Etiology
This group of diagnoses - ranging from BED, to ARFID, to simply a diagnosis of “otherwise specified eating disorder” - isn’t really much different from other diagnoses when it comes to etiology. The difference is that the exact frequency and range of behaviors isn’t better explained by a diagnosis of anorexia or bulimia. Since those disorders are narrow in their criteria, the majority of people with eating disorders fall under the OSFED umbrella. This diagnosis is flexible and accommodating to a wide range of behavior types or combinations. It isn’t a diagnosis indicating less severity but is instead a way of acknowledging the presence of dangerous eating behaviors, body image distress, and physiological harm for people who engage in a wider variety of behaviors or at different frequencies.
We might see a more restrictive presentation of OSFED, a restrictive eater who doesn’t have concurrent body image distress, someone who compulsively exercises and trends toward “orthorexic” tendencies, or someone who cycles back and forth between periods of bingeing or restriction. At the end of the day, the diagnosis isn’t the most important part of treatment. It helps with insurance coverage, it gets you a name to call your difficulties with eating, and it might help validate the struggles you are facing, but there is no “better” or “worse” disorder to be diagnosed with.
Behaviors, signs, symptoms
In the DSM-5 TR, to be diagnosed with OSFED a person must present with feeding or eating behaviors that cause clinically significant distress and impairment, but do not meet the full criteria for any of the other disorders.
A diagnosis might then be assigned that addresses the 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 for anorexia nervosa, except despite significant weight loss, the individual’s weight is within or above the “average” range. The current research shows that there are no differences between the medical complications, behaviors, or risks between anorexia and “atypical” anorexia. In fact, atypical anorexia is more common than anorexia and is often looked over since medical professionals are trained to look for small bodies when assessing for disordered eating. I, as a clinician, am in favor of abandoning the distinguishment between body size in the diagnosis of anorexia.
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).
BED and ARFID technically fall under the umbrella of OSFED, but you can find more information about these common diagnoses in previous posts.
Here are some examples of a behavior pattern that might meet OSFED criteria:
Going through periods of bingeing and restriction (maybe weeks or even months using one behavior before switching to the other)
Restriction followed by bingeing or purging
Heavy restriction but without being “underweight”
Compulsive exercise without leading to weight loss
Some level of restrictive bx related to emetophobia or fear of choking similar to ARFID, but with co-occurring body image distress.
Limiting food groups or food sources to a degree that inhibits appropriate nourishment alongside compulsive exercise but maintaining body weight.
Treatment + Goals for Recovery
In an initial assessment, the provider will be assessing for the span of behaviors a person is engaging in. From there, the clinician can make a treatment plan to address behaviors in a way, and potentially an order, that is most beneficial for both physical health, long term success, and encouraging behavior change. We will still have all the components of treatment as we have for any other diagnosis: education, skill building, processing, goal setting, exposure work, and many other options.
When thinking about goals of treatment, it’s important to zoom out and consider the actual behaviors and impact that are occurring rather than specifically the diagnosis. We still want to see healthy body image, normalization of eating patterns, appropriate nourishment for wellbeing, a balanced and considerate relationship with movement, and a sense of self-worth and self-compassion.
Subclinical Eating Disorders
One of the frustrating things about living on this planet (there are many frustrating things) is that healthcare is withheld from people who are asking for it if they don’t fit into someone else’s definition of needing support. I would encourage any person who is feeling uneasy or unsupported by their relationship with food, their exercise patterns, or their body image to seek help. There is no reason to delay support until things are worse—that doesn’t do anyone any good. You deserve help if you feel like you are struggling. You don’t owe the world more sickness in order to get better. If you can afford treatment, please seek it as soon as you can. Your body, your brain, and future you will be so grateful.
If you have an eating disorder or are the caregiver to someone with an eating disorder, I hope this guide helps you in tailoring your treatment to your own needs and desires. I also hope it helps you in seeking out a professional to support you on your journey - ask questions and make sure the provider’s approaches are in line with your goals and needs. This is just an introduction to the basics of understanding and treating a complex mental and physical disorder. If you have more questions or want more information, please feel free to reach out via the comments or DM me.
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