What is Atypical Anorexia Nervosa? (June 2022)
Several times a week, a client shares with me that they have been restricting their food and eating a very low-calorie diet that has led to significant weight loss—along with episodes of dizziness and nausea and difficulty engaging with other people.
Unfortunately, when the client shares this information with their doctor, they’re often met with responses such as, “You don’t look like someone who restricts” or “You look “normal” or even “You look good.” The doctor may praise the client for losing weight—or “fat shame” the client if they are currently in a larger body—while ignoring the potentially dangerous symptoms they just revealed.
When a client in a larger body or a “normal weight body opens up about restrictive eating disorder symptoms, they often are met with judgment and doubt because they don’t fit the stereotype of what restrictive eating disorders “look like.” Weight stigma plays into these stereotypes, but so does lack of awareness about atypical anorexia.
Atypical anorexia nervosa is listed in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) under the category titled OSFED, which stands for Other Specified Feeding and Eating Disorders. This category includes warning signs and medical/psychological conditions that are similar to, and sometimes as severe as, formally labeled eating disorders.
It may be that “atypical” anorexia is more typical than you might think. A 2013 study found that 2.8% of young women develop atypical anorexia nervosa by age 20, significantly higher than the 0.8% who develop “regular” anorexia nervosa. This study did not include men or gender non-conforming individuals, so we don’t know that those percentages might look like.
You might wonder what signs and symptoms suggest that your loved one or patient has atypical anorexia nervosa. The answer is simple: The signs and symptoms are exactly the same as those for anorexia nervosa, except for weight/BMI. With atypical anorexia, the individual’s weight is within or above the “normal” BMI range, despite significant weight loss. Regardless of BMI, people with anorexia typically fear gaining weight and living in a larger body, have a distorted view of their body shape, and are restricting their caloric intake to a level that may be less than what a growing baby needs—and certainly far less than is necessary to survive and optimally.
If you find it hard to wrap your head around the idea that someone can have anorexia and be in a larger body, I recommend exploring your biases around body shapes and sizes. We all have biases, so instead of denying your biases around weight or getting defensive, I suggest completing the Implicit Association Test (IAT) developed by Project Implicit, a collaboration between researchers at Harvard and several other universities. IATs are available for weight and several other common sources of bias. Uncovering your biases, and confronting them with compassion, will help you be helpful rather than harmful when your patient is sharing their story. I also encourage you to acquaint yourself with HAES (Health at Every Size) for more guidance on supporting all clients in all bodies.
While exploring and breaking down your biases—and being a good listener when your clients tell their stories—is invaluable, it’s also worth looking at how weight-inclusive your office environment is. I recommend having furniture that can accommodate people in larger bodies—for example, sturdy chairs without arms and wide enough couches—and take a close look at your current office set up. Will it accommodate all your clients no matter what their body size or degree of mobility? Take a close look at the literature and reading materials in your waiting room and consultation rooms. Does any of it promote diets or weight loss? Are their tabloid magazines that praise people for being “disciplined” or “strict” with their diets? I recommend removing any and all of that!
Whitelaw M, Lee KJ, Gilbertson H, Sawyer SM. Predictors of complications in anorexia nervosa and atypical anorexia nervosa: degree of underweight or extent and recency of weight loss? J Adolesc Health. 2018;63(6):717-723.
Masheb RM, Ramsey CM, Marsh AG, Snow JL, Brandt CA, Haskell SG. Atypical anorexia nervosa, not so atypical after all: prevalence, correlates, and clinical severity among United States military veterans. Eat Behav. 2021;41:101496.
Kennedy GA, Forman SF, Woods ER, et al. History of overweight/obesity as predictor of care received at 1-year follow-up in adolescents with anorexia nervosa or atypical anorexia nervosa. J Adolesc Health. 2017;60(6):674-679.
Stice E, Marti CN, Rohde P. Prevalence, incidence, impairment, and course of the proposed DSM-5 eating disorder diagnoses in an 8-year prospective community study of young women. J Abnorm Psychol. 2013;122(2):445-457.
“The Eating Disorder Trap: A Guide for Clinicians and Loved Ones” by Robyn L. Goldberg, RDN, CEDRD-S
“Health at Every Size: The Surprising Truth About Your Weight” by Lindo Bacon, PhD
“Body Respect: What Conventional Health Books Get Wrong, Leave Out, and Just Plain Fail To Understand About Weight,” by Lindo Bacon, PhD and Lucy Aphramor, PhD, RD
“Sick Enough: A Guide to the Medical Complications of Eating Disorders” by Jennifer Gaudiani, MD, CEDS, FAED