The Corpus Callosum

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 (298.9)." 

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.