What Is Atypical Anorexia? How Eating Disorders Can Hide In Plain Sight

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Today marks the start of National Eating Disorders Awareness Week, which runs from February 25 to March 3, 2019. This annual event is dedicated to spreading awareness about this specific category of mental illness, which according to the National Association of Anorexia Nervosa and Associated Disorders, affects at least 30 million people in the U.S. At least one person dies from an eating disorder every 62 minutes. In this feature, health reporter Georgina Berbari describes a particularly pernicious type of eating disorder: one that's almost completely invisible to outside observers. It's an important reminder that while wellness does involve physical rituals like healthy eating and exercise routines, true wellness cannot be achieved without mindful dedication toward the health and fitness of the mind.

An emaciated, visibly withdrawn female, all skin and bones, who rarely touches food because of her all-consuming desire to be thin.

For a long time, this is the stereotypical image that I allowed to materialize in my mind when I thought of anorexia—that is, until I realized that only a portion of sufferers fit this partly falsified and culture-driven mold.

Eating disorders affect people from all walks of life—all races and ethnicities, across the gender spectrum, younger, older, and, yes, people of all shapes and sizes. "We cannot tell when people have an eating disorder by their size or appearance," confirms Dr. Ovidio Bermudez, a clinician at the Eating Recovery Center in Denver, in an interview with mindbodygreen.

The truth is, eating disorders can—and often do—hide in plain sight. There's a somewhat new diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) that explains this phenomenon: atypical anorexia.

What is atypical anorexia?

"Atypical anorexia is a new diagnosis, and the incidence and prevalence has not been studied," Dr. Bermudez tells me. "It has occurred for a long time but not in the numbers that we are seeing now—thus its mention and inclusion in the DSM-5."

According to Dr. Bermudez, there are many similarities between "standard" anorexia (known medically as anorexia nervosa) and atypical anorexia, including the desire to lose weight, fear of weight gain, and difficulties with negative body image. What makes it "atypical," though, is that people who struggle with it maintain a "normal" weight appearance, whether that be overweight or thin without extreme emaciation. So they often fly under the radar without receiving treatment, all the while getting sicker and sicker.

Much like any eating disorder, atypical anorexia leads to both psychological and physiological complications. "An impaired energy output for an extended period of time leads to medical complications, regardless of weight," he tells me. This is because of the energy deficit that restriction introduces in the body—just because visible weight loss doesn't accompany anorexic behaviors doesn't mean that long-lasting, serious internal damage isn't still taking place. On the contrary: The behaviors in people with atypical anorexia are no different from those of people suffering from "standard" anorexia nervosa. The only difference is that the individual's weight remains within or above the normal range, making the disorder go culturally unnoticed often for far too long.

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The problem with labels.

Though a large and noteworthy step has certainly been taken by including atypical anorexia in the DSM-5, the "atypical" verbiage can be viewed as problematic. To Crystal Savoy, M.S., R.D., LDN, a dietitian specializing in disordered eating at a nutrition counseling group called Real Life Women's Health, the disorder actually isn't atypical at all.

"Atypical anorexia is by far more prevalent, occurring in up to 3 percent of the population compared to 1 percent with [standard] anorexia nervosa," she tells me, going on to say, "Labels of all kinds are tricky because they serve a purpose in terms of insurance and at the same time create problems—because they label a disorder that doesn't necessarily 'fit the mold' of the DSM criteria."

As someone who has recovered from anorexia herself, I personally can attest to the fact that admitting you're "sick enough" is hard enough itself without society telling you that you don't fit a stereotypical weight-centric image of thinness. So how do we remedy this?

"Perhaps with time, this term will go away," Dr. Bermudez speculates. "Right now, however, [the atypical label] is fair, if that's how people need to recognize it [as a serious illness]."

The psychological, physiological effects of atypical anorexia.

As mentioned, the effects of atypical anorexia are similar to what happens from "typical" anorexia nervosa. According to a 2015 study in the Journal of Eating Disorders, the physiological symptoms can include, but are not limited to, cardiovascular impairments, dermatologic issues, along with hematologic, gastrointestinal, ophthalmic, and pulmonary stultifications. In other words, atypical anorexia does not discriminate, affecting every inch of the body obdurately.

Eating disorders—atypical anorexia included—have the highest mortality rate of any mental illness. Ashley Solomon, Psy.D., the executive clinical director at Eating Recovery Center in Ohio, tells mbg that there are a host of cardiac rhythm disturbances that are directly caused by weight loss of any capacity and malnutrition. "These are undoubtedly causal in the heightened risk for sudden death seen in people with anorexia nervosa," she writes. "Despite these very serious cardiac concerns, many people with eating disorders are reluctant to get help. The disorders themselves are marked by a brain-based type of denial that can make even seeing that there's a problem very difficult. As a clinician, I find that sometimes the presence of these heart issues can help someone see just how high the risk to their health really is."

In terms of the psychological and emotional effects of the disorder, Savoy says these also mimic the mental infliction of typical anorexia, along with other eating disorders. "Research shows that adults with 'atypical' or 'subclinical' anorexia scored just as high on measures of eating disorder thoughts and behaviors as those with DSM-diagnosed anorexia nervosa and bulimia nervosa," she says.

These side effects include, but aren't limited to, lowered self-esteem, social withdrawal, decreased sex drive, insomnia, anxiety, and depression.

Why it's crucial to look beyond weight when diagnosing eating disorders.

Beyond challenging stereotypes and eliminating culture-bound stigmas around body size, which is certainly important in and of itself, it's clinically imperative to look beyond weight in the diagnosis of eating disorders, especially when it comes to atypical anorexia.

"Practitioners' assumptions and own bias about weight invalidate clients and delays treatment," Savoy explains. She cites Sick Enough by Jennifer Gaudiani, M.D., CEDS, FAED, who writes, "Many individuals with atypical anorexia nervosa don't believe they have an eating disorder because they aren't stereotypically emaciated. This is only reinforced by society and medical providers who not only miss the eating disorder but praise such patients for their weight loss and presumed 'health' when, in fact, the behaviors being used are the opposite of healthy."

Savoy adds that it's important to remember how different we are as individuals and that the body's response to restriction is going to vary (whether that be to lose weight, gain weight, or remain unchanged): "To rely on weight as an indicator of the severity of an eating disorder is highly problematic," she asserts.

"I just had something happen [in a client session] that sums up why this is so harmful," Savoy reflects. "One of my clients went to her PCP for stomach pain and acid reflux only to be told to lose weight, without any questions being asked about her lifestyle, simply because her BMI is above the 'normal' range. She already barely eats and is now feeling stressed, depressed, and I'm sure shamed. We must do better."

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Beginning the recovery process.

Choosing to recover from an eating disorder can be confusing, terrifying, and seemingly unattainable. As someone who does consider herself recovered, I know that despite the exceptional difficulty, the courageous decision is possible and worthwhile.

Neeru Bakshi, M.D., FAPA, a board-certified psychiatrist and the medical director for Eating Recovery Center in Washington, tells mbg that what's often hard for people to understand—family and friends, but even the person who themselves is suffering—is that having an eating disorder is not a choice. According to Dr. Bakshi, people can be predisposed to inheriting an eating disorder, but sociological factors can also play a role, such as traumatic events, significant life changes, or diets. The choice is whether or not to seek and accept treatment.

Part of that choice, for atypical anorexia patients, is to accept that they are indeed "sick enough" despite their weight or BMI not necessarily conforming to a falsified stereotype.

While types of treatment vary widely depending on practitioners and treatment centers, standard treatment for atypical anorexia, according to the National Eating Disorders Association, might include intensive inpatient or outpatient treatment (depending on severity of the illness), partial hospitalization, and/or psychotherapy (i.e., cognitive behavioral therapy, dialectical behavior therapy, evidence-based treatment, etc.). "All eating disorders require similar treatment in that it isn't just one factor to focus on and is multifactorial requiring a supportive treatment team," Savoy tells me. Research shows that a multidisciplinary team consisting of a medical doctor, psychiatrist, therapist, and a dietitian is most effective for lasting recovery, while medications as adjunctive treatment might also be considered on a case-by-case basis.

Considering wellness-based healing methods.

Aside from the above recovery methods and Western-based treatments, different Easternized modalities may also help. "This will look different for everyone," Savoy explains. "Meditation, gentle yoga, and journaling are a few that come to mind." Oftentimes, a hallmark of the eating disorder is a disconnection between the brain and the body, she says, "so mindfulness-based techniques can help to repair that disconnect and begin to heal the mind-body relationship."

It's crucial to note that, while using wellness-based healing methods can be incredibly healing throughout the often turbulent process of recovery, they are not a substitution for professional medical care or a supportive treatment team. "The message should not be: Hey guys, these things are good and you should try them first," Dr. Bermudez says. "Sometimes, people confuse individualized care with [idealizations of] I want an alternative treatment that lets me stay untreated. [However], the neurobiological restoration needs to take place first before any alternative methods can be relied on."

Within my own journey toward recovery, once I was neurobiologically restored, I found acupuncture to be a wonderful healing method (in conjunction with biweekly therapy sessions, weekly dietitian checkups, and close, constant monitoring from my PCP), especially in terms of restoring my menstrual cycle, a function that is lost by many sufferers of anorexia who are faced with amenorrhea. And meditation, restorative yoga, and journaling have been invaluable supplements in my recovery process.

The first step is always consulting with and listening to your treatment team, and the rest will follow, including the option and freedoms to experiment with wellness-based healing modalities that are available to you.

Recovery is possible.

"Know that recovery is always possible," Dr. Solomon tells mbg. "Even people who lived with an eating disorder for a very long time can expect a full and lasting recovery. It's not easy and can't be accomplished alone, but everyone suffering from an eating disorder can be helped."

In the meantime, Dr. Bermudez tells me that the Eating Recovery Center is making sure that delayed diagnoses in eating disorders (and most prominently, atypical anorexia cases) decrease.

"It's really important to work on your own biases if you're working with eating disorders and dig into what those beliefs are around weight—because that belief can and does directly influence the care that a person is receiving," Savoy adds.

Fortunately, a shift in the right direction is being made, due to observant, intuitive, and attentive doctors and inclusive, weight-neutral dietitians.

"When I put all the symptoms together, it's an eating disorder," Dr. Bermudez concludes. "It doesn't need to have a name."

For additional information about the Eating Recovery Center, call 877-789-5758, email info@eatingrecoverycenter.com, or visit www.eatingrecoverycenter.com to speak with a masters-level clinician.

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