Pathways to orthorexia nervosa: a case series discussion.

BACKGROUND: Orthorexia nervosa (ON) has gained increasing interest in the last 2 decades. Although a consensus on the diagnostic boundaries of ON has not yet been reached, there is some evidence for an overlap with eating disorders, obsessive-compulsive disorder, and psychotic disorder. Most of the knowledge about ON has emerged from studies of non-clinical and at-risk populations and is focused on differential diagnosis; therefore, further clinical studies are needed to better outline the ON phenomenon in a real-life setting. OBJECTIVE: This case series aims at describing clinical cases that developed symptoms suggestive of ON after being diagnosed with a prior psychiatric disorder and then discussing them in light of possible clinical pathways. METHODS: Four women consecutively admitted to an outpatient unit for the treatment of eating disorders were diagnosed with ON through a clinical interview, according to Dunn and Bratman's criteria and self-administered questionnaire assessment (ORTO-15), and were considered to be eligible for this case series study. Psychiatric anamnestic data were collected retrospectively. RESULTS: The anamnesis revealed that all patients were previously diagnosed with a psychiatric disorder (i.e. obsessive-compulsive disorder, bulimia nervosa, illness anxiety disorder, and psychotic disorder) before developing ON. CONCLUSION: Past literature focused on differential diagnosis between ON and other psychiatric disorders. This is the first description of clinical cases in a real-life setting that started with different psychiatric disorders and later developed symptoms suggestive of ON. These cases have generated a new research question on the possibility that different psychiatric disorders may associate with a later onset of ON. LEVEL OF EVIDENCE: Level V, descriptive study.

Definition and diagnostic criteria for orthorexia nervosa: a narrative review of the literature.

AIM: In some cases, detrimental consequences on health are generated by self-imposed dietary rules intended to promote health. The pursuit of an "extreme dietary purity" due to an exaggerated focus on food may lead to a disordered eating behavior called "orthorexia nervosa" (ON). ON raises a growing interest, but at present there is no universally shared definition of ON, the diagnostic criteria are under debate, and the psychometric instruments used in the literature revealed some flaws. This narrative review of the literature aims at assessing state of the art in ON definition, diagnostic criteria and related psychometric instruments and provides research propositions and framework for future analysis. METHODS: The authors collected articles through a search into Pubmed/Medline, Scopus, Embase and Google Scholar (last access on 07 August 2018), using "orthorexia", "orthorexia nervosa" and "obsessive healthy eating" as search terms, and filled three tables including narrative articles (English), clinical trials (English), and articles in languages different from English. The data extrapolated from the revised studies were collected and compared. In particular, for each study, the diagnostic criteria considered, the specific psychometric instrument used, the results and the conclusions of the survey were analyzed. RESULTS: The terms employed by the different authors to define ON were fixation, obsession and concern/preoccupation. Several adjectives emphasized these expressions (e.g. exaggerated/excessive, unhealthy, compulsive, pathological, rigid, extreme, maniacal). The suitable food and the diet were defined in different ways. Most of the papers did not set the diagnostic criteria. In some cases, an attempt to use DSM (edition IV or 5) criteria for anorexia nervosa, or avoidant/restrictive food intake disorder, or body dysmorphic disorder, was done. Specific diagnostic criteria proposed by the authors were used in few studies. All these studies indicated as primary diagnostic criteria: (a) obsessional or pathological preoccupation with healthy nutrition; (b) emotional consequences (e.g. distress, anxieties) of non-adherence to self-imposed nutritional rules; (c) psychosocial impairments in relevant areas of life as well as malnutrition and weight loss. The ORTO-15 and the Orthorexia Self-Test developed by Bratman were the most used psychometric tools. CONCLUSIONS: The present review synopsizes the literature on the definition of ON, proposed diagnostic criteria and psychometric instruments used to assess ON attitudes and behaviors. This work represents a necessary starting point to allow a further progression of the studies on the possible new syndrome and to overcome the criticisms that have affected both research and clinical activity until now. LEVEL OF EVIDENCE: Level V, narrative review.

On orthorexia nervosa: A review of the literature and proposed diagnostic criteria.

There has been a growing interest among clinicians and researchers about a condition where people restrict their diet based not on quantity of food they consume, but based on its quality. Bratman (1997) coined the term "orthorexia nervosa" to describe people whose extreme diets - intended for health reasons - are in fact leading to malnutrition and/or impairment of daily functioning. There has also recently been intense media interest in people whose highly restrictive "healthy" diet leads to disordered eating. Despite this condition being first described in the U.S., and receiving recent media interest here, orthorexia has largely gone unnoticed in the North American literature. This review article details the literature of orthorexia nervosa, describing its emergence as a condition first described by a physician in a yoga magazine, to its being discussed in the scientific literature. It also reviews prevalence studies and discusses marked shortcomings in the literature. Finally, diagnostic criteria are proposed, as are future directions for research.