What Is Orthorexia Nervosa and How to Assess It

Orthorexia nervosa is a behavioural phenomenon that has been increasingly discussed not only in the scientific community but also in magazines, in documentaries and the media in general. Orthorexia nervosa can be defined as an extreme and obsessive preoccupation with food perceived to be unhealthy. This phenomenon was first described by Steven Bratman, a medical doctor in the U.S. in 1997. He was apparently describing his own personal eating behaviour realizing the abnormal tendencies and pathological features.

Features of Orthorexia Nervosa

People suffering from orthorexia nervosa avoid certain foods and eat according to their own health criteria. They might be fixated on organic and biologically “clean” foods, dietary supplements, raw foods or a combination of these foods. The observed eating behaviour shows a lack of flexibility with a high feeling of discomfort when external circumstance requires to change the food plan or choices. It also involves long-term planning and destructive food choices that can lead into micro-and macronutrient deficiencies and social isolation. This behaviour does not progress overnight but develops over time getting more extreme as time passes.

Orthorexia nervosa is currently not officially recognized as a pathological eating disorder but experts are discussing whether it should be added to the diagnostic manual of psychiatric diseases DSM-5 which contains, for instance, the eating disorders anorexia nervosa and bulimia nervosa.

Similar to these eating disorders, those displaying features of orthorexia nervosa often show signs and symptoms of anxiety disorders. They are afraid of not being able to follow their strict dietary rules or of becoming seriously ill when not following their dietary rules.

Furthermore, both individuals with orthorexia or anorexia nervosa are very achievement-oriented. They see the adherence to their diet as a marker of self-discipline and the deviation from it as a failure of self-control. Both have limited cognitive insight into their condition and often deny the functional impairments associated with their disorder.

What is the difference between orthorexia nervosa and anorexia nervosa?

The difference is the focus on the personally defined perfect diet rather than an ideal weight. In addition, people with orthorexia often try to convince others to follow their pure and healthy diet which can lead into further social isolation by turning away from people who refuse to comply. Furthermore, friends and family might hesitate to spend time with the individual because the dietary rules clash with social activities and make a social get together that involves eating difficult.

Risk factors of developing Orthorexia Nervosa

Risk factors for the development of this behaviour also overlap in parts with risk factors for developing eating disorders. The lack of self-esteem, a tendency to perfectionism, depression and social anxiety are risk factors associated with all types of eating disorders. However, what seems to be unique for orthorexia nervosa is a previously diagnosed illness or the fear of it. The fear can be induced by witnessing the severe illness or death (e.g. caused by cancer) of a close relative or it can also be undetermined in origin.

Also, people following a vegan or vegetarian diet appear to be at higher risk for developing orthorexia nervosa compared to people without a certain restricted diet.

Assessment of Orthorexia Nervosa

Up to now, various questionnaires have been developed in the attempt to assess this behaviour. However, most lack validity, meaning that we do not have a good way to measure this disorder yet.

Nevertheless, Steven Bratman as well as other researchers in this field assess this disorder by asking questions such as:

1. Do you care more about the virtue of what you eat than the pleasure you receive from eating it?
2. Do you only enjoy eating foods considered healthy?
3. Does your diet socially isolate you?
4. Does your diet make it difficult for you to eat anywhere but at home, distancing you from family and friends?
5. Do you feel guilt or self-loathing when you stray from your diet?
6. Do your thoughts constantly revolve around healthy nutrition?
7. Do you organize your day around your diet?

If somebody answers affirmative to the majority of the questions, s/he can be considered as at risk of developing orthorexia nervosa or even suffering from this phenomenon. However, people with a high level restrained eating – the concept that was described in a previous video lecture – might also wrongly lead into the same conclusion.

Therefore, the line between restrained eating (for whatever reason) and a pathological disorder is thin, particularly in regard to the concept of orthorexia nervosa, where diagnostic features are less defined than with other eating disorders.

Cognition and Orthorexia Nervosa

When looking at those diagnostic questions, it becomes obvious that cognitive processes play a big role in this behavioural pattern. The cognitive bias and cognitive inflexibility are what all eating disorders (but many other psychiatric disorders as well) have in common. In the lecture on dietary restraint you heard about people’s conscious decision to control their intake. In people with orthorexia nervosa, this cognitive restraint is taken to another, much higher level, turning into an obsession surrounding their food intake. Their thoughts are not only preoccupied with food, meal preparation, cooking and purchasing but their dietary rules govern their everyday and their overall behaviour. Similar to other eating disorders, there is a tendency to categorize food into bad and good, leaving out any shades of grey. As a nutritional psychologist, I don’t believe that there are good or bad foods. I believe that some foods can be more beneficial for your health than others. But the main focus should be on the right amount of a food rather than the type.

One example of the extreme concern of people showing signs of orthorexia nervosa is the need to cook a certain vegetable with a certain degree for exactly 3 minutes. It is crucial for them that the time is exactly right and if it is off by only a couple of seconds, the person becomes anxious and, should this be the case, the vegetable is not eaten.

Why do we tend to categorize our foods into “good” and “bad”? Where might these irrational beliefs of food and food ingredients be coming from?

On the one hand, organic stores worldwide are spreading, and people are becoming more interested in and educated about foods free of engineered ingredients or chemical pesticides.

On the other hand, today’s Western society is increasingly interested in finding the “perfect” lifestyle and the “perfect” diet. More than ever people focus on diets that remove food group, such as leaving out gluten or lactose or carbohydrates, and so on. We are taught to believe that certain diets can make us happy and life better.

In addition, people search for diets that can fight disease and promote longevity. People believe that a certain diet can treat cancer or autism. Lastly, it seems that the search for spirituality and finding the meaning of life in the way we eat might also play a role. Looking for cooking or diet books in the bookstore or online can be overwhelming given the amount of books promising “happy hormones and a slim belly” or a diet that will heal whatever you are suffering from and finding “inner peace” in the process.

While very evident in people with orthorexia nervosa, it can also be observed in many other people that have developed a set of subjective dietary rules, ingredients or procedures. This cognitive set up and the high need for cognitive control is difficult to open up and one of the key elements in therapy settings.

Therapeutic approaches to Orthorexia Nervosa

Unfortunately, research regarding successful therapeutic approaches to treat this disruptive and abnormal eating behaviour is currently still lacking, but current best practices suggest that orthorexia nervosa can and should be treated with a combination of cognitive behavioural therapy, similar to other eating disorders and psychoeducation, and an example of therapeutic approach has been described in a previous article by a psychotherapist.