruation (no period in the 3months before assessment or on oral contraceptives) (DSM-IVcriterion D)

a Eating disorder not otherwise specified without the over-evaluation of shape and weight.

UNDERWEIGHT EDNOS OR ATYPICAL ANOREXIA?

International Journal of Eating Disorders 41:8 705–712 2008 707

where p5 .05 and n5 5. The final critical value of signifi-cance was therefore set at 0.01.

Results

Clinical Characteristics of EDNOS-W Cases

and Comparison with AN Cases

The EDE-based operational DSM-IV diagnosis ofparticipants was AN in 71 cases (80.7%), andEDNOS-W in 17 (19.3%) cases.

The clinical characteristics of the full sample andof the two diagnostic subgroups are described inTable 2. Most EDNOS-W cases were females, sin-gles in their twenties, with a longstanding durationof the eating disorder (66.9 6 67.8 months). Theywere severely underweight, but their EDE ratingindicated the absence of the over-evaluation ofshape and weight that characterized the pure casesof AN.

The most frequent reason for eating restraintreported by EDNOS-W cases was the presence ofgastric or colonic symptoms (e.g., bloating, nausea,

TABLE 2. Clinical characteristics of participants with eating disorders included in the study(mean (SD) or *number of cases (%) or 8median)

All cases (N5 88) EDNOS-Wa (N5 17) AN (N5 71)EDNOS-W versus ANTest Statistics, p value

Age (years) 25.3 (9.0) 24.5 (9.3) 25.5 (0.1) z 520.54, p 5 .588Current BMI (kg/m2) 14.4 (1.6) 14.3 (1.5) 14.4 (1.6) t 520.21, p5 .831Female gender* 81 (92.0) 16 (94.1) 65 (91.5) v2 5 0.03, p5 .854Education* v2 50.53, p 5 .465Elementary school 2 (2.3) 1 (5.9) 1 (1.4)Junior high school 27 (30.7) 4 (23.5) 23 (32.4)Senior high school (reference) 50 (56.8) 11 (64.7) 39 (54.9)Degree 7 (8.0) 1 (5.9) 6 (8.5)Other 1 (1.1) 0 1 (1.4)

Parents status* v2 52.44, p 5 .118Single (reference) 71 (80.7) 16 (94.1) 55 (77.5)Married 12 (13.6) 1 (5.9) 11 (15.5)Separated/Divorced 3 (4.6) 0 3 (5.6)

Historical variablesAge at onset of eating disorder (years) 17.4 (5.8) 19.9 (7.9) 16.8 (5.1) z 521.24, p 5 .215Duration of eating disorder (months) 88.2 (92.9) 66.9 (67.8) 93.2 (97.6) z 521.10, p 5 .272No. of previous inpatient treatments 2.2 (2.9) 1.0 (1.7) 2.5 (3.1) z 521.85, p 5 .064Maximum BMI (kg/m2)b 21.1 (3.6) 19.9 (2.7) 21.4 (3.7) z 521.46, p 5 .144Minimum BMI (kg/m2)b 13.5 (1.7) 13.7 (1.4) 13.4 (1.7) t5 0.72, p5 .473Pre-morbid BMI (kg/m2) 20.4 (3.1) 19.2 (2.1) 20.6 (3.2) z 521.39, p 5 .163

Eating disorder psychopathologyOverall severity (global EDEc) 3.4 (1.8) 1.6 (1.0) 3.9 (0.9) z 525.77, p\ .001Dietary restraint (subscalec) 3.6 (1.6) 1.9 (1.4) 4.0 (1.4) z 524.69, p\ .001Eating concern (subscalec) 3.1 (1.5) 1.5 (1.3) 3.5 (1.3) z 524.49, p\ .001Shape concern (subscalec) 3.6 (1.3) 1.6 (1.1) 4.1 (0.8) z 525.80, p\ .001Weight concern (subscalec) 3.5 (1.8) 1.3 (1.1) 4.0 (1.5) z 525.49, p\ .001

Eating disorder behaviorObjective bulimic episodes* 25 (28.4) 2 (11.8) 23 (32.4) v2 5 2.87, p5 .090If present, episodes/28 days8 21.0 39.0 20.0 z 520.80, p 5 .422

Subjective bulimic episodes* 58 (65.9) 9 (52.9) 49 (69.0) v2 5 1.58, p5 .209If present, episodes/28 days8 17.5 3.0 28.0 z 523.48, p 5 .001

Self-induced vomiting* 31 (53.2) 4 (23.5) 27 (38.0) v2 5 1.26, p5 .261If present, episodes/28 days8 44.0 16.0 56.0 z 521.07, p 5 .286

Laxative misuse* 19 (21.6) 2 (11.8) 17 (23.9) v2 5 1.20, p5 .273If present, episodes/28 days8 28.0 14.5 28.0 z 521.07, p 5 .286

General psychopathologyBeck Depression Inventory 29.8 (14.2) 26.9 (15.5) 30.5 (13.9) t 520.94, p5 .349State-Trait Anxiety Inventory 57.2 (14.7) 57.6 (15.1) 57.1 (14.7) z 520.01, p 5 .923

Personality (TCI)d

Novelty Seeking 17.3 (5.4) 17.0 (5.0) 17.3 (5.6) z 520.34, p 5 .731Harm avoidance 22.2 (6.5) 22.2 (6.3) 22.2 (6.6) z 520.01, p 5 .991Reward dependence 14.7 (3.6) 15.1 (3.9) 14.6 (3.6) z 520.57, p 5 .569Persistence 5.4 (1.7) 5.6 (1.5) 5.3 (1.7) z 520.53, p 5 .598Self-directedness 20.7 (8.5) 24.3 (9.0) 19.8 (8.2) z 522.05, p 5 .041Cooperativeness 30.3 (6.6) 33.0 (5.7) 29.7 (6.6) z 521.98, p 5 .048Self-transcendence 13.6 (6.0) 13.2 (6.9) 13.7 (5.8) z 520.50, p 5 .614

a Eating disorder not otherwise specified without the over-evaluation of shape and weight.b Since menarche occurred.c Eating Disorder Examination.24d Temperament and Character Inventory.31

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708 International Journal of Eating Disorders 41:8 705–712 2008

epigastric discomfort, fullness, abdominal pain,constipation, and diarrhea), exacerbated by foodingestion. Two patients reported that their exces-sive eating control and the fear of food started soonafter a test for food intolerance and the medicaladvice to eliminate a few specific foods.

No significant differences were demonstratedbetween EDNOS-W and AN cases, with the excep-tion of lower scores in all the four EDE subscalesand in global EDE in EDNOS-W cases, and a signifi-cantly lower number of subjective bulimic episodesin the individual with this clinical feature.

Treatment Outcome

Twelve EDNOS-W cases (70.6%) and 54 AN cases(76.1%) completed treatment and achieved a nor-mal body weight (BMI � 18.5 kg/m2) (Table 3). Inno EDNOS-W cases the normalization of bodyweight was associated with the appearance of theover-evaluation of shape and weight.

Both the drop-out rate (EDNOS-W, 29.4%; AN,23.9%) and the time to drop-out (EDNOS-W: me-dian 55 days, range 19–89; AN, median 40, range 7–79) were similar in the two groups. No significantdifferences emerged between AN and EDNOS-Wcases on BMI, eating disorder psychopathology,and general psychopathology treatment changes.By the end of treatment no significant differencesin BMI, eating disorder psychopathology, and

general psychopathology were present between thetwo diagnostic categories.

Conclusion

The study has four principal findings: (1) a non-negligible proportion of severe underweight casesadmitted to an eating disorder inpatient unit donot report an over-evaluation of shape and weight;(2) there are no significant clinical differences,except the reported severity of eating disorder psy-chopathology, between AN and EDNOS-W cases;(3) the lack of over-evaluation of shape and weightis not modified by normalization of body weight;(4) the outcome of severely underweight peoplewith EDNOS-W and AN is similar in response to acognitive behavior inpatient treatment.

The study has certain strengths. First, it assessedpresence of the over-evaluation of shape andweight using the EDE interview, one of the mostaccurate instruments for evaluating eating disorderpsychopathology. The operational EDE-based crite-ria adopted for the diagnosis of AN and EDNOS-Ware clearly described and give external validity toour results, at least within ethnic and culturalbounds. Second, it assessed treatment outcomeand the over-evaluation of shape and weight inEDNOS-W before and after body weight normaliza-tion using the same instrument. The over-evaluation

TABLE 3. Nutritional status, features of eating disorder and general psychopathology before and after treatment inthe completers of the two diagnostic subgroups (mean (SD) or *number of cases (%) or median8)

EDNOS-Wa (N5 12) AN (N5 54)

Pre-treatment Post-treatment Pre-treatment Post-Treatment

Body mass index (kg/m2) 14.2 (1.3) 19.8 (0.9)§ 14.4 (1.6) 19.3 (1.2)y

Eating disorder psychopathology (EDE)b

Overall severity 1.5 (1.0) 1.2 (1.1) 3.9 (0.9) 1.4 (0.9)y

Dietary concern 1.7 (1.2) 0.5 (0.6)§ 3.9 (1.3) 0.6 (0.8)y

Eating concern 1.4 (0.9) 1.0 (1.2) 3.5 (1.3) 1.2 (1.0)y

Shape concern 1.5 (1.2) 1.8 (1.6) 4.1 (0.9) 2.2 (1.3)y

Weight concern 1.2 (1.2) 1.5 (1.3) 3.9 (1.5) 1.8 (1.3)y

Eating disorder behaviorObjective bulimic episodes* 2 (16.7) 0 19 (35.2) 3 (5.5)y

If present, episodes/28 days8 39.0 / 14.0 5.0Subjective bulimic episodes* 7 (58.3) 5 (41.7) 38 (70.4) 18 (33.3)y

If present, episodes/28 days8 3.0 10.0 28.0 7.5Self-induced vomiting* 3 (25.0) 0 21 (38.9) 6 (11.1)y

If present, episodes/28 days8 22.0 / 56.0 3.0Laxative misuse* 2 (16.7) 1 (8.3) 14 (25.9) 0If present, episodes/28 days8 14.5 12.0 30.0 /

General psychopatologyBeck depression inventory 29.3 (17.4) 17.4 (15.1) 30.4 (14.2) 15.3 (11.7)y

State-trait anxiety inventory (form-Y) 56.6 (15.8) 50.8 (14.9) 56.7 (14.6) 49.1 (12.6)§

Superscripts indicate the significance of difference between pre- and post-treatment values: yp\ .001; §p\ .01.a Eating disorder not otherwise specified without the over-evaluation of shape and weight.b Eating Disorder Examination.24

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International Journal of Eating Disorders 41:8 705–712 2008 709

of shape and weight did not change, which providesan important clinical result rarely evaluated by pre-vious studies.

A previous inpatient study found a 26% preva-lence of participants without morbid fear of weightgain and body size distortion in underweight eatingdisorder patients.11 Our study found a similar fig-ure (19.3%) of EDNOS-W, confirming that this cate-gory is relatively common also in Western inpatientsettings.

The severity of disorder and the clinical featuresof EDNOS-W cases, with the exception of the eatingdisorder psychopathology, were similar to those ofAN cases. Although a study in a nonwestern samplefound that underweight patients with weight phobiahad a higher premorbid BMI,9 this difference wasnot found in our study and in another Westernstudy.10 Minor differences were observed in the fre-quency of behaviors associated with the eating dis-order psychopathology, EDNOS-W cases being char-acterized by a lower frequency of subjective bulimicepisodes. Very few data on the effect of weight nor-malization on the fear of weight gain and on theover-evaluation of shape and weight in inpatientEDNOS-W cases are available. In a group of‘‘atypical’’ patients with AN, only 10% developedweight phobia and body image disturbance duringfollow-up.11 In our experience, the absence of theover-evaluation of shape and weight also persistsafter complete weight restoration, and is a stablefeature of these atypical cases. We cannot exclude atreatment effect, but the possibility that treatmentmay prevent the appearance of the over-evaluationof shape and weight is very unlikely in our setting.First, the cognitive behavioral strategies used in thissubgroup of patients specifically focused on the im-portance of controlling eating per se, and not on theover-evaluation of control over shape and weight.Second, treatment was associated with a rapidincrease in body weight, a condition that usuallytriggers the concerns over shape and weight inunderweight eating disorder patients.

EDNOS-W and AN cases had the same drop-outrate and time-to-dropout, and similar changes inBMI, eating disorder psychopathology, and generalpsychopathology in response to a cognitive behav-ior inpatient treatment. At discharge no significantdifferences were present between the two groupsas to BMI, eating disorder behaviors and psychopa-thology, and general psychopathology. The onlyprevious study on this issue showed that under-weight patients with the absence of weight phobiaand body image disturbance had lower weight dropafter discharge in comparison with typical AN, anda lower cumulative risk of binge eating.11

The study was not designed to test the rea-son(s) accounting for the lack of over-evaluationof shape and weight in our EDNOS-W, whichmight be either the results of denial or minimiza-tion, or represent a real psychological character-istic of these individuals.

Denial is a common process in AN,36,37 and it hasbeen defined as any consciously or unconsciouslymotivated omission, concealment, or misrepresen-tation of behavior or internal experience,38 andthere is no general agreement on the definition,cause, and mechanisms of this complex process.

An alternative to denial is that our EDNOS-Wcases really do not have the fear of weight gain andconcerns over shape and weight. Most of ourEDNOS-W cases reported that their main reasonsto reduce food intake was the presence of gastric orcolonic symptoms, exacerbated by food ingestion.This finding raises the question as to whether theEDNOS-W cases should be sub-divided into twosubgroups: (a) participants who restrain for con-trolling shape and weight, and (b) participants whohave somatic complaints. The limited study sampleof our report does not allow any separate analysis.An alternative interpretation is to consider EDNOS-W participants as true cases of AN with a self-eval-uation largely or exclusively based on their abilityto control their eating per se.4

The onset of gastric or colonic symptoms mightbe associated with some forms of psychologicaldistress.39 A potential mechanism might bethrough corticotrophin-releasing hormone that, atleast in patients with irritable bowel disease, seemsto act centrally, modulating both gastrointestinalmotility and symptoms.40 In accordance with thecognitive behavior theory of AN, we propose thatwhen individuals with a need of self-control in gen-eral (i.e., a need to control various aspects of theirlives, such as work, sport, or other interests) start toreduce food intake to alleviate gastrointestinalsymptoms ‘‘the control over eating becomes prom-inent’’ (p. 4)41 because it is experienced as a ‘‘suc-cessful behavior in the context of perceived failurein all other areas of functioning’’ (p. 173)42 thatcannot be maintained under control. The gastroin-testinal symptoms could be also exacerbated by pe-culiar cognitive processes, such as paying an undueattention to abdominal sensation that normallypass unnoticed,18,20 and by the negative effects ofweight loss on gastric empting.39 These factors,associated with other cognitive and interpersonalreinforces,41 could also explain why the generalself-control becomes primarily focused on eating.

Unfortunately, EDE interview does not allow dif-ferentiate patients that deny or minimize symptoms

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710 International Journal of Eating Disorders 41:8 705–712 2008

from those who really do not have them. To over-come this limitation, it has been suggested to mod-ify a few items of the EDE, but there is lack ofevidence that asking questions in a different way orusing other instruments may help understandwhether a patient denies or minimizes symptoms.37

The study has certain limitations. First, samplesize was not based on a priori power analysis onthe clinical differences between AN and EDNOS-W.Previous data in the literature were carried out onsmall samples,10,11 making it difficult any correctcalculation. In our convenient sample, the largedifference in group size between AN and EDNOS-W reflects the clinical setting of a typical eating dis-order inpatient unit. Accordingly, our study shouldbe considered only exploratory and needs largervalidation. Second, the absence of a long follow-updoes not permit to evaluate if EDNOS-W have aless malignant course and outcome than typicalcases of AN, as suggested by a previous study.11

Third, it evaluated a single inpatient unit thatmainly treats adult patients. Future research onEDNOS-W should also focus on less severe cases ofEDNOS-W treated in outpatient settings.

In conclusion, the absence of significant clinicaldifferences, except the reported severity of eatingdisorder psychopathology, between AN and EDNOS-W cases, and the similar treatment outcomebetween the two groups give some preliminarysupport to the proposal to include the EDNOS-Wcases in the diagnosis of AN in the forthcomingDSM-V classification. We would agree with thisproposal for three main reasons. First, it will reducethe high prevalence of EDNOS within the spectrumof eating disorders, favoring research in this area.Second, it will facilitate inpatient treatment of mostsevere cases, considering that health care systemsbase their hospital payments on the clinical impactof diseases with a definite diagnosis, within catego-ries of similar resource use. Finally, from thepatients’ side, it will improve patients’ awareness oftheir disorder, giving it the name of a community-accepted diagnosis, not an idea of uncertainty. Wehope that this proposal will soon be supportedby other studies in different settings, with longerfollow-up.

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