Atypical Anorexia Nervosa: Current Knowledge and Ongoing Questions

In October of 2022, the New York Times article “You Don’t Look Anorexic” by Kate Siber introduced many readers to one of the lesser-known types of eating disorders: atypical anorexia nervosa.

The article generated 1,000+ comments, including people identifying with these symptoms and others doubting the existence of this diagnosis.

What is atypical anorexia nervosa?

Atypical anorexia nervosa describes someone’s experiencing symptoms of anorexia nervosa (i.e., food restriction resulting in weight loss and intense fear of weight gain) and being underweight for one’s body’s needs, even if weight falls within or above what is regarded as normal.

Although atypical anorexia nervosa is not as well-known as anorexia nervosa, people with this diagnosis are presenting more frequently. In one hospital, atypical anorexia cases increased by 500% from 2008 to 2014, and other studies suggest that the prevalence of atypical anorexia nervosa may be as high or even higher than anorexia nervosa.

Why is it called ‘atypical’?

In her classic book on eating disorders, published in 1973, Hilde Bruch MD coined the term to describe individuals who had lost significant weight but did not have the typical psychological symptoms of anorexia nervosa such as overconcern with shape and weight. For example, an individual with schizophrenia who lost weight because of a delusion that their food was poisoned.

A narrower definition was included in the Diagnostic and Statistical Manual for Mental Disorders 5th edition (DSM-5) in 2013. In a section of syndromes causing significant distress or impairment but not meeting full criteria for any recognized disorder, a description of atypical anorexia nervosa was included: “All of the criteria for anorexia nervosa are met, except that despite significant weight loss, the individual’s weight is within or above the normal range” (p. 353).

Atypical anorexia nervosa vs. anorexia nervosa.

Our field wants to better understand atypical anorexia nervosa, and this is reflected in the rate of research being done. Between 2013-2015, only 10 papers on the disorder were published, increasing to 47 between 2019-2021. Two Columbia team members, B. Timothy Walsh, MD and Kelsey Hagan, PhD, along with Carlin Lockwood, MPH, recently took a rigorous look at the research. They analyzed 24 papers comparing symptoms of people with atypical anorexia nervosa, people with anorexia nervosa, and people without an eating disorder. Here are some key takeaways:

  1. Across multiple studies, individuals with atypical anorexia nervosa had more severe psychological symptoms specific to eating disorders (i.e. overconcern with appearance/weight) compared to those with anorexia nervosa.
  2. People with atypical anorexia nervosa have similar levels of depression as those with anorexia nervosa. Unsurprisingly, both groups report more depression symptoms than peers without eating disorders.
  3. Atypical anorexia nervosa is associated with similar serious medical complications as anorexia nervosa. For example, individuals with either diagnosis can experience dangerous changes in their heart function and decreases in bone density.

There is much more we need to know and do.

Misunderstanding and misinformation about who gets eating disorders abound. Besides increasing diagnostic accuracy, it is important to conduct more research on atypical anorexia because there may be a greater proportion of males and non-white individuals within the atypical anorexia nervosa patient population compared to anorexia nervosa. Prior research indicates that males and individuals from ethnic/racial minority groups with eating disorders are less likely to seek treatment than others. To decrease barriers and increase access to care, we need to know who we are missing.

Atypical anorexia nervosa is testing the stereotype of an eating disorder patient as a thin, white, female, which is likely why the New York Times article on atypical anorexia nervosa was met with skepticism from some readers. There is emerging evidence refuting this stereotype in multiple eating disorders, not just atypical anorexia, including reports of no difference in prevalence, onset, and many risk factors for eating disorders (i.e., body dissatisfaction) across white, African American, Hispanic American, and Asian American females and no differences in eating disorder symptoms between cisgender male and female youths. Eating disorders can happen to anyone and may “look” very different from the stereotype.

There are also some glaring gaps in knowledge about treatment for atypical anorexia nervosa. There is not consensus as to how much weight loss (and over what period) should be required for a diagnosis of atypical anorexia nervosa. Gathering this information would help clinicians better spot signs of illness and decrease the likelihood of conflating these symptoms with other eating disorders. There is also uncertainty about how to establish weight restoration goals for this group, and which markers of physical and psychological health are meaningful.

Many of the research studies reviewed had small samples. To be more confident of findings, studies need to be replicated with bigger samples, and for samples to be bigger, we must build awareness of this diagnosis among more healthcare providers and the public.

How to recognize signs of atypical anorexia.

Recognizing signs of atypical anorexia nervosa can be difficult, as dietary changes and/or weight loss do not necessarily indicate an eating disorder. A visit to a primary care provider may be appropriate if you or your loved one:

  • has experienced significant weight loss and has an acute fear of weight gain,
  • has noticeably changed the foods eaten and/or is following strict food rules,
  • is eating in unusual patterns (for example, consuming large amounts of food followed by frequent trips to the bathroom),
  • is experiencing social difficulties because of concerns about eating.

If you or someone you know is experiencing symptoms of an eating disorder and is looking for treatment:

For a closer look at our publication, read here:

Walsh, B.T., Hagan, K.E., & Lockwood, C. (2022). A systematic review comparing atypical anorexia nervosa and anorexia nervosa. International Journal of Eating Disorders, 1-23.

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