Content/Trigger Warning: This article discusses Atypical Anorexia, Anorexia, and generalized eating disorder behavior. If you suffer from an eating disorder, proceed with caution.
When I was fourteen years old, I was diagnosed with Atypical Anorexia Nervosa. As a competitive athlete, I was still extremely fit. No one would have expected me, a perfectly healthy-looking girl, to develop an eating disorder (ED). Yet, there I was with my parents in the waiting room of an ED specialist after suddenly passing out.
The doctor spent a long time asking me questions about my eating habits, the relationship I had with my body, how much time I worked out, and of course, my weight. At the close of the session, she handed me a book with big black letters on the shiny cover: ALMOST ANOREXIC. My heart sank. After suffering in silence for far too long, I felt as if this doctor didn’t believe me. I didn’t feel like I was actually sick yet. She continued to explain that I had Atypical Anorexia due to my weight remaining in a normal BMI range. She then shooed me along with my brain ruminating over the appointment. Did she really just insinuate I was too fat to have Anorexia? That I was almost there, but not yet… like in her book? My physical size officially impacted my mental illness diagnosis.
Atypical EDs vs. “typical” EDs
Unfortunately, my situation was not an isolated case. To receive an Atypical Anorexia diagnosis from the DSM-V, it states that “all of the criteria for anorexia nervosa are met, except that despite significant weight loss, the individual’s weight is within or above the normal range.” This directly correlates to the DSM’s diagnosis of Anorexia Nervosa, where the patient’s severity is only considered “mild” if the BMI is above 17. However, according to The National Association of Anorexia Nervosa and Associated Disorders (ANAD), only 6% of ED patients are clinically underweight. If ANAD is correct with this statistic, why is it considered “atypical” to be a normal weight while struggling? Why isn’t Atypical Anorexia the one we talk about? If the weight loss and behaviors are “significant”, why isn’t the diagnosis?
Atypical Anorexia is actually a subtype of Other Specified Feeding or Eating Disorder (OSFED). OSFED was previously known as Eating Disorder Not Otherwise Specified (EDNOS) in the DSM-IV. OSFED, while a real and valid ED diagnosis, unfortunately, serves as a catch-all for diagnosing EDs that don’t quite fit the criteria of Anorexia, Bulimia, or Binge-Eating Disorder (BED). Other than Atypical Anorexia, it includes Purging Disorder and “lower-frequency” versions of Bulimia and BED. This continues to draw a line between “typical” and “atypical” disorders by insinuating severity based on how many physical behaviors and side effects are present. Why are these mental illness being considered “atypical” with only slight physical differences? Why is physical illness an indication of mental illness?
Weight does not indicate my mental illness
I was often left wondering what made my restriction atypical compared to other patients I encountered in treatment. EDs are a largely competitive illness, so hearing my weight was “too high” made me feel like the situation wasn’t serious. I felt like I needed to lose more, which continued to trigger my already raging ED. As someone originally in a larger body, even losing over 30% of my body weight wasn’t seen as clinically “severe” in an inpatient setting. I even encountered patients who asked me why I needed treatment since I was “already fat”.
But, according to a study by Dr. Andrea K Garber, a professor at UC San Francisco, almost one third of inpatient facilities are composed of patients with Atypical Anorexia. If this disorder is so prevalent, why is the depiction of restrictive EDs always an emaciated young woman?
Harmful stereotypes affect treatment
This stereotype proves to be harmful against an already invalidating diagnosis, as many go underdiagnosed based on their physical appearance. In a study supported by the American Academy of Pediatrics, it was found that young adults who are overweight are less likely to get the ED diagnosis they clinically qualify for, as opposed to those who are normal or underweight. Clearly, it begins to show apparent weight bias in the research and treatment of EDs. Unfortunately, those with Atypical Anorexia often don’t receive the care they need until they lose enough weight to receive an Anorexia diagnosis. Dr. James Greenblatt of Walden Behavioral Care, a leading ED treatment facility in Dedham, Mass. commented on this in a journal.
“A recent study shows that EDNOS has as high a mortality rate as anorexia, but unfortunately many insurance companies won’t cover these patients, leaving those who are sick to either not seek treatment or, worse, make themselves sicker so they can get the diagnosis that will afford them coverage.”
At the time of the study, EDNOS was used for the diagnostic subtype now known as Atypical Anorexia. This being said, if clinicians were even noticing these diagnostic discrepancies, why hasn’t the diagnostic system changed yet?
Atypical Anorexia can lead to anorexia
As someone who was diagnosed with Atypical Anorexia in the past, it pains me to say that I eventually received that elusive Anorexia Nervosa diagnosis. I lost that weight which put me over the edge from one diagnosis to the next. If the original diagnosis was never given to me, I might not have suffered for as long. Still, I am lucky to have a provider who is Health At Every Size (HAES) informed. She used my weight charts to realize that my threshold for underweight is higher than what BMI normally (and often wrongly) dictates. If I did not have a clinician put in the research to even understand the intricacies of the diagnoses, I also might not have had access to the treatment I received to this day. While the diagnosis can be removed after weight restoration, this proves the problematic nature of this disorder.
At the end of the day, if anorexia and Atypical Anorexia are mental illnesses, why does my weight matter to my therapist? Why is my body a discussion when I am trying to heal my mind? It is never typical to be sick… so why am I atypical?
Eating Disorders have one of the highest mortality rates of all mental illnesses. If you believe that you or a loved one may be struggling with an ED, please reach out to the National Eating Disorder Association for resources. To reach a 24/7 crisis texting line, text “NEDA” to 741741. Most importantly, if you are experiencing a medical or psychiatric emergency, please call 911 or go to the nearest ER. You deserve recovery and you deserve help.