Could Your Higher Weight Patient Have Atypical Anorexia?


Spotts-De Lazzer, A., & Muhlheim, L. (2019). Could your higher weight patient have atypical anorexia? Journal of Health Service Psychology, 45, 3–10.


When an overweight or obese patient presents with weight loss as a treatment goal, a psychologist may initially view this request as both positive and consistent with current public health campaigns. However, the psychologist must explore further because a significantly different clinical picture may emerge. Without knowledge specific to eating disorders and awareness of weight stigma, the psychologist could unwittingly cause harm to a patient with this presentation. This article addresses the following: the goal of weight loss; clinical considerations associated with atypical anorexia, a diagnosis signifying that criteria have been met for anorexia nervosa with the exception of low weight; and treatment of this eating disorder.

Registrants can read the full article on


Academy for Eating Disorders, Medical Care Standards Task Force. (2012). Eating disorders: Critical points for early recognition and medical risk management in the care of individuals with eating disorders [Brochure]. Retrieved from

Alberga, A. S., Russell-Mayhew, von Ranson, K. M., & McLaren, L. (2016). Weight bias: a call to action. Journal of Eating Disorders (2016) 4:34. doi:10.1186/s40337-016-0112-4

American Psychiatric Association. (2006). Treatment of patients with eating disorders (3rd ed.). American Journal of Psychiatry, 163 (Suppl. 7), 4–54. Retrieved from

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

American Psychiatric Association. (2012). Guideline watch (August 2012): Practice guideline for the treatment of patients with eating disorders (3rd ed.). Retrieved from

American Psychological Association. (2017). Ethical principles of psychologists and code of conduct (2002, Amended June 1, 2010 and January 1, 2017). Retrieved from

Bacon, L., & Aphramor, L. (2011). Weight science: Evaluating the evidence for a paradigm shift. Nutrition Journal, 10(1), 9.

Bulik, C. (2014, December 1). Negative energy balance: A biological trap for people prone to anorexia nervosa [Blog post]. Retrieved from

Costin, C. (2007). The eating disorder sourcebook (3rd ed.). New York, NY: McGraw-Hill.

Dahlgren, C. L., & Wisting, L. (2016). Transitioning from DSM-IV to DSM-5: A systematic review of eating disorder prevalence assessment. International Journal of Eating Disorders, 49(11):975-997. doi: 10.1002/eat.22596. Epub 2016 Aug 16.

Ellis-Ordway, N., Harrop, E., Collins, L., Clark, D., & Dios, E. (August, 2018) Weight stigma is a social justice issue. Pre-conference workshop presented at the meeting of the Association for Size Diversity and Health, Portland, OR.

Fairburn, C. G. (2008). Cognitive Behavior Therapy and Eating Disorders. New York: Guilford Press.

Fairburn, C. G., Marcus, M. D., & Wilson, G. T. (1993). Cognitive-behavioral therapy for binge

eating and bulimia nervosa: A comprehensive treatment manual. In C. G. Fairburn & G. T. Wilson (Eds.), Binge eating: Nature, assessment and treatment (pp. 361–404). New York, NY: Guilford Press.

Fildes, A., Charlton, J., Rudisill, C., Littlejohns, P., Prevost, A. T., & Gulliford, M. C. (2015). Probability of an obese person attaining normal body weight: Cohort study using electronic health records. American Journal of Public Health, 105(9), e54-59.

Forney, K. J., Brown, T. A., Holland-Carter, L. A., Kennedy, G. A., & Keel, P. K. (2017). Defining “significant weight loss” in atypical anorexia nervosa. The International Journal of Eating Disorders, 50(8), 952–962.

Goodrick, G. K., Poston, W. S., Kimball, K. T., Reeves, R. S., & Foreyt, J. P. (1998). Nondieting versus dieting treatment for overweight binge-eating women. Journal of Consulting and Clinical Psychology, 66(2), 363–368.

Harvard Opinion Research Program. (2018, January 16). Discrimination in America: Final summary. National Public Radio, Robert Wood Johnson Foundation, & Harvard T.H. Chan School of Public Health. Retrieved from

Hudson, J. I., Hiripi, E., Pope, H. G., & Kessler, R. C. (2007). The prevalence and correlates of eating disorders in the national comorbidity survey replication. Biological Psychiatry, 61(3), 348–358. doi:10.1016/j.biopsych.2006.03.040

Keys, A., Brozek, J., Henschel, A., Michelsen, O., Taylor, H. L., Simonson, E., & Wells, S. (1950). The biology of human starvation (Vol. 1–2). Min- neapolis, MN: University of Minnesota Press.

Lebow, J., Sim, L. A., & Kransdorf, L. N. (2015). Prevalence of a history of overweight and obesity in adolescents with restrictive eating disorders. The Journal of Adolescent Health: Official Publication of the Society for Adolescent Medicine, 56(1), 19–24.

Mann, T. (2018). Why do dieters regain weight? Calorie deprivation alters body and mind, overwhelming willpower. Psychological Science Agenda, American Psychological Association. Retrieved from

Martinussen, M., Friborg, O., Schmierer, P., Kaiser, S., Øvergård, K. T., Neunhoeffer, A.-L., … Rosenvinge, J. H. (2016). The comorbidity of personality disorders in eating disorders: a meta-analysis. Eating and Weight Disorders – Studies on Anorexia, Bulimia and Obesity, 22(2), 201–209. doi:10.1007/s40519-016-0345-x

Meadows, A., & Daníelsdóttir, S. (2016). What’s in a word? On weight stigma and terminology. Frontiers in Psychology, 7. doi:10.3389/fpsyg.2016.01527

Millner, R. (2018). Is atypical anorexia really atypical? The interplay of weight suppression, weight bias, and atypical anorexia. SCAN’s Pulse, 37(2) 5-7.

Montani, J.-P., Schutz, Y., & Dulloo, A. G. (2015). Dieting and weight cycling as risk factors for cardiometabolic diseases: who is really at risk? Obesity Reviews, 16, 7–18. doi:10.1111/obr.12251

Murray, S. B., Griffiths, S., & Mond, J. M. (2016). Evolving eating disorder psychopathology: Conceptualising muscularity-oriented disordered eating. British Journal of Psychiatry, 208(05), 414–415. doi:10.1192/bjp.bp.115.168427

Nowakowski, M. E., McFarlane, T., & Cassin, S. (2013). Alexithymia and eating disorders: a critical review of the literature. Journal of Eating Disorders, 1(1), 21. doi:10.1186/2050-2974-1-21

Park, S., Wilkens, L. R., Maskarinec, G., Haiman, C. A., Kolonel, L. N., & Le Marchand. L. (2018). Weight change in older adults and mortality: the multiethnic cohort study. International Journal of Obesity, 42(2): 205–212. doi:10.1038/ijo.2017.188.

Peebles, R., Hardy, K. K., Wilson, J. L., & Lock, J. D. (2010). Are diagnostic criteria for eating disorders markers of medical severity? Pediatrics, 125(5), e1193-1201.

Pitt, P. D. (2018). Treating youth obesity: Review and application of APA practice. Journal of Health Service Psychology, 44, 54–60.

Puhl, R. M., Andreyeva, T., & Brownell, K. D. (2008). Perceptions of weight discrimination: prevalence and comparison to race and gender discrimination in America. International Journal of Obesity, 32(6), 992–1000. doi:10.1038/ijo.2008.22

Provencher, V., Bégin, C., Tremblay, A., Mongeau, L., Corneau, L., Dodin, S., … Lemieux, S. (2009). Health-At-Every-Size and eating behaviors: 1-year follow-up results of a size acceptance intervention. Journal of the American Dietetic Association, 109(11), 1854–1861.

Puhl, R. M., & Heuer, C. A. (2009). The stigma of obesity: A review and update. Obesity, 17(5), 941–964. doi:10.1038/oby.2008.636

Puhl, R. M., Latner, J. D., King, K. M., & Luedicke, J. (2013). Weight bias among professionals treating eating disorders: Attitudes about treatment and perceived patient outcomes. International Journal of Eating Disorders, 47(1), 65–75. doi:10.1002/eat.22186

Spotts-De Lazzer, A., & Muhlheim, L. (2016). Spotts-De Lazzer, A., & Muhlheim, L. (2016). Eating disorders and scope of competence for outpatient psychotherapists. Practice Innovations, 1(2), 89-104.

Stice, E. (2016). Interactive and mediational etiologic models of eating disorder onset: Evidence from prospective studies. Annual Review of Clinical Psychology, 12, 359–381.

Tobin, D. L., Banker, J. D., Weisberg, L., & Bowers, W. (2007). I know what you did last summer (and it was not CBT): A factor analytic model of international psychotherapeutic practice in the eating disorders. International Journal of Eating Disorders, 40(8), 754–757. doi:10.1002/eat.20426

Tomiyama, A. J., Ahlstrom, B., & Mann, T. (2013). Long-term effects of dieting: Is weight loss related to health? Social and Personality Psychology Compass, 7(12), 861–877.

Tomiyama, A. J., Finch, L. E., Belsky, A. C. I., Buss, J., Finley, C., Schwartz, M. B., & Daubenmier, J. (2014). Weight bias in 2001 versus 2013: Contradictory attitudes among obesity researchers and health professionals. Obesity, 23(1), 46–53. doi:10.1002/oby.20910

Towne, T. L., De Young, K. P., & Anderson, D. A. (2017). Trends in professionals’ use of eating disorder assessment instruments. Professional Psychology: Research and Practice, 48(4), 243–250.

Ulfvebrand, S., Birgegård, A., Norring, C., Högdahl, L., & von Hausswolff-Juhlin, Y. (2015). Psychiatric comorbidity in women and men with eating disorders results from a large clinical database. Psychiatry Research, 230(2), 294–299. doi:10.1016/j.psychres.2015.09.008

United States Census Bureau. (2018, September 24). U.S. and world population clock. Retrieved from

Vandereycken, W. (2006). Denial of illness in anorexia nervosa—a conceptual review: part 1 diagnostic significance and assessment. Eur. Eat. Disorders Rev., 14: 341-351. doi:10.1002/erv.721

Wade, T. D., Keski-Rahkonen A., & Hudson J. (2011). Epidemiology of eating disorders. In M. Tsuang and M. Tohen (Eds.), Textbook in Psychiatric Epidemiology (3rd ed.) (pp. 343-360). New York: Wiley.

Wilson, G. T., Grilo, C. M., & Vitousek, K. M. (2007). Psychological treatment of eating disor- ders. American Psychologist, 62, 199–216. http://

Thank You to Our Winter 2019 Advertisers

Full Articles on

Available to Registrants

View All Articles

1200 New York Ave NW, Ste 800

Washington DC 20005

p: 202.783.7663

f: 202.347.0550

Endorsed by the National Register