Orthorexia: Distinct Disorder or Sub-Type of Obsessive Compulsive Disorder or Anorexia
Overview of Orthorexia
Many individuals at some point in their lives decide to eat healthier. They may carry out extensive research and 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, if they stick with it, over time it will simply become another normal part of their routine.
However, some people see healthy eating as a means to achieving physical purity and, through this, spiritual purity and virtue. For these individual, eating healthy may become so important it seems almost like a religion, complete with penitence for failing to maintain their healthy eating by even just a tiny amount such as eating a single peanut. Penitence often involves increased dietary rules and strictness, with more foods avoided. When this process occurs it can develop to the point that it overshadows everything else in their lives (Kratina,2006).
If the condition becomes so severe that it begins to interfere with a person's daily functioning in important areas such as social relationships or work, it is considered to be an eating disorder. Research has demonstrated that this type of eating disorder can be extremely dangerous leading to complete disability and dysfunction or even death (Borgida, 2012).
This condition was first described by physician Steven Bratman who suffered from the condition himself. He name the syndrome Orthorexia which literally means “fixation on righteous eating/” However, he described it as being more serious than the term fixation would imply. He referred to it as an obsession to avoid consuming anything that is perceived as unhealthy until most food groups are considered forbidden (Bratman, 1997).
When Healthy Eating Goes Too Far
Is Orthorexia a Form of Obsessive Compulsive Disorder? (OCD)
Studies have shown that Orthorexics do experience strong urges to eat foods that they do not consider to be “pure” but the accompanying guilt, anxiety, and unpleasant over-arousal prevents them from giving in to these urges (Donini, Marsilli et al., 2004). The anxiety results from uncontrollable, intrusive and recurrent thoughts which may revolve around the theme that the food someone eats has been contaminated by fertilizers, tainted during processing or that the individual preparing the food will contaminate the meal. Some say that the compulsive qualities related to the process of gathering ingredients and preparing meals has remarkable similarities to the type of compulsive behavior found in those with obsessive-compulsive disorder (OCD).
Both OCD and Orthorexia Nervosa, are characterized by intrusive, repetitive, unwanted thoughts which in the case of Orthorexia and some cases of OCD involve unwanted fear of contamination, which trigger intense anxiety. In order to control the anxiety the individual gives into the obsession, in the case of Orthorexia involves controlling the food they eat and increasingly limiting the foods they eat. Like in OCD, giving in to the obsession by performing the appropriate behavior, limiting foods allowed, decreases the anxiety for a brief period of time. As the condition continues the amount of time the anxiety is appeased decreases such that more foods are forbidden at a quicker pace increasing the likelihood malnutrition will develop which can go on to become life threatening. As a result of the common symptom of experiencing seemingly uncontrollable urges or obsessions the syndrome has been referred to as a form or Obsessive Compulsive Disorder. To date, many experts continue to refer to this eating difficulty as a sub-clinical version of OCD, citing the obsession with food observed in these individuals.
Some of the aspects of food, fluids and other consumables that orthorexics may obsess over and compulsively resist (e.g. Quinlan, 2011) include the following:
- Wheat and other grains
- Anything processed
- High caloric foods
- Sugar (especially “refined” sugar)
- High fructose corn syrup
- Hydrogenated or partially hydrogenated fat (trans fats)
- Salt / sodium
- Processed drinks including soda, juices and energy drinks
- Daily vitamins
- Dairy products
- Animal products
- Fatty acids
- Artificial colors, flavors, preservatives or other additives
- Anything believed to have been grown with pesticide
- Anything non-organic
- Anything genetically modified
- Anything that is not vegetarian, vegan or macrobiotic
- Anything with a low Glycemic Index value
Orthorexics may feel the need to avoid specific grocery stores, restaurants, brands of food, until they develop the need to ensure they see every aspect of their food preparation to ensure it is not contaminated. This means that they avoid any food that is prepared sticking exclusively to raw foods. An individual with Orthorexia may spend an enormous amount of time in thinking about what food they are still able to eat, obtaining their food and planning their meals to the point they have little time left for anything else. This can lead them to become socially isolated, something which makes it harder to cope with the disorder as social support is a known resiliency factor against almost any stressor or difficulty an individual may be having. This is true even if the individual does not recognize they have a problem (Southwick, Sippel, Krystal, Charney, Mayes & Pietrzak, 2016).
While the individual does experience obsessions (recurrent thoughts) regarding what they eat, in OCD the individual recognizes these thoughts are unreasonable and attempts to resist them or performs repetitive behaviors (compulsions) the person feels they must do in order to get rid of the obsessions and associated distress (APA, 2013). In comparison, those with Orthorexia don’t feel their obsessions are in any way unreasonable. As mentioned they are more likely to experience them as highly spiritual, and thus they don’t perform actions to prevent the constant thoughts they have related to eating healthy as the thoughts themselves aren’t creating the distress. Distress is created by not adhering to their strictly defined eating rules. So the obsessions found in those with Orthorexia lead the person to inhibit responses, eating unhealthy foods, and anxiety is causes by failing to adhere to their dietary rules. However, In OCD the obsessions cause the individual to perform a behavior to decrease the associated anxiety and attempts to inhibit the response lead to increased anxiety that becomes intolerable. Most significantly, in terms of differentiating Orthorexia from OCD, according to the DSM criteria for OCD, 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 obsessions experienced by those with an eating disorder and those suffering from OCD are different in scope, magnitude and number. It can be concluded that Orthorexia in not a sub-type of OCD.
Is Orthorexia a Sub-Type of Anorexia?
Musolino, and colleagues (2015), coined the term “Healthy Anorexia,” to describe and explain the condition of Orthorexia. This study examined the eating and bodily practices that involve natural, medical and ethical concerns that characterize Orthorexia. Specifically, these authors studied how these issues are assimilated into an individual’s anorexic eating patterns and believed in as a logic of self-care.
It was determined in this study that anorxics who have orthorexic eating behaviors adjust categories of health and self-care within the conceptualization of taking responsibility for their health. In other words, they adjust the knowledge they obtain about self-care activities aimed at maintaining a healthy body so it fits the beliefs they already have. It they encounter information that is inconsistent with their beliefs, they change what they recall to match their ideas prior to encoding it.
Pursuing the ideal of a healthy lifestyles is believed to be a moral virtue which includes physical appearance based on society’s expectations. Physical attractiveness which is accepted to include remaining thin, is part of a health conscious awareness in those with "healthy anorexia". Additionally, health is believed to be something solely under the individual’s control and is accepted as an obligation that must be fulfilled. This means that often there is no consultation with nutritionists or other health care professionals nor is diet thought of as something to bring up in routine health care appointments. The authors maintain that the distorted view of being healthy leads individuals with "healthy anorexia" to believe they are participating in the active pursuit of self-care activities that are promoting a healthy body and lifestyle. This belief and the tendency to alter information remembered so as to be consistent with their ideas strongly contributes to maintaining the disordered eating patterns. One of the main findings in this study was participants with "healthy anorexia" made choices that were in line with their understanding of healthy habits even when this understanding was distorted or incorrect. In fact, they interpreted their extreme dieting practices as a sign of ‘good moral character and individual worth.’
While this article shows an overlap between Orthorexia and Anorexia, there are differences in characteristics found in each of the disorders. The primary distinguishing characteristic between the two disorder is what drives the behavior. Those with Orthorexia focus almost exclusively on the health value of the food they eat and the idea of maintaining good health through their diets. In contrast, those with Anorexia are obsessed with continuous weight loss and body appearance. While both disorders are the basis of self-worth, in anorexia self- worth results from weight loss, the ability to maintain a rigid weight loss program, and the belief the individual can restrict their food intake better than anyone else. In Orthorexia self-worth results from the sense of moral superiority garnered from maintaining a healthy body and the ability to restrict diet to only healthy foods. Orthorexia is not related to weight loss specifically. Summing the difference up succinctly, Anorexia is related to quantity of food while Orthorexia is related to quality of food.
Other support provided for the belief that orthorexia is a subtype of anorexia is based on the high degree of overlap between the two disorders. Some of the characteristics that Orthorexia and Anorexia share include perfectionism, high levels of trait anxiety, and a significant need to exert control, along with potentially substantial weight loss. Individual who have Orthorexia and those with Anorexia both are focused on achievement, the assign a great deal of value to adhering rigidly to the diet which they see as a measure of self-discipline and as a source of self-esteem, and they view even the slightest slip as indication they have no self-control. Compensatory or disciplinary actions are taken when a slip happens which often involves an even stricter diet in both disorders (Koven and Avery, 2015).
Individual’s suffering from either Anorexia or Orthorexia have limited insight into their condition, behavior and the physical danger that could result even then they’ve been hospitalized for a major health event such as heart problems, difficulty breathing or decreased organ function. One of the characteristics of both conditions that prevents insight is the continued ability to exercise excessively and not perceiving any type of functional deficiency such that the view themselves as healthy. Yet while Anorexia focuses on weight loss and body image, Orthorexia focuses on improved health and purifying the body. Delusions are part of both disorders and in both some of these surround the misconceptions of physical fitness, appearance and normality. In anorexia delusions involve disturbed body image or the belief that the person is fat despite having a dangerously low body weight. In Orthorexia, the delusions are focused on the nature fallacy or the belief that anything natural is healthy. So while there is overlap of symptoms in Anorexia and Orthorexia, the specifics of the focus of each symptom and whether the overall purpose is related to weight loss or improving health can quickly differentiate the two conditions.
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On The Overlap of Symptoms in Orthorexia, OCD, Anorexia
There also seems to be a triangle of sorts between Anorexia, Orthorexia and OCD which has been proposed, and used to support the idea that Orthorexia is a type of Anorexia. Similar to the symptom overlap between Orthorexia and OCD, there is also a symptom overlap between Anorexia and OCD. Some practitioners who see Orthorexia as a sub-type of OCD use the symptom of reported obsession with food as evidence that Orthorexia is also a type of Anorexia (e.g. Dell’Osso, Abelli, Carpita, Pini, Castellini, Carmassi, & Ricca, 2016).
This method of classifying these disorders is a bit confusing given that although Anorexia involves obsessions with food as does Orthorexia, it is classified as an Eating Disorder in the DSM, while OCD is classified as a completely different disorder. These two disorders are considered separate and distinct disorders although some OCD like behaviors may be observed in individuals with Anorexia, (e.g. refusing to let their lips touch the tines of a fork, or complex ways of arranging foods on their plate and refusal to eat if the food is not arranged properly). However, in anorexia you either don’t have the accompanying obsessions as you do in OCD or if obsessions are present they don’t drive the behavior to the same extent as they do in OCD . So while there is overlap with both Anorexia and Orthorexia, and ultimately, neither are considered by most to be a subtype of OCD as the specifics of the symptoms differ. Similarly, while there is overlap between Anorexia and Orthorexia, most notably an obsession with food, the specifics and focus of this obsession are different enough that the symptom cannot be uses to classify Orthorexia under Anorexia. So, describing Orthorexia as a type of either OCD or Anorexia would be a misnomer.
Symptom Overlap in Orthorexia, Anorexia and OCD
Should Orthorexia Be Considered a Distinct Disorder?
While Orthorexia isn’t an official diagnosis in the DSM 5, it does meet the primary requirements which are used to define the point when a habit or behavior is has crossed the line to become defined as a disorder. Specifically, in the case of Orthorexia, healthy eating turns from a positive lifestyle change into a psychological manifestation which interferes in important functional areas of the individual’s life. Using the general criteria of the DSM-V it would be considered a disorder though it is not specifically listed as a separate diagnosis.
The current version of the DSM defines a mental disorder as ". . .a syndrome characterized by clinically significant disturbance in an individual's cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress in social, occupational, or other important activities” (APA, 2013). It’s difficult to entertain the argument that individual’s suffering from the symptoms of Orthorexia do not meet these criteria, given they become socially isolated, become so over focused on health related issues related to food that they have time to do little else. They will also frequently suffer a spiritual crises if they believe they have ingested something they consider impure, which they respond to with more severe restrictions when can have serious health consequences including death. These characteristics appear to fit the intended definition of clinically significant distress, a significant increased risk of suffering and impairment in important areas of functioning.
Most importantly though while the symptoms of Orthorexia overlap with the symptoms of anorexia and OCD, there are important differences that distinguish the three disorders from one another. The nature of the obsessions in Orthorexia and OCD differ significantly, in that in OCD the obsessions serve to drive a behavior and in Orthorexia they to inhibit a behavior. In anorexia then primary purpose of the two disorders are different. In Anorexia the focus is on losing weight and correcting then flaws that are believed to exist due to a distorted body image. In Orthorexia, then eating behavior may initially be related to weight loss, but the main focus is on maintaining a healthy diet. In Anorexia the focus is on quantity of food and decrease in body fat and mass. In Orthorexia the focus is quality of food and removing toxins and contaminants from the body while preventing new ones from entering. Based on these factors and others discussed previously, it is clear that Orthorexia is a distinct disorder. However, as little is known about it, more research needs to be conducted to determine the disorder’s etiology, co-existing conditions, treatment options and risk and resiliency factors related to the development of disorder and response to treatment.
What Do You Think?
Does trying to eat healthy increase your overall stress level?
Proposed Criteria for Orthorexia
Despite increasing support for Orthorexia being designated as a distinct diagnosis, this cannot happen without a way to arrive at the diagnosis. This is accomplished through diagnostic criteria. Diagnostic criteria provide more than just a label. The criteria should reliably lead to a diagnosis such that the treatment implications associated with the diagnosis are effective. In a review article by Dunn and Bratman (2016), the state of theory about and research on Orthorexia, is discussed and criteria for the disorder proposed. Several sets of criteria have been proposed, including the Moroze et al., (2015) criteria which are widely available. However Dunn & Bratman point out that each set is missing an important indicator of Orthorexia, including the Moroze et al. criteria that fail to include potential weight loss due to the extreme diet restrictions.
The criteria as put forth by Dunn and Bratman are included below, take verbatim from their study:
Obsessive focus on “healthy” eating, as defined by a dietary theory or set of beliefs whose specific details may vary; marked by exaggerated emotional distress in relationship to food choices perceived as unhealthy; weight loss may ensue as a result of dietary choices, but this is not the primary goal. As evidenced by the following:
- Compulsive behavior and/or mental preoccupation regarding affirmative and restrictive dietary practices believed by the individual to promote optimum health.
- Violation of self-imposed dietary rules causes exaggerated fear of disease, sense of personal impurity and/or negative physical sensations, accompanied by anxiety and shame.
- Dietary restrictions escalate over time, and may come to include elimination of entire food groups and involve progressively more frequent and/or severe “cleanses” (partial fasts) regarded as purifying or detoxifying. This escalation commonly leads to weight loss, but the desire to lose weight is absent, hidden or subordinated to ideation about healthy eating.
The compulsive behavior and mental preoccupation becomes clinically impairing by any of the following:
- 1. Malnutrition, severe weight loss or other medical complications from restricted diet.
- 2. Intrapersonal distress or impairment of social, academic or vocational functioning secondary to beliefs or behaviors about healthy diet.
- 3. Positive body image, self-worth, identity and/or satisfaction excessively dependent on compliance with self-defined “healthy” eating behavior.
Although not included in their proposed criteria, the authors recognize other factors that may help clarify or confirm cases of Orthorexia. These traits include:
- Obsessions related to purchasing and preparing ingredients, choice of foods, meal planning and consumption;
- Food not seen as pleasurable but regarded instead as responsible for health
- Loathing or a sense of discomfort when in contact with forbidden foods
- Inflated belief that consuming or avoiding certain types of foods can prevent or cure illnesses and diseases
- Evaluation of others worth based on their food choices
- Distorted image based on perception of impurity instead of weight
- Continued certainty that the diet is health promoting despite malnutrition or other health problems.
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, 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 don’t 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. Further research is needed to narrow down criteria specific to Orthorexia, design better assessment measures and provide evidence for effective treatments.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed). 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
Bratman, S., & Knight, D. (2000). Health food junkies: Orthorexia nervosa: Overcoming the obsession with healthful eating. New York: Broadway.
Dell’Osso, L., Abelli, M., Carpita, B., Pini, S., Castellini, G., Carmassi, C., & Ricca, V. (2016). Historical evolution of the concept of anorexia nervosa and relationships with orthorexia nervosa, autism, and obsessive–compulsive spectrum. Neuropsychiatric Disease and Treatment, 12, 1651.
Donini, L., Marsili, D., Graziani, M., Imbriale, M., & Cannella, C. (2005). Orthorexia nervosa: Validation of a diagnosis questionnaire. Eating and Weight Disorders—Studies on Anorexia, Bulimia and Obesity, 10(2), e28–e32.
Dunn, T.M & Bratman, S. (2016). On orthorexia nervosa: A review of the literature and proposed diagnostic criteria. Eating Behaviors, 21, 11 -17.
Koven, N. S., & Abry, A. W. (2015). The clinical basis of orthorexia nervosa: emerging perspectives. Neuropsychiatric Disease & Treatment, 11.+Kratina, K., (2006). Orthorexia Nervosa. National Eating Disorders Association. Retrieved, 12/17/2016.
Moroze, R. M., Dunn, T. M., Holland, J. C., Yager, J., & Weintraub, P. (2015). Microthinking about micronutrients: A case of transition from obsessions about healthy eating to near-fatal “orthorexia nervosa” and proposed diagnostic criteria. Psychosomatics, 56(4), 397–403
Musolino, C., Warin, M., Wade, T., & Gilchrist, P. (2015). ‘Healthy anorexia’: The complexity of care in disordered eating. Social Science & Medicine, 139, 18-25.
Quinlan, K., (2011) Orthorexia: Where Eating Disorders Meet OCD. OCD Center of Los Angeles. Retrieved 12/20/2016.
Southwick, S. M., Sippel, L., Krystal, J., Charney, D., Mayes, L., & Pietrzak, R. (2016). Why are some individuals more resilient than others: the role of social support. World Psychiatry, 15(1), 77-79.
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