For Erin Harrop, an assistant professor of social work at the University of Denver, signs of an eating disorder began to appear at a young age.
It initially started at the age of six with little things – consuming only fat-free products, not using mayonnaise and eating a piece of bread instead of a tortilla. But by the time Harrop, who uses they/their/them pronouns, was 12- years old, they began meticulously counting their calories.
“I received messages as a young child – as young as I can remember – that my body was good because it was skinny,” Harrop, 38, says. “I was ‘lucky’ because so many people in my family had larger bodies. This made me afraid of one day having a larger body.”
Not only did the media’s portrayal of the “ideal body” distort Harrop’s perception of themself and influence their relationship with food, but dieting was also religiously charged. As a pastor’s child, they were constantly reminded that gluttony should be disparaged, while self-control was celebrated. Harrop participated with other women from their church in “praise aerobics” classes, which are high-energy aerobics set to spiritual music.
“Many of the women in my life as a young child were very concerned about losing weight or managing their weight,” Harrop says. “I learned early on that fat was bad.”
Harrop was diagnosed with anorexia nervosa at age 15. By their mid-20s, they continued to struggle with self-starvation. But this time, doctors diagnosed them with atypical anorexia nervosa, an eating disorder that meets all the same criteria for anorexia with one distinguishing factor: People with atypical anorexia are not underweight. Instead, they’re often within a normal weight range, or are overweight.
As Harrop began outpatient treatment under their doctor’s supervision at an eating disorder clinic, they gained back more weight and their heart issues started to slowly resolve. Today, Harrop is in remission from atypical anorexia and continues to see a therapist, dietitian and doctor.
“I think I will always have to be on the lookout to avoid relapsing into old, harmful eating habits,” says Harrop. As a licensed medical social worker, they have made it their mission to help others with eating disorders, including those with atypical anorexia.
What Is Atypical Anorexia?
In 2013, the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition – the official diagnostic handbook used by clinicians and researchers to diagnose and classify mental disorders –included atypical anorexia as a mental health disorder with all the same symptoms of anorexia except one: extreme thinness.
Atypical anorexia is a serious eating disorder characterized by significant weight loss, severe restrictive eating habits, potentially life-threatening heart issues and electrolyte imbalances, as well as psychological issues.
“People living with atypical anorexia have the same symptoms as anorexia, same amount of medical problems and sometimes even worse,” says Dr. Cheri Levinson, associate professor and director of the Eating Anxiety Treatment Laboratory and Clinic at the University of Louisville in Kentucky. “Atypical anorexia is associated with similar to higher levels of psychological distress and distortions about both eating and body image compared to anorexia.”
Appearances can be deceiving when it comes to atypical anorexia, experts say. Those impacted by atypical anorexia severely restrict calories, obsess about food, miss meals, eat in secrecy and follow special rules about what foods they allow themselves to eat. However, despite the restrictive eating, people with atypical anorexia find it challenging to lose weight because of their body’s slower metabolism.
As a result, they can still appear to be within a normal weight range, or even heavier, though they lose significant amounts of weight.
How Common Is Atypical Anorexia?
A 2012 study reported that between 0.9% and 2.0% of females and 0.1% to 0.3% of males will develop anorexia during their lifetime. A separate 2013 report, published in the Journal of Abnormal Psychology, estimated the prevalence of atypical anorexia by age 20 years at 2.8% versus 1% for anorexia.
“Unfortunately, the research funding for eating disorders at the federal level is very low, which means that large population studies to track what eating disorders look like in many subsets of the population are nonexistent or the data is old and not as relevant,” says Elizabeth Thompson, CEO of the National Eating Disorders Association in Dover, Delaware.
Eating disorders are on the rise worldwide, with a major surge during the pandemic when rates of anxiety and stress multiplied. A 2020 survey, reported in the International Journal of Eating Disorders, found that individuals with anorexia experienced a worsening of symptoms as the pandemic hit.
Atypical Anorexia Diagnosis
Diagnosing atypical anorexia is more difficult than typical anorexia because individuals do not “look anorexic,” or are not underweight.
“My patients usually go to multiple doctors because of symptoms like hair loss (and) rapid heartbeat,” Levinson says. “Their doctors never attribute it to an eating disorder because many assume you have to be underweight to have an eating disorder, or you have to be binge eating and purging.”
As a result, atypical anorexia often goes undiagnosed for years, and can become a larger health issue if left untreated.
“The longer an eating disorder goes without recognition the harder it becomes to treat,” Levinson adds. “Many people with atypical anorexia do not believe they have an eating disorder because they are not underweight, when in fact, they are as sick or sicker many times than those who are below normal weight.”
Symptoms of Atypical Anorexia
Similar to those with anorexia, atypical anorexia may include physical and behavioral symptoms.
- Attention on food and nutritional content.
- Difficulty thinking and focusing.
- Distorted body image.
- Hyperfocus on body weight, size and shape.
- Increased emotional dysregulation, such as irritability and mood swings.
- Intense fear of being overweight or having body fat.
- Low self-worth.
- Overvaluation of weight and shape.
- Refusing to eat or to be seen eating by others.
Long-Term Health Consequences of Atypical Anorexia
When a person’s body repeatedly goes through patterns of yo-yo dieting, clinically referred to as weight cycling, all of that losing and regaining weight eventually takes a serious physical toll on the body.
“Some think that atypical anorexia is not as severe as other eating disorders because people are not underweight,” Moskowitz says. “This is absolutely not the case, as it often comes with the same or worse medical and psychological consequences of anorexia.”
Serious health consequences can include:
A 2014 study, published in World Psychiatry journal, evaluated the risks of suicide among mental health disorders. Those with the highest all-cause mortality ratios, which is defined as death from any cause, were substance abuse disorders like opioid addiction (14.7%) and anorexia (5.9%). After cardiovascular complications, suicide is the second leading cause of death among those with anorexia, according to a 2018 report from Current Opinions in Psychology.
Treatment of Atypical Anorexia
Those who feel they may be suffering from atypical anorexia should talk to their doctor, or seek help from an eating disorder specialist.
“If you think you may have atypical anorexia, or someone you love may be battling this eating disorder, do not hesitate to reach out for medical advice,” Levinson says. “It will be life-saving and life-changing and the sooner you reach out for help the better.”
Most treatment of atypical anorexia is delivered in an outpatient setting, such as hospitals and clinics.
This is for individuals with severe atypical anorexia who require round-the-clock medical supervision to stabilize their health. Usually, this takes place at hospital medical units or psychiatric units.
Inpatient therapy can last for a few weeks and may transition to outpatient treatment or at-home care. A key driver for inpatient care is the need to address severe weight loss through a refeeding program, oftentimes using feeding tubes, that allows for a gradual restoration of healthy weight.
A personalized meal plan is established, which consists of three main meals and three snacks a day. There’s also 24/7 residential care therapy available to address the symptoms of atypical anorexia. This care may last for several months or even as much as a year, depending on the severity of the case.
Individuals with atypical anorexia will undergo various forms of therapy to address the underlying issues of their eating disorder. Types of psychotherapy include cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT) and acceptance and commitment therapy.
Another key form of therapy is family-based treatment to get a patient’s family to be part of the recovery process. With guidance from a doctor, families take the lead on the refeeding routines that would be typically done in the hospital. Family meals become a critical part of the treatment, so that everyone eats the same food and the same amounts of food.
Two types of outpatient treatment include:
- Intensive outpatient or partial hospitalization treatment: A typical treatment day in an outpatient setting includes a variety of therapeutic and educational activities, personalized guidance, focused feedback, supervised meals and opportunities for relaxation and recreation. Intensive outpatient and partial hospital treatment is much less expensive than inpatient therapy, and can often help the patient avoid relapse by easing the transition between the clinic and their home.
- Psychiatric medicines: In addition to refeeding programs, some patients may start taking medications, especially if they also live with other mental health issues such as depression and anxiety. While there are no drugs approved by the Food and Drug Administration specifically for atypical anorexia, the antipsychotic medication olanzapine, also available under the brand name Zyprexa, has been shown to reduce psychological stress around the refeeding phase of treatment.
One 2012 study found that those taking olanzapine showed a greater rate of increase in weight and improvement of obsessive symptoms.
“The weight gain is small and needs to be weighed carefully with the potential side effects of the medication such as potential metabolic, cardiac, movement and liver issues,” Moskowitz says.