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Archives of Psychiatry and Psychotherapy, 2012; 1 : 55–60
Anna Brytek-Matera
Orthorexia nervosa – an eating disorder, obsessive-
-compulsive disorder or disturbed eating habit?
Summary
food restriction / health food / eating attitude
INTRODUCTION
There is relatively little information availa-
ble about orthorexia nervosa (ON) [1] because
it is a new term and does not have a universally
accepted definition or valid diagnostic criteria.
This disturbing behaviour is not present neither
in DSM-IV-TR nor in ICD-10. Orthorexia nervosa
is a new concept about eating behaviour disor-
ders [2] and is composed of pathologic obsession
for biologically pure foods [3], which can cause
substantial dietetic limitations [4] and which is
able to lead to obsessive thoughts about foods,
affective dissatisfactions and intense social iso-
lation [2, 5, 6].
This is not a weight loss regimen but an im-
mense phobia about eating only “pure” food.
Having orthorexia nervosa not only means that
people are obsessed with eating “healthily”, but
also that they have a specific attitude to food,
they prepare their food in a certain way [1] as
well as avoid consumption of some foods or all
of a some group of foods since they consider
them to be harmful for their health. The quali-
ty of the foods they consume is more important
than personal values, interpersonal relations, ca-
reer plans and social relationships [7]. In fact, the
desire to consume healthy foods is not a disturb-
ing behaviour in itself, and it is only defined as
orthorexia nervosa when it causes a person to
give up his or her normal lifestyle [1].
Orthorexia nervosa could be considered as a
disorder connected with behaviour and person-
ality due to paying too much attention to con-
suming healthy food, spending an excessive
56 Anna Brytek-Matera
Archives of Psychiatry and Psychotherapy, 2012; 1: 55–60
amount of time with this preoccupation, and ex-
periencing associated dysfunctions in everyday
life [1]. Orthorexia nervosa can be regarded as
a harmful behaviour, because healthy eating is
connected to fear and worries about health, eat-
ing and quality of food [8].
DEFINITIONS OF ORTOREXIA
The term “orthorexia” has been produced from
“orthos”, which literally means “accurate, straight,
right, valid or correct” and “orexis” meaning hun-
ger or appetite. This term is used for “obsession
with healthy and proper nutrition” [1, 6, 9]. Steven
Bratman [6] defined this concept for the first time
in 1997. The author used orthorexia nervosa to de-
fine a pathological fixation on the consumption of
appropriate and healthy food [5]. The term of or-
thorexia is used to describe an unhealthy fixation
withhealthyeating[10].BaĝciBocietal.[7]de-
scribed orthorexia nervosa as “highly sensitive be-
haviour with regard to healthy nutrition”.
People with orthorexia are likely to shun foods
which may contain pesticide residues or geneti-
cally modified ingredients, unhealthy fatty foods
having too much salt or too much sugar and other
components. The methods of preparation (a partic-
ular way of cutting vegetables) and materials (ce-
ramics only or only wood) are also part of the ob-
sessive ritual [11]. The configuration of the day-
to-day diet, which takes up a lot of time, could be
divided into four phases [2, 5]. The first section is
devoted to thinking with concern and cautiously
about what will be eaten on that day or the fol-
lowing day; a second phase pertaining to the thor-
ough and hypercritical acquisition of each ingredi-
ent; a third phase referring to the culinary prepa-
ration of these ingredients, which must consist of
techniques and procedures that are not linked to
health hazards; the fourth stage is a stage of satis-
faction, comfort or guilt based on the appropriate
enforcement of the three preceding phases. If any
of these phases is not attainable or it is not possible
to abide by these rituals, a sense of guilt and con-
cern for the violation will appear.
DIAGNOSTIC CRITERIA
In spite of the fact that the diagnostic criteria
are not yet sufficiently verified, they have been
proposed for orthorexia [12]. However, Bratman
and Knight [13] propose a test that allows to es-
tablish whether expression of feeding behaviour
in health education ought to be considered as
pathological or not. Authors [14] have suggest-
ed a short Bratman’s Orthorexia Test (BOT) as a
screening tool useful for early diagnosis of the
disorder. This diagnostic test for orthorexia con-
sists of ten questions (e.g. “Do you spend more
than 3 hours a day thinking about your diet?”,
“Has the quality of your life decreased as the
quality of your diet has increased”, “Do you feel
guilty when you stray from your diet?”). If the
person answers “yes” to 4 or 5 questions, this
means that it is necessary for her/him to relax
more in regard to their food (unless it is a pre-
scription diet). If the person answers “yes” to
all questions, then she/he has an important ob-
session with healthy eating and should examine
this behavior with the help of a qualified profes-
sional [13].
MEASURE OF ORTHOREXIA NERVOSA
Donini et al. [12] developed the ORTO-15 test
for the diagnosis of orthorexia based on a brief
10-item orthorexia questionnaire by Bratman
[13]. They used some of the items from Brat-
man’s test and added some new items to cre-
ate the ORTO-15 questionnaire. The original ver-
sion of ORTO-15 was first developed in Italy. It
is a 15-item self-report questionnaire that deter-
mines the prevalence of highly sensitive behav-
iour related to health and proper nutrition. Items
assess an individual’s behaviours (obsessive at-
titudes) related to the selection, purchase, prep-
aration, and consumption of food that they con-
sider to be healthy (e.g. “When you go in a food
shop do you feel confused?”, “Are you willing
to spend more money to have healthier food?”,
“Do you think your mood affects your eating
behaviour?”). Donini et al. [12] aimed to devel-
op items that would assess individuals in terms
of emotional and rational aspects. For this rea-
son, some items assess the cognitive-rational do-
main, some the clinical domain, and others the
emotional domain. Each item is answered on a
4-point Likert scale. Individuals are required to
answer with “always – often – sometimes – nev-
er”, to reflect how often they define themselves
Orthorexia nervosa – an eating disorder, obsessive-compulsive disorder or disturbed eating habit? 57
Archives of Psychiatry and Psychotherapy, 2012; 1 : 55–60
with these expressions. Items that reflected an
orthorexic tendency are scored as “1”, and items
that reflected a tendency towards normal eat-
ing behaviour are scored as “4”. Scores below 40
points in the ORTO-15 test are defined as orth-
orexic (having highly sensitive behaviour), eat-
ing behaviour reaches more normal standards
as the score increases [12].
PREVALENCE
Donini et al. [1] investigated the prevalence
rate of orthorexia nervosa by studying 404 peo-
ple in Italy, and provided suggestions for diag-
nostic criteria. Participants were evaluated in
terms of their food selection behaviours, and
obsessive-compulsive and phobic symptoms.
In relation to food selection behaviour, 17.1% (n
= 69) of the sample were defined as ´health fa-
natics´. People diagnosed with orthorexia ner-
vosa accounted for 6.9% (n=28) of their entire
sample. The specific ´feelings´ towards food,
that is ´dangerous´ to describe a conserved prod-
uct, ´artificial´ for industrially produced prod-
ucts and “healthy” for biological produce, as
well as the demonstration of a strong or un-
controllable yearning to eat when feeling nerv-
ous, happy, excited, or guilty has been associat-
ed with orthorexic subjects. The prevalence rate
among people suffering from orthorexia nervo-
sa was higher among men compared to women
(11.3% vs 3.9%). As stated by Donini et al. [1], “it
is possible that with the present trend towards
the presence of men in the world of ´body cul-
ture´ (meaning the attention given to one’s phys-
ical aspect in order to live up to the high lev-
el stereotypes dictated by society), males may
have found an optimal behaviour pattern in the
´health-fanatic´ food choice” [p. 156].
In Spain the prevalence of this disorder is at
present unknown, as it is a new phenomenon,
though some specialty care centers relate be-
tween 0.5% and 1% of orthorexic patients [11].
A Turkish study [7] carried out among 318
resident physicians at a hospital in Ankara, has
found that 45.5% of the participants were exces-
sively sensitive to their own eating habits and
they scored below 40 points in the ORTHO-15
test. It has been seen that medical doctors who
take care of the nutritional quality while buying
foods, score low in ORTO-15, which points to
the fact that they have highly sensitive behav-
iour about healthy nutrition. The average score
on the ORTO-15 is lower in those who do their
shopping themselves, substitute lunch or din-
ner with salad/fruit, and care about the quality
of the things they eat. Indeed, in this study 20.1%
of the male doctors and 38.9% of the female doc-
tors stressed that their food selection had been
affected by TV programs on healthy eating hab-
its. Like authors [7] emphasize, it is a compelling
reason for the fact that such a large number of
people with a high level of education are able to
be so heavily impacted by the media.
It is worth pointing out that the prevalence of
highly sensitive attitudes to healthy eating at
this high socioeconomic level shows that med-
ical doctors are also in need of education about
the tenets of a balanced and proper diet [7].
Another study [3] has found that the preva-
lence of orthorexia was 43.6% among medical
students (n=878) (scored above 27 in the ORTO-
15 test). This research has also shown that the
prevalence of orthorexia among the male medi-
cal students was higher than that among the fe-
male medical students.
Some people with orthorexia are terrified of
unhealthy food due to genetic predisposition, a
perfectionist personality, unrealistic demands,
misinformation or social pressures [9]. The high-
er risk groups for orthorexia nervosa are women,
adolescents, people who practice sports (body-
building, athletics) [2, 5, 15], medical physicians
and medical students [3], dieticians [16] as well
as performance artists [14]. Research concern-
ing orthorexia nervosa among Turkish perform-
ance artists (39 men and 55 women) has shown
that a total of 56.4% of the artists have orthorex-
ia nervosa [14]. While the highest prevalence of
orthorexia nervosa was recorded among opera
singers (81.8%), it was 32.1% among ballet danc-
ers and 36.4% among symphony orchestra mu-
sicians. Hungarian research [8] has shown that
56.9% of the university students have an inclina-
tion to orthorexia nervosa. This study has also
indicated the correlation between orthorexia and
eating and body image disturbance (if orthorex-
ia features are present, the eating and body im-
age disturbance are more intensive).
The results of Turkish research [15] have dem-
onstrated that married people showed more
58 Anna Brytek-Matera
Archives of Psychiatry and Psychotherapy, 2012; 1: 55–60
symptoms than unmarried ones of a tendency
towards orthorexia.
WHAT KIND OF DISORDER IS ORTHOREXIA?
The clinicians and scientists still carry on the
debate on whether orthorexia is a real and unique
disorder and whether it is worth its own catego-
rization in the “Diagnostic and Statistical Manual
of Mental Disorders”
1
together with eating disor-
ders (anorexia nervosa, bulimia nervosa and eat-
ing disorder not otherwise specified) [5].
On the one hand, eating disorder experts in
the United Kingdom [9] argue that orthorexia is
not currently identified with eating disorder be-
cause it does not begin with low self-esteem, but
it may in time result in an eating disorder as the
diet becomes more refined and compulsive. Or-
thorexia nervosa is marked by an excessive de-
sire to consume pure and healthy foods, unlike
other eating disorders in which a preoccupation
with weight loss is observed [15]. Unlike ano-
rexia and bulimia, which are obsessions about
the quantity of food intake (and also physical
appearance), orthorexia nervosa results from an
obsession about the quality of food intake [6, 7].
In contrast to patients with anorexia and bulim-
ia, the motivation of the people with orthorexia
is not to lose weight but to achieve a feeling of
perfection or purity [5]. On the other hand, even
though orthorexia is not an independent diag-
nostic category, it has some similarities with oth-
er eating disorders: a genetic predisposition to
perfectionism as well as a need for control [5].
Preoccupation with consuming healthy and pure
foods can result in malnutrition and weight loss
as in anorexia nervosa [3]. Nonetheless, some ar-
gue that the preoccupation with food in ortorex-
ia is not as distinctive as in anorexia and bulim-
ia cases, as it is only related to the quality of the
food; therefore, it should not be placed in a sep-
arate category [10].
However, both disorders share many character-
istics. People with orthorexia often have a histo-
ry or features in common with anorexic patients.
1 Since orthorexia nervosa is not recognized as a
mental disorder by the American Psychiatric Associ-
ation (it is not listed in the DSM-IV or planned to be
included in the DSM-V), there are very few peer re-
viewed original papers published in English to date
[e.g. 17, 18, 19].
They are very detailed, careful and tidy persons
with an exaggerated need for self-care and pro-
tection [2, 11]. Bartina [11] supposes that when the
obsession with healthy eating becomes extreme,
the person starts to concentrate only on food and
this leads to severe restrictions as well as biolog-
ical and psychological complications (e.g. severe
social isolation). Being in control of what the per-
son eats becomes a priority. People with orthorex-
ia have a desire to be perfect, which is consistent
with other eating disorders such as anorexia or
bulimia nervosa [11]. Zamora et al. [2] emphasize
that in patients with orthorexia “obsessive-com-
pulsive mechanisms with personality traits similar
to those of restrictive anorexia (rigidity, perfection-
ism, need to control your life transferred to eating),
phobic mechanism (intense anxiety regarding cer-
tain foods and their avoidance) and hypochondri-
ac mechanisms are described” [p. 67].
Orthorexia may be affected by a distorted eat-
ing attitude and obsessive-compulsive symp-
toms. The relationship between changes in eat-
ing behaviour in orthorexia nervosa and obses-
sive–compulsive disorders are presently being
studied[1,2,7].ResearchbyArusoĝluetal.[15]
has shown that orthorexic tendency could be re-
lated to a pathological eating attitude
2
(eating at-
titude was noted to be a good predictor of orth-
orexic tendency) and that obsessive-compulsive
symptoms had a significant effect on orthorex-
ic tendency. Individuals that had higher obses-
sive-compulsive symptoms had greater ortho-
rexic tendencies. The authors’ clinical observa-
tions suggest that the number of people with an
orthorexic tendency is increasing [15].
Mathieu [5] wonders why it could be possible
that someone obsessed with achieving the perfect
diet does not even belong in the category of eat-
ing disorders, but should instead be classified as
having obsessive-compulsive disorder (OCD)?
TREATMENT AND THERAPEUTIC ORIENTATION
AccordingtoArusoĝluetal.[15]interventions
could be managed in accordance with the iden-
tified symptoms. For people with an orthorexic
tendency, clinicians might focus on the yearning
2
Food preoccupation, body image for thinness,
vomiting and laxative abuse, dieting, slow eating,
clandestine eating as well as perceived social pres-
sure to gain weight were classified as abnormal eat-
ing attitudes.
Orthorexia nervosa – an eating disorder, obsessive-compulsive disorder or disturbed eating habit? 59
Archives of Psychiatry and Psychotherapy, 2012; 1 : 55–60
to consume “pure healthy foods” rather than con-
centrating on the desire to be thin. The treatment
assumptions that were developed for well-known
eating disorders could then be broadened accord-
ing to the needs of the orthorexic population.
A person suffering from orthorexia should real-
ize that she/he has a problem concerning eating be-
haviour, understand that the quality of food con-
sumed is not the only factor determining health
and learn to eat without falling into an obsession.
The treatment of orthorexia demands a multi-
disciplinary team including physicians, psycho-
therapists and dieticians [11]. In some cases, cog-
nitive behavioural therapy combined with selec-
tive serotonin reuptake inhibitors (such as ser-
traline, fluoxetine and paroxetine) can be useful
in treatment of people with orthorexia [5]. It is
also worth pointing out that unlike other pa-
tients with eating disorders, people with orth-
orexia tend to respond better to treatment, be-
cause of their concerns about their health and
self-care [5]. Working with the immediate envi-
ronment of patients and promoting nutrition ed-
ucation are early components essential to achiev-
ing the final solution to the problem [11].
CONCLUSIONS
A healthy diet should have a positive impact
on health and, at the same time, not affect re-
lationships with other people or the quality of
life and emotional states. In recent years, social
awareness of diet, nutrition and healthy eating
has increased
3
, nevertheless, among some people
to the point where this knowledge shows signs
of an obsession. Instead of caring about provid-
ing the adequate amount of nutrients for the
body, they are preoccupied with worries about
what might constitute the “healthiest” food.
Knowledge about human eating habits as well
as eating behaviour is essential for assessing the
nutritional profile of people addicted to healthy
products, as it is in the case of orthorexia.
Orthorexia nervosa could not be labelled as a
new eating disorder because it does not include
the most characteristic symptoms of anorexia
and bulimia nervosa that is immense fear of be-
coming fat, extreme weight-control behaviour
3 We should take into consideration that popular
media and the food industry (e.g. “natural” foods,
“organic” foods) also have influence on the develop-
ment of orthorexia nervosa.
as well as overevaluation of shape and weight.
However, since orthorexia involves disturbance
of eating habits it ought to be treated as a dis-
order concerning abnormal eating behaviour
inseparably linked with obsessive-compulsive
symptoms (on account of paying too much at-
tention to consuming healthy food and constant
thinking about the quality of food intake).
REFERENCES
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Archives of Psychiatry and Psychotherapy, 2012; 1: 55–60
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