Anorexia Diagnosis

Jennifer Huddy, MS, RD, LD
Dietitian and Nutrition Writer
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Anorexia nervosa is a serious eating disorder that causes numerous health risks. It is essential for people with a suspected eating disorder to seek a full medical workup and be diagnosed correctly. Receiving a proper diagnosis helps improve a person’s chance of long-term recovery and minimizes medical complications. 

A person with anorexia typically presents with rapid weight loss, intense calorie restriction, and a distorted body image. However, it can sometimes be challenging to diagnose in the early stages of the disease because people with anorexia often make great efforts to conceal outward-facing symptoms.

Doctors and health care providers must be aware of some of the other signs and symptoms of anorexia, such as amenorrhea and infertility, abnormal blood tests, gastrointestinal problems, and low heart rate. Sometimes a patient will see a doctor for help with one of these issues before they are diagnosed with anorexia. More commonly, a diagnosis can be made based on a patient's physical presentation and psychological symptoms without extensive medical tests. 

Family and friends also play a vital role in helping a person with anorexia get a proper diagnosis since they are typically the first to notice rapid weight loss and other troubling symptoms. They may see the person eating tiny amounts and avoiding settings where food is present. They may also notice the person commenting on their relationship with food and their body in a concerning way.

DSM-5 Diagnostic Criteria

The 5th edition of the Diagnostic and Statistical Manual (DSM-5) is most commonly used in diagnosing anorexia nervosa. To be diagnosed with anorexia, a person must meet the following three criteria: 

  1. Severe restriction of food intake below one’s energy needs, resulting in significantly low body weight. 
  2. Intense fear of weight gain or intentionally interfering with weight gain.
  3. Feeling distressed about one’s body weight and experiencing body dysmorphia.

The previous version of the manual, the DSM-IV, included additional criteria that have since been dropped. The DSM used to specify that a person’s weight had to be below 85% of their ideal body weight to be diagnosed with anorexia. However, this was removed in the DSM-5 because it was a barrier to receiving diagnosis and care for people who barely missed the weight cutoff. The new criteria of “significant low body weight” casts a wider net and allows for more accurate eating disorder diagnoses. 

The DSM also used to include criteria around females’ menstrual cycles, stating there had to be at least three missed periods in a row. While this is an important sign of anorexia that should not be ignored during assessment and treatment, it was removed from the diagnostic criteria because it made diagnosing males and prepubescent females difficult. 

Anorexia Subtypes

The DSM also acknowledges two different subtypes of anorexia nervosa to further categorize the eating disorder: restricting type and binge eating purging type. 

Restricting type

The restricting type of anorexia occurs when a person meets all of the above DSM-5 criteria and does not routinely experience binge eating and purging. It is the most common type of anorexia and is what most people imagine when thinking of anorexia.

Binge eating purging type

The binge eating purging type of anorexia includes all of the above DSM-5 criteria but has an additional criterion. People with this type of anorexia routinely engage in binge eating and purging behaviors in addition to having restrictive tendencies. They may also purge after eating small amounts of food and not routinely engage in binge eating. 

The binge eating purging type of anorexia can be confused with bulimia nervosa, an eating disorder characterized by frequent binge eating and purging. People with bulimia do not generally have the same intense food restriction characteristics as anorexia and do not necessarily present with low body weight.

Atypical anorexia 

Atypical anorexia is a newer diagnosis, previously known as “subthreshold anorexia.” It occurs when a person meets all of the DSM-5 criteria for anorexia, except they are not significantly underweight. It can happen when a person who lives in a larger body experiences significant weight loss due to anorexia but is not underweight from a body mass index standpoint. 

Historically, people who met these criteria were diagnosed with an “eating disorder not otherwise specified,” which made it difficult for these patients to get the specialized care they needed. Atypical anorexia is an important diagnosis option because it helps more people with anorexia to be appropriately diagnosed and treated. It also enables more people to get insurance coverage for anorexia treatment. 

Atypical anorexia should not be interpreted as being less risky. Research shows it has similar health implications as traditional anorexia nervosa. People with atypical anorexia are also less likely to be promptly diagnosed and treated since they present with a “normal weight.” This means they might be living with anorexia for much longer and experience severe medical issues as a result. 

The addition of the atypical anorexia diagnosis also helps to fight against the stereotype that all people with anorexia are emaciated and severely underweight. This stigma leads many people with eating disorders who present with normal or elevated weights to fly under the radar and not get the treatment they need. 

Seeking Help

If you are struggling with anorexia and are looking for an outpatient level of care, it can be overwhelming to find the right fit. The registered dietitians at Nourish are experts in treating eating disorders. Nourish offers remote one-on-one meetings that are covered by insurance. Your dietitian will work with you and your treatment team to help you achieve remission. Don’t wait to get treatment – get started today

Sources:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1857759/ 

https://www.magonlinelibrary.com/doi/full/10.12968/hmed.2020.0099?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org 

https://www.sciencedirect.com/science/article/abs/pii/S1538544217300470?via%3Dihub 

https://www.ncbi.nlm.nih.gov/books/NBK519712/table/ch3.t15/ 

https://www.nationaleatingdisorders.org/learn/by-eating-disorder/anorexia 

https://www.ccjm.org/content/87/3/172

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