By: Jenna DiLossi, PsyD, ABPP
When you think about someone with anorexia nervosa, what image pops into your mind? It’s probably someone who is underweight which is characterized by a degree of starvation and malnutrition. These individuals are more likely to be flagged for potential eating disorders when they go to the doctor, or when they are presenting with symptoms like dizziness, fatigue, or fainting. However, restrictive eating disorders and malnutrition do not only impact people living in smaller bodies. Some people whose bodies fall in the “healthy,” “overweight,” or “obese” range in the BMI [Body Mass Index] chart (which is outdated and flawed) are living in malnourished bodies.
Due to the misconception of anorexia, weight bias, and general cultural misunderstanding, many individuals are not getting the potentially lifesaving care they need and deserve. Our assumptions and misunderstanding of anorexia combined with the body bias our society and medical system still generally holds lead to misdiagnosis, missed opportunities for early intervention, and can lead even motivated individuals to avoid seeking care. It’s important to recognize atypical anorexia and why we have such a skewed understanding of malnutrition, so we can better understand restrictive eating disorders and better serve those who are suffering.
What is atypical anorexia?
For a long time, the Diagnostic and Statistical Manual of the American Psychiatric Association’s (DSM’s) criteria for anorexia nervosa included a rigid numerical threshold for weight (i.e., 15% under ideal body weight). DSM-5 eliminated that criterion; however, there is still an emphasis on weight that falls beneath the “normal” range of what is expected within the context of age, sex, developmental trajectory, and physical health (American Psychiatric Association, 2013). To diagnose someone with anorexia, practitioners use the BMI to see where the individual falls in this range. Therefore, anyone with a “normal” or higher weight range will not meet criteria for anorexia, even if their behaviors and struggles otherwise are the same. Instead, these individuals would be considered as presenting with “atypical anorexia,” and fall under the “other specified feeding and eating disorder” diagnosis.
Atypical anorexia is almost identical to typical anorexia. People engage in extreme food restriction that typically leads to significant malnutrition and they consistently engage in behaviors that are aimed to prevent weight gain. They may or may not lose weight rapidly. Psychologically, they experience an intense fear of gaining weight or “becoming fat,” struggle with body image, and over-value their body image. The only factor that precludes a diagnosis of anorexia is that their weight is within or above the “normal” range. However, atypical anorexia is often missed completely or misdiagnosed for a variety of reasons.
Why do we have such a limited picture of malnutrition and anorexia? And how are people getting missed?
There are three possibilities that stand out: 1) the widespread reliance on BMI in the medical community; 2) the misunderstanding, or over attribution, between lifestyle and weight; and 3) the media representation of pop cultural norms regarding body image, weight, and eating disorders.
Though we’ve made progress as a society, thin is still generally idealized as “best.” It is not uncommon for physicians to gloss over patient weights that are considered mildly underweight, attributing the low weight to athletics or a fast metabolism. This same degree of “grace” is often not given for individuals who are considered mildly “overweight.”‘ In many of these cases, exercise or dietary changes are encouraged without even inquiring about the person’s baseline diet, exercise regimen, and/or consideration of their genetics or relevant biological factors. To put it simply, weight bias is largely responsible for this problematic oversight. Failure to identify restrictive eating disorders early in the disorder’s onset often means that windows for vital intervention may have already closed by the time a diagnosis is made, if it’s made at all. This unfortunate, yet common clinical oversight has harmful implications for symptom progression, treatment planning, and overall prognosis.
Not only is the phenomenon of atypical anorexia often unnoticed in families, schools, and healthcare settings, these individuals are often praised for their weight loss and restrictive habits. Praise comes in the form of compliments about their body’s aesthetic and their “dedication to health” when they start eating less or differently. These reactions reinforce the disordered eating behavior, which in turn strengthens the cognitions about self-worth and body image and fears about weight gain. They also may receive invalidating information from professionals, offering medications for weight loss or attributing pain or medical concerns to their higher weight.
Because people so often equate “thin” with “healthy,” critical opportunities for noticing, addressing, and treating eating disorders are lost. However, organ function continues to erode concurrently over time for individuals with atypical anorexia at higher weights, just as they do in individuals with the more common diagnosis of anorexia. The impact of starvation and malnutrition doesn’t discriminate based on BMI. Despite being within a “normal” weight range, adolescents with atypical anorexia can be more medically compromised (sometimes requiring hospitalization) than some of their peers who were underweight and diagnosed with typical anorexia (Peebles et al., 2010). They also displayed high rates of complications (18%) once admitted to the hospital.
If people were more aware of the impact of atypical anorexia and the signs and symptoms, we would be able to help those suffering earlier. The implication of this is a lower prevalence rate, less use of the health care system, and fewer fatalities. It is vital that clinicians assessing and treating eating disorders not assume that individuals with atypical anorexia are healthier than those with typical anorexia, or that one can only be in a state of malnourishment when in a smaller body. Additionally, it’s critical to be mindful of the messaging we are sending to individuals at higher weights regarding weight and health. Just because someone is in a larger body does not mean they do not need to decrease calories and/or lose weight. Current eating disorder treatment programs have shifted to assess whether any given patient has malnutrition effects due to their illness, regardless of presenting BMI. When we have a broader understanding of eating disorders, typical and atypical presentations in particular, we can ensure that people suffer less frequently, for a shorter duration, and are able to live well as soon as possible.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
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.