Other Specified Feeding and Eating Disorder (OSFED): What You Need to Know

Other specified feeding and eating disorder (OSFED), formerly known as eating disorder not otherwise specified (EDNOS) in previous versions of the DSM, is less well known than higher-profile diagnoses like anorexia nervosa, bulimia nervosa, and binge eating disorder. Despite its lack of public attention, as a catch-all category that includes a wide range of symptoms.

OSFED is actually the most common eating disorder diagnosis, representing an estimated 32% to 53% of all people with eating disorders. It was developed to encompass people who did not meet the full diagnostic criteria for anorexia nervosa or bulimia nervosa but still had a significant eating disorder.

Symptoms

Like other eating disorders, symptoms include behavioral, emotional, and physical aspects.

Behavioral symptoms of OSFED often include a preoccupation with weight, food, calories, fat grams, dieting, and exercise, including:

• Refusing to eat certain foods (restriction against categories of food like no carbs, no sugar, no dairy)
• Frequent comments about feeling “fat” or overweight
• Denial of feeling hungry
• Fear of eating around others
• Binge eating
• Purging behaviors (frequent trips to the bathroom after meals, signs and/or smells of vomiting, wrappers or packages of laxatives or diuretics)
• Food rituals (such as excessive chewing or not allowing foods to touch)
• Skipping meals or eating small portions at regular meals
• Stealing or hoarding food
• Drinking excessive amounts of water (or non-caloric beverages)
• Using excessive amounts of mouthwash, mints, and gum 
• Hiding body with baggy clothes 
• Exercising excessively (despite weather, fatigue, illness, or injury) 

The emotional symptoms of OSFED can include:

• Low self-esteem
• Depression
• Strong need for approval
• Anxiety
• Little motivation to engage in relationships or activities
• Easily irritated
• Extremely self-critical

The physical symptoms of OSFED include:

• Noticeable fluctuations in weight
• Gastrointestinal symptoms (such as stomach cramps, constipation, and acid reflux)
• Menstrual irregularities and amenorrhea (missing periods)
• Difficulty concentrating
• Anemia
• Low thyroid and hormone levels
• Low potassium
• Low blood cell counts
• Slow heart rate
• Dizziness
• Fainting/syncope
• Feeling cold all the time
• Sleep troubles
• Cuts and calluses across the top of finger joints (a result of inducing vomiting)
• Dental problems (such as discolored teeth, enamel erosion, cavities, and tooth sensitivity)
• Dry skin
• Dry and brittle nails
• Swelling around the area of salivary glands
• Fine hair on the body
• Thinning of hair or dry and brittle hair
• Muscle weakness
• Yellow skin (from eating large quantities of carrots)
• Cold, mottled hands and feet
• Swelling of feet
• Poor wound healing
• Impaired immune system

Causes

OSFED is a complex illness, and while we don't know the exact cause, genetics and environmental factors both appear to play a role. When it comes to eating disorders, it's often said that "genes load the gun, but the environment pulls the trigger.”

In other words, in those who are genetically vulnerable, certain situations and events contribute to or trigger the development of an eating disorder.

Environmental factors include:

• Abuse
• Bullying
• Dieting
• Weight stigma
• Illness
• Puberty
• Stress
• Life transitions
• Media influence

Diagnosis

One problem with psychiatric diagnoses, in general, is that many patients do not fit neatly into the typical diagnostic categories. It’s not always clear-cut. Sometimes people meet most but not all of the criteria for a diagnosis.

In the case of eating disorders, a person who does not qualify for a specific eating disorder diagnosis would be classified as OSFED. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) includes five examples of patients who would be classified as OSFED:

• Atypical anorexia nervosa: The person meets many but not all of the criteria for anorexia nervosa. For example, they may restrict food intake and display other features of anorexia nervosa without meeting the low weight criteria.
• Subthreshold bulimia nervosa: The person may meet most of the criteria for bulimia nervosa, but the binge eating and/or purging behaviors occur at a lower frequency and/or are of a shorter duration than required for a bulimia diagnosis.
• Subthreshold binge eating disorder: The person meets the criteria for binge eating disorder, but binge eating occurs at a lower frequency and/or is of a limited duration.
• Purging disorder: The person engages in calorie purging (by vomiting, misuse of laxatives or diuretics, and/or excessive exercising) to influence weight or body shape but does not binge eat, which is the factor that distinguishes this disorder from bulimia nervosa. 
• Night eating syndrome: The individual engages in recurrent episodes of night eating, eating after awakening from sleep, or engages in excessive food consumption after the evening meal, and there is awareness and recall of the eating.

Many of the people with OSFED have as severe an eating disorder as those who meet the criteria for clearly defined disorders like anorexia nervosa, bulimia nervosa, and binge eating disorder. OSFED, along with unspecified feeding or eating disorders (UFED), replaces the EDNOS category.

People with OSFED will experience health risks similar to those of other eating disorders, including:

• Weakened bones
• Loss of brain mass
• Cardiovascular problems
• Gastrointestinal problems (chronic constipation or diarrhea)
• Dental issues from self-induced vomiting
• Dry skin
• Loss of hair
• Loss of menstrual cycle, amenorrhea
• Increased risk of infertility
• Kidney failure
• Hospitalization

At least one previous study showed the mortality rate for OSFED (at the time, known as EDNOS) was as high as for people who meet the defined thresholds for anorexia.

Furthermore, since eating disorder diagnoses are not stable over time, it is not uncommon for people to meet the diagnosis of OSFED on their way to a diagnosis of anorexia, bulimia, or binge eating disorder or on their way to recovery.

Treatment

Even if your symptoms and experience don't seem to fit a specific diagnosis, if you are experiencing distress related to eating, exercise, body shape, and weight, you should consult a professional as soon as possible. Research supports that early intervention makes a big difference in OSFED recovery. 

In general, treatment recommendations will be based on the eating disorder that most closely resembles your symptoms. For example, if you're mostly showing symptoms of lower frequency bulimia, your treatment plan will involve the same therapies and medications used for bulimia.

Medications

While there are no prescription drugs specifically designated to treat OSFED, there are drugs that can be used to help manage symptoms and co-occurring depression or anxiety.

• Anorexia: There is some limited evidence that second-generation antipsychotic medications (also called atypical antipsychotics), such as Zyprexa (olanzapine), can help lead to small weight increases. Benzodiazepines may also be prescribed to reduce anxiety before meals; however, there is limited evidence to support this practice, and benzodiazepines can become addictive.
• Binge eating disorder: There are three main drugs used in the treatment of BED, including Prozac (fluoxetine), an antidepressant; Topamax (topiramate), an anticonvulsant; and Vyvanse (lisdexamfetamine), an ADHD medication.
• Bulimia nervosa: SSRIs have been well-studied for the treatment of bulimia nervosa. In fact, Prozac (fluoxetine) is the only medication specifically approved by the Food and Drug Administration (FDA) for adults with bulimia nervosa. It's also common for other drugs, such as Topamax (topiramate), to be used off-label for bulimia.
• Night eating syndrome: SSRIs, including Paxil (paroxetine), Luvox (fluvoxamine), and Zoloft (sertraline), have been studied and used to treat night eating syndrome.
• Co-occurring disorders: Several different classes of antidepressants are also often prescribed to treat co-occurring depression or anxiety.

Medication is almost always used in conjunction with psychotherapy and nutrition therapy.

Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT) is one of the most successful treatments for bulimia nervosa and binge eating disorder and is also used to treat OSFED, especially in people who have symptom profiles similar to bulimia and BED.

CBT for eating disorders commonly includes the following:

• Self-monitoring via paper or apps
• Meal planning
• Delays and alternatives
• Regular eating
• Cognitive restructuring
• Limiting body-checking
• Food exposure
• Body image exposure
• Relapse prevention

Dialectical behavior therapy (DBT), a type of CBT that teaches skills to live in the moment, cope with stress, regulate emotions, and improve relationships, has also been found effective in people with eating disorders, especially in those with binge eating disorder and bulimia nervosa. In DBT, the patient and therapist work together to resolve the seeming contradiction between self-acceptance and change in order to bring about positive changes.

Family-Based Therapy

Family-based treatment (FBT) is a leading treatment for adolescent eating disorders, including OSFED. In FBT, therapists don't try to analyze why the eating disorder developed nor do they blame families for the disorders. Instead, FBT views the family as experts on the child and an essential part of the treatment team.

Nutritional Therapy

Nutritional therapy, which is conducted by a registered dietitian, can help someone with OSFED repair physical health and normalize food intake and behaviors. After a dietitian assesses your nutritional status, medical needs, and food preferences, they will help you plan meals.

Coping

Staying healthy physically and emotionally will go a long way toward helping you cope with an eating disorder. In addition to talking to a therapist or joining a support group (like Eating Disorders Anonymous), enlist a trusted friend or family member who can help you along your path to recovery.

Another productive way to cope is to identify a few healthy distractions you can turn to when you find yourself obsessing about food and weight or experiencing the urge to turn to disordered eating or behaviors. Here are a few to consider:

• Go for a walk
• Try a stretching class
• Practice mindfulness meditation
• Invest in an adult coloring book
• Start a journal
• Take up a new hobby, like painting or photography

Final Thoughts

Recovery from OSFED can be challenging, and while it will take courage, it is possible, especially with the right support system in place. There's no shame in getting professional help and reaching out to loved ones as you begin the journey toward a healthy relationship with food and yourself.