The Reality of Atypical Anorexia Nervosa

If you’ve recently become aware that a loved one has been diagnosed with atypical anorexia nervosa, and you are not quite sure what that means, you are not alone. It is a relatively new diagnosis. It was introduced about a decade ago in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), filling an important gap. Here are a few commonly asked questions about it.

What is atypical anorexia nervosa?

Atypical anorexia nervosa is defined as meeting the criteria of anorexia nervosa, with the exception that body weight is not in an ‘objectively’ low range based upon commonly used medical standards. In recent years, it has become more widely recognized that people at a “normal” or higher-than-average body size can experience the same medical consequences, psychological distress, and day-to-day impairment as those with an objectively low body weight. This typically occurs in the setting of highly restrictive eating. Weight loss sets off similar psychological and physical symptoms of malnutrition as those seen in anorexia nervosa.

Read here for the history of the term atypical anorexia nervosa and what we have learned about the disorder in the last decade.

What is the difference between this and healthful weight loss or diet changes?

Reductions in weight that precede a diagnosis of atypical anorexia nervosa tend to be rapidly occurring and significant in magnitude. Eating behavior changes a lot – not a little. And, it begins to clearly sit on the eating disorder end of the eating behavior spectrum. Eating behavior may involve:   

• Rigid food rules, such as the elimination of entire food groups or categories
• Secrecy around food, making excuses for not eating, denial of hunger
• Extreme difficulty being flexible about food or in eating-related situations (i.e., dining at restaurants or while traveling) 

Restrictive eating, weight loss, and a state of relative starvation based on one’s body’s needs lead to changes in emotions and mood. Like what is seen in anorexia nervosa, people describe feeling more anxious, depressed, irritable, fatigued, and isolated. Treatment of these symptoms will require the implementation of “regular eating.”

My loved one lost weight and is now in a “normal” weight range. Isn’t that healthier?

Simply put: not necessarily. Weight (or body size) is not the sole indicator of health! Other important markers of health include specific proteins and hormones, blood pressure, and resting heart rate (not to mention psychological well-being).  

There is a common misconception that because people with atypical anorexia nervosa are not underweight according to their body mass index (a standardized weight for height calculation), they must be at a healthy weight.  Body mass index, however, is a population measure. It is designed to capture potential correlations between weight and chronic illness. It is also used as a screening tool to gauge disease risk. For more on the history of and flawed nature of body mass index, check out this video.

Body mass index is limited in what it conveys about any particular individual. For example, many factors, such as age, sex, race, muscle mass, activity level, and more, are not included in the calculations. However, they are necessary for wholly understanding an individual’s health status. Also, these norms were primarily developed based on white males and thus are not representative of the general population.

Even within this limited and imperfect framework, the “normal” body mass index category for adults can span a 40-lb weight range. This underscores that not everyone’s natural, ideal weight is the same. We would not expect everyone at the same height to have the same shoe size. So we also would not expect everyone at the same height to have precisely the same weight.

With that in mind, someone with atypical anorexia nervosa might be at a seemingly reasonable weight that is actually underweight or undernourished for them.  

Will my loved one need to gain weight to get well?

An individual’s healthy weight is variable and specific to them. When someone is below their healthy weight, weight gain is crucial. Like in anorexia nervosa, a critical aspect of treatment is to reverse malnutrition. The goal is to help the individual reach a weight that is associated with psychological and physical health for them.

Is it less serious than anorexia nervosa?

Many people think that atypical anorexia nervosa is a less severe diagnosis than anorexia nervosa. This may be because of its name. Or, because the problem falls under the “other” eating disorder category in the DSM-5. But data collected over the past decade suggest otherwise. For example, those with atypical anorexia nervosa seem, on average, to experience very similar and sometimes even more severe restrictive eating behavior, eating disorder symptoms such as body dissatisfaction, and medical complications, like low heart rate and low blood pressure, compared to those with anorexia nervosa. Regardless of weight at the start of treatment, those people who have lost weight rapidly and/or lost a lot of weight from their baseline appear to have a more severe version of the illness.

Who is commonly affected by this disorder?

There are many myths that anorexia nervosa only affects certain types of people. However, countless studies have shown that people can experience eating disorder symptoms. This is true regardless of race/ethnicity, weight, socioeconomic status, age, sex, and gender identity. Some data suggest that males and non-white individuals make up a great proportion of cases compared to anorexia nervosa. This may be partly explained by cultural differences in eating behavior and diet. Or, by differences in body image ideals across sex, gender identity, culture, and race/ethnicity, all of which can impact eating disorder symptoms. 

False ideas about who is at risk for developing an eating disorder can lead to:

• stigma,
• lack of recognition of illness severity, and
• failure to seek treatment, specifically for higher-weight individuals, racial and ethnic minorities, male and gender minorities, or people of lower socioeconomic status. 

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