Tuesday, November 1, 2016

Other Specified Feeding or Eating Disorders (OSFED): Your Symptoms Have a Name!

By Kathryn Coniglio
Mary is a 35 year old woman who is of normal weight. She frequently diets, going through bouts of restricting calories for a few days, and then binges on her “forbidden foods.” Mary constantly worries about food and calories, even when she is busy doing things she likes, like being in the company of friends or reading a book. Mary is worried she may have an eating disorder, so she tries to find more information online about what her diagnosis might be. She quickly realizes she does not meet criteria for anorexia nervosa (AN), bulimia nervosa (BN), or binge eating disorder (BED), which are the only eating disorders Mary has ever heard of. Mary feels confused and disheartened.
Does Mary’s experience sound familiar to you? If it does, you are not alone. Actually, Mary very likely does meet criteria for an eating disorder – OSFED. Other Specified Feeding or Eating Disorder (OSFED) is more common than the other, more commonly known eating disorder diagnoses, like AN, BN, or BED. In fact, in our outpatient eating disorders clinic in Boston, OSFED makes up about 25% of all diagnoses.  Clinicians and researchers used to think of OSFED as a kind of subthreshold eating disorder (ED), but in fact research shows that individuals with OSFED have similar levels of impairment and share similar genetic risk factors to individuals with full threshold EDs (Fairweather-Schmidt & Wade, 2014). Our clinic frequently receives calls on our intake phone line from people of all ages, races, and genders who seek an evaluation, but who qualify their symptoms by saying “I am not underweight so I don’t know if I really have an eating disorder” or “I don’t binge every single day, so I’m not sure if this is really the right place for me.”
AN and BN are extreme examples of eating disorders, but are relatively rare, with lifetime prevalence rates at only around 1.7% and 0.8%  respectively (Smink et al. 2014). Due to the media attention these disorders receive, some people with clinically significant eating problems (but who don’t meet criteria for AN or BN) may not realize that their symptoms, too, have a name. The often impairing and distressing symptoms that these individuals are experiencing are well deserving of clinical attention and we are always glad they called us for help.
Luckily, the newest (5th) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) included an improved classification, featuring broader diagnostic criteria, for diagnosing eating disorders. For example, many individuals who normally would not have met criteria for AN or BN in the 4th edition (DSM-IV) would now receive such a diagnosis in DSM-5 (Quick et al. 2014). DSM-5 also improved on the criteria for OSFED. Where DSM-IV labeled eating disorders that did not fit into any category as eating disorders as “Eating Disorder Not Otherwise Specified (EDNOS)”, DSM-5 replaced this category with OSFED.
OSFED includes five specific example presentations. Atypical anorexia nervosa (OSFED-AA) is a type of OSFED that encompasses individuals who have a fear of weight gain and body image disturbance, but who are not underweight. OSFED – Purging disorder describes individuals who engage in purging but do not engage in bingeing, while OSFED – Night eating syndrome is likely appropriate for an individual who wakes up, after already having fallen asleep, and consumes a large amount of food. Two OSFED categories capture the symptoms of individuals who are both bingeing and purging (OSFED-BN) or just bingeing (OSFED-BED). But perhaps binge frequency isn’t as important in determining impairment; one study found that feeling a loss of control while eating, rather than binge frequency and size, is a better predictor of clinically significant binge eating (Vannucci et al. 2013).
Some individuals may be experiencing distressing eating symptoms or attitudes, but still might not fall into any of these categories. For these individuals, a diagnosis of OSFED-Other can be assigned. A 2014 study found that, among patients presenting for outpatient eating disorder treatment, two thirds would have been diagnosed with EDNOS in DSM-IV, whereas just over 1% had a diagnosis of Unspecified Feeding or Eating Disorder (UFED) in DSM-5, which is to be used when not enough information can be obtained in order to assign a more specific diagnosis. In our clinic, both OSFED-Other and UFED are becoming more rare, given the multiple broad examples of symptom presentations offered in the OSFED category.
So, overall, DSM-5 succeeded in adding specificity to various symptom pictures. Some medical professionals argue that OSFED categories may unnecessarily pathologize symptoms, like negative body image or dieting, that many individuals may experience to some degree over the course of their life. However, most patients are relieved when a clinician can assign a diagnosis to the suffering they are experiencing; it is often validating for an individual’s suffering to be recognized and named. Further, from a clinical standpoint, treatment can be formulated to address only the symptoms the patient is currently experiencing, rather than a “one size fits all” model.
A 2013 longitudinal study found that individuals with OSFED-BN and OSFED-BED eventually developed BN or BED over the course of the 8-year follow-up (Stice et al. 2013). Therefore, not only are these OSFED categories useful for patients, they may help clinicians identify who might be at risk for developing another eating disorder diagnosis later on.
The good news is that individuals with OSFED can benefit greatly from treatment. A popular evidence-based treatment for eating disorders is enhanced cognitive behavioral therapy (CBT-E; Fairburn 2008), which has been shown to alleviate symptoms in individuals with OSFED-BN as well (Waller et al. 2014). Researchers are also working on other ways to disseminate treatment to individuals who have OSFED. For instance, a randomized controlled trial of an Internet-based intervention showed that, among individuals with OSFED, both eating disorder attitudes and behaviors (like bingeing and purging) were significantly reduced (Jacobi et al. 2011) compared to the control group.
If you would like to learn more about OSFED, Almost Anorexic: Is My (Or My Loved One’s) Relationship with Food a Problem? is a helpful, reader-friendly guide written by Dr. Jennifer J. Thomas, the co-director of the Eating Disorders Clinical and Research Program at Massachusetts General Hospital. In sum, if you think you might have OSFED, please don’t hesitate to seek treatment. Your experiences and symptoms have a name and are valid and worthy of attention and because they are treatable. Instead, you could follow Mary’s example: she went to see a psychologist and was diagnosed with OSFED. He recommended she enroll in weekly sessions of CBT-E, after which Mary saw significant improvement in her binge frequency and her attitudes about food and eating in general.

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