Anorexia Nervosa & Atypical Anorexia Nervosa
What are Anorexia Nervosa and Atypical Anorexia Nervosa?
Today we want to share information about another eating disorder diagnosis our team sees on a regular basis Anorexia Nervosa. Anorexia Nervosa (AN) has one of the highest mortality rates among mental health diagnoses [2] due to malnutrition, complications, and/or suicide [3]. While AN is a commonly known eating disorder often characterized by an individual having a very low body weight, it is critical to understand that it can affect people in a variety of body sizes and shapes. Below, we break down the differences and similarities between AN and atypical anorexia (AAN) (hint: there is only 1 major difference), causes, symptoms, and treatment.
Anorexia Nervosa
Diagnostic Criteria
Some of the criteria a practitioner would look for in an AN diagnosis include:
Restriction of energy intake relative to requirements that leads to significantly low body weight for an individual’s age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or expected.
Intense fear of weight gain or becoming fat.
Disturbance in self-perceived weight or shape [1].
Subtypes
Binge/Purge Type: Engagement in recurrent episodes of binging and purging behavior (i.e. self-induced vomiting, misuse of laxatives, diuretics, and/or enemas) over the past 3 months.
Restricting Type: Engagement in dieting, fasting, or excessive exercise for the purpose of weight loss over the past 3 months, without engaging in binge/purge behaviors listed above.
Atypical Anorexia Nervosa
AAN falls into the OSFED (Other Specified Feeding or Eating Disorder) category in which an individual meets all criteria for anorexia, but their weight is in the normal range. You might be surprised to know that AAN is 2-3 times more common than AN [5, 6], with less than 8% of people struggling with eating disorders being classified as ‘underweight’. Though labeled, as atypical, it is anything but, as it is estimated that up to 4.9% of people might experience AAN in their lifetime [5]. Of individuals seeking inpatient eating disorder care, 25-40% have a diagnosis of AAN [5]. Despite this number, people with AAN are less likely to receive treatment or be referred out for care, especially inpatient care [7].
Size and weight bias are evident in the differentiation of AN and AAN. Because AN is often associated with bodies that look thin or emaciated, significant groups of people presenting as ‘normal’ or even ‘overweight’ (over what weight?!) are overlooked, leading to concerns of not being sick enough or not really having a struggle because they don’t ‘look’ like they have an eating disorder.
Eating disorders do not have a look. Eating disorders affect people of all genders, ethnicities, abilities, and body shapes/sizes. The influence of diet culture and the thin ideal has seeped over into diagnostic criteria, acting as a gatekeeper to treatment for people that desperately need it.
Symptoms of Anorexia Nervosa/Atypical Anorexia Nervosa
development of food rituals
intense fear of weight gain
disturbances in body size, shape, or weight
inflexible thinking
excessive and rigid exercise to ‘burn off’ calories
limited social eating and social spontaneity
GI distress
dry skin and nails
dental problems
impaired immune functioning and poor wound healing
dizziness
difficulty concentrating [4]
** this is not an exhaustive list
What Causes Anorexia Nervosa?
Like other mental health disorders, AN and AAN have no single cause, but rather a variety of biological, psychological, and social (bio-psycho-social) components.
Biological and Psychological
AN/AAN has strong heritability, ranging from 40-60%, with individuals being 11 times more likely to develop anorexia if someone in their immediate family has struggled with AN [3]. Additionally, certain personality traits like “perfectionism, low impulsivity, harm avoidance, low self-esteem, anxiety, low self-directedness, and overvaluation of body image [3]” are all linked to AN/AAN. There are also strong correlations between AN with other psychiatric disorders like obsessive-compulsive disorder, anxiety, and depression, which can be co-occurring disorders [3]. Trauma history, lack of emotional regulation, and body image struggles are also contributing factors.
Social
We’ve discussed in other posts the effects diet culture, fatphobia, and the thin ideal have on how we approach and engage with food, and the same is true with anorexia. Being in environments where the pressure to maintain a certain weight or have your body look a specific way in order to find success or acceptance can also play a role.
Medical Complications
For AN/AAN, the major cause of medical complications is an imbalance between energy requirements and intake (restriction), which leads to a hypometabolic state. In order to achieve and maintain homeostasis in a malnourished state, “the body down-regulates, causing many of the signs and symptoms” consistent with AN/AAN [2].
Bradycardia
Amenorrhea
Hair thinning/loss
low blood pressure
dehydration
fatigue
osteoporosis
fertility issues [3]
** this is not an exhaustive list
Treatment
Treatment for AN/AAN is dependent on the level of care needed. Due to the nature of medical complications, medical treatment, and nutritional rehabilitation/therapy are crucial, especially if weight restoration is required. This can be done in an inpatient or outpatient setting, depending on the severity. Psychotherapy is also recommended to challenge and reframe maladaptive coping strategies and thought patterns. Family-Based Treatment (FBT), Cognitive Behavioral Therapy (CBT), Dialectical Behavioral Therapy (DBT), and Acceptance and Commitment Therapy (ACT) are among the strongest evidence-based treatment modalities [8].
Socialization is another important part of treatment [2]. Eating disorders like AN/AAN can be extremely isolating and can consume much of a person’s life. Building support systems, finding new hobbies, and building independence can aid in recovery!
Seeking Help
The therapists and dietitians at Collaborative Counseling and Nutrition specialize in treating eating disorders, including AN/AAN. If you or a loved one is struggling with AN/AAN, please reach out to our team today! We know it can be difficult to reach out, but we would love to help!
Resources Used:
[1] American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5 (5th ed.). American Psychiatric Publishing.
[2] Moskowitz, L., & Weiselberg, E. C. (2017). Anorexia Nervosa/Atypical Anorexia Nervosa. Current Problems in Pediatric and Adolescent Health Care, 47(4), 70–84. https://doi.org/10.1016/j.cppeds.2017.02.003
[3] Anorexia Nervosa Treatment & Recovery Centers | Eating Recovery Center. (n.d.). Eating Recovery Center. https://www.eatingrecoverycenter.com/conditions/anorexia
[4] National Eating Disorders Association. (2018, February 28). Anorexia Nervosa. https://www.nationaleatingdisorders.org/learn/by-eating-disorder/anorexia
[5] Harrop, E.N., Mensinger, J.L., Moore, M. & Lindhorst, T. (2021). Restrictive eating disorders in higher weight persons: A systematic review of atypical anorexia nervosa prevalence and consecutive admission literature. International Journal of Eating Disorders: 54(8); 1328-1357
[6] Harrop, E. N., Mensinger, J. L., Moore, M., & Lindhorst, T. (2021). Restrictive eating disorders in higher weight persons: A systematic review of atypical anorexia nervosa prevalence and consecutive admission literature. International Journal of Eating Disorders, 54(8), 1328–1357. https://doi.org/10.1002/eat.23519
[7] Golden, N.H. & Mehler, P.S. (2020). Atypical anorexia nervosa can be just as bad. Cleveland Clinic Journal of Medicine 87(3); 172-174.
[8] Eating Disorder Recovery Center. (n.d.). Atypical Anorexia. Retrieved May 11, 2023, from https://www.eatingrecoverycenter.com/conditions/atypical-anorexia
Collaborative Counseling & Nutrition is an outpatient nutrition and body image counseling center, with locations in Indianapolis and Carmel, that provides compassionate, holistic eating disorder treatment. Through practicing mindfulness, intuition, and Health At Every Size, we are on a mission to help you find a true state of well-being! We take an anti-diet, weight-inclusive approach with all our clients and work to help guide you towards a way of healthy living designed by you, just for you! This post is for education purposes only and should not be used as a substitute for treatment for an eating disorder. If you are looking for a registered dietitian or therapist to assist you on your recovery journey, please reach out today!
