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Clinicians Prepared to Address Emerging Eating Disturbances
By Jennifer Van Pelt, MA

Every day we are bombarded by marketing messages about the best diet and the healthiest foods, with images of svelte celebrities touting the most effective way to lose weight.

As our society’s views on food and body image evolve so are the many ways that individuals perceive food, a healthy diet, and body type. Consequently, eating disorders and their manifestations are also evolving. The “official” clinical diagnoses of eating disorders have not yet changed; however, other eating disturbances are receiving attention.

Recent news articles have reported on new conditions that involve issues with food and body image. Two of the more common conditions are adult selective eating and orthorexia. Other proposed conditions include diabulimia, pregorexia, and drunkorexia.

Adult Selective Eating
Adult selective eating involves limiting the diet to a very narrow range of foods—much like children go through a phase where they want to eat only one or two foods. This condition takes picky eating to the extreme, and only foods of a certain texture, shape, or food group are eaten.

The condition does not seem to involve any body image issues, but selective eating may interfere with social activities. Some clinicians and researchers speculate that adult selective eating is a manifestation of obsessive-compulsive disorder (OCD).

Orthorexia was introduced in 1997 by Stephen Bratman, MD, to describe individuals with an unhealthy fixation on what they perceive is healthy eating. In some cases, the fixation can lead to severe malnutrition and anorexia.

However, the underlying thought process of orthorexia differs from anorexia. While people with anorexia want to lose weight, people with orthorexia want to feel healthy or natural, not thin.

Symptoms of orthorexia may include obsession with healthy food and being healthy, reading many books about health and diet, spending more than three hours per day thinking about food, increasing strictness with diet, and feeling guilty or self-loathing when straying from the diet. Orthorexia may also be a manifestation of OCD.

Individuals with type 1 diabetes can deliberately manipulate their insulin for the purpose of weight control or loss. Often people with diabulimia have another eating disorder that they are more open to discussing in therapy but will hide the insulin manipulation. Diabulimia can result in life-threatening diabetic ketoacidosis, diabetic neuropathy, and renal failure.

Typically, diabulimia starts in adolescence and is more common in women. The condition is more likely to be diagnosed by medical symptoms such as spikes in hemoglobin A1c, electrolyte disturbances, and edema or by monitoring prescription refills for insulin rather than in a counseling session.

Although not previously recognized as an eating-related behavior, insulin manipulation is a common practice recognized by clinicians in diabetes care.

Pregorexia is anorexia that develops in pregnant women and women who have just given birth as a result of feelings of guilt and shame regarding weight gain during pregnancy and/or the inability to lose “baby weight.” Behaviors are similar to anorexia and may include starvation and excessive exercise. Some eating disorder treatment centers have begun offering programs specifically for women with pregorexia.

This condition is binge drinking combined with aspects of anorexia and bulimia. The extra calories from alcoholic beverages are offset by starving and purging behaviors. The typical “drunkorexic” is a college-aged female. 

Clinicians’ Comment
The media attention given to new eating issues can make it difficult for social workers to keep up, says Esther Kane, MSW, a Vancouver, Canada-based therapist on food and body image issues who has authored books and audio programs and conducts workshops on eating disorders. The two emerging disorders she has heard of most frequently are adult selective eating and orthorexia. According to Kane, orthorexia seems to have developed from societal obsessions with being thin and healthy and is being fueled by marketing messages and the numerous diet books popularized in the media.

Personally, Kane has struggled with orthorexia. “My eating disorder began when I was a teen who turned to vegetarianism. Then I went vegan, then to raw foods. Then I applied rules about food combinations to the point where almost my entire day was spent thinking about food. It eclipsed the rest of my life,” she admits.

Individuals with orthorexia start by making healthy changes to their diet and gradually build to an obsession so that food is thought to be the answer to all health concerns. “My struggle reveals how someone can go from prioritizing healthy eating to obsessing about it. Now, 18 years later, I still consider myself to be in the recovery process. I liken orthorexia to a quiet voice in the background,” Kane explains.  She has summarized coping strategies in her book, It’s Not About the Food: A Woman’s Guide to Making Peace With Food and Our Bodies, including how to sort out emotional vs. physical hunger, changing mindset with cognitive behavioral therapy, and meditation and relaxation.

The coining of new terms for various eating behaviors may be progressing too fast, but social workers with experience in eating disorder therapies are well prepared to help clients with these new eating conditions, even if they’ve never heard of drunkorexia or diabulimia.

“These are not yet official diagnoses and, in my caseload, show up as eating disturbances or subclinical eating issues, not eating disorders,” says Jean Fain, LICSW, MSW, a licensed psychotherapist and psychiatry teaching associate at Cambridge Health Alliance, affiliated with Harvard Medical School.

Outpatient treatment, though, is basically the same for all eating issues, she says. The main components are a caring, trusting therapeutic alliance; basic nutrition education; cognitive behavioral strategies, such as food diaries and progress charts, social or group support; and self-compassion instruction with mindfulness practices, according to Fain.

She adds that self-compassion is the newest aspect of current treatment for eating disorders and can apply to these new eating issues as well. In her recently published book, The Self-Compassion Diet, Fain explains how cultivating self-compassion can combat emotional eating and other food-related issues. 

“Essentially, clients learn to view and then treat themselves like a friend or loved one—with care and concern. Self-compassion can address the self-criticism and emotional distress that fuels emotional eating and help establish a harmonious relationship with food,” she says.

Becky Davidson, LCSW, a private practice therapist with more than 10 years of experience treating eating disorders and body image issues, has not yet identified any of these emerging eating conditions in her clients.  Her work has focused on the more commonly recognized eating disorders—binge eating, anorexia, and bulimia. 

“The more clinicians and researchers study eating disorders and the more experience we get treating them, the more we learn about the different faces of the disease,” she says.

Even if these new eating “disorders” never become official clinical diagnoses, it is likely that social workers will begin to see more clients with more varied eating-related behaviors due to evolving societal influences.

— Jennifer Van Pelt, MA, is a Reading, PA-based freelance writer.