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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 47 PATHOLOGY PERSPECTIVES that can range from extended fasting to extra exercise, often followed by a commitment to an even more limited diet. Those who go through treatment for standard eating disorders like anorexia or bulimia may eventually find themselves on the orthorexia merry-go-round. They replace one food-related goal (being thin) with another (being healthy), but it doesn't necessarily improve their well-being. 6 To make things even more difficult, many people start down this path because they begin with some kind of digestive upset or other health problem that can be addressed with nutritional changes. Sometimes it's because a loved one is battling a disease and they are making dietary adjustments for their sake. But for reasons that aren't clear, the range of foods they can consume without pain or negative reactions becomes restricted to the point that it is impossible to access the range of nutrients, vitamins, and minerals that are necessary for even baseline function. People can make themselves sick; people can even die from complications related to this disorder. Anecdotes from caregivers include the development of anemia, acidosis, osteopenia, and dangerous changes to blood chemistry and heart function. WHAT CAN BE DONE? As researchers Nancy Koven and Alexandra Abry put it, "Asking severely orthorexic patients to abandon false food beliefs is really a request to discard a deeply held ideology." 7 Treatment for orthorexia is a largely undeveloped field. Even experts in anxiety disorders and eating disorders are often at a loss. Some recommend low-dose antidepressants, which can also act as anti-anxiety medication. Antipsychotic medication may be prescribed to interrupt the delusional thinking about food that orthorexic patients experience. Psychotherapy that focuses on control issues, similar to that used with anorexia, is often called for. The goal of treatment isn't primarily to change how someone eats; it is to change how that person feels about preparing and eating food, which can require imaginative and personally customized treatment. Many people in recovery find their way to wellness with the help of medical professionals and loved ones, but always with the fear of the damage they will do to themselves by reverting to their former, "impure," eating habits. MASSAGE THERAPISTS, MASSAGE THERAPY Regardless of whether orthorexia is ever recognized as a disorder in the DSM, it is clear that a certain population of people experience deep unhappiness and physical illness paradoxically caused by their efforts to be healthy. Whether this should be considered an eating disorder, an anxiety disorder, or some combination of the two, the research supports massage therapy as a relaxation-inducing coping mechanism for people who can receive it well. In addition, massage therapy provides a way to connect with another human being on a profound, if nonverbal, level. This can serve to gently alter the isolation that many people feel when they are forced by their condition to separate themselves from many social situations. As people who are aware of healthy nutrition, massage therapists are vulnerable to orthorexic tendencies. And, like it or not, we serve as role models for our clients. Clients may follow the examples we set—rather than the advice we provide—about exercise, getting massage, smoking, getting enough sleep, and also about our relationships with food. This isn't to suggest that every massage therapist needs to be perfect in all things. But it does suggest— strongly—that we can serve our clients best when we are models of optimism, of conscientiousness about taking care of ourselves, and perhaps above all, of forgiving ourselves with good humor when we fall short of our goals. Notes 1. Steven Bratman and David Knight, Health Food Junkies: Overcoming the Obsession with Healthful Eating (New York: Broadway, 2001). 2. Steven Bratman, "The Health Food Eating Disorder," Yoga Journal, October 1997, accessed May 2015, www.orthorexia.com/original-orthorexia-essay. 3. Anna Brytek-Matera et al., "Orthorexia Nervosa and Self- Attitudinal Aspects of Body Image in Female and Male University Students," Journal of Eating Disorders 3, no. 2 (2015). 4. Ryan M. Moroze et al., "Microthinking About Micronutrients: A Case of Transition From Obsessions About Healthy Eating to Near-Fatal 'Orthorexia Nervosa' and Proposed Diagnostic Criteria," Psychosomatics, March 19, 2014. 5. Nancy S. Koven and Alexandra W. Abry, "The Clinical Basis of Orthorexia Nervosa: Emerging Perspectives," Neuropsychiatric Diseases and Treatment 11 (2015): 385–94. 6. Cristina Segura-Garcia et al., "The Prevalence of Orthorexia Nervosa Among Eating Disorder Patients After Treatment," Eating and Weight Disorders, December 28, 2014, accessed May 2015, www.ncbi.nlm.nih.gov/pubmed/25543324. 7. Nancy S. Koven and Alexandra W. Abry, "The Clinical Basis of Orthorexia Nervosa: Emerging Perspectives." Ruth Werner, BCTMB is a former massage therapist, a writer, and an NCTMB-approved continuing education provider. She wrote A Massage Therapist's Guide to Pathology (Lippincott Williams & Wilkins, 2013), now in its fifth edition, which is used in massage schools worldwide. Werner is available at www.ruthwerner.com.