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A Quick Guide to Orthorexia Nervosa

When people think of eating disorders, the first thing that comes to mind is often anorexia nervosa or bulimia nervosa. The most common kind of eating disorder, binge eating disorder, also comes to mind. The common factor these three disorders share is a sense of dissatisfaction with body size and weight. Although the symptoms of each disorder are different, they are all in some way related to dieting, attempts at weight loss, and a fear of gaining weight.

However, not every eating disorder shares this characteristic. Some disorders have as many mental and physical health effects, but center around a fear of certain kinds of food rather than weight gain. One of these is Avoidant Restrictive Food Intake Disorder (ARFID), which is caused by a fear of impurity or danger from eating certain foods. Another, less common but no less dangerous, is orthorexia nervosa.

Here, we’ll go over the signs and symptoms of this disorder, what the causes might be, and what treatment looks like. Although orthorexia nervosa is not included as a standalone disorder in the DSM-V, it’s recognized by most in the psychiatric and eating disorder treatment communities as a serious disorder. Because it’s not as prominent as other forms of eating disorders, orthorexia may go under the radar, but hopefully, we can shed some light on it.

What Is Orthorexia?

Orthorexia nervosa is a form of eating disorder characterized by an extreme focus on “healthy” eating. The term was first used by Stephen Bratman, MD, in 1996. He called it a “fixation on righteous eating.” This put a formal name to what psychiatrists, nutritionists, and doctors had been noticing for years. There is a bit of irony here. In some cases, it helped those professionals understand that some of their well-intentioned advice could have contributed to their patients’ eating disorders.

When a person has orthorexia, they go beyond trying to eat healthily. It’s quite common for people to try to eat better. They may try to avoid saturated fats, watch their cholesterol, or go vegan to better their health, among other reasons. Normally, this is not an issue (and if you take anything away from this blog, please remember that trying to eat healthy foods is not in and of itself a bad thing), and is encouraged by their doctors.

When healthy eating becomes an obsession, the individual in question starts to cut out more and more foods and food groups from their diet. They may, for example, stop eating gluten (without a diagnosis of an allergy or celiac disease), any processed food, seafood or fish, all sugars, and so on. People with orthorexia usually start with a few foods they won’t eat and then progress to more and more.

With orthorexia, the desire for healthy eating begins to affect a person’s physical and psychosocial health. Even though the root cause is not a desire to lose weight, in advanced cases extreme weight loss can occur, similar to the weight loss seen in anorexia nervosa. In addition to the health risks associated with malnutrition and weight loss, the individual also faces psychological trauma and social difficulties.

What Causes Orthorexia?

Like other eating disorders, orthorexia nervosa doesn’t have a single cause, but rather is a combination of several factors. Previous experiences with other kinds of disordered eating indicate a higher risk for orthorexia, but it can begin with no earlier disordered eating symptoms. Many aspects of orthorexia share symptoms of obsession with OCD, such as a compulsion to behave a certain way out of fear of negative consequences. This also manifests in an obsession with only eating healthy foods. In a similar vein, a high tendency for perfectionism is common in people with orthorexia, just as it’s common in other eating disorders and OCD.

Family history is another indicator that there is a risk for orthorexia developing. People whose family members have experienced an eating disorder are more likely to develop one themselves. Households with a strong focus on healthy eating and calorie counting may create an environment more likely to produce orthorexia nervosa, although of course is only rarely the case. In addition to these factors, orthorexia is often a response to high stress and anxiety situations.

What Are the Symptoms of Orthorexia?

As discussed, the main symptoms of orthorexia are refusal to eat certain foods out of magnified concerns about their healthiness, and weight loss due to inadequate nutrition. However, there are several other behavioral signs that a person might be struggling with orthorexia:

  • Constantly checking ingredient labels and nutritional information (for every single thing eaten)
  • Spending inordinate amounts of time on “health food” or nutritional sites, or similar social media sites (i.e. Instagram “healthy eating” groups)
  • An outside sense of pride in their health and eating habits (body image is not always a concern, but it can be)
  • An increase in concern about the health of ingredients
  • Increasing inability to eat certain kinds of foods and an increasing amount of “fear foods”
  • Cutting out an increasing number of food groups (all sugar, all carbs, all dairy, all meat, all animal products)
  • Showing great interest in what close associates are eating
  • Becoming stressed when thinking about social events where food is served
  • Avoiding eating with others if they do not control the menu
  • Difficulties at work or school events where “unhealthy” foods are shared
  • Showing high levels of distress when “safe” or “healthy” foods aren’t available
  • Frequent “cleanses” where the person fasts or eats a specific diet intended to purge the system of “toxins”

Many of these symptoms might be observed in people with other eating disorders, especially anorexia nervosa. They also often feel discomfort in social situations centering around food, and the weight loss can be similar. However, in making a diagnosis, psychiatrists and eating disorder treatment specialists will ascertain whether body image distortion and desire to lose weight are primary causes. If not, they are likely to recommend specialized orthorexia nervosa treatment rather than anorexia treatment.

Attitudes About Orthorexia

Momentarily, we’ll get into the methods of treatment used for orthorexia nervosa. For the moment, it’s worth examining some of the challenges that surround getting help in the first place. Because it’s relatively rare compared to other eating disorders (in a study performed in 2017, based on their seriousness about healthy eating and whether their diet had led to impairment in everyday activities and medical problems, less than 1 % of the sample fell into such a category), orthorexia may be overlooked by some professionals. It might also be lauded by the people close to the individual, who unwittingly encourage the disordered eating behaviors when they see them “eating healthy.”

There is also an attitude that suggests orthorexia is “harder to cure” than other eating disorders. Of course, eating disorder recovery outcomes vary from disorder to disorder and person to person. However, in a study conducted by Courtney C. Simpson and Suzanne E. Mazzeo, a survey comparing stories of anorexia nervosa, binge eating disorder, bulimia nervosa, and orthorexia nervosa was conducted. They found that attitudes about treatment for orthorexia nervosa were less optimistic than the others. Respondents thought that orthorexia patients were less likely to “pull it together” than other patients and that the disorder was less severe than the others. This is not true, of course. However, these attitudes can complicate treatment by making it seem less necessary than it actually is.

What Does Orthorexia Treatment Look Like?

Eating disorder treatment, in general, is a combination of psychological treatment, mindfulness training, and nutritional education. If the client is severely underweight or malnourished, medical care may be necessary along with a weight restoration plan. These situations normally warrant residential treatment, which can provide constant care for severe cases. Outpatient or day treatment options are available for step-down programs, less intensive cases, and for people who have commitments they cannot avoid for 30 days of residential treatment.

Although orthorexia nervosa shares some commonalities with OCD, there are no medications specifically designed for it. As a rule, medications like SSRIs and anti-anxiety drugs are not used for eating disorder treatment, although they might be prescribed for co-occurring disorders. Instead, psychological treatment is the core component of an orthorexia treatment plan. There are several kinds of psychotherapy that might be used:

  • Group therapy – Sharing your story with others who know what you’re going through is a powerful experience. Many people with orthorexia and other eating disorders, before they go into treatment, feel like they’re all alone in their disorder. Hearing others speak on their experiences and comparing them to your own allows for a feeling of solidarity and comfort opening up. Group therapy leads to connections with peers and often facilitates breakthroughs in treatment.
  • Behavioral therapy – Evidence-based techniques like Cognitive Behavioral Therapy (CBT), Dialectical Behavior Therapy (DBT), and Acceptance and Commitment Therapy (ACT) are all slightly different takes on how to change behavior. They normally begin with working to identify how disordered thoughts lead to disordered behaviors. Using mindfulness techniques, clients in treatment learn to experience these thoughts without acting on them. This leads to normalized eating behaviors over time and a reduction in food restrictions caused by orthorexia.
  • Exposure therapy – This form of therapy is especially useful in orthorexia recovery. During exposure therapy sessions, the client is gradually exposed to their “fear foods” over time. They may start by just being in the same room as those foods, or watching someone else eat them. Then they will try to eat a tiny bit of one of those foods, then a bit more, then several of the foods, and so on. It’s good practice for when treatment ends and helps the client keep going when there are no formal sessions.

Getting Help Isn’t as Hard as You Think

Despite some of the challenges discussed above, orthorexia nervosa is eminently treatable. Upon visiting a therapist or psychiatrist, a diagnosis can be made. Then you should reach out to an accredited eating disorder treatment facility. They can help assess your situation, help arrange transportation and insurance information, and schedule you for intake. It might seem overwhelming, but it’s an important step to recovery. If you or a loved one is becoming obsessed with healthy eating to the point it affects your wellbeing, reach out today. A recovered life is within reach.

Melissa Orshan Spann, PhD, LMHC, RTY 200, is Chief Clinical Officer at Monte Nido & Affiliates, overseeing the clinical operations and programming for over 50 programs across the U.S. Dr. Spann is a Certified Eating Disorder Specialist and clinical supervisor as well as an accomplished presenter and passionate clinician who has spent her career working in the eating disorder field in higher levels of care. She is a member of the Academy for Eating Disorders and the International Association of Eating Disorder Professionals where she serves on the national certification committee, supervision faculty, and is on the board of her local chapter. She received her doctoral degree from Drexel University, master’s degree from the University of Miami, and bachelor’s degree from the University of Florida.