Anorexia nervosa, bulimia nervosa, binge eating disorder: the three most well-known eating disorders. Avoidant/restrictive food intake disorder, pica, rumination disorder: the less commonly known but still discussed eating disorders. Regardless of how well-known an eating disorder is, the psychological distress that stems from a distorted relationship with food can be severely impairing.
In addition, these eating disorders have been formally identified by the American Psychiatric Association’s fifth edition of the Diagnostic and Statistic Manual of Mental Disorders (DSM-V), which means that people who have eating disorders can be clinically diagnosed based on a set of criteria. The webpage to the manual even states that “diagnostic criteria are provided for pica, rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, and binge-eating disorder.” What about the “other” eating disorders, the unidentified, unknown eating disorders that hide in the shadows of clinically diagnosable ones. What are they?
People who have disordered relationships with food are often grouped together in an obscure category of eating disorders called “other specified feeding or eating disorder” (OSFED). Formerly known as “eating disorder otherwise not specified” (EDNOS), OSFED is the broadest category of eating disorders that, according to the DSM-V, includes atypical anorexia nervosa, bulimia nervosa of low frequency and/or limited duration, binge-eating disorder of low frequency and/or limited duration, purging disorder, and night eating syndrome (American Psychiatric Association, 2013). Some of these OSFED eating disorders appear to be better known because they contain the words “anorexia,” “bulimia,” “binge-eating,” and “purging,” but why are they classified under OSFED?
Based on other information provided by the DSM-V, the category “applies to presentations in which symptoms characteristic of a feeding and eating disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the feeding and eating disorders diagnostic class” (American Psychiatric Association, 2013). For this reason, OSFED is the most common diagnosis given to individuals. However, individuals seeking help and not knowing what they need to get better may get frustrated with being labeled as “other.”
According to multiple scholarly sources, OSFED comprises from forty to sixty percent of treatment-seekers at eating disorder specialty clinics, with OSFED prevalence of up to ninety percent in non-specialty settings (Rockert, Kaplan, & Olmsted, 2007; Fairburn et al., 2007; Zimmerman, Francione-Witt, Chelminski, Young, & Tortolani, 2008). One prevalence study showed that seventy-five percent of young women received OSFED diagnoses. OSFED also touches upon men, ethnic minority groups, athletes, children and adolescents, and the elderly (Thomas, Vartanian, & Brownell, 2009). Based on these extensive studies, the OSFED category continues to be too broad for use as a diagnostic criterion in each individual case.
To ameliorate some of the concerns associated with grouping individuals under OSFED, a group of researchers and clinicians characterized a large sample of adult outpatients diagnosed in the “other” category (Rockert, Kaplan, & Olmsted, 2007). They classified individuals into six subtypes (i.e., anorexia nervosa (AN) restricting, AN binge-purge, bulimia nervosa (BN) purging, BN non-purging, normal-weight restrictors, and subthreshold AN, BN, and BED) to specify the experiences of these participating individuals. What they found was that of 1,449 participants, forty percent were classified under OSFED, and that the percentage of patients who meet the full criteria of DSM-V feeding and eating disorders was greater than that reported in other literature in outpatient community settings (Rockert, Kaplan, & Olmsted). For instance, the most frequent subtypes were reported to be normal-weight restrictors, patients who purged in the absence of binge-eating, and patients with subthreshold BN, which accounted for seventy-five percent of the OSFED group (Rockert, Kaplan, & Olmsted).
Another research group (Sysko & Walsh 2011) conducted 267 telephone interviews between April and December 2009 using the Broad Categories for the Diagnosis of Eating Disorders (BCD-ED) criteria scheme. The group found that 247 of the individuals met criteria for an eating disorder, particular 97 individuals who were classified to have OSFED (i.e., 39.3% of the interview participants had an OSFED diagnosis), and 97.6% of the OSFED-diagnosed individuals were reclassified under this scheme. If reclassification has proven to successfully guide individuals with OSFED into treatment, therapy, and recovery more appropriate for them, then what about the remaining 2.4% of individuals who never get reclassified?
According to the National Eating Disorders Collaboration website, the most effective way to help individuals who had not had their eating disorder reclassified is by following the treatments for the disorder that most closely resembles the individual’s symptoms. For example, if a person presents with many of the symptoms of anorexia nervosa, that person will be recommended to seek the same or similar treatment approaches. Some of the most popular treatments include psychotherapy (CAT, CBT, DBT), family therapy (support, intervention, and education), self-help, nutrition management (via dietitian or nutritionist to adapt optimal lifestyle modifications), and medication (vital especially in cases of comorbid disorders or illnesses, e.g., depression). These are tried-and-true therapies that work best in concert with each other, and when offered to individuals with OSFED, can benefit their symptoms and experiences.
For individuals with OSFED who can be re-diagnosed for more well-known eating disorders, the treatment and recovery options may be more available within their reach. For those who remain under the OSFED diagnosis, the most optimal approach to treatment and recovery would be to individualize treatment based on the services described above. Being diagnosed with an unknown eating disorder may be daunting, especially when the disorder is unknown to its fullest extent, but the more aware we become about these unknown eating disorders, the more awareness we can spread to help those in need of finding answers for themselves.
American Psychiatric Association. (2013). Feeding and Eating Disorders. Other Specified Feeding or Eating Disorders. http://dx.doi.org/10.1176/appi.books.9780890425596.dsm10
Machado, P. P. P., Machado, B. C., Gonçalves, S., & Hoek, H. W. (2007). The prevalence of eating disorders not otherwise specified. International Journal of Eating Disorders, 40(3), 212–217. https://doi.org/10.1002/eat.20358
National Eating Disorders Collaboration. (2016). Treatment approaches. Retrieved from http://www.nedc.com.au/treatment-approaches. Accessed 27 April, 2017.
Rockert, W., Kaplan, A. S., & Olmsted, M. P. (2007). Eating disorder not otherwise specified: The view from a tertiary care treatment center. International Journal of Eating Disorders, 40(S3), S99–S103. https://doi.org/10.1002/eat.20482
Sysko, R., & Walsh, B. T. (2011). Does the broad categories for the diagnosis of eating disorders (BCD-ED) scheme reduce the frequency of eating disorder not otherwise specified? International Journal of Eating Disorders, 44(7), 625–629. https://doi.org/10.1002/eat.20860
Thomas, J. J., Vartanian, L. R., & Brownell, K. D. (2009). The relationship between eating disorder not otherwise specified (EDNOS) and officially recognized eating disorders: meta-analysis and implications for DSM. Psychological Bulletin VO – 135, (3), 407.