I have heard it proposed that the description “Atypical Anorexia” should be ditched.
Eating disorder classifications have changed over the years. We have had eating disorders classified in many ways, as anorexia, bulimia, ednos, fednec, osfed, orthorexia, and so on. Some psychiatrists even tried to have “obesity” included in eating disorder classification. We do NOT call each variant a “diagnosis” and we should not confuse a “classification” with a diagnosis.
The classifications were invented for a number of reasons. Most importantly they were
A to legitimise treatment and to make it available to people who beforehand viewed their behaviour as mad or bad.
B to identify treatment pathways that are appropriate for the behaviour in the room. One would not treat a 14-year-old restricting person the same way as a middle-aged overweight person whose eating was objectively out of control. Well-meaning professionals have devoted their lives (think Janet Treasure or Christopher Fairburn) to developing treatments for different client presentations.
The criteria that led to the classifications were based on frequency of observed behaviour and time. We have also needed to add thinking typical for each classification. For example, with anorexia nervosa there is a relentless pursuit of low weight that is not experienced by people who lose control of food and who are not underweight.
To qualify for having an “eating disorder” you have to be doing what you are doing fairly consistently and to be doing it often enough that it makes a difference to your life. If a person overeats and then induces vomiting to avoid weight gain once every 6 months, it is hard to know what is wrong, if at all.
The problem therefore with classifications is that they have never been clear-cut and people do not fit neatly into just one classification as they exist right now. To have anorexia, at the moment, one criterion is to be underweight at a specific level. Anorexia is also a mindset, that is well understood by people who are trained clinicians. So where do we “fit” someone with an anorexic mindset but who is not underweight or just marginally so?
Where do we fit people who compensate for overeating by purging but not very often? And where do we fit people who purge without having overeaten beforehand?
The eating disorder classifications as things stand – allow for this variance by saying that there is behaviour that fits the current criteria; and there is behaviour and thinking that almost fits but doesn’t tick all the boxes, one being weight.
Let’s make one thing absolutely clear. We need to sort a client into one or more categories for our own protection and for ethical practice. I mean, a client can have bulimia and ALSO present with orthorexia or night eating syndrome. When we have sorted this in our own mind we can determine an evidence-based adaptable treatment plan. I had plenty of clients over the past 40 years who behave and think like people with anorexia nervosa. But they are not underweight. The person who first comes to mind was anorexic without doubt but she had a BMI of 30. The reasons for this are complex. Am I going to call them OSFED or FEDNEC cases? Is that better than ATYPICAL ANOREXIA?
I really don’t care. I have enough experience to think of my client as I choose. The issue is, do we NEED to tell our client about what label we have assigned to them? Whatever “diagnosis” we give them is arguably dehumanising. Does it really make a difference to think that my client has OSFED or a condition that is similar to anorexia, but not quite?
The OSFED and FEDNEC categories are much too broad for my liking and mean nothing for a treatment plan. If you are going to surrender the labels “atypical anorexia / bulimia,” then first decide what you will replace them with, and whether it makes a difference.
AT NCFED in our interactions with clients, we often (not always) avoid labels. Because they don’t help with engagement or therapy outcomes. We know how to decide if they have an unhelpful, harmful relationship with food and we invite the client to create their own identifier for their experience of eating and body weight. But as clinicians, we have some tick-boxes to rely upon to determine a category, for ethical reasons.
The category “atypical anorexia” has meaning, and specific symptoms. If you can come up with something more useful and why, please let me know. I’m listening.