A New Assessment of Atypical Anorexia
By: Masha Sardari MS, RD, LDN
Published: March 18, 2024

Let’s start with the definition of this life threatening and increasingly common eating disorder.

People with atypical anorexia nervosa (AAN) have all the symptoms of anorexia nervosa, except for low body weight. These may include restriction of energy (food) intake, intense fear of gaining weight, hyperfocus on body weight or shape, recent and extreme weight loss, and severe nutritional deficiencies.

The one difference: A person with atypical anorexia is within or above the “normal” weight range. Because of that, the condition is often missed by medical providers, the person who is living with it, and their loved ones.

Assessment and treatment

At Koru Spring eating disorder center, we don’t see this condition as “atypical,” in fact it is a significant portion of the eating disorders we treat.

In assessing a resident who may have it, we ask the full spectrum of eating disorder related questions to accurately identify and diagnose the particular disorder an individual might be battling. Using a transdiagnostic approach, we focus on understanding the specific behaviors and thought processes of each resident in addition to the general eating disorder diagnosis they may have.

Our first priority is nutritional restoration for the resident. This may take several forms. Some residents need to restore micronutrients, for example, while others may have avoided entire food groups and have lived in a deficit for an extended period of time.

We evaluate each resident’s medical and clinical data which can include high blood pressure, low heart rate, electrolyte abnormalities and other conditions that require medical nutrition therapy.

The problem with the concept of “atypical”

Historically, “atypical” anorexia nervosa was understood as a less severe version of anorexia nervosa (AN). This is problematic as patients with AAN can be just as medically ill as their peers with AN and present with even greater symptom severity. Understanding the disorder as “atypical” may lead to delayed diagnosis and limited access to appropriate treatment.

Evidence suggests that AAN is in fact more common than AN, but individuals experiencing it are less likely to receive timely care. Due to weight stigma, severity may be missed and individuals may suffer longer.

The provider lens: Diagnosing this condition is challenging for medical professionals. Most don’t receive adequate training in eating disorders and may not know the signs. Weight loss is also often praised and individuals may be wrongly encouraged to continue engaging in behaviors such as dieting and restriction which may exacerbate disordered behaviors.

Also, many providers face heavier-than-ever patient loads, so they’re getting less time with their patients. This means less time to ask the kinds of questions that lead to clarity with this challenging condition.

That’s why it is so important to see an eating disorder expert when you or a loved one is exhibiting new and problematic behaviors around food and eating.

These professionals are trained to recognize the signs, ask the right questions, and use the appropriate screening tools necessary to make an accurate diagnosis and recommend the best treatment plan.

The patient lens: Atypical anorexia is a difficult condition to recognize even by those who are living with it. On the one hand, a person might be severely restricting their food intake and be terrified at the thought of gaining weight.

Yet on the other hand, every time they look in the mirror, they’re not medically underweight, so how can they possibly have anorexia?

At Koru Spring residents with this condition will sometimes say they don’t have a “textbook” eating disorder. In saying this, many are implying that they don’t think they’re that sick. Some people feel like they need to be sicker, and significantly thinner, to “deserve” ED treatment.

In response to that, I will sometimes gently challenge the resident with this: Okay, if you had anorexia nervosa, why is that more legitimate? Why would that make you more deserving of treatment?

This all gets back to what I said earlier about the “atypical” aspect of this condition. We don’t prefer that term because it leads some residents to believe they don’t have “real” anorexia.

But they do, because it’s not about what the condition is called, it’s about the behaviors they’re engaging in. Eating disorders exist on a spectrum and are serious conditions with a variety of presentations that often to do not fall under a single diagnosis.

For those who are living with an eating disorder or suspected eating disorder, please remember: Conditions and diagnoses are compiled by researchers who are not living your life. Everyone’s ED presents differently, and symptoms can be fluid over time. Just because your symptoms don’t fit a textbook diagnosis doesn’t mean you’re not sick.

The loved one lens: The “atypical” aspect of this condition can also pose challenges for the family and friends of the person who is struggling.

My advice: As much as you don’t want to believe there’s a serious problem, be open to that possibility. If your loved one is restricting portions, eating alone more often, replacing foods with no-calorie beverages, is preoccupied with their weight or body shape, and so on, don’t disregard those signs just because they’re still at a “normal” or higher weight.

Rather, offer judgement-free support, and assure them you’re there to listen and help.

If you’re pretty sure something is going on, ask your loved one if they would consider seeing an ED specialist. You might also offer to help them do that, and ask if it’s okay to go with them to their first visit. Note: You’ll find listings of eating disorder providers here.

Final thoughts on atypical anorexia

If you or a loved one are struggling with this condition, it is vital to seek help as soon as possible. Early diagnosis and treatment provide the best chance for recovery.

Remember, eating disorders do not discriminate based on age, gender, wealth, job status, sexual orientation, ability, neurodiversity, body shape and size, race, or ethnicity. They are capable of affecting anyone, and require ongoing support and, in some cases, medical treatment to recover from.

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