National Eating Disorders Association

Other Specified Feeding and Eating Disorders (OSFED) was previously known as Eating Disorder- Not Otherwise Specified (EDNOS) in previous editions of the Diagnostic and Statistical Manual. Despite being considered a ‘catch-all’ classification that was sometimes denied insurance coverage for treatment as it was seen as less serious, OSFED/EDNOS is a serious, life-threatening, and treatable eating disorder. The category was developed to encompass those individuals who did not meet strict criteria for anorexia or bulimia but still had a significant eating disorder. In community clinics, the majority of individuals were historically diagnosed with EDNOS.

Research into the severity of EDNOS/OSFED shows that the disorder is just as severe as anorexia and bulimia based on the following:

  • Children hospitalized for EDNOS had just as many medical complications as children hospitalized for anorexia nervosa
  • Adults with ‘atypical’ or ‘subclinical’ anorexia and/or bulimia scored just as high on measures of eating disorder thoughts and behaviors as those with DSM-diagnosed anorexia and bulimia
  • People with EDNOS were just as likely to die as a result of their eating disorder as people with anorexia or bulimia

Symptoms

Because OSFED encompasses a wide variety of eating disordered behaviors, any or all of the following symptoms may be present in people with OSFED.

  • Frequent episodes of consuming very large amount of food followed by behaviors to prevent weight gain, such as self-induced vomiting.
  • A feeling of being out of control during the binge-eating episodes.
  • Self-esteem overly related to body image.
  • Dieting behavior (reducing the amount or types of foods consumed).
  • Expresses a need to “burn off” calories taken in.
  • Use of compensatory behaviors (self-induced vomiting, laxative abuse) even after eating normal amounts of food.

Changes to the latest edition of the DSM were meant to clarify definitions of anorexia, bulimia, and binge eating disorder to more accurately diagnose eating disorders. Although this reduced the number of OSFED diagnoses, it remains a common diagnosis. In the DSM-5, a person must present with a feeding or eating behaviors that cause clinically significant distress and impairment in areas of functioning, but do not meet the full criteria for any of the other feeding and eating disorders.

A diagnosis might then be allocated that specifies a specific reason why the presentation does not meet the specifics of another disorder (e.g., bulimia nervosa - low frequency). The following are further examples for OSFED:

  • Atypical Anorexia Nervosa: All criteria are met, except despite significant weight loss, the individual’s weight is within or above the normal range.
  • Binge Eating Disorder (of low frequency and/or limited duration): All of the criteria for BED are met, except at a lower frequency and/or for less than three months.
  • Bulimia Nervosa (of low frequency and/or limited duration): All of the criteria for bulimia nervosa are met, except that the binge eating and inappropriate compensatory behavior occurs at a lower frequency and/or for less than three months.
  • Purging Disorder: Recurrent purging behavior to influence weight or shape in the absence of binge eating.
  • Night Eating Syndrome: Recurrent episodes of night eating. Eating after awakening from sleep, or by excessive food consumption after the evening meal. The behavior is not better explained by environmental influences or social norms. The behavior causes significant distress/impairment. The behavior is not better explained by another mental health disorder (e.g. BED).

Statistics

NEDA has gathered data on the prevalence of eating disorders from the US, UK, and Europe to get a better idea of exactly how common eating disorders are. Older data from other countries that use more strict definitions of anorexia and bulimia give lower prevalence estimates. Several more recent studies in the US have used broader definitions of eating disorders that more accurately reflect the range of disorders that occur, resulting in a higher prevalence of eating disorders:

  • In a study of 31,406 Swedish twins born from 1935-1958, 1.2% of the women had strictly defined anorexia nervosa during their lifetime, which increased to 2.4% when a looser definition of anorexia was used.
  • A 2007 study asked 9,282 English-speaking Americans about a variety of mental health conditions, including eating disorders. The results, published in Biological Psychiatry, found that:
    • 0.9% of women and 0.3% of men had anorexia during their life
    • 1.5% of women and 0.5% of men had bulimia during their life 
    • 3.5% of women and 2.0% of men had binge eating disorder during their life (Hudson et al., 2007).
  • When researchers followed a group of 496 adolescent girls for 8 years, until they were 20, they found: 
    • 5.2% of the girls met criteria for DSM5 anorexia, bulimia, or binge eating disorder. 
    • When the researchers included nonspecific eating disorder symptoms, a total of 13.2% of the girls had suffered from a DSM-5 eating disorder by age 20.

Have these numbers changed over time? The answer isn’t clear. It does appear that, at least for the last two decades, the rates of new diagnoses of anorexia and bulimia have remained relatively stable, while the rates of EDNOS/OSFED have increased.

  • An analysis of many studies from Europe and North America revealed that rates of anorexia increased sharply until the 1970s, when they stabilized. 
  • Rates of bulimia increased during the 1980s and early 1990s, and they have since remained the same or decreased slightly. 
  • A British study also found stability in new anorexia and bulimia diagnoses in both males and females, although rates of EDNOS diagnoses increased in both groups. 
  • Eating disorder symptoms are beginning earlier in both males and females, which agrees with both formal research and clinical reports.

References:

Crow, S. J., Peterson, C. B., Swanson, S. A., Raymond, N. C., Specker, S., Eckert, E. D., & Mitchell, J. E. (2009). Increased mortality in bulimia nervosa and other eating disorders. American Journal of Psychiatry.

Fairburn, C. G., Cooper, Z., Bohn, K., O’Connor, M. E., Doll, H. A., & Palmer, R. L. (2007). The severity and status of eating disorder NOS: implications for DSM-V. Behaviour research and therapy, 45(8), 1705-1715.

Favaro A, Caregaro L, Tenconi E, Bosello R, and Santonastaso P. (2009). Time trends in age at onset of anorexia nervosa and bulimia nervosa. Journal of Clinical Psychiatry, 70(12):1715-21. doi: 10.4088/JCP.09m05176blu. 

Hart LM, Granillo MT, Jorm AF, and Paxton SJ. (2011). Unmet need for treatment in the eating disorders: a systematic review of eating disorder specific treatment seeking among community cases. Clinical Psychology Reviews, 31(5):727-35. doi: 10.1016/j.cpr.2011.03.004. 

Hoek HW and van Hoeken D. (2003). Review of the prevalence and incidence of eating disorders. International Journal of Eating Disorders, 34(4):383-96. doi: 10.1002/eat.10222. 

Hudson JI, Hiripi E, Pope HG Jr, and Kessler RC. (2007). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 61(3):348-58. doi:10.1016/j.biopsych.2006.03.040.

McIntosh, V. V., Jordan, J., Carter, F. A., McKenzie, J. M., Luty, S. E., Bulik, C. M., & Joyce, P. R. (2004). Strict versus lenient weight criterion in anorexia nervosa. European Eating Disorders Review, 12(1), 51-60.

Micali N, Hagberg KW, Petersen I, and Treasure JL. (2013). The incidence of eating disorders in the UK in 2000–2009: findings from the General Practice Research Database. BMJ Open, 3(5): e002646. doi: 10.1136/bmjopen-2013-002646. 

Peebles, R., Hardy, K. K., Wilson, J. L., & Lock, J. D. (2010). Are diagnostic criteria for eating disorders markers of medical severity?. Pediatrics, 125(5), e1193-e1201.

Raevuori A, Hoek HW, Susser E, Kaprio J, Rissanen A, and Keski-Rahkonen A. (2009). Epidemiology of anorexia nervosa in men: a nationwide study of Finnish twins. PLoS ONE, doi: 10.1371/journal.pone.0004402. 

Smink FR, van Hoeken D, and Hoek HW. (2012). Epidemiology of eating disorders: incidence, prevalence and mortality rates. Current Psychiatry Reports, 14(4):406-14. doi: 10.1007/ s11920-012-0282-y. 

Stice E & Bohon C. (2012). Eating Disorders. In Child and Adolescent Psychopathology, 2nd Edition, Theodore Beauchaine & Stephen Linshaw, eds. New York: Wiley. 

Stice E, Marti CN, Shaw H, and Jaconis M. (2010). An 8-year longitudinal study of the natural history of threshold, subthreshold, and partial eating disorders from a community sample of adolescents. Journal of Abnormal Psychology, 118(3):587-97. doi: 10.1037/a0016481.