First named by Steven Bratman in 1997, orthorexia nervosa (ON) from the Greek ortho, meaning correct, and orexi, meaning appetite, is classified as an unspecified feeding and eating disorder in the Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5).1,2
Hypothetical Case
Mr. P is a 30-year-old male who presented to the mental health clinic with his wife. The patient recounted that he had wanted to “be healthy” since childhood and has focused on exercise and proper diet, but anxiety about diet and food intake have steadily increased. Two years ago, he adopted a vegetarian diet by progressively eliminating several foods and food groups from his diet. He now feels “proud” to eat certain organically grown fruits, vegetables, nuts, beans, and drink only fruit or vegetable juice.
His wife stated that he spent between 3 and 5 hours daily preparing food or talking to friends and family about “correct foods to eat.” He also believed that errors in dietary habits caused physical or mental illnesses. He reported significant guilt and shame whenever he “slips up” on his dietary regimen and eats anything containing seafood, beef, or pork products, which he corrects by a day of fasting. His wife was frustrated because he refused to go to restaurants and started declining offers from friends to eat dinner at their homes unless he could bring his prepared food. He describes feeling “annoyed” when he sees other people eating fast food or meat.
Mr. P reported no significant medical or surgical history. His family history was significant for anxiety in his mother. He used to drink alcohol socially but ceased a few years ago due to its carbohydrate content. He never smoked or used illicit drugs.
A mental status exam revealed a thin male who appeared his stated age. He was cooperative, casually dressed, and made fair eye contact. He spoke clearly with an anxious tone and appropriate rate and volume. His affect was congruent with stated anxious mood. He was alert, awake, and oriented to person, place, and time. He reported no paranoia, auditory or visual hallucinations, and suicidal or homicidal ideation.
A physical exam revealed a thin male in no distress who measured 5 feet 10 inches tall and weighed 145 pounds, which yielded a body mass index of 20.8. His vitals included temperature of 98° F, blood pressure 115/76, pulse 74, and oxygen saturation 98% on room air. The remaining physical examination revealed no abnormalities. A complete blood count, thyroid function, urinalysis, and urine drug screens were within normal limits. Comprehensive metabolic profile revealed decreased sodium of 130 meq/L. Electrocardiogram revealed bradycardia.
An ON diagnosis is made primarily through a clinical interview. Collateral information from individuals familiar with the patient can be helpful. Experts have proposed and recently revised criteria for ON (Table). Although the ORTO-15 assessment tool may assist with diagnosis, the tool does not substitute for the clinical interview.
Discussion
There is no reliable measure of prevalence of ON, though Varga and colleagues initially estimated ON to occur in 6.9% of the general population, and ON may occur more frequently in health care professionals and performance artists.3 However, these may be overestimates, as the assessment tool used in the study does not adequately separate people with healthy eating habits from those with ON.4,5
Most prevalence studies were conducted in Europe and Turkey, and prevalence of ON may differ in the U.S. population. A recent assessment determined a prevalence of about 1%, similar to that of other eating disorders.5 No study has reported a correlation between ON and gender, but a survey of 448 college students in the U.S. (mean age 22 years) reported highest ON tendencies in Hispanic/Latino and overweight/obese students.6
Relationship to Other Illnesses
There is significant debate whether ON is a single syndrome, a variance of other syndromes, or a behavioral and culturally influenced attitude.7,8 Although ON may lead to or be comorbid with anorexia nervosa (AN) or obsessive-compulsive disorder (OCD), subtle differences exist between ON and these conditions.
To meet DSM-5 diagnostic criteria for AN, patients must weigh below minimally normal weight for their height and age, have an intense fear of gaining weight or becoming fat, and have a disturbed experience of their weight or body shape or cannot recognize the severity of the low weight.2 In contrast, an individual with ON may possess normal or low-normal weight. Patients with AN focus on food quantity, while patients with ON tend to focus on food quality. As summarized by Bratman, “People are ashamed of their anorexia, but they actively evangelize their orthorexia. People with anorexia skip meals; people with orthorexia do not (unless they are fasting). Those with anorexia focus only on avoiding foods, while those with orthorexia both avoid foods they think are bad and embrace foods they think are super-healthy.”9
Similarities between ON and OCD include anxiety, a need to exert control, and perfectionism. However, patients with OCD tend to report distress from compulsive behavior and a desire to change, thus exhibiting insight into their illness.8,10 Similarities between obsessive-compulsive personality disorder (OCPD) and ON include perfectionism, rigid thinking, excessive devotion, hypermorality, and a preoccupation with details and perceived rules.11
While no studies have yet described ON as a feature of somatoform disorders, some experts have hypothesized that preoccupation with illness in a patient with somatization disorder may engender a preoccupation with food and diet as a way to combat either real or perceived illness.11 Finally, there is a report of ON associated with the prodromal phase of schizophrenia, and the development of ON may increase risk for future psychotic disorders.11,12
