Is orthorexia a psychiatric disorder?

People who adhere to a strict diet of healthy food to a point that it endangers their wellbeing, suffer from ‘orthorexia’. Psychiatrist Eric van Furth explains why it is not a clinical diagnosis.
Leestijd 4 minuten — Wo 14 februari 2018
Health & happiness

Prof Dr Eric van Furth (LUMCH/GGZ Rivierduinen Eating disorders Ursula) has 30 years of experience in treating patients with eating disorders. In his lecture 'Extreme food obsession' he explains that even though orthorexia nervosa sounds like a clinical disorder, it actually is not. The line between living healthy and having a disorder is not always easy to draw.

Van Furth begins his lecture by illustrating the various bodily ideals that have been dominating our collective imagination for the past few decades: thin and muscular. Ideals that were already persistent long before the recent 'fitgirl' trend on Instagram started. The ideal is still prominent today, but it has expanded to also include a strong focus on health. Just search for 'fitspiration' on Tumblr and you will find an endless stream of motivational quotes that help you stick to your diet or exercise plan.

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The rise of orthorexia?

Together with the rise of various health and fitness trends a new problematic food obsession surfaced. For people who suffer from orthorexia nervosa their entire day is filled with anxiety about food. Typically, they suffer from a combination of anxiety, perfection and a desire for control. Van Furth shows an item from ABC News that features a young woman who suffers from orthorexia. Ordering a coconut milk latte makes her anxious because “she doesn't deserve the calories since she didn't work out at all today.”

The term 'orthorexia nervosa' was coined by Bratman in 1997 to describe an extreme fixation on healthy food. He refined his ideas in 2015 and formulated diagnostic criteria. The first part of the criteria details the obsessive focus on 'healthy' eating, including compulsive behaviour regarding a restrictive dietary practice, and the second part describes the clinically impairing consequences, such as weight loss due to malnutrition or social distress.

The first part of the criteria is extreme, Van Furth notes, but does not necessarily count as problematic. It it the second part that Van Furth finds most alarming. But this does not mean we are officially dealing with a disorder. Van Furth: “Even though orthorexia nervosa sounds like a medical diagnosis, it is not. These are not formal diagnostic criteria and orthorexia is not officially classified.”

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How to get orthorexia in the DSM

Mental disorders that are medically recognized are included in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Van Furth suggests that we should tread lightly when adding disorders to the DSM. Once a disorder is part of the DSM the consequences are more extensive than just being able to diagnose and treat patients. It also affects the economics of health care, for example, since health insurances will need to cover the new treatments. But more importantly: it can potentially label a big part of society as 'sick' or in need of medical care. This has a huge impact on what we consider 'normal' behaviour.

People often wonder if orthorexia overlaps with other disorders in the DSM. The first hunch might be to compare it with eating disorders, but the differences are substantial. For example: in the case of an eating disorder, patients suffer from hidden rules related to eating and fear of gaining weight, while in the case of orthorexia, the fear of gaining weight is lacking and there are clear, rationalized rules for eating. When comparing orthorexia with OCD (obsessive compulsion disorder), there are similarities, but the compulsion is only food related, with serious health consequences. The disorder that has most similarities to the description of orthorexia is avoidant/restrictive food intake disorder (ARFID) as it brings together both the obsession with food and the physical and social impairing effects of orthorexia.

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The case for odd behaviour

Since orthorexia does not closely match one of the existing disorders one could make the case that orthorexia could or should be added to the DSM. The problem is that almost no research is being conducted nor has been in the past years. “Without research that leads to distinct criteria I don't see orthorexia being added to the DSM in my lifetime.” He adds that the number of people that actually suffer from orthorexia is relatively small: only a handful of patients in his clinic have been treated with problems that could be labelled as orthorectic.

The fact that psychiatry is a conservative discipline means that it is not easily influenced by hypes and trends. The consequence is that people feel left out or not taken seriously. How can we help people that recognize themselves, or maybe their friends, in the 'symptoms' of orthorectic behaviour? Van Furth thinks that we should not be too quick giving medical labels to behaviour that is different, but not necessarily problematic. We tend to juxtapose good, healthy behaviour with unhealthy, illness-driven behaviour, forgetting about everything that lies in between. Odd behaviour, Van Furth prefers to call this. So there is no need to worry when you adhere to a strict diet or feel a bit guilty after eating a chocolate-bar. As Van Furth puts it: "We should be tolerant about odd behaviour, unless it does us harm."