Many individuals arrive at a point in their lives when they decide to eat healthier. They may change many things at once or do it more slowly, a few foods at a time. Once they feel they have established a healthy eating regimen, over time it will become another part of their regular routine. However, some people see healthy eating as a means of achieving physical purity and through this, spiritual purity and virtuosity. For these individual, eating healthy may become so important to them it becomes like a religion, complete with penitence for failing to maintain their healthy eating by even just a tiny amount such as a single peanut necessitating increased dietary rules and rigidity, until it overshadows everything else in their lives (Kratina,2006).
When this condition begins to interfere with daily functioning in important areas such as social relationships or work many individuals consider it an eating disorder, and research has demonstrated that it can become dangerous, leading to incapacitation or death (Borgida, 2012). This condition was first described by physician Steven Bratman who suffered from the condition himself. He called the syndrome Orthorexia which literally means "fixation on righteous eating." However, he described it as being more serious than the term fixation would imply. Instead he refers to it as an obsession to avoid any unhealthy food (Bratman,1997).
Is Orthorexia a Form of Obsessive Compulsive Disorder (OCD)?
A number of practitioners in the medical field believe that Orthorexia is not a distinct disorder, but is a subtype of Obsessive Compulsive Disorder (OCD). They emphasize that individuals with Orthorexia are "obsessed" with defining and maintaining a healthy diet (Stossel & Sanchez, 2008), and it is this obsession that leads to their dangerous dieting behavior.
Several studies have shown that Orthorexics do experience overwhelming urges to eat, (e.g. Donini, Marsilli et al., 2004). As a result of these findings documenting that these individuals experience the symptom of "urges" or "obsessions," the syndrome has been conceptualized as a form of OCD. To date, despite the lack of sufficient research, many experts continue to refer to this eating difficulty as a subtype of OCD, citing the obsession with food as support.
However, there are important symptoms and characteristics that distinguish Orthorexia from OCD. While someone suffering from Orthorexia does experience obsessions (recurrent thoughts) regarding what they eat, in OCD the individual recognizes these instrusive thoughts are unreasonable. Attempting to resist them until overwhelmed they then attempt to neutralize the obsessions through repetitive behaviors (compulsions) which rids them of distress and prevents some unknown catastrophe from occurring (APA, 2000).
In comparison, those with Orthorexia don't believe their obsessions are unreasonable. Instead, they are more likely to experience these beliefs as highly spiritual, and thus avoid actions to prevent these constant thoughts related to eating healthy as the thoughts do not cause their distress. Distress is created by not adhering to their strictly defined eating rules which they believe allows toxins to enter their body rendering them impure. For Orthorexics, a healthy diet is a religion, and their bodies their temples (ABCNews.com, 2011).
In addition, when Orthorexics feel strong urges to break their diets, this results in psychological symptoms including guilt, anxiety, and over-arousal. However, as opposed to the anxiety that results from the obsessions in OCD driving the performance of unnecessary action, in Orthorexia these psychological symptoms do the opposite. They prevent the individual from giving in to their urges, inhibiting their behavior not triggering it (Donini, Marsilli et al., 2004).
Most significantly, according to the DSM criteria for OCD (APA, 2000), the symptoms cannot be restricted to preoccupation with food such as in an eating disorder. This is based on the principle derived from extensive research that the thoughts and beliefs associated with an eating disorder are based on disturbed body image, which differs from the types of repetitive thoughts that are characteristic of individuals with OCD.
Is Orthorexia Nervosa a Form of Anorexia Nervosa
Many practitioners also focus on the symptom of food obsession to support the theory that orthorexia not only is a subtype of OCD but is a subtype type of anorexia as well (Eating Disorders Help Guide, 2006). This is a bit confusing as Anorexia Nervosa is classified as an Eating Disorder in the DSM, while OCD is classified as an anxiety disorder, two completely different categories. OCD and Anorexia are considered distinct disorders, although some OCD like behaviors may be observed in individuals with Anorexia, (e.g. complex ways of arranging foods on their plate). However, in anorexia these behaviors aren't driven by obsessions, whereas this is a major criteria for OCD (APA, 2000).
Other support provided for classifying orthorexia as a subtype of anorexia is based on the restrictive nature of both problems (Eating Disorders Help Guide, 2006). Yet this assertion is also problematic, especially when examining the different driving forces behind each of these disorders. Whereas the restrictive behavior seen in individuals with anorexia is driven by the desire to be thin when they believe they are, individuals with Orthorexia know they are thin, driven instead by the desire to eat a perfectly healthy, pure diet (Getz, 2009). There is also a delusional quality to Anorexia. Despite being dangerously thin, these individuals see a fat person whenever they look in the mirror (APA, 2000). There is no evidence such delusions or disturbed body image is involved in orthorexia.
In addition, according to Ederyd (2011), "Orthorexics rarely consider food or the act of eating to be disgusting the way Anorexics do. Their obsession is about whether the food is acceptable by their self-set standards of healthy eating." The author adds that another symptom involves becoming fixated on reading lables and studying nutritional values on food packaging which takes up hours a day.
Should Orthorexia Be Considered a Distinct Disorder?
While Orthorexia isn't an official diagnosis in the DSM IV-TR, it does meet the primary requirements used to define the point when a behavior has crossed the line to warrant a diagnosis as a disorder. Specifically, in the case of Orthorexia, when healthy eating becomes all consuming and interferes in important functional areas of the individual's life, based on the general criteria of the DSM-IV-TR it would be considered a disorder.
The current version of the DSM defines a disorder as "a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual [which] is associated with present distress... disability...or a significant increased risk of suffering." Most diagnoses also include the criteria that the disorder must result in "clinically significant distress or impairment in social, occupational, or other important areas of functioning," (APA, 2000). It's difficult to entertain the argument that individual's suffering from the symptoms of Orthorexia do not meet these criteria. They become socially isolated, over focused on health issues related to food until they have time to do little else. They suffer a spiritual crisis if they believe they have ingested something judged impure, responding with more severe restrictions. These characteristics appear to fit the definition of clinically significant distress, and increased risk of suffering and impairment in important areas of functioning.
Treatment for Orthorexia
As is true with Anorexia, treatment options for Orthorexia are not well defined nor do they have a high percentage of positive outcomes. However, this is not surprising, as the problem is still controversial with many not believing it exists despite the climbing number of deaths resulting from the symptoms. Similar to other eating disorders Orthorexia is quite complex and results from numerous interrelated experiences, circumstances and physical and mental functioning. According to Mark (2012), included in the triggers and causes are those that are "psychological, physiological, physical, genetic and social," as well as combinations and interactions of these factors.
Thus, treatment must be based on a comprehensive assessment to discover how the individual is functioning in each of these areas. Other information must also be gathered to gain a complete understanding of the individual as a whole, including information about the individuals history, religious/spiritual beliefs, relationships, personality, and coping mechanisms among others. It is crucial, prior to treating any disorder including Orthorexia, the individual's manner of viewing their world and operating withing it understood along with how this impacts their eating behavior.
Treatments used for disorders that are heavily influenced by thought patterns and belief systems are largely of little use with Orthorexia. Cognitive behavioral therapy whereby maladaptive or irrational thought patterns are altered would be largely useless. This is due to the fact that Orthorexics do not believe there is anything wrong with the way they think about food, nor the feelings and behaviors that result from these thoughts.
Graduated exposure would be rejected as these individuals will not agree to ingest even a small amount of food they have decided is toxic and ruled out of their diets. The use of medication would likely also be refused, due to being judged unnatural and impure.
However, considering that few research studies have been conducted examining Orthorexia, prior to creating treatment programs, first gaining a better understanding of the disorder such that reliable criteria for diagnosing the condition could be established would seem paramount. It is impossible to determine effective possibilities for treating Orthorexia prior to developing an accurate diagnosis that leads to specific treatment implications.
Obviously, if the individual is dangerously underweight, restoring and maintaining a healthy weight is imperative. However, the underlying facets that lead an individual to develop the disorder are diverse and while the disorder may appear to resemble anorexia and/or OCD there are significant differences in these disorders. This emphasizes the need for further research to discern the specifics of Orthorexia as distinct from other disorders as opposed to lumping it together with Anorexia and/or OCD and treating it utilizing the same techniques used for those disorders.
Concluding Comments
As previously stated, Orthorexia is not currently a diagnosis in the DSM, even based on the criteria that fall under the "Not Otherwise Specified" Category. However, this category, as now defined, includes behaviors specifically related to Anorexia or Bulimia Nervosa and fails to acknowledge that there are a wide range of other eating related problems that exist, and based on their symptoms would fit within the general category. These includes disorders such as Orthorexia which cause the individual distress or disability as well as negative psychological states, and impairs their functioning due to their withdrawal from social activities, occupational endeavors and other areas of their lives, significantly affecting their overall quality of life. It is difficult to argue that the symptoms of Orthorexia Nervosa and the experiences of those who suffer from them do not constitute an eating disorder based on the general criteria for defining a mental disorder set forth by the American Psychiatric Association in the DSM-IV-TR. More attention to this devastating problem is clearly needed.
Sources
- American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
- Borgida, A., (2012, April). In Sickness and In Health: Orthorexia Nervosa, the Study of Obsessive Healthy Eating. Proquest. Retrieved 1/17/2012.
- Bratman, S., (1997, October). The Health Food Eating Disorder. Yoga Journal. Retrieved 1/17/2012
- Eatingdisordershelpguide.com, (2006). Orthorexia -- A Different Kind of Eating Disorder. Eating Disorders Ventures. Retrieved 1/27/2012
- Ederyd, C., (2011, February 3). Orthorexia Nervosa - a dangerous obsession. Arts, London News. Retrieved 1/29/2012.
- Getz, L., (2009, June) Orthorexia: When Eating Healthy Becomes an Unhealthy Obsession. Today's Dietitian, 11, pp 40.
- Kratina, K., (2006). Orthorexia Nervosa. National Eating Disorders Association. Retrieved, 1/17/2012.
- Stossel, J., (2011, March 10). Eating Disorders: Orthorexia. ABCNews.com. Retrieved 1/29/2012.
- Mark, D., (2012). Orthorexia Nervosa Strikes at the Core of the Diet-Obsessed. Nursezone.com: Health and Wellness. Retrieved 1/29/2012.
- Stossel, J., & Sancho, M., (2008, Sept. 5). Orthorexia: Obsessing Over Health Food. ABC News. Retrieved 1/27/2012.
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