Many people fit into a “gray area” when it comes to eating disorder behaviors. Perhaps they experience purging, but not bingeing. Or they show signs of bulimia, except their symptoms don’t occur as often. Or maybe they present with symptoms of multiple eating disorders, or they shift between diagnoses.
If you’re noticing behaviors that don’t fit neatly into the commonly-known eating disorders (like bulimia, anorexia, or binge eating disorder), that doesn’t mean you don’t have a diagnosis or aren’t “sick enough” to deserve care. Learning more about Other Specified Feeding and Eating Disorder, or OSFED, can be an empowering step.
OSFED is a more general eating disorder diagnosis with five common sub-categories:
- Purging disorder
- Binge eating disorder (of low frequency and/or limited duration)
- Bulimia nervosa (of low frequency and/or limited duration)
- Night eating syndrome
- Atypical anorexia
It’s important to note that these conditions used to fall under the term Eating Disorder Not Otherwise Specified, or EDNOS. OSFED has now replaced EDNOS as the clinically recognized term in the DSM-V. Let’s take a closer look at the signs and symptoms of each.
This type of OSFED describes when someone has repeated purging behavior, including self-induced vomiting or misuse of laxatives or diuretics, but doesn't experience episodes of binge eating.
For Jasmine Kelley, Peer Mentor at Equip, their purging began in an attempt to relieve anxiety, “I had no idea how quickly it would then become something I did to try to lose weight,” they say. “Learning that this was a real mental illness was the first real step toward recovery for me.”
Binge eating disorder (of low frequency and/or limited duration)
This sub-type of OSFED eating disorder is characterized by meeting all of the diagnostic criteria for binge eating disorder (BED), except that episodes of binge eating occur, on average, less than once a week or for less than 3 months.
Kirstin Quinn Siegel, LMFT and therapist at Equip, struggled with binge eating but didn’t feel like she met the full criteria for BED: “I saw so many people around me who also felt out of control around food, so that normalized what wasn’t normal.”
The reality is that “low frequency and/or limited duration” diagnoses can be just as serious, but people with these symptoms can often feel discouraged from getting help. As Nicky England, Peer Mentor at Equip, puts clearly, “Your struggle is just as valid. There’s no hierarchy of diagnoses, and all people deserve compassionate, effective, accessible care.”
Bulimia nervosa (of low frequency and/or limited duration)
This diagnosis applies to patients who demonstrate binge eating and compensatory behaviors characteristic of bulimia nervosa (BN), but these behaviors occur, on average, less than once a week or for less than 3 months. Binge eating is defined as a sense of loss of control while eating large amounts of food, and compensatory behaviors can look like excessive exercising, self-induced vomiting, or misuse of diuretics.
Just like binge eating disorder (of low frequency and/or limited duration), this diagnosis doesn’t mean symptoms aren’t as serious or deserving of treatment.
Night eating syndrome
This is a specific type of OSFED where a person experiences repeated episodes of disordered eating in the evening. The diagnostic criteria includes that the person eats 25% of their caloric intake at night, and eats upon waking in the middle of the night. Some people are conscious while eating, while others are still asleep and fully unaware that they are engaging in these habits when they are happening.
“Atypical anorexia is when someone meets all the diagnostic criteria for anorexia nervosa, except that the person’s weight is above what’s considered low weight according to their body mass index (BMI),” says Kathryn Gordon, Ph.D. and Manager of Provider Training & Consultation at Equip.
Many believe atypical anorexia would be better categorized as anorexia nervosa, restrictive (AN-R). This is because including atypical AN under OSFED can sometimes create a misconception that “atypical anorexia” is less severe or common than AN-R. Also, creating a separate diagnosis based solely on the flawed BMI scale can perpetuate weight bias in treatment settings.
England, who was diagnosed with atypical anorexia, adds, “Atypical AN and AN-R usually look the same behaviorally, and respond to the same types of treatment. Providing all people with anorexia the same quality of care, regardless of body size, combats the weight stigma many patients face.”
Other types of OSFED
While these are the most commonly seen and treated forms of OSFED, there are other diagnoses that may fit into the category. These conditions include:
- Rumination disorder: A consistent pattern of regurgitating undigested food from the stomach. This regurgitation typically occurs within the first 15 minutes after eating, and the food is either spit out or re-swallowed.
- Chew & spit disorder: A repeated habit of chewing food and then spitting it back out before swallowing. Many people engage in this disordered behavior in order to “taste” food without it affecting one’s weight.
- Pica: An eating disorder where someone compulsively eats non-food items such as paper, soap, hair, or ice. Pica is commonly seen in children or neurodivergent populations, but it can affect people of all backgrounds.
- Orthorexia: An obsession with ‘healthy eating’ that leads to disordered eating and exercise. This often includes the elimination of entire food groups, like gluten or dairy, or restriction to only ‘clean’ or raw foods. While not considered a formal eating disorder diagnosis in itself, someone with orthorexia can fall into the OSFED category.
Signs and symptoms of OSFED
Because there are many different types of OSFED eating disorders, the signs can look very different depending on the person. According to Gordon and Quinn Siegel, some of the general signs may include:
- Preoccupation with food, weight, or body image
- Rigid rules about food
- Self-induced vomiting or excessive laxative use
- Feeling a loss of control around food
- Missing out on social events because of concerns related to eating or weight
Ultimately, Quinn Siegel advises, “Pay attention to the level of distress these behaviors are causing you and affecting your life. If this is something that’s impacting your relationships, joy, or your ability to live out your values, then it may be time to seek support.
Like other eating disorders, OSFED is associated with a variety of physical and mental health risks. “Depending on the symptoms, people with OSFED may experience fatigue, dehydration, electrolyte concerns, or other issues. Mental health risks include anxiety, depression, and suicidal thoughts and behaviors,” says Gordon.
Is the term “OSFED” helpful?
For many, an OSFED eating disorder diagnosis can help validate what they’ve been feeling and help them get treatment access or insurance coverage. For others, it can feel hard to relate to, and they may identify more closely with their subtype diagnosis (like nighttime eating or purging disorder).
For Kelly, it was a mix of both. “I'd only thought of purging as this secret thing I did because I was a bad kid, so receiving the diagnosis helped me understand that this was something more. At the same time, my family and friends had never heard of OSFED, so it didn’t help me explain what I was experiencing.”
Quinn Siegel also sees the pros and cons, “Personally I didn’t need a label in order to heal, but it can be extremely validating to know that there’s a name for what you’re experiencing; that it’s a thing.”
What treatment looks like
There are several evidence-based treatments available to folks who fall under the OSFED eating disorder, including enhanced behavioral therapy (CBT-E) and family-based therapy (FBT). “Because OSFED can present in so many different ways, treatment should be individualized to meet the specific person's needs,” says Gordon. “Most forms of treatment for OSFED include establishing regular eating patterns and healthy coping skills.”
Finding others who share similar experiences can also be a core part of treatment, “If you’re wondering ‘are there people out there who’ve been through this?’, the answer is yes,” says Quinn Siegel. “We aren’t meant to heal in isolation.” At Equip, patients are matched with a peer mentor who has experience recovering from an eating disorder to provide hope and guidance.
Diagnoses can be complicated, and you don’t have to know which one best fits in order to get support. Schedule a free consultation to learn more about virtual treatment at Equip.
- “DSM-5 Changes: Implications for Child Serious Emotional Disturbance [Internet].” National Center for Biotechnology Information. Accessed November 7, 2023. https://pubmed.ncbi.nlm.nih.gov/30199184/.
- Table 1, DSM-IV and DSM-5 diagnostic criteria for binge-eating disorder ... Accessed November 7, 2023. https://www.ncbi.nlm.nih.gov/books/NBK338301/table/introduction.t1/.
- Salman, EJ, Rian Kabir. “Night Eating Syndrome.” StatPearls [Internet]. StatPearls Publishing; 2023. PMID: 36251825.
- Kusnik, Alexander, Sarosh Vaqar. “Rumination Disorder.”StatPearls [Internet]. StatPearls Publishing; 2023. PMID: 35015429