Pathologically “healthy” eating
Case studies in the literature detail patients with severe health complications who used diet to control medical conditions. In one case, profound medical complications (including hyponatremia, pancytopenia, pneumomediastinum, and pneumothorax) were seen in a 30-year-old man.6 His restricted eating consisted of limited amounts of brown rice and fresh vegetables for the exclusive purpose of treating a tic disorder.
In a second case, severe malnutrition and a body mass index (BMI) of 10.7 were seen in a 28-year-old woman. To treat her acne, she had been eating only uncooked vegetables after slowly reducing items she would eat—a nutritionist had suggested removing fats from her diet.7
Finally, a third case involved a 28-year-old man whose drive for achieving purity and health by dieting resulted in severe malnutrition and a BMI of 12.3.8 This last case study was notable in that it was the first to appear in a mainstream US psychiatric journal and the first to codify proposed diagnostic criteria in a peer-reviewed publication.
There are 4 different proposed diagnostic criteria sets meant to identify individuals suffering from ON; 3 have been developed since 2015. The earliest set was developed by a US dietitian in a self-published quick reference guide for health care providers. It is not in wide circulation, nor has it been peer reviewed. There are also criteria developed by Barthels and her group that are published in German.9 The most widely cited criteria are those put forth by Moroze and colleagues8 (Table 1) and those generated in a later publication by Dunn and Bratman3 (Table 2).
The prominent features of the proposed criteria sets are as follows:
• Preoccupation with nutrition or healthy eating resulting in malnutrition, health complications, being underweight, and/or social impairment;
• Drive for health and not for thinness; no disrupted body image;
• Anxiety, even panic, about unhealthy food;
• Guilt or distress after violating diet;
• Insistence on eating a “healthy” diet despite resulting medical complications;
• Rigid avoidance of unhealthy foods;
• Unrealistic ideas about how foods can cure disease or promote health ;
• Fears about not eating healthfully reduced by ritualized preoccupation with food;
• Positive sense of self strongly associated with compliance in self-imposed healthy dieting;
• Sense of superiority over others because ones own diet is better.
All of the proposed criteria sets include important exclusions. For example, caution is warranted in applying ON in instances where intake is restricted based on food allergy, food intolerance, or on religious beliefs. ON would also be an inappropriate diagnosis for an individual whose presentation is due to another psychiatric condition, such as someone with schizophrenia that includes delusional beliefs about the benefits of food.
Although ON is distinct from AN, the two share significant overlap. Both conditions start with a sensible premise. For individuals with AN, it is sensible to avoid obesity, and for ON, it is sensible to have a healthy diet. In both conditions, however, individuals transition to pathological dieting that may affect their health or cause clinical impairment. It is our experience that both conditions involve a denial on the part of individuals about the functional impairment of their diet and have significant obsessive-compulsive features.
Although evidence is lacking, we have observed that traits of perfectionism, inflexibility, and extremism (refusing to see other points of view) are present in both conditions, as are deeply held ideologies that help provide order and structure to one’s life and help exert control over their environment. Finally, based on clinical observations, both patients with ON and patients with AN tend to be achievement oriented and can have cognitive distortions about food.
ON is also different from ARFID. Although patients with ARFID become malnourished or underweight because of their food intake, the majority of those patients restrict their intake because of an aversive experience that they have had with food. Aversion is defined in the classical conditioning sense that eating has become paired with a noxious experience, such as choking, vomiting, or constipation. Less frequently, those with ARFID are underweight because of extremely picky eating, or objections to the sensory properties of food. Based on case studies of ON, none of these properly accounts for individuals whose “healthy” diet is so strict that they become malnourished, develop medical complications, or whose social functioning is affected.6,8
Dr Dunn is Professor, School of Psychological Sciences, University of Northern Colorado, Greeley, CO; and Staff Psychologist, Denver Health Medical Center; Dr Hawkins is Chief Executive Officer and Licensed Psychologist, Center for Change, Orem, UT.
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2. Donini L, Marsili D, Graziani M, et al. Orthorexia nervosa: a preliminary study with a proposal for diagnosis and an attempt to measure the dimension of the phenomenon. Eat Weight Disord. 2004;9:151-157.
3. Dunn TM, Bratman S. On orthorexia nervosa: a review of the literature and proposed diagnostic criteria. Eat Behav. 2016;21:11-17.
4. Missbach B, Dunn TM, König JS. We need new tools to assess orthorexia nervosa. A commentary on “prevalence of orthorexia nervosa among college students based on Bratman’s test and associated tendencies.” Appetite. 2017;108:521-524.
5. Dunn TM, Gibbs J, Whitney N, Starosta A. Prevalence of orthorexia nervosa is less than 1%: data from a US sample. Eat Weight Disord. 2017;22:185-192.
6. Park SW, Kim JY, Go GJ, et al. Orthorexia nervosa with hyponatremia, subcutaneous emphysema, pneumomediastimum, pneumothorax, and pancytopenia. Electrolyte Blood Press. 2011;9:32-37.
7. Zamora MLC, Bonaechea BB, Sánchez FG, Rial BR. Orthorexia nervosa: a new eating behavior disorder? Actas Españolas de Psiquiatría. 2005;33:66-68.
8. Moroze RM, Dunn TM, Holland JC, et al. Microthinking about micronutrients: a case of transition from obsessions about Healthy eating to near-fatal “orthorexia nervosa” and proposed diagnostic criteria. Psychosomatics. 2015;56:397-403.
9. Barthels F, Meyer F, Pietrowsky R. Die Düsseldorfer Orthorexie Skala–Konstruktion und Evaluation eines Fragebogens zur Erfassung ortho-rektischen Ernährungsverhaltens (in German). Zeitschrift Klin Psychol Psychother. 2015;44:91-105.