Anorexia Nervosa

What is anorexia nervosa?

Anorexia nervosa is characterized by an irrational dread of becoming fat coupled with a relentless pursuit of thinness. People with anorexia go to extremes­ to reach and maintain a dangerously low body weight. But no matter how much weight is lost, no matter how emaciated they become, it’s never enough. The more the scale dips, the more obsessed they become with food, dieting, and weight loss.

The key features of anorexia nervosa are:

• Refusal to sustain a minimally normal body weight
• Intense fear of gaining weight, despite being underweight
• Distorted view of one’s body or weight, or denial of the dangers of one’s low weight

There are two types of anorexia. In the restricting type, weight loss is achieved by restricting calories. Restricting anorexics follow drastic diets, go on fasts, and exercise to excess. In the purging type, people get rid of calories they’ve consumed by vomiting or using laxatives and diuretics.

Anorexia is most common in adolescent girls and young women, with a typical age of onset between the ages of 13 and 20. But people of all ages­—including men and children—can suffer from anorexia.

The difference between dieting and anorexia

Eating disorders, including anorexia, often begin with normal dieting. A person may start dieting and exercising to get in shape, but as the pounds come off, a desire to lose even more weight is triggered. This cycle continues until the person almost completely stops eating.

Many factors influence this destructive progression from healthy dieting to full-blown anorexia. For many anorexics, self-starvation is a way to feel in control. People with anorexia may feel powerless in their everyday lives, but they can control what they eat. Restricting food is a way to cope with painful feelings such as anger, shame, and self-loathing. Saying “no” to food, getting the best of hunger, and controlling the number on the scale make them feel strong and successful—at least for a short while.

Unfortunately, this boost to self-esteem is short-lived. Anorexics believe that their lives will be better—that they’ll finally feel good about themselves—if they lose more weight. But no amount of dieting or weight loss can repair the negative self-image at the heart of anorexia. In the end, anorexia only leads to greater emotional pain, isolation, and physical damage.

Is it a Diet or Anorexia?
Healthy Dieting	Anorexia
Weight loss is viewed as a way to improve health and appearance.	Weight loss is viewed as a way to achieve happiness.
Self-esteem is based on more than just weight and body image.	Self-esteem is based entirely on how much you weigh and how thin you are.
Is an attempt to control weight	Is an attempt to control your life and emotions
The goal is to lose weight in a healthy way.	Becoming thin is all that matters; health is not a concern.

Signs and symptoms of anorexia

People with anorexia often hide their condition, so the warning signs are not always easy to spot. Furthermore, anorexics will typically try to explain away their disordered eating behaviors when confronted. But as anorexia progresses, the signs and symptoms become increasingly obvious and difficult to deny.

Eating and food behavior signs and symptoms

• Dieting despite being thin – Follows a severely restricted diet. Eats only certain low-calorie foods. Bans “bad” foods such as carbohydrates and fats.
• Obsession with calories, fat grams, and nutrition – Reads food labels, measures and weighs portions, keeps a food diary, reads diet books.
• Pretending to eat or lying about eating – Hides, plays with, or throws away food to avoid eating. Makes excuses to get out of meals (“I had a huge lunch” or “My stomach isn’t feeling good.”).
• Preoccupation with food – Eats very little, but constantly thinks about food. May cook for others, collect recipes, read food magazines, or make meal plans.
• Strange or secretive food rituals – Often refuses to eat around others or in public places. May eat in rigid, ritualistic ways (e.g. cutting food “just so”, chewing food and spitting it out, using a specific plate).

Appearance and body image signs and symptoms

• Dramatic weight loss – Rapid, drastic weight loss with no medical cause.
• Feeling fat, despite being underweight – May complain about being overweight in general or just “too fat” in certain places such as the stomach, hips, or thighs.
• Fixation on body image – Obsessed with weight, body shape, or clothing size. Frequent weigh-ins and concern over tiny fluctuations in weight.
• Harshly critical of appearance – Spends a lot of time in front of the mirror checking for flaws. There’s always something to criticize. They’re never thin enough.
• Denies being too thin – Refuses to believe that his or her low body weight is a problem, but may try to conceal it (drinking a lot of water before being weighed, wearing baggy or oversized clothes).

Purging signs and symptoms

• Using diet pills, laxatives, or diuretics – Abuses water pills, herbal appetite suppressants, prescription stimulants, ipecac syrup, and other drugs for weight loss.
• Throwing up after eating – Frequently disappears after meals or goes to the bathroom. May run the water to disguise sounds of vomiting or reappear smelling like mouthwash or mints.
• Compulsive exercising – Follows a punishing exercise regimen aimed at burning calories. Will exercise through injuries, illness, and bad weather. Works out extra hard after bingeing or eating something “bad.”

Anorexia causes and risk factors

What sets someone on a course toward self-starvation? It’s easy to blame a culture that equates slenderness with beauty and success and portrays stick-thin women as the physical ideal, but eating disorders have been around for centuries.

Although our culture’s idealization of thinness plays a powerful role in the development of anorexia, there are other contributing factors, including genetics, individual personality traits, and family environment.

Biological causes of anorexia

Research suggests that a genetic predisposition to anorexia may run in families. If a girl has a sibling with anorexia, she is 10 to 20 times more likely than the general population to develop anorexia herself. Brain chemistry also appears to play a significant role. People with anorexia tend to have high levels of cortisol, the brain hormone most related to stress, and decreased levels of serotonin and norepinephrine, which are associated with feelings of well-being.

Psychological causes of anorexia

People with anorexia are often perfectionists and overachievers. They’re the “good” daughters and sons who do what they’re told, excel in everything they do, and focus on pleasing others. But while anorexics may appear to have it all together on the surface, inside they feel helpless, inadequate, and worthless. They view themselves through a harshly critical lens. If they’re not perfect, they’re a total failure.

Family and social pressures

In addition to the cultural pressure to be thin, there are other family and social pressures that can contribute to anorexia. This includes participation in an activity that demands slenderness, such as ballet, gymnastics, or modeling. It also includes having parents who are overly controlling, put a lot of emphasis on looks, diet themselves, or criticize their children’s bodies and appearance. Stressful life events—such as the onset of puberty, a breakup, or going away to school—can also trigger anorexia.

Effects of anorexia

The severe calorie restriction of anorexia has dire physical effects. When the body doesn’t get the fuel it needs to function normally, it goes into starvation mode. It slows down to conserve energy and turns in on itself for essential nutrients. In essence, the body begins to consume itself. As the self-starvation continues and more body fat is lost, the medical complications pile up.

The first physical signs and effects of anorexia are:

Loss of menstrual periods Lack of energy and weakness Feeling cold all the time Dry, yellowish skin

Constipation and abdominal pain Restlessness and insomnia Dizziness, fainting, and headaches Growth of fine hair all over the body and face

Source: WomensHealth.gov

If anorexia continues unchecked, the health problems only get worse. Over time, anorexia causes hair loss, infertility, stunted growth, osteoporosis, heart problems, kidney failure, and death. Other effects of anorexia include tooth decay and gum damage from malnutrition and vomiting, and damage to the esophagus and larynx from acid reflux. Anorexia can also lead to depression, severe mood swings, and thoughts of suicide.

Anorexia treatment and recovery

While the physical and emotional consequences of anorexia can be devastating, the good news is that it’s a treatable condition. With the right treatment team, people with anorexia can and do get better. They can regain their health, learn to eat normally again, and develop healthier attitudes about food and their bodies.

Since anorexia involves both mind and body, both attitudes and behaviors, a team approach is often best. Those who may be involved in anorexia treatment include medical doctors, mental health professionals, and dieticians. The participation and support of family members also makes a big difference in anorexia treatment success.

If you’re interested in seeking anorexia treatment, a visit to the doctor is the first step. In order to make an official diagnosis, the doctor will conduct a complete assessment of you or your loved one’s symptoms, eating behaviors, mental state, and physical health. The doctor will also rule out all possible health conditions that could be causing the weight loss. If anorexia is diagnosed, you will work with the doctor to develop the right treatment plan for your needs.

Medical treatment for anorexia

The first priority in anorexia treatment is to address and stabilize any serious health issues. Hospitalization may be necessary to prevent starvation, suicide, or a medical crisis. Dangerously thin anorexics may also need to be hospitalized until they reach a less critical weight. Outpatient treatment is an option when the patient is not in immediate medical danger.

Getting back to a normal weight is no easy task, especially for those being treated against their will. Fear of weight gain is extraordinarily frightening to people with anorexia, and forced weight gain even more so. But research shows that the closer body weight is to normal at the end of treatment, the greater the chance of recovery, so weight restoration should be a top treatment goal.

Nutritional therapy for anorexia

A second component of anorexia therapy is nutritional counseling. In nutritional counseling, a nutritionist or dietician teaches the patient about healthy eating, proper nutrition, and balanced meals. The nutritionist also helps the person develop and follow meal plans that include enough calories to reach or maintain a normal, healthy weight.

Counseling and therapy for anorexia

Therapy plays a crucial role in anorexia treatment. Its goals are to identify the negative thoughts and feelings about weight and the self that are behind the anorexic behaviors, and to replace them with healthier and less distorted attitudes. Another important goal is to teach the anorexic how to deal with difficult emotions, relationship problems, and stress in a productive, rather than a self-destructive, way.

Types of Therapy for Anorexia Treatment
Cognitive therapy	Explores the critical and unhealthy thoughts underlying anorexia. The focus is on increasing self-awareness, challenging distorted beliefs, and improving self-esteem and sense of control. Cognitive therapy also involves education about anorexia.
Behavior therapy	Promotes healthy eating behaviors through the use of rewards, reinforcements, self-monitoring, and goal setting. Teaches the patient to recognize anorexia triggers and deal with them using relaxation techniques and coping strategies.
Family therapy	Examines the family dynamics that may contribute to anorexia or interfere with recovery. Often includes some therapy sessions without the anorexic patient—a particularly important element when the person with anorexia denies having an eating disorder.
Group therapy	Allows people with anorexia to talk with each other in a supervised setting. Helps to reduce the isolation many anorexics may feel. Group members can support each other through recovery and share their experiences and advice.

Helping a person with anorexia

Encouraging an anorexic friend or family member to get treatment is the most caring and supportive thing you can do. But because of the defensiveness and denial involved in anorexia, you’ll need to tread lightly. Waving around articles about the dire effects of anorexia or declaring “You’ll die if you don’t eat!” probably won’t work. A better approach is to gently express your concerns and let the person know that you’re available to listen. If your loved one is willing to talk, listen without judgment, no matter how out of touch the person sounds.

You can also seek advice from a health professional, even if your friend or family member won’t. And you can bring others—from peers to parents—into the circle of support. You can also help by being a good role model for healthy eating, exercising, and body image. Don’t make negative comments about your own body or anyone else’s. And whatever you do: don’t turn into the food police. A person with anorexia needs support, not an authority figure standing over the table with a calorie counter.

Related links for anorexia nervosa

General information about anorexia nervosa

Anorexia Nervosa – Covers the signs, causes, risk factors, diagnosis, and treatment of anorexia. Includes information on nutritional and dietary therapies. (University of Maryland Medical Center)

Negative Voices – Description of the negative, self-critical “voices” that tell anorexics that they’re powerless and worthless. Includes tips on dealing with them. (The Something Fishy Website on Eating Disorders)

Distorted Perceptions – Article on the distorted perceptions that anorexics have about themselves and their bodies. (The Something Fishy Website on Eating Disorders)

Anorexia signs and symptoms

Noticing the Signs and Symptoms – Detailed list of the signs and symptoms of anorexia nervosa, including physical, emotional, and behavioral red flags. (The Something Fishy Website on Eating Disorders)

Eating Disorders Warning Signs – Covers the warning signs and symptoms of anorexia and other eating disorders, including dieting behaviors, over-excercising, and purging. (Anorexia Nervosa and Related Eating Disorders, Inc.)

Killer Workout – Questions and answers on activity anorexia, in which weight loss is achieved through strenuous, compulsive exercise. Includes a discussion of symptoms. (Psychology Today)

Anorexia causes and risk factors

What Causes Eating Disorders? – Describes current research and theories on anorexia’s causes and risk factors, including biological, psychological, and social factors. (Anorexia Nervosa and Related Eating Disorders, Inc.)

Anorexia treatment and therapy

Promising treatments for anorexia and bulimia – Description of a treatment option for anorexia that involves the entire family; it helps affected teens start eating again. (American Psychological Association)

Questions to Ask When Considering Treatment Options – Provides a list of questions to ask potential eating disorder therapists or treatment facilities. (National Eating Disorders Association)

Eating Disorders Survival Guide – Provides step-by-step recommendations for finding appropriate anorexia treatment and insurance coverage. (National Eating Disorders Association)

Anorexia in athletes and men

Males with eating disorders – Discussion of anorexia in men, including the signs, symptoms, risk factors, and treatment. (Anorexia Nervosa and Related Eating Disorders, Inc.)

Athletes with eating disorders – Focuses on the signs, symptoms, causes, and effects of anorexia in athletes. Includes tips for coaches on getting them into treatment. (Anorexia Nervosa and Related Eating Disorders, Inc.)

Online resources for finding anorexia treatment providers

Eating Disorder Treatment Finder – Searchable directory of anorexia treatment providers, including doctors, therapists, dieticians, support groups, and inpatient or residential programs. (The Something Fishy Website on Eating Disorders)

EDReferral.com – Comprehensive, easy-to-search database of anorexia and eating disorder treatment providers. (The Eating Disorder Referral and Information Center)

Melinda Smith, M.A., Ellen Jaffe-Gill, M.A, Robert Segal, M.A., and Jeanne Segal, Ph.D., contributed to this article. Last modified on: 2/27/08