What if I told you that atypical anorexia didn't used to be defined over a normal / non-underweight BMI?

I think we all know the struggle with the atypical anorexia nervosa diagnosis. You only got typical anorexia with a BMI under 18.5, anything above and you count as 'atypical'. Pretty strange since many people with anorexia do in fact have a BMI above 18.5 (so how are they atypical if there are so many?), but for me and many others it is just this constant struggle to fit the diagnostic criteria to be taken seriously or you are "not sick enough". 

Yet, I have barely ever been able to meet this criteria. My body just won't reach such a low weight easily, let alone the seriously underweight category of below 17.5, but I feel compelled to constantly chase the 'typical' diagnosis to prove something to myself and others. Which is messed up in itself. 

The other day, while I was reading Decoding Anorexia by Carrie Arnold, one sentence startled me:

 "Although not everyone with anorexia has the body distortions and fears of becoming fat — known as 'nonfatphobic anorexia nervosa' or 'atypical anorexia'(Carter and Bewell-Weiss, 2011)." (p.34)

What does she mean with atypical anorexia is simply non-fatphobic anorexia (i.e. anorexia without wanting to lose weight)? I had never heard this before. All my life I thought this had only to do with BMI.

So I follow the trail of citations. I start with the cited 2011 paper by Carter and Bewell-Weiss on non-fatphobic anorexia in which again they describe it as a form of atypical anorexia. They base their clinical definitions on a 1973 book by Hilde Bruch called 'Anorexia Nervosa and the Person Within'. So we are going back in time quite a bit.

I cannot access the book but I find an academic paper from the same author from 1981 in which she defines atypical anorexia nervosa as:

"The differentiation of the distinct clinical syndrome of anorexia nervosa from atypical cases is based on the following distinguishing features: a relentless pursuit of thinness; an almost delusional disturbance of body image; an inability to correctly identify hunger from other bodily or tension states; a lack of an identity awareness; and a paralyzing sense of ineffectiveness."

In other words, if you deviate from the above 5 criteria, you count as atypical. Did you notice what Bruch did not mention? That's right, neither weight nor BMI. She defines typical and atypical anorexia exclusively based on its psychological features. 

So where does the whole BMI focus in the diagnostic manuals come from? Well, I am not entirely certain, but a quick google search shows that in 1972 the BMI was declared the gold standard of body composition. In the 1980s (just after Bruch published her book and paper) the WHO started to first use BMI as a way of tracking obesity in the population. While intended for studying populations only, this time period probably marks the beginning of the BMI as the main measurement many doctors use to evaluate your health (an entirely different discussion in itself).

Many things can be said about BMI: It's inaccurate, it's racist, it doesn't differentiate between fat and muscle, it was pushed by insurance companies who wanted to improve profits, etc. 

But the particular bone I have to pick with it seems to be that it massively influenced the diagnostic criteria of anorexia nervosa. I cannot proof this definitely, but it seems to me that many researchers and especially the writers of the DSM eventually dropped the psychological definition of atypical anorexia to instead accommodate a weight criterion (and only this criterion).

It seems so silly especially considering how much time I mentally wasted trying to match these definitions that pay no attention to the psychological suffering of having an eating disorder. Another point to be mentioned is that it leads us on to believe that such extreme weight loss is possible for everyone if we just try hard enough, and that if we do not achieve it, we are not really sick.

But people's bodies are different. If everyone could easily shed weight like that, our species would have long died out during a famine. (There is an excellent podcast episode with Erin Harrop on this)

Sometimes fighting against my eating disorder feels equally as much as a fight against clinical definitions. Sure, there are researchers like Harrop, Carter and Bewell-Weiss who seem to care about those of us who are not white, female, middle class, young or below a BMI of 18.5. But still: When will the rest of them realize that it is not helpful to make a simple number the holy grail of eating disorder diagnosis with a disorder that mentally latches onto numbers like a moth flying into the flame?