Because No One In The History of EVER Said Eating Healthy is A Mental Disorder: What Is Orthorexia, Anyway?

There is been quite a bit of snark in social media lately about the term orthorexia nervosa. While it is not a recognized DSM diagnosis (and since it won’t be anytime soon, since the DSM just had a revision and isn’t due another for a few years, most  likely), and the term has actually been around since 1997, discussing orthorexia is as cool as my Member’s Only jacket was in 1984. And all the cool kids are making fun of it. The outcry centers on how mental health treatment (psychiatry most  explicitly, the rest of us implicitly) is out to make everything a mental illness that we can then charge eleventy trillion dollars to “treat” (make sure you insert my Dr. Evil impression here, as you are reading this).

Jaxen’s article (linked above), starts with the following:

In an attempt to curb the mass rush for food change and reform, psychiatry has green lighted a public relations push to spread awareness about their new buzzword “orthorexia nervosa,” defined as “a pathological obsession for biologically pure and healthy nutrition.” In other words, experts are saying that our demand for nutrient-dense, healthful food is a mental disorder that must be treated.

So let’s talk about the disconnect in that statement.  There is an enormous difference in demanding nutrient-dense, healthful food and having a pathological obsession with what and how we eat. I love that so many people are waking up to the fact that how we eat (in the larger global sense) is killing us.  My doctor told me recently that while he knew that Type II diabetes was reversible he had never seen anyone do it until he met me. It was really difficult to do and meant changing so much of how I lived my life and continue to live my life. The fact that I now manage control my blood sugars (as well as the other diseases of western diet that had come with my Type II diabetes, such as high blood pressure and high cholesterol  saved my life, and there is nothing pathological about it. I do not have a mental disorder or an addiction any more than someone who enjoys sex is a sex addict or someone who likes a glass of wine with dinner is an alcoholic.

So let’s talk for a minute about what an addiction is.

Scientific understanding of how addictions are created and how they manifest has increased significantly in the past few years. Addiction is as much about the process as the substance. And some addictions don’t involve anything being put into the body at all (gambling, shopping, sex).  Gabor Maté (In The Realm of Hungry Ghosts; 2010) noted new research in neuroscience is finding that addiction is a function of more than just compulsive use and craving, and created a definition based on what we now know:

Addiction is any repeated behavior, substance-related or not, in which a person feels compelled to persist, regardless of its negative impact on his life and the lives of others.

                Addiction involves:
1.            Compulsive engagement with the behavior, a preoccupation with it;
2.            Impaired control over the behavior;
3.            Persistence or relapse despite evidence of harm; and dissatisfaction, irritability, or intense craving when the object – whether it be a drug, activity, or other goal – is not immediately available. (p. 136-137)

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Dr. Mate wrote extensively about his own addictive behaviors, a shopping addiction that involves classical music. It may seem silly to an outsider but it started controlling his life. He was missing work, hiding things from his family, spending enormous amounts of money on music that he hoarded rather than listened to. He could not control his behavior when it came to music. And when he looked at his trauma history, the impulse to purchase classical music made sense (I won’t ruin the story, go read the book). It may seem silly to an outsider, but he had zero control over his spending and behavior, the addiction controlled him.

And that’s the thing with orthorexia. There was a gap in understanding of our knowledge of eating disorders for some time. We understood anorexia, bulimia, and compulsive overeating. Even different subsets of these behaviors like exercise bulimia. But what about the people who so freak out about everything that goes in their mouth? People without allergies who are on diets so prescriptive that the diet controls their life?  People who use restrictive diets without a medical, religious, or ethical need to do so allows them the excuse them not eating certain things, or going out to eat with friends and family. It puts a frame over what is really going on. It becomes an excuse for disordered eating.

 The enormous market for gluten free products speak to this. Some people can get deathly ill from gluten products because of Celiac disease. I know a couple of them. Some people get painful joint swelling and feel quite unwell from gluten. I know a few more of them. Most people do not have an allergy or food sensitivity to gluten. For some people it’s an interesting fad, for others it is a mechanism of controlling a food addiction. Vegetarianism, veganism, a paleo diet, or a raw diet can be other such examples, and I’m sure I’ve leaving quite a few out. I’ve seen many people make those choices out of health. And others make that choice because it was hiding an underlying need to control something that felt entirely out of control for them. Their addiction is no different than individuals who engage in starving, bingeing, purging, and compulsive overeating, And they deserve the same empathy, understanding, and treatment support as anyone else. Not ridicule.

Making fun of orthoexia diminishes a very real problem that many people experience. The problem is the underlying process, the addictive thinking patterns that go into how we nourish our selves. And thinking you need to live by kale alone, that you can never enjoy a muffin, or a night out with friends at a local pizza place is a miserable way to live.

Beyond now being a diet and weight controlled Type II diabetic, I’m lactose intolerant. Lactose makes me quite sick. It also makes my dad sick and my brother sick. It’s pretty common among indigenous peoples, actually.  My son is not only lactose intolerant, all dairy makes him break out in cystic acne, even lactose free products.  So we read labels carefully. Eat at vegan places quite often because we know we’re “safe” there. Get excited when we find good substitutes for things we’ve missed. Kiddo digs on my homemade cashew cheese like whoa. Thanks, Pinterest.

Hell yes, I want to stay healthy. Being sick sucks, and it still happens to both of us at times. Lesson learned when it does. But our food sensitivities don’t own us. It’s something we live with, but it doesn’t define us. 

Healthy is the key word there. Orthoexia veers into the unhealthy quite quickly, using “health” as the cloak it uses to wrap the disordered behavior. You can’t read, for example, Jordan Younger’s story about her struggles with orthorexia and think that she was making healthy choices by the time she sought help. Did she start out feeling better as a vegan? Totally. Did it spiral into a problem pretty quickly? Absolutely. She ended up letting go of her vegan diet because it triggered her orthorexia. Of COURSE you can be vegan (or gluten free, or a fruitarian, or raw food person, whatevs) and not be orthorexia. But Jordan Younger couldn’t. Her vegan diet was a trigger.

I can buy a lottery ticket. If I remembered to do so and have a dollar in my pocket. If I’m lucky I may remember to check the numbers on it later.

 I have a former client with an addiction history who will buy a lottery ticket and it spirals, within a month, into drug use relapse. Gambling, starting with just one ticket, triggers her. Jordan Younger’s vegan diet triggers her orthorexia.

We need to stop shaming the mechanisms of our addictions. It’s one of the biggest barriers to treatment. No, treatment professionals are not trying to label everything as disordered and maladaptive. 

(As an aside? The APA did NOT label selfies as a mental disorder. Though I have been tempted to smack a selfie stick out of someone’s hand a time or two.)

 But treatment professionals such as myself ARE trying to shift and evolve our understanding of human behaviors and human needs within a culture that is evolving so fast it is hard to keep up.

When working with addictive behaviors, I focus strongly on using self-compassion, mindfulness, relational supports, and the neuroscience behind how we develop (and how we overcome) addictive behaviors and patterns. The mechanism of addiction is less important than you would think. If someone tells me that they have a part of their life that feels out of control, we work on getting control back.

And there is nothing unhealthy about that.