Motivation and emotion/Book/2024/Orthorexia and emotion

Orthorexia and emotion:
What are the emotional risk factors and consequences of orthorexia?

Multimedia presentation (3 min)

Overview

Figure 1. Understanding the brain and it's connection to mental health. Case study A 20-year old woman, Evangeline, was presented to the hospital, under the request of her doctor, with issues regarding rapid weight loss, constant fatigue, bodily discomfort, anaemia, chills, and hair loss. At first mental health professionals suspected anorexia nervosa; however, upon further assessment Evangeline claimed that she did not fear gaining weight, or that she did not have a distorted view of her body, therefore, she was given the diagnosis of Orthorexia nervosa after she reported on her excessive healthy eating habits. Proclaiming she was too fearful of being unhealthy and would remove specific food groups, such as sugar, nuts, certain meats and dairy products, from her diet due to fear of developing a chronic illness.

Orthorexia nervosa is an emerging eating disorder that is characterised by obsession with healthy eating, and fixation on the purity of the food consumed (Herman & Polivy, 2002). Although orthorexia is not defined as a proper eating disorder within the DSM-IV , it is an ongoing conversation in the mental health community; as orthorexia has related concepts of distorted eating behaviours (Messer et al,. 2022). Studies show that orthorexia is strongly motivated by extreme healthy eating; individuals with orthorexia exhibit extreme dietary rules often evading entire food groups and being increasingly hyper-aware of the nutritional content. However, the question remains "what are the emotional contributions of orthorexia?" and "what are the ramifications of orthorexia?".

This chapter discusses the complexity of orthorexia and emotion. In particular, gaining insight into psychological science, and individual characteristics of eating disorders. We continue to further dive into the emotional risk factors of orthorexia, the consequences of orthorexia including mental health disorders that can further develop due to the eating disorder, and the role of media and social influences. Furthermore, we explore the emotional and physiological advantages of healthy dieting and compare a healthy dieting mindset to those suffering orthorexia.

Focus questions: What is Orthorexia nervosa? What are the physiological and emotional consequences of orthorexia? What are the emotional influences that cause someone to develop orthorexia? What are the emotional risk factors? What are the strategies for treating orthorexia?

Eating disorders

Figure 2. Food aversion which is a common symptom of an eating disorder.

The prevalence of eating disorders are constantly growing, particularly amongst western societies (Polivy & Herman, 2002). Eating disorders are behavioural conditions that present in an individual's disturbance in eating behaviours, often caused by experiencing distressing thoughts and emotions; to which may lead to a change in eating behaviours, individuals exposed to trauma can be predisposed to developing eating disorders (Barthels et al., 2019).

Eating disorders are the most life-threatening psychiatric disorder, as they impact the physical body and mental state of the individual and can often be difficult to treat at the same time (Qian et al., 2020), anorexia nervosa and bulimia nervosa are found to be the most common forms of distorted eating; however, over time the Diagnostic and statistical Manual of Mental Disorders, 4^th edition (DSM-IV) has identified certain eating disorders that are not otherwise identified as anorexia nervosa or bulimia nervosa are classified as EDNOS – eating disorder not otherwise specified (Qian et al., 2020).

Table 1.

Types of Eating Disorders

Common eating disorders	Definition of each of the following eating disorders
Anorexia Nervosa	Anorexia nervosa is often characterised when an individual has an obsessive fear of gaining weight and a distorted perception of their body, it is seen that this fear of gaining weight manifests itself through food restrictions and can coincide with an increased motive of physical activity (Eating disorder Victoria, 2024). A common behaviour found from those suffering from the illness is food restriction, whereby an individual may severely restrict their food intake and may follow or create rules surrounding the types of food they consume or how they might consume it (Moore & Bokor, 2023).
Bulimia Nervosa	Bulimia nervosa is another common eating disorder found within the DSM-IV, it is characterised by a period of binge eating and followed by self-induced vomiting, periods of fasting, over-exercising or a misuse of laxatives which is used in efforts of avoiding weight gain after a binge (Jain & Yilanli, 2023).
Binge Eating	This psychiatric disorder follows episodes of binge eating. Binge eating involves a person eating an excessive amount of food, to which can occur during a small amount of time, or over an extended phase (Eating disorders Victoria, 2024). During these binge eating episodes, a person may not feel hunger or continue past the point of feeling hungry. It is a common occurrence for individuals to eat in secrecy and experience feelings of guilt, shame and disgust during or after a binge.
OSFED	OSFED also referred to as Other Specified Feeding and Eating Disorder in the DSM-IV, includes eating disorders that share the concern about eating, body shape, and weight and also engage in disordered eating behaviours (Balasundaram & Santhanam, 2023). A person with this diagnosis will often present signs of an eating disorder, however, may not meet all of the diagnostic criteria of, for instance, anorexia nervosa, or binge eating disorder.
Orthorexia Nervosa	Orthorexia nervosa is still a relatively new form of eating disorder, often associated with an obsessive preoccupation with healthy food consumption and a hyper fixation on food purity (Horovitz & Argyrides, 2023). Similar to anorexia nervosa, a person suffering orthorexia exhibit extreme dietary rules, avoid certain food groups and focus purely on nutritional contents of their food. Many individuals suffering this type of eating disorder hold a different motivation in comparison to those diagnosed with anorexia or bulimia, being that the desire is more to feel health and natural, rather than to lose weight (Saraswati & Nagendraswamy, 2024).

As described in Table 1. Orthorexia is a complex pathological obsession with proper nutrition, although orthorexia is not recognised as a psychiatric disorder it is associated with attempts to maintain optimum health through a highly restrictive diet – which often leads to malnourishment, loss of relationships and the development of other psychiatric disorder, which is common amongst current eating disorders (Koven & Abry, 2015). With regards to the diagnostic criteria of orthorexia nervosa, a lot of its symptoms do resemble that of obsessive-compulsive disorder and anorexia nervosa, the following diagnostic criteria of orthorexia was proposed by Moroze et al 2014:

1. Consuming a nutritionally unbalanced diet due to the preoccupying beliefs about food “purity”.
2. Anxiety and worries about consuming impure or unhealthy foods and the effect of food quality on physical or mental health.
3. Avoidance of food believed by the individual to be “unhealthy”, which may contain any preservatives or fats, additives, animal products or other ingredients that the individual may believe to be unhealthy.
4. Individuals experience guilt or worries after consuming unhealthy foods or not adhering to their strict dietary rules.
5. Intolerance to other’s food beliefs.
6. Impairment of physical health due to nutritional imbalances.
7. Severe distress or impairment of social or academic functioning due to obsessional thoughts and behaviours regarding the individual’s beliefs about “healthy” eating.

Orthorexia has a profound impact on an individual’s psychological well-being, with many suffers of this disorder face extreme anxiety surrounding their food choices (Horovitz & Argyrides, 2023). Feelings of shame and guilt are common for those with orthorexia, a typical experience when the individual may deviate from their self-imposed dietary practices (Horovitz & Argyrides, 2023). Social isolation is an occurring aspect of orthorexia, individuals avoid certain social situations where their food choices may be questioned or judged; furthermore, social gatherings that involve food can lead suffers of orthorexia to feel immense anxiety around the purity of food (Horovitz & Argyrides, 2023).

1 Orthorexia nervosa is a disorder that can be defined within the DSM-IV. True False 2 Individuals diagnosed with an eating disorder often experience distressing thoughts. True False

Healthy dieting vs. unhealthy dieting

Figure 3. Healthy eating pyramid - a visual guide to the recommended proportions of food consumption.

Diet provides a base structure to target the management and prevention of physical illness, as well as health mental illness; research has shown associations between healthy eating habits and positive mental well-being (Collins et al., 2020). Traditionally, the approaches to weight loss or health improvement are for a person to restrict their calorie in-take and increase exercise. However, dieting in a healthy way is a lot more complex – individuals need to further consider the biological processes, food nutrition and the potential risks to the body’s physiology and mental health.

Understanding healthy dieting

What constitutes as a healthy diet is continuously evolving as more research and evidence surfaces regarding the types of food groups that allow the body to absorb essential nutrients, that function in preventing health complications and improve mental well-being (Cena & Calder, 2020). Furthermore, a healthy diet is defined as the appropriate consumption of macronutrients that support energetic and physiologic needs, whilst also needing sufficient hydration and micronutrients to support psychological and physiological development (Cena & Calder, 2020). Macronutrients (compounds which are consume in larger quantities) are carbohydrates, proteins and fats, whereas micronutrients (consumed in smaller quantities, but are equally important) are vitamins, minerals and antioxidants (Savarino, Corsello & Corsello, 2021).

From the perspective of health psychology, Ridder et al (2017) further define healthy eating behaviours as making conscious choices to avoid certain foods that may impact weight loss or cause harm to a person's health. Ridder et al (2017) also found through their analysis that adhering to recommended daily portions of food consumption, which can be represented using the health food pyramid (see Figure 3), increases life longevity and decreases the development of illnesses. Furthermore, Ridder et al (2017) and Kepka et al (2022) both emphasis that the health food pyramid promotes all food groups and does not label food as either “good” or “bad” rather encourages certain food groups to be either consumed more regularly or in moderation. However, research suggests that more people desire to change their diet with the intention of weight loss, rather than to better adhere to dietary recommendations with the intention to improve health (Ridder et al., 2017). In saying this, majority of people have difficulties maintaining weight loss long-term, or develop the risk of becoming too overly concerned with food.

Consequences of extreme dieting

Being conscious of the food we consume plays an important role in the prevention of diseases and mental health illness (Kiss-Leizer & Rigo, 2018). Calorie intake restriction has been a popular form of dieting for the purpose of weight loss or weight management (Ridder et al., 2017). Without the proper knowledge, people can cross the line of what is considered an appropriate diet and make dietary choice that have a negative impact on the body. As seen within those suffering orthorexia nervosa, extreme forms of dieting are typically motivated by the fear of contracting a chronic illness that is caused by unhealthy eating (Kiss-Leizer & Rigo, 2018). Individuals with orthorexia may be fixated on only consuming raw or unprocessed food, with the intention to limit risk of food-related illnesses; orthorexia suffers are unknowingly engaging in calorie reduction (Leizer & Rigo, 2018).

The dependence on such a restrictive diet can result in an inadequate intake of essential nutrients and vitamins, often resulting in several nutritional and mineral deficiencies, that are vital for the body’s physiological functions and can further compromise a person’s quality of life (Chaki et al., 2013). Individuals with a prolonged adherence to restrictive diets are at risks of developing muscle weakening, osteoporosis, heart disease and a weakened immune system (Horovitz & Argyrides, 2023; Wani et al., 2023).

1 Calorie deficit diet has the best results for long-term weight loss management. True False 2 A restrictive diet results in an inadequate intake of essential nutrients. True False

Emotional risk factors of orthorexia

Figure 4. Physical sign of an individual experiencing emotional distress.

Emotional regulation is a process in which an individual can express and regulate their emotions (Gross, 2003). Emotional dysregulation encompasses emotion description and identification (also known as alexithymia), regulation of negative emotions, and behaviour (Mitchell et al., 2024). Empirical research has found that individuals who display eating disorder related behaviours experience high levels of intense emotions, including having less adaptive strategies to regulate negative emotions and reframe from engaging in impulsive behaviours (Mitchell et al., 2024). Interpersonal experiences are often risk factors leading to emotional dysregulation and further influences the development of eating disorders, for instance, individuals’ exposure to abuse, trauma, or certain life stressors that are not easily controlled are all contributing factors (Trompeter et al., 2022).

Common aspects of the emotional dysregulation in Orthorexia nervosa

Individual's suffering orthorexia nervosa has a fixation on "clean eating", individual's suffering this disorder often have an intense preoccupation with the quality of food or purity of food they are consuming (Horovitz & Argyrides, 2023). Perfectionism has been associated with eating disorders such as anorexia nervosa and bulimia; similarly, literature suggests that suffers of orthorexia also present with characteristics of perfectionism (Barnes & Caltabiano, 2017). Many individuals with orthorexia showcase the personality type that is associated with perfectionism, being that these individuals have a strict adherence to rules, set high standards and expectations, experience excessive criticism of themselves and of others (Barnes & Caltabiano, 2017). However, there are a lack of studies to suggest that perfectionism is correlated to orthorexia. In saying this, a study conducted by Koven & Senbonmatsu (2013) had found a significant relationship between orthorexia nervosa and perfection, being that many individuals diagnosed with orthorexia also presented traits of obsessive-compulsive disorder. In orthorexia, individuals strive to eat the “perfect” diet and follow strict dietary food rules, therefore it seems plausible that perfectionism factors into the emotional dysregulation of orthorexia nervosa (Barnes & Caltabiano, 2017).

Fear and anxiety towards becoming sick or developing certain illnesses may reinforce the behaviour of excessive dieting. Factors of anxiety and fear within orthorexia suffers appears to present more as health motivation, being excessive dieting is used as a coping mechanism for anxiety or worry surrounding the potential development of illness (Barlow, Lee & Saling, 2024). Yilmaz and Dundar (2022) have identified a prevalence of individuals with orthorexia exhibiting high anxiety scores, furthermore, the study also found a significant relationship between anxiety and the level of obsession with healthy eating; therefore, increasing the likelihood of developing orthorexia behaviours. Another study by Tragantzopoulou & Giannouli (2024) conducted one-on-one interviews with 13 adults who self-reported obsessive eating behaviours (4 out of 13 adults were currently suffering a chronic health condition), to further understand the emotional triggers that cause orthorexia tendencies and whether this only affects individuals who are currently suffering a chronic illness. Interestingly, the findings revealed that regardless of whether participants were suffering from a chronic illness or not, excessive healthy eating practices was primarily motivated by anxiety around developing an illness.

Emotional dysregulation and dysfunctional cognitive processes are widely documented in eating disorder literature. An individual that presents a high level of emotional comprehension, awareness and acceptance is able to effectively manage adverse emotional experiences and avoids engaging in maladaptive coping mechanisms (Gerges et al., 2023; Strahler et al., 2022). In most cases, individuals that have difficulties in emotional regulation are at an increased risk of developing an eating disorder. Due to the discourse of dieting, avoidance of “impure” foods and harsh dietary restrictions is mainly caused by emotional dysregulation and maladaptive coping strategies to relive stress (Gerges et al., 2023).

Factors that contribute to the emotional dysregulation of Orthorexia nervosa

Social media has had a significant influence over dieting, being there is a substantial number of unrealistic standards when it comes to body types and appearances. The media tends to label certain food groups as "bad" or "unhealthy", articles that contain information on types of diets may not have the appropriate certification on nutrition. An analysis conducted by Joshi & Mohan (2018) found a lack of evidence to suggest the long-term benefits of calorie restriction, finding that such extreme diets are caused by the influence of socio-cultural factors and the role of media. Izydorczyk et al (2020) further expand on the influence that media has over ‘diet culture’, specifically promoting unrealistic body standards, or even labelling certain food groups as unhealthy. Sanchez-Ruiz et al (2001) conducted a study to test the impact of mass media and socio-cultural variable on eating behaviour in young adults, researchers found that media had a significant impact on eating related behaviours. Media tends to advertise false information on the nutritional facts of food and in most cases the media can utilise fear to motivate people into avoiding certain food groups (Izydorczyk et al., 2020).

Orthorexia nervosa is linked to attachment-related anxiety and avoidance according to a recent study by Strahler et al., 2022, negative emotions that impact an individual’s emotional regulation competence can initiate the attachment system. The attachment theory refers to the relationship or bonds between child and their primary caregiver, depending to the type of relationship that is formed between the caregiver and child impacts the child’s future interpersonal attachments, how to express, experience and regulate their emotions (Yip et al., 2018). In relation to Strahler et al., 2022 review, individuals with insecure attachment styles formed in childhood were predicted to over-engage in emotional eating, while avoidant or fearful attachment patterns were found to have a higher likelihood of developing eating disorders such as anorexia and orthorexia nervosa. Anxious or avoidant attachment patterns that are linked to orthorexia nervosa are typically mediated by maladaptive coping strategies to ease emotional distress surrounding food (Strahler et al., 2022). In understanding this research, it is clear that the attachment theory has a significant effect on the development of orthorexia nervosa, particularly for those individuals with an anxious or avoidant style of attachment generally struggle to regulate emotions such as fear and express it through disordered eating.

Treatment strategies

In using psychoeducation, it informs individuals of the potential consequences when engaging in excessive dieting. Furthermore, it provides information on the nature of orthorexia nervosa and the underlying impacts it can further cause on mental well-being. Individuals who are at risk of developing orthorexia nervosa often exhibit personality characteristics as such perfectionism, neuroticism and obsessive-compulsive behaviours – all of which can manifest itself into disordered eating behaviours. Psychoeducation can challenge an individual's thoughts and beliefs surrounding their distorted eating behaviours; furthermore, psychoeducation is useful to for individuals to understand the socio-cultural influences of excessive dieting and this can foster into strict and harmful dieting behaviours.

Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) offers intervention, that is evidenced based, and targets maladaptive behaviours and thoughts related to Orthorexia nervosa (Horovitz & Argyrides, 2023). CBT requires individuals with orthorexia to monitor their dietary patterns and emotional responses to assess and become more aware of triggers or stressors that contribute to orthorexia behaviours (Horovitz & Argyrides, 2023). This provides an opportunity where individuals learn to identify and restructure unhealthy thoughts on food, and further assists with managing anxiety and distress related emotions. Once individuals suffering from orthorexia are able to understand their thoughts and beliefs regarding healthy and unhealthy forms of dieting and food, they are able to modify maladaptive behaviours and emotional responses; this allows individuals to foster more posi tive diet habits and promotes mental well-being (Horovitz & Argyrides, 2023).

Acceptance-based therapy and mindfulness practices

Emerging therapeutic approach for orthorexia nervosa patients, involves remaining aware of the present moment, acceptance of one's thoughts and feelings, and sensations throughout the body. The approach teaches individuals to detach themselves from any distressing thoughts and emotions that may be experienced, whilst observing their thoughts and fears regarding food or their dietary habits. Acceptance-based therapy with the added component of mindfulness practices, encourages individuals to accept their vulnerabilities and imperfections without being critical or judgmental of themselves (Horovitz & Argyrides, 2023). The goal of these exercises is to allow individuals to remain present and be mindful of thoughts, feelings and potential maladaptive actions that may occur when faced during distressing events. This approach works on fostering self-compassion and resilience to reduce the need for dietary perfectionism and anxieties surrounding the “purity” of food; this further challenges the beliefs associated with orthorexia nervosa (Horovitz & Argyrides, 2023).

Case study After Evangeline's doctor had discussed with her the symptoms and the health consequences of orthorexia nervosa, she was encouraged to seek treatment to manage the effects that the disorder was having on her mental health. After some consideration and medical advice from her doctor, Evangeline decided to commit to cognitive behavioural therapy and trial medication to manage her anxiety. Through committing to weekly therapy session, Evangeline was tasked to monitor her eating patterns and has been able to identify triggers and emotional responses that cause her to engage in her orthorexia tendencies. From there Evangeline has been able to alter her behaviours and thoughts and form more adaptive ways of coping.

Conclusion

Orthorexia has not yet been defined as a psychiatric disorder due to a lack of clear diagnostic criteria, which makes it difficult for mental health professionals to differentiate between excessive healthy eating as a form of obsession-compulsive behaviour or a proper eating disorder (Horovitz & Argyrides, 2023). This book chapter discusses the role of emotional dysregulation which is a common factor found from those suffering with orthorexia, individuals that struggle to coping with stressors tend to engage in maladaptive behaviours to manage. Furthermore, Strahler et al (2022) found that emotional dysregulation is said to be influenced by attachments formed between a primary caregiver and child. Being, that avoidant and insecure attachment styles are predictors in eating disorder, especially orthorexia. Through understanding the causes and risks factors of orthorexia, treatment strategies such as cognitive behavioural therapy and acceptance-based therapy have been utilised to aid individuals combat the disorder.

Research continues to highlight concerns surrounding the impacts of media, specifically how media promotes "good" and "bad" foods without the proper certifications which can impact individuals who already engage in strict dietary behaviours. However, it is also important to understand that not all diets have consequences, the food pyramid in particular serves as a guide in which food groups should be consume more so than others; benefits of the food pyramid include representing all food groups without the negative label.

See also

• Trauma and emotion (Book chapter 2023)
• Emotional eating (Book chapter 2021)
• Food and fear (Book chapter 2019)
• Anorexia nervosa and extrinsic motivation (Book chapter 2016)

References

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External links

• Orthorexia Eating Disorders - eating disorders Victoria
• Emotional dysregulation - Medical news
• Orthorexia nervosa, symptoms & treatment - Healthline