Anorexia Nervosa

What is anorexia nervosa?

People with anorexia nervosa usually have a distorted perception of the size and shape of their bodies. Their sense of self-worth is likely to depend on their size, so they become preoccupied with monitoring it through mirrors, scales, and clothing - or avoid it altogether with loose clothing. Consequently, they may use drastic measures around food restriction and exercise - usually through overly restrictive diets, starvation, self-induced vomiting (purging), laxatives/diuretics, weight loss medication, and excessive exercise.

For people with anorexia, focusing on their weight will often become a compulsion, and they may go to extreme lengths to lose or avoid gaining it. A personalized treatment plan that includes working with a mental health professional and physician is significantly more likely to lead to a complete recovery from anorexia.

However, the treatment of and recovery from anorexia looks different for everybody; some people will recover completely, while others may always have issues with food and body image.

Symptoms and signs of anorexia

Anorexia has many warning signs and symptoms, but not everybody who suffers from the disorder will experience all of them. For example, somebody can be of a healthy weight but experience many psychological symptoms of anorexia and restrict their food intake.

Often, sufferers will not get a clinical diagnosis until they reach a dangerously low weight that is enough to meet the criteria, hence why it is essential to begin treatment early to prevent this from happening. The development of anorexia nervosa can be subtle at first, and a change in behavior usually appears before physical symptoms do.

Symptoms may include some of the following:

Behavioral

• Preoccupation with diets or ‘healthy eating’ that is overly restrictive or cuts out entire food groups
• Missing meals completely or ‘fasting’
• Claiming they have eaten, will eat later or that they have eaten more than they have
• Cutting food up into very small pieces and/or taking a long time to finish eating
• Sudden interest in the nutritional information of food e.g., calories, fat, carbohydrates and how ‘good’ or ‘bad’ they are
• Often making comments around feeling ‘fat’ or ‘overweight’, even when there has been a significant drop in weight
• Avoiding removing baggy clothing to hide severe weight loss
• Regularly giving reasons why they can’t be around in situations where food would be involved
• Excessive exercising and showing signs of irritability/anxiety when they are not able to
• Making themselves vomit (purge) to get rid of any food they have eaten
• Misusing weight loss medicine, laxatives, or diuretics

Physical

• Rapid or extreme weight loss
• Gaunt appearance
• Fatigue/ reduced energy levels and physical weakness
• Insomnia or sleep issues
• Dizziness/ fainting
• Irregular menstrual cycle
• Yellowing or dry skin
• Feeling cold more frequently and poor circulation
• Digestive issues such as bloating, constipation and abdominal pain
• Hair thinning/loss
• Growth of fine, soft body hair (lanugo hair)^[1]

Causes of anorexia

Anorexia is a complex illness, and there is often no direct cause or trigger. However, research has identified specific social, psychological, and environmental factors that may increase the risk of it developing.

These risk factors include:

• If a parent or sibling has or had an eating disorder (including bulimia nervosa)
• Being a high-achiever or perfectionist
• Experiences of being bullied for weight
• Overexposure to online/social media content that depicts unrealistic beauty standards
• A diagnosis of depression, alcohol/ drug addiction, autism spectrum disorder, BPD (borderline personality disorder), bipolar disorder, or OCD (obsessive compulsive disorder)
• Experiences with trauma and PTSD (post-traumatic stress disorder)

Diagnosing anorexia

If a patient is suspected of having anorexia, medical professionals will carry out an evaluation to confirm. The DSM-5-TR is the latest edition of The Diagnostic and Statistical Manual or Mental Disorders which is the American Psychiatric Association (APA) classification and assessment tool.

According to DSM-5, the diagnostic criteria that need to be met for an official diagnosis of anorexia nervosa are as follows:

1. Restriction of caloric intake relative to individual requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health.
2. Intense fear of gaining weight or becoming fat or persistent behavior that interferes with weight gain.
3. Disturbed by one’s body weight or shape, self-worth influenced by body weight or shape, or persistent lack of recognition of seriousness of low body mass.
4. In menstruating females, absence of at least 3 consecutive non-synthetically induced menstrual cycles.

Anorexia nervosa has two additional subtypes; restricting or binge-eating/purging, which depends on whether the patient only reports food restriction or binge/purging of food within the past three months as an additional weight control method.

Just because someone does not meet the above criteria for anorexia nervosa does not mean you should rule out their symptoms. It is advisable to speak with a health professional, even if only experiencing some of these symptoms, as getting help as early as possible can reduce recovery time.

If anorexia symptoms are present, presented a healthcare professional may:

• Perform a physical exam that involves vital organ and blood tests to assess overall health, which also helps rule out other causes of weight loss.
• Take dietary and exercise histories.
• Confirm family history of similar disorder.
• Check on the regularity of menstruation along with hormone tests if there is evidence of irregularity.

Complications of anorexia nervosa

Anorexia can lead to several health risks due to malnutrition and starvation. Vital organs like the brain, heart, and kidneys can be affected in severe cases, and sometimes this damage can be irreversible or even fatal.

Other severe medical complications of anorexia nervosa can include:

• Heart arrhythmia (irregular heartbeat) and other cardiac issues, including heart failure
• Osteoporosis (weakening of the bones)
• Reduced sex drive
• Anemia (low red blood cell count, which can cause fatigue and weakness)
• Gastrointestinal problems including stomach pain and bowel problems ^[3]

Treatment for anorexia

Most patients with anorexia nervosa undertake treatment at home and within the community, as an outpatient. However, in extreme circumstances, short to long-term hospital (inpatient) treatment is required, especially if other high-risk mental or physical health conditions present or the patient is at risk of harming themselves or others.

Anorexia should be treated under the supervision of a specialist eating disorder service, using a personalized treatment plan. It is essential to start treatment as soon as possible because although it is very treatable, and many people recover, this can take months or even years.

Most treatment options include both medical and psychological interventions, usually delivered by various health professionals. The biggest hurdle is changing an individual’s attitudes about food and their distorted body image, which requires a great deal of unlearning harmful beliefs and courage to start eating a healthy diet again.

Ideally, patients would do this with the support of a licensed psychologist or therapist specializing in eating disorders and a nutritionist with experience in anorexia. Nutritional rehabilitation for weight stabilization should always begin under careful supervision, as significantly malnourished patients can develop something called ‘refeeding syndrome,’ which is very dangerous if left untreated. Additionally, blood pressure, nutritional levels, and heart rate requires regular monitoring.

In terms of psychological interventions, the therapeutic approach most often used is a form of CBT (Cognitive Behavioral Therapy) called CBT-ED. CBT-ED aims to treat the disorder using a practical and psychological approach by addressing nutrition, cognitive restructuring, mood regulation, social skills, body image concerns, self-esteem, and relapse prevention.

For younger patients, family-based treatment and therapy can also be beneficial in successfully treating anorexia, as having your family understand your condition and support you in making good choices at home can go a long way to restoring a healthy relationship with food.

Finally, if other psychological disorders, such as depression or anxiety, are present, medication, such as antidepressants, may be used alongside therapy.

If you or someone you know is seriously ill or having suicidal thoughts, you should contact a medical professional immediately.

Prevention of Anorexia

There is no guarantee that you can prevent anorexia, but starting treatment as early as possible is beneficial to avoid serious complications. If you or anyone you know shows signs of anorexia, you should contact a medical professional.

Education about healthy eating and a balanced diet is vital in preventing eating disorders of any kind. On top of that, promoting a healthy body image is key.

Frequently asked questions about anorexia nervosa

Do you have to be underweight to be anorexic?

No, anyone can be affected by anorexia regardless of their weight or body type.

What is the difference between anorexia and bulimia?

Anorexia and bulimia are both eating disorders and share characteristics such as a preoccupation with food and a desire to be thin. The major difference is that people with anorexia tend to avoid eating food or eat very little, whereas bulimics go through episodes of binge eating and then purging (either through self-inducing vomiting or laxatives) to prevent weight gain. Anorexia and bulimic tendencies often occur together, and diagnosing anorexia involves taking this into consideration. 

To find out more about how they differ, read our article on the difference between anorexia and bulimia.

How common is anorexia?

28.8 million Americans will have an eating disorder at some point during their life, roughly 9% of the US population. ^[4].

When did anorexia start?

Cases of eating disorders have been documented as early as the Middle Ages when multiple cases of women dying from anorexia mirabilis (a mental health condition similar to anorexia nervosa, but with the goal of spiritual purity rather than attaining a certain weight or body shape) were recorded ^[5].