Atypical eating disorder presentations challenge traditional diagnostic frameworks, leading to underdiagnosis and diagnostic delay, as each patient had prior clinical contacts in which eating disorder pathology went unrecognized. This study examines four cases highlighting unique risk factors, including high-performance athletics, trauma history, substance use, gender dysphoria, and environmental stressors. These patients were not identified as having eating disorders at initial clinical contact, as presenting complaints, including anxiety, alcohol use disorder, attention-deficit/hyperactivity disorder, and environmental stressors, obscured the underlying eating pathology. Athletes, particularly those in weight-class sports, may engage in restrictive eating while maintaining higher body weight, as seen in Case 1. Trauma history increases vulnerability, yet routine screening remains inadequate. Case 2 demonstrates the interplay between alcohol use disorder and binge-purge cycles, where substance use masked eating pathology. Gender dysphoria in Case 3 contributed to restrictive behaviors as a means of body modification, underscoring the importance of integrating gender-affirming care. Case 4 illustrates how environmental instability can drive disordered eating independent of body image concerns. These cases emphasize the necessity of broadening screening criteria and provider education to recognize atypical presentations. Addressing coexisting psychiatric conditions and social determinants of health is critical for early intervention and improved outcomes in patients with eating disorders.
Prasad et al. (Sun,) studied this question.