This post is about a journal article that describes mortality rates in
populations of persons with eating disorders. It is sort of
about that. The article is in the APA green journal, which is not
openly accessible. Only the abstract is free. Usually I
don’t write about closed-access articles. But this is different,
because I am not going to do a traditional post about a peer-reviewed
article. You don’t need to have access to the whole article to
get the point.
Mortality in Bulimia Nervosa and Other Eating Disorders
Am J Psychiatry 2009; 166:1342-1346
(published online October 15, 2009; doi: 10.1176/appi.ajp.2009.09020247)
OBJECTIVE: Anorexia nervosa has been consistently
associated with increased mortality, but whether this is true for other
types of eating disorders is unclear. The goal of this study was to
determine whether anorexia nervosa, bulimia nervosa, and eating
disorder not otherwise specified are associated with increased
all-cause mortality or suicide mortality. METHOD: Using computerized
record linkage to the National Death Index, the authors conducted a
longitudinal assessment of mortality over 8 to 25 years in 1,885
individuals with anorexia nervosa (N=177), bulimia nervosa (N=906), or
eating disorder not otherwise specified (N=802) who presented for
treatment at a specialized eating disorders clinic in an academic
medical center. RESULTS: Crude mortality rates were 4.0% for
anorexia nervosa, 3.9% for bulimia nervosa, and 5.2% for eating
disorder not otherwise specified. All-cause standardized mortality
ratios were significantly elevated for bulimia nervosa and eating
disorder not otherwise specified; suicide standardized mortality ratios
were elevated for bulimia nervosa and eating disorder not otherwise
specified. CONCLUSIONS: Individuals with eating disorder not
otherwise specified, which is sometimes viewed as a “less severe”
eating disorder, had elevated mortality risks, similar to those found
in anorexia nervosa. This study also demonstrated an increased risk
of suicide across eating disorder diagnoses. [emphasis added]
Note that the study population was at “a specialized eating disorders
clinic in an academic medical center.” It is likely that this
represents a relatively more severely-afflicted subpopulation. I
don’t think you see mortality rates like that in primary care clinics,
or college counseling centers.
Having said that, those mortality rates are rather daunting.
One of my points is this: a while back, a commenter proclaimed that all
NOS (not otherwise specified) diagnoses should be banned, or something
like that. While I understand the sentiment, the fact is, that
these diagnoses have a valid purpose. Used properly, they can
improve patient care.
Sometimes NOS diagnoses are thought of as “garbage can” categories:
labels to use when you can’t really tell what is gong on, or labels to
use when the condition is not as serious as the “real” diagnoses.
Perhaps they are used that way, sometimes. But as the study
shows, it is a dangerous misconception to think that an NOS
diagnosis is not serious.
Illnesses are what they are, and there is no law of nature that says
that disease have to fit in the little boxes that we make for
them. Some people have illnesses that do not have precise
corresponding diagnoses. See, for example, this article (pdf)
for a case report of anti-NMDA receptor psychosis that initially looks
a lot like manic psychosis. There is not a specific name for this
condition. But it clearly exists, and it clearly is
serious. At some point, it would have been entirely reasonable
for the treating physician to call it “Psychotic Disorder NOS
My second point is that eating disorders in general are serious.
Not all cases are terrible. Some people get better with a short
course of psychotherapy and a little bit of education. Some get
better with no treatment at all. But then, some people die from
it. There are not a lot of specialty clinics to deal with
this. Insurance companies killed many of them, including one that
I used to work in. Others were allowed to whither on the vine, so
to speak, by academic departments that chose to put their resources
elsewhere (another where I used to work).
It doesn’t help that these are problems that afflict mostly women, and
that it is easy for judgmental persons to view them as moral failings,
or as illnesses that people choose to have. The implication is
that a person could “snap out of it” if they really wanted to.
This also is a dangerous misconception.