Stigmatization of anorexia nervosa versus atypical anorexia nervosa: An experimental study.

Abstract

Stigmatization of anorexia nervosa (AN) includes paradoxical attributions of both personal responsibility and feelings of admiration. Despite comparable severity to AN, atypical AN (i.e., meeting all criteria for anorexia nervosa without having low weight) is perceived as a less serious illness. While stigmatization has been compared across eating disorders and within a single eating disorder diagnosis (i.e., varying severity of a specific eating disorder), there are no investigations of how stigmatization may compare across full and subthreshold presentations. The present study experimentally tested the stigma associated with AN versus atypical AN and hypothesized that atypical AN may be associated with greater stigma because individuals do not meet the low-weight criterion. One hundred participants (77.9% female, M age = 19.06, M BMI = 23.34) were randomly assigned to read either a vignette describing a female with AN or a vignette describing a female with atypical AN. Following the vignette, participants completed measures of eating disorder stigma. Hypotheses were tested using univariate analysis of covariance (ANCOVA). Participants randomized to the atypical AN condition assigned the target significantly greater levels of overall stigma ( p = .037) and illness controllability ( p = .031) than participants in the AN condition; however, there were no significant differences across conditions in assignments of selfishness/vanity ( p = .094) or illness trivialization ( p = .050). Individuals with atypical AN may be viewed as having a more controllable illness than individuals with AN, underscoring the complexity of AN stigmatization, particularly for nonprototypical presentations.

Differentiating anorexia nervosa and atypical anorexia nervosa with absolute weight cut‐offs results in a skewed distribution for premorbid weight among youth

“…For example, an adolescent with premorbid BMI% = 80th must lose much more weight to be diagnosed with AN than an adolescent with premorbid BMI% = 10th, even if eating disorder symptoms are identical. This is problematic because atypical AN is widely considered to be less serious than AN (e.g., Cunning & Rancourt, 2023;Eiring et al, 2021;Kons et al, 2024;Veillette et al, 2018) despite contrary evidence (Billman Miller et al, 2024;Garber et al, 2019;Sawyer et al, 2016;Zanna et al, 2021). Patients with higher BMIs face disparities in eating disorder care (e.g., Harrop et al, 2021) due to misconceptions of being less 'sick' than clinically 'underweight' counterparts with AN (e.g., Cunning & Rancourt, 2023;Eiring et al, 2021;Kons et al, 2024;Veillette et al, 2018).…”

“…This is problematic because atypical AN is widely considered to be less serious than AN (e.g., Cunning & Rancourt, 2023;Eiring et al, 2021;Kons et al, 2024;Veillette et al, 2018) despite contrary evidence (Billman Miller et al, 2024;Garber et al, 2019;Sawyer et al, 2016;Zanna et al, 2021). Patients with higher BMIs face disparities in eating disorder care (e.g., Harrop et al, 2021) due to misconceptions of being less 'sick' than clinically 'underweight' counterparts with AN (e.g., Cunning & Rancourt, 2023;Eiring et al, 2021;Kons et al, 2024;Veillette et al, 2018). Given significant associations between premorbid BMI and weight loss in ours and prior samples of youth with AN and atypical AN (Coners et al, 1999;Föcker et al, 2015;Hebebrand et al, 2024;Peters et al, 2021), coupled with overlapping characteristics and sequelae in both illnesses (Billman Miller et al, 2024;Garber et al, 2019;Sawyer et al, 2016;Zanna et al, 2021), we propose that differentiating diagnoses with clinical 'underweight'-in the absence of empirical support-inadvertently reinforces widespread weightbiased stereotypes about restrictive eating disorders.…”

“…Historically, AN has been synonymized with 'underweight,' with patients described with 'extreme emaciation' or 'inanition' dating back to the mid-19th century (Gull, 1997;Lasègue, 1997). Presenting weight is often considered a proxy for illness severity in restrictive eating disorders, with presenting BMI driving many providers' diagnostic impressions and clinical recommendations (Cunning & Rancourt, 2023;Eiring et al, 2021;Kons et al, 2024;Veillette et al, 2018). Consequently, compared to clinically 'underweight' counterparts with AN, patients with atypical AN are less likely to be screened for and diagnosed with a restrictive eating disorder and are less often referred to and/or reimbursed for specialty care (Ali et al, 2017;Harrop et al, 2021;Kastner et al, 2021;Kennedy et al, 2017;Kons et al, 2024).…”

Dismantling weight stigma in eating disorder treatment: Next steps for the field

“…BMI has historically been used as a diagnostic criterion for Anorexia Nervosa (AN), which led to higher-weight individuals being labeled with “atypical anorexia nervosa” (AAN) despite being the more common presentation of AN. AAN is often perceived as less severe ( 66 ), which may prevent higher-weight individuals with severe restrictive pathology from receiving immediate and life-saving services ( 56 ). BMI does not necessarily reflect problematic behaviors utilized to reach or maintain a current weight, nor does it adequately contextualize an individual’s current weight with respect to their developmental history.…”

“…Data consistently suggests that individuals with higher body weight are less likely to be diagnosed with an eating disorder and experience a longer delay before receiving treatment ( 57 ). Providers are also more likely to perceive eating disorders as less severe and recommend less intensive treatments for larger bodied individuals ( 66 , 67 ). Observed examples of this in practice include prescribing lower calorie (more restrictive) meal plans to larger bodied patients or offering combined treatment for Binge Eating Disorder and “Obesity.” Such treatment conflates recovery from an ED with goals and activities that may have contributed to its development.…”