Diagnostic Sign of the Times

Along with the distance from the early 2000s came a demystification of these diagnoses. Rising awareness and access to the internet meant people could share their experiences firsthand, and slowly, the image of the restrictive eating disorder gained a realistic perspective. Gradually, the blurry, distorted picture turned into describable experiences and discussions of mental health. The names of the diagnoses are ones you may be more familiar with. Anorexia nervosa, arguably the one in the most direct spotlight, is characterized by a very low body weight, restriction, fear of weight gain, and a self-image unduly influenced by one’s body. Bulimia nervosa also has the key components seen in anorexia, however most notably, it is characterized by cycles of binging followed by compensating behaviors, such as purging or over-exercise (American Psychiatric Association, 2013)

Despite being the most recognizable diagnoses of eating disorders, they are also the rarest. What may come as a surprise, the vast majority of eating disorder patients are diagnosed with EDNOS, namely Eating Disorder Not Otherwise Specified. (Treasure et al., 2020). This category encompasses any symptomatology which is characteristic of eating disorders, such as restriction or fear of weight gain, but which does not fit the narrow presentation of anorexia or bulimia (or other). Having a “catch all” diagnosis was necessary, getting treatment to more people before they got to meet the restrictive criteria of specified eating disorders, and treating patients as individuals rather than as their diagnosis, meeting them where they are in their recovery at the moment. 

With no tried and true list of symptoms for an unspecified diagnosis, turning to research on etiology and epidemiology is the best way for us to better understand the monster we are trying to slay. While there are many etiological explanations for the development of eating pathology, popular belief attributes modern presentations of anorexia to a rise in social media though promoting unrealistic beauty standards. Interestingly enough, epidemiological studies on eating disorders suggest an overall downward trend in anorexia and bulimia. That’s the good news. The bad news is, the unspecified category of EDNOS is on the rise (Treasure et al., 2020) And we’re not exactly sure why. How did we get so much better at understanding specified eating disorders, but missed the mark on EDNOS?

There may be a few reasons. As with all things science, every benefit has its drawback, and unspecified diagnostic categories are no exception. Primarily, a concern of having an unspecified category of illness within diagnostic manuals means that there is much less research on the topic (Fairburn & Bohn, 2004). Without research, there is little understanding, leading to limited awareness, treatment, and prevention efforts. One solution is to focus on a broad category and find common symptoms within it, consequently isolating new syndromes. Some preliminary research has been done in this direction, with consideration of new diagnoses, e.g. purging disorder (Thomas et al., 2009). There is however, a popular candidate that may emerge from the unspecified pool of symptoms – orthorexia nervosa.

While no officially recognized diagnosis exists at the time of writing this article, several diagnostic criteria have been proposed. Fundamentally, orthorexia nervosa’s restriction is said to be characterized by an obsessive focus on health and perceived “cleanliness” of food, rather than on modifying one’s body weight through severe restriction of caloric intake. Some of the proposed criteria include consuming an unbalanced diet to accommodate for perceived food “purity”, preoccupation and worry over eating unhealthy or impure food, rigid avoidance of impure foods, and intolerance to other’s beliefs about food (Moroze et al., 2015). If you want to think about it through the lens of restriction that these previously mentioned eating disorders share, you can imagine it as a restriction of one’s dietary choices through cutting out food groups one by one or a steady limiting of food brands seen as approved and “safe”. 

This image may sound familiar to you. Maybe even so familiar, that you barely recognize it as being disordered. In recent internet trends, new terms have been circulating which seem resoundingly similar to the experience of someone with orthorexia nervosa. The “crunchy girl”, “almond mom” or even “gym bro” have become the new, modern day archetypes of disordered eating, representing much more subtle ways of restriction. All can be characterized by their individual ways of more socially acceptable overindulgence in exercise and strict diets, perceived as discipline and health rather than taking things a bit too far. The almond mom specifically has become its own character in social media. Typically, she is represented by teenagers and young adults who turn to humor and community to make light of shared experiences, such as memories of their moms’ imposing strict food rules growing up, coming from their own struggles with diet culture, or leading by unhealthy examples of under-eating and restricting. 

These new emerging archetypes have in a way replaced their predecessors of the early 2000s diet culture, heroin chic of the 90s and 80s, and so forth, amplifying the need for diagnostics of eating disorders to change with the times. In a twisted way, the development of disordered eating presentation in media combined with the forthcoming diagnosis of orthorexia, provides a truly interesting timeline, showcasing how cultural change can, and should, shape diagnoses (Doris et al., 2015). 

With that being said, there is still research to be done to understand the viability of orthorexia as the new shiny thing in ED diagnostics. Thus far, novel research has been able to establish shared traits of executive dysfunction between orthorexia and other eating disorders and OCD, as well as compulsivity traits shared with the category (Koven & Abry, 2015). A new specified diagnosis may be the saving grace for people who would have never been able to get targeted treatment otherwise, but it is yet uncertain whether orthorexia nervosa will make it to our diagnostic manuals, or become lost to another sign of the times. <<