Effective Strategies and Predictable Complications in the Treatment of Orthorexia
In our previous article about Orthorexia, we described this relatively unknown and misunderstood condition. In this, the second and final installment in this series, we discuss strategies and pitfalls in the treatment of Orthorexia.
Orthorexia, being a somewhat new conceptualization of a psychological disorder, is under-researched and often misunderstood within the mental health and medical communities. Many mental health professionals have found success treating individuals with Orthorexia using evidence-based treatment methods that are used to treat other Eating Disorders, OCD, and related OC Spectrum Disorders.
Cognitive-Behavioral Therapy (CBT) and Mindfulness are two highly effective treatment methods used to treat Orthorexia. Using CBT, individuals with Orthorexia learn to challenge and change their distorted thoughts (cognitions) related to their body and the foods they eat. Education about nutrition and what is considered “healthy” should also be integrated into CBT when treating Orthorexia, using logical, evidence-based strategies.
Using Mindfulness Based Cognitive Behavioral Therapies such as Acceptance and Commitment Therapy (ACT), clinicians can help those who suffer with Orthorexia to gain greater awareness and acceptance of uncomfortable thoughts, feelings, sensations and urges related to food and their body. This approach also helps clients to become more aware of and conscious of their food consumption. The goal is for clients to become more comfortable with their bodies and their actual health (as opposed to their feared bad health). Using these techniques, sufferers can change their relationship with a variety of foods and with their food-related anxiety.
The primary behavioral component of treatment for Orthorexia is Exposure and Response Prevention (ERP). Some common ERP assignments might include the following:
- Gradually introducing a broader variety of foods into the client’s diet, including healthy foods that the client has previously decided were unacceptable;
- Restricting, and ultimately eliminating time spent researching food;
- Restricting, and ultimately eliminating time spent discussing the health values of food;
- Returning to normal social interactions, including meals with others.
It is important to note here that clients are encouraged to eat a healthful diet. Some mistakenly believe that giving up their Orthorexia eating style will be the same as eating a bad diet. Nothing could be further from the truth. The goal is not to help the client learn that all food is healthy – after all, there are foods that are legitimately unhealthy, especially if eaten to excess. Rather, the goal is to help the client learn to have a more balanced perspective towards food, and to eat in a manner that is both healthy and enjoyable. In other words, the goal is not to teach the client to eat a diet of Big Macs and Slurpees, but rather to be able to eat based on choice, not fear.
Orthorexia In Perspective
Diagnosing and treating Orthorexia can be complicated by a number of factors:
First, the culture at large, and the news media in particular, reinforce on a daily basis that we should be hyper-conscious of health, weight, and nutrition, and that we should eat as purely as possible.
Second, people who experience Orthorexia often do not see that their obsessive thoughts and compulsive behaviors are problematic. They see their diets as ideal and healthy, and see others’ diets as disgusting and unhealthy. Great pleasure and satisfaction are gained from the belief that they have mastered and will continue to perfect their diet. This may become an issue during treatment, as sufferers are likely to initially reject any suggestion that their diet is problematic, and equally likely to resist the idea that change would benefit them in a positive way.
Third, those with Orthorexia may initially feel significant discomfort during the exposure therapy that is so critical to treatment. Exposures typically involve eating foods that individuals with Orthorexia deem “unhealthy” or “impure”. They may at first have a strong visceral reaction when trying foods that they have long identified as disgusting and toxic. The ultimate goal of exposure is for the client to learn that they need not fear less-than-perfect foods, that they may actually enjoy such foods in moderation, and that eating them does not result in a catastrophic outcome.
Fourth, those with Orthorexia are even more likely than the average client to reject the use of anti-depressants and other medications that may potentially help to reduce their anxiety and obsessionality. Individuals with Orthorexia frequently view such medications as “poison”, and clinicians should be prepared for the possibility that the client will never be open to pharmacotherapy in any way.
Orthorexia is a significant and growing problem that requires serious consideration by the medical and psychological communities. While Orthorexia is not yet recognized by the APA as a formal, free-standing diagnosis, failure to accurately identify and treat the condition will result in serious problems for many people who don’t necessarily meet the requirements for a formal eating disorder diagnosis. Fortunately, Orthorexia responds well to treatment with Cognitive Behavioral Therapy (CBT) and Mindfulness Based CBT, especially if the clinician is able to first help the sufferer recognize the excessive and distorted nature of their thoughts and behaviors related to food purity.
To read part one of our series on Orthorexia, click here.
•Kimberley Quinlan, MA, is a psychotherapist at the the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions, including Orthorexia. In addition to individual therapy, the center offers six weekly therapy groups, as well as online therapy, telephone therapy, and intensive outpatient treatment. To contact the OCD Center of Los Angeles, click here.
Any thoughts about how orthorexia impacts parenting? This diagnosis sounds like a very good fit for my mother. Her intensely righteous and controlling behavior around what I was allowed to eat created a great deal of conflict between her and me when I was a child.
I am thinking there might be some diagnosis like orthorexia by proxy, similar to the separate diagnoses of Munchausen’s Syndrome and Munchausen’s Syndrome by Proxy.
I have often wondered if something like orthorexia played a part in Joel Steinberg’s murder of the child he had illegally adopted, Lisa. Descriptions of the child’s last night all mention that he fatally beat her out of anger that she hadn’t been drinking enough water. http://law.jrank.org/pages/3434/Joel-Steinberg-Trial-1988-89-Cocaine-Rage.html While this is usually described as a trivial reason for his rage that people usually attribute to drug use or sadism, I wonder if he also had controlling behavior around extreme food beliefs. While I was lucky my mother was not as troubled as Mr. Steinberg, my experiences with her made it very easy for me to imagine a parent going into an uncontrollable rage because a child hadn’t drunk 8 eight ounce glasses of water a day.
Thank you for your comments.
I hadn’t considered, nor have I ever seen, Orthorexia-by-proxy. But we have treated numerous cases of Hypochondria-by-proxy, in which someone worries obsessively not about their own health, but that of their child (or another person such as a spouse). I can see how that could be quite similar to your conceptualization of Orthorexia-by-proxy.
As for the Steinberg case, I remember it well. And while I am not prepared to make a diagnosis of someone I have never met, I can say that news reports at the time indicated that Steinberg was sociopathic, and that his problem far exceeded anything related to Orthorexia.
Ultimately, I think the main issue is that those who suffer from Orthorexia (whether it be a mother, child or anyone for that matter) do not know that their obsession actually has a name and that help is out there. Your question again confirms my reasoning for writing the article. Education and awareness about this disorder are crucial in order for those with Orthorexia to seek treatment. If you feel that your mother did suffer from Orthorexia (or Orthorexia-by-proxy) , I hope that my articles bring you clarity as to why she behaved the way she did.
My mother has orthorexia. She eats only organic food, drinks only artesian water, gets labs done monthly, sees multiple specialists, spends over $1000 a month on supplements, takes more than 60 pills per day and refuses to travel because she has to stay near her natural doctor. She forces/ manipulates my father into taking more than 40 pills a day. He wants to stop, but is afraid that she will be angry with him. He now has extremely high blood pressure(he does not have a history of high blood pressure) and is worried it is being caused by something she is giving him. I definitely see this as orthorexia and orthorexia by proxy.
While I cannot provide a diagnosis via a third-party report on a blog, the things you are describing strongly suggest the possibility that your mother has Orthorexia. As for your father, there is no way for me to provide anything resembling a diagnosis related to his high blood pressure.
Unfortunately, a reasonable concern about one’s health sometimes takes a turn into Orthorexia. If your mother at any point voices concerns about the impact of her food and diet choices on her life, then I encourage you to show her our Orthorexia articles at that point. Take care.
Very interesting… thank you for this post; I have learned a lot. Do you think the fact that those with Orthorexia often derive pleasure from their obsessive compulsive behavior precludes this disorder from actually being a “type” of OCD? Those with OCD are distressed by their obsessions and compulsions. I’m also wondering how/why/when those with Orthorexia seek help, as they, unlike most OCD sufferers, do not realize their behavior is irrational.
Thanks in advance for your insight!
Thank you for your comment Janet. I appreciate your thoughts.
We do not diagnostically conceptualize Orthorexia as being the same as OCD. As noted in our earlier article on Orthorexia, we see it as being a hybrid of an eating disorder and Obsessive Compulsive Disorder. Essentially, we see it as an OC Spectrum Disorder.
Like other eating disorders, Orthorexia is driven by anxiety and the thrill of being in control (which may in turn be mistakenly understood as pleasure). Similar to obsessions involved in OCD, the obsession of food perfection can be quite stressful and taxing. Just as those with OCD have a constant stream of “what if…” thoughts, those with Orthorexia constantly have obsessive thoughts along the lines of “Oh no, what if something toxic were to enter my body – that would be catastrophic“. These obsessive thoughts lead to compulsive and avoidant behaviors that are done in the hope of reducing anxiety, and gaining control and certainty.
As you note, and as I mentioned in the article, those who suffer Orthorexia often resist treatment. They are less likely to seek help, until such time as their compulsive and avoidant behaviors have negatively impacted their life to the extent that they realize they have a problem. These negative, maladaptive behaviors often cause havoc to their health, social life, familial relations and overall psychological well being.
I really loved this article. It has been very helpful. I have suffered with orthorexia to some degree or another most of my adult life. I agree with the outlined treatments in which I have followed myself with success. Thanks again for the great information.
Thank you for your kind words. I’m glad you found the article helpful, and that you have had success in managing your Orthorexia using the principles of CBT. Keep up the good work.
The fact that orthorexia is generally ego-syntonic makes me wonder if it’s really more related to Obsessive-Compulsive Personality Disorder (OCPD) rather than OCD. Many of the stories told by orthorexics remind me of the behavior of people with OCPD that I’ve known. I also wonder if there’s a subtype that’s associated with autism-spectrum disorders, particularly if dietary purity is one of a few restricted interests.
Eric, your observations are very interesting. I myself haven’t observed these similarities, but I can see your point of view. This brings up again the importance of correct diagnosis. If you are concerned about a loved one and feel that their dietary behaviors are problematic to their health, have them assessed by a mental health professional. Thank you for reading!
In your experience, does Orthorexia manifest itself in control over a sibling that is dearly loved? In our situation a family member who is compulsive in knowing exactly the calorie, content and type of food that is consumed by their sibling and has significant, nearly destructive anxiety when she is unable to obtain this information. Anxiety has not been helped with conventional Anorexia treatment approaches despite the concurrent use of medication and hospital direct CBT. I have not been able to find much written about cases in which a siblings is the source of an obsessive type of eating disorder and control and the recommended treatment approach – any further insight is appreciated.
Hello there Concerned Aunt,
While I don’t know of specific research statistics of these behaviors occurring with siblings, I can say that we often have cases in which a person’s food-related obsessions focus on a family member or friends. I encourage your family member to seek treatment that heavily emphasizes graduated Exposure and Response Prevention (ERP) and Mindfulness. The therapeutic work will involve the family member with Orthorexia tolerating the discomfort of not knowing the exact dietary behavior of her sibling, and not seeking certainty.
Please let us know if there is anything we can do to help. The good news is that ERP does work and Mindfulness is a tool that can be used for a lifetime, helping people to better manage their Orthorexia symptoms.
I seem to have found myself in the middle of a Scrupulosity and Orthorexia mix. The reason behind my strict diet is because I fear it might be sinful not to have such exacting dietary standards. I need to “eat like Jesus would have” which in this day and age would mean nothing wrapped in plastic, not canned, fresh, organic, free range, humane meats and organic fruits and vegetables but not too much fruit because of sugar. No added sugars, limited salt, no processed, man made, genetically modified foods. This also applies to the soaps I use, the clothes I wear… which now have to be organic, and free trade. No plastic in my home, nothing ‘toxic’ or I am willingly sinning by exposing myself and my family to poison. I have been fighting the urge to actually do all these things fully and it has been causing me great distress and anxiety. I keep thinking “what if this is a command of God over my life and I am being disobedient?” I’ve been praying for a sign in either direction, to commit or not to this lifestyle, and I think God led me to this to show me it’s just OCD like my scrupulosity is as well. This is interesting and something I’ve been struggling with. Thank you.
Your comment is a great example of how Orthorexia is really a variant of OCD in which the obsessional focus is on food purity, rather than a “true” eating disorder, in which the sufferer is primarily concerned with weight and appearance. And I think you conceptualize your experience quite well when you describe it a combination of Orthorexia and Scrupulosity, as both are just variants of OCD.
That said, I see no evidence that eating in the same manner as Jesus is a “command of God”. It sounds much more like a command of OCD. I don’t recall the bible saying anything about GMOs or plastic wrap. This idea that you are supposed to live exactly as Jesus lived seems entirely fabricated by your OCD, and also seems quite arbitrary and unrealistic. Jesus didn’t drive a car, or have access to refrigerators, air conditioning, or hot showers, and I assume you use all of these on a regular basis.
If these obsessions continue to plague you, I encourage you to seek out a therapist who specializes in the treatment of OCD.
My daughter has been treated with therapy for binge eating disorder, although I believe that she has a variant of OCD together with orthorexia which eventually triggered her bingeing. Her main complaint is constant thinking about what should she eat, and how complicated the process of planning food is, so she often then ends up bingeing on junk food. This provokes even more thinking about food and planning. I wonder whether you have any recommendations about therapy practice in Philadelphia area. I think that she needs an OCD therapist with an emphasis on orthorexia.
It is not surprising that your daughter’s symptoms are a bit difficult to categorize – the line between OCD and binge eating can at times be quite grey, and the line between orthorexia and OCD is virtually non-existent. Any therapist who specializes in both OCD and eating disorders should be able to help. I encourage you to visit the website of the International OCD Foundation at http://www.iocdf.org. They have an online database of therapists that is searchable by location.
The description of this condition fits my young adult son to a T. It’s pretty much impossible at this point to get him to eat anything except 100% organic, vegetarian, gluten-free “superfoods.” He will go without eating rather than lower his strict standards on what he’ll put in his body. He brings a large bottle of his specially-formulated protein drink to school to keep him going through the day, prepares the majority of his own meals, and avoids most social activities.
This crept up on us gradually as we live in a coastal SoCal town where healthy eating is very part of the culture. Initially, we were proud to see him shun junk food and load up on salads, veggies, etc. But now? He wouldn’t even try a taste of his own (gluten-free) birthday cake.
I had eating disorders as a teen/young adult (due to pressure to be thin from running coaches), so unfortunately I understand what’s going on in his brain. I hope some day he will join me in raising a big bowl of ice cream as a toast to dietary moderation!
Everything you write sounds like textbook Orthorexia. This is a treatable condition, so long as your son recognizes the irrationality of his food obsessions, and seeks treatment with a therapist who understands Orthorexia.