New, but Not So Improved

This diagnosis made its first appearance in 2013, with the release of the DSM-5. Since then, throughout the years, it has brought about some controversy within helping professionals and clients alike. Essentially, the "point" to this diagnosis was to give a classification to those that met every single criterion for Anorexia Nervosa, except for one: being clinically underweight. This means that there are the same amount of medical, cognitive, emotional, and practical symptoms and problems, but the weight loss doesn't classify someone as underweight according to their BMI. This translates to, "It's 'typical' for those struggling with Anorexia Nervosa to be clinically underweight. If you are not, you must be atypical." So, let's look at what atypical really means. According to Oxford Languages, atypical is defined as "not representative of a type, group or class." This would mean that those that do not meet the weight criteria must not be representative of this group of people. This is strange though, as those not deemed as clinically underweight make up 94% of those struggling with eating disorders. Why is the 6% considered to be "typical?"

6%

Research across the board has shown that only this small percentage of individuals will be deemed as clinically underweight when they are diagnosed. Doesn't this almost sound, atypical? Better yet, what if there wasn't a classification system based off of weight loss that told our clients whether they were typical or not? This new diagnosis inherently created another severity system. Those with Anorexia Nervosa are viewed as having more "severe" eating disturbances because of the consequence of more weight loss. This language emphasizes, as does the criteria listed in the DSM-5, that weight loss is merely a symptom. With this being said, it's somehow the "most important."

A parallel to draw would be the percentage of individuals who consider suicide or attempt suicide of those diagnosed with Major Depressive Disorder. Is the symptom of suicidality sometimes prevalent in this population? Yes. Is it a defining and determining factor in diagnosing? No. This distinction is important because it highlights that the symptom of suicidality, commonly and loosely seen as a "severity indicator" in Major Depressive Disorder, is still viewed as equal with other possible symptoms. Could you imagine if we waited for our client's depression to get more "severe" by thinking of or attempting suicide before we gave them their rightful diagnosis? Why is this different with Anorexia Nervosa? When we give the Atypical Anorexia diagnosis, we are basically saying to our clients, "You don't have the one key severity symptom, therefore, you do not meet criteria. You are, atypical."

Why is this Narrative so Harmful?

A common experience for someone experiencing an eating disorder is anosognosia, or not understanding, seeing, or believing the severity or presence of his or her illness. This symptom is not seen across the board, but is extremely common, specifically, with those struggling with both anorexia diagnoses. This means that when a client seeks, is mandated, or is highly suggested to seek treatment, they may already have little to no insight into their disorder.

This individual may also struggle with Body Dysmorphic Disorder, so they aren't able to see their body as others do, meaning they may not see extreme weight loss, or still perceive themselves as, "fat." They may also struggle with comparisons to other people, meaning they have seen others lose more weight, eat less, workout more, or simply present as more "sick" than they feel themselves. Finally, especially if the symptom of extreme weight loss isn't present, an individual may feel invalid, as those around them may congratulate their body changes, praise their eating habits, or express little to no concern over the actions of the one that is struggling.

For all of these reasons, it's already often hard for a client to truly experience, understand, and feel validated in their struggles. When they bravely walk into that office, mandated or not, they are being brave, vulnerable, and highly aware of how they're being perceived. So, when that atypical diagnosis is given, what message does this send to our clients in this state?

These words tell our client:

1) You aren't sick enough, yet.

2) Your perceptions of self are right; you still could lose more weight.

3) Insurance may not cover you, because you aren't severe enough.

4) Your body image perception is also right, you are still too fat.

5) My other patients/clients are sicker than you are.

6) Your other symptoms aren't as important as your weight.

7) Other people struggle more than you do.

Say it With Me : "BMI Should Have No Place in Mental Health."

I think the most pressing distinction to be made, is that as mental health professionals, we are diagnosing based off of mental health, not physical health. This makes sense, considering we are all not trained in physiological sciences, but are extensively trained in psychological sciences. This begs the question, why are we using physiological indicators when diagnosing conditions regarding mental health? Furthermore, why are we using the BMI scale as the determining factor in diagnosis? The BMI scale came about as long ago as the 1800s, was created by a mathematician (not a scientist or medical doctor), and was considered to be relevant or created for White males. This furthers the point that BMI has no place being in the DSM-5. Where is the data relating to African American females? What about those with increased muscle mass? What if- this information is simply not relevant over 200 years later? It's already been somewhat widely accepted that people shouldn't "hang their hat" on their BMI because of so many influencing factors that it doesn't take into account. However, when discussing anorexia diagnoses, this BMI scale is still the determining factor for diagnosis, treatment accessibility, insurance coverage, and overall perception by clinicians.

What Can We Do?

As clinicians and mental health professionals alike, we need to advocate on behalf of our clients. We need to be well versed in the areas of body-positivity, the Health At Every Size model, and the role of fatphobia in our culture today. We must express our disagreement to this diagnosis with our clients, and remind them that they are valid, just the way they are. We must indicate that we see them, believe them, and hear their struggle, regardless of their weight changes. We have to instill in them and demonstrate through our care that, they are sick enough. We may need to help them before they can help themselves, and this includes validating their experiences before they may feel valid themselves.

Atypical Anorexia

Drawing Parallels to Addiction in the Treatment of Anorexia Nervosa

“Thin to Win”