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F r e e S O A P n o t e s w i t h M a s s a g e B o o k f o r A B M P m e m b e r s : a b m p . u s / M a s s a g e b o o k 45 "After a year or so of this self-imposed regime, I felt light, clear headed, energetic, strong, and self-righteous. I regarded the wretched, debauched souls about me downing their chocolate chip cookies and fries as mere animals reduced to satisfying gustatory lusts … … Gradually, however, I began to sense that something was wrong. The need to obtain food free of meat, fat, and artificial chemicals put nearly all social forms of eating out of reach. Furthermore, intrusive thoughts of sprouts came between me and good conversation. Perhaps most dismaying of all, I began to sense that the poetry of my life had diminished. All I could think about was food." 2 Bratman developed a set of criteria whose purpose was to determine whether a patient might show orthorexic tendencies. The criteria include these features: • Investing three hours or more each day in planning, finding, preparing, eating, and concentrating on food (this is for people who don't work in the food industry). • Feeling superior to others whose diets are not as "pure." • Rigid adherence to an eating regime; any faults or shortcomings are followed with compensatory action (usually fasting and additional restrictions). • Associating self-esteem with adherence, and the converse: associating lack of adherence with self-loathing, disgust, and guilt. • Being centrally focused not on weight or appearance, but on eating properly. In addition, Bratman developed a questionnaire of 15 items called the ORTHO-15, in which people are asked to rate on a 4-point Likert scale their feelings or behaviors about food. A sample question might read, "I spend hours every day thinking about food safety," with the instruction to choose "Always," "Often," "Sometimes," or "Never." The higher the score, the fewer orthorexic tendencies are identified, and a score of 40 or under is proposed as the diagnostic marker for the condition. 3 While it has been useful to have these benchmarks, the diagnostic criteria and questionnaire developed by Bratman have not been fully validated in clinical research. As of this writing, the bulk of research into orthorexia nervosa has been done in Europe. Several items on the original ORTHO-15 have no cultural reference for some of the studied populations, so other versions of the questionnaire have been developed. In addition, because the Bratman survey doesn't account for food-related obsessive- compulsive behaviors, some specialists recommend combining the ORTHO-15 tool with another survey that is sensitive to obsessive-compulsive disorder (OCD) issues, the Minnesota Multiphasic Personality Inventory. As the study of this phenomenon has evolved, other specialists have proposed alternate diagnostic criteria, using many of Bratman's concepts but adding others, including: • Intolerance for others' food beliefs. • Spending excessive amounts of money relative to one's income on foods because of their perceived quality and composition. And they go further to identify when the habits that start out as virtuous turn vicious: • Health becomes impaired because of nutritional imbalance or malnutrition. • Severe distress and social impairment interfere with function in social, academic, and vocational settings, because of the patient's beliefs about healthy eating. And a final nuance: • The disturbance is specifically not due to another disorder like OCD or schizophrenia. • The behavior is not accounted for by religious food observance or in relation to professionally diagnosed needs for a special diet. 4 ORTHOREXIA: COMPARE AND CONTRAST Many eating-disorder specialists agree that Bratman's description is a real phenomenon. Having a set of clear and validated diagnostic criteria for this condition is important; otherwise, health-care providers or researchers can't know that they're talking about and trying to identify and treat the same condition. This all boils down to a central question: what is orthorexia? Is it an eating disorder? Or is it an anxiety disorder? Or both—or neither? The lack of a clear answer is problematic because the characteristics of orthorexia overlap substantially with characteristics of other psychiatric issues, especially anorexia and OCD. This muddies the water both for clear diagnosis and for finding the best possible treatment options. Here is one researcher's definition of orthorexia: