Maybe you’ve been dieting for years and you can’t get down to the weight you desire. Or maybe you’ve been at a much higher weight, but have successfully lost a lot of weight recently. You still don’t feel satisfied with your weight. Others may be applauding your weight loss. You may be skipping meals, limiting high-fat foods, or exercising frequently.
Or maybe your teen has gone from being “overweight” to “a healthy weight.” You (or your teen) may have some physical symptoms that surprise you because you don’t think there’s anything wrong: lightheadedness, hair falling out, loss of period, trouble sleeping, or others. Medical doctors and people around you may not be able to explain these physical symptoms or even think there is a problem. You may not believe you (or your teen) could have an eating disorder because you (or they) “are not thin enough.”
When people think of a person with anorexia (or an eating disorder for that matter), they commonly picture a very emaciated person. However, there is a diagnosis called “Atypical Anorexia” that may affect people in not thin and even large bodies. Yes, you (or your teen) may have Atypical Anorexia: Anorexia in a Larger Body. Yes, anyone of any size can have an eating disorder!
What is Atypical Anorexia Nervosa?
Atypical Anorexia (AAN) was added to the Diagnostic and Statistical Manual (DSM-5) in 2013 as a type of Other Specified Feeding or Eating Disorder (OSFED). People diagnosed with AAN are described as follows: “All of the criteria for anorexia nervosa are met, except that despite significant weight loss, the individual’s weight is within or above the normal range.” Their weight may be low compared to a previous higher weight or according to where their body would be if they ate more sufficiently.
Symptoms of Atypical Anorexia Include:
- Restricted food intake relative to energy needs
- Significant weight loss or maintenance of a lower body weight than expected if intake were more regular
- Intense fear of gaining weight or being fat
- Behaviors—such as dieting, skipping meals, and excessive exercise—that interfere with weight gain
- Obsessing about food, eating, and body image
- Viewing weight or shape as central to one’s value
- Persistent lack of recognition of the seriousness of the problem
- Low blood pressure
- Low heart rate
Unfortunately, society often sees weight loss by people who have been in bigger bodies as an accomplishment; it may be harder to spot the signs of anorexia than it is in a person who is at a low weight. Healthcare providers and doctors may even encourage you to continue dieting or to lose more weight. This can be very confusing…you appear overweight but have a diagnosis of anorexia?
Our colleague was quoted in a recent NY times piece about AAN: “Most people in higher-weight bodies are shocked to hear that they have anorexia,” says Rachel Millner, a psychologist based in Pennsylvania who specializes in eating disorders among people with larger bodies. “Nobody ever told them that you can be in a higher-weight body and have anorexia, and they’re convinced that their problem is their weight.”
How Common is Atypical Anorexia Nervosa?
Recent studies have recognized that AAN is actually more common than anorexia nervosa (AN) (Harrop et al., 2021), leaving many in the field aware that the very title, “Atypical Anorexia” is a misnomer, reinforced by weight stigma. The label is confusing and problematic and leads people who have this diagnosis to feel less worthy of treatment. But this is not the case. You need and deserve treatment.
People with AAN now account for half of all patients hospitalized in eating disorder programs. (NY Times). AAN can be diagnosed in people of all ages, genders, ethnicities, and economic statuses. This is one reason why we never recommend dieting for a person of any body size.
Weight Stigma in Atypical Anorexia Nervosa
Unfortunately, because weight stigma is so prevalent, and because people with AAN are not typically underweight (and may even be in weight categories typically classified as “overweight or “obese,”) the diagnosis of an eating disorder is often missed in people with AAN. People with AAN often don’t believe they have an eating disorder, and neither do their communities. This can lead to delays in receiving treatment. And when they do receive treatment, it is often inadequate (Harrop, 2019). In fact, the DSM-5 presents diagnoses in a hierarchical fashion, with anorexia nervosa presented as the most serious. AAN’s inclusion in the OSFED category suggests it is a less severe illness. However, this is not the case.
People with AAN often report that their eating disorder behaviors were encouraged by health professionals. At EDTLA, we understand that bodies are meant to be of diverse sizes and do not pathologize larger bodies. We understand weight stigma and take AAN as seriously as AN. We diagnose and treat our clients based on behaviors and not body size.
Atypical Anorexia Nervosa is as Serious as Anorexia Nervosa
A recent review paper found that the physiological and psychological symptoms of individuals with AAN are generally similar to those of individuals with AN. Two medical consequences—loss of menses and loss of bone mineral density—may be less severe in individuals with AAN than AN. However, other physical symptoms—including low heart rate and low blood pressure—were mostly similar. Psychological symptoms including concerns about shape and weight and depression were very similar between individuals with AAN and AN. Individuals with AAN may even demonstrate more severe eating disorder-related cognitive disturbances than those with AN. The authors conclude that given the finding of “few differences between AAN and AN,” AAN “might be considered a subtype of AN” and many experts believe AAN and AN are the same condition (Walsh et al., 2022). Some have argued for a new category entitled “Restrictive Eating Disorders,” which would incorporate both AN and AAN under a single diagnosis, with a low-weight subtype (Golden, 2022).
Erin Harrop, Ph.D., LICSW, an eating disorder researcher with lived experience as a person with both AN (as an adolescent and young adult) and AAN (as a later adult), wrote “there was no identifiable threshold I crossed wherein my lived ED experience became qualitatively different; I heard the same ‘ED voice,’ exhibited the same behaviors at similar frequencies and severities and suffered similar physiological consequences…” (Harrop, 2022). In a paper (2019), Harrop details the differences in and increased stigmatization when they had treatment in their larger body than in their smaller body.
Treatment for Atypical Anorexia Nervosa
If you are in a higher-weight body, it may be harder to find treatment and get insurance to cover your treatment at higher levels of care. This is because insurance often relies too heavily on BMI for medical necessity for a higher level of care. Thus, you might need to advocate for appropriate care.
If you (or your teen) have AAN it is very important to see a medical doctor who is informed about eating disorders and AAN. If you need referrals we can recommend some of our preferred physicians.
Treatment for AAN should be similar to that for AN and should usually include weight restoration and renourishment with a sufficient meal plan. Be aware that eating disorder professionals tend to underestimate the energy needs of people with AAN and underfeed them. Further, eating disorder providers often fail to adequately restore weight in those with AAN. But continued weight suppression—being at a lower than a previous higher weight or at a weight lower than your body wants to be at—maintains the eating disorder.
For teens with AAN, we can provide Family-Based Treatment, which installs parents as critical members of the treatment team and overseeing meals. Unlike many other providers, we use an individualized method to establish adequate weight goals based on historic growth patterns. If your teen was previously at a higher weight, they will likely need to go back to a higher weight in order to recover. For parents, this may involve unlearning some of your “diet culture” beliefs that you’ve assimilated or learned from other treatment providers.
For college students and adults with AAN, our therapists can help you with our HAES-informed CBT approach. We will help you to increase your intake and restore weight and provide education about weight stigma and the importance of allowing your body to settle at a healthy weight for your body.
Golden NH. Atypical Anorexia Nervosa is not atypical at all! Commentary on Walsh et al. (2022). Int J Eat Disord. 2022 Dec 13. doi: 10.1002/eat.23871. Epub ahead of print. PMID: 36513600.
Harrop, E. N. (2019). Typical-atypical interactions: One patient’s experience of weight bias in an inpatient eating disorder treatment setting. Women & Therapy, 42(1–2), 45–58.
Harrop EN. A lived experience perspective on the classification of atypical anorexia nervosa. Int J Eat Disord. 2022 Dec 28. doi: 10.1002/eat.23884. Epub ahead of print. PMID: 36577133.
Siber, Kate. “You Don’t Look Anorexic.” New York Times Magazine, October 18, 2022.
Walsh BT, Hagan KE, Lockwood C. A systematic review comparing atypical anorexia nervosa and anorexia nervosa. Int J Eat Disord. 2022 Dec 12. doi: 10.1002/eat.23856. Epub ahead of print. PMID: 36508318.