"You aren’t thin enough to have an eating disorder."
If you're struggling with an eating disorder and aren't visibly underweight, you've probably heard some version of this. Possibly you've finally managed to go and talk to your GP about your restrictive eating only to be placed on the scale and told not to worry too much because your weight looks okay. Or possibly your family or friends notice your weight loss and congratulate you rather than get concerned " you look great! whatever you're doing keep it up!". In our diet and weight obsessed culture, when an apparently healthy person loses weight, it's almost always seen as a positive thing. It's rarely, if ever, considered that the weight loss could have been caused by an eating disorder.
I had a client who is 1.5 metres (5 foot) tall; she had lost approximately 20% of her body weight, she had a resting pulse of 40 beats bpm, and had no periods for a year, but she was dismissed by her GP because her BMI remained within the 'normal' range at 19.
Definition of atypical anorexia
Atypical anorexia nervosa is one of the five eating disorders categorised in the DSM-V under OSFED (Other Specified Feeding and Eating Disorders).
Atypical anorexia is defined by the DSM-V as an eating disorder in which “all of the criteria for AN are met, except that despite significant weight loss, the individual's weight is within or above the normal range.”
Despite this definition, eating disorders in people at higher weights are commonly misdiagnosed, leading to delays in treatment of months and sometimes years, and as a result, to more negative prognoses. Disturbingly, proper diagnosis may not be made until the person has become visibly underweight or even severely malnourished.
Even when it is diagnosed, experience shows us that doctors view an eating disorder in someone at a higher weight as less serious than an eating disorder in someone who is underweight.
A research study by Sawyer et al. (2016) examined adolescents with atypical anorexia nervosa (AN) and compared them to adolescents with full-threshold AN to assess how the physical and psychological complications of these two illnesses compare.
Results of this study showed that, when compared with full-threshold AN, adolescents diagnosed with atypical AN were more likely to experience more severe eating disorder symptoms, lower self-esteem, and present for treatment having lost more weight over a longer period of time.
Medical complications of atypical AN and full-threshold AN were similar; no significant differences ( indicating either increased or decreased seriousness) in symptoms such as frequency of bradycardia ( very low resting pulse rate, typically 60 bpm or less), marked orthostatic changes (low blood pressure that happens when you stand up or sit down), hypothermia, or admissions to hospital. There were also no significant differences on measures of binge eating, purging, psychiatric comorbidity, self-harm, suicidal ideation, severity of depressive symptoms, or obsessive compulsiveness.
This study concluded that atypical AN in adolescents is a major psychiatric illness with physical and psychological complications similar to full-threshold AN, except with more severe distress related to eating and body image.
Also, despite not being underweight, nearly 1 in 4 adolescents in this study with atypical AN had bradycardia, 1 in 3 had amenorrhea, and more than 40% required inpatient hospitalisation. Thirty-eight percent also had psychiatric conditions (depressive disorders were most common at 31% followed by anxiety disorders at 17% and obsessive-compulsive disorder at 5%) and 43% experienced self-harm or suicidal ideation.
With this in mind, We have to look beyond body weight when diagnosing and assessing eating disorders. Clearly weight loss must always be a red flag, (especially when dealing with adolescents, a period when weight tends towards an upward trajectory). Obviously,this does not mean that everyone who loses weight has an eating disorder, but if you're a medical professional, or a friend or family member, it's important not to assume that weight loss is healthy or intentional.
And If you're struggling with atypical anorexia yourself, and you remember only one thing from this post, make it that research has not found a difference in the medical and psychological impact of anorexia and atypical anorexia. You are ill enough , and you should get help.
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References
Sawyer SM, Whitelaw M, Le Grange D, et al. Physical and Psychological Morbidity in Adolescents With Atypical Anorexia Nervosa. Pediatrics. 2016; 137 (4).