Unspecified Feeding or Eating Disorders (USFED)

What is USFED?

USFED stands for unspecified feeding and eating disorder. This diagnosis applies when someone suffers severe distress or a crisis due to an eating disorder but does not meet full Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for a specific eating disorder, such as anorexia nervosa (AN), bulimia nervosa (BN), or binge eating disorder (BED). (6)  

Healthcare professionals sometimes diagnose someone with USFED when they do not want to specify why someone does not meet full DSM-5 criteria. This typically happens in a crisis setting, such as the emergency room, to expedite care when a full evaluation by a psychiatrist or psychologist is not possible. Making a correct diagnosis can take hours of interviewing, and in an emergency/suicidal situation, clinicians use USFED to expedite care. (5,7)

This category, along with OSFED (other specified feeding or eating disorders), accounts for the largest percentage of eating disorders–as high as 60% in some studies. And symptoms are just as serious and detrimental as anorexia, bulimia, binge eating disorder, and other eating disorders that have their own diagnosis and specific criteria. (5,7)

Types of USFED

Examples of eating disorders that would receive a diagnosis of USFED include: (7,8)

• Someone may meet most criteria for anorexia nervosa, such as having an intense fear of gaining weight and missing menstrual cycles, but may not have a low enough body weight according to current criteria. (5)‍
• Someone may meet most criteria for bulimia nervosa, but binging episodes occur sporadically, over many months or years. To be diagnosed with BN, someone must purge at least once weekly for at least three months. If someone comes to the ER because food became stuck in their esophagus during a binge episode, a physician may diagnose the person with USFED. 
• Someone may attempt to lose weight by vomiting or using laxatives, enemas, or diuretics, which is consistent with purging disorder, but does not binge eat. Someone may experience these symptoms sporadically, during stressful situations, for example. They may go for years symptom free. If someone arrives in the ER due to severe dehydration as a result of excessive laxative use, they may receive a diagnosis of USFED.
• PICA is an eating disorder that is characterized by compulsively eating nonfood items, such as chalk, clay, cloth, coal, dirt, gum, hair, metal, paint, paper, pebbles, soap, string, or wool, but it also doesn’t have its own diagnosis. 

Lab tests are usually ordered to check someone’s electrolytes, liver enzymes, thyroid function, vitamin levels, and blood sugar. 

When Within Health is part of a treatment team, we do our best to coordinate with any crisis or hospital team to ensure a smooth transition of care.

Signs & Symptoms of USFED

People often struggle with eating disorders for years before reaching out for help. They may not realize they have an eating disorder. They may be afraid or ashamed. This can result in a crisis situation, forcing someone to get help. 

Signs and symptoms of USFED include but are not limited to: (1,5,7,8) 

• Inability or refusal to, or overly self-conscious about eating in front of others
• Frequently disappearing after meals to purge
• Low confidence
• Low self esteem
• Poor body image
• Socially withdrawn
• Excessively introverted
• Overwhelming feelings of guilt, shame, and anxiety
• Wearing overly loose clothing or dress in heavy layers to hide their body
• Overly preoccupied with counting calories 
• Strict dieting
• Signs of dramatic weight loss
• Denies feeling hungry
• Obsessive food rituals (for example, not allowing any food types to touch on their plate)
• Excessive exercise, to the point of injury and stress fractures
• Facial cheek swelling (edema from frequent vomiting)
• Discolored or stained teeth
• Calluses on the backs of hands and knuckles from self-induced vomiting

Effects of USFED

The long- and short-term consequences of undiagnosed and untreated USFED are as severe and life threatening as specified eating disorders. USFED stands as a temporary diagnosis until someone can be formally evaluated at length. 

Short-Term Effects

• Fatigue
• Difficulty concentrating
• Drops in school and work performance
• Poor exercise and sports tolerance
• Mood swings
• Irritability

Long-Term Effects

• Heart damage and digestive system disruption due to electrolyte abnormalities from purging
• Moderate to severe sleep disorders and sleep apnea from binging
• Esophageal cancer and tooth decay from chronic vomiting
• High blood pressure and heart disease
• Major depressive disorder and suicidal ideation (1,5,7,8)

Related Complications and Disorders

Many medical complications and mental health disorders can precede or result from eating disorders, such as: (7,8)

• Major depressive disorder
• Esophageal impaction, rupture, and cancer
• Oral and dental disease
• Cyclothymic disorder
• Acute stress disorder
• Post traumatic stress disorder
• Generalized anxiety disorder
• Panic disorder
• Agoraphobia
• Suicidal ideation and attempt.

Diagnosing USFED

An ER physician typically assigns a diagnosis of USFED in the setting of an emergency, such as trauma or a life-threatening situation. A patient may be brought in due to a suicide attempt, fractures, severe self-harm, or syncope (passing out) due to extended periods of starvation. 

When someone receives a diagnosis of USFED, usually their symptoms have persisted untreated for years. They may not realize they have an eating disorder, they may be in denial, or they may be ashamed to get help. These individuals tend to “slip through the cracks” of the healthcare system, unfortunately, and quietly endure until a crisis occurs.

Treatment of USFED

Typically, when someone comes to Within Health after a crisis episode with a diagnosis of USFED, we may advise them to continue with hospital (inpatient) care until they can safely return home.

Once someone has transitioned home, our providers monitor vitals using remote patient monitoring (RPM). We follow blood pressure, heart rate, and temperature using numberless monitors, to be sensitive to those with heightened anxiety around numbers. Clinical experience has taught us that focusing on numbers can cause unnecessary added stress.

We perform a comprehensive evaluation and develop a personalized treatment plan, so every individual receives the care they need.  Our multidisciplinary approach entails a support team that includes a:

• Nurse
• Dietitian/Nutritionist
• Psychotherapist
• Psychiatrist

Therapies for USFED

Some of the most commonly recommended therapies for eating disorders, including USFED, are: (7,8) 

• Cognitive behavioral therapy (CBT) or dialectical behavioral therapy (DBT): CBT and DBT are types of talk therapy in which therapists work with individuals to help them understand what may be causing their behaviors  and teach them how to change their negative thought patterns and behaviors .
• Medication: Our psychiatrists participate in shared decision making to determine if someone’s co-occurring conditions warrant medication, or if therapy alone suffices.
• Nutritional Rehabilitation: An integral part of healing includes restoring a positive relationship with food, without the pressures or rules of dieting. This involves learning how to recognize, respect, and follow hunger cues.
• Mood or food diary: Some may find this overwhelming or anxiety inducing, while others find this helpful with the assistance of a dietician and nutritionist. Keeping a diary can identify unconscious behaviors and triggers.
• Alternative medicine: Eating disorders often stem from traumatic events that happened during childhood, such as physical, sexual, or emotional abuse, death of a caregiver or close family member, divorce, poverty, or natural disaster. Depending on the type of trauma suffered, alternative treatments such as massage, music, art, body awareness, yoga, biofeedback, and acupuncture therapy can be extremely beneficial. (4)

Levels of Care for USFED

There are typically three levels of care:

1. Partial hospitalization program (PHP)
2. Intensive outpatient program (IOP)
3. Outpatient program (OP)

History of USFED

Other specified feeding or eating disorders (OSFED) and Unspecified Feeding or Eating Disorders (USFED) replaced the former term “eating disorder not otherwise specified” (EDNOS) in the DSM-4. Some providers still use EDNOS and frequently confuse OSFED and USFED. Previously, nearly 70% of persons with eating disorders received an EDNOS diagnosis. Healthcare professionals mistakenly believed their cases were not as severe as those with formal ED diagnoses. This resulted in those persons not getting the care they needed. (3) But now providers are more informed, and individuals are getting the care they need.

How to Help Someone with USFED

If you suspect you or a friend or family member may have  an USFED, please seek professional care as soon as possible. 

Here are some tips to keep in mind when talking to someone who you think may have an eating disorder: 

• Stay open and accepting
• Listen without judgment
• Set healthy boundaries
• Try not to enable ED behaviors
• Avoid making comments about their weight or eating habits
• Approach setbacks with patience
• Share your concern and encourage them to get help
• Offer to support them in any way you can

Call our clinical care team today to start treatment for an eating disorder. Our admissions team can discuss first steps with you, and introduce you to our virtual care program for USFED.