Diagnosis du jour? Considering Orthorexia Nervosa
by Barbara Rittner
It is always tempting to try to predict the next psychiatric diagnosis du jour. I have watched autism replace bipolar which replaced ADHD as the front runner in the race for popularity in children and adolescents diagnoses. It is clearly incumbent on us to view these emerging trends with healthy skepticism. To put it in perspective, in the last 20 years autism rates increased from 1 in 10,000 (1990s) to 1 in 68.
The shift in autism diagnosis rates certainly should raise questions about how valid the diagnosis is when what was once considered a rare condition is now so common that it occurs in 1.5% of the population. That makes it as common as red hair (estimated at 1-2%).
Increases in autism as the diagnosis du jour follows on the heels of diagnosing acting-out adolescents as bipolar and encouraging the use of medications until the medication side effects were tied to increasing rates of tumors and diabetes (Harley, et al, 2007; Pfeifer et al 2010; van Winkel et al 2008) in these youth.
But I confess that the latest diagnosis du jour to emerge caught me completely by surprise. An article in BMC Psychiatry reported on the partial validation of an instrument (Ortho-15) that supposedly supports the existence of Orthorexia Nervosa (ON), a newly invented diagnosis for people who are too concerned about their healthy diets. (This diagnosis is not in the DSM-5 but may come under consideration).
There is no question that we all know people who endorse very restricted diets, many of whom might even meet criteria for this “alleged” diagnosis using the Ortho-15. Some restrict their diets because of a desire to eat healthy, some because they have a medical condition that limits what they can eat or made them re-evaluate how they eat, some because of their religious or spiritual beliefs, and some because they have an eating disorder (either anorexia nervosa or bulimia nervosa – AN or BN) often co-morbid with obsessive compulsive disorder (OCD) and obsess about health foods.
Any of these reasons for restricting a diet to health foods would probably meet the clinical criteria for this “alleged” ON diagnosis but technically only those who meet criteria for co-morbid AN or BN and OCD should. It is easy to challenge the criteria in the Ortho-15 as flawed but it is the premise that is flawed because there is nothing new here.
Relabeling the well-documented eating disorder co-morbid with OCD using a new label does not provide any useful clinical information. In fact, this co-morbidity is so well documented in the literature that in the last 15 years there have been 250 peer reviewed articles published globally on comorbid OCD and AN.
It begs the question of how the newly labelled Orthorexia Nervosa needs to be differentiated from the well-known co-morbidity of eating disorders and obsessive compulsive disorders. This, hopefully, will never become the next diagnosis du jour.
Do you have a favorite “diagnosis du jour”?
What do you think of the new Orthorexia Nervosa diagnosis?
Let us know – leave a comment!
“Tree Restaurant” cartoon by Katie McKissick is licensed under Creative Commons BY-NC-ND 3.0 See more of her work at http://www.beatricebiologist.com
References:
Varga, Márta et al.When eating healthy is not healthy: orthorexia nervosa and its measurement with the ORTO-15 in Hungary. BMC Psychiatry 2014, 14:59
About
Barbara A. Rittner, PhD, LCSW, is Associate Professor and Associate Dean for Advancement at the UB School of Social Work. She teaches Psychopathology online, and was past Director of the PhD program. Formerly, she chaired the Group for Advancement of Doctoral Education, and has served on CSWE’s Board of Directors and Commission on Research.
SocialWorkSynergy 
Reblogged this on Dissociatieve Identiteitsstoornis.
As someone with a lot of dietary restrictions due to health problems, I admittedly had a strong reaction to the coining of this term and its use in diagnosis. I understand that any behavior that negatively impacts activities of daily living (no matter how well-intended) is a matter for concern. However, at a point where people are increasingly recognizing the impact of nutrition on physical and mental health, I’m worried about the implications this sort of diagnosis may have. For example, recent research has found a strong relationship between the consumption of sugar and increased risk of depression, poorer outcomes for individuals with schizophrenia, and the worsening of anxiety symptoms (Sack, 2013). Yet sugar can be found in almost all processed foods, making it both difficult and time-consuming for a person to cut out from his or her diet. So even if a restrictive diet is beneficial to one’s health, according to NEDA’s criteria on Orthorexia Nervosa, a person could still be diagnosed with the disorder if he or she:
• wishes that occasionally he or she could just eat and not worry about food quality
• wishes he or she could spend less time on food and more time “living and loving”
• finds it beyond his or her ability to eat a meal prepared “with love” by someone else and not try to control what is served
• is constantly looking for ways foods are unhealthy for him or her
• puts love, joy, play and creativity in the back seat to following the perfect diet?
• feels guilt or self-loathing when straying from his or her diet?
• feels in control when sticking to the “correct” diet?
• puts him or herself on a nutritional “pedestal” and wonder how others can “possibly eat the foods they eat.”
This isn’t currently a DSM diagnosis, so there’s no set number of criteria that should be met to make a diagnosis, but I can say for myself that I identify with at least half of those statements. Frankly, I think most people with food sensitivities, allergies, or a number of digestive health problems could agree with a number of those statements. Let’s face it: most people in our society eat what they want, when they want to, without consideration of the nutritional value of what their eating or the impact it will have on their physical or mental health (and yet there’s no movement to turn that sort of lifestyle into a diagnosable disorder). But for people with health problems that are acerbated by certain foods, having to stick to a strict diet is frustrating, and at times it can even be alienating. By pathologizing this sort of experience, I’m worried that we might be doing more harm than good for these people. As for individuals without health problems, or where Orthorexia Nervosa might be comorbid with Anorexia Nervosa, Bulimia Nervosa, or Obsessive Compulsive Disorder, I think a sub-type or specifier for AN, BN, or OCD might serve better in treating the unique aspects of this focus on healthy eating than would creating a completely new diagnosable disorder.
Resources:
National Eating Disorders Association. (2014). Orthorexia Nervosa. Retrieved from: https://www.nationaleatingdisorders.org/orthorexia-nervosa
Sack, D. (2013, September 2). Where Science Meets the Steps. 4 ways sugar could be harming your mental health. Retrieved from: http://www.psychologytoday.com/blog/where-science-meets-the-steps/201309/4-ways-sugar-could-be-harming-your-mental-health
Those are such excellence concerns and dead on target with this “diagnosis du jour.” In the absence of context, it is easy to inappropriately label behaviors as pathology and you have described the real problem eloquently in doing so!
As someone with a lot of dietary restrictions due to health problems, I admittedly had a strong reaction to the coining of this term and its use in diagnosis. I understand that any behavior that negatively impacts activities of daily living (no matter how well-intended) is a matter for concern. However, at a point where people are increasingly recognizing the impact of nutrition on physical and mental health, I’m worried about the implications this sort of diagnosis may have. For example, recent research has found a strong relationship between the consumption of sugar and increased risk of depression, poorer outcomes for individuals with schizophrenia, and the worsening of anxiety symptoms (Sack, 2013). Yet sugar can be found in almost all processed foods, making it both difficult and time-consuming for a person to cut out from his or her diet. So even if a restrictive diet is beneficial to one’s health, according to NEDA’s criteria on Orthorexia Nervosa, a person could still be diagnosed with the disorder if he or she:
• wishes that occasionally he or she could just eat and not worry about food quality
• wishes he or she could spend less time on food and more time “living and loving”
• finds it beyond his or her ability to eat a meal prepared “with love” by someone else and not try to control what is served
• is constantly looking for ways foods are unhealthy for him or her
• puts love, joy, play and creativity in the back seat to following the perfect diet?
• feels guilt or self-loathing when straying from his or her diet?
• feels in control when sticking to the “correct” diet?
• puts him or herself on a nutritional “pedestal” and wonder how others can “possibly eat the foods they eat”
This isn’t currently a DSM diagnosis, so there’s no set number of criteria that should be met to make a diagnosis, but I can say for myself that I identify with at least half of those statements. Frankly, I think most people with food sensitivities, allergies, or a number of digestive health problems could agree with a number of those statements. Let’s face it: most people in our society eat what they want, when they want to, without consideration of the nutritional value of what their eating or the impact it will have on their physical or mental health (and yet there’s no movement to turn that sort of lifestyle into a diagnosable disorder). But for people with health problems that are acerbated by certain foods, having to stick to a strict diet is frustrating, and at times it can even be alienating. By pathologizing this sort of experience, I’m worried that we might be doing more harm than good for these people. As for individuals without health problems, or where Orthorexia Nervosa might be comorbid with Anorexia Nervosa, Bulimia Nervosa, or Obsessive Compulsive Disorder, I think a sub-type or specifier for AN, BN, or OCD might serve better in treating the unique aspects of this focus on healthy eating than would creating a completely new diagnosable disorder.
Resources:
National Eating Disorders Association. (2014). Orthorexia Nervosa.
Sack, D. (2013, September 2). Where Science Meets the Steps. 4 ways sugar could be harming your mental health.