Atypical Anorexia

What is Atypical Anorexia Nervosa?

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Atypical anorexia nervosa is an eating disorder that presents with the same symptoms as anorexia nervosa, except that the person is within a “normal” or higher weight range after losing a significant amount of weight.¹ Despite being labeled as “atypical,” some studies have found that atypical anorexia is equally if not more common than anorexia with 0.2% – 4.9% of people experiencing the disorder at some point in their lifetimes, a rate two or three times higher than that of anorexia.² Furthermore, in the last decade research has found that the number of patients seeking treatment for atypical anorexia has increased substantially and led to a greater proportion of patients seeking hospitalization for complications due to the disorder.^3,4

Unfortunately, despite the increasing prevalence, individuals with atypical anorexia are less likely to be diagnosed and receive eating disorder treatment than those with anorexia due to weight bias among providers and the stereotype that a person has to be underweight to have an eating disorder.⁵ The reality, however, is that anyone regardless of their shape and size can have a serious and life threatening eating disorder that requires treatment. Since atypical anorexia can often go undiagnosed and untreated, it is important that if you or a loved one is experiencing any symptoms of this disorder they seek professional help as early as possible.⁶ 

How is Atypical Anorexia Diagnosed?

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The DSM-5 TR categorizes atypical anorexia as part of the group of eating disorders called Other Specified Feeding or Eating Disorders (OSFED). In order for a person to be diagnosed with atypical anorexia nervosa, they must meet all the same criteria for anorexia nervosa including:¹

• Restrictive eating behaviors leading to significant weight loss. 
• Intense fear of gaining weight.
• Body weight and shape disturbance.

Except the individual’s weight is within or above what is considered in the “normal” range. 

What are the Signs and Symptoms of Atypical Anorexia?

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A growing body of research has found that compared to anorexia nervosa, people with atypical anorexia experience similar symptoms of medical instability and that rapid weight loss at any body size can lead to serious life threatening medical complications often associated with malnutrition.⁵  Individuals with atypical anorexia also exhibit equal or more severe psychological symptoms compared to individuals with anorexia.⁷ In particular, studies have found that people with atypical anorexia have the same or higher rates of distress about their weight and body shape than those with anorexia.⁸ Below is a list of the signs and symptoms of atypical anorexia. However, please note that even though these are common symptoms not everyone with the disorder displays all of them:^1,7,9,10 

Emotional and Behavioral Signs and Symptoms

• Has disturbed experience of body weight or shape, or undue influence of weight or shape on self-evaluation.
• Is preoccupied with weight, food, calories, fat grams, and dieting.
• Refuses to eat certain foods, and often eliminates whole food groups.
• Has intense fear of weight gain.
• Complains of constipation, abdominal pain, cold intolerance, lethargy.
• Denies feeling hungry.
• Develops food rituals (e.g., eating foods in certain orders, excessive chewing, rearranging food on a plate).
• Makes excuses to avoid mealtimes or situations involving food.
• Engages in compensatory behaviors such as self-induced vomiting, diuretic/laxative use, fasting/restricting, or manipulation of insulin dosage.
• Maintains an excessive, rigid exercise regimen – despite weather, fatigue, illness, or injury. 
• Withdraws from friends and previously pleasurable activities and becomes more isolated and secretive.

Physical Signs and Symptoms

• Significant weight loss while being within or above the “normal” range for weight.
• Stomach cramps, other non-specific gastrointestinal complaints (constipation, acid reflux, etc.)
• Difficulties concentrating
• Abnormal laboratory findings (anemia, low thyroid and hormone levels, low potassium, low blood cell counts, slow heart rate, low blood pressure), though some people do not have all of these or any laboratory abnormalities.
• Dizziness
• Fainting/syncope
• Low heart rate 
• Feeling cold all the time
• Menstrual irregularities, primary or secondary amenorrhea (not starting the menstrual cycle or the loss of the menstrual cycle) or only experiencing a period when taking hormonal supplements.
• Dental problems due to purging including erosion of enamel; bleeding gums/periodontal disease; temperature sensitivity; cavities; discoloration of teeth; dry mouth; enlarged parotid/submandibular glands and swallowing problems.
• Dry skin
• Dry and brittle nails
• Fine hair on body (lanugo)
• Thinning of hair on head, dry and brittle hair 
• Muscle weakness
• Cold, mottled hands and feet or swelling of feet and ankles
• Poor wound healing

What Conditions Frequently Co-Occur?⁹

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• Anxiety disorders including generalized anxiety disorder, social anxiety, phobias, panic disorder and post-traumatic stress disorder.
• Depression and other mood disorders.
• Self-injurious behaviors (cutting and other forms of self-harm without suicidal intent).
• Suicide Ideation.

What are the Health Consequences of Atypical Anorexia?

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The health consequences of atypical anorexia can be just as severe or more severe as anorexia nervosa and can affect all organs of the body. These health consequences can include:⁷

• Cardiovascular problems such as low heart rate (bradycardia) and low blood pressure (hypotension). 
• Gastrointestinal problems which can lead to issues such as nausea, bloating, constipation, acid reflux and involuntary vomiting.
• Kidney problems.
• Electrolyte changes such as low levels of phosphorus (hypophosphatemia), potassium (hypokalemia), serum sodium (hyponatremia) and/or magnesium (hypomagnesemia).
• Neurological issues which can lead to seizures, dizziness, fainting, sleep problems, and difficulty concentrating.
• Hormonal changes which can lead to problems like loss of menstrual periods and increased bone loss.
• Anemia or low red blood cell count.
• Death.

Learn more about health consequences.

How is Atypical Anorexia Treated?¹⁰

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Treating atypical anorexia requires working with a multidisciplinary team of health and mental health professionals who have expertise in treating eating disorders. This treatment team may include a physician, psychiatrist, psychotherapist, and dietician. Given the serious physical and psychological consequences that can result from atypical anorexia it is essential to seek professional help as soon as possible since early intervention has been shown to be an important factor in improving treatment outcomes.^2,6 

What are Barriers to Treatment?

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Despite the need for timely intervention, many people with atypical anorexia are misdiagnosed and underdiagnosed when symptoms are missed or individuals delay seeking treatment due to weight stigma and stereotypical beliefs that only people in smaller body sizes can have restrictive or serious eating disorders.¹¹ Sadly this stereotype and discrimination based on weight is not only pervasive in our larger society, but all too common among healthcare providers, and even some eating disorder professionals  as well.

Indeed, studies have found that despite there being equal or higher rates of atypical anorexia compared to anorexia, healthcare providers are more likely to overlook eating disorder symptoms in patients with higher weight bodies.¹² As a result, people with atypical anorexia are far less likely to be referred to eating disorder specific treatment and receive clinical care.^2,13 People living in larger bodies are more likely to be referred to “weight management” clinics than eating disorder care. 

Another barrier to getting necessary treatment for atypical anorexia, is that health insurance plans use weight requirements to determine the severity of the illness, classifying lower weights as more severe and eligible for higher levels of care.² These guidelines, which are based on the DSM-5 diagnostic criteria for anorexia nervosa, prevent patients from accessing necessary treatment and reinforce harmful stereotypes that only those who are underweight experience serious eating disorders.² Such policies may also promote weight stigma and worsen restrictive eating behaviors by setting up a system where patients end up believing they are not “sick enough” to qualify for treatment.⁶

Next Steps

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To combat these barriers and dispel harmful myths, it is vitally important that healthcare providers are aware that anyone regardless of their weight can have an eating disorder, that living in a larger body increases eating disorder risk and that those with atypical anorexia experience health consequences and eating disorder symptoms just as severe as those patients with anorexia. It is also important that patients of all weights are screened for restrictive eating disorders so that individuals with this life-threatening disorder get the help they need and deserve. It is equally important to ensure that patients with atypical anorexia are not being recommended to treatments that carry the risk of worsening their restrictive eating disorder.²

If you or someone you love is experiencing signs of atypical anorexia it is important to seek professional help from an eating disorder professional. To address the systemic barriers to care and weight stigma that many individuals with atypical anorexia face when seeking help, it is important to seek care from eating disorders and medical professionals whose practices are rooted in weight inclusive care.  

Learn more about treatment here.

Learn more about finding treatment providers in your area here.