What is Anorexia Nervosa?

Anorexia nervosa is an eating disorder characterized by the following: (1) the restriction of food intake, which can result in significantly low body weight. (2) An intense fear of gaining weight or becoming fat. This fear typically contributes to behaviors that prevent weight gain. In addition to the reduction of food intake, this may take the form of exercise or purging. (3) Distorted body image. People with anorexia nervosa may experience their body as “fat,” despite objectively low body weight. They may believe that their body weight or shape is the most important determinant of their self-worth. Body image disturbance may also result in denial of the significance of weight loss and persistence toward restricted food intake. Severity of anorexia nervosa is based not only on weight but also on symptoms, disability from the disorder, and need for supervision.

The restrictive and the binge/purge types

There are two identified “types,” restrictive or binge/purge type. These descriptions acknowledge whether the person with anorexia engages in binge eating and purging behavior. Purging is using self-induced vomiting, laxatives, diuretics, or enemas to compensate for calories consumed during binge eating episodes. There is commonly crossover between the subtypes. That is, someone with anorexia nervosa may go through periods of bingeing and purging and have times where they only rely on restriction to maintain lower than ideal body weight.

While extreme weight loss resulting in thinness or emaciation is a strong indicator that a person may be showing signs of anorexia nervosa, it is also possible to have a diagnosis of anorexia at a “normal” weight while still having a significant eating disorder. When someone experiences symptoms of anorexia nervosa but does not meet the low weight requirement, it may be called atypical anorexia nervosa, or diagnosed in the OSFED (other specific feeding or eating disorder) category. No matter the name, anyone experiencing symptoms of anorexia nervosa should seek help. Despite common misconceptions and stereotypes, a serious eating disorder can exist at any weight and getting professional treatment right away is recommended. Anorexia nervosa is a psychological disorder with serious physical consequences that can’t be diagnosed based on what someone looks like or weight alone, and it is unlikely to resolve on its own without treatment.

The difficulty to reconize anorexia

It is common for people struggling with anorexia nervosa to fail to recognize the seriousness of their condition. They rarely have insight and deny that they have a problem at all. This is a consequence of the disorder itself and also partially a result of culture/environment. Our culture normalizes and encourages many eating disorder behaviors making it difficult for many to recognize the dangerousness of these behaviors and the gravity of living with an eating disorder.

Thinness is idealized in American culture and most people are praised when they begin to lose weight. Furthermore, when a body is underfed and does not have the nutrients it needs in order to function on a daily basis, it begins to feel a great amount of stress. Many begin to feel depressed, irritable, anxious, hopeless and alone as a result, which are all symptoms of malnutrition. It is also common for someone with anorexia to isolate themselves from others. Sadly, anorexia nervosa has the highest mortality rate of any psychiatric illness, with approximately 5% per decade. Death resulting from anorexia is usually the result of medical complications. However, suicide risk is also higher in people with anorexia with rates of approximately 12 per 100,000.

Signs and Symptoms

Eating disorders are complex and unique to each person; they may not look the same from person to person. The following are some signs and symptoms of anorexia nervosa:

  • Markedly low weight, significant weight loss or failure to maintain growth curve
  • Intense fear of weight gain or becoming fat (not alleviated by weight loss)
  • Checking one’s body frequently by weighing, measuring, or visually checking
  • Amenorrhea (loss of menstrual period)
  • Exercising excessively
  • Purging (using vomiting, laxatives, diuretics, or enemas)
  • Preoccupation with food, calories, macros/points, recipes
  • Depressed mood
  • Social withdrawal
  • Decreased interest in sex
  • Excuses for not eating meals (ie. ate earlier, not feeling well)
  • Unusual eating habits (ie. cutting food into tiny pieces, picking at food)
  • Noticeable discomfort around food
  • Complaining of being “too fat”
  • Cooking for others, but not eating themselves
  • Restricting food choices to only diet foods
  • Guilt or shame about eating
  • Depression, irritability
  • Wearing baggy clothes
  • Difficulty eating in public
  • Very secretive about eating patterns

Physical/Medical Complications

  • Fatigue and lack of energy
  • Muscle weakness
  • Amenorrhea (loss of menstruation)
  • Anemia
  • Skin problems
  • Dizziness
  • Headaches
  • Dehydration
  • Shortness of breath
  • Irregular heartbeats
  • Cold hands and feet
  • Bloating
  • Constipation
  • Hair loss
  • Stomach pains
  • Decreased metabolic rate
  • Edema (water retention)
  • Lanugo (fine downy hair covering the body)
  • Loss of bone mass
  • Kidney and liver damage
  • Electrolyte imbalances
  • Osteoporosis
  • Insomnia
  • Infertility
  • Cathartic colon (caused by laxative abuse)
  • Dental enamel erosion
  • Scars or calluses on the back of the hands from self-induced vomiting
  • Low potassium (most common cause of nocturnal cardiac arrest)
  • Cardiac arrest

Causes

There is no single identified specific cause of eating disorders. The development of an eating disorder is a combination of biological, social-environmental, and psychological factors. Studies of biological relatives and twins have shown that there is a strong genetic component to anorexia development and expression. Some personality traits may also put some at risk like obsessiveness, perfectionism, persistence, impulsivity, agreeableness, and harm avoidance.

Anorexia nervosa is more likely to develop in environments that promote and idealize thinness, as well as within activities or occupations that promote it, such as modeling, gymnastics. Eating disorders often develop during difficult life transitions and experiences. Trauma, loss, going to college, getting married, divorced, and having children are common experiences during which eating disorders begin. Dieting can also be a risk factor for developing an eating disorder. While eating disorders typically develop during adolescence, they have also been observed in children and older adults. Contrary to popular belief, anorexia nervosa also occurs in boys and men (though less commonly), and among diverse cultural groups. 

Treatment

As previously stated, it is common for someone with anorexia to resist seeking treatment or deny the need for treatment. If you or someone you love is struggling with anorexia nervosa, it’s best to take a treatment team approach with the following professionals who specialize in eating disorders: licensed therapist, registered dietitian familiar with working with eating disorders, medical doctor, and possibly a psychiatrist. Outpatient individual treatment with a licensed therapist and/or dietician is often appropriate, but higher levels of care may be necessary.

These options include intensive outpatient treatment, partial hospitalization, residential treatment, or medical hospitalization. The right level of care is dependent not only on weight, but overall physical and mental health, and eating disorder behaviors. If a person is medically unstable it is important to begin with the highest level of care and step down over time as the individual’s condition improves. In those who are do not need medical monitoring, they may begin with outpatient therapy and pursue a higher level of care if they are not improving.

For children and young adults who live at home or can return home to live with family, The Maudsley Approach (also known as family-based treatment (FBT)) is an effective alternative to inpatient or residential treatment that empowers the family to facilitate recovery. In addition to individual treatment, many people with eating disorders find it helpful to get involved in an outpatient eating disorder treatment group or professionally run support group to connect with others in the recovery process. Early intervention offers the best chance for recovery from anorexia nervosa. It is not uncommon for people to experience relapse, but with treatment from professionals and support from loved ones, recovery is possible.  

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Additional Reading

References

  • Twin Studies of Eating Disorders – International Journal of Eating Disorders
  • Genetic factors in Anorexia Nervosa – National Institutes of Health
  • Surviving an Eating Disorder: Perspectives and Strategies for Family and Friends by Michelle Siegel, Ph.D., Judith Brisman, Ph.D., and Margot Weinshel, Ph.D. – Harper & Row Publishers, NY, 1988
  • Walking A Thin Line by Pam Vredevelt and Joyce Whitman – Mullnomah Press, Oregon 1985
  • Eating Disorders Handout – Sudbury General Hospital Eating Disorders Clinic (information for handout obtained from NEDIC)
  • Shisslak, C.M., Crago, M., & Estes, L.S. (1995). The spectrum of eating disturbances. International Journal of Eating Disorders, 18 (3), 209-219.

Updated 11/2019 by Elisha Mitchell Carcieri, Ph.D.
Written By: Colleen Thompson