PHOTO: Katarina Wolnik Vera
Text: Alejandra Misiolek
In this post we are going to define what an atypical anorexia is and discuss the risks of underdiagnosing this disorder.
Before we define atypical anorexia, let´s first have a look at the diagnostic criteria of the typical anorexia nervosa according to DSM 5.
A person can be diagnosed with anorexia nervosa if they meet the following criteria:
- Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health.
- Intense fear of gaining weight or becoming fat, even though underweight.
- Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.
Even if all the DSM-5 criteria for anorexia are not met, a serious eating disorder can still be present. Moreover, atypical anorexia includes those individuals who meet the criteria for anorexia but who are not underweight despite significant weight loss. Interestingly, research studies have not found a difference in the medical and psychological impacts of anorexia and atypical anorexia.
Atypical anorexia nervosa turns out to be more frequent than most people would expect. However, frequently it is underdiagnosed. The reason why it is not frequently diagnosed is, on the one hand, that mental health professionals still tend to associate Eating Disorders with low body weight and, on the other, that people whose body weight is normal over higher than what is considered to be “normal” tend to assume their problem is the excess of body weight and not a disturbed eating behavior.
As anorexia is still directly associated with thinness and that leaves out not skinny people without correct diagnosis and treatment, we need a change of the paradigm and a shift in this field.
Many mental health professionals and especially medical doctors continue to resist letting go of the metric of weight as it would require altering the organizing principle by which anorexia is conceived.
Why do we consider it to be important?
The main reason is that people still underestimate how damaging for a person´s health is not only being underweight but also losing a lot of weight in little time or starving oneself for a long time.
When a person is going through a long period of starvation, they undergo a series of biological, metabolic, and hormonal changes to ensure their own survival. Our metabolism slows to conserve energy and the body starts prioritizing certain tissues, that are vital to our survival, over others. To produce glucose, that is essential to our brain, we consume fat and muscle. Our digestion simmers down, ending up in gastrointestinal problems, our body temperature lowers, and the blood flow decreases. Many people who chronically undereat have a constant feeling of cold or shiver. If malnutrition worsens, the hair can become fragile and falls out, and the muscle mass dwindles.
Prolonged periods of starvation can be responsible for serious somatic health consequences of anorexia such as orthostatic hypotension and low heart rate, electrolyte imbalances that may cause arrhythmias or even lead to cardiac arrest. Moreover, a malnourished body can shut down the production of sex hormones that are produced out of cholesterol and that may lead to amenorrhea (no period) and low libido.
There is still little research on atypical anorexia, however, it shows that the medical complications appear to be the same as for typical anorexia and occur in similar rates across body sizes. Recent research has found that body size is a less relevant indicator of the severity of both eating disorders than other factors, including the percentage of body mass lost, the speed of that loss and the duration of the malnourished state.
What about the psychological similarities and differences?
The reason why some people starve themselves to being skinny and others don´t is multifactorial. Some of the reasons are genetic, other psychological or environmental. In typical anorexia we observe the compulsively desire to lose more weight, as if a mental switch flipped. Losing weight can become exciting or even addictive for some. Interestingly, in the short term, resisting hunger pangs can make people feel powerful and even euphoric. However, the effects of starvation on the brain in the long run include mental fog, difficulty concentrating and memory issues. Moreover, people become irritable and inflexible in their thinking. People with anorexia are characterized by rigidity that can be both the cause and the consequence of the illness or even a vicious circle of the fish biting its own tail. It has been observed that even the gray matter of the brain shrinks, and it appears that the neural pathways related to rewards can be reversed. Food that typically results in a dopamine hit now inspires fear and hunger can produce more dopamine. The dread of gaining weight becomes stronger than the biological urge to eat, spiraling downward into more weight loss and distorted thinking.
What happens in atypical anorexia? There is still not enough research, however we could hypothesize that this “flip” does not occur. Either because of lower rigidity, more mentalizing capacity, different genetic predisposition or a lower proneness to dopamine. Nevertheless, although there is no additional health risk of low body weight, there is definitely the risk of the detrimental effects of starvation and even a more probable switch to developing further bulimic patterns.
The point is that we need to stop judging people by their weight and rather enquire more about their patterns of thoughts, emotions and behaviors to be able to better evaluate if they need psychological or medical treatment for their condition. Recommending losing weight to an overweight person with atypical anorexia can be a very harmful mistake that can only lead to more stigma, shame and ambivalence in asking for help. Yet, a very frequent medical error. Therefore, people with atypical anorexia do not get treatment they deserve and need. And that should definitely change.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
Forney, K. J., Brown, T. A., Holland‐Carter, L. A., Kennedy, G. A., & Keel, P. K. (2017). Defining “significant weight loss” in atypical anorexia nervosa. International Journal of Eating Disorders, 50(8), 952-962.