What Is Other Specified Feeding and Eating Disorder (OSFED)?

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Other specified feeding and eating disorder (OSFED), previously known as eating disorder not otherwise specified (EDNOS), is a classification of eating disorders in which a person has a significant eating disorder, but does not meet all of the criteria for anorexia nervosa, bulimia nervosa, or binge eating disorder.

While less commonly discussed, OSFED is the most common presentation of an eating disorder and is considered at least as harmful, disruptive, and dangerous as the more well-known eating disorders such as anorexia nervosa and bulimia nervosa.

Young girl eating from bowl while sitting on kitchen floor

Mayur Kakade / Getty Images

Symptoms

Symptoms of OSFED overlap quite a bit with other eating disorders, including:

  • Anorexia nervosa
  • Bulimia nervosa
  • Binge eating disorder

With OSFED, the criteria are never fully met for any of the three.

What Are Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder?

Anorexia nervosa: Intentional calorie restriction leading to significantly low body weight, intense fear of gaining weight/becoming fat, and a disturbance in the way in which one's body weight or shape is experienced.

Bulimia nervosa: Recurrent episodes of binge eating, and recurrent episodes of inappropriate compensatory behavior, such as induced vomiting, the misuse of laxatives or diuretics, or excessive exercise. Both of these episodes occur at least once a week for three or more months.

Binge eating disorder: Recurrent episodes of binge eating that occur at least once a week for three months or longer.

Examples of presentation that can be specified using the designation of OSFED include:

Atypical Anorexia

When the criteria for anorexia nervosa are met, but the individual is "normal" or above average in weight, a diagnosis of atypical anorexia may be reached.

Bulimia Nervosa (of Low Frequency and/or Limited Duration)

A diagnosis of bulimia nervosa (of low frequency and/or limited duration) is reached when the criteria for bulimia nervosa is met, except for the specification that symptoms must be present at least once a week for three or more months.

This diagnosis allows for treatment to begin earlier, with the goal of increasing the chances of a successful outcome.

Binge Eating Disorder (of Low Frequency and/or Limited Duration)

As with bulimia nervosa (of low frequency and/or limited duration), binge eating disorder (of low frequency and/or limited duration) is deemed when a person meets the criteria for a diagnosis of binge eating disorder, except for the frequency and duration requirements of at least once a week for three or more months.

With both bulimia nervosa (of low frequency and/or limited duration), and with binge eating disorder (of low frequency and/or limited duration), a person's diagnosis can change if the frequency and duration criteria are met at a later time.

Purging Disorder

A person with purging disorder exhibits purging behaviors such as:

  • Vomiting
  • Excessive exercise
  • Using laxatives or diuretics in an effort to control their weight

The person does not experience binge eating.

Night Eating Syndrome

Night eating syndrome does not have specific criteria laid out in the most recent edition of DSM-5 but is considered a subtype of OSFED.

Night eating syndrome may be characterized by:

  • Repeated excessive eating after the evening meal
  • Waking up to eat
  • Feeling it is necessary to eat in order to sleep

The person is aware of the eating episodes, and the episodes cannot be explained by changes to their sleep/wake cycle, other eating disorders, or other mental health conditions.

Other Eating Disorders Associated With OSFED

While not included in these examples of OSFED, other eating disorders are sometimes included in the OSFED category. They are not in the DSM-5, but are recognized by many health care professionals. These include:

  • Orthorexia: An excessive fixation or obsession with "proper" or "healthful" eating.
  • Diabulimia: Misuse of insulin by a person with diabetes (usually type 1) with the goal of losing weight.

General symptoms of eating disorders that fall under the umbrella of OSFED include:

Emotional and Behavioral

  • Preoccupation with weight loss, dieting, control of food, calories, fat grams, body weight/shape and/or control of food
  • Skipping meals or taking small portions
  • Refusal to eat certain foods or groups/categories of foods (e.g. carbohydrates)
  • New food practices, including fad diets, or cutting out whole food groups/categories (no sugar, no carbs, no dairy, vegetarianism/veganism, etc.)
  • Food rituals, such as no foods touching, chewing a certain number of times, or only eating foods from a certain group (e.g. condiments)
  • Frequent dieting
  • Denial of hunger/feeling hungry
  • Drinking a lot of water or calorie-free drinks 
  • Comments about feeling fat, despite weight loss
  • Loose or layered clothing
  • Withdrawal from friends and activities 
  • Discomfort eating around others or eating in public
  • Preoccupation with perceived flaws in appearance, frequent mirror checks 
  • Recurring episodes of binge eating (eating a much larger amount of food during a short period of time than most individuals would eat under similar circumstances)
  • Feeling a lack of control over the ability to stop eating  
  • Indications of binge eating, such as large amounts of food disappearing in short periods of time, lots of wrappers, and other evidence of a lot of food being eaten 
  • Stealing, hoarding, or hiding food
  • Purges (self-induced vomiting, excessive exercise, misuse of laxatives or diuretics, etc.) with or without being preceded by a binge
  • Indications of purging behaviors, such as disappearing after meals (often to the bathroom), signs and/or smells of vomiting, or evidence of laxatives or diuretics 
  • Overuse of mouthwash, mints, and gum  
  • Rigid adherence to an excessive exercise regimen aimed at burning calories, which continues despite obstacles such as weather, fatigue, illness, or injury
  • Lifestyle schedules or rituals made to accommodate binge-and-purge sessions  
  • Extreme mood swings

Physical

  • Noticeable fluctuations in weight (gain and loss) 
  • Weight (usually) within the normal range or higher
  • Gastrointestinal issues such as constipation, abdominal pain, stomach cramps, or acid reflux
  • Bloating from fluid retention 
  • Swelling of the cheeks or jaw area/swelling around the area of salivary glands
  • Menstrual irregularities, including missing periods or only getting a period with the help of hormonal contraception
  • Abnormal test findings (anemia, low thyroid and hormone levels, low potassium, low blood cell counts, slow heart rate, etc.) 
  • Cold intolerance/feeling cold all the time
  • Cold, mottled hands and feet
  • Feet swelling 
  • Muscle weakness
  • Poor wound healing and/or impaired immune functioning 
  • Dizziness and/fainting
  • Sleep problems 
  • Lethargy, and/or excess energy 
  • Difficulty concentrating 
  • Calluses/cuts on the back of the hands and knuckles (from self-induced vomiting) 
  • Dental problems such as discolored/stained teeth, enamel erosion, cavities, and tooth sensitivity
  • Dry skin 
  • Yellow skin (often seen when large amounts of carrots are consumed) 
  • Dry, brittle nails 
  • Fine hair on the body (lanugo)
  • Thinning, dry, and brittle/or hair on the head

Risks and Complications

Despite the misconception that it is a "milder" eating disorder, the harmful effects and complications of OSFED are just as serious as with other eating disorders and can be life-threatening.

One study found a mortality rate of 5.2% for OSFED, which was higher than that of anorexia nervosa and bulimia nervosa. These serious complications can occur even if the person with OSFED does not become underweight.

Cardiovascular

  • Drop in pulse and blood pressure due to inadequate nutritional and fluid intake
  • Electrolyte (potassium, sodium, and chloride) imbalances caused by purging (vomiting, diuretics, drinking excessive water), which can lead to irregular heartbeats, seizures, and cardiac arrest
  • Reduced resting metabolic rate (the number of calories burned while completely at rest), as the body tries to conserve energy

Gastrointestinal

  • Gastroparesis (slowed digestion)
  • Interference with normal stomach emptying and the digestion of nutrients
  • Stomach pain, bloating, nausea, vomiting, constipation
  • Fluctuations in blood sugar
  • Intestinal blockages (caused by solid masses of undigested food)
  • Bacterial infections
  • Feeling full after a small amount of food
  • A ruptured stomach (a life-threatening emergency) due to binge eating
  • A ruptured esophagus (a life-threatening emergency) due to vomiting
  • Sore throat, hoarse voice (due to vomiting)
  • Swollen salivary glands from vomiting episodes over a long period of time
  • Pancreatitis (inflammation of the pancreas)
  • Problems such as intestinal perforation, infection, or poisoning, caused by eating non-food items

Neurological

  • Problems such as difficulty concentrating or obsessing about food due to insufficient energy (calories) in the brain
  • Sleep difficulties resulting from extreme hunger or fullness at bedtime
  • Damage to the peripheral nerves (can cause numbness in hands, feet, and extremities)
  • Seizures and muscle cramps caused by extreme dehydration or electrolyte imbalance
  • Fainting or dizziness, especially upon standing, from insufficient amount of blood able to be pushed to the brain
  • Increased risk of sleep apnea (a sleep condition in which someone repeatedly stops breathing while sleeping) for people who are at higher body weights

Endocrine (Hormones)

  • Lowered sex hormones, which can result in problems with menstruation, and cause significant bone loss, raising the risk for fractures
  • Insulin resistance from binge eating (over time), which can lead to type 2 diabetes
  • A drop in core body temperature (potentially resulting in hypothermia) due to lack of energy (calories)
  • High cholesterol levels due to starvation (not an indication to restrict dietary fats, lipids, and/or cholesterol)

Other Complications

  • Kidney failure resulting from severe, prolonged dehydration
  • Fatigue, weakness, and shortness of breath caused by anemia (too few red blood cells, and/or iron deficiency)
  • Reduction in white blood cells (infection-fighting cells) due to malnutrition

Causes

While there is no definitive cause for OSFED, a number of factors are thought to contribute to an increased risk of developing an eating disorder.

Biological

  • Genetics
  • Family history of eating disorders or mental illness
  • Temperament
  • Neurobiology (involved in the regulation of internal hunger and satiation signals)

Psychological

  • Low self-esteem or problems with body image
  • A history of trauma or abuse (particularly sexual abuse)
  • Stress
  • Feelings of loneliness, inadequacy, or loss of control
  • Difficulty adapting to change
  • Discomfort with developmental milestones (or sexuality)
  • Experiencing other mental health conditions, such as anxiety, depression, obsessive-compulsive disorder, borderline personality disorder, substance use disorder, or other eating disorders

Sociocultural (Societal Norms)

  • Pervasive imaging and messaging about body image, equating thin with good
  • Normalization of diet culture and dieting
  • The misconception that healthy living equates to weight loss
  • Negative and false narratives that portray obesity as a signal of laziness or other undesirable traits
  • The societal creation of an ideal body type and the pressure to achieve and maintain it

Diagnosis

To meet the criteria of an OSFED diagnosis as defined by the DSM-5, a person must exhibit feeding or eating behaviors that cause clinically significant distress and impairment in social, occupational, or other areas of life, but do not meet the full criteria for any of the other eating disorders.

A diagnosis of OSFED typically begins with a visit to the person's primary health care provider. After discussing symptoms, medical and family histories, and feeding/eating practices, the provider may run lab tests.

The primary care provider will either make a diagnosis themselves or refer the person to an eating disorder specialist for further evaluation.

Treatment

Treatment for OSFED depends on which eating disorder the symptoms most closely resemble, and can take several approaches.

Therapy

Therapy for OSFED might include:

  • Psychotherapy
  • Behavioral therapy
  • Individual therapy
  • Group therapy
  • Family therapy

Medication

Medication may be used, particularly if there is a co-existing additional mental health condition such as anxiety or obsessive-compulsive disorder.

Education

Learning about OSFED is an important step in treatment. It can help a person understand why they feel and behave as they do, recognize triggers, and be able to explain their condition to the important people in their lives.

Physical Health Stabilization

In order to address the mental health part of OSFED, physical health needs to be achieved and maintained. This, along with other treatments, is often done through a clinic or hospital, in one of three types of programs:

  • Inpatient: Hospital admission (uncommon with OSFED)
  • Outpatient: Visits to the hospital or clinic for treatment appointments, but is not admitted
  • Day Patient: Days are spent at the hospital or clinic, but not nights. More intensive than outpatient, with the goal of avoiding the need for inpatient care

Nutrition Support

This area of treatment focuses on learning healthy feeding and eating practices, and ensuring the person with OSFAD is receiving proper nutrition.

In more severe cases, meals may be supervised.

Coping

Receiving support is one of the best ways to help cope while receiving treatment for and living with OSFED. This support can look like:

  • Online support groups
  • Group meetings with other people living with OSFED
  • Workshops
  • Family support groups, in which loved ones learn how they can help a person who is experiencing OSFED
  • Helplines for people with eating disorders

Help Is Available

If you or a loved one are coping with an eating disorder, contact the National Eating Disorders Association (NEDA) Helpline for support at 1-800-931-2237. 

For more mental health resources, see our National Helpline Database.

A Word From Verywell

While lesser known than eating disorders such as anorexia nervosa and bulimia nervosa, OSFED is at least as serious, as common, and as life-threatening as other eating disorders.

Because people with OSFED are not typically underweight, it often goes unrecognized or downplayed by health care professionals and by people who are living with OSFED. If you are experiencing symptoms of OSFED, even if you are within a normal weight range or above, speak with your health care provider right away—the earlier treatment starts the better.

Like other eating disorders, OSFED can be hard work to overcome—but you and your health are worth it.

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Article Sources
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